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Ch. 13 Vascular Access and Medication Administration

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Drawing Medication from a Vial (Step 2):

-Determine the amount of medication that you will need and draw that amount of air into the syringe. -Allow a little extra room to expel some air while removing air bubbles.

Colloid Solutions:

-A colloid solution contains molecules (usually proteins) that are too large to pass out of the capillary membranes and remain in the vascular compartment. -These large protein molecules give colloid solutions a high osmolarity. As a result, they draw fluid from the interstitial and intracellular compartments into the vascular compartments. -Colloid solutions work well in reducing edema (as in pulmonary or cerebral edema) while expanding the vascular compartment. -They can cause dramatic fluid shifts and place the -patient in considerable danger if they are not administered in a controlled setting. -Examples of colloids are albumin and hetastarch. Whole blood and blood products are also colloid solutions.

Crystalloid Solutions:

-A crystalloid solution contains dissolved crystals (salts or sugars) in water. -The ability of these fluids to cross membranes and alter the various fluid levels makes them the best choice for the prehospital care of injured patients who need fluid replacement for body fluid loss. -When using an isotonic crystalloid for fluid replacement to support blood pressure from blood loss, remember the 3-to-1 replacement rule: 3 mL of isotonic crystalloid solution is needed to replace 1 mL of patient blood. -This amount is needed because approximately two-thirds of the infused isotonic crystalloid solution leaves the vascular spaces in about 1 hour. -Crystalloid solutions do not have the capability to carry oxygen. -Give boluses of 250 mL to maintain perfusion (radial pulses), but not to restore blood pressure to the patient's normal level. -Increasing blood pressure with IV solutions not only dilutes remaining blood volume, decreasing the proportion of hemoglobin, but it may also increase internal bleeding by interfering with hemostasis. Blood pressure should be titrated to 90 mm Hg systolic in adults, unless otherwise noted by local protocol.

Hypertonic Solutions:

-A hypertonic solution has an osmolarity higher than serum, which means the solution has more ionic concentration than serum and pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. -Hypertonic solutions shift body fluids into the vascular spaces and help stabilize blood pressure, increase urine output, and reduce edema. -These fluids are rarely, if ever, used in the prehospital setting. -Often, the term hypertonic refers to solutions that contain high concentrations of proteins. They have the same effect on fluid as sodium. -Careful monitoring is needed to guard against fluid overloading when using hypertonic fluids, especially in patients with impaired heart or kidney function. -Hypertonic solutions should not be given to patients with diabetic ketoacidosis or others at risk of cellular dehydration. -Hypertonic solutions have been studied in the treatment of patients experiencing hemorrhaging to help restore blood pressure while minimizing fluid overloading.

Metered Dose Inhaler (MDI):

-A patient with a history of respiratory problems will usually have a metered-dose inhaler (MDI) to use on a regular basis or as needed. -MDIs are usually administered by the patient using the patient's own prescribed medications, but you must know how to administer via this route because you may assist the patient with administration. -Medications administered by the MDI can be delivered through a mouthpiece held by the patient or by a mask—with or without a spacer device—for young children and patients who are unable to hold the mouthpiece

Saline Locks:

-A saline lock is a way to maintain an active IV site without having to run fluid through the vein. -These access devices are used primarily for patients who do not need additional fluids but may need rapid medication delivery. -Saline locks are access ports commonly used with patients who have disorders such as heart failure or pulmonary edema. -A saline lock is attached to the end of an IV catheter and filled with approximately 2 mL of normal saline to keep blood from clotting at the end of the catheter. -Because this is a sealed-access site, the saline remains in the port without entering the vein, preventing clotting. -These are also known as intermittent, or INT, sites because they eliminate the need to reestablish an IV line each time the patient needs medication or fluid.

Body Fluid Composition:

-A solution is a mixture of two things: >Solvent: The fluid that does the dissolving, or the solution that contains the dissolved components (in the body, the solvent is water) >Solute: The dissolved particles contained in the solvent -As the solute concentration increases, the solvent concentration decreases.

Administering Medication via the Intranasal Route (Step 6):

-Dispose of the atomizer device and syringe in the appropriate container.

Active Transport:

-Active transport is a method used to move compounds to create or maintain an imbalance of charges. -An example is the sodium/potassium pump. The cell uses sodium outside the cell and potassium inside the cell for an important cellular function called depolarization. To maintain this imbalance, the cell must use energy in the form of ATP and actively transport compounds across its membrane. -Even though active transport demands a high-energy expenditure, the benefits outweigh the initial utilization of ATP. -Pumping sodium out of the cell and potassium into the cell has the added benefit of moving glucose into the cell at the same time.

Administering Medication via the Subcutaneous Route (Step 2):

-Advise the patient of potential discomfort while explaining the procedure. -Assemble and check the equipment needed: >alcohol preps and a 3-mL syringe with a 24- to 26-gauge needle. -Draw up the correct dose of medication.

Obtaining Vascular Access (Step 8):

-Advise the patient to expect a needlestick. While applying distal traction at the site with one hand, insert the catheter at approximately 45° with the bevel up. -This traction will stabilize the vein and help to keep it from "rolling" as you stick.

Medication Concentration:

-After receiving a drug order (the desired dose), determine how much of the medication that you have available. -In other words, you must know its concentration—the total weight (micrograms, milligrams, or grams) of the medication contained in a specific volume (mL or L). -An example of a common prepackaged drug concentration is 50% dextrose, 25 g/50 mL. -Note that medications are contained in different volumes of solution. -This is your volume on hand. -To administer a medication, you must know the weight of the medication that is present in 1 mL. -This will tell you the concentration of the medication that you have on hand. -The formula for calculating this is as follows: >Total weight of the medication ÷ Total volume in milliliters = Weight -By using this formula and the examples of common prepackaged medications, you can calculate how much of the medication is contained in each milliliter (dose on hand). -For example, if the drug order is for dextrose, 25 g/50 mL, you would calculate the concentration as follows: >25 g (total weight) ÷ 50 mL (total volume) = 0.5 g/mL

Volume to be administered:

-After you have determined the concentration of the medication present in each milliliter (dose on hand), you must calculate how much volume is needed to give the amount of the medication ordered (desired dose). -Use the following formula to calculate the volume to be administered: >Desired dose (mg) ÷ Concentration on hand (mg/mL) = Volume to be administered (mL) -Notice that the desired dose is in milligrams and the concentration on hand is in milligrams per milliliter. -There may be instances where the desired dose is in a different unit, such as grams or micrograms. -Before using the above formula, the units in the desired dose must match the units in the top of the concentration-on-hand fraction. -If they do not, you will need to do a quick calculation to convert the desired dose units to match the units in the top half of the concentration on hand. -You will be able to determine how much volume to give to achieve the required dose. -Example: You are ordered to administer 12.5 g of dextrose to a hypoglycemic patient. You have a prefilled syringe containing 25 g of D50 in 50 mL. How many milliliters of dextrose will you give? >Step 1: Determine the concentration/dose on hand (in g/mL).25 g ÷ 50 mL = 0.5 g/mL (dose on hand) >Step 2: Determine how much volume to administer.12.5 g (desired dose) ÷ 0.5 g/mL (dose on hand) = 25 mL -You will need to administer 25 mL, or half of the 50-mL syringe.

Drawing Medication from a Vial (Step 4):

-After you have the correct amount of medication in the syringe, withdraw the needle and expel any air in the syringe.

Ampules:

-Ampules are breakable sterile glass containers that are designed to carry a single dose of medication -Naloxone (Narcan) is an example of a medication that comes in the form of an ampule.

Choosing an administration set:

-An administration set moves fluid from the IV bag into the patient's vascular system. -IV administration sets are sterile as long as they remain in their protective packaging. -Each IV administration set has a piercing spike protected by a plastic cover. After the piercing spike is exposed and the seal surrounding the cap is broken, the set must be used immediately or discarded. -There are different sizes of administration sets for different situations and patients. -A drip set is another term for an administration set. -Most drip sets have a number visible on the package, which indicates the number of drops it takes for 1 mL of fluid to pass through the orifice and into the drip chamber. -Drip sets come in two primary sizes: >A microdrip set allows 60 gtt (drops)/mL through the small, needlelike orifice inside the drip chamber. >Microdrips are ideal for medication administration or pediatric fluid delivery because it is easy to control their fluid flow. >A macrodrip set allows 10 to 15 gtt/mL through a large opening between the piercing spike and the drip chamber. >Macrodrip sets are best used for rapid fluid replacement. >A blood set is a special type of macrodrip set designed to facilitate rapid fluid replacement by manual infusion of either multiple IV bags or IV/blood replacement combinations. >Most blood sets have dual piercing spikes that allow two bags of fluid to be hung simultaneously for the same patient

(Systemic Complications) Circulatory Overload:

-An unmonitored IV bag can result in circulatory overload. -Healthy adults can handle as much as 2 to 3 extra liters of fluid without compromise. -Problems occur when the patient has cardiac, pulmonary, or renal dysfunction; these types of dysfunction do not tolerate any additional demands from increased circulatory volume. -In trauma patients, increased circulatory volume from overaggressive resuscitation can disrupt clot formation and actually increase ongoing hemorrhage. -The most common cause of circulatory overload in the prehospital setting is failure to readjust the drip rate after flushing an IV line immediately after insertion. -Always monitor IV bags to ensure the proper drip rate. -Patient presentation includes dyspnea, jugular vein distention, and increased blood pressure. -Crackles are often heard when evaluating breath sounds. -Acute peripheral edema can also be an indication of circulatory overload. -To treat a patient with circulatory overload, slow the IV rate to keep the vein open and raise the patient's head to ease respiratory distress. -Administer high-flow oxygen and monitor vital signs and breathing adequacy. -Contact medical control immediately and inform personnel of the developing problem because medications can be administered to reduce the circulatory volume. -Document the event.

Distal Tibia IO Site:

-For the distal tibia IO site, use palpation as well. -First, identify the medial malleolus. -Then palpate 2 to 3 cm above that site. -For pediatric patients, you should palpate 1 to 2 cm above the medial malleolus.

(Systemic Complications) Vasovagal Reactions:

-Anxiety may cause vasculature dilation, resulting in a decrease in blood pressure and patient collapse. -A patient can present with anxiety, diaphoresis, nausea, and a syncopal episode. -Treatment for a patient with a vasovagal reaction (also known as vagaling down) centers on treatment for shock: >Place patient in the position dictated by protocol for shock management. >Apply high-flow oxygen. >Monitor vital signs. >Establish an IV line in case fluid resuscitation is needed.

Obtaining Vascular Access (Step 5):

-Apply the constricting band above the intended IV site. -It should be placed approximately 4 to 8 inches above the intended site.

Administering Medication via the Sublingual Route (Step 2):

-Ask the patient to rinse his or her mouth with a little water if the mucous membranes are dry. -Explain the procedure and ask the patient to lift his or her tongue. -Place the tablet or spray the dose under the tongue or ask the patient to do so. -Advise the patient not to chew or swallow the tablet, but to let it dissolve slowly. -Monitor the patient's condition, and document the medication given, route, administration time, and patient response.

Administering Medication via the Intranasal Route (Step 3):

-Attach the mucosal atomizer device to the syringe, maintaining sterility.

Performing IO Infusion (Step 5):

-Attach the needle to the EZ-IO gun and remove the protective cover. -Examine the needle. -If you find any imperfections, discard the needle and select another one.

Obtaining Vascular Access (Step 12):

-Attach the prepared IV line. Hold the hub of the catheter while connecting the IV line.

Performing IO Infusion (Step 8):

-Attach the syringe and extension set to the IO needle. -Pull back on the syringe to aspirate blood and particles of bone marrow to ensure proper placement. -The absence of marrow does not mean the access failed. -Check the site for other signs of extravasation. -Slowly inject saline to ensure proper placement of the needle. -Responsive patients should receive 1% lidocaine prior to infusion of fluids. -Watch for extravasation and stop the infusion immediately if any evidence of extravasation is noted. -It is possible to fracture the bone during insertion of the IO needle. -If this happens, then remove the IO needle and switch to the other insertion site. -Connect the administration set and adjust the flow rate as appropriate. -Fluid does not flow as rapidly through an IO catheter as through an IV line; therefore, crystalloid boluses should be given with a syringe in children and a pressure infuser device (a sleeve placed around the IV bag and inflated to force fluid from the IV bag) in adults. -Secure the needle with tape and support it with a bulky dressing. -Stabilize in place in the same manner that an impaled object is stabilized. -Use bulky dressings around the catheter, and tape securely in place. -Be careful not to tape around the entire circumference of the leg because this could impair circulation and potentially result in compartment syndrome. -Dispose of the needle in the proper container.

Choosing and IV Site (Cont.):

-Bulging veins can move side to side during cannulation, causing you to miss the vein and resulting in possible infiltration. -Apply manual traction to the vein to lock it into position. -Hold hand veins in place by pulling the skin over the vein taut with the thumb of your free hand as you flex the patient's hand. -Stabilize wrist veins by flexing the wrist and pulling the skin taut over the vein. -Applying lateral traction to the vein with your free hand can stabilize veins in the forearm and antecubital areas. -Use caution when cannulating leg veins, because there is a potential of greater risk of infection or of venous thrombosis and subsequent pulmonary embolus.

Butterfly Catheter:

-Butterfly catheters derive their name from the plastic tabs attached to the sides of the needle. These allow for a stable anchoring platform.

Arterial Puncture:

-Cannulation of an artery is easily recognized because bright red blood is quickly seen either spurting from the catheter after the needle is withdrawn or backing up into the IV tubing and the IV bag because of the high pressure that exists in the arteries. -If cannulation of an artery occurs, stop IV administration, remove the catheter, and apply direct pressure to the site with gauze for at least 15 minutes and certainly until any bleeding is controlled.

(Systemic Complications) Catheter Shear:

-Catheter shear occurs when part of the catheter is pinched against the needle, and the needle slices through the catheter, creating a free-floating segment. -The catheter segment can travel through the circulatory system and possibly end up in the pulmonary circulation, causing a pulmonary embolus. -Blockage of other vessels may result in a myocardial infarction, stroke, or other problems. -If you suspect a catheter shear, place the patient in a left lateral recumbent position with the legs down and the head elevated to try to keep the catheter remnant out of the pulmonary circulation. -Treatment involves surgical removal of the sheared tip. -Catheter hubs are radiopaque (that is, they will appear white on a radiograph) to aid in diagnosing this type of problem. -Never rethread a catheter. -Dispose of the used one and use a new one. -Patients who have experienced catheter shear with pulmonary artery occlusion may present with sudden dyspnea, shortness of breath, and possibly diminished breath sounds. -They will mimic the presentation of a patient with an air embolus and can be treated the same way. -These patients will need continued IV access, and you must try to obtain an IV line in the other extremity.

Changing and IV Bag:

-Change the bag when approximately 25 mL of fluid is left. -To change an IV fluid bag: >Stop the flow of fluid from the depleted bag by closing the roller clamp. >Prepare the new IV bag by removing the pigtail from the piercing spike port. >Inspect the new bag of IV fluid for clarity and discoloration, as well as the expiration date. >Remove the piercing spike from the depleted bag and insert it into the port on the new bag. >Do not touch the piercing spike of the administration set. >Ensure the drip chamber is appropriately filled, and then open the roller clamp and adjust the fluid rate accordingly.

Drawing Medication from an Ampule (Step 1):

-Check the medication to be sure that the expiration date has not passed and that it is the correct medication and concentration. -Shake the medication down into the base of the ampule. -If some of the medication appears to be stuck in the neck, gently thump or tap the stem.

Drawing Medication from a Vial (Step 1):

-Check the medication to be sure that the expiration date has not passed, and that it is the correct medication and concentration. -Check that it is not discolored. -Remove the sterile cover or clean the top with alcohol if it was previously opened.

Performing IO Infusion (Step 1):

-Check the selected IV fluid for proper fluid, clarity, and expiration date. -Look for discoloration and for particles floating in the fluid. -If particles are found in the fluid, discard the bag and choose another bag of fluid. -Select the appropriate equipment, including an IO needle, syringe, saline, extension set, antiseptic swabs, and gauze pads. -A three-way stopcock may also be used to facilitate easier fluid administration. -Select the proper administration set. -Connect the administration set to the bag. -Prepare the administration set. -Fill the drip chamber and flush the tubing. -Ensure all air bubbles are removed from the tubing. -Prepare the syringe and extension tubing. -Ensure the tubing is not tangled. -Cut or tear the tape and prepare bulky dressings. -This can be done at any time before IO puncture.

Troubleshooting IV Therapy:

-Check your IV fluid. -Thick, viscous fluids such as blood products and colloid solutions infuse slowly and may be diluted, if needed, to help speed delivery. -Cold fluids run slower than warm fluids. -If you can, warm IV fluids before administering them in cold weather. -Check your administration set. -Macrodrips are used for rapid fluid delivery, whereas microdrips are designed to deliver a more controlled flow. -Check the height of your IV bag. -The IV bag must be hung high enough to overcome the patient's own blood pressure. -Hang the bag as high as possible. -Check the type of catheter used. -The wider the catheter (the smaller the gauge), the more fluid can be delivered—14 gauge is the widest, 27 gauge the narrowest. -Catheter length also affects flow—the shorter the catheter, the more rapid the flow. -Check your constricting band. -One of the most overlooked factors is leaving the constricting band on the patient's arm after completing the IV-line setup.

Obtaining Vascular Access (Step 1):

-Choose the appropriate fluid and examine for clarity and expiration date. -Ensure that no particles are floating in the fluid and that the fluid is appropriate for the patient's condition. -Choose the appropriate drip set and attach it to the fluid. -A macrodrip set (e.g., 10 gtt/mL) should be used for a patient who needs volume replacement, and a microdrip set (e.g., 60 gtt/mL) should be used for a patient who mainly needs a route for medication. -If an IV extension set is available, attach it to the end of the tubing to assist the hospital staff in manipulating the IV tubing at the hospital. -Fill the drip chamber by squeezing it together.

Obtaining Vascular Access (Step 7):

-Choose the appropriate-size catheter and twist the catheter to break the seal. -Do not advance the catheter upward as this may cause the needle to shear the catheter. -Examine the catheter and discard it if you discover any imperfections, such as "burrs" on the edge of the catheter. -Loosen the catheter hub.

Obtaining Vascular Access (Step 6):

-Clean the area using an aseptic technique. -Use an alcohol pad to cleanse in a circular motion from the inside out. -Use a second alcohol pad to wipe straight down the center.

Administering Medication via the Intramuscular Route (Step 2):

-Cleanse the area for the administration (usually the upper arm or the hip) using aseptic technique.

Administering Medication via the Subcutaneous Route (Step 3):

-Cleanse the area for the administration (usually the upper part of the arm or thigh) using aseptic technique.

Administering Medication via the Intraosseous Route (Step 2):

-Cleanse the injection port of the extension tubing with alcohol or remove the protective cap if using the needleless system.

Performing IO Infusion (Step 4):

-Cleanse the site appropriately. -Follow aseptic technique by cleansing in a circular manner from the inside out.

Administering a Medication via a Small-Volume Nebulizer (Step 3):

-Connect the T piece with the mouthpiece to the top of the bowl, or the mask to the bowl, and connect it to the oxygen tubing. -Set the flowmeter at 6 L/min to produce a steady mist. -Remove the oxygen mask from the patient if oxygen is being administered.

Geriatric IV Considerations:

-Consider using alternative options such as paper tape or commercial devices that reduce the risk of skin damage. -Try using smaller catheters (such as 20-, 22-, or 24-gauge) because they may be more comfortable for the patient and can reduce the risk of extravasation. -Always monitor fluid administration carefully. -Consider the possibility of poor vein elasticity. -Avoid small, spidery veins that weave back and forth because they may rupture easily. -Do not use varicose veins.

Assisting a Patient with a Metered-Dose Inhaler (Step 4):

-Continue administering supplemental oxygen. -Allow the patient to breathe a few times, then give the second dose per direction from medical control or according to local protocol. -Monitor the patient's condition, and document the medication given, route, administration time, and response of the patient.

Administering Medication via the Intramuscular Route (Step 4):

-Cover the puncture site. -Immediately dispose of the needle and syringe in the sharps container. -Store any unused medication properly. -Monitor the patient's condition, and document the medication given, route, administration time, and patient response.

Dehydration

-Dehydration is defined as depletion of the body's total systemic fluid volume. -It is more common in older adults and young children. -It may take days to manifest and may be a result of a medical condition. -As fluid is lost from the vascular compartment, the body reacts by shifting interstitial fluid into the vascular area. This forces a shift of fluid from the intracellular to the extracellular compartments. A total systemic fluid deficit occurs. -Signs and symptoms of dehydration include: >Decreased level of consciousness (LOC) >Orthostatic hypotension >Dry mucous membranes >Tachycardia >Poor skin turgor >Flushed, dry skin >Decreased urine output -Causes of dehydration include: >Diarrhea >Vomiting >GI drainage >Hemorrhage >Insufficient fluid/food intake >Infection

Drawing Blood:

-Draw blood first, before fluids or medications are administered. -If you are having difficulty drawing blood, stop and finish establishing the IV line. -A Vacutainer connects to a catheter to assist with blood collection. -Attach the Vacutainer to the hub of the catheter sheath and release the hand holding pressure. -Grasp the Vacutainer in one hand to stabilize it while you insert the tubes for the blood draws. -If you do not have a Vacutainer setup, you can draw blood from the IV site using a 15- to 20-mL syringe. -Label all the tubes with: >The patient's name >Date >Time >Your name

Administering Medication via the Intranasal Route (Step 2):

-Draw up the appropriate dose of medication in the syringe, dispel air, and reconfirm medication. -Dispose of the needle properly.

Administering Medication via the Intranasal Route (Step 4):

-Explain the procedure to the patient (or to a relative if the patient is unresponsive) and the need for the medication. -Stop ventilation of the patient if necessary; remove any masks. -Insert the mucosal atomizer device into the larger and less deviated or less obstructed nostril while pinching off the opposite nostril.

External Jugular IV Lines:

-External jugular IV lines provide venous access through the external jugular veins of the neck. -These are the same veins used to assess jugular vein distention. -The vein is tamponaded by placing a finger or the edge of a tongue depressor on the vein just above the clavicle, causing the vein to fill. -If the vein is difficult to find, place the patient supine to facilitate venous return. -The catheter is inserted into the vein in the same manner as a normal IV line, except the insertion point is very specific. -The catheter is inserted midway between the angle of the jaw and the midclavicular line, with the catheter pointed toward the shoulder on the same side as the puncture site. -These punctures are difficult because a tough fibrous sheath that makes access difficult surrounds these veins.

Potential Complications if IO Infusion:

-Extravasation occurs when the IO needle does not rest in the IO space, but rather rests outside the bone. -The risk of extravasation can be reduced substantially by insuring the IO needle is at a 90° angle to the bone. -Suspect extravasation if the infusion does not run freely or if the site rapidly becomes edematous. -Discontinue the infusion immediately and reattempt insertion in the opposite leg. -Osteomyelitis is inflammation of the bone and muscle caused by an infection. -Failure to identify the proper anatomic landmark can damage the growth plate. -Through-and-through insertion occurs when the IO needle passes through both sides of the bone. -A pulmonary embolism can occur if particles of bone, fat, or marrow enter into the systemic circulation and lodge in a pulmonary artery. -Suspect a pulmonary embolism if the patient experiences acute shortness of breath, pleuritic chest pain, and cyanosis.

Obtaining Vascular Access (Step 9):

-Feel for a "pop" as the stylet enters the vein and observe for "flashback" as blood enters the catheter. -The clear chamber at the top of the catheter should fill with blood when the catheter enters the vein. -If you note only a drop or two, you should gently advance the catheter farther into the vein, approximately 1⁄8 to 1⁄4 inch (0.3 to 0.6 cm). -Apply pressure to occlude the catheter to prevent blood leaking while removing the stylet. -Place the thumb of the hand not holding the catheter over the end of the catheter that is currently situated inside the vein, so as not to pull the catheter and to prevent blood running out when you remove the needle. -With practice, you will be able to feel the catheter.

Filtration:

-Filtration is commonly used by the kidneys to clean blood. -Water carries dissolved compounds across the cell membranes of the tubules of the kidney. -The tubule membrane traps these dissolved compounds but lets the water pass through in much the same way that a coffee filter traps the grounds as water passes through it. -This cleans the blood of wastes and removes the trapped compounds from circulation, so they can be flushed out of the body.

Obtaining Vascular Access (Step 2):

-Flush or "bleed" the tubing to remove any air bubbles by opening the roller clamp. -Make sure no errant bubbles are floating in the tubing.

Nebulizer:

-For more severe problems, liquid bronchodilators may be aerosolized in a nebulizer for inhalation. -Small-volume nebulizers (also called updraft or handheld nebulizers) are the most commonly used method of administration of inhaled medications in the prehospital setting. -Oxygen or a compressed air source is connected to the nebulizer to produce the aerosolized mist. -Some nebulizers have been adapted with child-friendly shapes and images to ease the use with pediatric patients. -They may allow for blow-by administration to help the patient tolerate the medication. -Other methods used on patients include a nebulized mask that does not require the patient to hold the device. -Some adapters have been designed to allow providers to administer nebulized medications to intubated patients with each ventilation. -These devices may also be adapted for use with continuous positive airway pressure (CPAP) masks. -Patients with respiratory emergencies may be breathing inadequately (i.e., inadequate tidal volume, fast or slow respiratory rate) may not be able to effectively inhale beta agonist medications into the lungs via a nebulizer or an MDI. -Use a small-volume nebulizer in-line with the assistive device. -If the patient is intubated, assist with bag-mask ventilation or a ventilator by placing a short piece of corrugated tubing, separated by a T piece, to connect the nebulizer.

Converting pounds to kilograms:

-For patients who do not know their weight in pounds or who are unresponsive and unable to provide you with this information, you must: >Estimate the patient's weight in pounds (lb) >Convert pounds to kilograms (kg) -Although many of the medications given in emergency medicine are administered in a standard dose (for example, 1 mg of epinephrine), other paramedic-level medications are administered based on the patient's weight in kilograms (for example, 1 to 1.5 mg/kg of lidocaine). -Most medications administered to pediatric patients are based on their weight in kilograms. -There are two formulas that can be used to convert pounds to kilograms; use the one that is easiest for you to remember. -For example, when converting a 170-lb man's weight to kilograms, the formula would be as follows: >170 lb ÷ 2.2 = 77.27 kg -Because the value following the decimal point in the preceding example is less than 0.5, you may round the patient's weight in kg to 77.0. -If the value after the decimal point had been greater than 0.5, you would round the weight in kg to 78.0. -Although this may seem negligible, it is important to administer the most appropriate amount of the medication to the patient; it is good practice. -For example, when converting a 120-lb woman's weight to kg, the formula would be as follows: >Step 1: 120 lb ÷ 2 = 60 lb >Step 2: 60 lb × 10% = 6 >Step 3: 60 - 6 = 54 kg

Oral Administration:

-Forms of solid and liquid oral medications include capsules, timed-release capsules, lozenges, pills, tablets, elixirs, emulsions, suspensions, and syrups. -Oral medications are used when the desired effect is systemic and the medications are taken up by the intestines. -To give oral medications, you may use a small medicine cup, a medicine dropper, a teaspoon, an oral syringe, or a nipple. -Gather the appropriate equipment for the form of medication you are administering. -Check for indications, contraindications, precautions, and the 10 rights before administering an oral medication. -Medications administered by AEMTs using the oral route include aspirin and oral glucose. Follow these steps: >Take standard precautions. >Determine the need for the medication based on patient presentation. >Obtain a history, including any medication allergies. >Follow standing orders or contact medical control for permission. >Check the medication to be sure it is the right medication and not cloudy or discolored and that its expiration date has not passed. >Check the 10 rights of medication administration. >Determine the appropriate dose. >If the medication is liquid, pour the desired amount into a calibrated cup. >Instruct the patient to swallow the medication with water, if administering a pill or tablet. >Monitor the patient's condition, and document the medication given, route, time of administration, and patient response.

Hematoma:

-Hematomas result from vein perforation or improper catheter removal that allows blood to accumulate in the surrounding tissues. -Blood can be seen rapidly pooling around the IV site, resulting in tenderness and pain and in extreme cases, skin necrosis and slough. -Patients with a history of vascular diseases (including diabetes) or patients receiving certain medications (such as corticosteroids) may have a predisposition to vein rupture or have tendencies for hematomas to develop rapidly on IV insertion. -If a hematoma develops while you are attempting to insert a catheter, stop and apply direct pressure to help minimize bleeding. -If a hematoma develops after a successful catheter insertion, evaluate the IV flow and the hematoma. If the hematoma appears to be controlled and the flow is not affected, monitor the IV site and leave the line in place. -If the hematoma develops as a result of removing the IV line, apply direct pressure with a 4-inch × 4-inch gauze pad to the site.

Drawing Medication from an Ampule (Step 4):

-Hold the syringe with the needle pointing up, and gently tap the barrel to loosen air trapped inside and cause it to rise.

Hypotonic Solutions:

-Hypotonic fluid has a lower concentration of sodium than the cell. When this fluid is placed in the vascular compartment, it begins diluting the serum by introducing more solvent. Soon the serum osmolarity is less than the interstitial fluid; water is pulled from the vascular compartment into the interstitial fluid compartment and, eventually, the same process is repeated. -Hypotonic solutions hydrate the cells while depleting the vascular compartment. -These solutions may be needed for a patient on dialysis when diuretic therapy dehydrates the cells. They may also be used for hyperglycemic conditions such as diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. -Hypotonic solutions can cause a sudden fluid shift from the intravascular space to the cells, causing cardiovascular collapse and increased intracranial pressure, so hypotonic solutions are dangerous to use with patients experiencing a stroke or any head trauma. -Using hypotonic solutions on patients with burns, trauma, malnutrition, or liver disease is hazardous, because these patients are at risk for third spacing, an abnormal fluid shift into the serous linings of the body.

Isotonic Solutions:

-IV solutions are also categorized by their tonicity. -The three categories related to tonicity are: >Isotonic >Hypotonic >Hypertonic -Isotonic solutions such as normal saline (0.9% sodium chloride) possess nearly the same osmolarity as serum and other body fluids. -A solution's osmolarity indicates how easily (or not easily) water will move. -Because normal saline has similar osmolarity as serum and other body fluids, it stays inside the intravascular compartment. -Isotonic solutions expand the contents of the intravascular compartment without shifting fluid to or from other compartments. -This is useful when dealing with hypotensive or hypovolemic patients. -Although isotonic fluid does a good job of hydrating, this fluid remains in the vascular compartment, so be careful to avoid fluid overloading. -Patients with hypertension and heart failure are at greatest risk of fluid overload. -The extra fluid increases the workload of the heart, creating fluid backup in the lungs. -Lactated Ringer solution is generally used in the field for patients who have lost large amounts of blood. It contains the buffering compound lactate, which is metabolized in the liver to form bicarbonate—the key buffer that combats the intracellular acidosis associated with severe blood loss. -Lactated Ringer solution should not be given to patients with liver problems because they cannot metabolize the lactate. -D5W is a special type of isotonic solution. As long as it remains in the bag, it is considered an isotonic solution. -After administration, the dextrose is quickly metabolized, and the solution becomes hypotonic.

Performing IO Infusion (Step 3):

-Identify the proper anatomic site for IO puncture. Palpate the landmarks and then prepare the site. -Tibia placement: This site is reserved for the EZ-IO and the BIG. -Humerus placement: Humeral placement is typically reserved for adults when using the EZ-IO or the BIG.

Sternal IO Site:

-Identify the sternal IO site by palpating the sternal notch and using the IO device's adhesive target. -The sternal site has an extremely rapid flow rate. -The device location is near the chest compression landmarks; however, the device does not impede chest compressions.

Contraindications to IO Infusion:

-If a functional IV line is available, IO cannulation is not indicated. -Other contraindications to IO cannulation and infusion include: >Fracture of the bone intended for IO cannulation >Osteoporosis >Osteogenesis imperfecta (a congenital disease resulting in fragile bones) >Bilateral knee replacements (humeral and sternal sites remain an option) >A prosthetic limb at the IO site

Obtaining Vascular Access (Step 13):

-Open the IV line to ensure fluid is flowing and the line is patent. -Observe for any swelling or infiltration around the IV site. -If the fluid does not flow, check to see if the constriction band has been released. -If infiltration is noted, immediately stop the infusion and remove the catheter while holding pressure over the site with a piece of gauze to prevent bleeding.

Occlusion:

-If the flow rate is not sufficient to keep fluid moving out of the catheter tip and if blood enters the catheter, a clot may form and occlude the flow. -The first sign of a possible occlusion is a decreasing drip rate or the presence of blood in the IV tubing. -A positional IV site can cause occlusion, which means that fluid flows at different rates depending on the position of the catheter within the vein. -Proximity to a valve is often the reason for occlusion. -Other causes can be related to patient movement that allows the line to become physically blocked from either resting on the line or crossing the arms. -Occlusion may also develop if the IV bag nears empty and the blood pressure overcomes the flow and backs up in the line. -To determine whether an IV line should be reestablished, you may use a syringe prefilled with saline, or you may draw the saline from an IV bag. -After you have a full syringe of clean IV fluid, you will use it to add pressure to the line. -Gently apply pressure to the plunger to disrupt the occlusion and reestablish flow. -If flow is reestablished, ensure that the line is free and the rate is sufficient. -If the occlusion does not dislodge, discontinue the administration and reestablish an IV line in the opposite extremity or at a proximal location on the same extremity.

Administering a Medication via a Small-Volume Nebulizer (Step 2):

-If the medication is in a premixed package, then add it to the bowl of the nebulizer. -If it is not premixed, then add the medication to the bowl and mix it with the specified amount of normal saline, usually 2.5 to 3 mL.

Make sure you understand the physician's orders:

-If the orders are unclear or seem inappropriate for the patient's condition (for example, the dosage is more than the usual range or an unusual route of administration is requested), ask the physician to repeat the order. Do not assume that the physician is infallible.

Assisting a Patient with a Metered-Dose Inhaler (Step 3):

-If the patient has a spacer, then attach it to allow more effective use of the medication. -Have the patient depress the handheld inhaler as he or she begins to inhale deeply. -Instruct the patient to hold his or her breath for as long as he or she comfortably can to help the lungs absorb the medication.

Inquire about any medication allergies the patient may have:

-If the patient is unresponsive, try to obtain this information from another reliable source of information. -Check for medic alert jewelry or tags as well.

Obtaining Vascular Access (Step 10):

-Immediately dispose of all sharps in the proper container.

Nerve, Tendon, or Ligament Damage:

-Improper identification of anatomic structures around the IV site can result in perforation of tendons, ligaments, or nerves. -An IV site choice around joints increases the risk for perforation of these structures. -Patients will experience sudden, severe shooting pain when a nerve, tendon, or ligament is perforated. -Numbness in the extremity after the incident is common. -Immediately remove the catheter and select another IV site. Be sure to document the event.

Diffusion:

-In diffusion, compounds or charges concentrated on one side of a cell membrane will move across it to an area of lower concentration to balance themselves across the membrane. -To visualize this, imagine that too many people show up for a theater performance. -The management decides to open another seating area to accommodate the crowd. -Patrons (charges or compounds) are concentrated in the small seating area (the cell) outside the door (the cell membrane) leading to the new seating area. -When the theater manager opens the door, patrons can move through (selective cell membrane permeability) from the congested seating area (down a concentration gradient). -The patrons spread themselves out evenly (diffuse) throughout the total area, some choosing to stay behind in the original seating area as others move into the new area, so that they all have an equal amount of room.

Volume Conversions:

-In the prehospital setting, you will usually be dealing with only two measurements of volume: milliliters and liters. -Because 1 L equals 1,000 mL, simply divide or multiply by 1,000 or move the decimal point three places to the left or right. -When you are converting milliliters to liters, divide the smaller unit of volume by 1,000 or simply move the decimal point three places to the left. -When you are converting liters to milliliters, multiply the amount in liters by 1,000 or move the decimal point three places to the right.

Infiltration:

-Infiltration is the escape of fluid into the surrounding tissue. This escape of fluid causes a localized area of edema. -Some of the more common reasons for infiltration include: >The IV line has passed completely through the vein and out the other side. >The patient is moving excessively, causing the catheter to become dislodged from the vein. >The tape used to secure the area has become loose or dislodged (again causing the catheter to become dislodged from the vein). >The catheter was started at an angle that is too shallow and has only entered the fascia surrounding the vein (this is more common with IV lines in larger veins, such as those in the upper arm and neck). -Signs and symptoms include: >Edema at the catheter site >Continued IV flow after occlusion of the vein above the insertion point >Patient complaints of tightness and pain around the IV site -To correct the infiltration, discontinue administration and reestablish the IV line in the opposite extremity or at a more proximal location on the same extremity. -Apply direct pressure over the swollen area to reduce further swelling or bleeding into the tissue. -Avoid wrapping tape around the extremity for direct pressure because this could create a constricting band.

Drawing Medication from an Ampule (Step 3):

-Insert a filtered needle into the ampule without touching the outer sides of the ampule. -Draw the solution into the syringe and dispose of the ampule in the sharps container.

Administering Medication via the IV Bolus Route (Step 2):

-Insert the needle into the port (or screw the syringe into the needless hub) and pinch off the IV tubing proximal to the administration port. -Failure to shut off the line will result in the medication taking the pathway of least resistance and flowing into the bag instead of into the patient. -Administer the correct dose of the medication at the appropriate rate. -Some medications must be administered very quickly, whereas others must be pushed slowly to prevent adverse effects.

Administering Medication via the Intraosseous Route (Step 3):

-Insert the needle into the port and clamp off the IV tubing proximal to the administration port. -This is usually managed with a three-way stopcock. -Failure to shut off the line will result in the medication taking the pathway of least resistance and flowing into the bag instead of into the patient. -Administer the correct dose of the medication at the proper push rate. -Some medications must be administered quickly, whereas others must be pushed slowly to prevent adverse effects.

Intramuscular Administration:

-Intramuscular (IM) injections are made by penetrating a needle through the dermis and subcutaneous tissue into the muscle layer. -This allows administration of a larger volume of medication (up to 5 mL) than the subcutaneous route -Common anatomic sites for IM injections for adults and children include the following: >Deltoid muscle—the muscle of the upper part of the arm that covers the prominence of the shoulder. The site for injection is approximately 11⁄2 to 2 inches below the acromion process on the lateral side. >Vastus lateralis muscle—the large muscle on the lateral side of the thigh >Rectus femoris muscle—the large muscle on the anterior side of the thigh >Gluteal area—the buttocks, specifically the upper lateral aspect of either side -AEMT medications that may be administered intramuscularly include epinephrine and glucagon.

Intranasal Medications:

-Intranasal medications include nasal spray for congestion or solutions to moisten the nasal mucosa. -Intranasally administered medications are rapidly absorbed, providing a more rapid onset of action than IM injections. -Administration of emergency medications via the intranasal route is performed with a mucosal atomizer device.

Intraosseous Infusion:

-Intraosseous (IO) means "within the bone." -Intraosseous infusion is a technique of administering fluids, blood and blood products, and medications into the intraosseous space of the proximal tibia, humeral head, or sternum. -Long bones, such as the tibia, consist of a shaft (diaphysis), the ends (epiphyses), and the growth plate (epiphyseal plate). -IO vasculature drains into the central circulation by a network of venous sinuses and canals. -When peripheral veins collapse, it makes IV access extremely difficult. -The IO space remains patent unless trauma has been sustained to its bony structure. -The IO space absorbs IV fluids and medications rapidly into the central circulation. -IO infusion is indicated when you are unable to rapidly obtain IV access in a critically ill or injured patient (e.g., in profound shock, cardiac arrest, or status epilepticus). -Attempt one or two IV lines within 90 seconds prior to an IO infusion attempt.

Drawing Medication from a Vial (Step 3):

-Invert the vial, clean the rubber stopper with an alcohol prep, and insert the needle through the rubber stopper into the medication. -Expel the air in the syringe into the vial and then withdraw the amount of medication needed.

Complications of IV Therapy: Local IV Site Reactions:

-Local reactions include problems such as infiltration; phlebitis; occlusion; vein irritation; hematoma; nerve, tendon, or ligament damage; and arterial puncture. -Systemic complications include allergic reactions, circulatory overload, air embolus, vasovagal reactions, and catheter shear. -Most local reactions require that you discontinue the administration, reestablish the IV line in the opposite extremity, and document the event.

Verify the form, dose, and route of the medication:

-Make sure that the form of the medication, the dose, and the route are all consistent with the order you received. -For example, suppose that you are told to administer a sublingual nitroglycerin tablet. The patient's nitroglycerin bottle is empty, but he has another bottle of nitroglycerin capsules. These are to be swallowed four times per day. The medication is the same, but the form, dose, and route of delivery are different from the order given. You may not substitute the capsules for the tablets without specific orders from medical control. -You are responsible for knowing the appropriate doses for the medications you carry on your ambulance. -You are also responsible for accurately calculating the appropriate dose of the medication. -Always recheck your medication calculations before administration to ensure that you are administering the right dose. -A medication given by an inappropriate route—even if it is the right medication—could have disastrous and possibly fatal consequences.

Manually inserted IO needles:

-Manually inserted IO needles (i.e., Jamshedi needle, Cook catheter) were the original devices used for establishing IO access in children and are still widely used in the prehospital setting. -They consist of a solid boring needle (trocar) inserted through a sharpened hollow needle. -The IO needle is pushed into the bone with a screwing, twisting action. -After the needle pops through the bone, the solid needle is removed, leaving the hollow steel catheter in place. -The IV tubing is attached to this catheter. -Because manually inserted IO needles are long, rest at a 90° angle to the bone, and are easily dislodged, they require full, careful immobilization. -Stabilize the IO needle in the same manner that you would any impaled object.

Medications Administered by Inhalation:

-Many medications used in the treatment of respiratory emergencies are administered via the inhalation route. -The most common inhaled medication is oxygen. -Beta-2 agonist bronchodilators (e.g., albuterol [Ventolin, Proventil], isoetharine [Bronkosol], metaproterenol [Alupent]) are often administered in the prehospital setting for patients experiencing respiratory distress.

Administering Medication via the Intranasal Route (Step 7):

-Monitor the patient's condition, and document the medication given, route, time of administration, and patient response.

(Systemic Complications) Allergic Reactions:

-Often, allergic reactions are minor, but anaphylaxis is possible and therefore any allergic reaction must be treated aggressively. -Allergic reactions can be related to an individual's unexpected sensitivity to medication being infused with the intravenous fluid or to a prep solution such as iodine used to prepare the site for intravenous administration. -Maintain vigilance with any IV line for a possible reaction. -Common signs and symptoms of an allergic reaction include: >Itching >Shortness of breath >Edema of face and hands >Urticaria >Bronchospasm >Anaphylaxis >Wheezing -If an allergic reaction occurs, discontinue IV administration of the medication and remove the solution. -Leave the catheter in place as an emergency medication route. -Notify medical control immediately and maintain an open airway. -Monitor the patient's airway, breathing, and circulation and vital signs. -Document the event and keep the IV bag or medication for evaluation by the hospital.

Osmosis:

-Osmosis is movement of water across a cell membrane. -Osmosis occurs when there are different concentrations on each side of a membrane, and equal numbers of molecules on either side are displaced to the other side. Essentially, osmosis is diluting a solution by adding water, whereas diffusion is moving solid particles to accomplish the same thing. -Increasing the concentration of sodium in the surrounding (extracellular) fluid decreases the water in that fluid. Water moves out of the cell to create a balance of water molecules and to dilute the increased concentrations of sodium. Where sodium goes, water follows. -The movement of water adds additional molecules to the extracellular compartment to create a balanced solution. This increased, yet balanced, volume puts pressure against the cell wall, called osmotic pressure. -Osmotic pressure drives several important metabolic functions in the body, including cellular perfusion. -The effects of osmotic pressure on a cell are referred to as the tonicity of the solution.

Over-the-needle Catheter:

-Over-the-needle catheters are sized by their diameter, which is referred to as the gauge. -The larger the diameter of the catheter, the smaller the gauge. Thus, a 14-gauge catheter has a greater diameter than a 22-gauge catheter. -The larger the diameter, the more fluid can be delivered through the catheter. Select the largest-diameter catheter that will fit the vein you have chosen or that will be the most appropriate and comfortable for the patient. -A good rule of thumb to follow: the more distal the IV site, the smaller the catheter. -An 18-gauge catheter is usually a good size for adult patients. -Metacarpal veins of the hand accommodate 18- to 20-gauge catheters. -Antecubital veins of the upper arm can often accommodate larger gauge catheters. -Over-the-needle catheters can be used for all adults and most children for long-term IV therapy. The plastic catheter allows for greater patient movement and often does not require immobilizing the entire limb. -Over-the-needle catheters come in different gauges as well as in different lengths. The most common lengths are 1 inch and 11⁄4 inches. -The shorter the catheter, the faster fluid can flow through it. -Newer over-the-needle catheters use several different methods to protect an AEMT from the possibility of a contaminated stick. -One of the more common methods is automatic needle retraction after insertion, usually accomplished with a locking slide mechanism or a spring-loaded slide mechanism.

Specific Medications AEMTs can administer:

-Oxygen -Oral glucose -Glucagon -50% dextrose in water (D50W) -IV fluids—D5W (5% dextrose in water), normal saline, lactated Ringer solution -Epinephrine (intramuscular [IM] or subcutaneous) -MDI medications—albuterol -Nebulized medications—albuterol -Nitroglycerin—spray, paste, tablets -Nitrous oxide -Naloxone -Aspirin -Others based on local protocols

Parenteral Medications:

-Parenteral medications are those that are given through any route other than the GI tract and include: >Subcutaneous >IM >IV >bolus >IO >Sublingual >Transcutaneous >Transdermal >Inhalation -IV administration is the most common route used in the prehospital setting and generally is the quickest route for getting medication into the central circulation. -Choose the appropriate-size syringe and appropriate needle length for the desired route. -Syringes consist of a plunger, body or barrel, flange, and tip. -The 3-mL syringe is the most commonly used for injections.

(Systemic Complications) Air Embolus:

-Patients who are already ill or injured can be affected if any air is introduced into the IV line. -Properly flushing an IV line helps eliminate potential of introducing air into a patient. -Be sure to replace empty IV bags with full ones. -Entrapment of air may also occur if IV catheters in large vessels, such as external jugular veins, are left open to the air. -Quickly attach the IV line to prevent such an occurrence. -If your patient begins to experience respiratory distress with unequal breath sounds, consider the possibility of an air embolus. -Other associated signs and symptoms include: >Cyanosis (even in the presence of high-flow oxygen)Signs and symptoms of shock >Loss of consciousness >Respiratory arrest -Place the patient on his or her left side with the head down to trap any air inside the right atrium or right ventricle, and rapidly transport to the closest, most appropriate facility. -Be prepared to assist ventilations if the patient experiences increasing shortness of breath or inadequate tidal volume. Document the event.

Performing IO Infusion (Step 6):

-Perform the IO puncture by first stabilizing the tibia, then placing a folded towel under the knee, and finally holding the extremity in a manner to keep your fingers away from the site of puncture. -For humeral placement, continue to apply pressure on the anterior and inferior aspects of the humerus. -Insert the needle at a 90° angle to the insertion site. -Advance the needle with a twisting motion until a "pop" is felt. -Unscrew the cap and remove the stylet from the needle.

Administering Medication via the Subcutaneous Route (Step 4):

-Pinch the skin surrounding the area, advise the patient of a stick, and insert the needle at a 45° angle. -Pull back on the plunger to aspirate for blood. -The presence of blood in the syringe indicates you may have entered a vein. -Remove the needle and hold pressure over the site. -Discard the syringe and needle in the sharps container. -Prepare a new syringe and needle and select another site. -If there is no blood in the syringe, inject the medication and remove the needle. -Immediately place it in the sharps container.

Administering Medication via the IV Bolus Route (Step 3):

-Place the needle and syringe into the sharps container. -Unclamp the IV line to flush the medication into the vein. -Allow it to run briefly wide open, or flush with a 20-mL bolus of normal saline. -Readjust the IV flow rate to the original setting. -Properly store any unused medication. -Monitor the patient's condition, and document the medication given, route, time of administration, and patient response.

Administering Medication via the Intraosseous Route (Step 4):

-Place the needle and syringe into the sharps container. -Unclamp the IV line to flush the medication into the site. -Flush with at least a 20-mL bolus of normal saline. -Readjust the IV flow rate to the original setting. -Store any unused medication properly. -Monitor the patient's condition, and document the medication given, route, time of administration, and response of the patient.

Prefilled Syringes:

-Prefilled syringes are designed for ease of use. -There are also single-dose disposable cartridges that use a reusable syringe such as a Tubex or Abboject. -Prefilled syringes come in tamper-proof boxes and are separated into the glass medication cartridge and a syringe. -D50W is an example of a medication that comes as a prefilled syringe. -To assemble the two-part prefilled syringe, pop the yellow caps off of the syringe and the medication cartridge, insert the drug cartridge into the barrel of the syringe, and screw them together. -Remove the needle cover and expel air in the manner previously described.

Choosing and IV Solution:

-Prehospital patient care and IV therapy center on identifying the type of situation and the needs of the patient. -Ask yourself: >Is the patient's condition critical? >Is the patient's condition stable? >Does the patient need fluid replacement? -Each IV solution bag is wrapped in a protective sterile plastic bag and is guaranteed to remain sterile until the posted expiration date. -After the protective wrap is torn and removed, the IV solution has a shelf life of 24 hours. -The bottom of each IV bag has an access port for connecting the administration set.A removable pigtail that represents a point-of-no-return line protects the sterile access port. After this pigtail is removed, the bag must be used immediately or discarded. -IV solution bags come in different fluid volumes. Volumes commonly used in hospitals are 1,000 mL, 500 mL, 250 mL, and 100 mL; the more common prehospital volumes are 1,000 mL and 500 mL.

Drawing Medication from an Ampule (Step 5):

-Press gently on the plunger to dispel any air bubbles. -Recap the needle using the one-handed method to avoid contamination. -Dispose of the needle in the sharps container and attach a standard hypodermic needle to the syringe if necessary to administer the medication.

Administering Medication via the Intranasal Route (Step 5):

-Quickly spray the medication dose into a nostril.

Drawing Medication from a Vial (Step 5):

-Recap the needle using the one-handed method and avoiding contamination. -Label the syringe if it is not immediately given to the patient.

Obtaining Vascular Access (Step 11):

-Remove the constricting band.

Preparing Administration Set (Step 2):

-Remove the protective covering found on the end of the IV bag. -The bag is still sealed and will not leak until the piercing spike punctures this port. -Remove the protective cover from the piercing spike (remember, this spike is sterile and sharp!) and slide the spike into the IV bag port until it is seated against the bag.

Performing IO Infusion (Step 7):

-Remove the stylet from the catheter.

The 10 Rights of medication administration:

-Right patient -Right medication -Right dose -Right route -Right time -Right documentation and reporting -Right assessment -Right to refuse -Right evaluation -Right patient education

Obtaining Vascular Access (Step 15):

-Secure IV tubing and adjust the flow rate while monitoring the patient.

Obtaining Vascular Access (Step 14):

-Secure the catheter with tape or a commercial device.

Assisting a Patient with a Metered-Dose Inhaler (Step 2):

-Shake the inhaler vigorously several times. -Stop administering supplemental oxygen and remove any mask from the patient's face. -Ask the patient to exhale deeply and, before inhaling, to put his or her lips around the opening of the inhaler.

Rectal Administration:

-Some AEMTs may be allowed to administer D50, but whether rectal administration is allowed depends on local protocols. -If it is allowed, administering D50 by this route is a last resort, when a patient is hypoglycemic and no other route is an option (IV access cannot be established). -Check for indications, contraindications, and precautions before giving D50 rectally. -Follow these steps: >Take standard precautions. >Determine the need for the medication based on patient presentation. >Obtain a history, including any medication allergies. >Follow standing orders, or contact medical control for permission. >Determine the appropriate dose, and check that the medication is the right medication, there is no cloudiness or discoloration, and the expiration date has not passed. >When inserting a suppository, use a water-soluble gel for lubrication. Insert the suppository into the rectum approximately 1 to 11⁄2 inches while instructing the patient to relax and not to bear down. >For medications that are in liquid form, some modifications are needed. >You may use a nasopharyngeal airway, a small endotracheal (ET) tube, an 18-gauge IV catheter without a needle, or a commercial device as your delivery device. >Lubricate the end of the nasal airway or ET tube with a water-soluble gel, and gently insert it approximately 1 to 11⁄2 inches into the rectum. >Instruct the patient to relax and not to bear down. >With a needleless syringe, gently push the medication through the tube. >After the medication has been delivered, remove and dispose of the tube or syringe in an appropriate container. >Monitor the patient's condition, and document the medication given, route, time of administration, and patient response.

Preparing Administration Set (Step 3):

-Squeeze the drip chamber to fill to the line marking the chamber (half full) and then run fluid into the line to flush the air out of the tubing.

Administering Medication via the Intramuscular Route (Step 3):

-Stretch the skin over the cleansed area, advise the patient of a stick, and insert the needle at a 90° angle. -Pull back on the plunger to aspirate for blood. -The presence of blood in the syringe indicates you may have entered a blood vessel. -Remove the needle, and hold pressure over the site. -Discard the syringe and needle in the sharps container. -Prepare a new syringe and needle and select another site. -If there is no blood in the syringe, inject the medication and remove the needle.

Subcutaneous Injection:

-Subcutaneous injections are given into the loose connective tissue between the dermis and the muscle layer. -Volumes administered subcutaneously are usually 1 mL or less. -The injection is performed using a 24- to 26-gauge 1⁄2-inch to 1-inch needle. -Common sites include: >The upper part of the arms >The anterior part of the thighs >The abdomen -An example of an AEMT medication that is administered subcutaneously is epinephrine. -Use aseptic technique. -Aseptic technique may be accomplished via: >The sterilization of equipment used >Antiseptics >Disinfectants

Obtaining Vascular Access (Step 4):

-Take standard precautions before making contact with the patient. -Palpate a suitable vein. Veins should be "springy" when palpated. -Stay away from areas that are hard when palpated.

Performing IO Infusion (Step 2):

-Take standard precautions.

Administering Medications through a Saline Lock:

-Take standard precautions. -Determine the need for the medication based on patient presentation. -Obtain a history, including any medication allergies and vital signs. -Follow standing orders, or contact medical control for permission. -Check the 10 rights of medication administration including ensuring that it is not cloudy or discolored and that its expiration date has not passed. -Explain the procedure to the patient and the need for the medication. -Assemble needed equipment and draw up the medication. -Draw up 20 mL of normal saline to use as a flush for the medication. -Cleanse the injection port with alcohol or remove the protective cap if using the needleless system. -Insert the needle into the port while holding it carefully or screw the syringe onto the port. -Pull back slightly on the syringe plunger and observe for blood return. -If blood appears, slowly inject the medication, watching for infiltration. If resistance is felt, or if the patient complains of any discomfort, discontinue administration immediately. -A new site will need to be established. -Place the needle and syringe into the sharps container. -Clean the port and insert the needle with the syringe containing the flush. -Flush the saline lock and place the needle in the sharps container. -Store any unused medication properly. -Monitor the patient's condition, and document the medication given, route, time of administration, and patient response.

Administering a Medication via a Small-Volume Nebulizer (Step 1):

-Take standard precautions. -Determine the need for an inhaled bronchodilator based on patient presentation. -Obtain a history, including any medication allergies and vital signs. -Follow standing orders or contact medical control for permission. -Check the 10 rights of medication administration. -Assemble and check needed equipment.

Administering Medication via the Intranasal Route (Step 1):

-Take standard precautions. -Determine the need for the medication based on patient presentation. -Obtain a history, including any medication allergies and vital signs. -Assemble and collect the needed equipment, including the mucosal atomizer device. -Follow standing orders, or contact medical control for permission. -Check the 10 rights of medication administration out loud with your partner.

Administering Medication via the Intramuscular Route (Step 1):

Administering Medication via the IV Bolus Route (Step 1):

Administering Medication via the Subcutaneous Route (Step 1):

Administering Medication via the Intraosseous Route (Step 1):

Administering Medication via the Sublingual Route (Step 1):

Preparing Administration Set (Step 1):

-Take standard precautions. -Ensure you have chosen the correct administration set, tubing is not tangled, and protective covers are in place. -Ensure you have the proper solution, that it is clear and has not expired, and that the protective tail port covers are in place. -Move the roller clamp to the off (or open) position.

Assisting a Patient with a Metered-Dose Inhaler (Step 1):

-Take standard precautions. -Obtain an order from medical control or follow local protocol. -Assemble the needed equipment. -Ensure you have the right medication, right patient, right dose, and right route, and that the medication is not expired. -Ensure the patient is alert enough to use the inhaler. -Check to see whether the patient has already taken any doses. -Obtain baseline breath sounds for comparison after a few minutes of inhaler use. -Ensure the inhaler is at room temperature or warmer.

Securing the line:

-Tape the area so that the catheter and tubing are securely anchored in case of a sudden pull on the line. -Double back the tubing to create a loop that will act as a shock absorber. -Avoid any circumferential taping around any extremity.

Obtaining Vascular Access (Step 3):

-Tear tape prior to venipuncture or have a commercial device available. -Collect and open antiseptic swabs, gauze pads, and anything else needed for vascular access per local practice.

Pediatric IV Considerations:

-The 20-, 22-, 24-, or 26-gauge catheters are best for insertion depending on the size of the patient and the size of available veins. -Butterfly catheters are ideal for pediatric patients. -Scalp veins are best used in young infants. -Explain what you are doing to both the child and the parent. -Hand veins are painful and difficult to manage in younger pediatric patients but remain the location of choice for starting peripheral IV lines. -Shine a penlight through the palm side of the hand to illuminate the veins on the back side of the hand. -Graze the surface of the hand with your fingernail so you can find the location. -Proceed with the IV insertion. -When securing a scalp vein, tape a paper cup over the site to avoid applying any direct pressure to the butterfly catheter.

Bone Injection Gun (BIG):

-The Bone Injection Gun (BIG) is a spring-loaded device that is used to insert an IO needle into the proximal tibia of adult and pediatric patients and the humeral head in adults. -It comes in an adult size and a pediatric size. -Although both versions offer the same operational features, the depth of insertion is different for the adult and pediatric devices. -The BIG uses the safety lock as the stabilization device after the device has been inserted. -When you are ready to remove the device, use the stabilization device as the removal tool. -Place the wider side of the removal tool over the connection port. -Pull the device out in one swift motion while grasping onto the removal tool.

EZ-IO Device:

-The EZ-IO features a handheld battery-powered driver, to which a special IO needle is attached. -This device is used to insert an IO needle into the proximal or distal tibia of adults and children and the humeral head in adults when IV access is difficult or impossible to obtain. -The battery-powered driver of the EZ-IO is universal, but different sizes of needles are available depending on the patient. -The needle size is estimated based on the insertion site and patient's weight; however, the ultimate determining factor in needle size selection is the amount of subcutaneous tissue present over the insertion site. -When sizing the needle, you should ensure at least one hash mark (5 mm) can be seen after insertion. -Use a 10-mL syringe to remove an EZ-IO. -Attach the syringe to the IO's Luer lock, twist the syringe clockwise, and pull the device out in one swift motion.

FAST Devices:

-The FAST devices (First Access for Shock and Trauma) were the first IO devices approved for use in patients age 12 years and older. -Four design elements allow IO placement in the sternum using FAST devices: >An infusion tube and subcutaneous portal >An introducer >A target/strain relief patch >A protective dome -FAST devices can be used during cardiac arrest. -Although chest compressions can coincide with FAST IO use, you must pause mechanical CPR devices during the insertion phase. -Mechanical CPR can continue after the FAST device is stabilized. -The FAST1 is the original sternal IO device. -It consists of a 14-gauge infusion tube and 10 stabilization needles. -The device is completely manual (no batteries required). The FAST Responder (FASTR) is an updated device that has some advantages. -Many of the components are already assembled, expediting the insertion process. -The device also has a safety lock that must be removed before insertion. -The FASTR only requires 32 pounds (15 kg) of pressure for insertion. -If sternal IOs are the preference for your EMS system, familiarize yourself with both devices. -Both devices are designed to remain in place for a maximum of 24 hours. -To remove either FAST device, firmly grasp the insertion tube and pull steadily until the device is dislodged. -Use one continuous motion for removal; avoid starting and stopping.

Administering Medication via the Intraosseous Route:

-The IO route is used for critically ill or injured children and adults when IV access is difficult or impossible to obtain. -Unlike with an IV line, fluid does not flow well into the bone because of resistance, so it is necessary to use a large syringe to infuse the fluid. -Use a pressure infuser device when infusing fluids in adults.

Administering Medication via the IV Bolus Route:

-The IV route places the medication directly into the circulatory system. -This is the fastest route of administration because it bypasses most barriers to drug absorption. -Some medications require an initial bolus and then a continuous IV infusion to maintain a therapeutic level of the medication.

New Intraosseous Device (NIO) Device:

-The New Intraosseous (NIO) device is a device that is placed in the proximal tibia of an adult patient. -The humeral head is an alternative site for this device. -The spring-loaded device contains neither drill nor battery. -It is inserted by unlocking a safety cap. -While applying downward pressure with the dominant hand, the fingers of the other hand are used to pull trigger wings up to deploy the device. -The device is then pulled up in a rotating motion while the needle stabilizer is held against the skin. -After the introducing trocar is removed, any Luer-lock tubing can be attached. -A pediatric version, NIO Pediatric (NIO-P), is also available. -This device has an adjustable dial, allowing the provider to adjust by age or depth (if excessive girth for the age is anticipated). -At the time of this writing, the NIO-P is approved for placement in the proximal tibia only.

Desired Dose:

-The desired dose (that is, the drug order) is the amount of a medication that the physician orders you to administer to a patient. -It may be expressed as:A standard dose (for example, 25 g of dextrose)A specific number of grams or milligrams per kilogram of body weight (for example, 0.1 mg/kg is the pediatric dose for naloxone)

Proximal Tibia IO Site:

-The flat bone of the proximal tibia is located medial to the tibial tuberosity, the bony protuberance just below the knee. -It is necessary to feel the leg to know the difference between the first and second landmarks (these cannot be seen; they must be felt). -To locate the proximal tibia IO site, palpate the tibial tuberosity, then palpate 2 cm medially. -This is the site for adult patients. -For pediatric patients, palpate 1 to 2 cm distally to avoid the epiphyseal plate.

Overhydration

-When the body's total systemic fluid volume increases, overhydration occurs. -Fluid fills the vascular compartment, filters into the interstitial compartment, and finally is forced from the engorged interstitial compartment into the intracellular compartment. This fluid backup can result in death. -Signs and symptoms of overhydration include: >Shortness of breath >Puffy eyelids >Edema >Polyuria (excessive urination) >Moist crackles (rales) >Acute weight gain -Causes of overhydration include: >Unmonitored IV lines >Kidney failure >Prolonged hypoventilation

CPAP

-When utilizing CPAP, most manufacturers have a nebulizer that is designed to work with their device. -The nebulizer should be placed between the assistive device and mask, or ET tube if the patient is intubated, with a separate oxygen line connected to the nebulizer.

Inserting the IV Catheter:

-The following considerations apply to any technique: >Keep the beveled side of the catheter up when inserting the needle in a vein. >Maintain adequate traction on the vein during cannulation. >Apply a constricting band above the site you have chosen for the insertion to allow blood to fill the veins. >A constricting band helps create additional vascular pressure to engorge the veins with blood below the band. >Constricting bands should be snug enough to substantially diminish venous flow but should not hamper arterial flow. >Leave the constricting band in place only long enough to complete the IV insertion, blood draws, and line attachment. >Do not leave the constricting band applied while you assemble IV equipment. -If a commercial device is not available, constricting bands can be made of any available material, such as: >A Penrose drain > A blood pressure cuff Gloves >Surgical tubing -Prep the site with an alcohol swab, iodine swab, or chlorhexidine (Chlora-Prep). -Apply gentle downward or lateral traction on the vein with your free hand while holding the catheter, bevel side up, in your dominant hand. -Establish an insertion angle of approximately 45°. -Advance the catheter through the skin until the vein is pierced (there may or may not be a flash of blood in the catheter flash chamber); then immediately drop the angle down to approximately 15° and advance the catheter a few more millimeters to ensure the catheter sheath is in the vein. -Slide the sheath off the needle and into the vein. -After the catheter is fully advanced, apply pressure to the vein proximal to the end of the indwelling catheter, remove the needle, and dispose of it in a sharps container.

Check the expiration date and condition of the medication:

-The last step before administering a medication is to make sure the expiration date has not passed. Prescription and OTC medications should have an expiration date on their labels. Check the date. If no date can be found, be suspicious. -Check for defects in the vial, preloaded syringe, or ampule, noting whether the container appears to be cracked or damaged. -If the medication looks suspicious in any way, do not use it. -If you find discoloration, cloudiness, or particles in a liquid medication, you should not administer it. -If a patient with asthma gives you a metered-dose inhaler (MDI) and the expiration date on it is smudged, you should not administer it. -Confirm medication compatibility. -If you have orders to administer more than one medication, make sure that the medications are compatible. Some medications will not mix with others, which could cause a precipitate to form in the solution. -Should any cloudiness occur after a medication has been injected into IV tubing, clamp the tubing immediately and replace it with a new administration set. -Dispose of any syringes and needles safely. -Do not try to recap a needle, for the likelihood of sticking yourself in the process is quite high; rather, immediately dispose of the needle and syringe in a sharps container. -Monitor the patient for possible adverse side effects. -Reassess the vital signs, especially heart rate and blood pressure, at least every 5 minutes or as the patient's condition warrants. -Always document your actions and the patient's response on the patient care report after administering a medication. -Include: >Name of the medication >Dose of the medication >Time you administered the medication >Route of administration >Your name or the name of the person who administered the medication >Patient's response to the medication, whether positive or negative >Did the patient's condition improve, get worse, or not change at all? >Were there any side effects? >If your performance should ever be questioned, documentation is your best defense.

The Metric System:

-The metric system is a decimal system based on multiples of 10. -It is used to measure length, volume, and weight. >Meter (m): The basic unit of length >Liter (L): The basic unit of volume >Gram (g): The basic unit of weight -Prefixes demonstrate the fraction of the base being used. -Commonly used prefixes, from smallest to largest, include: >micro- = 0.000001 >milli- = 0.001 >centi- = 0.01 >kilo- = 1,000 -The volume (for example, milliliters) and weight (for example, micrograms, milligrams, grams) of the medication to be administered is usually only a fraction of the total amount of its packaged form. -You must be able to convert weights and then determine how much volume is required to achieve the desired dose.

Obtain an order from medical control:

-This order may be given to you directly, through online medical control via telephone or radio, or it may be indirect, through protocols that contain standing orders for the administration of certain medications. -When communicating with medical control about administering a particular medication, make sure that the medication is indicated for the patient's condition. -Given the patient's clinical presentation, you must know: >The right time to administer a medication (that is, when the medication is indicated) >When not to administer a medication (that is, when the medication is contraindicated) >Specific intervals for repeated doses -The decision to order the administration of any given medication is complex, involving such considerations as the patient's age, weight, clinical status, allergy history, concomitant medical problems, and other drugs he or she may be taking, including prescription medications, over-the-counter (OTC) medications, and recreational drugs. -It is critical that you obtain and communicate complete, accurate information about the patient to enable the physician to make prudent, correct decisions about medication administration. -Verify that your patient is indeed the right patient. In situations in which there are multiple patients, reconfirm the patient's name and compare it with the wristband or triage tag. -If you are assisting a patient with his or her medication, be sure it is prescribed to that patient.

Repeat any orders, word for word, for verification:

-This will help ensure that you understand the order and that the physician did not inadvertently give you an incorrect dosage order. -In the repetition, state: >The name of the medication >The dose >The route by which it is to be given -If your partner does not hear the exchange of information, you should repeat the order to him or her as an additional safety measure.

Thrombophlebitis:

-Thrombophlebitis is not usually seen with the emergency prehospital patient. -You may encounter it in patients who abuse drugs, as well as in patients who are receiving long-term IV therapy in a hospital, home care, or hospice setting. -Often, thrombophlebitis is associated with fever, tenderness, and red streaking up the associated vein. -Hardening of the vein can occur if a vein has been repeatedly punctured, as seen with drug abuse. Some of the more common causes for thrombophlebitis include localized irritation and infection from nonsterile equipment, prolonged IV therapy, or irritating IV solutions. -Vein irritation is usually caused by an infusion that is too rapid. -If redness develops at the IV site with rapidly developing thrombophlebitis, discontinue the infusion and save the equipment for later analysis. -Reestablish the IV line in the other extremity with all new equipment in case there were unseen contaminants in the old equipment. -Document the event and the patient's response.

Administering a Medication via a Small-Volume Nebulizer (Step 4):

-With the MDI or handheld nebulizer in position, instruct the patient on the proper way to breathe. -Have the patient breathe as deeply as possible and hold his or her breath for 3 to 5 seconds before exhaling. -Continue to coach the patient as needed. -Monitor the patient's condition, and document the medication given, route, time of administration, and response of the patient to the medication.

Attaching a FAST 1 Device:

-To attach a FAST1 device: >Align the adhesive target on the patient and prepare to insert the device into the manubrium. >The manubrium is approximately 15 mm below the sternal notch, and at 13.3 mm, it is the thickest part of the sternum. >The stabilization needles prevent you from pushing the insertion tube to an inappropriate depth. -Prepare the insertion site on the patient's manubrium. -Position yourself behind the patient's head, place two hands on the FAST1 device, align the stabilization needles with the target, and apply approximately 45 pounds (20 kg) of pressure until you feel the infusion tube separate from the FAST1 introducer. -Discard the stabilization needle in a sharps container and attach the IV tubing to the insertion tube's Luer lock. >Aspirate blood and particles of bone marrow to ensure proper placement. >Slowly inject the IV solution to ensure proper placement of the needle. >Adjust the flow rate as appropriate. >Place the protective dome and begin using the device.

Assembling Equipment for IV Administration:

-To avoid delays or the possibility of IV site contamination, gather and prepare all your equipment before you attempt to start an IV line. -Sometimes the condition and presentation of the patient make full preparation difficult. This is where working as a team becomes critical. -Equipment includes: >Elastic constricting band (preferably nonlatex; these are sometimes called tourniquets; not to be confused with tourniquets used for bleeding control) >Antiseptic wipe or solution >Gauze >Tape or adhesive bandage

Discontinuing an IV LIne:

-To discontinue the IV line: >Shut off the flow from the line with the roller clamp. >Gently peel the tape back toward the IV site. >Stabilize the catheter while you loosen all the remaining tape holding the catheter in place. >Do not remove the IV tubing from the hub of the catheter. >Fold a 4-inch × 4-inch piece of gauze and place it over the site, holding it down while you pull back on the hub of the catheter. >Gently pull the catheter and the IV line from the patient's vein while applying pressure to control bleeding.

Administering Medication via the Subcutaneous Route (Step 5):

-To disperse the medication through the tissue, rub the area in a circular motion with your gloved hand. -Properly store any unused medication. -Monitor the patient's condition, and document the medication given, route, administration time, and patient response.

Humeral IO Sites:

-To locate the humeral IO site, you will need to manipulate the patient's arm and palpate the humeral head. -Begin by placing the patient's hand over his or her abdomen, which causes an internal rotation of the humeral head. -Place the ulnar aspect of one of your hands vertically over the axilla near the humeral head that will be used for insertion. -Place the ulnar aspect of your other hand laterally along the midline of the upper portion of the patient's humerus. -Place your thumbs together, palpating up the surgical neck to the humeral head. -When this site is used, medications can reach the right atrium within 3 seconds of rapid IV push. -Appropriate needle selection and stabilization are crucial to use this site successfully.

Preparing Administration Set (Step 4):

-Twist the protective cover on the opposite end of the IV tubing to allow air to escape. -Do not remove this cover yet because the cover keeps the tubing end sterile until it is needed. -Let the fluid flow until air bubbles are removed from the line before turning the roller clamp wheel to stop the flow. -Next, go back and check the drip chamber; it should be only half filled. -The fluid level must be visible to calculate drip rates. If the fluid level is too low, squeeze the chamber until it fills properly; if the chamber is too full, with the roller clamp in the off (open) position, invert the bag and the chamber and squeeze the chamber to empty the fluid back into the bag. -Hang the bag in an appropriate location with the end of the IV tubing easily accessible.

Fluid and Electrolyte Movement:

-Unequal concentrations on different sides of a cell membrane will move to balance themselves equally on both sides of the membrane. -Balance across a cell membrane has two components: >Balance of compounds (such as water or electrolytes) on either side of the cell membrane >Balance of charges (the one or two charges carried) -The natural tendency for materials is to flow from an area of higher concentration to one of lower concentration. This movement establishes a concentration gradient.

Choosing and IV Site:

-Use the following criteria to select a vein: >Locate the vein section with the straightest appearance. >Choose a vein that has a firm, round appearance or is springy when palpated. >Avoid areas where the vein crosses over joints. >Avoid any extremity that shows signs of trauma, injury, or infection. >Avoid any extremity that shows signs of edema. >Avoid any extremity with a dialysis fistula. >Avoid any extremity on the same side as a prior mastectomy or lymph node dissection surgery. -Also pay careful attention to areas of the vein that have tract marks; this is usually a sign of sclerosis caused by frequent puncture or cannulation. -For patients who are in critical condition, always start at the antecubital fossa or higher. -Otherwise, limit IV access to the more distal areas of the extremities. -Any fluid introduced immediately below an open wound has the potential to enter the tissue and possibly cause damage.

Drawing Medication from an Ampule (Step 2):

-Using a 4-inch × 4-inch (10-cm × 10-cm) gauze pad or an alcohol prep, grip the neck of the ampule and snap it off where the ampule is scored. -If the ampule is not scored and an attempt is made to break it, some sharp edges may be present. -Drop the stem in the sharps container.

Vials:

-Vials may contain single or multiple doses. -Vials have a rubber-stopper top and are made of glass or plastic. -Many medications used in prehospital care are carried in vials. -Norepinephrine and naloxone (Narcan) are two examples of medications that may come in vials. -When administering a vial of medication, first determine how much of the medication you will need and how many doses are in the vial. -For a single-dose vial, draw up the entire amount in the vial. -For multiple-dose vials, draw out only the amount needed. -Remember that after you remove the cover from a vial, it is no longer sterile. -If you need a second dose, clean the top of the vial with alcohol before withdrawing the medication. -Some medications that are stored in vials need to be reconstituted; these may come in two separate vials or in a single vial divided into two compartments by a rubber stopper. -To reconstitute a medication contained in an Act-o-Vial, squeeze the two vials together, which releases the center stopper and allows the contents to mix. -Shake vigorously to mix the contents before drawing out the medication. -To mix the contents of two separate vials, draw the fluid out of the first vial as described. -Insert the syringe into the top of the second vial and expel all fluid into it. -Shake vigorously to mix. -After the medication is reconstituted, regardless of the manner, draw up the medication as described for single- and multiple-dose vials.

Verify the proper medication and prescription:

-You have received and confirmed the medication order and determined that the patient is still a candidate for the medication. You must now make sure that the medication you are about to give is the correct medication. -Carefully read the label. If it is the patient's own prescription, the bottle may show the trade name or the generic name. -If you have any questions at all, contact online medical control. -Examine the label to confirm that the medication is prescribed to the patient and not to a family member or friend. -Never give a medication to a patient that has been prescribed for someone else. -Note the concentration printed on the label. -Read the medication label at least three times before administration to ensure that you have the right medication: >When it is still in the drug box it came in >When you prepare the medication for administration >Before actually administering the medication to the patient

Intro to IVs

-You must have a thorough understanding of how the medication will affect the body, including: >Mechanism of action >Indications >Contraindications >Routes of administration >Dose >Adverse reactions >What to do in the event of an adverse reaction -The first rule of medicine is, "First, do no harm." -Intravenous (IV) therapy is one of the most invasive procedures an AEMT learns. -Homeostasis produces optimal physical performance. -Drug doses and flow rate calculations are common areas of confusion for many prehospital personnel.

Weight Conversion:

-You will likely only need to convert weight when assisting a paramedic with administering a medication to a pediatric patient. -Converting weight from g to mg is a matter of multiplying or dividing by 1,000 or moving the decimal point three places to the right or left. -To convert g to mg, multiply the larger unit of weight by 1,000 or simply move the decimal point three places to the right -To convert a smaller unit to a larger unit when the difference is 1,000 (such as milligrams to grams or micrograms to milligrams), divide the mg by 1,000 or move the decimal point three places to the left. -Remember that 1 g equals 1,000 mg and 1 mg equals 1,000 mcg.

Enteral Medications:

-are those that are given through some portion of the digestive or intestinal tract. -Oral and Rectal Administration

Hypertonic Solution:

-has a greater concentration of sodium than does the cell. -Water is drawn out of the cell, and the cell may collapse from the increased extracellular osmotic pressure.

Hypotonic Solution:

-has a lower concentration of sodium than does the cell. -Water flows into the cell, causing it to swell and possibly burst from the increased intracellular osmotic pressure.

Isotonic Solution:

-has the same concentration of sodium as does the cell. In this case, water does not shift and no change in cell shape occurs.

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