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Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program

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1 Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program
Basic EMT IV Therapy Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program

2 Agenda for the day……. Base Hospital & ADHS/BEMS policy review
Anatomy & physiology Identifying the purposes of IV infusions IV solutions Setting up an IV IV catheters Selecting the IV site Starting the IV Complications Trouble-shooting Removing the IV line Case Reviews Drip calculations

3 Prerequisites: Certified EMT-Basic, under Medical Direction Course Competencies This course is designed to develop the following course competencies: Identify the need for fluid resuscitation in pediatric and adult victims Identify and describe the vascular anatomy and venous access for the pediatric or adult victims Identify and differentiate isotonic, hypotonic, and hypertonic solutions; Select fluids, set up and manage equipment Identify and demonstrate aseptic and safety techniques Identify and describe indications and contraindications for intravenous site selection Perform all peripheral intravenous cannulation techniques, monitor infusion Demonstrate 100% accuracy in intravenous techniques in selected scenarios Demonstrate 85% proficiency on a written examination.

4 R9-25-505. Protocol for IV Access by an EMT-B
A. In this Section, unless the context otherwise requires, “EMS provider agency” means the emergency medical services provider or the ambulance service for whom the EMT-B is acting as an EMT-B. B. An EMT-B is authorized to perform IV access only after completing training that meets all requirements established in Exhibit 1. C. Before performing IV access, an EMT-B trained in IV access shall have received prior written approval from the EMT-B’s EMS provider agency and from an administrative medical director who agrees to provide medical direction for the EMT-B. D. An EMT-B shall perform IV access only under “on line” medical direction, under standing orders approved by the administrative medical director, or under the direction of a currently certified EMT-I or EMT-P who is also attending the patient upon whom the EMT-B is to perform the procedure. E. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B’s IV access attempts. F. An EMT-B trained in this optional procedure shall have a minimum of 5 IV starts per year. If less than 5, the EMT-B shall participate in a supervised base hospital clinical experience in which to obtain the minimum of 5 IV starts.

I. PURPOSE This protocol defines the scope of authority afforded to prehospital providers in the performance of their duties with and without on-line medical direction. This protocol will enable the pre-hospital provider to understand all skills allowed without on-line medical direction, specialized skills allowed with proof of training and skills allowed only AFTER on-line medical direction has concurred. II. DEFINITIONS A. STANDARD PERMISSIVE SKILLS Standard permissive skills are defined as skills that MAY be performed by pre-hospital personnel after approved initial training WITHOUT on-line medical direction. No telemetry or verbal orders are needed prior to the initiation of these skills for stabilization. Verification of on-going competency skill assessments must be obtained every two (2) years.

6 HAZ-MAT drug antidote therapy by toxicology paramedics
B. EXPANDED SCOPE OF PRACTICE: NON PERMISSIVE Expanded practice is defined as skills allowed by prehospital personnel with advanced training in the specific area. Prior approval of administrative medical direction authority is required. These skill MAY require on-line medical direction at the discretion of the medical direction authority. ALS BLS HAZ-MAT drug antidote therapy by toxicology paramedics Activated Charcoal Administration Inter-facility IV infusion pump monitoring Automatic transport ventilators Immunization Administration Adult I/O Rapid Sequence Intubation CPAP Patient Assisted Nitroglycerin Tablets or Spray Patient Assisted Nitroglycerin Tablets EMT IV Access Skills Endotracheal Intubation Combitube Insertion

7 GUIDELINES Pre-Hospital Intravenous Access by EMT-Basic guidelines:
One (1) hour yearly review of curriculum related to Intravenous Therapy. Five (5) successful IV starts in 6 month period (Jan. thru end of June----July thru end of December). Use of QA form related to EMT-B IV Access for each encounter and attached it to the Patient Care Report. Ongoing use of EMT-B IV Therapy form. Form to be reviewed randomly by Pre-Hospital Manager and QA/QI Officer, and at end of 6 months. Cycle describe above. EMT-B will be limited to three (3) attempts at IV access peripherally per patient for this incident. EMT-B will not initiate IV access on any patient less than 6 years of age. It is an expectation that any problems related to this advanced skill will immediately be brought to the immediate attention of the Pre-Hospital Manager.


Incident #: _________________ Date: _______________ EMT #: _________________ Name: ______________(EMT-B) Agency: ________________ Patient Age: _________________ Sex: M F BLS on scene time: ________ IV start time: _________ IV start on scene: Y/N IV start enroute: Y/N Type of fluid: ______________________ Total volume infused: _______________ Medical Control Authorization: Circle One On-Line base hospital patch time: _________ Standing Orders ( attach SO form) Paramedic/IEMT Direction Ambulance on scene time: ____________ ALS on scene time: ____________ ALS meds given by IV Y/N Time given: __________ EMT IV attempts: ______ If greater than 2 give reason: _____________________________________________________________ _____________________________________________________________ Complications: Y/N SUCCESSFUL/UNSUCCESSFUL Describe: Patient Outcome:


11 Anatomy

12 Introduction Knowing the anatomy will aid you in performing your skills, even when you cannot see the veins. After this block of instruction you should be able to differentiate between veins and arteries, and show where these items can be found.

13 Some questions we’ll need to answer
What is skin? What is an artery? Where are arteries found? What is a vein? Where are veins found? What is blood? Question:

14 Skin Covers the entire body and acts as a protective layer between the body and the environment. The main functions of the skin are: Protection from harmful influences Control of body temperature Conveyance of sensory impressions Some areas of the bodies skin are highly sensitive and the insertion of a needle in one area may cause a great deal of pain, while another area may be practically painless.

15 Besides epithelial cells and connective tissue cells, the skin also contains delicately entwined nerves and blood vessels.

16 Blood Vessels With the exception of capillaries, the walls of the blood vessels consist of three layers, though the thickness or construction of the individual layers can vary according to the vessel type.

17 Blood Vessels The outer layer consists of connective tissue and facilitates the fitting of the vessel into its environment. The middle layer is composed of smooth muscle containing elastic fibers. The inner layer consists of thin connective tissue. It is covered by a layer of single-layered endothelial cells.

18 Arteries The arteries are blood vessels which transports blood away from the heart. They are different in construction from the veins in that they have an additional layer of an elastic membrane situated between the inner and middle wall layers.


20 Arteries Depending on the task and the location of the artery, its middle layer may be dominated by smooth muscle or elastic fibers.

21 Arteries When the heart pumps blood into the arteries during the expulsion phase (systole), their high proportion of elastic fibers permits them to distend. During the relaxation phase (diastole) of the heart, they contract again, transporting blood on further. Arteries with muscle predominating are able to widen (vasodilation) or narrow (vasoconstriction) their diameter through contraction, thus enabling the amount of blood contained within them to increase or decrease with the demands of the body. Arterioles are the smallest arteries.

22 Veins The veins are the blood vessels which transport blood towards the heart. The wall layers of the veins are thinner than those of the arteries, yet contain more connective tissue. The muscle layer is less marked. The diameter of veins are larger than that of arteries.

23 Veins As a result of the thin layer of muscle the veins are not able to move blood themselves. They are aided by the surrounding musculature around them. In order to prevent the blood from flowing back, some of the veins, especially those within the extremities, are equipped with venous valves. When the blood is flowing towards the heart, the venous valves lie flat against the venous wall. If the blood congests or starts to flow back, the valves close.

24 Capillaries Capillaries are the smallest blood vessels in the body
They are connected to the arterioles and into the venules, thus representing the link between arteries and veins.

25 Capillaries environment.
In contrast to arteries and veins, capillaries have neither a middle or outer wall layer. They only have an inner layer, constructed of connective tissue and endothelial cells. The diameter of capillaries is very small because of they are so small they circulate in single file. This fact, and the thinness of their wall layer promote their ability to exchange material and Water with their environment. The oxygen and nutrients contained within the blood are pressed out of them as a result of the blood pressure and passed off to the intercellular cavities. Carbon dioxide and metabolic products are absorbed by the blood in the exchange

26 Blood 4-5x thicker than water Liquid connective tissue
Adults = 7% of patients weight 4-6 Liters of blood Children = 9% of patients weight

27 Physical Characteristics of Blood
Color range Oxygen-rich blood is scarlet red Oxygen-poor blood is dull red pH must remain between 7.35–7.45 Blood temperature is slightly higher than body temperature (100.4)

28 Functions of Blood Transportation – oxygen, nutrients, hormones, heat, electrolytes. Carries away from the body tissues - Waste matter - CO2 Protection – Vital role in our immune system; clotting mechanisms that prevent blood loss Regulation – pH, body temperature, water content

29 Components of Blood PLASMA – is the yellowish fluid of the blood and consists primarily of water (92%) and plasma proteins (7%) Proteins – albumin and fibrinogen FORMED ELEMENTS – solid component of the blood consisting of red blood cells, white blood cells, and platelets BLOOD = 55% plasma

30 Blood Plasma Composed of approximately 92 percent water Contains:
Nutrients, salt solution Respiratory gases Hormones Proteins, Waste products

31 Plasma Proteins Albumin – regulates osmotic pressure
Clotting proteins – help to stem blood loss when a blood vessel is injured Antibodies – help protect the body from antigens

32 Formed Elements “Types of Cells”
Erythrocytes = Red Blood Cells Leukocytes = White Blood Cells Thrombocytes = Platelets

33 Erythrocytes “Red Blood Cells”
The main function is to carry oxygen Anatomy of circulating erythrocytes Cells without a nucleus Produced continuously in the bone marrow from stem cells at a rate of 2-3 million cells per second. ─ Hemoglobin 95% of a red cell Approximately 120 days life span Outnumber white blood cells 1000:1

34 Leukocytes “White Blood Cells”
These are complete cells, with a nucleus Crucial in the body’s defense against disease. Ingest pathogens & destroy Produce antibodies Can respond to chemicals released by damaged tissues

35 Thrombocytes “Platelets”
Cell fragments without nuclei that release blood clotting chemicals Life span of 5-9 days Needed for the clotting process Platelets and clotting proteins work together.

36 So….Why should we allow EMT’s to start IV’s??

37 Purpose of starting IV’s
To deliver fluids To deliver medications

38 Cellular Physiology Body Fluid
1. Total body water = 60% of body weight Intracellular = 45% of body weight Extracellular = 15% of body weight 2. Electrolytes Cations = positive charge sodium potassium magnesium calcium

39 Anions = negative charge
Bicarbonate chloride Principles of electrolyte balance Water follows sodium Potassium > intracellular Sodium > extracellular Changes in ion concentration effect muscle and nerve function

40 3. Protein 4. Fluid loss Albumin Plasma Other Blood loss Plasma loss
Nausea/vomiting/diarrhea Sweating

41 Movement of Body Fluids
Osmosis – the flow of fluid across a semi permeable membrane (cell wall) from a lower solute concentration to a higher concentration.

42 Isotonic – IV fluids that approximate the osmolaity of blood plasma. I
Isotonic – IV fluids that approximate the osmolaity of blood plasma. I.e.: 0.9% Normal Saline (note the biconcave shape of the cells as they circulate in blood.) Hypotonic – IV solutions that have a lower osmolarity than blood plasma thus drawing fluids into the cell. I.e.: D5W. (note the cells are visibly swollen and have lost their biconcave shape, and at 100 mOs, most have swollen so much that they have ruptured, leaving what are called red blood cell ghosts. In a hypotonic solution, water rushes into cells.) Hypertonic – IV fluids that have a higher osmolality than normal blood plasma thus drawing fluids out of the cells and they get irritated when infused.I.e.: D50 (note water has flowed out of the cells, causing them to collapse and assume the spiky appearance you see.)

43 Types of IV Solutions 0.9% Sodium Chloride Lactated Ringers D5W

44 0.9% Sodium Chloride Also called normal saline
Isotonic solution of sodium chloride in water 9 grams of sodium chloride per liter Indications Restore loss of water and sodium chloride Fractures Trauma Dehydration Hypoglycemia Non-traumatic hypoperfusion Contraindications Use with caution in CHF and pulmonary edema

45 Lactated Ringers Source of water, electrolytes, and calories
Indications To replenish fluid and calories, and restore loss of electrolytes Trauma Burns OB Non-traumatic hypotension dehydration Contraindications Use with caution in CHF, pulmonary edema, and liver disease

46 D5W Hypotonic solution of dextrose in water (50 grams of dextrose per liter) Indications Directed by MD Contraindications Head injury Children

47 All fluids come in 250cc, 500cc, and 1000cc bags.
Combinations of Normal Saline, Lactated Ringers, and D5W are often common. All fluids come in 250cc, 500cc, and 1000cc bags.

48 Setting Up An IV

49 Assemble and prepare the necessary equipment
You will need: The correct IV solution The correct administration set An IV catheter An IV start pack Tourniquet Alcohol prep Opsite or equivalent Tape

50 Inspect the container and solution
Check the label and the expiration date Look for tears in the bag Assess the clarity of the solution; if it is not clear – DO NOT USE IT! Look at the pull-tab and make sure that it is intact

51 Types of administration sets
IV administration sets differ mainly in the drop factor (the rate of flow they produce)

52 Minidrip/Microdrip/Pediatric Drip
Delivers 60 gtts (drops) per cc (ml). Used on all patients that fluids need to be restricted on. I.e.: heart failure patients, dialysis patients, and pediatric patients.

53 Standard/Macrodrip Delivers gtts (drops) per cc (ml). Used on patients that require a large amount of IV fluid. i.e.: trauma, overdoses, burns, heat related emergencies.

54 Blood tubing A “Y” shaped tubing that is also is a 10 gtts per cc set, but is used with NS for blood administration.

55 Preparing the IV bag Remove the protective tab from the insertion port
Close the flow clamp on the administration set Remove the protective cap from the administration set Holding the port carefully and firmly with one hand, insert the spike with the other hand Hang the bag and squeeze the drip chamber until it is half full

56 Priming the IV tubing Open the flow clamp. Hold the end of the tubing over a collection container. Be sure to maintain the sterility of the tubing! Leave the clamp open until the IV solution flows through the entire length of the tubing, forcing out all air. After priming the tubing, close the clamp.

57 IV Catheters

58 Selecting the IV catheter
Two types of needless and catheters are commonly used in peripheral lines: Over-the-needle catheters Winged-tip or scalp-vein needles

59 IV catheters The higher the number, the smaller the gauge
The larger the gauge, the more fluid that can be delivered The shorter the catheter the more fluid that can be delivered

60 General rule of thumb for selection of size:
Medical patient’s Use at least a 20 gauge catheter A 22 gauge can be used if the patient has small, fragile veins Pediatric patient’s (NOT USED on ages SIX and UNDER) Use gauge Trauma patient’s Use at least an 18 gauge catheter

61 Selecting the site Peripheral veins – usually for short-term use (less than 3 weeks) When choosing a peripheral vein both arms should be assessed. Large veins are best suited for emergency infusions Avoid arms with injuries, burns, open sores. Call for medical direction for mastectomy side possible Start with a vein at the most distal site so you can move upward as needed for additional insertion sites.

62 EXCEPTION: In a code arrest use the antecubital vein as it is closer to the central circulation. Fluids and medications do not have as far to travel to reach the central circulation.

63 The most favorable venipuncture sites are:
- veins in the dorsum of the hand - antecubital vein - basilic vein - cephalic vein Be sure the vein can accommodate the catheter used.

64 Factors affecting site selection
Type of solution Condition of vein Duration of therapy Cannula size Patient age Patient preference Patient activity Presence of disease or prior surgery, i.e.: mastectomy or shunt (Call for medical direction)

65 Patient preparation TALK TO YOUR PATIENT. Explain what you are going to do Prepare equipment Check solution for correct type, valid expiration date, and clarity Place patient in supine position to decrease vasovagal reaction

66 Select site and catheter
Apply tourniquet Cleanse site

67 Hold skin taut, by placing thumb on non-dominant hand 1-2 inches below intended insertion site and gently pull skin

68 Insert needle through the subcutaneous tissue at a degree angle beside or directly into the vein, bevel up

69 Assess for blood return
When blood return is obtained decrease the angle of the catheter and very carefully advance the needle and the catheter approximately ¼ inch to assure the catheter is in the vein A steady backflow of blood indicates a successful venipuncture

70 Pull needle back into but not out of the catheter
Pull needle back into but not out of the catheter. Advance the catheter into the vein while continuing to hold the skin taut

71 Release the tourniquet
Gently place pressure over the vein above the catheter tip to prevent bleeding while removing the needle. Do not compress catheter!

72 Attach fluid source Regulate flow rate

73 Arm boards Arm boards should be used to support areas of joint flexion or to restrain IV sites in extremely active patients or children Arm boards should be padded to maintain comfort and prevent nerve or tissue damage Normal joint configuration should be maintained by supplemental padding Tape should NOT be wrapped completely around the patient’s arm, nor should it be applied too tightly because it will act as a tourniquet, decreasing peripheral circulation distal to the IV site

74 Complications of IV therapy
The potential hazards of IV therapy range from minor to life threatening They may be associated with the venipuncture or with the infusion Lack of aseptic technique is a major cause of complications as it induces pathogens into the circulatory system Complications may be local or systemic

75 Local Complications

76 Site infections (Local contamination of insertion site)
Signs and symptoms Redness, warmth, tenderness, and swelling at site Possible purulent material Possible causes Failure to maintain aseptic technique during starting or removing IV catheter Actions Remove IV and restart in unaffected arm Prevention measures Maintain strict aseptic technique of IV insertion

77 Clotting (Blockage at the end of the device in the patient’s vein)
Signs and symptoms Tenderness at IV site Sluggish flow rate Possible causes IV rate too slow to maintain patency of catheter Activity of patient causes increase back-flow of blood Actions Remove IV and restart in another area Prevention measures Maintain constant flow rate Tightly secure all connections

78 Hematoma (Raised, discolored area caused by leakage of blood at puncture site)
Signs and symptoms Tenderness at venipuncture site Area around site appears “bruised” Inability to advance IV Possible causes Vein “blown” or punctured through other wall at time of venipuncture Leakage of blood from needle displacement Actions Remove IV catheter Apply pressure to area Prevention measures Do not advance needle further if resistance is met on venipuncture Choose a vein that can accommodate size of IV catheter

79 Infiltration (Leakage of IV fluids into surrounding tissues)
Signs and symptoms Swelling, tenderness above the IV site that may extend along the entire arm Decreased skin temperature around the site Fluid continues to infuse even when vein is occluded Back-flow of blood is absent Flow rate is slower or stopped Possible causes Catheter is dislodged from vein or vein is perforated Actions Remove IV catheter Apply ice (early) or warm (later) to aid absorption Elevate extremity Restart IV infusion above infiltration or in another limb Prevention measures Check IV site frequently Do not obscure area above site with tape Restrict movement of limb by placing on arm board

80 Phlebitis (Irritation along vein)
Signs and symptoms Area along vein is red, tender, and warm Vein is hard and cord-like when palpated Irritation increases with infusion Possible causes Hypertonic solutions Repeated use of same vein for therapy Movement of catheter in vein Catheter is too large or flow rate too rapid for size of vein Clotting at tip of catheter Actions Remove IV catheter Apply warm packs Restart IV infusion is a different limb Prevention measures Use large veins for hypertonic solution infusion Choose smallest IV needle for situation and size of vein Stabilize the catheter to decrease movement in vein

81 Systemic Complications

82 Catheter embolism Signs and symptoms Possible causes Actions
Related to specific location of embolus: discomfort, decreased BP, cyanosis, weak pulse, respiratory distress, altered LOC Possible causes Rethreading stylet into catheter Actions Apply tourniquet above IV site to discourage further traveling of device into venous system Prevention measures Withdraw catheter and stylet together is venipuncture is unsuccessful

83 Air Embolism Signs and symptoms Possible causes Actions
Respiratory distress Unequal breath sounds Weak pulse Decreased BP Loss of consciousness Possible causes Disconnect between catheter and tubing thus allowing air to be sucked in IV tubing that runs dry or is not purged of air properly Solution container empty Actions Discontinue IV infusion Turn patient to left side, head down Administer oxygen Prevention measures Purge tubing completely of air before infusion starts

84 Circulatory overload Signs and symptoms Possible causes Actions
Patient discomfort Neck vein engorgement Increased blood pressure Fluid in lungs; rales, shortness of breath Possible causes Roller clamp loosened to allow “run-away” IV Miscalculation of fluid requirements Actions Slow or stop infusion rate Raise head of patient’s bed Prevention measures Double check IV rate ordered for size and condition of patient Administer oxygen

85 Systemic infection Signs and symptoms Possible causes Actions
Fever, chills without apparent reason Nausea, vomiting malaise Possible causes Contaminated IV devices or solution Failure to maintain aseptic technique during insertion Actions Remove IV catheter Restart in another area Prevention measures Examine fluid and container Monitor vital signs Maintain aseptic technique Secure all connections

86 What to do when infusion stops
Check IV site for infiltration Check IV catheter (position of patients extremity, the tip of catheter may be against the wall of vein, tape may be too tight) Check the flow clamp Check the tubing Check the air vent If one is required (i.e.: glass bottles) Check to be sure the spike is pushed in far enough into bag Try flushing the line with 5-10cc of saline. ** If the IV still does not run after all the above have been checked, then it should be discontinued and restarted! **

87 Changing the solution Turn the flow clamp off
Quickly remove the spike from the bag and insert it into the new bag (assure sterility!) Turn the flow clamp back on and regulate the rate

88 Removing a peripheral IV line
An IV should be removed if it infiltrates, fails to run or the site becomes infected Gather necessary supplies Band-aid or tape Sterile gauze (2x2) Turn the flow clamp off Gently remove all the tape from the catheter and skin Hold the sterile gauze over the insertion site and withdraw the catheter with a gentle, brisk movement keeping it parallel to the skin Cover the site with a band-aid or tape Document: Reason for removal Time Catheter integrity



91 Patient Care Report documentation should include:
Time Site/Location of IV # of attempts Gauge of catheter Solution type Rate of IV Absence of problems Total volume infused at transfer of care 1310 IV 0.9% NS started Left posterior hand 1st attempt with TKO rate. No signs/symptoms of infiltration. IV infusing without difficulty. 50cc infused upon transfer of care to…….



94 Any Questions?????

95 Let’s do some drip calculations

96 IV drip rate: Volume to be infused (ml) X drip factor of tubing
gtts/min = Time (min) to be infused i.e.: ml X 10 = 166 gtts/min 60min

97 Do IV flow rate calculation sheet now

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