40: Assisting With Intravenous Therapy

1. Know the types of IV fluid used in the prehospital setting.

2. Analyze and differentiate between the various intended applications for each of the IV solutions.

3. Analyze and differentiate between administration sets and their appropriate applications.

4. Analyze and differentiate between the various types of catheters used in IV therapy and their appropriate use.

Cognitive Objectives (1 of 3)

Cognitive Objectives (2 of 3)

5. Analyze and discuss the need for properly securing the IV tubing to the patient following IV insertion.

6. Analyze the need for alternative IV insertion sites and equipment, and differentiate between them: saline locks (buff caps) intraosseous needles, external jugular IVs.

7. Analyze and differentiate between the various types of local and systemic complications in IV therapy: infiltration, phlebitis, occlusion, vein irritation, hematoma, allergic reactions, air embolus, catheter shear, circulatory overload, vasovagal reaction.

Cognitive Objectives (3 of 3)

8. Correctly define terms: access port, crystalloid, piercing spike, drip set, macrodrip, microdrip, drip chamber, keep-vein-open (KVO), butterfly catheter, over-the-needle catheter.

9. Analyze and appreciate the differences in treatment required for pediatric IV therapy.

10. Analyze and appreciate the differences in treatment required for geriatric IV therapy.

Affective Objectives (1 of 2)

11. Apply and maintain proper body substance isolation throughout the entire IV therapy process.

12. Explain the concept of IV equipment assembly before any catheter insertion.

13. Explain and appreciate the special requirements and training needed for alternative IV sites: saline lock (buff cap), intraosseous needles, external jugular IVs.

Affective Objectives (2 of 2)

14. Understand possible complications associated with IV therapy.

15. Explain how to troubleshoot and correct complications associated with IV therapy.

16. Appreciate the limits of fluid administration for both geriatric and pediatric patients.

Psychomotor Objectives

17. Demonstrate the proper sterile technique for assembly of the IV equipment, including: gloves, 4" x 4" gauze sponges, proper IV tape.

18. Spike the IV bag with the proper IV administration set. Correctly fill the administration set, including the drip chamber.

19. Demonstrate the proper technique for securing IV tubing to the patient.

20. Demonstrate the proper technique for choosing age-appropriate catheter sizes for pediatric and geriatric patients.

• All of the objectives in this chapter are noncurriculum objectives.

• Equipment must be kept sterile. • Assemble equipment before starting IV.

Techniques and Administration

IV Solutions

Administration Sets

Administration sets move fluid from the IV bag into the patient’s vascular system.

Drip Sets

• Number refers to number of drops per milliliter. • Either microdrip or macrodrip

Preparing anAdministration Set

1. Remove rubber pigtail.

2. Remove cover from spike.

3. Slide spike into port.

4. Run fluid through tubing.

5. Twist cover to let air escape.

6. Fill drip chamber half way.

7. Hang bag.

Catheters

Securing the Line

• Prepare tape before inserting catheter. • Create a loop. • Do not tape around extremity.

Saline Locks

Maintain IV site without running fluid

Intraosseous (IO)

• Needle inserted into bone

• Used in pediatric patients in emergency situations

• Inserted in the proximal tibia with a Jamshedi needle

External Jugular

• Provides venous access through the external jugular veins.

• Vein is compressed by placing a finger on the vein above the clavicle.

Possible Complications

• Reactions may be local or systemic.

• Local reactions are limited.

• Systemic reactions involve other body systems.

Infiltration (1 of 2)

• Escape of fluid into surrounding tissue

• Caused by:

– Catheter passing through vein

– Improper catheter placement

– Patient movement

– Tape securing site loosened

Infiltration (2 of 2)

• Signs and symptoms

– Edema/tightness

– Slow flow rate

• Correction

– Remove IV.

– Apply direct pressure.

Phlebitis

• Inflammation of the vein • Causes

– Nonsterile equipment– Prolonged IV therapy– Irritating IV fluids

• Watch for fever/tenderness/red streaking.• Discontinue IV.

Occlusion

• Physical blockage of vein or catheter • Can be caused by insufficient fluid flow or

patient movement• Watch for slow flow and blood in tubing.

Vein Irritation

• Can be caused by rapid infusion rate

• Watch for redness and phlebitis.

• Discontinue IV.

Hematoma (1 of 2)

• Accumulation of blood

• Watch for blood pooling around IV site.

• Apply direct pressure.

Hematoma (2 of 2)

Hematomas can be caused by improper removal of a catheter, causing tenderness and pain.

Allergic Reactions

• Sensitivity to IV fluids or medications• May be mild or result in anaphylaxis• Discontinue IV. • Monitor IV.

Air Embolus (1 of 2)

• Air introduced into circulatory system• Improperly prepared or monitored IV

Air Embolus (2 of 2)

• Signs and symptoms– Shock– Respiratory distress/arrest

• Correction– Place patient on left side with head lowered.

Catheter Shear

• Portion of catheter is shaved off.

• Caused by improper insertion technique

• Watch for sudden shortness of breath.

Circulatory Overload

• Too much fluid delivered to patient • Unmonitored IV administration • Watch for respiratory difficulty and edema. • Slow IV, raise patient’s head, and administer

high-flow oxygen.

Vasovagal Reactions

• Reaction to needles or sight of blood

• Watch for syncope and anxiety/diaphoresis.

• Treat for shock.

Troubleshooting Problems

• Check:– Fluids– Administration set – Height of IV bag– Type catheter– Constricting band

Pediatrics

• Use smaller gauges of catheters. • Other sites may be used. • Control fluid delivery with Volutrol.

Geriatrics (1 of 2)

It may be necessary to use a Volutrol IV set to prevent fluid overload.

Geriatrics (2 of 2)

• Smaller catheters may be required. • Skin and veins may be fragile. • Closely monitor fluids.

Review

1. A/an ____ gauge IV catheter is larger than a/an ____ gauge IV catheter.

A. 18, 16

B. 14, 16

C. 20, 18

D. 22, 18

Review

Answer: B

Rationale: As it applies to IV catheters, the smaller the number, the larger the gauge (bore). Therefore, a 14-gauge catheter is larger than a 16-gauge catheter and can deliver a greater amount of volume over a shorter period of time.

Review

1. A/an ____ gauge IV catheter is larger than a/an ____ gauge IV catheter.

A. 18, 16

Rationale: An 18 gauge is smaller than an 16 gauge.

B. 14, 16

Rationale: Correct answer

C. 20, 18

Rationale: A 20 gauge is smaller than an 18 gauge.

D. 22, 18

Rationale: A 22 gauge is smaller than an 18 gauge.

Review

2. Your paramedic partner is preparing to start an IV and asks you to set up the equipment using a 500 mL bag of normal saline and a microdrip administration set. You should recall that a microdrip set delivers ____ mL of volume for every ____ drop(s).

A. 1, 60

B. 60, 1

C. 1, 10

D. 10, 1

Review

Answer: A

Rationale: A microdrip administration set—which allows for more precise fluid administration than a macrodrip—delivers 1 mL of volume for every 60 drops (gtts). Although several types of macrodrip administration sets exist, the most common type delivers 1 mL of volume for every 10 gtts.

Review2. Your paramedic partner is preparing to start an IV and asks

you to set up the equipment using a 500 mL bag of normal saline and a microdrip administration set. You should recall that a microdrip set delivers ____ mL of volume for every ____ drop(s).

A. 1, 60Rationale: Correct answerB. 60, 1Rationale: 60 mL would be a total of 3600 drops.C. 1, 10Rationale: This is a macro drip, delivering 1 mL for every 10

drops (gtts).D. 10, 1Rationale: 10 mL would be a total of 600 drops.

Review

3. After your EMT-Intermediate partner has inserted an IV and secured it in place, you note that the IV is not flowing. Which of the following is the MOST likely cause of this?

A. The proximal tourniquet has not been removed

B. Your partner used a 20- or 22-gauge IV catheter

C. The IV bag is above the level of the patient’s heart

D. You used a microdrip set instead of a macrodrip set

Review

Answer: A

Rationale: There are several factors that could cause failure of the IV to flow. The proximal tourniquet may still be in place, the tip of the catheter may be resting against a valve in the patient’s vein, or the IV bag is below the level of the patient’s heart, among others. The IV bag should be above the level of the patient’s heart; if not, blood will backup into the IV tubing, which will impede the forward flow of the IV fluid.

Review3. After your EMT-Intermediate partner has inserted an IV and

secured it in place, you note that the IV is not flowing. Which of the following is the MOST likely cause of this?

A. The proximal tourniquet has not been removedRationale: Correct answerB. Your partner used a 20- or 22-gauge IV catheterRationale: The catheter size only effects how quickly the fluid can

flow — a 20 gauge is larger than a 22 gauge.C. The IV bag is above the level of the patient’s heartRationale: The IV must be above the level of the heart or blood will

start to back-up into the tubing.D. You used a microdrip set instead of a macrodrip setRationale: The size of a drip set has no bearing on whether an IV

will flow or not.

Review

4. All of the following are local IV reactions, EXCEPT:

A. hematoma.

B. infiltration.

C. vein irritation.

D. catheter embolus.

Review

Answer: D

Rationale: If the IV needle is reinserted back into the catheter, it may shear a portion of the catheter off, resulting in a free-floating catheter fragment that could travel throughout the body and lodge in a major artery (catheter embolus). Hematoma, infiltration, and vein irritation are examples of local IV reactions.

Review

4. All of the following are local IV reactions, EXCEPT:

A. hematoma.

Rationale: A hematoma is an example of a local IV reaction.

B. infiltration.

Rationale: Infiltration is an example of a local IV reaction.

C. vein irritation.

Rationale: Vein irritation is an example of a local IV reaction.

D. catheter embolus.

Rationale: Correct answer

Review

5. After inserting the piercing spike of the administration set into a bag of IV fluid, you should next:

A. write the time, date, and your initials on the IV bag.

B. remove air bubbles from the tubing by flushing the line.

C. squeeze the drip chamber until it is approximately 50% full.

D. attach the line to the catheter that has been inserted into the vein.

Review

Answer: C

Rationale: After inserting the piercing spike into a bag of IV fluid (“spiking” the bag), you should squeeze the drip chamber until it is approximately 50% full. Next, open the roller clamp on the tubing and allow fluid to run through it (“priming” the tubing); this will fill the line with fluid and remove any air bubbles. After these steps are completed, the IV line is ready to be attached to the catheter inside the patient’s vein.

Review5. After inserting the piercing spike of the administration set into

a bag of IV fluid, you should next:

A. write the time, date, and your initials on the IV bag. Rationale: This process is usually not done unless the IV bag

has been filled with a specific medication in addition to the normal IV solutions.

B. remove air bubbles from the tubing by flushing the line. Rationale: This is done after the drip chamber has been partially

filled.C. squeeze the drip chamber until it is approximately 50% full. Rationale: Correct answerD. attach the line to the catheter that has been inserted into the

vein. Rationale: The line must be flushed before being attached to an

IV site, otherwise air will be infused into the patient.

Review

6. When assisting with an IV on a geriatric or pediatric patient, it is important to remember that:

A. fluids should not be given unless the patient is in cardiac arrest.

B. geriatric and pediatric patients are susceptible to fluid overload.

C. hypotonic fluids should be used if the patient requires rehydration.

D. geriatric and pediatric patients can easily handle 2,000 mL of fluid.

Review

Answer: B

Rationale: Geriatric and pediatric patients are susceptible to fluid overload—also called circulatory overload—so pay careful attention to how much fluid they are receiving. If the patient is dehydrated, he or she should receive an isotonic crystalloid (eg, normal saline). Hypotonic fluids push fluids from the bloodstream into the cell; therefore, they will not expand circulating volume.

Review6. When assisting with an IV on a geriatric or pediatric patient, it is

important to remember that:

A. fluids should not be given unless the patient is in cardiac arrest. Rationale: Fluids are used for many reasons other than cardiac

arrest.B. geriatric and pediatric patients are susceptible to fluid overload. Rationale: Correct answerC. hypotonic fluids should be used if the patient requires

rehydration. Rationale: An isotonic fluid (Normal Saline [NaCl]) should be used

for rehydration.D. geriatric and pediatric patients can easily handle 2,000 mL of

fluid. Rationale: A fluid bolus is typically 20 mL per Kg, so 2000 mL would

mean that the patient weighs about 100 Kg or 220 lbs.

Review

7. All of the following are commonly used IV fluids in the prehospital setting, EXCEPT:

A. Hespan.

B. normal saline.

C. lactated ringers.

D. 5% dextrose in water.

Review

Answer: A

Rationale: Hespan is a synthetic colloid, and is not commonly used in the prehospital setting for IV therapy. Normal saline, lactated ringers, and 5% dextrose in water (D5W) are commonly used. Normal saline and lactated ringers are used to expand circulating volume (ie, hypovolemia), while D5W is used when the patient needs an IV line for the purpose of medication administration.

Review

7. All of the following are commonly used IV fluids in the prehospital setting, EXCEPT:

A. Hespan.

Rationale: Correct answer

B. normal saline.

Rationale: Normal saline is a commonly used IV fluid.

C. lactated ringers.

Rationale: Lactated ringers is a commonly used IV fluid.

D. 5% dextrose in water.

Rationale: 5% dextrose in water is a commonly used IV fluid.

Review

8. While attempting to resuscitate an infant in cardiac arrest, the paramedic is unable to establish IV access after several attempts. He or she will MOST likely insert a/an:

A. saline lock.

B. butterfly catheter.

C. external jugular IV.

D. intraosseous catheter.

Review

Answer: D

Rationale: Saline locks and butterfly catheters require venous cannulation, which the paramedic has been unsuccessful at. External jugular vein cannulation is not practical because it requires adequate access to the neck; infants do not have much of a neck. An intraosseous catheter will likely be inserted into the child’s proximal tibia. Unlike IV therapy, an intraosseous catheter delivers fluids and medications to the patient through the bone.

Review8. While attempting to resuscitate an infant in cardiac arrest, the

paramedic is unable to establish IV access after several attempts. He or she will MOST likely insert a/an:

A. saline lock.Rationale: A saline lock attaches to the end of a venous

catheter once access has been established.B. butterfly catheter. Rationale: A butterfly catheter requires venous access and this

patient does not have that.C. external jugular IV.Rationale: An external jugular IV is not practical in infants due to

their small necks.D. intraosseous catheter. Rationale: Correct answer

Review

9. You have been asked by your partner to prepare an IV setup. As you remove the cover on the piercing spike of the administration set, you drop the administration set on the floor of the ambulance. What should you do?

A. Ask your partner what he or she would like for you to do

B. Discard the contaminated administration set and get a new one

C. Cleanse the spike with an alcohol prep and use it to spike the bag

D. Recap the administration set and dispose of it in a sharps container

Review

Answer: B

Rationale: The piercing spike is sterile and should immediately be used to prevent contamination. If you drop it or touch it with anything other than the port on the IV bag, you should discard it and get a new sterile one. Your partner should not have to tell you this.

Review (1 of 2)

9. You have been asked by your partner to prepare an IV setup. As you remove the cover on the piercing spike of the administration set, you drop the administration set on the floor of the ambulance. What should you do?

A. Ask your partner what he or she would like for you to doRationale: Your partner should know that he or she should discard

the administration set.B. Discard the contaminated administration set and get a new oneRationale: Correct answer

Review (2 of 2)

9. You have been asked by your partner to prepare an IV setup. As you remove the cover on the piercing spike of the administration set, you drop the administration set on the floor of the ambulance. What should you do?

C. Cleanse the spike with an alcohol prep and use it to spike the bag

Rationale: The piercing spike needs to be sterile and using an alcohol prep does not make it sterile.

D. Recap the administration set and dispose of it in a sharps container

Rationale: It does not require disposal into a sharps container. It is solid waste and can be discarded in a garbage can.

Review

10. Approximately 10 minutes after starting an IV on a 50-year-old man, he tells you that he itches all over. You assess him and note widespread urticaria and facial swelling. This patient is MOST likely experiencing:

A. circulatory overload.

B. a vasovagal reaction.

C. an allergic reaction.

D. a systemic infection.

Review

Answer: C

Rationale: Itching, urticaria (hives), and facial swelling are signs of an allergic reaction. Allergic reactions are often related to an individual’s unexpected sensitivity to an IV fluid. If an allergic reaction occurs, the ALS provider must discontinue the IV and be prepared to treat the patient for anaphylactic shock.

Review10. Approximately 10 minutes after starting an IV on a 50-year-

old man, he tells you that he itches all over. You assess him and note widespread urticaria and facial swelling. This patient is MOST likely experiencing:

A. circulatory overload. Rationale: Overload will present with difficulty breathing and

pulmonary edema.B. a vasovagal reaction. Rationale: A vasovagal reaction will cause the patient’s heart

rate to slow down.C. an allergic reaction. Rationale: Correct answerD. a systemic infection.Rationale: An infection will present with symptoms of a fever.