module: session: advanced care paramedicine intravenous therapy 7 4

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Module : Session: Advanced Care Paramedicine Advanced Care Paramedicine Intravenous Therapy 7 4

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Page 1: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Module:

Session:

Advanced Care ParamedicineAdvanced Care Paramedicine

Intravenous Therapy

7

4

Page 2: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Thirty years ago…

Rampart, Squad 51.

We have a 20 year old male motorcycle rider involved in a motor vehicle collision complaining of neck, back and leg pain.

He presents with compound fractures to both femurs and has significant blood loss.

We are requesting an order for two large bore IV’s and Ringer’s Lactate.

Page 3: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Objectives

Identify the reasons IV therapy is performed in the prehospital setting

Identify the fluids commonly administered State the basis of fluid and electrolyte balance Identify factors affecting water loss Explain the recommended uses of IV solutions Identify common complications and reactions Calculate a flow rate Demonstrate proper skin cleansing and aseptic

venipuncture technique Demonstrate proper IV cannulation technique

Page 4: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Why do we cannulate?

Fluid administration Medication administration To maintain life (electrolytes, blood…)

Do we do them to be EHSNS protocol compliant?

Page 5: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

IV fluids

Normal saline (0.9% NS) Lactated Ringer’s (LR)

Also known as Hartman’s solution or RL

D5W ½ NS D5 ½ NS

D5RL (D5LR)

Page 6: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Isotonic Solutions

Characteristics Same tonicity as plasma Osmotic pressure is the

same as the inside of the cell

Fluid never leaves or enters the cell

Approximate osmolarity is 240 – 340 mOsm/L

Will increase circulating volume, which may lead to fluid volume excess or overload.

Solutions 2.5% dextrose/0.45%

NaCl 0.9% NaCl Lactated Ringers 2.5% dextrose in ½

lactated ringers 6% dextan and 0.9%

NaCl 10% dextran and 0.9%

NaCl

Page 7: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Normal Saline

Most commonly administered IV fluid prehospitally

IV fluid of choice for EHSNS protocols

Why?

Page 8: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Lactated Ringers

Composed of multiple electrolytes in saline

Has fallen out of favor as one of main IV fluids for treatment of traumatic hypovolemia in past decade

Why?

Page 9: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Hypotonic Solutions

Characteristics May cause blood cells to

swell and burst May cause changes or

damage endothelial cells Exert less osmotic

pressure than the fluid in the extracellular compartment

Fluid is drawn into the cells

Approximate osmolarity < 240 mOsm/l

Solutions 0.45% NaCl 10% dextran and 5%

dextrose (slightly hypotonic)

Page 10: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Hypertonic Solutions

Characteristics May cause blood cells to

shrink May cause dame/changes

to endothelial cells Exert more osmotic

pressure then the extracellular fluid

Fluid is drawn from the cell into the vascular space

Approximate osmolarity > 340 mOsm/l

Solutions 5% dextrose/0.2% NaCl 5% dextrose/0.9% NaCl D5W D10W D50W 5% NaHCO3

10%, 15% and 20% Mannitol

6% dextran and 0.9% NaCl

Page 11: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Administration Sets

The calibration of the administration set must be known in order to calculate the flow of the IV fluids correctly. Macrodrip sets

10, 15 or 20 gtts/ml Microdrip (minidrip)

60 gtts/ml

Page 12: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Where do we cannulate?

Hand Forearm Neck Foot

Page 13: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Equipment Required

Solution Administration set IV cannula Tourniquet Alcohol swab Gloves Sharps bin Op site and gauze Tape If performing a Lock

Lock, syringe and saline

Page 14: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Catheter specifics

Color Size Int Dia/Length Max FlowGrey 16 G 1.4 mm/45 mm 180

mls/minGreen 18 G 1.0 mm/45 mm 80 mls/minPink 20 G 0.8 mm/32 mm 54 mls/minBlue 22 G 0.6 mm/25 mm 31 mls/min

The length and diameter will affect the amount of fluid able to be infused through the catheter Larger diameter and shorter length gives more fluid Small diameter and long length gives less fluid

Page 15: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Types of catheters

Jelco

Cathelon

Insyte

Page 16: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Types of catheters

Protective

Protective Plus

Page 17: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Administration Sets

10 gtts/ml 15 gtts/ml 60 gtts/ml Blood sets

Page 18: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Vein Selection

Based on: Condition

Palpate to confirm type of vessel Should be soft and spongy

Straight with no turns or bumps Location

Is the pt right or left handed Is the extremity injured Avoid joints (stabilization) Does the pt have a shunt (fistula)

Purpose Fluid replacement, Medication route, Safety line (lock) Dictates flow rate and type of fluid to be infused Try to use large veins for large quantities of fluid

Duration What type of patient (trauma, cardiac or outpatient) Patient comfort over long period of time Prolonged therapy may require multiple punctures For long durations use distal veins first

Page 19: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Fluid Replacement

Blood Replaced at a ratio of 3:1 of IV fluid to blood being replaced

Minimum daily requirements 1st 10 kg 100 ml/hr 2nd 10 kg 50 ml/hr 3rd 10 kg 20 ml/hr 4th 10 kg 10 ml/hr 5th 10 kg 10 ml/hr

Example 50 kg patient 100 ml/hr + 50 ml/hr + 20 ml/hr + 10 ml/hr + 10 ml/hr = 190 ml/hr

Page 20: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Contraindications

Distal to a fracture site in a limb Through damaged or abraded skin

Burns may be an exception if there is no other accessible site

In an arm affected by a radical mastectomy, edema, blood clot or infection

In an arm with a fistula for dialysis or a peripherally inserted control catheter (PICC Line)

Page 21: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Procedure

Obtain consent and explain rationale for IV therapy Assess that the pt meets the criteria for the procedure Ensure that there are no contraindications for the procedure Observe universal precautions for body substance exposures Prepare all necessary equipment Position the patient Apply a tourniquet 3 – 5 inches above the selected site

Patient may make a fist to assist in engorging the vein Select the most appropriate venipuncture site

Condition Location Purpose Duration

Prepare the pt’s arm using alcohol swab

Page 22: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Procedure

Insert needle through skin Should be at an 30° angle

Lower angle (15°)and enter vein Observe flashback Enter vein a ‘little bit more’ Enter catheter into vein Release tourniquet Withdraw needle and discard in sharps container,

tamponade the vein to avoid blood spill Attach iv tubing and open flow valve observing for

infiltration Cover with Op site or other sterile dressing, tape in

place

Page 23: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

IV Access

Page 24: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Complications

Local complications Hematomas Infiltration Necrosis Thrombophlebitis

Systemic complications Pulmonary edema Speed shock Pyrogenic reaction Pulmonary embolism

blood Air

Catheter shear

Page 25: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Local - Hematomas

Causes:

Symptoms:

Preventative actions:

Punctured vein

Bruising Tenderness Swelling

Proper techniques

Page 26: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Local - Infiltration

Causes:

Symptoms:

Preventative actions:

Poor insertion techniques Improper taping Over active patient IV slows or stops

Swelling or hardness Feeling of coldness Leaking at the site

Armboards, proper taping Routine checks of IV flow

and site

Page 27: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Local - Necrosis

Causes:

Symptoms:

Preventative actions:

Irritation of tissues from infiltrated drug or fluid

Swelling, tenderness Inflammation or

bruising

Routine checks Report any changes

Page 28: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Local - Thrombophlebitis

Causes:

Symptoms:

Preventative actions:

Trauma to endothelium from chemical means

Pain, redness, swelling along infected vein

Generalized symptoms such as fever, malaise, rapid pulse

Avoid insertion over joint Select veins with adequate

blood flow for infusions of hypertonic solutions

Page 29: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Systemic – Pulmonary Edema

Causes:

Symptoms:

Preventative actions:

Circulatory overload from too rapid infusion when patient has impaired renal or cardiac function

JVD, ↑BP, ↑Resps, dyspnea, agitation

Watch rate Oxygen, sit pt upright Slow IV and contact

OLMC

Page 30: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Systemic – Speed Shock

Causes:

Symptoms:

Preventative actions:

IV running to rapidly Rapid injection of a

drug

↓BP, rapid pulse Labored resps,

cyanosis Faint, ↓LOC

Use controlled volume infusion set

Upon initiation, ensure free flowing prior to rate adjustment

Page 31: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Systemic – Pyrogenic Reaction

Causes:

Symptoms:

Preventative actions:

Contaminated IV solutions

Symptoms generally occur after IV begun

↑temp, chills, headache, N/V, circulatory collapse

Check IV fluids for cloudiness and particles

Use fresh open IV’s

Page 32: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Systemic – PE (Blood/Embolus)

Causes:

Symptoms:

Preventative actions:

Unfiltered blood Partially dissolved drug Particulate matter in IV

solution

Dyspnea, cyanosis, pain, anxiety, tachycardia, tachypnea

Infuse blood through filter Dissolve drugs

completely Use good judgment when

syringing IV’s

Page 33: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Systemic – PE (Air)

Causes:

Symptoms:

Preventative actions:

Failure to clear tubing of air Allowing air to enter the

system

Cyanosis, ↓BP, weak, tachycardia, ↓LOC, non-specific chest or ABD pain

Don’t let IV run dry Clear tubing properly Check syringe prior to

injecting If occurs place pt on left

side and contact OLMC

Page 34: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Troubleshooting

If blood begins to flow back in the IV tubing Check location of the bag to insure it is in a gravity flow location Insure all valves are open If continues, reassess site and assure arterial cannulation has not

occurred If your IV does not run… Start at the top, work your way back to the patient Is the bag empty? Check the IV set clamps to insure they are open Check tubing for kinks Check site for any problems

Blood backing up Infiltration

Do you need to flush the site Is your tourniquet still one!

Page 35: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

External Jugular (EJ) cannulation

Page 36: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

EJ’s

Often used in severe cases of shock, unresponsiveness and cardiac arrest since they are HUGE and relatively easy to cannulate.

Why are they not commonly used in those who are conscious ?

Why are they not a good choice for patients of multi system trauma ?

Page 37: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

EJ cannulation procedure

Place patient supine / slight reverse Trendelenburg Why ??? Turn patients head slightly to opposite side

Cleanse with antiseptic using universal precautions

Create tourniquet effect with fingers by applying light pressure to the inferior aspects of the EJ being cannulated.

Page 38: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Procedure

Aim needle towards ipsilateral nipple

Insert needle and enter vein

Observe flashback

Withdraw needle and attach IV tuning

Cover site with sterile dressing

Page 39: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

EJ cannulation

Page 40: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Calculating flow rates

Drip sets Factor10 gtt/ml (macro) 10 drops = 1 ml 615 gtt/ml 15 drops = 1 ml 420 gtt/ml 20 drops = 1 ml 360 gtt/ml (micro) 60 drops = 1 ml 1

Volume to be administered (ml)

Time to be infused (min)

X Drip set (gtts/ml)= Drops/min

(gtts/min)

Page 41: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Calculations

Your patient is to receive 1000 ml of normal saline (NS) over a 12 hour period using a microdrip (60 gtt/ml) administration set. The formula will now look like this:

Volume to be administered (ml)

Time to be infused (min)

X Drip set (gtts/ml)=

Drops/min (gtts/min)

1000 ml

720 min

X 60 gtts/ml=

Drops/min (gtts/min)

83.333 =Drops/min (gtts/min)

Page 42: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Now add medications

A physician orders 2 mg/min of Lidocaine to your patient. She orders 2 g of lidocaine to be added to 500 ml NaCL. Using a 60 gtt/ml set, calculate the gtt/min.

Page 43: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Calculation

[ ] = Mass

Volume

= 2.0 g

500 ml

= 2000 mg

500 ml

= 4 mg/ml

Dose = D

H

X V

= 2 mg/min

2000 mg

= 1000 mgml/min

2000 mg

= 0.5 ml/min

X 500 ml

Page 44: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

Calculation

Volume to be administered (ml)

Time to be infused (min)

X Drip set (gtts/ml)=

Drops/min (gtts/min)

0.5 ml

1 min

X 60 gtts/ml=

Drops/min (gtts/min)

30 =Drops/min (gtts/min)

Page 45: Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

A Variation to the Same

Volume (ml)

On Hand (mg)X Drip set (gtts/ml) =

Drops/min (gtts/min)

=Drops/min (gtts/min)

30 =Drops/min (gtts/min)

X Ordered (mg/min)

500 ml

200 mgX 60 gtt/ml

X 2 mg/min