2014 aemt introduction to iv administration and med administration
DESCRIPTION
Introduction to IV administration and MED administration for Advanced EMT students and Early paramedic Students. Several good videos are inbedded as well.TRANSCRIPT
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!