Medication Medication AdministrationAdministrationNovember 2009 CENovember 2009 CE

Advocate Condell Medical Advocate Condell Medical CenterCenter

Objectives prepared by: Mike Higgins, FF/PMObjectives prepared by: Mike Higgins, FF/PM Grayslake Fire DepartmentGrayslake Fire Department

Power point prepared by Sharon Hopkins, RN, BSN, EMT-PPower point prepared by Sharon Hopkins, RN, BSN, EMT-P

ObjectivesObjectivesUpon successful completion of this module, Upon successful completion of this module,

the EMS provider will be able to:the EMS provider will be able to:

1. Identify the six rights of drug 1. Identify the six rights of drug administration correctly administration correctly

2. Identify medical control’s role in drug 2. Identify medical control’s role in drug administration administration

3. Identify knowledge of proper use of 3. Identify knowledge of proper use of standard precautionsstandard precautions

4. Identify knowledge of proper disposal of 4. Identify knowledge of proper disposal of contaminated equipmentcontaminated equipment

5. Identify the importance of maintaining a 5. Identify the importance of maintaining a sterile and clean environment sterile and clean environment

ObjectivesObjectives 6. Accurately calculate the drug dosage for 6. Accurately calculate the drug dosage for

a pt with weight stated in pounds, a pt with weight stated in pounds, converting weight to kilogramsconverting weight to kilograms

7. Identify the various routes used to 7. Identify the various routes used to administer medicationadminister medication

8. Identify the proper technique for 8. Identify the proper technique for drawing up meds from an ampule drawing up meds from an ampule

9. Identify the proper technique for 9. Identify the proper technique for drawing up meds from a vialdrawing up meds from a vial

10. Identify the proper administration of a 10. Identify the proper administration of a medication from a prefilled syringe medication from a prefilled syringe

ObjectivesObjectives 11. Identify the proper administration of 11. Identify the proper administration of

sub-lingual medicationssub-lingual medications 12. Verbalize the proper administration of 12. Verbalize the proper administration of

rectal medicationsrectal medications 13. Identify the proper administration of IV 13. Identify the proper administration of IV

piggy-back medicationspiggy-back medications 14. Identify the proper administration of 14. Identify the proper administration of

in-line nebulizer medications in-line nebulizer medications 15. Identify the proper administration of 15. Identify the proper administration of

endotracheal medicationsendotracheal medications

ObjectivesObjectives 16. Identify proper documentation of 16. Identify proper documentation of

medication administrationmedication administration 17. Demonstrate the proper administration 17. Demonstrate the proper administration

of subcutaneous medicationsof subcutaneous medications 18. Demonstrate the proper administration 18. Demonstrate the proper administration

of intramuscular medicationsof intramuscular medications 19. Demonstrate proper administration of 19. Demonstrate proper administration of

intravenous medications / IO medsintravenous medications / IO meds 20. Demonstrate the insertion of the EZ-IO 20. Demonstrate the insertion of the EZ-IO

correctly correctly

6 Right of Medication 6 Right of Medication AdministrationAdministration

The The RIGHTRIGHT patient patient In the field this is the patient lying in In the field this is the patient lying in

front of youfront of you When doing clinical in the hospital, it is When doing clinical in the hospital, it is

extremely important to check wrist extremely important to check wrist bands for identifying the right patientbands for identifying the right patient

The The RIGHTRIGHT drug drug Check all medications 3 times prior to Check all medications 3 times prior to

administrationadministration Did you grab the correct medication?Did you grab the correct medication?

6 Rights6 Rights

The The RIGHTRIGHT dose dose Most field medications can be easily Most field medications can be easily

calculated in your headcalculated in your head Double check if you are ever unsure of Double check if you are ever unsure of

the dosethe dose The The RIGHTRIGHT time time

In the field the time is nowIn the field the time is now

6 Rights6 Rights

The The RIGHT RIGHT routeroute IV/IOIV/IO InjectedInjected

IMIM SQSQ

InhaledInhaled IVPBIVPB

6 Rights6 Rights The The RIGHTRIGHT documentation documentation

Drug nameDrug name Dose – verify order in mgDose – verify order in mg

Dose often stated in ‘amps”, “tab”Dose often stated in ‘amps”, “tab” Route of deliveryRoute of delivery Time administeredTime administered Person administering the medicationPerson administering the medication

Use skill check boxUse skill check box Patient response to the medicationPatient response to the medication

AllergiesAllergies

Important to screen all patients for Important to screen all patients for their allergy status prior to their allergy status prior to medication administrationmedication administration

If you are in doubt regarding an If you are in doubt regarding an allergic reaction versus side effect allergic reaction versus side effect (ie: abdominal distress), contact (ie: abdominal distress), contact medical control for clarificationmedical control for clarification

Facts and AllergiesFacts and Allergies Lidocaine and NovocainLidocaine and Novocain

These are different “caine” families so These are different “caine” families so allergy to one does not cross over to the allergy to one does not cross over to the otherother

Morphine sulfate Morphine sulfate This is NOT a sulfa drugThis is NOT a sulfa drug

Lasix – furosemideLasix – furosemide There is a There is a lowlow risk of patients allergic to risk of patients allergic to

sulfa drugs having a reaction to Lasixsulfa drugs having a reaction to Lasix Monitor the patient receiving Lasix if Monitor the patient receiving Lasix if

they have a sulfa allergythey have a sulfa allergy

Medical ControlMedical Control

You operate under the license of the You operate under the license of the Medical DirectorMedical Director

You are still individually responsible You are still individually responsible for having knowledge of the for having knowledge of the medications you are deliveringmedications you are delivering

Inappropriate delivery of Inappropriate delivery of medications, even when the patient medications, even when the patient does not suffer harm, may result in does not suffer harm, may result in legal ramificationslegal ramifications

Medical ControlMedical Control Medical control is available as an on-Medical control is available as an on-

line resourceline resource Clarification regarding indicationsClarification regarding indications Clarification regarding dosageClarification regarding dosage Clarification regarding orders received Clarification regarding orders received

from a physician on the scenefrom a physician on the scene In an acute care center, clinic, doctor’s In an acute care center, clinic, doctor’s

office, you cannot accept orders unless office, you cannot accept orders unless that physician is willing to go with to that physician is willing to go with to the hospitalthe hospital

Standard PrecautionsStandard Precautions Establishing routes for drug administration Establishing routes for drug administration

creates the potential exposure to blood creates the potential exposure to blood and body fluidsand body fluids

Decrease risk of exposure by following Decrease risk of exposure by following standard precautionsstandard precautions GlovesGloves GogglesGoggles MaskMask

The best standard precaution often The best standard precaution often forgotten:forgotten:

HANDWASHINGHANDWASHING

Sterile vs Clean Sterile vs Clean EnvironmentEnvironment

Sterile – free from all forms of lifeSterile – free from all forms of life Generally uses extensive heat or Generally uses extensive heat or

chemicalschemicals Difficult in the field to maintain sterile Difficult in the field to maintain sterile

environmentsenvironments Most packages are sterile until openedMost packages are sterile until opened

Clean environmentClean environment Minimize risk of infectionMinimize risk of infection Careful handling of equipment to Careful handling of equipment to

prevent contaminationprevent contamination

Disposal of Disposal of EquipmentEquipment

Minimize tasks done in a Minimize tasks done in a moving ambulancemoving ambulance Need to decrease risk of EMS exposureNeed to decrease risk of EMS exposure

Immediately dispose of sharps in a Immediately dispose of sharps in a sharps containersharps container Rigid, puncture-resistant containerRigid, puncture-resistant container

Recap needles only as a last resortRecap needles only as a last resort Use one handed techniqueUse one handed technique

Metric SystemMetric System Pharmacology’s principle system of Pharmacology’s principle system of

measurementmeasurement Widely used in science and medicineWidely used in science and medicine 3 fundamental units3 fundamental units

Grams – weight or massGrams – weight or mass Liters – volumeLiters – volume Meters – distanceMeters – distance

To avoid use of multiple zero’s , usually To avoid use of multiple zero’s , usually change the prefixes (ie: kilo, centi, milli, change the prefixes (ie: kilo, centi, milli, micro)micro)

Drug Administration and Drug Administration and Mathematical SkillsMathematical Skills

To properly prepare and administer To properly prepare and administer medications, need understanding of:medications, need understanding of: MultiplicationMultiplication DivisionDivision FractionsFractions Decimal fractionsDecimal fractions ProportionsProportions PercentagesPercentages

Converting Pounds to Converting Pounds to KilogramsKilograms

Many medications are dosed based Many medications are dosed based on patient weighton patient weight Adults – acceptable to be “close Adults – acceptable to be “close

enough”enough”Can round off the adult weightCan round off the adult weight

Pediatrics – must practice a more Pediatrics – must practice a more precise formulaprecise formulaLess room for error in calculationLess room for error in calculation

Pounds to KilogramsPounds to Kilograms

1 kilogram = 2.2 pounds1 kilogram = 2.2 pounds In the field, usually acceptable to In the field, usually acceptable to

take the adult patient’s weight in take the adult patient’s weight in pounds and divide in half to be close pounds and divide in half to be close enough to the kilogramsenough to the kilograms

In peds, need to take the weight in In peds, need to take the weight in pounds and divide by 2.2pounds and divide by 2.2

ExerciseExercise Convert 150 pounds to kilogramsConvert 150 pounds to kilograms

150/2.2 can be written as 150 150/2.2 can be written as 150 2.2 2.2

As a fraction, top number (numerator) is As a fraction, top number (numerator) is divided by the bottom number divided by the bottom number (denominator)(denominator)

150 = dividend150 = dividend 2.2 = divisor2.2 = divisor

The divisor must always be a whole The divisor must always be a whole numbernumber

Answer = quotientAnswer = quotient

ExerciseExercise

2.2 1502.2 150 Need to make 2.2 a whole numberNeed to make 2.2 a whole number In the metric system, you are multiplying In the metric system, you are multiplying

by “10”by “10” When multiplying with any derivative of When multiplying with any derivative of

10, count the zeros and move the decimal 10, count the zeros and move the decimal that many numbers to the rightthat many numbers to the right

What you do with the divisor, you must do What you do with the divisor, you must do with the dividend (actions inside and with the dividend (actions inside and outside the box must match)outside the box must match)

Example – 150# = ? Example – 150# = ? kilogramskilograms

2.2 150 = 22 15002.2 150 = 22 1500

68.168.1 22 1500.022 1500.0

132132 180180 176176

4040 2222 1818

Medication By Patient Medication By Patient WeightWeight

Most typical order is Lidocaine (mg/kg) and Most typical order is Lidocaine (mg/kg) and pediatric drugs (mg/kg)pediatric drugs (mg/kg) Calculate the patient’s kilogramCalculate the patient’s kilogram

Divide pounds by 2.2Divide pounds by 2.2Acceptable to divide the adult weight by Acceptable to divide the adult weight by 22

Multiply the kilogram by the number of mg Multiply the kilogram by the number of mg per kilogramper kilogram

Then you need to calculate the volume (ml) Then you need to calculate the volume (ml) to draw up in the syringeto draw up in the syringe

ExampleExample Give your 132 pound patient 1.5mg/kg Give your 132 pound patient 1.5mg/kg

LidocaineLidocaine Lidocaine is packaged as 100 mg/5mlLidocaine is packaged as 100 mg/5ml Steps to calculateSteps to calculate

Convert pounds to kilogramsConvert pounds to kilograms Based on the kilograms, calculate the Based on the kilograms, calculate the

number of mg requirednumber of mg required Multiply kilograms by mg/kg requiredMultiply kilograms by mg/kg required

Calculate the ml volume to draw upCalculate the ml volume to draw up

AnswerAnswer 132 132 2.2 = 1320 2.2 = 1320 22 = 60 kg 22 = 60 kg 1.5 mg/kg = 1.5 mg x 60 kg = 90mg1.5 mg/kg = 1.5 mg x 60 kg = 90mg Now, draw up 90 mg (Lidocaine comes Now, draw up 90 mg (Lidocaine comes

100 mg/5ml)100 mg/5ml) Formula #1: Formula #1: x ml = x ml = desired dose x vol on handdesired dose x vol on hand dose on handdose on hand

Formula #2: Formula #2: mg in bottlemg in bottle = = mg orderedmg ordered ml in bottle x mlml in bottle x ml

Formula #1Formula #1 Formula #1: Formula #1: x ml = x ml = desired dose x vol on handdesired dose x vol on hand dose on handdose on hand

x ml = x ml = 90 mg x 5 ml90 mg x 5 ml 100 mg 100 mg x ml = x ml = 450 450 (this fraction means 450 (this fraction means 450 100) 100) 100 (top number divided by bottom 100 (top number divided by bottom

number)number) x ml = 4.5 mlx ml = 4.5 ml

Formula #2Formula #2 Formula #2: Formula #2: mg in bottlemg in bottle = = mg orderedmg ordered

ml in bottle x mlml in bottle x ml

100 mg100 mg = = 90 mg90 mg

5 ml x ml5 ml x ml

(cross multiply) 100 x = 450(cross multiply) 100 x = 450

(divide by 100 to get (divide by 100 to get 100 x100 x = = 450450

x by itself) 100 100x by itself) 100 100

(divide top by bottom #) 450 / 100 = (divide top by bottom #) 450 / 100 = 450450100100

4.5 ml is answer4.5 ml is answer

Do Brain CheckDo Brain Check

Give 90 mg LidocaineGive 90 mg Lidocaine Lidocaine packaged 100 mg / 5 mlLidocaine packaged 100 mg / 5 ml Your answer was to give 4.5 mlYour answer was to give 4.5 ml Brain checkBrain check

90 mg is slightly smaller than the total 90 mg is slightly smaller than the total amount of 100 mgamount of 100 mg

4.5 ml is slightly smaller than 5 ml4.5 ml is slightly smaller than 5 ml So our math must be correctSo our math must be correct

Routes of Medication Routes of Medication AdministrationAdministration

4 basic categories4 basic categories PercutaneousPercutaneous

Applied or absorbed thru the skinApplied or absorbed thru the skin PulmonaryPulmonary

Absorbed via inhalation or injectionAbsorbed via inhalation or injection EnteralEnteral

Absorbed thru the gastrointestinal (GI) tractAbsorbed thru the gastrointestinal (GI) tract ParenteralParenteral

Administration outside the GI tractAdministration outside the GI tract Generally includes the use of needlesGenerally includes the use of needles

Percutaneous Medication Percutaneous Medication RoutesRoutes

Meds absorbed through skin or mucous Meds absorbed through skin or mucous membranesmembranes Sublingual routeSublingual route

Medication absorbed through the Medication absorbed through the mucous membrane under the tonguemucous membrane under the tongue

Sub = below; lingual = tongueSub = below; lingual = tongue Area extremely vascularArea extremely vascular Moderate to rapid rate of absorptionModerate to rapid rate of absorption Avoids the digestive tractAvoids the digestive tract

Mucous Membranes cont’dMucous Membranes cont’d Nasal routeNasal route

Uses a medication atomization device (MAD)Uses a medication atomization device (MAD) Coming soon to Region XComing soon to Region X

Relatively rapid absorption rate in the Relatively rapid absorption rate in the absence of IV accessabsence of IV access

MAD provides a fine mist that allows MAD provides a fine mist that allows even and widespread distribution of even and widespread distribution of medication across the nasal mucosamedication across the nasal mucosa

The Region is preparing to The Region is preparing to incorporate use of the MAD device in incorporate use of the MAD device in the near future the near future

Pulmonary Medication Pulmonary Medication Route Route

To administer medications into the To administer medications into the pulmonary system via inhalation or pulmonary system via inhalation or injectioninjection

Generally include gases, fine mists, or Generally include gases, fine mists, or liquidsliquids

Most medications used for Most medications used for bronchodilation for respiratory bronchodilation for respiratory emergenciesemergencies

Inhalation also used for humidificationInhalation also used for humidification

NebulizerNebulizer

Uses pressurized oxygen to disperse Uses pressurized oxygen to disperse a liquid into a fine aerosol spray or a liquid into a fine aerosol spray or mistmist

Inhalation carries the aerosol to the Inhalation carries the aerosol to the lungslungs

Enteral Route - RectallyEnteral Route - Rectally

Medication absorbed through the GI Medication absorbed through the GI tracttract

Extreme vascularity promotes rapid drug Extreme vascularity promotes rapid drug absorptionabsorption

Absorption more predictableAbsorption more predictable Medications administered rectally do not Medications administered rectally do not

pass through the liver so are not subject to pass through the liver so are not subject to alteration in the liveralteration in the liver

Advantageous for the unconscious patientAdvantageous for the unconscious patient

Parenteral RouteParenteral Route

Any drug administration outside of Any drug administration outside of the GI tractthe GI tract

Typically, this route involves the use Typically, this route involves the use of needlesof needles Medication is injected into the Medication is injected into the

circulation or into tissuescirculation or into tissues Some parenteral forms (ie: IVP) are Some parenteral forms (ie: IVP) are

the most rapid for drug deliverythe most rapid for drug delivery

SyringesSyringes

Plastic or glass tube for drawing up Plastic or glass tube for drawing up medicationsmedications

Range of sizesRange of sizes Medications are given in dosages by Medications are given in dosages by

weight (ie: mg)weight (ie: mg) Syringes represent volume (ie: ml)Syringes represent volume (ie: ml) Weights (ie: mg) must be Weights (ie: mg) must be

mathematically converted to volume mathematically converted to volume (ie: ml)(ie: ml)

Syringe Syringe MarkingsMarkings

PlungerPlunger BarrelBarrel Hash marksHash marks Use most Use most

appropriate appropriate sized syringe sized syringe for for higher accuracy higher accuracy

TB Syringe

Medications in AmpulesMedications in Ampules

Breakable vessel with liquid Breakable vessel with liquid medicationmedication

Cone-shaped top with thin neckCone-shaped top with thin neck Thin neck is the vulnerable Thin neck is the vulnerable

point for intentionally breaking point for intentionally breaking open the ampuleopen the ampule

Contains a single dose of medContains a single dose of med

Withdrawing From an Withdrawing From an AmpuleAmpule

Confirm the medication and dosageConfirm the medication and dosage Hold the ampule uprightHold the ampule upright Tap the top to dislodge trapped liquidTap the top to dislodge trapped liquid Place gauze (or alcohol wipe package) Place gauze (or alcohol wipe package)

around thin nickaround thin nick Snap top off away from youSnap top off away from you Place tip of needle into ampule and Place tip of needle into ampule and

withdraw liquidwithdraw liquid Dispose of ampule into sharps containerDispose of ampule into sharps container

Medications in VialsMedications in Vials Plastic or glass containers with self-Plastic or glass containers with self-

sealing rubber topsealing rubber top Rubber top prevents leakage from Rubber top prevents leakage from

puncturespunctures May contain single or multiple dosesMay contain single or multiple doses Liquid is vacuum packagedLiquid is vacuum packaged

Withdrawing From a VialWithdrawing From a Vial

Confirm the medication and dosageConfirm the medication and dosage Prepare the syringe and needle based on Prepare the syringe and needle based on

volume of liquid to draw upvolume of liquid to draw up Use 1 ml TB syringe for any dose Use 1 ml TB syringe for any dose << 1 ml 1 ml

Because of the vacuum, draw up the Because of the vacuum, draw up the same amount of air as volume to be same amount of air as volume to be removedremoved

Cleanse rubber top with an alcohol wipeCleanse rubber top with an alcohol wipe Insert needle straight into rubber topInsert needle straight into rubber top

Vial cont’dVial cont’d Inject the air from the syringe into the vialInject the air from the syringe into the vial Withdraw the desired volume of liquidWithdraw the desired volume of liquid

Watch to keep tip of needle in liquidWatch to keep tip of needle in liquid Helpful to draw a small amount of extra fluid to Helpful to draw a small amount of extra fluid to

accommodate removing air bubblesaccommodate removing air bubbles Hold syringe with needle pointing upwardHold syringe with needle pointing upward Tap side of syringe with finger to Tap side of syringe with finger to

displace bubbles to distal end of displace bubbles to distal end of syringesyringe

Expel air bubbles and confirm exact Expel air bubbles and confirm exact volume required in syringevolume required in syringe

Medications in Prefilled Medications in Prefilled SyringesSyringes

Tamperproof containers packaged Tamperproof containers packaged with medication already in the with medication already in the syringesyringe

Generally contain Generally contain standard dosagesstandard dosages

May require assemblyMay require assembly

Prefilled SyringePrefilled Syringe Confirm the medication and dosageConfirm the medication and dosage Assemble syringeAssemble syringe

Pop off protective capsPop off protective caps Twist glass tube containing Twist glass tube containing

liquid into syringeliquid into syringe Glass tube becomes the plungerGlass tube becomes the plunger Expel excess airExpel excess air Confirm dosage volume requiredConfirm dosage volume required

Lidocaine cap is twisted to unlock and then Lidocaine cap is twisted to unlock and then remove the capremove the cap

Nonconstituted MedicationsNonconstituted Medications Extends viability and storage of time Extends viability and storage of time

for drugs with short shelf life or for drugs with short shelf life or instability in liquid forminstability in liquid form

Consists of 2 vialsConsists of 2 vials Powdered medicationPowdered medication Liquid mixing Liquid mixing

solutionsolution

Reconstituting MedicationsReconstituting Medications

Confirm medication and dosageConfirm medication and dosage Prepare syringe with liquidPrepare syringe with liquid Cleanse off top of powder vialCleanse off top of powder vial Inject liquid into powder vialInject liquid into powder vial Gently roll vial between palms to dilute Gently roll vial between palms to dilute

powderpowder Check that ALL particles have dissolvedCheck that ALL particles have dissolved

Redraw up liquid into syringe, expel Redraw up liquid into syringe, expel excess airexcess air

Medication Medication AdministratioAdministratio

nn

Medication AdministrationMedication Administration

Just because you administer Just because you administer medications now, does not mean medications now, does not mean your technique is accurateyour technique is accurate

The first rule in medicine:The first rule in medicine:

Primum non Nocere Primum non Nocere HippocratesHippocrates

First, do no harm!First, do no harm!

Sublingual Medication RouteSublingual Medication Route

Use Standard PrecautionsUse Standard Precautions Confirm medication and Confirm medication and

dosage 3 timesdosage 3 times Have patient lift their tongueHave patient lift their tongue Place the tablet between the tongue Place the tablet between the tongue

and the floor of the oral cavityand the floor of the oral cavity Instruct the patient to allow the pill Instruct the patient to allow the pill

to dissolve to dissolve

In-line Nebulizer Administration In-line Nebulizer Administration RouteRoute

For administration of Albuterol For administration of Albuterol when the patient is no longer when the patient is no longer able to ventilate effectively to able to ventilate effectively to inhale the medication into their lungsinhale the medication into their lungs

Can begin to bag the patient and Can begin to bag the patient and force the medication into the lungs force the medication into the lungs even prior to intubationeven prior to intubation Set the equipment up and ventilate via a Set the equipment up and ventilate via a

mask while waiting for intubationmask while waiting for intubation

Endotracheal Endotracheal AdministratioAdministratio

n Routen RouteDiscouraged route but not Discouraged route but not

forbiddenforbiddenStudies have failed to demonstrate Studies have failed to demonstrate

adequate absorption of medication via adequate absorption of medication via this routethis route

If used, double the calculated IVP dosageIf used, double the calculated IVP dosageHyperventilate to distribute the Hyperventilate to distribute the

medicationmedicationAcceptable for: Acceptable for: LLidocaine, idocaine, EEpinephrine, pinephrine,

AAtropine, and tropine, and NNarcan (ie: LEAN)arcan (ie: LEAN)

Rectal MedicationRectal Medication

Confirm medication and dosage 3 Confirm medication and dosage 3 timestimes

Via syringeVia syringe Use a small diameter syringe based on Use a small diameter syringe based on

size of patientsize of patient Lubricate tip of syringeLubricate tip of syringe Turn the patient onto their sideTurn the patient onto their side Insert tip of syringe into rectumInsert tip of syringe into rectum Inject medicationInject medication Remove syringe and hold cheeks togetherRemove syringe and hold cheeks together

Permits retention and absorptionPermits retention and absorption

Rectal Rectal AdministrationAdministration

Via IV catheterVia IV catheter In place of a syringe tip being placed In place of a syringe tip being placed

into the rectum, can place an IV into the rectum, can place an IV catheter on the needleless syringe and catheter on the needleless syringe and then inject the medicationthen inject the medication

Reduces the diameter of the equipment Reduces the diameter of the equipment usedused Helpful alternative especially in the Helpful alternative especially in the

pediatric populationpediatric population

Parenteral Medication Parenteral Medication RoutesRoutes

Intradermal injectionIntradermal injection Subcutaneous injectionSubcutaneous injection Intramuscular injectionIntramuscular injection Intravenous injectionIntravenous injection Intraosseous injectionIntraosseous injection

Preparing The Preparing The SyringeSyringe

Pull medication into the syringePull medication into the syringe Tap the side of the barrel to displace Tap the side of the barrel to displace

air bubbles to the distal tip air bubbles to the distal tip Express out the excess air bubblesExpress out the excess air bubbles Confirm accuracy of medication dosageConfirm accuracy of medication dosage

Rubber edge of the plunger lines up with Rubber edge of the plunger lines up with the dosage marking on the barrelthe dosage marking on the barrel

Then draw up an additional 0.1 ml of air Then draw up an additional 0.1 ml of air for SQ or IM injectionsfor SQ or IM injections The air plug pushes the med farther into The air plug pushes the med farther into

the site preventing leakage of medthe site preventing leakage of med

Preparing the SitePreparing the Site

Wipe the intended site with alcoholWipe the intended site with alcohol Start wiping from the center moving Start wiping from the center moving

outwardoutward Let the site air dryLet the site air dry

Introducing alcohol into the site causes Introducing alcohol into the site causes irritationirritation

Do not blow on the site to hasten drying Do not blow on the site to hasten drying – causes contamination– causes contamination

SQ RouteSQ Route Layer of connective tissue between skin and Layer of connective tissue between skin and

musclemuscle Less blood supply than IM so slower Less blood supply than IM so slower

absorption rateabsorption rate Slow onset of action but long duration of Slow onset of action but long duration of

drug action due to less blood supplydrug action due to less blood supply Maximum volume of medication is 1 mlMaximum volume of medication is 1 ml Preferred needle size is 25 – 27 G; Preferred needle size is 25 – 27 G; 33//88 - - 55//88

inchinch Preferred is 45Preferred is 4500 angle (90 angle (9000 angle acceptable angle acceptable

if using ½ inch needle)if using ½ inch needle)

Subcutaneous Subcutaneous Medication RoutesMedication Routes

SitesSites DeltoidDeltoid

AbdominalAbdominal

ThighsThighs

ButtocksButtocks

SQ TechniqueSQ Technique Prepare the syringe and needlePrepare the syringe and needle Identify the siteIdentify the site Cleanse the siteCleanse the site Pinch a fold of skin upPinch a fold of skin up Quickly dart the needle into the fold at a 45Quickly dart the needle into the fold at a 4500

angleangle 909000 angle is an alternative especially with ½ angle is an alternative especially with ½” ” needleneedle

Release the foldRelease the fold AspirateAspirate checking for blood return checking for blood return Inject steadilyInject steadily Quickly withdraw the needle and discardQuickly withdraw the needle and discard Massage the site to enhance absorptionMassage the site to enhance absorption

Aspiration Before InjectionAspiration Before Injection

PurposePurpose To check for inadvertent entry into a vesselTo check for inadvertent entry into a vessel If you did not check you could be giving an If you did not check you could be giving an

IVP drug instead of a SQ or IMIVP drug instead of a SQ or IM More common for vessel entry during an More common for vessel entry during an

IMIM If blood is returned, remove needle and If blood is returned, remove needle and

prepare a new syringe and needleprepare a new syringe and needle

Pediatric SQ InjectionsPediatric SQ Injections

Most common site is posterior upper armMost common site is posterior upper arm Next site used is the anterior aspect of the Next site used is the anterior aspect of the

thighthigh Limited volume up to 1 ml of volume SQLimited volume up to 1 ml of volume SQ Use 45Use 4500 angle injected into pinched skin angle injected into pinched skin Site has limited use in poor perfusion stateSite has limited use in poor perfusion state

IM RouteIM Route

Muscle is extremely vascular and allows for Muscle is extremely vascular and allows for systemic delivery throughout the whole systemic delivery throughout the whole body and a moderate absorption ratebody and a moderate absorption rate

Absorption is relatively predictableAbsorption is relatively predictable When using the buttock, important to avoid When using the buttock, important to avoid

the sciatic nervethe sciatic nerve If you strike the sciatic nerve, the patient If you strike the sciatic nerve, the patient

could develop chronic paincould develop chronic pain Typical needle size is 21 – 23 G; 1 – 1Typical needle size is 21 – 23 G; 1 – 111//22”” Use 90Use 9000 angle angle Volume limitation dependent on the site Volume limitation dependent on the site

usedused

Intramuscular Medication Intramuscular Medication RouteRoute

SitesSites DeltoidDeltoid

ButtockButtock Dorsal glutealDorsal gluteal VentroglutealVentrogluteal

ThighThigh Vastus lateralisVastus lateralis Rectus femorisRectus femoris

IM SitesIM Sites

DeltoidDeltoid Easily reachedEasily reached Smaller sized muscle limits volume used Smaller sized muscle limits volume used

2 ml maximum2 ml maximum Site is 2 - 3 finger breadths below the Site is 2 - 3 finger breadths below the

acromial process (AC) and above the acromial process (AC) and above the armpit creasearmpit crease

Area often identified as a triangleArea often identified as a triangle

IM routes cont’dIM routes cont’d Buttocks – dorsal glutealButtocks – dorsal gluteal

Can inject up to 5 mlCan inject up to 5 ml Minimal discomfort feltMinimal discomfort felt Must stay away from the Must stay away from the

sciatic nervesciatic nerve Avoid this site in kids < 2 and in Avoid this site in kids < 2 and in

emaciated patientsemaciated patients Find the site in the upper, Find the site in the upper,

outer quadrant of the buttockouter quadrant of the buttock Must avoid the sciatic nerveMust avoid the sciatic nerve

IM site cont’d - IM site cont’d - VentroglutealVentrogluteal

Volume 1 – 3 mlVolume 1 – 3 ml Good site for children <7monthsGood site for children <7months Place the palm over the trochanter of the Place the palm over the trochanter of the

femurfemur Make a V with the 2Make a V with the 2ndnd and 3 and 3rdrd fingers fingers

The 3The 3rdrd finger runs straight up to the iliac finger runs straight up to the iliac crestcrest

The 2The 2ndnd finger angles forward to the finger angles forward to the anterior superior iliac crestanterior superior iliac crest

The injection is made inside theThe injection is made inside the V V formed between the 2formed between the 2ndnd and 3and 3rdrd fingers fingers

IM routes cont’dIM routes cont’d

ThighThigh Vastus lateralis – side Vastus lateralis – side

of the thighof the thigh Rectus femoris – Rectus femoris –

muscle over the front muscle over the front of the thighof the thigh

Can inject up to 5 ml Can inject up to 5 ml volumevolume Practice often is to Practice often is to

divide larger volumes divide larger volumes into 2 injections of into 2 injections of smaller volumesmaller volume

Thigh Injection Thigh Injection SiteSite

To find the siteTo find the site Place one hand at the top of the thigh at the Place one hand at the top of the thigh at the

groingroin Place one hand on the distal (lower) thigh Place one hand on the distal (lower) thigh

above the kneeabove the knee The area between the 2 hands can be usedThe area between the 2 hands can be used Anterior surface of the thigh at the midline Anterior surface of the thigh at the midline

is the rectus femorisis the rectus femoris Lateral to the midline is the vastus lateralisLateral to the midline is the vastus lateralis

Pediatric IM InjectionPediatric IM Injection

Thigh is preferred site in pedsThigh is preferred site in peds Especially used in infants and young Especially used in infants and young

toddlerstoddlers Large muscle massLarge muscle mass No proximal nerves or blood vesselsNo proximal nerves or blood vessels Limited subcutaneous fat layerLimited subcutaneous fat layer

More developed muscle than other More developed muscle than other sitessites

Can accommodate larger volumes than other Can accommodate larger volumes than other pediatric injection sitespediatric injection sites

IM TechniqueIM Technique

Prepare syringe and needlePrepare syringe and needle Identify siteIdentify site Prepare site – let alcohol air dryPrepare site – let alcohol air dry Pull the skin tautPull the skin taut Dart the needle in at 90Dart the needle in at 9000

The quicker the dart like insertion, the The quicker the dart like insertion, the less painfulless painful

Slowly and steadily inject the medicationSlowly and steadily inject the medication Quickly withdraw needle and properly Quickly withdraw needle and properly

discarddiscard Massage site – enhances absorptionMassage site – enhances absorption

Intravenous Administration Intravenous Administration RouteRoute

Quickest route to deliver medication Quickest route to deliver medication directly into the bloodstreamdirectly into the bloodstream

Fastest absorption rateFastest absorption rate Dependent on adequate perfusionDependent on adequate perfusion

Many medications are in prefilled syringesMany medications are in prefilled syringes Pop off protective capsPop off protective caps Assemble syringeAssemble syringe Expel airExpel air Confirm dosageConfirm dosage Administer medicationAdminister medication Watch for responseWatch for response

IVP MedicationIVP Medication Confirm medication 3 Confirm medication 3

times for accuracy times for accuracy Prepare syringePrepare syringe Consider need for a flush Consider need for a flush Secure medication syringe Secure medication syringe

into an IV port as close to into an IV port as close to the IV site as possible the IV site as possible

Pinch off the IV tubingPinch off the IV tubing Inject the medication at the Inject the medication at the

prescribed speed for the medicationprescribed speed for the medication

Needleless IV TubingNeedleless IV Tubing

Standard IV tubing to minimize the Standard IV tubing to minimize the event of needle stickevent of needle stick

Port wiped with alcoholPort wiped with alcohol Needle twisted onto portNeedle twisted onto port Must pinch tubing above Must pinch tubing above

injection siteinjection site Fluid will move in direction Fluid will move in direction

of least resistance of least resistance

IVPB Administration IVPB Administration RouteRoute

To administer a medication over To administer a medication over a longer period of time a longer period of time

All IV bags hanging need to be All IV bags hanging need to be labeledlabeled

The bags can be hung at the The bags can be hung at the same heightsame height The IV bags will both drip The IV bags will both drip

independently of the other IV bagindependently of the other IV bag Secure the IVPB into a port as Secure the IVPB into a port as

close to the IV site as possibleclose to the IV site as possible

Disposal of Contaminated Disposal of Contaminated EquipmentEquipment

As soon as possible As soon as possible dispose of equipment dispose of equipment into sharps containerinto sharps container

After giving an injection, After giving an injection, snap the protective snap the protective cover over the needlecover over the needle

After starting the IV, the After starting the IV, the needle should be needle should be covered as it is covered as it is retracted after the retracted after the injectioninjection

Side Effects and Side Effects and ComplicationsComplications

Remember for all injectionsRemember for all injections Once delivered, cannot get the medication Once delivered, cannot get the medication

backback Be very sure of 5 “rights’Be very sure of 5 “rights’

PatientPatientDrugDrugDoseDoseRouteRouteTimeTime

Once administered, monitor for known side Once administered, monitor for known side effects and any other changes to the patienteffects and any other changes to the patient

Documentation of Medication Documentation of Medication AdministrationAdministration

TimeTime Drug nameDrug name Drug dosage in mgDrug dosage in mg RouteRoute Patient response Patient response

EZ-IOEZ-IO

IndicationsIndications Shock, arrest, impending arrestShock, arrest, impending arrest Unconscious/unresponsive to verbal Unconscious/unresponsive to verbal

stimulistimuli 2 unsuccessful IV attempts or 90 2 unsuccessful IV attempts or 90

seconds duration of a peripheral seconds duration of a peripheral attemptattempt

EZ IOEZ IO

ContraindicationsContraindications Fracture of the tibia or femurFracture of the tibia or femur Infection at insertion siteInfection at insertion site Previous orthopedic procedurePrevious orthopedic procedure

Knee replacementKnee replacement Previous IO within 48 hoursPrevious IO within 48 hours

Pre-existing medical conditionPre-existing medical condition Tumor near site, peripheral vascular diseaseTumor near site, peripheral vascular disease

Inability to locate landmarksInability to locate landmarks Excessive tissue at insertion siteExcessive tissue at insertion site

EZ IO NeedlesEZ IO Needles

Adult patientsAdult patients 88 pounds or over (40 kg)88 pounds or over (40 kg) 15 G; 25 mm blue needle 15 G; 25 mm blue needle

Pediatric patientsPediatric patients 7 - 88 pounds (3 kg – 39 kg)7 - 88 pounds (3 kg – 39 kg) 15 G; 15 mm pink needle15 G; 15 mm pink needle Think “pink” for “peds”Think “pink” for “peds”

EZ IO EquipmentEZ IO Equipment 10 ml syringe filled with 0.9 NS 10 ml syringe filled with 0.9 NS

5 ml of NS in syringe for peds patient5 ml of NS in syringe for peds patient EZ connect tubingEZ connect tubing Material to cleanse siteMaterial to cleanse site EZ IO driverEZ IO driver EZ IO needle in it’s caseEZ IO needle in it’s case Primed IV tubingPrimed IV tubing

1000 ml bag for adults1000 ml bag for adults 250 ml IV bag for geriatric and pediatric 250 ml IV bag for geriatric and pediatric

patientspatients Pressure bag (B/P cuff is no pressure bag)Pressure bag (B/P cuff is no pressure bag)

EZ IO drill EZ IO drill with with

storage storage casecase

EZ IO SiteEZ IO Site Most common site: Most common site:

proximal tibiaproximal tibia Palpate the tibial tuberosityPalpate the tibial tuberosity

Bump below the patellaBump below the patella Identify 2-3 finger widths below the Identify 2-3 finger widths below the

patellapatella Move 1 finger width medially (toward Move 1 finger width medially (toward

the big toe)the big toe) In smaller children often will not be In smaller children often will not be

able to palpate the tibial tuberosityable to palpate the tibial tuberosity

EZ IO - TechniqueEZ IO - Technique Prime EZ connect tubing Prime EZ connect tubing

Takes 1 ml to prime tubingTakes 1 ml to prime tubing Leave syringe attachedLeave syringe attached

Attach needle to driverAttach needle to driver Insert needle at 90Insert needle at 9000 angle into site angle into site

Release trigger once decreased Release trigger once decreased resistance is feltresistance is felt

Remove driver from needleRemove driver from needle Remove stylet by rotating counterclockwiseRemove stylet by rotating counterclockwise

EZ IO Technique cont’dEZ IO Technique cont’d Connect EZ primed tubing to needleConnect EZ primed tubing to needle

May notice backflow of bone marrowMay notice backflow of bone marrow Blood will NOT pump out of needleBlood will NOT pump out of needle

Using syringe, aspirate then flush Using syringe, aspirate then flush with remaining NS to confirm with remaining NS to confirm placementplacement Needle stands up on ownNeedle stands up on own Flushes easilyFlushes easily No infiltration feltNo infiltration felt

EZ IO Technique cont’dEZ IO Technique cont’d Remove syringeRemove syringe Attach primed IV tubing Attach primed IV tubing Secure pressure bag to permit flow of Secure pressure bag to permit flow of

fluidfluid Begin infusionBegin infusion Secure tubing to legSecure tubing to leg Apply wristbandApply wristband Monitor site for infiltrationMonitor site for infiltration Can administer any IVP medication Can administer any IVP medication

that would normally be given IV pushthat would normally be given IV push

EZ IO DocumentationEZ IO Documentation

Same information for starting an IVSame information for starting an IV TimeTime SolutionSolution Size IV bagSize IV bag SiteSite Person actually performing the Person actually performing the

puncturepuncture

Case Study #1Case Study #1

Your patient weighs 150 poundsYour patient weighs 150 pounds They need to receive 1.5 mg / kg They need to receive 1.5 mg / kg

LidocaineLidocaine Lidocaine packaged as 100 mg/5 mlLidocaine packaged as 100 mg/5 ml How much Lidocaine needs to be How much Lidocaine needs to be

drawn up and given?drawn up and given?

Case Study #1Case Study #1

Calculate pounds to kilogramsCalculate pounds to kilograms 150 150 2.2 = 68.1 rounded to 68 kg 2.2 = 68.1 rounded to 68 kg

Calculate total mg of medicationCalculate total mg of medication To receive 1.5 mg per kgTo receive 1.5 mg per kg Multiply 1.5 x 68 = 102mgMultiply 1.5 x 68 = 102mg

Calculate how much medication to Calculate how much medication to deliverdeliver Use formula of your choiceUse formula of your choice

Case Study #1Case Study #1 Formula #1Formula #1

X ml = X ml = desired dose x vol on handdesired dose x vol on hand dose on handdose on hand

X ml = X ml = 102 mg x 5 ml102 mg x 5 ml 100mg100mg X ml = X ml = 510510 100100 X ml = 510 X ml = 510 100 100 X ml = 5.1 ml (in the adult rounded to 5 X ml = 5.1 ml (in the adult rounded to 5

ml)ml)

Case Study #1Case Study #1

Formula #2Formula #2 100 mg = 102 mg100 mg = 102 mg 5 ml x ml5 ml x ml 100 x = 510100 x = 510 100x = 510100x = 510 100 100100 100 x = 510 x = 510 100 100 X = 5.1 ml (rounded to 5 ml)X = 5.1 ml (rounded to 5 ml)

Case Study #2Case Study #2

Your 45 year-old patient is having an Your 45 year-old patient is having an allergic reaction with airway allergic reaction with airway involvementinvolvement

The vital signs are The vital signs are stablestable What medications are indicated?What medications are indicated? How do you administer each of the How do you administer each of the

medications?medications?

Case Study #2Case Study #2 Epinephrine 1:1000 – 0.3 mg SQEpinephrine 1:1000 – 0.3 mg SQ

Bronchodilator, vasoconstrictorBronchodilator, vasoconstrictor Short needle (Short needle (33//88 - - 55//88”)”) 454500 angle angle Pinch up the skinPinch up the skin

Benadryl 50 mg IVP slowly or IMBenadryl 50 mg IVP slowly or IM AntihistamineAntihistamine Long needle (1Long needle (1” up to 1 ” up to 1 11//22”)”) 909000 angle angle Pull the skin taut before injectingPull the skin taut before injecting

Case Study #2Case Study #2

Always aspirate to check for Always aspirate to check for inadvertent entry into a veininadvertent entry into a vein If blood is noted, withdraw needleIf blood is noted, withdraw needle Prepare a new needle and syringePrepare a new needle and syringe

Injecting the blood can cause irritationInjecting the blood can cause irritation With blood in the syringe, may not be With blood in the syringe, may not be

able to detect aspiration of new blood able to detect aspiration of new blood at new siteat new site

Case Study #3Case Study #3

You are on the scene of a full arrestYou are on the scene of a full arrest You cannot find peripheral veinsYou cannot find peripheral veins What is you next alternative?What is you next alternative? How do you confirm needle How do you confirm needle

placement?placement?

Case Study #3Case Study #3

EZ IO needle is indicatedEZ IO needle is indicated Confirmation of needle placementConfirmation of needle placement

Needle stands up by itselfNeedle stands up by itself Able to flush the needle easily through Able to flush the needle easily through

the EZ connect tubingthe EZ connect tubing Fluid flows with a pressure bag attachedFluid flows with a pressure bag attached No infiltration is notedNo infiltration is noted

EZ IO NeedleEZ IO Needle

Needle always flushed via the EZ Needle always flushed via the EZ connect tubingconnect tubing NEVER flush the needle directly – too NEVER flush the needle directly – too

much pressuremuch pressure

Case Study #4Case Study #4

You have an 8 month-old infant with a You have an 8 month-old infant with a blood sugar of 45blood sugar of 45

The patient responds weakly to verbal The patient responds weakly to verbal stimulistimuli

What medication is necessary?What medication is necessary? How do you prepare the medication?How do you prepare the medication? How do you administer the How do you administer the

medication? medication?

Case Study #4 - Case Study #4 - HypoglycemiaHypoglycemia

Ages Ages >> 16 – Dextrose 50% 16 – Dextrose 50% Ages 1 – 15 – Dextrose 25%Ages 1 – 15 – Dextrose 25% Age < 1 years-old - Dextrose 12.5%Age < 1 years-old - Dextrose 12.5%

Diluted strength due to vein irritationDiluted strength due to vein irritation Calculate the dosageCalculate the dosage Draw up equal amounts normal saline Draw up equal amounts normal saline

and D25% to make a 1:1 dilutionand D25% to make a 1:1 dilution Administer slowly due to vein irritationAdminister slowly due to vein irritation

Case Study #4Case Study #4

Dextrose is given IVPDextrose is given IVP Wipe off the injection port with alcoholWipe off the injection port with alcohol Push on the needleless syringe and twist to Push on the needleless syringe and twist to

connectconnect Pinch off the tubing above the injection portPinch off the tubing above the injection port Slowly and steadily administer the Slowly and steadily administer the

medication medication Evaluate the site for infiltrationEvaluate the site for infiltration Evaluate the patient’s responseEvaluate the patient’s response

Case Study #5Case Study #5

You are on the scene for a 5 year old You are on the scene for a 5 year old having a seizurehaving a seizure Patient weighs 50 poundsPatient weighs 50 pounds History of seizure disorderHistory of seizure disorder Glucose level of 80Glucose level of 80

You are unable to establish a peripheral IVYou are unable to establish a peripheral IV What do you do for the airway?What do you do for the airway? What medication is indicated?What medication is indicated? How do you administer the medication?How do you administer the medication?

Case Study #5Case Study #5

Airway control – bag the patientAirway control – bag the patient In active seizure, the respiratory status In active seizure, the respiratory status

of the patient is difficult to evaluate and of the patient is difficult to evaluate and assume the patient is not ventilating assume the patient is not ventilating wellwell

Medication and routeMedication and route Valium 0.5 mg/kg (max 10 mg) rectallyValium 0.5 mg/kg (max 10 mg) rectally

Case Study #5Case Study #5 Calculate doseCalculate dose

50 pounds 50 pounds 2.2 = 22.7 = 23 kg 2.2 = 22.7 = 23 kg Multiple 0.5 mg x 23 kg = 11.5 mg = 12 Multiple 0.5 mg x 23 kg = 11.5 mg = 12

mgmg Max dose is 10 mgMax dose is 10 mg Valium comes 10 mg per 2 mlValium comes 10 mg per 2 ml Make sure syringe is needlelessMake sure syringe is needleless Insert syringe into buttocksInsert syringe into buttocks Inject medication and remove syringeInject medication and remove syringe Hold cheeks togetherHold cheeks together

Pediatric ResourcesPediatric Resources

What resources are available to What resources are available to calculate a pediatric dosage?calculate a pediatric dosage? Back of the SOP’sBack of the SOP’s Medical ControlMedical Control Broselow tapeBroselow tape

Valium listed as diazepamValium listed as diazepam Narcan listed as NaloxoneNarcan listed as Naloxone Normal saline listed as crystalloidNormal saline listed as crystalloid

BibliographyBibliography Bledsoe, B., Clayden, D., Papa, F. Prehospital Bledsoe, B., Clayden, D., Papa, F. Prehospital

Emergency Pharmacology 5Emergency Pharmacology 5thth Edition. Brady. 2001. Edition. Brady. 2001. Bledsoe, B., Porter, R., Cherry, R., Paramedic Care: Bledsoe, B., Porter, R., Cherry, R., Paramedic Care:

Principles and Practices. Brady. 2009Principles and Practices. Brady. 2009 Edmunds, M. Introduction to clinical Pharmacology. Edmunds, M. Introduction to clinical Pharmacology.

Elsevier. 2006.Elsevier. 2006. Marenson, D. Pediatric Prehospital Care. Brady. 2002.Marenson, D. Pediatric Prehospital Care. Brady. 2002. Region X SOP’s March 2007, Amended January 1, 2008Region X SOP’s March 2007, Amended January 1, 2008 Sanders, M. Paramedic Textbook. Rev 3Sanders, M. Paramedic Textbook. Rev 3rdrd edition. edition.

Mosby. 2007Mosby. 2007 wps.prenhall.comwps.prenhall.com www.vidacare.comwww.vidacare.com