2001 04 April Ems IVTherapy Meds
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IV Therapy and MedicationAdministration
CFD April QA Training
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Intravenous Therapy
Fluid/electrolyte administration
Normal blood volume is 4.5-5L IV fluids do not replace blood or carry O2
Introduce medications
Immediate drug absorption and effects
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Crystalloids-Fluids used in the field Normal Saline (1000 cc)
0.9% Sodium Chloride
Isotonic solution Lactated Ringers (1000cc)
Isotonic solution containing electrolytes such asNaCl, KCl, CaCl, and sodium lactate
D5W (250cc) Hypotonic solution containing glucose to provide
calories for metabolism
Glucose moves into cells rapidly
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Equipment needed IV solution
MedicalNS; TraumaLR and/or NS; Med dripD5W
Administration set with extension tubing Macro drip (10-15 gtts/cc) for all IVs
Micro drip (60 gtts/cc) for medication drip
Catheter Age >12 and need for fluid resus16 or 18 g
Age
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Equipment needed (cont) Gloves
Tape and bioclusive dressing
Tourniquet Alcohol/betadine pad
Use betadine in cases of suspected ETOH usewhere a crime may be involved (DUI)
Ensure no allergies when using betadine Arm board
Sharps container
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IV Complications Infiltration
Fluid outside vessel causing swelling, pain, little or
no IV flow Catheter shear
Piece of catheter separates
Air embolism
Air enters blood stream (10-100 cc have beenfatal)
Infection
Localized or systemic Home
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Saline lock vs. IV Saline lock
Potential need for single med
administration
IV
Multiple meds and/or D50, fluid admin
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Acceptable IV sitesArm
Multiple veins in hand and arm
Neck External jugular
Leg
Long saphenous vein*Anteromedial aspect of the tibia (IO)*Leg and foot veins involve a very high incidence of complications and
should only be used cautiously as a last resort.
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Fluid bolus Maintain blood pressure between 90-
100 mmHg systolic
Give 250 cc boluses one at a time
Closely monitor blood pressure, lungsounds and patient status prior to giving
additional boluses
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Medication Administration
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Five Rights1. Right patient
2. Right dose3. Right medication
4. Right route
5. Right time
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IV medication packaging Vials (Single or Multi-dose)
Draw equal amount of air into proper syringe
Inject air into vial and withdraw medication
Ampules Tap neck area to drain fluid
Using alcohol prep or 4X4, snap neck of vial
Withdraw proper amount of medication anddispose of ampule pieces in sharps container
Remember, always use aseptic technique and remove
air from syringe prior to injecting! Home
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IV medication packaging (cont) Prefilled syringes
Tubex (glass syringe without plunger)
attach to plastic plunger based on device dispel air and use as standard syringe
Prepackaged (style with two pieces)
remove caps and screw pieces together
dispel air and use as standard syringe Dry powder meds (lose efficacy when pre-mixed)
Depress plunger in vial to mix with prepackaged saline oradd saline to vial and mix thoroughly
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Med Math The basics
use like units
use common sense
find a formula/system that works for you
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Making weight.. 1 kilogram (kg) = 2.2 pounds (lb)
Actual conversion
Wt: 220 lb
220 divided by 2.2 = 100kg
10% or Midnight rule
Half of 220 = 110 10% of 110 = 11
Subtract 11 from 110 = 99kg
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Metric conversions 1 gram (g) = 1000 milligrams (mg)
1 mg = 1000 micrograms (mcg)
1 liter (L) = 1000 milliliters (ml) You need to give 500 mcg. How many mg?
Mg - move decimal 3 places to the left = 0.5 mg
OR 500 = half of 1000 so half of 1 = .5 mg
You need to give 100 mg. How many mcg? Howmany g? mcg - move decimal point 3 places to the right = 100,000 mcg
g - move decimal point 3 places to the left = 0.1 g
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Basic calculations
Desired dose (D)
Known dose on hand (H)
x Unit of measure or volume on hand (Q)
= volume or unit of measure to be administered (X)
D X Q = X
H
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Example You are ordered to give 5 mg Valium IV. The label
states there is 10 mg in 2cc (10mg/2cc). How manyccs will you give?
The equation will look like this:5mg x 2cc = X cc
10 mg
1 x 2 = X cc2
X = 1 cc
You will give 1cc! Home
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Calculations based on weightDesired dose (D) x Weight in kg (W)
Known dose on hand (H)
X Unit of measure or volume on hand (Q)
= volume or unit of measure to be administered (X)
D x W x Q = X
H
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Example You are to give 0.5 mg/kg IV push. Your patient
weighs 80 kg. The drug comes packaged:100mg/10cc. How many mg will you give? How
many ccs will you deliver?
Your equation to determine mg will look like this:
0.5 mg/kg x 80 kg = 40 mg to be given
Your equation to determine cc will look like this:
40 mg x 10 cc = 4cc
100 mg
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Drip calculationsClock method (used only for 4:1 ratio)
4
3 1
60
15
30
45
2
If your dose is 1 mg/min, your drip rate is 15 gtt/min.If the order is greater than 4 mg/min, add themtogether. A dose of 6 mg/min is 90 gtt/min (4 + 2
=6 so 60 + 30 = 90) Home
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Drip calculationsDesired dose x Size of bag x gtt set = gtt/min
Amount of drug on hand
The order is for 5 mg/min. You have a 500 cc bag of NS, a 60 gtt/ccadministration set, and 2 g of drug on hand. How many gtt/min willyou administer?
5 mg/min x 500 cc x 60 gtt/cc = 75 gtt/min
2000 mg
Note: If the dose is weight based, determine the total dose prior tobeginning the equation or multiply everything by the number of kg.
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Routes to administer medications Enteral (via digestive tract)
Oral (by mouth, PO)
10-90 minutes to begin working
Affected by digestion and absorption
Sublingual (under the tongue, SL)
3-5 min Rectal (via the rectum, RE)
5-30 minutes
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Med routes (cont) Parenteral
Inhalation (IH)
Endotracheal (ET) Transdermal (TD)
Time for effects variable based on medication
Subcutaneous (SQ) Intramuscular (IM)
Intravenous/Intraosseous (IV/IO)
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Medication delivery through the airway Inhalation
Takes effect in 2-3 min
Given by hand held nebulizer (HHN) ormetered dose inhaler (MDI)
Endotracheal Takes effect in 2-3 min
Must double IV dose and flush with saline
Narcan, Epinephrine, Lidocaine, Atropine
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Intramuscular and Subcutaneous Intramuscular
Takes effect in 10-20 min
Delivery 90 degree angle, 1 inch minimum needle
Subcutaneous
Takes effect in 15-30 min Delivery
45 degree angle, 1/2-1 inch needle
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Standing Orders vs. Physician Order Standing Order
Able to give med or start procedure if patient
meets certain preset criteria Physician Order
Must request med or procedure from on linedoctor
When giving report, ask for doctor before beginning Give report and paint clear picture of patient status
Specifically request the medication and dose you want togive
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Things to look for Onset of Action-time between administration and first effectsseen
Duration of Action-time after administration until effects are lastseen
Side effect-undesirable and often unavoidable effect thatoccurs. Effects are not the original reason for administering thedrug.
Interaction-good or bad effects that occur with administration ofmultiple drugs. Can increase or decrease effects of one or both
meds.
Synergism-action of a combination of drugs that is greater thanone drug alone
Allergy-systemic reaction to a drug involving the immuneresponse
Untoward effect-side effect that becomes harmful to the patient
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Glossary of Terms Absorption-process of drug moving from site of
introduction into circulation
Contraindication-factor that does not allowadministration of drug
Dependence-state where absence or less of drugcauses physical or emotional effects
Excretion-elimination of drug or toxins
Half life-time it takes for a drug level to reduce byhalf
Loading dose-large amount of drug given totemporarily increase blood levels
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Glossary (cont.) Maintenance dose-amount of drug needed to
maintain steady blood levels
Peak level-highest blood level from any given dose
Therapeutic action-wanted and intended effects of adrug
Tolerance-decreased response to drug after repeatedadministration. May require increased dose.
Toxic level-blood levels are such that they mayproduce adverse effects
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Prehospital Medications The following is a list of drugs given in
the TEMS region. Limited information is
included for a number of the drugs butdue to space constraints, everythingcould not be listed. Please review all
medications you are responsible foradministering
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Oxygen Standing order: EMT, ST, CT, PM
Dose: 2-15 LPM via nasal cannula, non-
rebreather, bag-valve-mask Indications: Any patient with reduced
oxygen levels or increased need foroxygen.
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Activated Charcoal (Actidose) Physician order: EMT, ST, CT, PM
Dose: Adult (50 g), Pediatrics (25-30 g) given bymouth
Action: Binds and absorbs ingested toxin and is thenexcreted.
Indication: Overdose or poisoning when induction ofvomiting is not indicated
Contraindications: Unable to swallow or maintainairway. Not useful in cyanide, methanol, causticacids or alkalis, heavy metals, or lithium poisonings.
Side Effects: None
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Oral Glucose Standing Order: EMT, ST, CT, PM
Dose: One tube
Action: Increases blood glucose Indication: Consider if patient has an altered
level of consciousness and/or knownhypoglycemia
Contraindications: Difficulty swallowing orunable to protect own airway.
Side Effects: None
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Epinephrine-SQ (Adrenalin) Patient Assisted Med: EMT Physician Order: ST
Standing Order: CT, PM
Dose: 0.01 mg/kg (up to .3 mg) SQ 1:1000
Action: Improves force of ventricular contractions andheart, bronchdilatation, peripheral vasoconstriction, andhistamine antagonist
Indication: Anaphylaxis, severe asthma
Contraindications: Hypovolemic shock, hypertension,
cardiac insufficiency Side Effects: Anxiety, restlessness, hypertension,
dysrhythmias
Note- Physician order for any patient over 40 years of ageand or cardiac history!
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Albuterol (Proventil, Ventolin) Patient Assisted Med: EMT
Standing Order: ST, CT, PM
Dose: PAM (1-2 puffs from MDI only), 2.5 mg
HHN repeated once Action: Relaxes smooth muscle of bronchial tree
and peripheral vasculature
Indication: Relief of bronchospasm, wheezing
Contraindications: Tachycardic dysrhythmias Side Effects: Anxiety, restlessness, palpitations,
increased blood pressure
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Nitroglycerin (NTG) Patient Assisted Med: EMT
Physician Order: ST
Standing Order: CT, PM
Dose: 0.4 mg SL every 3-5 min up total of 3 Action: Dilation of arterioles and peripheral veins causing
decreased workload of the heart and decreased oxygen demandby decreasing preload and afterload.
Indications: Chest pain, CHF
Contraindications: Viagra use in past 24 hours, systolicBP
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Aspirin (ASA) Physician order: ST
Standing Order: CT, PM
Dose: 324 mg (four 81mg chewable) Action: Antiplatelet and vasodilatory actions allowed
to occur through alterations in enzyme production.
Indication: Chest pain
Contraindications: ASA intake in past 24 hours Side effects: Bleeding, GI upset
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Diphenhydramine HCl (Benadryl) Physician Order: ST
Standing Order: CT, PM
Dose: 50mg IV or IM (adult) 1-2 mg/kg (peds)
Action: Binds to histamine receptor sites blocking thehistamine response
Indications: Allergic and EPS/dystonic reactions
Contraindications: Acute asthma attack, taking MAO
inhibitors, narrow angle glaucoma Side Effects: Drowsiness, hypotension, drying of
secretions, sedation
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Naloxone (Narcan) Physician Order: ST
Standing Order: CT, PM
Dose: 2-4 mg IV titrated to effect
Action: Reverses effects of narcotics by competing for receptorsites
Indications: Narcotic overdose, altered level of consciousnessor unconsciousness with unknown origin
Contraindications: Use cautiously in drug dependant patients asadministration can cause withdrawals
Side Effects: projectile vomiting and/or cardiac dysrhythmiaswith rapid admin, withdrawals, diaphoresis
Note-Narcans effects are shorter acting than the narcotics somonitor patient closely.
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Thiamine (Betaxin, Vitamin B1) Physician Order: ST
Standing Order: CT, PM
Dose: 100 mg IV or IM
Action: Combines with ATP to form a coenzyme necessary inthe metabolism of carbohydrates
Indications: Prior to the administration of D50 as part of theunconscious protocol, Wernickes encephalopathy
Contraindications: None
Side Effects: Hypotension from rapid admin, anxiety, nauseaand vomiting, diaphoresis, red streaks following up the vein
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Dextrose 50% (D50) Physician order: ST
Standing Order: CT, PM
Dose: 25 g in 50 cc for adult 0.25 g/kg of 25%
solution for peds Action: Increases blood glucose.
Indication: Blood glucose level
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CT and PM Meds Adenosine (Adenocard)-narrow complex tachycardias, SVT
PO: CT and SO: PM
Dose: 6mg, 12mg, 12mg rapid IV push
Atropine-asystole (SO: CT, PM)-1mg every 3-5 min up to 3mg Bradycardia (PO: CT and SO: PM)
0.5mg-1mg every 3-5 min up to a total of 0.04 mg/kg or 3mg
Bretylium (Bretylol)-Pulseless Vtach/Vfib or Vtach PO: CT, PM
5mg/kg rapid IV push repeated in 5 min at 10mg/kg to a max of 30mg/kgover 24 hours
Calcium chloride-Ca channel blocker overdose, crush syndrome,hyperkalemia, hypocalcemia PO: CT, PM
8-16 mg/kg slow IV push
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CT and PM meds (cont.) Cardizem (Diltiazem)-Afib or Aflutter
PO: CT, SO: PM
Dose: 0.25 mg/kg IV over 2 min
Diazepam (Valium)-sedation or seizure control
PO: CT, SO: PM
2-5 mg IV for adults, 0.2-0.3 mg/kg for peds
Dopamine (Intropin)-hypotension without hypovolemia
PO: CT, PM
5-20 mcg/kg/min IV drip (400 mg/250cc)
Epinephrine (Adrenalin)-cardiac arrest (IV, ET) SO: CT, PM
1 mg IV every 3-5 min in cardiac arrest, doubled for ET
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CT and PM meds (cont.) Epinephrine drip-profound symptomatic bradycardia
PO: CT, PM
2- 10 mcg/min IV drip (1mg/250cc)
Epinephrine nebulized-pediatric upper airway obstruction
PO: CT, PM
2-3 mg of 1:1000 in nebulizer
Furosemide (Lasix)-rales, CHF
PO: CT, SO: PM
40 mg IV or 0.5-1.0 mg/kg for adult and 1mg/kg for peds
Lidocaine (Xylocaine)-Vtach, Vfib, wide complex tachycardias SO: CT(cardiac arrest only), PM
1.5 mg/kg initial dose and repeat for cardiac arrest up to 3mg/kg total
0.5-0.75 mg/kg repeat dose with pulse up to 3mg/kg total
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CT and PM meds (cont.) Magnesium Sulfate-Torsades de pointes, refractory Vfib, preeclampsia
PO: CT, PM
1-2 g in 10cc IV over 1-2 min for arrest and 2-4 g in 50cc NS slow IV push
Midazolam Hydrochloride (Versed)-sedation, seizures
PO: CT, SO: PM
2mg slow IV push titrated to effect
Morphine Sulfate-pain, CHF
PO: CT and PM
1-3 mg slow IV for CHF and chest pain and 2-4 mg IV for burns
Sodium Bicarbonate (Bicarb)-tricyclic antidepressant overdose, returnof circulation after long arrest, known severe acidosis
PO: CT and PM
1 mEq/kg IV push
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CT and PM meds (cont.) Solumedrol (Methylprednisolone)-anaphylaxis, severe asthma
PO: CT and PM
125 mg IV
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