The 6Rs – The Right Route

More Thoughts on the 6 R’s

There are numerous routes of drug administration prehospitally:

Inhaled (Nebulized)
Oral (PO)
Lingual or Sub Lingual
IV (Intravenous – rapid, slow, drip)
IO (Intraosseus)
IM (Intramuscular)
SQ (Subcutaneous)
ET (Down the tube)

Some would say rectal is the only wrong route. I have never given a drug this way, but I can see how in a dire situation and depending what drugs you carry, rectal would be the right route. Say you carried Diastat (rectal valium) and had a seizing baby. In basic EMT class, my teacher talked about squirting a tube of glucose in an unconcious patient’s rectum. I am glad I am no longer a basic. Like I said, I have never had to go this route.

The most serious wrong route which I have written about in Medication Errors – Epinephrine— is epi 1:1000 IV. It can be and often is fatal. We are guarding against this by requiring our services to carry epi-pens as their front line drug. Epi should only be given IV in the 1:10,000 concentration, and even then, unless the patient is already in cardiac arrest, it must be given very slowly. (0.1 mg Epi 1:10,000 over 2-3 minutes).

Years ago, when we gave epi 1:1000 we gave it SQ. Since the 2005 AHA guidelines came out we have been giving it IM on the theory that a person possibly undergoing peripheral shutdown will get the drug quicker and more effectively IM.

Also, years ago, I also almost always gave Narcan to unresponsive heroin addicts IV. You wanted an IV in case they didn’t wake up with the narcan, or even if they did, it was easier to get the IV when they were unresponsive than if they were awake and battling you. (The other side would say, why put in an IV when they are just going to wake up and rip it out before they stalk away.) There was the long running joke about getting an IV in the heroin addict, putting the narcan syringe in the IV and then waiting to slam it as you came through the ED doors so the junkie would puke on the mean triage nurse.

That was wrong then and it is wrong today.

I don’t know how it is where you practice, but I don’t see as much cowboy stuff as I used to. I once “hotwired” a patient. I had heard of this technique and wanted to be cool, so I drew up my narcan and instead of bothering to get an IV or even do the standard IM or SQ, I shot it right into the apneic patient’s EJ (external jugular) vein with predictable results. The patient woke up puked, oh, and they were now bleeding from the neck. Stupid. My argument was — this guy is not breathing, he needs the drug right now and the fastest way is to hotwire him. But what would have been the harm in taking out the ambu bag, giving him some breaths and then giving him a nice easy IM dose?

I like the IM or SQ route for the narcan. Let them wake up slower and easier. If I do do it IV, I always push very slowly, just a little at a time.

Many of our drugs we give IV, but — at least prehospitally — I find many medics push the drugs way too fast. The thinking may be we are out in the wild and have to get the work done so time applies to us differently. I have seen medics demonstrate their sixty second push. They say “One, two, three, sixty,” as they push the plunger in.

A rapid IV push is the wrong route when the drug is supposed to be given over 1-2 minutes. Most of the drugs we carry with the exception of adenosine and drugs for cardiac arrest should be pushed over 1-2 minutes and not slammed in.

When I QA run forms, one of the most frequent mistakes I see is medics giving Amiodarone rapid IV push to a patient in VT (with pulses). Medics think wow — this patient is in VT — I have to do something quick and slam it in, forgetting or not knowing perhaps that this can cause a sudden and critical drop in blood pressure. (I confess I did this myself the first time I gave it). Mix it and drip it in over 10 minutes. In the meantime if you need to shock the patient if they are deteriorating, shock them.

Just because we are prehospital doesn’t mean we can create our own rules for drug administration.

Zofran needs to pushed over 2-5 minutes. The medics questioned this and I asked our medical director, how about letting medics do it over a minute. His response was, “What does the manufacturer say? And what would you want for yourself, what the manufacturer says or what is convenient for a medic? It is not that hard to push a drug over two minutes. A little bit at a time or slow and steady while you chat with your patient.

When I gave morphine years ago, nearly all my patients felt sick and nauseous. I was pushing it too fast. Now I always push it slow, real slooooowwww. And while I like to give it IV, sometimes IM is the right route. For instance, my patient has a broken leg is lying in the middle of a football field. I can give IM morphine more quickly and get some pain relief started until I can move the patient to the ambulance where I can then do the IV. If the patient with the broken leg is lying on her living room floor, then it is easier to do the IV right there, unless the lighting is poor and the apartment roach invested. In that case I would say IM is the best initial route.

We also have permission now to mix our morphine in a small IV bag and drip it in. I tried that for the first time the other day. 5 milligrams in 100 cc. It was a great. The patient slowly became more and more pleasant and animated until she suddenly realized hey I feel pretty good. I forgot my leg was broken.

D50 is an IV push, but pushing it too fast can cause severe headache for patients, not to mention the thick drug can cause severe damage to their veins. We are also able to dilute our D50 to make it D25 or D10 and drip it in. Works great, much better for some patients.

Ativan. We carry it in the 2 mg/2 ml concentration. It needs to be diluted 1-1 with saline before you give it IV. Many don’t do this. I didn’t until someone showed me where it said right on the vial. IV use requires dilution. It was in black and white. Now that we have the EZ-IO, I never have to go ET (Down the Tube) with drugs in a cardiac arrest. I still hear of some medics using this route routinely. The thinking may be get the drug in as soon as possible. The problem is the drugs are very unreliable by that route and likely do not even work.

What does this all mean? If you are going to give a patient a drug — there is a right route for it. Your job as a medic is to decide what that best and safest route is and provide your patient with the best care possible.


The 6Rs – The Right Dose

The 6Rs – The Right Drug


  • Medic22 says:

    Great stuff Peter. I’ve also started diluting many of my drugs in a flush to make for a slower push. I learned the trick from an ED nurse and now I routinely draw up zofan, Ativan and Morphine in a 10cc flush and push it that way.

  • Angelmedic says:

    Like your comments regarding push rate and concur that we need to model best practices despite the environment we practice in. Another really good way to slow down your push is to aspirate initially, and again once or twice during the injection- depending upon the volume. We make aspiration prior to ANY push standard procedure with our training. I think the ET route should be banned. I “do it right” (vents first, stop compressions, vents again then resume CPR/vents) and still generally always got a lot of foam. Not to mention the potential damage of some of the vehicles (oily substances for example that some valium was prepared in) was not too healthy for the lung tissues.

  • Bill C. says:

    We’ve been experiencing great success with intranasal medication administration especially in a situation where immediate access needs to be delayed or can be avoided at all. In a painful injury we often will get orders to intranasally administer a dose of fentanyl and even versed prior to manipulating the patient during extrication when access is not easily achieved. Likewise our medical director prefers us to reverse opioid effects with nasal naloxone and in the case of an overdose, if the patient responds we withhold vascular access unless respiratory depression recurs.
    The dilution of almost any drug in a 10 mL flush also works great when calculating for pediatric dosing.
    Unfortunately I think the rapid push is a global issue. It starts with our students watching it done by medics, then doing it themselves as students without correction, progressing to acceptance that it is an accepted practice. It is an issue our unit struggles with constantly with many people thinking it is up for debate when those that manufacture and test the drug define the safe administration time.

1 Trackback

Leave a Reply

Your email address will not be published. Required fields are marked *