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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