initiate and manage an iv

Initiate and Initiate and Manage an IVManage an IV

Initiate and Initiate and Manage an IVManage an IV

Department of Combat Medic Training

C168W055

Terminal Learning ObjectiveTerminal Learning Objective

Given a casualty requiring vascular access in a combat environment

establish vascular accessIAW Textbook of Basic Nursing, 7th Edition,

Rosdahl, Lippincott Chapter 63 principles Lippincott Manual of Nursing Practice,

Chapter 6, Prehospital Trauma Life Support Chapter7 and 21 and the principles of

Tactical Combat Casualty Care.

Safety NoteSafety Note*Everyone wears exam gloves and goggles.

*Place ALL needles in Sharp Containers after use.

Needles do not pierce skin unless an instructor is present. If you are unsure, WAIT!

*Inform Instructors if you suffer a Needlestick Injury.

*No one gets in trouble, the concern is your safety.

*OSHA says, “Needlestick injuries are wounds caused by needles that accidentally puncture the skin.”

Whether the puncture was with a clean needle or a used needle,

if the puncture was accidental, let an instructor know right away.

Enabling Learning Objective 1Enabling Learning Objective 1

Given the necessary equipment and a combat casualty requiring vascular access in a combat

environment,

prepare for vascular access,IAW Textbook of Basic Nursing, 7th Edition, Rosdahl,

Lippincott Chapter 63 principles Lippincott Manual of Nursing Practice, Chapter 6, Prehospital Trauma Life Support Chapter7 and 21 and the principles of

Tactical Combat Casualty Care.

.

VeinsVeins

Avoid veins that are infected, irritated,

injured or had an IV running proximal to the

proposed site.

"You may swim up the river, but not down the

river."

Basilic Vein

Median Cubital Vein

Cephalic Vein

Antecubital Fossa

Intraosseous Intraosseous

Bone marrow contains a network that immediately drains into the veins of the

cardiovascular system.

Any fluid or medication that can be administered through a vein can be

administered through an intraosseous (IO) infusion.

Intraosseous Intraosseous

Watch Videos:IO of Humerus into the Heart

IO of the Tibia

Intraosseous - WhenIntraosseous - When

Used when access through a vein is not possible or has been unsuccessful and the

individual requires fluid resuscitation immediately.

Small children

Trauma to extremities

Two unsuccessful IV attempts on a combat casualty. with an altered mental status and absent radial

pulses

Intraosseous - WhenIntraosseous - When

Intraosseous access is not recommended for dehydration casualties that have had two

unsuccessful IV attempts.

This casualty should be evacuated to a medical treatment facility.

Intraosseous - WhereIntraosseous - Where

For pediatric access, the proximal tibia is used because these bones have not fully hardened as

with adults.


The site of IO administration for combat casualties is the manubrium (upper portion of the sternum).


What is the advantage of training and having the supplies available to provide IO fluid

resuscitation to combat casualties specifically through the manubrium?

This area is protected by the casualty’s individual body armor, unlike the extremities.

Common Equipment - IVCommon Equipment - IV

Flash Chamber

Catheter

Hub

Needle

Needle Catheter


Needle Catheter

18 gauge is recommended for combat casualties

As the gauge increases, the diameter of the needle/catheter decreases.

Similar to hypodermic needles. (See Injections Lesson)


Saline LockAllows for ready access to the cardiovascular system

without having to administer fluids.

Connects to the catheter hub

Fluid or medications can be administered

through port


Transparent DressingSecures various parts of the IV or saline lock while still

allowing visualization of the access site.


Constricting BandPlace band with enough pressure to stop venous

return, but not arterial flow.


IV Tubing / Administration SetDifferent sizes based on the # of drops (gtts)

necessary to obtain 1 ml of fluid. Drops are counted through the clear drip chamber.

Drip ChamberDrip ChamberDistalDistalProximalProximal

Roller ClampRoller Clamp


IV BagsInspect IV bags for expiration date, bag is not ripped, torn or punctured and look at all ports

for leaks.

A small amount of condensation between the inner IV bag and the

outer container is acceptable.

The type of fluid should be verified with the MO orders similar to

any other medication.


IV BagsHold the IV bag to the light to check for foreign particles and changes in color and consistency.

Common Equipment - IOCommon Equipment - IO

Check on your Learning…Check on your Learning…

What is the criteria for administering an intraosseous infusion to a combat casualty?

Combat casualty with: Altered mental status and no radial pulse and two

unsuccessful IV attempts

Altered mental status and no radial pulse and trauma to the extremities.


What is the F.A.S.T 1 infusion tube and where is it located?

Remains in the bone after the F.A.S.T. 1 is deployed.

It is the tube the introduces the fluid to the body.

It is it located over the center needle of the needle cluster.


Given a combat casualty with vascular access in place,

manage complications of vascular access,

IAW Textbook of Basic Nursing, Rosdhahl, Lippincott Chapter 63.

InfiltrationInfiltration

Accumulation of fluid in the tissue surrounding an IV needle site

Caused by penetration of the vein wall by the

needle/catheter or later dislodgment.

The catheter is no longer in the vein.


Signs and Symptoms

Flow rate slower or stopped completely

Infusion site is cool, hard to the touch, pale & swollen

Casualty complains of pain, tenderness, burning, or irritation at infusion site

Fluid leaking around infusion site


Corrective Action

Stop IV infusion immediately, remove needle/catheter,

elevate extremity that had the IV

Apply warm compresses to encourage absorption

Notify supervisor of infiltration

Document observations and actions

Restart IV in another location, if directed


How can infiltration be prevented?

Tape catheter hub and tubing securely to limb

Stabilize extremity in use by applying arm board if necessary.

PhlebitisPhlebitis

Inflammation of the wall of the vein.

What are some of the causes of phlebitis?Injury to the vein during puncture

Irritation to vein as result of:

Long-term therapy (vein overuse)

Irritating or incompatible additive

Using large-bore catheters

Using lower extremities as IV sites

Infection

PhlebitisPhlebitis

Signs and SymptomsSluggish flow rate

Swelling around the infusion site

Casualty complains of pain and tenderness

Redness and warmth at the site and along the vein

Corrective actionStop IV infusion immediately

Report observations to supervisor

Restart IV in another site

Document

PhlebitisPhlebitis

PhlebitisPhlebitis

How can phlebitis be prevented?Keep infusion flowing at prescribed rate

Select large vein when irritating drugs/fluids are given

Change tubing IAW local SOP (usually about every 48 hours)

Change solutions and dressings IAW local SOP (usually about every 48 hours)

Change IV site as needed or IAW local SOP

Air Embolism Air Embolism

The obstruction of a blood vessel (usually occurring in the lungs or heart)

by air carried via the bloodstream.

How much air is necessary to cause an air embolism?

The minimum quantity is not known.

Animal experiments indicate fatal volumes are much larger than the quantity present in the entire length

of IV tubing (approx. 5 ml).


CausesFailure to remove air from the tubing

Allowing the solution to run dry

Disconnected IV tubing

Signs and SymptomsAbrupt drop in blood pressure

Weak, rapid pulse

Cyanosis

Chest pain


Corrective ActionNotify a medical officer immediately.

Immediately place patient on left side with feet elevated to allow the pulmonary artery to absorb

small air bubbles

Administer oxygen


What can be done to prevent air embolism?

Clear all air from tubing before attaching it to the patient

Monitor solution levels closely and change before they are empty

Check to see that all connections are secure

Circulatory Overload Circulatory Overload

An increased vascular volume resulting from excessive IV fluid being infused too

rapidly into the vein.

Caused by: Fluid delivered too fast

Reduced kidney function

Congestive heart failure or cardiac insufficiency


Signs and Symptoms

Elevated blood pressure

Distended neck veins (JVD)

Rapid breathing, shortness of breath, tachycardia, rhonchi or rales

Fluid intake is much greater than urinary output (I&O), unusual in healthy adults.


Corrective Action

Decrease flow rate to keep vein open (TKO)

Position of comfort to facilitate breathing

Notify medical officer immediately

Record observations and actions taken

Prevent circulatory overload by frequently checking the flow rate to maintain desired rate.

InfectionInfection

CausesUse of contaminated equipment

Poor aseptic venipuncture technique

Contaminated site

IV equipment not changed regularly

What might you observe that would lead you to believe a site was infected?

Redness, swelling, soreness or drainage from site.

Patient c/o chills, fever, malaise

Sudden rise in temperature and pulse

InfectionInfection

Corrective Action

Notify medical officer immediately

Discontinue IV

After a wound culture is taken, use strict aseptic technique to clean and dress the wound

Document

InfectionInfection

How can infection be prevented?

Use strict aseptic technique when starting an IV

Clean site thoroughly when IV is initiated and then periodically IAW local SOP to prevent infection

Anchor catheter and tubing securely

Check site at least daily for signs of inflammation IAW local SOP


Describe an infiltrated site.

Cool, hard to the touch, swollen, pale, fluid leaking

from the site


While a fellow medic is cleaning up after an IV placement, the patient begins to

complain of chest pain. You have a hard time finding a radial pulse. What should you immediately consider the problem to

be and what is the corrective action?

Air Embolism

Immediately place the patient on his left side with feet elevated.

Notify a MO and administer oxygen.


Given a casualty requiring vascular access,

initiate vascular access,IAW Prehospital Trauma Life Support

Chapter 7 and 21.

Demonstrations and

Practical Exercises

Saline Lock and Fluid Resuscitation F.A.S.T. 1

Direct IV Access, Fluid Resuscitation and Saline Lock Conversion


Given a casualty with vascular access in place,

manage vascular access,IAW Textbook of Basic Nursing, Rosdhahl, Lippincott Chapter 6 and IAW the principles

Lippincott Manuel of Nursing Practice, Chapter 6.

Prehospital SettingPrehospital Setting

What is a dirty stick?Any IV catheter placed in the prehospital setting.

The IV catheter will be replaced once the casualty has reached a MTF

taken in the interest of the casualty and to avoid the possibility of a future infection.

What considerations of vascular access management change in the prehospital

setting?Aspects of documentation

Manage Vascular Access at the MTFManage Vascular Access at the MTF

Replace the Solution ContainerWhen should the container be replaced?

IAW local SOP (Commonly every 24 hours when running a slow

infusion).

Before the solution container runs completely out.


Replace the Tubing When should the tubing be replaced?

IAW local SOP (Commonly every 48 hours)

Changing the tubing should coincide with the time the solution container will be changed.


Replace a CatheterWhen should a catheter be replaced?

When receiving the casualty from the prehospital environment a new catheter site is

normally achieved before any prehospital sites are removed.

In the hospital setting, the site should be changed IAW local SOP (Commonly every 72 hours).

Coincide with the time the solution container and tubing will be changed when possible.


In groups of three and with the information in your student handout,

each individual choose 1 of the following procedures to study and teach the other members of your

group:

Replace the Solution ContainerReplace the Tubing Replace a Catheter

You have three minutes to study and one minute to present your findings to the group.

Calculate an IV Flow RateCalculate an IV Flow Rate

Information required to determine flow rate:


Volume to be infused X Drops/ml of infusion setTotal time of infusion in minutes


SFC Murray received a physician's order to administer an intravenous infusion.

The order states the total volume of 1000 ml is to be delivered over a 4-hour period.

The IV set used will deliver 20 drops per milliliter.

How many drops per minute should be administered?


Total volume to be infused = 1000 ml.

Infusion set (drops/ml) = 20

Total time of infusion = 240 min (4 hrs X 60 min)


Volume to be infused X Drops/ml of infusion setTotal time of infusion in minutes

1000 ml X 20 gtts/ml =240 min

83.33 round to 83 gtts/min


When completing an IV in the prehospital setting, how is the intervention documented?

Location and size of the IV catheter should be written within the casualty’s documentation.

CPT Smith’s IV is ordered at 150 ml to be delivered over 1 hour. The administration set being used delivers 20 gtts/ml. Calculate the

drops/minute to be administered.

50 gtt/min


Mr. Cadiz has an order for 1000 ml of D5W. The administration set delivers 10 gtts/ml.

Calculate the flow rate of the fluid to be infused over 4 hrs and 2 hrs.

4 hrs = 41.66 or 42 gtts/min

2 hrs = 83gtts/min

SummarySummary

Doctor’s Order: Give 1000 ml. RL in 3 hrs. The IV was started at 0900; the IV was regulated to flow at 83 gtts/min. Upon checking the bottle at 1000, you find 800 ml left in the bottle. Available drip rate set is 15 gtts/ml. Though the initial order was to infuse IV fluid over 3 hrs, but you notice after one hour has gone by that you still have 800 ml left to infuse over

2 hrs.

100 gtts/min

Questions?

initiate and manage an iv

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