Megacode PEA Part 4

Peripheral IV Drug Delivery

·         Adults peak drug concentrations are lower and circulation times longer

·         Does not require interruption of CPR

·         Administer the drug by bolus injection and follow with a 20-mL bolus of IV fluid

·         Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

Endotracheal Drug Delivery

·         Results in lower blood concentrations than the same dose given intravascularly.

·         Give 2 to 2½ times the recommended IV dose.

·         Providers should dilute the recommended dose in 5 to 10 ml of water or normal saline and inject the drug directly into the endotracheal tube

Intraosseous Drug Delivery

·         Enables drug delivery similar to that achieved by peripheral venous access at comparable doses.

·         Is safe and effective for fluid resuscitation, drug delivery, and  blood sampling

·         Is attainable in all age groups.

Central IV Drug Delivery

·         Peak drug concentrations are higher and drug circulation times shorter

·         Central line placement can interrupt CPR.

·         a central line extending into the superior vena cava can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC

IV access on a hemodialysis patient is very challenging.   If peripheral IV access cannot be achieved, then consider intubating the patient and administering the medications through the ET tube.   Remember that peak concentrations are not as good so you will need to administer 2-2.5 times the usual dose of the medication.  

The technology for performing intraosseous access has improved and made it so much easier to obtain IO access on pediatric patients and adults.   So, IO access is another option to consider on those patient with poor peripheral IV access.

On some of the hemodialysis patients that I have resuscitated, I have looked at their functioning dialysis catheter or AV graft and wondered why I could not just administer the medications through them.   If the patient survives, you could always go back and have the graft or dialysis catheter declotted.   Any thoughts on this? 

 3:26 PM.   The rhythm change in response to the epinephrine is an agonal rhythm or a bradyasystolic rhythm.  Given the patient's history, we could consider some possible causes of the PEA rhythm as either hyperkalemia, hypokalemia,  hydrogen ions (acidosis),  hypovolemia,  hypoxia, thrombosis coronary and pulmonary, toxins.

The patient's actual potassium was on slightly elevated at 5.4.   Because metabolic acidosis was a likely problem with this patient, sodium bicarbonate was administered.  The acutal pH could have been determined by an ABG.   In addition, IV fluid boluses were given to the patient because of the potential problem of being hypovolemic related to the dialysis.  In addition, hemodialysis patients typically have a low H&H.   The patient was on a beta blocker so there was the possibility that the drug concentration had built up in the patient's system and slowed the patient's heart rate down.