Routes Of Access

Historically in ACLS, providers have administered drugs via the intravenous (IV) or the ET route. ET absorption of drugs is poor, and optimal drug dosing is unknown. Therefore, the intraosseous (IO) route is now preferred when IV access is not available. Below are the priorities for vascular access.

INTRAVENOUS ROUTE

A peripheral IV is preferred for drug and fluid administration unless central line access is already available. Central line access is not necessary during most resuscitation attempts, as it may cause interruptions in CPR and complications during insertion. Placing a peripheral line does not require CPR interruption.

If a drug is given via peripheral route of administration, do the following:

1. Intravenously push bolus injection (unless otherwise indicated).
2. Flush with 20 mL of fluid or saline.
3. Raise extremity for 10 to 20 seconds to enhance delivery of drug to circulation.

INTRAOSSEOUS ROUTE

Drugs and fluids can be delivered safely and effectively during resuscitation via the IO route if IV access is not available.

IO access can be used for all age groups, can be placed in less than one minute, and has more predictable absorption than the ET route.

When using peripheral IV route of administration, drugs can take up to two minutes or more to reach central circulation. The effect of medications given may not be seen until even longer. High-quality CPR helps circulate these drugs and is an important part of resuscitation.

Any ACLS drug or fluid that can be administered intravenously can also be given intraosseously.

If possible, administer any medication IV or IO early in any two-minute CPR segment.