Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4.
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Transcript of Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4.
Module:
Session:
Advanced Care ParamedicineAdvanced 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.
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
Why do we cannulate?
Fluid administration Medication administration To maintain life (electrolytes, blood…)
Do we do them to be EHSNS protocol compliant?
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)
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
Normal Saline
Most commonly administered IV fluid prehospitally
IV fluid of choice for EHSNS protocols
Why?
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?
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)
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
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
Where do we cannulate?
Hand Forearm Neck Foot
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
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
Types of catheters
Jelco
Cathelon
Insyte
Types of catheters
Protective
Protective Plus
Administration Sets
10 gtts/ml 15 gtts/ml 60 gtts/ml Blood sets
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
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
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)
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
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
IV Access
Complications
Local complications Hematomas Infiltration Necrosis Thrombophlebitis
Systemic complications Pulmonary edema Speed shock Pyrogenic reaction Pulmonary embolism
blood Air
Catheter shear
Local - Hematomas
Causes:
Symptoms:
Preventative actions:
Punctured vein
Bruising Tenderness Swelling
Proper techniques
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
Local - Necrosis
Causes:
Symptoms:
Preventative actions:
Irritation of tissues from infiltrated drug or fluid
Swelling, tenderness Inflammation or
bruising
Routine checks Report any changes
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
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
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
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
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
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
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!
External Jugular (EJ) cannulation
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 ?
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.
Procedure
Aim needle towards ipsilateral nipple
Insert needle and enter vein
Observe flashback
Withdraw needle and attach IV tuning
Cover site with sterile dressing
EJ cannulation
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)
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)
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.
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
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)
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