2014 aemt introduction to iv administration and med administration

Ada County ParamedicsEducational Outreach

VASCULAR ACCESS UPDATE

Advanced EMT introduction to Vascular Access

Objectives

Describe the basic distribution of fluids in the body

Discuss the basic role of Vascular access in EMS

Identify the main types of IV solutions encountered by EMS

Identify the basic equipment used by EMS to establish IV and IO access.

Basic Physiology of Fluid

KEY POINT:

We will actually go into a LOT of detail on fluids and shock later in the ..FLUIDS and SHOCK Lecture.

Water…Its good for you!

Total Body Water (TBW): approx. 60-70% of total body mass. Higher the younger you are

Quick Exercise

Did you know that 1 kg of water = 1 liter of water?

What is your weight in Kg?

Weight in Kg x 0.6 = estimated TB H2O in liters

Distribution of Fluids

Intracellular Fluid (ICF): The amount of water that’s inside our cells accounts for 2/3rds of our TBW.

Extracellular Fluid (ECF): The amount of water that surrounds our cells accounts for 1/3 of our TBW.  ECF is also known as interstitial fluid because it’s the fluid in between the cells.

Mnemonic to help you remember which is 1/3rd and 2/3rd:  ECF and ICF.  E comes before I in the alphabet, so E is 1/3rd and I is 2/3rd. ICF = 2/3 X TBW.  For example, 2/3 x 41L = 27L

ECF = 1/3 X TBW.  For example, 1/3 x 41L = 14L

Distribution of fluids

Extracellular Fluids

 ECF is also known as interstitial fluid because it’s the fluid in between the cells. Sometimes called the “third Space”

Tissue fluid: 2/3rd of ECF

Blood plasma: 1/3rd of ECF

Transcellular fluid: Often not calculated as a fraction of the extracellular fluid, but it is about 2.5% of TBW.

How much blood?

Blood is made up of blood cells and blood plasma.

TBV = 8% x Body Weight (kg).  Remember, we can calculate volume from mass

without a problem because that’s the beauty of the metric system (1.0kg water = 1.0L water)

Another quick exercise

Normally about 20% blood loss is an indication for IV fluid resuscitation (in addition to other indicators of shock, like your vital signs).

So take 8% of your TBW… That’s your total blood volume.

Figure up : 10% of total blood volume

15% of total blood volume

30% of total blood volume

40% of total blood volume

Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 2000 or more

Blood Loss (%BV)

Up to 15% 15-30% 30-40% >40%

HR 100 100 120 140 and up

BP Normal Normal Decreased Decreased

PP (mmhg) Normal-inc. Decreased Decreased Decreased

Refill Normal Positive Positive Positive

RR 14-20 20-30 30-40 >40

Urine OP ml/hr 30ml 20-30 5-15 Negligible

CNS Slightly anxious

Mildly anxious Anxious & confused

Confused-lethargic

Fluid replacement 3:1

Crystalloid Crystalloid Crystalloid & Blood

Crystalloid & Blood

Emergency War Surgery, NATO Handbook: part II

Remember that exercise?

Figure up : <15% of total blood volume – Class 1 shock

15%- 30% of total blood volume – Class II Shock

30% - 40% of total blood volume – Class III Shock

> 40% of total blood volume – Class IV Shock

Now do the same for a child….

TBW in KG

TBV = 8% x Body Weight (kg).

10% of total blood volume

15% of total blood volume

30% of total blood volume

40% of total blood volume

Ridley – 30 Pounds

COMMON SOLUTIONSIV Solutions

PURPOSE:

Four major indications for IV access: Replace fluids

Administer Blood Products

Route for administration of medications

Anticipated need for any of above

Question?

What is Bioavailability?

What is the considered “Onset” of bioavailability of medications administered via the IV route?

What is the % of bioavailability of medications administered via the IV route?

IV Solutions

Solutions are comprised of fluid (the solvent) and particles (the solute) dissolved in the fluid.

Water is the body's primary fluid and is essential for proper organ system functioning and survival. Although people can live several weeks without food, they can survive only a few days without water.

CLASSES OF IV FLUIDS:

Colloids: High molecular

weight Proteins that

do not diffuse across the CM

Colloid osmotic pressure

Volume expanders

$$$$ and short shelf life

Crystalloids: Water and

electrolytes The

electrolytes will readily diffuse across from the vascular space into the tissues

Used is pre-hospital environment

Other Methods of Classification

H Y P O T O N IC F L U ID S IS O T IO N IC F L U IDS H Y P E R T O N IC F L U ID S

IV F L U ID S

Key Point:

Osmolarity and Tonicity

The “Tonicity”: mainly refers to the Sodium and Dextrose content

ISOTONIC FLUIDS

Electrolyte composition is similar to plasma

When administered to normally hydrated patient, there is no appreciable fluid or electrolyte shift

HYPERTONIC FLUIDS

Higher solute level than plasma

Cause fluid to shift from IC to EC space

Hypotonic Fluids

Lower solute level than plasma

Cause fluid to shift from Extracellular to Intracellular and Intersticial space

LACTATED RINGER’S SOLUTION / HARTMANN’S SOLUTION

Class: Isotonic crystalloid

Description: One of the most frequently

used IV fluids in hypovolemic shock.

Contains: Sodium (Na+) 130 mEq/L

Potassium (K +) 4 mEq/L

Calcium (Ca2+) 3 mEq/L

Chloride (Cl-) 109 mEq/L

Lactate

(Lactic acid) 28 mEq/L

LACTATED RINGER’S SOLUTION / HARTMANN’S SOLUTION

Indications: Hypovolemia/KVO

Contraindications: CHF, renal failure

Administration: Crystalloids diffuse

out of the vascular space in <1hr. 3:1 ratio

0.9 PERCENT SODIUM CHLORIDE / NORMAL

SALINE Class: Isotonic crystalloid

solution

Description: Concentration of

sodium is near that of blood

Contains: Sodium (Na+) 154 mEq/L

Chloride (Cl-) 154 mEq/L

0.9 PERCENT SODIUM CHLORIDE / NORMAL SALINE

Indications: Heat problems Freshwater

drowning Hypovolemia DKA KVO

5% Dextrose in .9% Sodium Chloride (D5NS)

Class: Hypertonic crystalloid

Indications: Heat disorders,

freshwater drowning, hypovolemia, peritonitis

Cautions: May cause venous

irritation

5% Dextrose in Lactated Ringer’s Solution (D5LR)

Class: Hypertonic crystalloid

Indications: Hypovolemia Hemorrhagic shock Some cases of

acidosis

While we are talking about IV fluids….

From our friends in the military: Hetastarch

Colloid

Big Bang in a small package

“Colloid Pulling Power”

Hypertonic Saline

Crystalloid

“Pulls Fluid” Osmotic Pulling Power

Common IV equipment

Main routs of Vascular Access

Peripheral Lines Include: Hands Feet External Jugulars

Central Lines Include: Femoral (Groin) Internal Jugular (neck) Subclavian

Intraosseous Tib/Fib Ankle Sternum Humerous

A lot of changes…

What we do now:

Single Lumen Catheters

Twin Catheters

Central Lines

Intraosseous: EZ-IO

Pediatric / manual IO

Single Lumen IVs

Traditional Quick Good for 24-72

hours

Multi-Lumen IVs

Two (or more) lines in one IV site

Able to give multiple medications that are not compatible

Very useful in STEMI and Acute CVA patients

Peripheral IV Access Sites

Packaging of IV Fluids

Most packaged in soft plastic or vinyl bags.

Container provides important information: Label lists fluid type and expiration date.

Medication administration port.

Administration set port.

IV Solution Containers

Do not use:any IV fluids after their expiration date;

any fluids that appear cloudy, discolored, or laced with particulate;

or any fluid whose sealed packaging has been opened or tampered with;

Any fluids with red writing on the package

Just because there is no red writing does not mean its “safe” to give!

IV Administration Sets

Macrodrip—10 gtts = 1 ml, for giving large amounts of fluid.

Microdrip—60 gtts = 1 ml, for restricting amounts of fluid.

Blood tubing—has a filter to prevent clots from blood products from entering the body.

Measured volume—delivers specific volumes of fluids.

IV extension tubing—extends original tubing.

Electromechanical pump tubing—specific for each pump.

Miscellaneous—some sets have a dial that can set the flow rates.

IV Administration Sets (continued)

Macrodrip and Microdrip Administration Sets

Secondary IV Administration Set

Measured Volume Administration Set

Intravenous Cannulas

Over-the-needle catheter

Hollow-needle catheter

Plastic catheter inserted through a hollow needle

Over-the-Needle Catheter

Hollow-Needle Catheter

Catheter Inserted Through the Needle

Peripheral IV Access

Place the constricting band

Cleanse the venipuncture site

Insert the intravenous cannula into the vein.

Withdraw any blood samples needed.

Connect the IV tubing.

Secure the site.

Label the IV solution bag.

IV Access Complications

Pain Local infection Pyrogenic

reaction Catheter shear Inadvertent

arterial puncture

Circulatory overload

Thrombophlebitis Thrombus

formation Air embolism Necrosis Anticoagulants

Intraosseous

A lot of changes…

What we do now:

Single Lumen Catheters

Twin Catheters

Central Lines

What is coming: EZ-IO

Single Lumen IVs

Traditional Quick Good for 24-72

hours

Multi-Lumen IVs

Two (or more) lines in one IV site

Able to give multiple medications that are not compatible

Very useful in STEMI and Acute CVA patients

Central Lines

Better Access More complications More difficult Infection Compressible??

Intraosseous

A rigid needle is inserted into the cavity of a long bone.

Used for critical situations when a peripheral IV is unable to be obtained.

Typically initiated after 90 seconds or 2-3 unsuccessful IV attempts

Intraosseous

Vasculature always there, even in shock

Less difficulty than Central lines

Only good for 24 hours

Easier to train More costly

Traditional IO (Pediatric)

Traditional Intraosseous Needle

Traditional Intraosseous Needle

Not so traditional …

EZ IO

IO Indications….

A life or limb threatening condition exists. -Severe Volume depletion (dehydration or

hemorrhage) -Circulatory collapse -Cardiac arrest -Medication route if no other access is

available A peripheral IV cannot or is unlikely to be

established. Delay in administration of fluids or

medications may increase risk to the patient.

IO placement – All types

https://www.youtube.com/watch?v=0roDPk-VpAo&feature=player_embedded

6 Common mistakes with IO

https://www.youtube.com/watch?v=YXfyL8kvFTg&feature=player_embedded

Central venous AccessJUST AN FYI BIT…

Some other kinds of vascular access you will see in the field…

Central Lines

PICC Line

IVADD (Port-o-Caths)

Central Lines

Better Access More complications More difficult Infection Compressible??

PICC

“Peripherally inserted central catheter”

Can be single or multi lumen.

Used for extended home TPN

Home health care use Administration of meds

and fluids Used when repeated IV

sticks would be necessary

IVADs

Portacath-Inserted in the chest below the clavicle.Access is gained by puncturing the skin then the synthetic port

Permacath-Lasts longer.Up to a year

Passport-Placed in the arm instead of chest.Cheapest

IVAD

Can AEMTs access Central Venus devices?

In short: no…

Key Concerns:

Sterile Technique

Heparin in line

Damage to the CV device

Specialized equipment.

Aterial-Venous Fistula’s

A fistula is defined as an abnormal opening between body parts. In the case of an arterio-venous fistula (AVF), a surgeon creates a passageway or merge between an artery and vein, thereby allowing for an easier target vein to use for access.

Most commonly used for dialysis patients

Injections

Routes of Medication Administration

Parenteral medication: administration of a medication by injection into body tissues

Subcutaneous (SC) – into tissue below dermis of skin

Intramuscular (IM) – into the body muscle

Intravenous (IV) – into a vein

Intradermal (ID)– into the dermis just under the epidermis

What is an injection?

Injections are sterile solutions, emulsions or suspensions.

They are prepared by dissolving, emulsifying or suspending an active ingredient and any other substances in water for injection.

Injecting is the act of giving medication by use of syringe and needle to obtain the desired therapeutic effect taking into account the patients safety and comfort

How are drugs for injections presented?

Single dose preparations a pre - prepared volume of measured drug, in a syringe for single dose use i.e. Flu vaccines, Pneumovax and B12.

Multidose preparations multi-dose preparations contain a antimicrobiacteral preservative, are used on more than the one occasion and great care is required for its administration but especially it’s storage between successive withdrawals i.e Insulin

Why give drugs in injection form?

Injections usually allow rapid absorption

Can produce blood levels comparable to those of intravenous bolus injections

Injections can be given from 1ml and up to 2 mils in the Deltoid and up to 3 mls in the gluteal muscle in adults

Drugs that are altered or not absorbed by other methods of administration

Needle length and size

For intramuscular injections e.g flu, pneumonia and B12, the needle should be long enough to penetrate the muscle and still allow a quarter of the needle to remain external to the skin

When choosing the needle it is important to assess the amount of muscle, subcutaneous fat and weight of the patient - which in the majority of cases will be a blue needle

Syringes

Three main parts:– Barrel – chamber that holds the

medication– Plunger – part within the barrel that

moves back and forth to withdraw and instill medication

– Tip – part that the needle is attached toCalibration:

– Syringe sizes from 1 ml to 50 ml– Measure to a 1/10th or 1/100th depending

on calibration

Needles

Shaft of the needle– Length chosen depends on the depth

to which medication will be instilled– Tip of shaft is beveled or slanted to

pierce the skin more easily

Gauge: width of the needle (18 – 27 gauge) – a smaller number indicates a larger diameter and larger lumen inside the needle

Considerations when choosing a syringe and needle

Type of medicationDepth of tissue penetration

requiredVolume of medicationViscosity of medicationSize of the client

Parenteral Administration

Equipment Syringes

Syringe consists of a barrel, a plunger, and a tip.

Outside of the barrel is calibrated in milliliters, minims, insulin units, and heparin units.

Types Tuberculin syringe

Insulin syringe

Three-milliliter syringe

Safety-Lok syringes

Disposable injection units

Parts of a syringe

Parts of a syringe.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Dose?

Calibration of U100 insulin syringe.

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Dose?

Reading the calibrations of a 3-mL syringe.

TB Syringe

Safety-Glide syringe.

The pointy end

Parts of a needle.

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Equipment for the administration of injections

Clean tray/area in which to place drug and equipment

21g needle to ease reconstitution and drawing up

(Filter Straw if from a glass ampoule

Syringe of appropriate size

Swabs saturated with isopropyl alcohol 70%

Sterile topical swab if drug is presented in ampoule form

Drug to be administered

Patients prescription to check dose, route and timing

Notes available to record administration in accordance with law

Gloves

Asepsis and reducing the risk of infection

Good hand washing

Good hand drying

Aseptic technique

Good observation and questioning of the client

Skin preparation if required

INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS

Most often used for PPD

Site: the inner aspect of the forearm

Needle size is 25 - 27 gauge, 1/2 to 5/8 inch

Insert needle at 15o angle

Injection made just below the outer layer of skin

If injection does not form a wheal or if bleeding is noted, the injection was probably too deep and should be repeated

Review the provider’s order for accuracy

Ask the patient/parent if the patient is allergic to the medication

Wash your hands and gather supplies, equipment

Select proper needle size, length and gauge

INTRADERMAL INJECTIONS

Explain procedure to patient/parent

Ask for assistance with children

Position patient appropriately

Prepare injection site with alcohol - air dry

Support skin with thumb

With bevel up, completely insert bevel at a 15 o

angle

INTRADERMAL INJECTIONS

Inject medication gently, place a cotton ball over the site after needle removal

A visual wheal will be produced at the site

Dispose of needle as per policy

Wash hands

Document procedure and patient’s response

INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS

Correct Technique Tip of needle can be seen

directly beneath the surface of the skin

Resistance should be felt

when medication is

injected

Tense white wheal 5-10

mm in diameter appears at the point of the needle

Incorrect Technique Little resistance and a shallow bulge

Needle inserted too deep

- will cause an induration

that is difficult to measure

and interpret

Subcutaneous injection

SQ Injections

Many immunizations are given SQ

Insulin and Lovinox are some of the most common drugs in the subcutaneous injections for clinical use

Epi and Brethine used to be the most common in EMS

SQ is seldom used anymore in EMS IM is believed to be more reliable in critical

patients due to poor perfusion of SQ space.

Sites for SQ Administration

SUBCUTANEOUS INJECTION

Subcutaneous injection. Angle and needle length depend on the

thickness of skinfold.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

INTRAMUSCULAR INJECTION

IM Injections

Surprisingly common in EMS

EPI IM for anaphylaxis

Most other auto injectors are IM

Other meds when IV access is not practical (and IO is not practical , desirable , or available) Narcan

Anti-emetics

Pain meds

Anti-convulsants

Intramuscular injections

Gauge-20-22

Length-1-1 ½ inches

Angle-90 degrees

Darting motion

ASPIRATE

Intramuscular injections Intramuscular Injections

Involves inserting a needle into the muscle tissue to administer medication

Site Selection

Gluteal sites

Vastus lateralis muscle

Rectus femoris muscle

Deltoid muscle

Z-track Method

Used to inject medications that are irritating to the tissues

INTRAMUSCULAR INJECTION

IM INJECTION SITES

Deltoid Up to 2 ml

Dorsogluteal Up to 3 ml

Ventrogluteal Up to 2 ml

Vastus lateralis Up to 3 ml

DELTOID MUSCLE

GLUTEUS MAXIMUS

Locating right dorsogluteal site. Giving IM

injection in left dorsogluteal site.

(C, D, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

GLUTEUS MEDIUS

Locating IM injection for ventrogluteal site.

(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Institute of Nursing T

heory and Practice, P

rague 2007

VASTUS LATERALIS

Giving IM injection in vastus lateralis site on

adult.

Giving IM injection in vastus lateralis site on adult.

(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Intramuscular Injections and Pain

Factors that can cause pain are

The needleThe techniqueThe speed of the injection The solution and composition of the drugThe volume of the drug The approach and attitude of person administering the injection

Comparison of ID, SQ and IM

Angles of insertion for intramuscular (90°), subcutaneous (45°), and intradermal (15°).

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

QUESTIONS?

THANK YOU!