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  • Volume I:
    First Thirty Minutes
    • Section 1
      Acute Care Algorithm/ Treatment Plans/ Acronyms
      • CALS Approach
        • CALS Universal Approach
        • Patient Transport
      • Airway
        • Rapid Sequence Intubation Algorithm/Rescue Airways
        • Endotracheal Intubation FlowSheet
        • Rapid Sequence Intubation Medications
        • Rapid Sequence Intubation Drug Calculator
        • Rapid Sequence Intubation Dosage Chart
        • Obstructed Airway Algorithm Adult and Pediatric
        • Initial Laboratory Studies
      • Cardiovascular
        • CPR Steps for Adults, Children, and Infants
        • Automated External Defibrillator Algorithm
        • Ventricular Fibrillation-Pulseless Ventricular Tachycardia Algorithm
        • Pulseless Electrical Activity Algorithm-Adult and Peds
        • Asystole Algorithm-Adult and Peds
        • Bradycardia Algorithm
        • Tachycardia Algorithm
        • Atrial Fibrillation/Atrial Flutter Algorithm
        • Electrical Cardioversion Algorithm-Adult and Pediatric
        • Chest Pain Evaluation Algorithm
      • Emergency Preparedness
        • Therapeutic Hypothermia
        • Mobilization Checklist
        • Symptom Recognition-Therapy
        • Blast Injuries
      • Fluids & Electrolytes
        • Causes of Anion and Non-Anion Gap Acidosis
      • Infection
        • Sepsis Guidelines
      • Neonatal
        • Neonatal Resuscitation Algorithm
        • Inverted Triangle-APGAR Score
        • Drugs in Neonatal Resuscitation Algorithm
      • Neurology
        • Altered Level of Consciousness
        • Glasgow Coma Scale-Adult, Peds,Infant
        • Tips From the Vowels Acronym
        • NIH Stroke Scale (Abbreviated)
        • Status Epilepticus Treatment Plan
      • Obstetrics
        • Postpartum Hemorrhage Algorithm
        • Shoulder Dystocia—HELPERR
        • Vacuum Delivery Acronym-ABCDEFGHIJ
      • Ophthalmology
        • Central Retinal Artery Occlusion
        • Chemical Burn Exposure to Eye
      • Pediatrics
        • Pediatric Equipment Sizes
        • Modified Lund Browder Chart
      • Trauma
        • Shock Acronym-Shrimpcan
        • Burn Management Treatment Plan
        • Initial Care of Major Trauma
        • Trauma Flow Sheet
    • Section 2
      Universal Approach
      • CALS Universal Approach To Emergency Advanced Life Support
    • Section 3
      Steps 1-6
      • Steps 1-6
      • Step 1: Activate the Team
      • Step 2: Immediate Control and Immobilization
      • Step 3: Initial Survey
      • Step 3: Simultaneous Team Action By Team Members
      • Step 4: Preliminary Clinical Impression
      • Step 5: Working Diagnosis and Disposition
      • Step 6: Team Process and Review
    • Section 4
      Preliminary Impression/Focused Clinical Pathways
      • Pathway 1: Altered Level of Consciousness (Adult and Pediatric)
      • Pathway 2: Cardiovascular Emergencies (Adult and Pediatric)
      • Pathway 3: Gastrointestinal/Abdominal Emergencies (Adult and Pediatric)
      • Pathway 4: Neonatal Emergencies
      • Pathway 5: Obstetrical Emergencies
      • Pathway 6: Adult Respiratory
      • Pathway 7: Pediatric Respiratory
      • Pathway 8: Adult Trauma (Secondary Survey for Adults)
      • Pathway 9: Pediatric Trauma (Secondary Survey for Trauma in Children)
  • Volume II:
    Resuscitation Procedures
    • Section 5
      Airway Skills
      • Airway Skills 1: Aids to Intubation
      • Airway Skills 2: Bag-Valve-Mask Use
      • Airway Skills 3: Orotracheal Intubation
      • Airway Skills 4: Rapid Sequence Intubation
      • Airway Skills 5: Cricoid Pressure and the BURP Technique
      • Airway Skills 6: Esophageal Tracheal Combitube
      • Airway Skills 7: King Airway
      • Airway Skills 8: Intubating Laryngeal Mask Airway
      • Airway Skills 9: Nasotracheal Intubation
      • Airway Skills 10: Topical Anesthesia
      • Airway Skills 11: Retrograde Intubation
      • Airway Skills 12: Tracheal Foreign Body Removal
      • Airway Skills 13: Cricothyrotomy
      • Airway Skills 14: Tracheotomy
      • Airway Skills 15: Tracheotomy in Infants
      • Airway Skills 16: Transtracheal Needle Ventilation
    • Section 6
      Breathing Skills
      • Section 6 Breathing Skills Portals
      • Breathing Skills 1: Chest Tube Insertion
      • Breathing Skills 2: Chest Suction and Autotransfusion
      • Breathing Skills 3: Endobronchial Tube
      • Breathing Skills 4: Heliox
      • Breathing Skills 5: Needle Thoracostomy
    • Section 7
      Circulation Skills
      • Section 7 Circulation Skills Portals
      • Circulation Skills 1: Arterial and Venous Catheter Insertion
      • Circulation Skills 2: Central Venous Access
      • Circulation Skills 3: Central Venous Pressure Measurement
      • Circulation Skills 4: Emergency Thoracotomy
      • Circulation Skills 5: Intraosseous Needle Placement (Adult)
      • Circulation Skills 6: Pericardiocentesis
      • Circulation Skills 7: Rewarming Techniques
      • Circulation Skills 8: Saphenous Vein Cutdown
      • Circulation Skills 9: Transvenous Cardiac Pacing
    • Section 8
      Disability Skills
      • Section 8 Disability Skills Portals
      • Disability Skills 1: Skull Trephination
      • Disability Skills 2: Raney Scalp Clips
    • Section 9
      Trauma Skills
      • Trauma Skills Portals
      • Trauma Skills 1: Compartment Pressure Measurement
      • Trauma Skills 2: Femur Fracture Splinting
      • Trauma Skills 3: Pelvic Fracture Stabilization
      • Trauma Skills 4: Suprapubic Cystostomy
    • Section 10
      X-Rays Skills
      • X-ray Skills 1: Cervical Spine Rules and Use of Imaging Portal
      • X-ray Skills 2: Cervical Spine X-ray Interpretation
      • Xray Skills 3: Interpretation of a Pelvic X-ray
  • Volume III:
    Definitive Care
    • Section 11
      Airway
      • Rapid Sequence Intubation Portal
      • Airway Obstruction Portal
      • Heliox Treatment Portal
      • Ventilator Management Portal
      • Noninvasive Ventilatory Support Portal
      • Inspiratory Impedance Threshold Device Portal
      • Status Asthmaticus Portal
      • Anaphylaxis Portal
    • Section 12
      Cardiovascular
      • Cardiovascular 1: Classification of Pharmacological (Therapeutic) Interventions Portal
      • Cardiovascular 2: Cardiac Rhythms Portal
      • Cardiovascular 3: Pharmacology of Cardiovascular Agents Portal
      • Cardiovascular 4: Endotracheal Drug Delivery
      • Cardiovascular 5: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Portal
      • Cardiovascular 6: Pulseless Electrical Activity Portal
      • Cardiovascular 7: Asystole Treatment Portal
      • Cardiovascular 8: Tachycardia Treatment Portal
      • Cardiovascular 9: Electrical Cardioversion Portal
      • Cardiovascular 10: Bradycardia Treatment Portal
      • Cardiovascular 11: Acute Coronary Syndromes Portal (Acure Ischemic Chest Pain)
      • Cardiovascular 12: Acute Heart Failure Portal
      • Cardiovascular 13: Hypertensive Crises Portal
      • Cardiovascular 14: Digitalis Toxicity Portal
      • Cardiovascular 15: Long QT Syndrome Portal
      • Cardiovascular Diagnostic Treatment Portals
    • Section 13
      Emergency Preparedness
      • Emergency Preparedness 1: Community-Wide Collaboration Portal
      • Emergency Preparedness 2: Approaches to Planning
      • Emergency Preparedness 3: Hazard Vulnerability Analysis Portal
      • Emergency Preparedness 4: Incident Command System Portal
      • Emergency Preparedness 5: Emergency Management Program Portal
      • Emergency Preparedness 6: Basic All Hazards Response Portal
      • Emergency Preparedness 7: Rapid and Efficient Mobilization Portal
      • Emergency Preparedness 8: Emergency Event Response Classifications Portal
      • Emergency Preparedness 9: Triage Portal
      • Emergency Preparedness 10: Surge Capacity Planning and Scarce Resources Guidelines
      • Emergency Preparedness 11: Glossary of Terms
      • Emergency Preparedness 12: Resources
      • Emergency Preparedness 13: Introduction to Nuclear, Biological, and Chemical Warfare
      • Emergency Preparedness 14: Nuclear Devices Portal
      • Emergency Preparedness 15: Acute Radiation Syndrome Portal
      • Emergency Preparedness 16: Biological Agents Portal
      • Emergency Preparedness 17: Chemical Agents Portal
      • Emergency Preparedness 18: Explosion and Blast Injuries Portal
      • Emergency Preparedness 19: Patient Isolation Precautions
      • Emergency Preparedness 20: Additional References and Resources
    • Section 14
      Endocrine and Metabolic
      • Endocrine and Metabolic 1: Adrenal Crisis Portal
      • Endocrine and Metabolic 2: Diabetic Ketoacidosis Portal
      • Endocrine and Metabolic 3: Myxedma Coma (Severe Hypothyroidism) Portal
      • Endocrine and Metabolic 4: Thyroid Storm Portal (Severe Thyrotoxicosis/Hyperthyroidism)
      • Endocrine and Metabolic 5: Hyperosmolar (Hyperglycemic) Non-Ketotic State Portal
      • Endocrine and Metabolic 6: Acid-Base Portal Concepts and Clinical Considerations
      • Endocrine and Metabolic 7: Disorders of Electrolyte Concentration Portal
    • Section 15
      Environmental
      • Environmental 1: Hypothermia Portal
      • Environmental 2: Hyperthermia/Heat Stroke Portal
      • Environmental 3: Burns Management Portal
      • Environmental 4: Near Drowning Portal
      • Environmental 5: High Altitude Illness Portal
      • Environmental 6: Snake Bite Portal
    • Section 16
      Farming
      • Farming 1: Respiratory Illnesses Portal
      • Farming 2: Farm Wounds/Amputation Portal
      • Farming 3: Chemical Exposures Portal
    • Section 17
      Gastrointestinal/
      Abdominal
      • Gastrointestinal/Abdominal 1: Esophageal Varices Portal
    • Section 18
      Geriatrics
      • Geriatrics 1: General Aging Portal
    • Section 19
      Infection
      • Infection 1: Adult Pneumonia
      • Infection 2: Meningitis Portal
      • Infection 3: Sepsis in Adults Portal
      • Infection 4: Abdominal Sepsis Portal
      • Infection 5: Tetanus Immunization Status Portal
    • Section 20
      Neonatal
      • Neonatal 1: Neonatal Resuscitation Algorithm
      • Neonatal 2: Drugs in Neonatal Resuscitation
      • Neonatal 3: Meconium Suctioning Portal
      • Neonatal 4: Umbilical Artery and Vein Cannulation Portal
      • Neonatal 5: Inverted Triangle/Apgar Score Portal
      • Neonatal 6: Meningitis/Sepsis in Newborn Portal
      • Neonatal 7: Respiratory Distress Syndrome Scoring System Portal
    • Section 21
      Neurology
      • Neurology 1: Status Epilepticus Portal
      • Neurology 2: Stroke Portal
      • Neurology 3: NIH Stroke Scale Portal
      • Neurology 4: Phenytoin and Fosphenytoin Loading Portal
      • Neurology 5: Increased Intracranial Pressure Portal
    • Section 22
      Obstetrics
      • Obstetrics 1: Physiology of Pregnancy Portal
      • Obstetrics 2: Ultrasound Use Portal
      • Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
      • Obstetrics 4: Dilatation and Curettage Portal
      • Obstetrics 5: Fetal Heart Tone Monitoring Portal
      • Obstetrics 6: Preterm Labor Management Portal
      • Obstetrics 7: Bleeding in the Second Half of Pregnancy Portal
      • Obstetrics 8: Hypertension In Pregnancy Portal
      • Obstetrics 9: Trauma in Pregnancy Portal
      • Obstetrics 10: Emergency Cesarean Section Portal
      • Obstetrics 11: Imminent Delivery Portal
      • Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput Posterior Portal
      • Obstetrics 13: Assisted Delivery Portal
      • Obstetrics 14: Shoulder Dystocia Portal
      • Obstetrics 15: Third-stage and Postpartum Emergencies Portal
      • Obstetrics 16: Thromboembolic Disease and Pregnancy Portal
    • Section 23
      Pediatrics
      • Pediatrics 1: Physiologic and Anatomic Considerations Portal
      • Pediatrics 2: Tracheal Foreign Body Portal
      • Pediatrics 3: Epiglottitis Portal
      • Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
      • Pediatrics 5: Bacterial Tracheitis Portal
      • Pediatrics 6: Bronchiolitis Portal
      • Pediatrics 7: Pneumonia Portal
      • Pediatrics 8: Sepsis Portal
      • Pediatrics 9: Meningitis Portal
      • Pediatrics 10: Diphtheria Portal
      • Pediatrics 11: Glasgow Coma Scale Portal
      • Pediatrics 12: Intraosseous Vascular Access
    • Section 24
      Sedation/
      Pain Control/
      Anesthesia
      • Sedation/Pain Control/Anesthesia 1: Procedural Sedation
      • Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
      • Sedation/Pain Control/Anesthesia 3: Malignant Hyperthermia Portal
    • Section 25
      Toxicology
      • Toxicology 1: Systematic Approach
      • Toxicology 2: Essential Antidotes Portal
      • Toxicology 3: Acetaminophen Overdose Portal
      • Toxicology 4: Aspirin Overdose Portal
      • Toxicology 5: Tricyclic Antidepressants Overdose Portal
      • Toxicology 6: Beta Blocker Toxicity Portal
      • Toxicology 7: Calcium Channel Blocker Toxicity Portal
      • Toxicology 8: Bendodiazepine Overdose Portal
      • Toxicology 9: Alcohol Withdrawal Portal
      • Toxicology 10: Toxic Alcohols: Methanol and Ethylene Glycol
      • Toxicology 11: Cocaine Ingestion Portal
      • Toxicology 12: Narcotic Overdose Portal
      • Toxicology 13: Amphetamine Analog Intoxication Portal
      • Toxicology 14: Iron Ingestion Portal
      • Toxicology 15: Carbon Monoxide Poisoning Portal
      • Toxicology 16: Hyperbaric Oxygen and Normobaric Oxygen
      • Toxicology 17: Cyanide Poisoning Portal
      • Toxicology 18: Organophosphates Toxicity Portal
    • Section 26
      Trauma Care
      • Trauma Care 1: Shock Portal
      • Trauma Care 2: Shock Evaluation Overview Portal
      • Trauma Care 3: Use of Hemostatic Agents to Control Major Bleeding Portal
      • Trauma Care 4: Severe Traumatic Brain Injury—Adult 
      • Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
      • Trauma Care 6: Compartment Syndrome
    • Section 27
      Tropical Medicine
      • Tropical Medicine 2: Introduction
      • Tropical Medicine 3: Fever and Systemic Manifestations
      • Tropical Medicine 4: Gastrointestinal and Abdominal Manifestations
      • Tropical Medicine 5: Dermatological Manifestations
      • Tropical Medicine 6: Muscular Manifestations (Including Myocardium)
      • Tropical Medicine 7: Neurological Manifestations
      • Tropical Medicine 8: Ocular Manifestations
      • Tropical Medicine 9: Pulmonary Manifestations
      • Tropical Medicine 10: Urogenital Manifestations
      • Tropical Medicine 11: Disorders of Nutrition and Hydration
      • Tropical Medicine 12: Medicine in Austere Environs
      • Tropical Medicine 13: Antiparasitic Primer
      • Tropical Medicine 14: Concise Parasitic Identification
      • Tropical Medicine 15: Bibliography
    • Section 28
      Ultrasound
      • Ultrasound 1: Emergency Ultrasound Applications Portal
      • Ultrasound 2: Emergency Ultrasound Techniques Portal

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Cardiovascular 4: Endotracheal Drug Delivery

The endotracheal (ET) route for drug delivery may be used when a life-threatening or serious condition requires immediate drug intervention, but intravenous or intraosseous access is not readily available. While many medications are absorbed through the endotracheal route, it is uncertain if drug delivery via this route is clinically equivalent to intravenous/intraosseous administration. Blood levels achieved through endotracheal delivery may not be comparable to those produced by IV/IO administration, and optimal doses are unknown.1 Therefore, endotracheal administration of resuscitation drugs should be considered a second-line intervention utilized only if IV and IO access cannot be established in a timely manner.

Endotracheal Drugs

If vascular access is unavailable, the ET route may be used for the administration of certain drugs, including lidocaine, epinephrine, atropine, naloxone, and vasopressin.2-4

Remember the mnemonic NAVEL: or       LEAN (PEDS)
N-Naloxone
A-Atropine
V-Vasopressin (adults only)
E-Epinephrine
L-Lidocaine
L-Lidocaine
E-Epinephrine
A-Atropine
N-Naloxone

Endotracheal administration of medications other than those on this list may damage airway mucosa and is not recommended.1

Factors that Determine the Effectiveness of Endotracheal Drugs

  1. Method of Drug Delivery

In intubated patients, the ET delivered drug may be given either by direct injection of the solution down the ET tube or through a 5 French feeding catheter passed 0.5 cm beyond the distal tip of the ET tube. Some controversy exists regarding the degree of physiologic response when delivering a drug past the tip of the ET tube via a catheter placed through the ET tube.5,6 The American Heart Association (AHA) Guidelines recommend administration of the drugs directly down the endotracheal tube in adult and pediatric patients.1 No matter which method is used to deliver the drug, it is essential during resuscitation to stop chest compressions, spray the drug solution (adequately diluted) quickly down the tube, follow immediately with five manual ventilations to create a rapidly absorbed aerosol, and then resume chest compressions if necessary. Aerosolized sprays of drugs have been promoted as delivering the medications more distally and thus providing for more rapid absorption of drugs than solutions delivered in bolus form.7 While this may seem logical, this technique is cumbersome to accomplish in an arrested patient.

  1. Diluents Used With the Drugs

Various diluents used with an ET-delivered drug can affect the rate of absorption of a drug, the peak serum level attained by the drug, and the duration of therapeutic levels of the drug. Tracheal absorption is greater with distilled water as the diluent than with saline,8 but distilled water has a greater adverse effect on PaO2.9 Therefore, it appears to be safer to use saline as the diluent than to use distilled water.

  1. Volume

The most appropriate volume for ET drug delivery has not been determined. An insufficient volume may result in inadequate drug delivery and lack of the desired systemic effects. Placing an excess volume of solution into the ET tree may cause hypoxia or respiratory acidosis.2,9 Since many of the emergency drugs now come diluted in pre-filled syringes, this issue is frequently taken care of by the pre-diluted drug solutions that are available. AHA Guidelines1 suggest that in the adult the tracheal administered drug should be in 10 mL of solution and (PEDS) in pediatric patients the drug should be diluted up to 5 mL. The volume of solution (and the optimal drug doses) to give to neonates is unclear,10 but a reasonable volume to use is 2 mL.

  1. Drug Dosage

The true equivalent dose of drug delivered endotracheally versus intravenously is unknown. This controversy is apparent in the discrepancy in the AHA Guidelines for the drug doses to use for adults as opposed to (PEDS) pediatric or neonatal patients.4 For adults, the recommendation is to give all ET drugs at 2 to 2.5 times the recommended IV dose.1 PEDS: The recommended ET dose of epinephrine for pediatric patients is approximately 10 times the dose given via an IV route (Class IIb).4 The AHA Guidelines go on to state “it is logical to assume that doses of other resuscitation drugs administered tracheally should be increased compared with the IV dose.1"

  1. Duration of Drug Effect

Many studies2,5,11,12 have indicated that the duration of action of drugs given endotracheally is prolonged (depot effect) compared to the same drug dose given IV. Drugs where this depot effect has been observed include: epinephrine,5 atropine,11 and lidocaine.2

  1. The amount by which the kinetics of the drug is altered (if at all) when the drug is delivered endotracheally in shock/CPR is unknown.2

  2. The manner and the degree that accompanying diseases (like CHF, pulmonary edema, severe acidosis, COPD, or pneumonia frequently present in patients preceding cardiac and/or respiratory arrest) affect the absorption and physiologic response to drugs delivered to the respiratory tree is unknown.2

  3. The time interval from the ET administration of a drug until adequate physiologic response has not been adequately studied for many of the drugs used via the ET tube.2

  4. The maximum number of doses or the time interval between doses given via the endotracheal route has not been adequately studied.2

Specific Drug Observations and Recommendations:

Lidocaine: Current adult AHA Guidelines recommend4 that an ET-delivered dose of lidocaine of 2 to 4 mg/kg. For this ET dose to reach therapeutic levels takes 5 minutes and to reach peak levels takes 20 minutes. The level remains therapeutic for 30 to 60 minutes.13

Epinephrine: Current AHA Guidelines for ET use of epinephrine in an adult recommend4,14 using 2 to 2.5 times the standard IV dose of 1 mg (ET dose = 2 to 2.5 mg), while suggesting that the (PEDS) pediatric ET dose of epinephrine be increased by approximately 10 times the standard IV dose of 0.1 mL/kg of a 1:10 000 solution (0.01 mg/kg) (ET dose = 1 mL/kg of 1:10 000 solution or 0.1 mg/kg).4 For neonatal resuscitation, ET doses of epinephrine up to 0.1 mg/kg of a 1 to 10 000 (0.1 mg/mL) are suggested.4

Atropine: Current AHA Guidelines4 suggest that the recommended ET delivered dose of atropine be 2 to 2.5 the standard IV dose of 1 mg (ET dose= 2 to 2.5 mg). PEDS: AHA Guidelines4 suggest that the pediatric ET dose should be 0.04 to 0.6 mg/kg with a minimal dose of 0.1 mg.a

Naloxone: Human data on the use of naloxone ET is sparse to nonexistent. Current AHA Guidelines4 do not specifically give an adult dose for naloxone ET, but logic would suggest that the dose should be 2 to 2.5 times the standard IV/IO dose of 0.4 to 2 mg. PEDS: AHA Guidelines do not recommend ET use of naloxone in neonates; for pediatric patients, the AHA states that other routes are preferred.4 If used, a reasonable dose, based on 2 to 10 times the IV/IO dose of 0.1 mg/kg, would be 0.2 to 1 mg/kg. For a single dose, a maximum of 2 mg is consistent with standard dosing recommendations.

Vasopressin: The administration of vasopressin appears to be equally effective by ET and IV routes.3,15 No currently published studies clearly define the optimal dose of ET vasopressin. Therefore, at this time, using the standard IV dose of 40 units of vasopressin diluted with normal saline to 10 mL is reasonable. PEDS: There is no current recommendation for use of vasopressin in pediatric patients.

Conclusion
The administration of drugs via the ET route is an option in special situations in which IV/IO access cannot be obtained and critical medications must be given immediately. Continue to seek intravenous or intraosseous access and use in place of the ET route as soon as possible.

References

  1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S742, S881-S882.
  2. Ward JT Jr. Endotracheal drug therapy. Am J Emerg Med. 1983;1:71-82.
  3. Babbs CF, Berg RA, Kette F, et al. Use of pressors in the treatment of cardiac arrest. Ann Emerg Med. 2001:37:S152-S162.
  4. Hazinski MF, Samson R, Schexnayder S, eds. 2010 Handbook of Emergency Cardiovascular Care. Dallas, Tx: American Heart Association, 2010.
  5. Roberts JR, Greenberg MI, Knaub MA, Kendrick ZV, Baskin SI. Blood levels following intravenous and endotracheal epinephrine administration. JACEP 1979;8:53-56.
  6. Jasani MS, Nadkarni VM, Finkelstein MS, Mandell GA, Salzman SK, Norman ME. Endotracheal epinephrine administration technique effects in pediatric porcine hypoxic-hypercarbic arrest. Crit Care Med. 1994; 22:1174-1180.
  7. Beakey JF, Gaensley EA, Segal MS. Pharmacodynamics of pulmonary absorption in man; the influence of various diluents on aerosol and intratracheal penicillin. Ann Intern Med. 1949; 31:805-820.
  8. Courtice FC, Phipps PJ. The absorption of fluids from the lungs. J Physiol. 1946; 105:186-190.
  9. Greenberg MI, Baskin SI, Kaplan AM, Urrichio FJ. Effects of endotracheally administered distilled water and normal saline on the arterial blood gases of dogs. Ann Emerg Med. 1982; 11:600-694.
  10. Kleinman ME, Oh W, Stonestreet BS. Comparison of intravenous and endotracheal epinephrine during cardiopulmonary resuscitation in newborn piglets. Crit Care Med. 1999; 27:2748-2754.
  11. Elam JO. The intrapulmonary route for CPR drugs. In Safar P, Elam JO, eds. Advances in Cardiopulmonary Resuscitation. New York, NY: Springer Verlag Inc., 1977; 132.
  12. Kaplan SA, Jack ML, Alexander K, Weinfeld RE. Pharmacokinetic profile of diazepam in man following single intravenous and oral and chronic oral administration. J Pharm Sci. 1973;62:1789-1796.
  13. Collinsworth KA, Kalman SM, Harrison DC. The clinical pharmacology of lidocaine as an antiarrhythmic drug. Circulation. 1974;50:1217-1230.
  14. Aitkenhead AR. Drug administration during CPR: what route? Resuscitation. 1991:22:191-195.
  15. Wenzel V, Lindner KH, Prengel AW, Lurie KG, Strohmenger HU. Endobronchial vasopressin improves survival during cardiopulmonary resuscitation in pigs. Anesthesiology. 1997:86:1375-81.
Edition 13-October 2011

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