Amy Gutman MDEMS Medical Director

prehospitalmd@gmail.com

PARAMEDIC PHARMACOLOGY:

INTRAVENOUS FLUIDS & DRUG CALCULATIONS

Review of fluids & electrolytes

Techniques of intravenous & intraosseous infusions

Mathematical principles used in pharmacology & to calculate medication doses

Medication administration routes

OVERVIEW

#1 I am a woman I am bad at math Do not extrapolate ALL

women are bad at math

#2 This is a boring lecture This is a necessary

lecture Do not extrapolate ALL

my lectures are boring

DISCLAIMERS

Discussed Today

Intravenous (IV)Intraosseous (IO)

Other Routes

Sublingual (SL)Subcutaneous (SQ)Parenteral (PO)Rectal (PR)Inhalation (IH)Endotracheal (ET)Transdermal (TD)Intramuscular (IM)Intranasal (IN)

MEDICATION ADMINISTRATION ROUTES

Provider integrates pharmacology knowledge to formulate a treatment plan intended to mitigate emergencies & improve the overall health of patient

Administer medications within scope of practice

Understand “six rights” of medication administration

Understand advantages, disadvantages & techniques for establishing venous access

Review math concepts, including dose & rate calculations

Describe role of medical direction

NATIONAL EMS EDUCATION STANDARD COMPETENCIES ~ PHARMACOLOGY

Medication administration governed by local protocols &/or online medical direction

Standing Orders: Off-line or indirect medical control of predefined procedures

Online (Direct) Medical Control: Must contact physician prior to performing certain procedures

When in doubt, contact medical control

When an order is given: If unclear or inappropriate, ask physician to repeat the order Repeat back for confirmation the name, dose & route of

delivery

MEDICAL DIRECTION

In ill or injured patients, survival may depend on ability to obtain access for fluid & drug resuscitation Peripheral extremity Eternal jugular vein Intraosseous

Harm can result from improper technique or insuffi cient pharmacology knowledge

VASCULAR ACCESS

Right patient

Right drug

Right dose

Right route

Right time

Right documentation

“RIGHTS” OF MED ADMINISTRATION

Knowledge necessary prior to administration Mechanism of action Indications Contraindications Side effects Routes of administration Pediatric & adult doses Dose calculations Antidotes / reversal

agents

MEDICATION ADMINISTRATION

Name of drug

Dose of drug

Time administered

Administration route

Name of person administering drug

Patient’s response to drug

DOCUMENTATION

At beginning of each shift, check drugs, supplies & equipment Not expired Not damaged Readily available in required quantities

Paramedic responsible for documentation & security of all controlled substances State, regional & local distribution, security, exchanges &

accountability policies Double lock system in each vehicle & at base storage Drug log must be kept for at least 3 years Medical director DEA number used to order narcotics

DRUG CHECKS & LOGS

Treat all bodily fluids as infectious I don’t shake pt’s hands

without gloves (especially kids)

PPE, gloves & protective eyewear at all times Include full facial protection if

possible splatter

CDC states hand-washing most effective method to prevent the disease spread

UNIVERSAL PRECAUTIONS

Routine & thorough hand-washing

Hand-sanitizer before & after every patient contact if no easy access to soap & water

Keep equipment in clean conditions with disinfection between each patient & every shift

Antiseptics prior to any invasive procedure

Check linen, equipment & supplies prior to use for intactness, cleanliness

ASEPSIS

After needle penetrates skin, it is contaminated

After needle unsheathed, it is a weapon

Immediately dispose of sharps in a puncture-proof sharps container

Follow your agency protocol for disposal of infectious waste & cleaning of contaminated equipment

CONTAMINATED MATERIALS CLEANING OR DISPOSAL

Specific protocol

Specifics to that medication or IVF: Indications / Contraindications Therapeutic effects Side effects Appropriate dose & re-dosage Need (+/-) for medical control

Allergies: Known by patient Obtain from reliable source if not from patient Check for medic-alert jewelry or tags.

BASIC PHARMACOLOGY KNOWLEDGE

INTRAVENOUS FLUIDS

Based upon presenting & underlying illness or injury

Even a small amount of the poorly chosen fluid may be harmful to a patient

Most agencies have limited choices of each IVF class – easy to familiarize yourself with specifics of each

CHOOSING APPROPRIATE IVF

BODY COMPARTMENTS

Commonly used prehospitally Normal saline, lactated ringers,

dextrose & saline or water

Made of water & electrolyte solutions that easily cross a semi-permeable membrane

Rapidly alter intravascular fl uid levels

Non-oxygen carrying

Given as a constant rate or bolus Adult: 250cc Pediatric: 20cc/kg In trauma, consider permissive

hypotension

CRYSTALLOIDS

0.45% Normal Saline

Dilutes serum by pulling water from vascular compartment into interstitial compartment

Used for hyperosmolar conditions l ike severe dehydration Leads to hyponatremia if plasma sodium normal as has lower

concentration of sodium than serum Cells swell & burst from increased osmotic pressure If rapidly infused causes cerebral edema & central pontine

demyelinosis

May cause sudden fl uid shift from intravascular space to intracellular space leading to cardiovascular collapse

Slower but deadly is third spacing ~ abnormal shift into serum if not enough protein to “hold” fl uid in vascular space

IV FLUIDS: HYPOTONIC

1.8% - 10% saline, mannitol

Osmolarity higher than serum as has more particles than serum

Pulls fluid & electrolytes from the intracellular to intravascular (ECF) compartment

Large volumes cause hypernatremia & severe dehydration Cells may collapse from increased extracellular osmotic

pressure

A little goes a long way to: Increase BP Reduce cerebral edema

IV FLUIDS: HYPERTONIC

0.9% Normal Saline

Principal resuscitation fluid

Contains sodium, potassium, chloride in almost same concentrations as “body water” or “plasma”

Iso-osmolar compared to plasma so stays almost entirely in the extracellular space

3-1 replacement rule: 3cc isotonic solution needed to replace 1 mL of blood

IV FLUIDS: ISOTONIC

Albumin, blood, dextran, hetastarch

Contain particles which do not readily cross semi-permeable membranes

Volume stays almost entirely within intravascular space for prolonged time compared to crystalloids

Because of gelatinous properties cause platelet dysfunction interfering with fibrinolysis & coagulation factors (factor VIII)

Can cause significant coagulopathy in large volumes

IV THERAPY: COLLOIDS

Blood contains hemoglobin which carries oxygen to cells

Impractical for prehospital unless specialized critical care transport Refrigeration & unique storage “Non-cross matched blood”, or “type O”

expensive, rare, with potential complications

Synthetic blood available, but rarely used outside trauma research institutions or the military PolyHeme, HemoPure (HBOC

Hemoglobin-Based O2 Carrying Solutions)

OXYGEN-CARRYING SOLUTIONS

CHOOSING THE RIGHT SITE:

ANATOMY & TECHNIQUES

Based on purpose of IV, patient age, location

Over-the-needle catheters preferred in prehospital setting Readily secured Minimally cumbersome Allow for some patient movement Do not need to immobilize the

entire limb

Sized by diameter (gauge) Smaller gauge = larger diameter Choose largest-diameter catheter

for chosen vein New needles retract after insertion

CHOOSING AN IV CATHETER

Gloves, PPE

Tape & bio-occlusive dressing

Tourniquet

Alcohol, betadine, chlorhexadine

Arm board

Sharps container

EQUIPMENT NEEDED

IV solution Medical: NS Trauma: LR or NS* Medication drip: NS or D5W

Administration set w/ extension tubing Macro drip (10-15 gtts/cc) for volume Micro drip (60 gtts/cc) for medications

Catheter >12 yo + fluid resuscitation: 16-18g, IO <12 yo +/- fluid resuscitation: 20-24g, IO <6 yo: 20-24g, IO

EQUIPMENT NEEDED

Most packaged in clear plastic bags

Labeling: Fluid type Expiration date

Do not use after expiration date, appear cloudy, discolored, with visible particulate, or if packaging not intact

IV SOLUTION CONTAINERS

Over-The-Needle Hollow-Needle

INTRAVENOUS CANNULAS

Macrodrip 10 gtts = 1 mL, for large

amounts of fluid

Microdrip 60 gtts = 1 mL, for

restricted amounts of fluid

Measured volume & secondary infusion sets

Blood tubing Filter prevent clots from

entering body

IV ADMINISTRATION SETS

Blood type identified by obtaining blood type & cross-match

“Blood-band” identifies blood type & blood product hung Blood must be checked against bracelet & verified by

medic even if already checked by nursing

Blood administered through specific tubing

Assess vitals q15 mins & monitor for hemolytic reactions

Tachycardia, hives, respiratory distress, CP

BLOOD TRANSFUSIONS

PERIPHERAL ACCESS

Prepare new bag / bottle

Occlude flow from depleted bag or bottle

Remove spike from depleted & insert into new IV bag / bottle

Open clamp to & titrate to appropriate flow rate

CHANGING INTRAVENOUS BAG OR BOTTLE

Thick fluids (colloids) infuse slowly

Cold fluids run slower than warm fluids

Height of IV bag must overcome gravity if not a pressure bag

The larger the diameter, the faster fluid can be delivered

Check for constricting band, BP cuff

Evaluate for infi ltration or trauma proximal to IV site

FACTORS AFFECTING IV FLOW RATES

Puncturing vein may cause massive hematomas

Tape may damage skin

Use smaller catheters (20, 22, 24 g)

Cardiovascularly sensitive to rapid fluid shifts

Poor vein elasticity

GERIATRIC CONSIDERATIONS

Pain

Infection / Phlebitis

Allergic reaction

Catheter shear

Arterial puncture

Circulatory overload

Air embolism

Necrosis

IV ACCESS COMPLICATIONS

Escape of fl uid into surrounding tissue IV catheter passes through vein IV becomes dislodged Catheter inserted at too shallow an angle only entering

fascia

SSX: Edema at the catheter site Continued IV flow after proximal vein occlusion Tightness, burning, pain at IV site

Treatment: Discontinue IV & reestablish in opposite extremity or more

proximal location Apply direct pressure

IV COMPLICATION ~ INFILTRATION

Vein, catheter or tubing blockage

1 s t sign is decreasing / no drip rate or blood in tubing

Causes: Position of catheter within the vein BP overcoming flow Tourniquets!

Inject 1-5 cc saline into IV to gently increase pressure to overcome obstruction & reestablish fl ow If occlusion does not dislodge, discontinue IV

& re-establish in opposite extremity or proximal to current site

IV COMPLICATION ~ OCCLUSION

Hematoma Accumulation of blood in tissues

around IV Causes: vein perforation, improper

catheter insertion or removal Stop IV, apply direct pressure

Arterial puncture Bright red spurting blood Suspect if you have a great IV that

does not flow, after checking for obstruction

Withdraw catheter, apply direct pressure for 5 mins or bleeding stops

Always check for a pulse prior to cannulation

IV COMPLICATIONS ~ HEMATOMA & ARTERIAL PUNCTURE

Anaphylaxis Sensitivity to IV fluid or

medication Treat according to allergic /

anaphylaxis protocol

Pyrogenic reactions Pyrogens are foreign proteins

capable of producing fever secondary to allergic reactions

Characterized by abrupt fever with chills, backache, HA, N/V, weakness

Stop infusion immediately Treat according to allergic /

anaphylaxis protocol

IV COMPLICATIONS ~ SYSTEMIC

IV COMPLICATIONS ~ NECROSIS & INFECTION

Healthy adults can handle 2-3 extra liters of crystalloids

Problems pts with cardiorespiratory or renal dysfunction who can’t tolerate hemodynamic stress from increased circulatory volume

SSX: Dyspnea, JVD, HTN, rales, hypoxia,

edema

Treat by converting to saline lock, respiratory distress protocol

IV COMPLICATIONS ~ CIRCULATORY OVERLOAD

Flushing IV line & replacing empty IV bags limits likelihood of air embolism

SSX: Respiratory distress, unequal BS,

cyanosis Focal neurological symptoms Shock & cardiorespiratory arrest

Treatment: LLR & Trendelenburg position 100% oxygen, treat specific symptoms

according to pertinent protocol Rapid transport

IV THERAPY COMPLICATIONS ~ AIR EMBOLUS

Part of catheter pinches against needle & slices through catheter creating a free-flowing segment

SSX similar to air embolus

Treatment Surgical removal of the tip LLR & Trendelenburg Do not rethread

IV COMPLICATIONS ~ CATHETER SHEAR

More than using a “BFN”

Have a favorite site, favorite “Jelco” & favorite technique

Have a back-up And a back-up to your

back-up

Practice, practice, practice

CHOOSING THE RIGHT SITE

ANTECUBITAL VEIN

DORSAL “DIGITAL” VEINS

EXTERNAL JUGULAR

ACCESSING EXTERNAL JUGULAR VEIN

Technique of administering fl uids, blood products & drugs into intraosseous space of tibia, humerus or sternum

Long bones consist of a shaft (diaphysis), the ends (epiphyses) & growth plate (epiphyseal plate)

IO space is spongy cancellous epiphyseal & diaphysis medullary cavity.

When in shock, peripheral veins collapse making IV access diffi cult

IO space always patent to rapidly absorb fl uids & drugs, similar to a central l ine

INTRAOSSEOUS

Cannot locate landmarks

Fractures at / above site

Amputations distal to site

Previous surgery at site

Infection at site

Local vascular compromise

Previous attempt in same site

Osteogenesis imperfecta

Occasionally diffi cult in combative & the obese

GENERAL IO CONTRAINDICATIONS

Identify landmarks & anatomy

Have all equipment ready prior to startingManufacturer-specific device & equipment

IV tubingMedications

IO INFUSION

OBJECTIVE Determine time difference to obtain IO vs IV wearing

HazMat PPE

METHODS 22 EMT-Ps placed anterior tibial EZ-IOs & antecubital

IVs Measured: time to skin access, vascular access & fluid

infusion

CONCLUSIONS With provider & mannequin in PPE, needle to skin

time, vascular access time, & fluid infusion time all favored EZ-IO

SYYAMA J, ET AL. IO VS IV ACCESS WHILE WEARING PPE IN A HAZMAT SCENARIO. PEC

2007

HUMERAL IO

Supine position, humerus adducted

Palpate midshaft humerus proximally until reach humeral head

At shoulder there is a protrusion (greater tubercle) which is the insertion site

With opposite hand “pinch” anterior & inferior aspects of humeral head to confi rm position of greater tubercle

Stabilize arm, place IO at 90 degree angle to skin

Humeral cortex less dense than tibia so minimal force required

HUMERAL APPROACH

DISTAL TIBIA IO

Landmarks are anterior distal tibia & medial malleolus (middle ankle bone protrusion)

Medial insertion site, 2 finger widths proximal to medial malleolus

“Big Toe = IO”

DISTAL TIBIAL APPROACH

PROXIMAL TIBIA IO

Tibial tuberosity is round protrusion distal to patella

From tuberosity, move 1 inch medially to tibial plateau

From tibial plateau, go proximally 0.5 inch towards patella

This is thinnest portion of tibial bony cortex

PROXIMAL TIBIA APPROACH

STERNAL IO

STABILIZE THE IO

STABILIZE THE BABY

Large, deep veins that do not collapse until late shock Internal jugular, subclavian,

femoral

Though IO “peripheral”, it’s flow rate & placement in marrow makes it function essentially as central access

CENTRAL VENOUS ACCESS

Surgically implanted device permitting repeated access to central venous circulation

Generally located on anterior chest near the 3 rd-4th rib lateral to sternum

Accessed with a special needle specific to the device

Requires special training

CENTRAL ACCESS DEVICE

Dilated vein acts like an artery due to AV graft

Do not access!

Most common complication is bleeding

Direct pressure +/- proximal tourniquet

DIALYSIS FISTULA

MATHEMATICAL PHARMACOLOGY

PRINCIPALS

Vials Single or multi-dose Draw air into syringe,

inject into vial & withdraw drug

Ampules Tap neck area to drain

fluid Using 4X4, snap neck of

vial & withdraw drug Dispose of ampule

pieces in sharps container

Prefilled Syringes Remove caps & screw

pieces together Dispel air & use as

standard syringe

Dry Powder meds Depress plunger in vial

to mix with prepackaged saline

Mix thoroughly until particulates completely absorbed

IV MEDICATION PACKAGING

Decimal system based on multiples of ten measuring length (meter), volume (liter), weight (gram)

Prefi xes indicate fraction of base being used Micro = 0.00001 Milli = 0.001 Centi = 0.01 Kilo = 1,000

Drugs packaged in diff ering units of weight & volume so conversion often required

METRICS

Necessary information:Desired dose (amount of drug)

Drug concentration (total weight of drug contained in specific amount of volume)

Volume on hand (volume of solution containing drug)

BASICS OF DOSE CALCULATION

Most pediatric drugs weight-based Length-based

resuscitation tape Pediatric wheel charts EMS field guide /

Smartphone app

Once weight known, calculations same as for adults

PEDIATRIC DRUG DOSAGES

1 gram (g) = 1000 milligrams (mg)

1 mg = 1000 micrograms (mcg)

1 liter (L) = 1000 milliliters (ml)

If going from large to small value, move decimal point to right

If going from small to large value, move decimal point to left 1 Kg = 1000 g 1Kg = 1,000,000 mg 1 Kg = 1,000,000,000 mcg

METRIC CONVERSIONS

Kg x 2.2 = pounds (lbs) 1 Kg = 2.2 lbs 3 am: (lbs/2) – 10% =

kg

To convert kg to lbs: Kg x 2.2 = lbs (Kg x 2) + 10% = lbs

POUNDS TO KILOGRAMS

You want to give 5mg valium. Label states 10 mg in 2cc (10mg/2cc). How many cc’s will you give?

Therefore…1 cc of valium = 5mg of valium

Phenergan ordered for 12.5 mg Supplied in 25 mg/ 2cc Therefore 12.5 mg / 1cc

CALCULATION EXAMPLE

5mg x 2cc = X cc

10 mg

Adjust flow rate according to pt’s condition & per protocol

You must know: Volume to be infused Period over which it is to be infused Properties of the administration

Therefore, flow rate is: Volume to be infused x gtt/mL of administration set/total

time of infusion in minutes = gtt/min

CALCULATING FLUID INFUSION RATES

Desired dose (D) x Patient’s kg Weight (W) = Volume to be Administered (X)

Known dose on hand (H)

WEIGHT-BASED CALCULATIONS

You are giving 0.5 mg/kg IVP to an 80kg patient. Drug prepackaged in 100mg/10cc

To determine total dose: 0.5mg x 80kg = 40mg

To determine total volume: 40 mg x 10cc = 4cc total volume

100 mg

CALCULATION EXAMPLE

Desired dose x Size of bag x gtt set = gtt/min

Order is for 5 mg/min. You have 500cc NS, a 60 gtt/cc admin set & 2g of drug. How many gtt/min?

DRIP RATE CALCULATIONS

Desired Dose x Volume of IV Bag x Administration Set gtt = gtt / min

Amount of Drug

5mg/min x 500cc x 60gtt/ cc = 75gtt / min

2000mg

Volume x administration set / time (cc x gtt) / minutes

You want to give a 500cc bolus using a 15 gtt set over 1 hour (500cc x 15gtt) / 60 mins = 125

gtts/min

SIMPLER DRIP RATECALCULATION

Caroline’s Emergency Care in the Streets 7 t h Edition (Principles of Pharmacology, Medication Administration & Emergency Medications). Jones & Bartlett. 2013

Pharmacology Drug Dosage Calculations. Shelby County EMS Training Division 2010

Linscott et al. Emergency Care. IV Access, Blood Sampling & IO Infusions. Brady 2009.

Photo credits (IV insertion, EJ cannulation) Scott Metcalf MD©

REFERENCES

Find math formula or system that works for you Use Smartphone but remember that

phones die! Back-up with paper, pen & brain

IVF classes, pathophysiology & indications

Diff erent techniques, equipment & indications for vascular access

“6 rights” of drug administration including basics of BLS & ALS medication utilization

When in doubt contact medical control

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