Chapter 14 medication administration (b)

The rate that fluid can flow through a tube is defined by the law of physics with the following formula:

(change in pressure) x Radius - Length of the catheter.

The fast device

(first access for shock and trauma) were the first IO devices approved for use in patients 12 years and older. Four design elements allow for a IO placement in the sternum using FAST devices: an infusion tube and subcutaneous portal, an introducer, a target/strain relief patch, and a protective dome. Mechanical CPR must be paused during insertion and continue once stabilized. Easy to locate manubrium and because it is easier to penetrate other bones. The target device is shaped so that it lines up with the sternal notch, minimizing the margin for error. Fast 1: original device consists of 14-gauge infusion tube and 10 stabilization needles. no batteries FAST responder: updated device that has some advantages. many components already assembled. adhesive target comes attached to the device. also has a safety lock that must be removed before insertion. requires 32 pounds of pressure for insertion. remain in place for a maximum of 24 hours.

Pyrogenic reactions

-Foreign proteins that produce fever, abrupt elecation in temperature. Associated with severe chills, backache, headache, weakness, nausea, and vomiting. -Avoid by inspecting IV bag before use (Begins within 30 minutes after infusion has started) STOP INFUSION IMMEDIATELY!

First rule of standard precautions

treat any body fluid as being potentially infectious.

Helpful IV hints

-allow the patients arm to hang off the stretcher -pat or rub the area, without being too firm. If this is done too vigorously, then it can initiate a vasoconstriction reflex. -Apply wrapped chemical heat packs for about 60 seconds -If you meet resistance from a valve, then elevate the extremity -After two misses, let your partner try -Try sticking without a constricting band if the IV line keeps infiltrating - Never pull the catheter back over the needle - the more IV insertions your perform the more proficient you will become.

Assembling your equipment

-elastic tourniquet -Antiseptic wipe or solution -Gauze -Tape or adhesive bandage -Appropriate-size IV catheter -IV extension set -A saline flush -IV administration set

Attaching the fast device steps

1. 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. 2. Prepare the insertion site on the patients manubrium 3. Position yourself behind the patients head, place two hands on the FAST 1 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 fast 1 introducer. 4. Discard the stabilizaiton needle in a sharps container and attach the IV tubing to the insertion tubes 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.

Inserting the IV catheter

1. Keep the beveled side of the catheter up when you are inserting the needle in a vein 2. Maintain adequate traction on the vein during cannulation Penrose drain: larger diameter and denser band known as a surgical hose. Advance the catheter through the skin until the vein is pierced (you should see a flash of blood in the catheter flash chamber), then immediately drop the angle down to about 15degrees.

EJ steps

1. Place the patient in a supine, head-down position to fill the jugular vein. Turn the patients head to the side opposite the intended venipuncture site. Always feel carefully for a pulse before cannulating an EJ vein. It is imperative not to pierce the carotid artery 2. Appropriately cleanse the venipuncture site. 3. Occlude the jugular vein with your finger, distal to the catheter insertion site, to facilitate backflow of blood, this will allow the vein to become more visible. 4. Align the catheter in the direction of the vein, with the point aimed toward the shoulder on the side of the venipuncture. 5. Make the puncture midway between the angle of the jaw and the midclavicular line. Stabilize the vein by placing a finger lightly on top of it just above the clavicle. 6. Proceed as described for cannulation of a peripheral vein. Do not let air enter the catheter once it is in the vein. Patients can draw in as much as 10% of their tidal volume through an open EJ vein, causing a large air embolism. 7. Tape the line securely but do not put circumferential dressing around the neck.

Document the establishment of an IV line, you need to include the following

1. The gauge of the needle 2. The IV attempts versus successes 3. The site (for example, left forearm, left EJ) 4. The type of fluid you are administering 5. The rate at which the fluid is running

Step for accessing an implanted

1. Use aseptic technique, prepare all necessary equipment -huber needle, empty 10-to 20- mL syringe (nothing less than a 10-mL syringe should be used), 10- mL normal saline flush, sterile glvoes, chlorahexidine gluconate (chloraPrep) or btadine, 10-gtt administration set, 500 mL normal saline. 2. Identify the site in the upper part of the chest. Stabilize it between the thumb and index finger of your nondominant hand. 3. Clean the site with chlorahexidine. If an allergy is present, then clean the site with betadine. 4. Apply pressure around the edges of the port to stretch the skin over the injection site. 5. While stabilizing the device, insert the huber needle at a 90 degree angle. 6. Withdraw at least 10 mL of blood from the needless extension set. Discard immediately 7. Flush the set with a 10-mL normal saline flush. Attach the 10-gtt IV administration set. 8. Administer directly into the drop set medication port. 9. Monitor the patients condition, and document the medication given, route of admin, time, and response. Central lines imply that a pt has a significant medical history that should be investigated and that standard IV access may be difficult to obtain. -Many devices sit inside the vena cava. -these devices are all preserved with heparin, which is why providers must withdraw at least 10 mL of blood from the device. Because EMS providers do not routinely carry heparin, ems providers must keep the IV administration set minimally at KVO/TKO to prevent clots from forming.

Prefilled syringe

2 types: those seperated into a glass drug cartridge and a syringe. and the preassembled prefilled syringe.

Hypocalcemia

Causes: Sepsis, inadequate vitamin D, pancreatitis parathyroid disease SS: Irritability, hyperactive deep tendon reflexes, twitching of the face or spasms of the hand, tetany, convulsions, paresthesia, abdominal cramps, muscle cramps, neural excitability.

Lactate ringer and (0.9% Na CL)

the salt and electrolytes in these fluids serve as particles. Their sodium concentration approximates that of the extracellular space, and the intracellular space is excluded. smaller volume of distribution

Volutrol

A microdrip set allows you to fill a 100-200 mL calibrated drip chamber with a specific amount of fluid and administer only that amount to avoid inadvertent fluid overload. This type of set is commonly used in pediatric patients. A proximal roller clamp allows you to shut off the volutrol drip chamber from the IV bag. If the patient needs additional fluids, then simply open the proximal roller clamp and fill the volutrol with more fluid.

Packaging of parenteral medications

Ampules: breakable sterile glass containers that are designed to carry a single dose of medication. they contain as little as 1 mL or as much as 10 mL, depending on med. Steps to drawing med from ampule. step 1: check medication and esnure the expiration date has not passed, -shake the medication inot the base of the ampule. if some of the drug is stuck in the neck, then gently thump or tap the stem. Step 2: Using a 4x4 inch gauze pad, an alcohol prep, or an ampule breaker, grip the neck of the ampule and snap it off where the ampule is scored. If the ampule is not scored an an attempt is made to break it, some shaprs may end up in the med. 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. 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. Step 5: press gently on the plunger to dispel any air bubbles. Recap the needle using the one-handed method. dispose of the needle in the sharps container and attach a standard hypodermic needle to the syringe if necessary to administer the medication.

Albumin

An IV fluid that can expand the intravascular volume by 80% of the infused volume (compared with 25% for ringers lactate and normal saline). The role of albumin and other colloids in the resuscitation of critically ill and injured patients has been the source of great debate for decades, with no current consensus.

Choosing an IV site

Avoid areas that contain valves and bifurcations because a catheter will not pass through these areas easily and the needle may cause damage. -Locate the vein section with the straightest appearance -chose a vein that has a firm, round appearance or is springy when palpated. -Avoid areas where the vein crosses over joints -Avoid edematous extremities and any extremity with a dialysis fistula or on the side a mastectomy was done non articulated veins: sights that have no joints

Hypercalcemia

Cancer with metastases and parthyroid disease, overactivity SS: weakness, irritability, dehydration, headache, hypertension, renal stone.

Several factors can influence the flow rate of an IV line

Check the IV fluid: thick, viscous fluids such as blood products and colloid solutions infuse slowly and may be diluted to help speed delivery. Cold fluids run more slowly than warm fluids. if possible, warm IV fluids before administering them in a cold environment Check the administration set: Macrodrips are used for rapid fluid delivery, microdrips deliver a more controlled flow. Check the height of the IV bag: the IV bag must be hung high enough to overcome gravity. Hang it as high as possible. the closer it is to the patient, the slower it will be. If it falls below the level of the patient, then it will begin to draw blood out of the vein. Check the type of catheter used: The larger the diameter of the catheter, the faster fluid can be delivered. Check the constricting band: Do not leave the constricting band on the patients arm after establishing the IV line. Check the entire line to ensure it is not clamped at any point: occasionally, the roller clamp or the clamp from an extension set is left closed. May be a positional problem.

Hypermagnesemia

Chronic renal failure SS: reduced neuromuscular irritability, loss of deep tendon reflexes, sedation, confusion

Hyperphosphatemia

Chronic renal failure, treatment of acute leukemia and lymphoma SS: hypocalcemia

Volume to be administered

DD/COH

rectal administration

Diazepan can be administered rectally because IV access can be challenging when the patient is seizing. (commonly prescribed for children with seizures) rectal mucosa is highly vascular they also bypass first pass metabolism, rapid onset. certain antiemetic medications are availbe in suppository form (ex, promethazine (phenergan), and under certain circumstances, you might be asked to administer them. suppository: drug mixed in a firm base that melts at body temperature and is shaped to fit the rectum. Enema: a fluid solution that is administered into the rectum, such as for imaging studies of the GI tract. Steps 6: use a water soluble gel for lubrication when you insert a suppository. 1-1.5 inches (3-4 cm) while intstructing the pt to relax. 7. Meds in liquied form you may use a NPA, a small ET tube, an 18 guage without needle, or a commercial deivce. -lubricate end of device and gently insert 1-1.5 inches -with needless syringe, gently push the medication through the tube. - Once the medication has been delivered, remove and dispose of the tube or syringe in an appropriate container.

Formula 4 Drip infusion base on weight

Dopamine drip Dose desired Drops/mL of IV set - X = Drops/min Dose on hand

formula 3

Drip infusion not based on weight (ex lidocaine drip dose desired Drops/mL - X = Drops/Min Dose on hand 1

drops per minute required to deliver the appropriate amount of IV fluids

Drop factor of IV set (gtt/mL) - x Total hourly volume =gtt/min 60 min x hr

Ocular Medication Admin

Drops or ointments are commonly administered via the ocular route. indications: pain relief, allergies, drying of the eyes, or infections medication admin is rare in the prehospital setting besides, assisting the patient with his or her own. A commercial device known as the Morgan Lens can be used to administer some opthalmic medications, particularly local anesthetics. The device uses a proprietary lens that connects to an IV drop set and IV fluid. while its used predominantly for irrigation, some medications may be used in or with the Morgan lens. Steps: place the pt in a supine position, or have the patient place his or her head back and look up. 4. Without touching the eyeball, expose the conjunctiva by gently pulling down on the lower eyelid. 5. Administer the required amount of medication on the conjunctival sac by using an eye dropper. Do not apply medication directly on the eyeball 6. Advise the pt to close his or her eyes for 1-2 minutes

EZ- IO device

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 imposible to obtain. Battery powered driver is universal but different sizes of needles are available. Needle size estimated based on insertion size and patients weight, 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 can be seen after insertion. use a 10 mL syringe to remove an EZ-IO NEEDLE sizes: 15 mm determination 3-39 kg 25 MM- >40 kg 45 MM excessive subcutaneous tissue and humeral IO insertion

particles in solution that attract water, or exert osmotic pressure, are sodium and serum proteins (albumin)

Fluids that have less osmotic pressure with the body under normal conditions are called isotonic. fluids that have less osmotic pressure are hypotonic, and hypertonic fluids have greater than normal osmotic pressure.

nebulizers

For more severe problems, liquid bronchodilators may be aeroslized 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.

Hypotonic solution

Has a lower concentration of sodium ((osmolarity) than the cells serum. When this fluid is placed in the vascular compartment, it begins diluting the serum. soon the serum osmolarity is less than that of the interstitial fluid, water is pulled from the vascular compartment into the interstitial compartment; then repeated and pulled from the interstitoal compartment into the cells. cells burst from the increased intracellular osmotic pressure. Hydrate cells while depleting the vascular compartment. indi: dialysis when diuretic therapy dehydrates the cells. solutions such as hypotonic saline may be used for hyperglycemic conditions such as diabetic ketoacidosis, where high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. can caused a sudden fluid shift from the intravascular space to the cells, leading to cardiovascular collapse and ICP. from shifting fluid ino the brain cells. Giving D5W for an extended period can increase intracranial pressure. contra: stroke or any head trauma, administering to patients with burns, trauma, malnutrition, or liver disease is also hazardous because these patients are at risk of 3rd spacing., an abnormal fluid shift into the serious linings.

Circulatory overload

Healthy adults can handle as much as 2-3 extra liters of fluid without compromise. Problems occur when the patients has cardiac, pulmonary, or renal dysfunction, these types of dysfunction do not tolerate an additional demands from increased circulatory volume.

IV piggyback

IV administration set that is connected directly to the hub of the IV catheter is referred to as the primary line. This line is generally used to administer an isotonic solution. Saline is the preferred isotonic solution because it mixes with all medications in the prehospital and interfacility setting. When you are performing a continous infusion, take the distal end of the drip set that is attached to the mixed medication and connect it to a port on the primary line. The line that is connected to the continous infusion is refered to as a piggyback or secondary line. Multiple lines are present on a patient, it is important to label the lines. This will ensure that when medications are administered en route, there are no medication interactions. Step 4: cleanse the injection port of the secondary IV bag (into which the medication will be infused) with alcohol. inject the medication into the second IV bag and then place the syringe into the sharps container. Gently swirl the IV bag to mix the injected medication into the solution. Step 5: remove the protective cover on the secondary IV bag. Insert the tubing spike into the second IV bag tail port. Turn the bag with the medication upright. Squeeze the drip chamber until it is half full. Maintain sterility. Step 6: Unclampnthe line from the secondary IV bag to dispel air from it, or utilize the infusion pump to accomplish this step. Maintain sterility. While removing the air, try to minimize the loss of fluid. Clamp the line after all air bubbles have been removed. Step 7: if applicable, program the IV infusion pump with the appropriate dose and rate. Place the cartridge from the secondary IV bag in the pump. Step 8: cleanse the port on the primary IV line. Attach the distal end of the secondary IV line to a port on the primary IV line. Begin the flow and ensure that the rate is appropriate. Maintain sterility.

Potential complications

If the proper technique is used (proper anatomic landmark identification, aseptic technique), then IO infusion is associated with a relatively low complication rate. The same potential complications associated with IV therapy -thrombophlebitis, local irritation, allergic reaction, circulatory overload, and air embolism- can occur with IO infusion, as well as several others unique to this method of infusion.

Isotonic Fluid distribution

In a healthy person, 1 hour after infusion of 1,000 mL of isotonic fluids, only 250 mL of the infused fluid remains in the intravascular space. In critically ill or injured patients, the amount of fluid that remains in the vascular space can be less than 200 ml The total volume of fluid delivered should be three to 5 times the amount of blood loss to increase the intravascular fluid.

Hypophosphatemia

Long-term IV nutrition, sustained vomiting or diarrhea, alcoholism parathyroid disease SS: Weakness, tremors, eventually numbness of the face and fingers, irritability to seizures

Thrombophlebitis

Inflammation of the vein May occur in association with venous cannulation. Most frequently caused by lapses in aseptic technique Encountered in patients who abuse drugs as well as in patients who are recieiving long-term IV therapy in a hospital or hospice setting or with vein-irritating solutions (dextrose solutions, which have a low pH, or hypertonic solutions of any sort) Mechanical factors, such as excessive motion of the IV needle or catheter after it has been placed. Manifested by pain and tenderness along the vein and redness and edema at the venipuncture site. Signs appear hours later typically.

Formula 2

Infusion of a measured amount of fluid in a set amount of time (ex, fluid challenge) total volume X drops/mL of IV set - = drops/min Time in minutes ex 200 ML X 15 gtt/mL = 3,000/20 minutes = 150 gtt/min 20 minutes

Volume of Distribution of various IV fluids Normal saline (0.9%) or Ringers lactate solution (isotonic)

Intracellular 0 mL Extracellular 1,000 mL Interstitial 750 mL Intravascular 250 mL

0.5 normal saline (0.45%)

Intracellular 333 mL Extracellular 667 mL Interstitial 500 mL Intravascular 167 mL

0.25 Normal saline (0.23%)

Intracellular 500 mL Extracellular 500 mL Interstitial 375 mL Intravascular 125 mL

D5W

Intracellular 666 mL Extracellular 333 mL Interstitial 250 mL Intravascular 83 mL unique type of isotonic solution. once administered the dextrose is quickly metabolized, and the solution becomes hypotonic. Rarely administered by itself. usually administered with dopamine or amiodarone.

Human body volume

Intracellular fluid (ICF), fluid found inside the cells, extracellular fluid (ECF), which comprises intravascular fluid and interstitial fluid (fluid between the cells and outside the vascular bed)

Manually inserted IO needles

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 needel is pushed into the bone with a screwing, twisting action. Once the needle pops through the bone, the solid needle is removed, leaving the hollow steel needle in place. The IV tubing is attached to this catheter.

Percutaneous medication administration

Medications are applied to and absorbed through the skin and mucous membranes. bypass GI tract, their absorption is more predictable. include transdermal, sublingual, buccal, ocular, aural, and nasal routes.

Enteral Medications

those given through some portion of the digestive or intestinal tract. (alimentary medication) includes meds, orally, or rectally

External Jugular Vein Cannulation

Runs downward and obliquely backward behind the angle of the jaw until it pierces the deep fascia of the neck just above the middle of the clavicle. It ends in the subclavian vein, where valves return the backflow of blood. The EJ vein is failry large and usually easy to cannulate, -rolls easily You should exhaust all other means of cannulating a peripheral vein before attempting EJ. risks: inadvertent puncture of the carotid artery, a rapidly expanding hematoma if infiltration occurs, and air embolism.

IV fluid composition

Sodium is used as the benchmark to calculate a solutions tonicity. The concentration of sodium in the cells of the body is approximately 0.9% A patients electolytes can become altered from excessive vomiting, diarrhea, dietary issues, medications , blood loss, or a variety of other injuries.

Accessing a tunneling device

Step 1: prepare all of equipment, empty 10-20 mL syringe (nothing less tahn a 10-mL syringe should be used), 10-mL normal saline flush, sterile gloves, alcohol prep, 10 gtt administration set, 500 mL normal saline. -ensure all lumens are clamped. Air embolism is a serious risk with these patients because many of these devices go directly into the vena cava. That is why central lines must be clamped whenever they are not in use. Step2: attach the empty syringe and withdraw a minimum of 10 mL of blood from the lumen. Discard this immediately into the sharps container. Do not withdraw too forecefully. If you meet resistance, then gently flush and withdraw. Ask the patient to turn his or her head in the opposite direction of the central line. Step 3: after you have withdrawn the 10 mL of blood, attach the 10-mL syringe filled with normal saline and slowly administer it. Step 4: attach the prepared IV drip set and set it up for at least 10 mL/h. Depending on the size of the catheter, you can infuse at a rate of 125 to 250 mL/h. -the line must be running continuously because heparin is not available. -Monitor the pts condition, and document the med given, route, admin time, and response.

Administering medication via a nasogastric tube

Step 1: take standard precaustions confirm proper G-tube placement. Attach a 60 mL-cone-tipped syringe to the gastric tube and slowly inject air as you or your partner auscultates over the epigastrium. TO further confirm proper placement, withdraw on the plunger of the syringe and observe for the return of gastric contents in the tube. Leave the gastric tube open to air. step 2: draw up 30-60 mL of normal saline into the syringe, and irrgate the gastric tube. If your meet resistance, ensure the tube is not kinked. Step 3: draw up the appropriate amount of medication, ensure it is the correct medication and amount, and slowly inject the medication into the gastric tube. Step 4: Inject 30-60 mL of normal saline into the Gtube following administration of th emed. This will ensure the tube is flushed and the patient has receiveed the entire dose of the medication. Step 5: clamp off the proximal end of the G-tube. Do not attach the G-tube to suction because this will result in removal of the medication from the stomach. Monitor the patient for adverse reactions. Doc the med, given, route, dose, admin time, and condition and response of the pt. Repeat if indicated.

Subcutaneous medication administration

Subcutaneous injections are given into the loose connective tissue between the dermis and the muscle layer. volumes admin less than 1 mL injection performed using a 24-26 gauge 1/2 inch to 1 inch needle. common sites include upper arms, anterior thighs, and the abdomen. Patients who take insulin injections usually vary the sites owing to the multiple injections they require. Step 2: advise the patient of potential discomfort while explaining the procedure Assemble and check equipment needed: alcohol preps and a 3 mL syringe with a 24-26 gauge needle. Draw up the correct dose of the medication and dispel the air while maintaining sterility. Step 3: Cleanse the area for the administration (usually the upper arm or thigh) using aseptic technique Step 4: pinch the skin surrounding the area, advise the patient of a stick, and insert the needle at a 45 degree angle, inject the medication and remove the needle. Immediately dispose of the needle and syringe in the sharps container. Step 5: to diseperse the medication through the tissue, rub the area in a circular motion with your glvoed hand (unless contraindicated for the medication) properly store any unused medication.

Vein irritation

TIngling stinging, itching, and burning. In such cases observe for an allergic reaction . Causes: too rapid insfusion rate. If redness develops at the IV site- sign suggesting thrombophelbitis - discontinue the IV line and save the equipment for later analysis.

Desired dose

The amount of a drug that the physician orders for a patient; the drug order.

Concentration on hand

The amount of drug present in ml

Buccal medication administration

The buccal region, which is also highly vascular, lies in between the cheek and gums. Most medications administered via the buccal route are in the form of tablets or gels. Glucose is one of the few medications that may be administered buccally in the prehospital setting.

Isotonic solution

The effects of osmotic pressure on a cell is referred to as the tonicity of the solution Tonicity: is the concentration of sodium in a solution and the movement of water in relation to the sodium levels inside and outside the cell. Normal saline have almost the same osmolarity (concentration of sodium) as serum and other body fluids. As a consequence, isotonic solutions expand the contents of the intravascular compartment without shifting fluid to or from other compartments, or changing cell shape- an import consideration when you are caring for hypotensive or hypovolemic patients. Patients with hypertension and CHF are at greatest risk of this problem.

INfiltration

The escape of fluid into the surrounding tissue, which causes a localized area of edema. causes: -The IV catheter passes completely through the vein into the other side -the patient moves excessively -The tape used to secure the IV line becomes loose or dislodged. -The catheter is inserted at too shallow an angle and enter only the fascia surrounding the vein. (more common in larger veins SS: tightness bruning, pain around the site. Discontinue and reastablish in opposite extremity. apply direct pressure to reduce swelling.

Pediatric Maintenance Fluid

The first 10 kg of weight, the IV fluid rate is 4 mL/hr per kilogram) The second 10 kg of weight (10-20 kg of body weight), add 2 mL/kg for each additional kilogram Calculate a child heavier than 20 kg add an additional 1 mL/hr per kilogram First 10 = 40 mL/hr Second 10 kg = 20 mL/hr remaining 5 kg = 1 mL/kg per hour x5 kg = 5 mL/hr Therefore, the total maintenance rate is 65 mL/hr.

IV techniques

The most important point to remember about V therapy is to keep the IV equipment sterile.

Diffusion

The movement of a solute (salt) across a semipermeable membrane from an area of higher concentration to an area of lower in order to achieve equilibrium

Osmosis

The movement of a solvent (water) across a semipermeable membrane from an area of lower concentration to an area of higher concentration in order to achieve equilibrium

Arterial puncture

The risk of arterial puncture is especially high when cannulating an EJ vein. If you insert a catheter into an artery by mistake, then bright red blood will spurt back through the catheter. Remove catheter and apply pressure over the puncture site for at least 5 minutes of until bleeding stops

IV infusion pumps

When the rate is critical. advantages: they deliver the rate that is set by the pump without deviating, and they calculate the amount of fluid that has been infused and the amount of fluid remaining. disadvantages: lack of uniformity among manufacturers. can cause air trapping in the lines that is detected by the pumps. When air is detected the pump stops the infusion and an alarm sounds. This becomes problematic during transport when an ambulance travels over potholes, makes hard tunes, and is exposed to other applied forces. deliver medication via positive pressure. common safety features include alarms that alert you to the presence of occlusion (ex air in the tubing or depletion of medication. rate established in mL/hour. Volume to be infused is the amount of solution remaining to be infused.

LOng term Vascular access devices

Where IV access is imperative but difficult to obtain. may be receiving antibiotic regimen, chemotherapy, regular blood draws for chronic disorders, hemodialysis, or other acute or chronic illnesses. pt will be upfront about there medical device and generally request that you not insert a peripheral line. type types non tunneling and implanted. usually preserved with heparin to prevent clotting.

Dehydration

a loss of water from the fluid space inside the cells. can take hours to days to develop. as the cell dehydrates, it begins to malfunction, leading to poor function of tissues, metabolic acidosis, and eventually organ failure. fluid administration should occur based on how rapidly or slowly the dehydration occured. doctors will not exceed half the amount of Liters of free water lost as fluid loss occurs from the vascular compartment, the body reacts by shifting intersitial fluid into the vascular area, fluid also shifts from the intracellular to the extracellular compartments. as a consequence a total systemic fluid deficit occurs. SS: decrease LOC, orhtostatic hypotension, tachypnea, dry mucous membranes, decreased urine output, tachycardia, poor skin turgor, and flushed dry skin. Causes: diarrhea, vomiting, GI drainage, infections, metabolic disorders ex DKA, hemorrhage, environmental emergencies, high-caffiene diet, insufficient fluid intake. Healthy person: looses 2-2.5 liters of fluid daily through urine output, through the lungs (exhalation) and through the skin. these loses are replaced by intake of fluids and y nutrients that are partially converted to water in their metabolism.

Hematoma

accumulation of blood in the tissues surrounding an IV site, often resulting from vein perforation or improper catheter removal. Predispositions: vascular diseases (include diabetes) and patients taking certain medications (corticosteroids or a blood thinner such as coumadin) or drinking alcohol can have a predisposition to vein rupture or to hematoma development with IV insertion.

Fluid bolus by age

adult is 1,000 mL over 15-60 minutes septic shock may require boluses of 30 mL/Kg in adults. A fluid bolus in a pediatric patient is 10-20 mL/kg The key too rapid IV fluid administration for an adult is two large-bore IV catheters, either 14, or 16 gauge.

Body fluid compartments

adults 45% -65% of body is water. Total body water: the amount of water in the body -Divided into two compartments ICF and ECF 2/3rds of body water is found in the ICF, 1/3rd found in the ECF -1/4 is found in the intravascular fluid -3/4 found in the interstitual fluid

Ultrasonography

allows providers to see deeper veins, often in the upper arm, that are not visible to the naked eye and may not be palpable veins compress easily, arteries do not

parenteral medication admin.

any route other than the GI tract. routes include: intradermal, subcutaneous, IM, IV, IO, and percutaneous routes.

Transdermal medications admin

applied topically, on the surface of the body. ordinarily intact skin is an effective barrier to medication absorption. medications have been specially prepared to cross that barrier at a slow steady rate, so the transdermal route is useful for the sustained release of certain medications. ex: Nitroglycerin, estrogen, nicotine, and analgesic patches, are applied to the skin and release medications over a specific period. creams lotions, and pases (nitro paste, corticosteroid cream) factors that increase the speed of absorption, include admin of too much of the medication. (inadvertent or intentional overdose) and thin or nonintact skin. decreased speed of absorption can be caused by factors such as thick skin, scar tissue in the area to which the medication is applied, and peripheral vascular disease.

Crystalloids

are IV fluid in which sodium is the primary particle that controls volume distribution. -ringers lactate and normal saline. The trapped particles do not attract the water, the difference in concentration gradients between the two compartments does. IV fluids that use electrolytes to provide osmotic pressure The ability of these fluids to cross membranes and alter fluid levels make them the best choice for prehospital care of injuried patients who need body fluid replacement. WHen replacing an isotonic crystalloid solution for fluid replacement to support blood pressure after blood loss, remeber the 3-1 replacement rule 3ml of isotonic cyrstalloid solution is needed to replace 1 ml of patient blood. 5 liters of blood in the human body The amount is needed because approx, 2/3 of infused crystalloids is either absorbed into the intersitial space or excreted. Crystalloid solutions can not carry oxygen. Should be used to maintain perfusion (radial pulses, adequate mental status) but not to restore blood pressure to the patients normal level. Increasing blood pressure to much can dilute remaining blood volume, thereby decreasing the proportion of hemoglobin, But in the care of hemorrhagic shock, may also increase internal bleeding by interfering with hemostasis - the bodys internal blood clotting mechanism. Mainted at 90 mmhg.

Intramuscular

are given by penetrating a needle through the dermis and subcutaneous tissue and into the muscle layer. This technique allows the administration of a larger volume of medication (up to 5 mL) than the subcutanous route. potential for damage to nerves. common sites for adults and children: -vastus lateralis muscle- 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. When injecting into the gluteal area, you should use the upper, outer quadrant to avoid the sciatic nerve. Deltoid muscle: the muscle of the upper arm that covers the prominence of the shoulder. The site for injection is approximately 1.5 to 2 inches below the acromion process on the lateral side. effective absorption requires adequate peripheral perfusion. Clearly not the case in pts in profound shock or cardiac arrest. should not be given into skin that is hardened, bruised, red, or otherwise discolored, or stained. step 2: cleanse the area for administration (usually the upper arm or the hip) using aseptic technique Step 3: Stretch the skin over the cleansed area, advise the patient of a stick, and insert the needle at a 90 degree 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. In such a case, remove the needle, and hold pressure on the site. Discard the syringe and needle in the sharps container. Prepare a new syringe and needle, and select another site. If no blood in the syringe, then inject the medication and remove the needle. Step 4: immediately dispose of the needle and syringe in the sharps container. Store any unused medication properly. Monitor the patients condition, and document.

push dose pressors

available in a small dose format. Epinephrine and phenylephrine (neosynephrine) are currently available in push-dose format. Phenylephrine seen in ICUS, EDS, and critical transport.

Oxygen carrying solutions

best fluid to replace blood loss is whole blood. contains hemoglobin, . o-negative blood universal compatible blood type, may be used outside hospital setting. requires refirdgment. Synthetic blood substitutes which do not have the ability to carry oxygen, are being researched and, in some places field tested. they show great potential for improving treatment of patients who have significant blood loss.

Hypovolemia

can be from internal or external Composed of water and electolytes (vomiting and diarrhea) Or composed of plasma and red blood cells (acute hemorhage) The concentration of red bloods cells increases with a decrease in intravascular fluid, whereas the number of red blood cells remains unchanged. In contrast within several hours of volume loss from acute blood loss, the blood counts (hemoglobin and hematocrit) decrease from the loss of red blood cells and intravascular blood.

COmplications of IV therapy

categorized as Local reactions: infiltration and thrombophlebitis, occlusion, vein irritation, hematoma, nerve, tendon, or ligament damage, and arterial puncture. Ssytemic: allergic reactions, circulatory overload, air embolus, vasovagal reactions, and catheter shear.

Changing an IV bag

change the bag when about 25 mL of fluid is left

Salts

chemical compounds consisting of a substance with a positive electrical charge combined with a substance with a negative electrical charge, resulting in an electrically neutral substance. When salts are dissolved in water they have the potential to conduct electricity and are known as electrolytes. Sodium: most prominent electrolyte in the blood and intersitial fluid Potassium: most prominent electrolyte in body cells.

Intraosseous space

collectively comprises the spongy cancellous bone of the epiphyses and the medullary cavity of the diaphysis Its vasculature drains into the central circulation by a network of venous sinuses and canals. When a patient is in shock, cardiac arrest or other hemodynamicallly compromised condition, peripheral veins often collapse, making iV access extremely difficult The IO stays intact and commonly is referred to as a noncollapsible vein. anything given IV can be given IO indicated: when you ar unable to obtain IV access in a critically ill or injured patient. (ex, profound shock, cardiac arrest, or status epilepticus. Depending on local protocol you will typically attempt two iv lines within 90 seconds prior to an IO infusion attempt.

syringes and needles

consist of a plunger, body or barrel, flange, and tip. most are marked with 10 calibrations per milliter on one side of the barrel, where each small line represents 0.1 mL the other side of the barrel is marked in minims. Syringes vary from 1 mL to 60 mL, the 3- mL syringe is the one most commonly used for injections. Syringe selection is based on the volume of medication that you will administer. Hypodermic needle lenghths vary from 3/8 inch to 2 inches (0.9 cm-5cm) for standard injections. As with IV catheters, the gauge of the needle refers to the diameter. smaller gauge used for subcutaneous larger for IM/IV injections.

Formula 1

ex, bolus of lidocaine, or IM injection of benadryl Desired dose - Concentration at hand Fill in known values cross out like terms

New intraosseous (NIO) device

device placed in the proximal tibia of an adult patient The humeral head is an alternative site for this device. contains neither drill nor battery. inserted by unlocking a safety cap. then apply 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. Once the introducing trocar is removed, any luer-lock tubing can be attached. A pediatric version (NIO-P) adjustable dial, allowing the provider to adjust by age or depth )if excessive girth for the age is anticipated). approved for placement in the proximal tibia only

Non tunneling devices

devices that have been inserted by direct venipuncture through the skin directly into a selected vein. Most common devices will be encountered in the prehospital and IFT, are peripheral inserted central catheters (PICCs), midline, and central venous catheters. PICCS: long-term medication administration, generally used for frequent venous sampling, and total parenteral nutrition. -inserted at the ac, while distal end is verified by a radiograph. -may be left in place for 6-8 weeks. -may be accessed by family or home health regularly. -single, double, or triple lumen. Midlines are also inserted at the AC vein. however the distal end of the midline rests at the proximal end of the extremity. Midlines can generally be used for approximately 4 weeks. -can also be used for shorter medication therapies and venous therapies. CVCs are generally inserted in emergent situations by physicians into the subclavian, femoral, or internal jugular vein, and are used for emergent medication administration, fluid resuscitation, blood administration, or blood sampling. -Generally large-bore and may sit near the vena cava.

IV bolus medication admin

directly into the circulatory system. needless system, the syringe simply screws into the injection port of the administration set (IV tubing). If a needless port is punctured with a needle, then the system will leak. you can place a syringe filled with saline on the needless port to fix this. Step 1: Explain the procedure to the patient and the need for the medication. Assemble needed equipment, and draw up the medication. Expel any air in the syringe. 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 Step 2: Insert the needle into the port, 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 quickly, whereas others must be pushed slowly to prevent adverse effects. 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 and label any unused medication. -monitor the patients condition and document.

Adding medication to an IV bag

dopamine, lidocaine, epinephrine. Step 2: check the medication name on the ampule, vial, or prefilled syringe. Check the concentration of the drug it contains (for example, mcg/mL or mg/mL) 3. compute the volume of the drug to be added to the IV bag. Draw up that amount in a syringe (if a prefilled syringe is used, not the proportion of th evolume of the syringe required). step 4. Cleanse the medication injection port on the IV bag with an alcohol swab. Step 5: inject the desired volume of medication into the IV bag by puncturing the rubber stopper on the medication injection port Step 6: withdraw the needle, and dispose of the needle and syringe in the sharps container. Agitate the IV bag gently to ensure the medication added is well mixed in the solution step 7: label the IV bag, on a piece of tape, write the name of the medication added, the amount added, the concentration of medication in the IV bag (for example, mcg/mL or mg/mL), the date and time and your name.

Overhydration

fluid fills the vascular compartment, and is forced from the engorged interstitial compartment into the intracellular compartment. this fluid backup can lead to death. Causes: impaired kidney function, when health care professionals administer an amount of fluid that is beyond what the body can excrete. Prolonged apnea neonates are also more likely to experience overhydration because their kidneys are not yet fully developed. SS: shortness of breath, puffy eyelids, edema polyuria, moist crackles and acute weight gain.

Water or Dextrose 5% in water

free of any particles, is added to one compartment it is then freely distributed to the various body fluid compartments in proportion to their percentages of TBW. An IV fluid that distributes throughout several body compartments is said to have a large volume of distribution. Large volume of distribution

Lactated RInger solution

generally used in the field for patients who have significant blood loss. It contains lactate which is metabolized in the liver to form bicarbonate- the key buffer that combats the intracellular acidosis associated with severe blood loss. Should not be given to patients with liver problems because they cannot metabolize the lactate.

Hypertonic Saline Solutions

have a concentration greater than the isotonic concentration of 0.9% typically 3,5, or 7% saline, roughly three to five times higher sodium concentration than standard normal saline. The administration results in normalization cell volume below normal, animal research has demonstrated that administration of 7.55 Research shows that during the periods of stress and shock, cells actually become fat and swell with additional water. the result of hypertonic saline results in normalization of cell volume below normal. danger: the cells may collapse from the increased extracellular osmotic pressure. hypertonic solutions shift body fluids into the vascular spaces and help stabilize blood pressure, increase urine output, and reduce edema. solution that contains high concentrations of proteins, which have the same effect on fluid as sodium also hypertonic solutions should not be given to patients with diabetic ketoacidosis or others at risk of cellular dehydration.

Sublingual med admin

highly vascular, so meds are given via the sublingual route are rapidly absorbed. relative to enterally admin get into the circulation much faster. Nitro spray or tablet Medications may also be injected into the network of veins (venous plexous) under the tongue (basically another form of IV injection). this technique is especially useful for giving narcotic antagonist to patients who have overdose on heroin because finding a suitable vein in such patients may be nearly impossible.

IO sites

humeral IO: manipulate the patients arm and palpate the humeral head. Begin by placing the patients hand over his or her abdomen, which causes an external 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 patients 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. stabilization and needle selection are crutial in this site. sternal IO site: palpate the sternal notch and using the IO devices adhesive target. Extremely rapid flow rate. does not impede chest compressions. Proximal tibia: the flat bone is located medialy 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 plapate the tuberosity then palpate 2 cm medially. for adults pediatrics: palpate 1-2 cm distally to avoid the epiphyseal plate: consists of a layer of cartilage present only during the growth period and vanishes soon after puberty in long bones. Distal tibia IO site: use palpation as well, first identify the medial maleolus, then palpate 2-3 cm above that site. For pediatric patients, you should palpate 1-2 cm above the medial malleolus.

Cognitive load

if you are not confident with a drug dose, indication, contraindication, or any other aspect of medication administration, then you should use your protocols, a drug formulary, a flip guide, a smartphone or tablet application.

Implanted

implanted in surgery, sutured under the skin. These devices are palpable outside the skin but are not exposed to the outside environment. -consist of self-sealing core inserted in a stainless steel, titanium, or plastic shell connected to a catheter that runs into the superior vena cava. These devices can only be accessed with a huber needle that is non coring and has a mild angle. -can be used for long term medication administration, total parenteral nutrition, chemotherapy, blood products, or venous blood sampling. Atriovenous AV fistulas: used for a variety of disorders. They are created by connecting a vein and an artery. For kidney failure, hemodialysis uses AV fistulas to dialize the blood. AV fistulas are also used for plasmapheris in various disorders such as myasthenia gravis and gullain-Barre syndrome. Av fistulas require a unique skill set to access and generally should not be accessed by paramedics. Accessing an implanted vascular access device is not in the scope of paramedic practice in most places, special training and medical authorization are required to perform this skill.

oral medications

include, capsules, timed-release capsules, lozenges, pills, tablets, elixirs, emulsions, suspensions, and syrups. absorption 30-90 minutes. administration devices, small medicine cup, a medicine dropper, a teaspoon, an oral syringe, or a nipple.

Blood

increases oxygen delivery to peripheral tissues. Administered for intravascular volume expansion, or to improve blood-clotting ability in a wide variety of clinical situations.

Osteomyelitis

inflammation of the bone and muscle caused by an infection. Osteomyletis can occur from IO insertion but is rare.

Disinfectants

toxic to living tissues, only use on nonliving object such as inside of ambulance laryngoscope blades, and other disposable equipment,

Aural medication administration

mainy antibiotics, analgesics, and earwax removal preparations - are administered via the mucous membranes of the aural (ear) canal. steps: place the patient on his or her side with the affected ear facing up -expose the ear canal by pulling the ear up and back (adults) or down and back (infants and children) -administer the medication in the appropriate dose with a medicine dropper.

Hypomagnesemia

malnutrition, cirrhosis, pancreatitis, diarrhea SS: weakness, confusion, irritbillity, tremors, nausea, hypotension, seizures, and arrhythmias

accidental needlsticks

most common route for disease transmission in the health care setting.

Choosing an IV catheter

most common types used over the needle catheter: a teflon catheter inserted oer a hollow needle (ex, angiocath, terumo, jelco) Butterfly catheter: hollow stainless steel needle with two plastic wings to facilitate handling. most common in phlembotomy but sometimes used for scalp veins in children. 10 and 12 gauge catheters do exist but used mostly for needle decompression 18 gauge catheters should be used when the patient requires fluid replacement (ex hypovolemic shock), large catheters do not help enough to make a difference, and the miss rate is higher and pain more significant. able to insert an 18 gauge into the AC or EJ vein.

anatomic landmarks in bone

need to be in red bone marrow near the ends of the bone

Hyperkalemia

occurs in renal failure and presents with GI symptoms of nausea, abdominal pain, and or diarrhea. other causes include burns, crush injuries, diabetic keto acidosis, and severe infections. Signs: initially peaked T waves, widening of the QRS complex, and depression of the ST segment. Can progress to heart block and cardiac arrest. Pts with a rapid rise in potassium levels will experience severe signs and symptoms at lower levels than will patients with chronic or episodic hyperkalemia such as those with chronic renal failure. Treatments, calcium, sodium bicarb, albuterol, dextrose and insulin.

Extravasation

occurs when the IO needle does not rest in the IO space, but rests outside the bone (because the bone was missed completely or is fractured). IN such a case, IV fluid will collect in the soft tissues. can be reduced by using correct technique. fluid does not run freely, discontinue and reattempt insertion in the opposite leg. Undetected extravasation could result in compartment syndrome.

Occlusion

physical blockage of a vein or catheter. If fluid is not sufficient in the enterence to the catheter than blood could clot. SS: blood in tubing or decreased drip rate. Positional line may cause this Flow fluid into the line or discontinue line and administer on opposite extremity or at a proximal location on the same extremity

Hypokalemia

results from chronic medical conditions such as reduced dietary intake or potassium, chronic diuretic therapy, diarrhea, short bowel syndrome, vomiting, and burns. SS: muscle weakness, abdominal distention, and constipation. On an EKG the T waves tend to flatten and progress to atrioventricular block and cardiac arrest. Potassium administration: Should always be diluted and slowly administered to reduce the likelihood of pain from inflammation of the vein (phlebitis) Pts with adequate renal function and good urine output. Potassium chloride most common form administered.

5 rights of IO administration

right site right needle right patient right flush right amount of pressure power flush critical perisalstio tissue has nerves in it and causes the pain.

Nerve, tendon, or ligament damage

selecting a IV site located near joints increases the risk for perforation of these structures. When this type of injury occurs, patients will experience sudden and severe shooting pain. numbness or tingling in the extremity after the incident is common.

Autoresucitate

shift fluid from both the intracellular space and intersitial space into the intravascular space The result is that cells can become dehydrated and malfunction, causing organ failure. shortly after acute blood loss, the body recognizes the need to expand the intravascular volume and responds by shifting fluid from the extravascular space toward the intravascular space. In this manner, the body automatically attempts to resuscitate itself (autoresuscitation)

Intradermal

small amount of medication <1 mL into the dermal layer, just beneath the epidermis. 1 mL syringe and 25-27 gauge and 3/8-1 inch needle avoid areas that contain superficial blood vessels to minimize the risk of systemic medication absorption. Because of high visibility and relative lack of hair, the most common anatomic locations for intradermal injections are the forearm and upper back. slow rate of absorption minimal to systemic distribution. med remains locally collected at the site of injection. Unless anesthetizing the skin before establishing an IV line, you will rarely use the intradermal route. typically given to test for Purified protein derivative a skin test for TB step 9: pull the skin taut with nondominant hand step 10: insert the needle a ta 10-15 angle with the bevel up step 11: slowly inject the medication while observing for the formation of a wheal, or small bump, which indicates the medication is collecting in the intradermal tissue. 12: remove the needle. Immediately dispose of the needle and syringe in the sharps container. 13. Monitor the patients condition, and document the medication given, route, administration time, and response of the patient.

gastric tubes

the most common solution to be administered through gastric tubes during interfacility transports is liquid nutrition for tube feeding. use warm saline for injections. Because the solution will be going directly into the digestive tract with a temperature of Approx 98.6 degrees F, a solution at room temperature has the possibility of placing the patient in hypothermia.

vials

small glass or plastic bottle with a rubberstopper top. clean the top of the vial with alcohol before withdrawing a second dose. reconstituted medications: methylprednisolone sodium succinate (solu-medrol) and glucagon. glucagon: stored in two vials, one with the powdered form of the drug and the other with sterile water. drug reconstitution: involves injecting the sterile water (or provided diluent) from one vial into the vial that contains the powder, thereby making a solution for injection. To reconstitute the contents from two vials, draw the fluid out of the first vial and inject it into the vial that contains the powder. Solumedrol is stored in a mix o vial: two seperate containers in one. squeeze the two vials together to release the center stopper and allows the contents to mix. Shake vigorously to mix the contents before drawing out the medication. Steps: step 2: determine correct amount of medication and draw that amount into the syringe. Allow a little extra room to expel some air while removing air bubbles. 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. Step 4: once you have the correct amount of medication in the syringe, withdraw the needle from the vial and expel any air in the syringe. Step 5: recap the needle using the one-handed method. Label the syringe if it is not immediately given to the patient.

Bone injection Gun device

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. Adult and pediatric size Safety lock as stabilization device, once the device has been inserted. use stabilization device as removal tool.

Gaining IO acces steps

step 1. Check the selected IV lfuid for proper fluid, clarity, and expiration date. Look for discoloration and for particles floating in the fluid. If particles are found in the fluid, then 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. Step 2: take standard precaustions 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 Step 4: cleanse the site appropriately. Follow aseptic technique by cleansing in a circular manner from the inside out. Step 5: Attach the needle to the EZ-IO gun and remove the protective cover. Examine the needle. If you find any imperfections, then discard the needle and select another one. 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 degree 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. 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 it 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 place 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.

Obtaining Vascular access

step 1: Choose the appropriate fluid, and examine the bag for clarity and expiration date. -ensure no particles are floating -choose appropriate drip set and attach it to the fluid. -fill the drip chamber step 2: Flush or bleed the tubing to remove any air bubbles by opening the roller clamp. Ensure no errant bubbles are floating in the tubing. step 3: Before the venipuncture, tear tape needed to secure the site, collect and open antiseptic swabs, gauze pads, and anything else needed for vascular access per local practice. step 4: Take standard precaustions before making contact with the patient. Palpate a suitable vein. Veins should be springy when palpated. Avoid areas that are hard when palpated. step 5: Apply the constricting band above the intended IV site. It should be placed approximately 4-8 inches (10-20 cm) above the intended site. Step 6: clean the area using 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. Step 7: choose the appropriate-size catheter an twist the catheter to break the seal. Do not advance the catheter upward because this may cause the needle to shear the catheter. Examine the catheter and discard it if you discover any imperfections. Loosen the catheter hub. step 8: advise the patient to expect a needlestick, while applying distal traction at the site with one hand, insert the catheter at an angle of approximately 45 degrees with the bevel up. 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 not only a drop or two, then you should gently advance the catheter father into the vein, approx, 1/8 to 1/4 inch -apply pressure to the site to occlude the catheter and prevent blood from leaking while removing the stylet. Hold the hub while withdrawing the needle so as not to pull the catheter out of the vein. Step 10: immediately dispose of all sharps in the proper container. step 11: attach the prepared IV line. Hold the hub of the catheter while connecting the IV line. Step 12: remove the constricting band. Step 13: Open the IV line to ensure fluid is flowing and the IV is patent. Observe for any swelling or infiltration (the escape of fluid into the surrounding tissue, causing a localized area of edema) around the IV site. If the fluid does not flow, then check whether the constriction band has been released. if infiltration is noted, then immediately stop the infusion and remove the catheter while holding pressure over the site with a piece of gauze to prevent bleeding. Step 14: secure the catheter with tape or a commercial device step 15: secure IV tubing and adjust the flow rate while monitoring the patient.

Steps to inserting a saline lock

step 7: Assemble needed equipment, and draw up the medication. Draw up 20 mL of normal saline to use as a flush for the medication. step 8: cleanse the injection port with alcohol, or remove the protective cap if using the needleless system. step 9: Insert the needle into the port while holding it carefully, or screw the syringe onto the port. Clamp off the IV tubing proximally to prevent backflow into the IV solution. Step 10: pull back slightly on the syringe plunger, and observe for blood return. If blood appears, then slowly inject the medication, watching for infiltration. If resistance is felt, or if the patient reports any discomfort, then discontinue administration immediately. A new site will need to be established. 11. Place the needle and syringe into the sharps container. 12: Clean the port, and insert the needle with the syringe containing the flush 13. Flush the saline lock, and place the needle in the sharps container. 14: store any unused medication properly

Vascular access time and flow rate for various IO sites

sternal 469 mL/Min Humeral 148-286 mL/min proximal tibial 154-204.6

Drop factor

the number of drops into the chamber required to administer 1 mL of fluid.

Colloid solutions

use complex molecules such as proteins and complex sugars for osmotic pressure. Contain large molecules that are to large to pass through capillary membranes. therefore remain in the vascular space. Colloids and hypertonic fluids provide an advantage for these providers by providing greater volume expansion with less fluid administered. These large protien molecules give colloid solutions a high osmolarity. as a result They draw fluid from the interstitual and intracellular compartments into the vascular compartments. Work well in reducing edema while expanding the vascular compartment. They could cause dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled setting. Because of the short duration of action and low cost-benefit ration in prehospital setting, they are rarely used examples: albumin, dextran, plasmanate, and hetastarch)

IO medication admin

used for critically ill or injured children and adults when IV access is difficult or impossible to obtain. Shock, status epilepticus, and cardiac arrest are but a few reasons. Unlike an IV line fluid does not flow well into the bone because of resistance, it is necessary to use a large syringe to infuse the fluid. A pressure infuser device - a sleeve placed around the IV bag and inflated to force from the IV bag - should be used when infusing fluids in adults. Complications: IO similar to those of IV route. including the risk for compartment syndrome if fluid leaks outside the bone and into the osteofascial compartment. Step 1: assemble needed equipment and draw up the medication. Also draw up 20 mL of normal saline for a flush. Step 2: cleanse the injection port of the extension tubing with alcohol, or remove the protective cap if using the needleless system. Step 3: insert the needle into the port, and clamp off the IV tubing proximal to the administration port. -this 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 quick and some slow to prevent adverse effects. 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 patients condition, and document the medication given, route,

antiseptics

used to cleanse an area before performing an invasive procedure such as iv therapy or medication admin. capable of destroying pathogens, they are not toxic to living tissues. ex Isoproyl alcohol (rubbing alcohol), iodine, and 2% chlorhexidine gluconate (chloraprep) are the three most common antiseptics you will use in the field

INtraosseous infusion

within the bone, technique of adminstering 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).

Intranasal

within the nose) medications include nasal spray for congestion or solutions to moisten the nasal mucosa. intranasal administered medications are rapidly absorbed, providing a more rapid onset of action than IM injections. ex: some studies suggest that intranasal fentanyl has an equal onset and duration to IV morphine. Performed with a mucosal atomizer device. meds include: narcan midazolam, glucagon, ketoralaz, flumazenil, fentanyl citrate. Typically intranasal meds require 2-2.5 times the dose of IV medications.