Medications in adult cardiac arrest. ARC and NZRC Guideline 2010.

Intravenous (IV) drug administration is preferable and IV access is quickly and most easily achieved via a peripheral cannula inserted into a large peripheral vein. If there are no visible peripheral veins, the external jugular vein should be considered. Lower limb veins should be avoided due to impairment of venous return below the diaphragm during cardiac arrest. Intravenous drug administration must be followed by a fluid flush of at least 20–30 mls and external cardiac compression. If a central line is present it should be used. Central access provides more rapid drug delivery but insertion of a new line may be difficult, takes time to establish and has major risks. [Class A; Expert consensus opinion] Intraosseous (IO) route: Intraosseous is the preferred route if intravenous access is not available. Two prospective trials in adults and children and 6 other studies documented that IO access is safe and effective for fluid resuscitation, drug delivery, and laboratory evaluation, and is attainable in all age groups. If IV access cannot be established, intraosseous (IO) delivery of resuscitation drugs will achieve adequate plasma concentrations. A number of devices are now available for use in adults. [Class A; Expert consensus opinion] Endotracheal route: If IV/IO access cannot be attained and an endotracheal tube is present, endotracheal administration of some medications is possible, although the absorption is variable and plasma concentrations are substantially lower than those achieved when the same drug is given by the intravenous route (increase in dose 3–10 times may be required). There are no benefits from endobronchial injection compared with injection of the drug directly into the tracheal tube. Dilution with water instead of 0.9% saline may achieve better drug absorption. Adrenaline, lignocaine and atropine may be given via endotracheal tube, but other cardiac arrest drugs should NOT be given endotracheally as they may cause mucosal and alveolar damage. This route cannot be used if a laryngeal mask airway is present. [Class A; Expert consensus opinion] Intracardiac injection: Intracardiac injection is not recommended because of the limited benefit and the high risk of complications.