Alternatives for Medication Administration When IV Access Cannot Be Obtained

Introduction to Alternative Access Routes

The American Heart Association recommends intraosseous (IO) access as the preferred alternative route for medication administration in emergency situations, as it provides drug delivery comparable to peripheral IV access and can be established rapidly without interrupting critical interventions 1

IO cannulation provides access to a noncollapsible venous plexus, enabling drug delivery similar to peripheral venous access at comparable doses, according to the American Heart Association 1
The American Society of Anesthesiologists suggests that preferred insertion sites for IO access are the tibia and the humerus 2, 3
IO access is faster to establish than central venous access and can be used for resuscitation fluids, drugs, and blood sampling, as stated by the American Society of Anesthesiologists 2, 4
Commercially available manual and automated devices facilitate IO placement in all age groups, according to the American Heart Association 1, 2

The American Academy of Pediatrics notes that intramuscular (IM) administration is less preferred than IV/IO routes because it does not allow for medication titration and is painful at delivery 5
The American College of Emergency Physicians states that for acute agitation without IV access, IM lorazepam or IM haloperidol can be used, but diazepam IM is not recommended due to erratic absorption, however this information is from Praxis Medical Insights and will be replaced with a more authoritative source if available 6
Alternative routes including intranasal, transdermal, and inhaled medications offer rapid relief comparable to IV opioids for pain management, according to the American Academy of Pediatrics 5

The American Society of Anesthesiologists advises against routine peripheral cannula changes at 72-96 hours, as this is not advocated 2, 3
The American Heart Association recommends that when administering drugs via peripheral IV during resuscitation, follow with a 20-mL bolus of IV fluid and briefly elevate the extremity to facilitate central circulation delivery 1, 7
The American College of Emergency Physicians states that respiratory monitoring is crucial when administering benzodiazepines via any route, with reversal agents readily available, however this information is from Praxis Medical Insights and will be replaced with a more authoritative source if available 6