Presentation on theme: "Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program"— Presentation transcript:
1Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program Basic EMT IV TherapyDawn Daniels RN, CCRNTucson Medical CenterPre-hospital Program
2Agenda for the day……. Base Hospital & ADHS/BEMS policy review Anatomy & physiologyIdentifying the purposes of IV infusionsIV solutionsSetting up an IVIV cathetersSelecting the IV siteStarting the IVComplicationsTrouble-shootingRemoving the IV lineCase ReviewsDrip calculations
3Prerequisites:Certified EMT-Basic, under Medical Direction Course CompetenciesThis course is designed to develop the following course competencies:Identify the need for fluid resuscitation in pediatric and adult victimsIdentify and describe the vascular anatomy and venous access for thepediatric or adult victimsIdentify and differentiate isotonic, hypotonic, and hypertonic solutions;Select fluids, set up and manage equipmentIdentify and demonstrate aseptic and safety techniquesIdentify and describe indications and contraindications for intravenous site selectionPerform all peripheral intravenous cannulation techniques, monitor infusionDemonstrate 100% accuracy in intravenous techniques in selected scenariosDemonstrate 85% proficiency on a written examination.
4R9-25-505. 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 actingas 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 inwhich to obtain the minimum of 5 IV starts.
5SAEMS PRE- HOSPITAL PROTOCOLS 75 SCOPE OF PRACTICE ADMINISTRATIVE 2.9 I. PURPOSEThis 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. DEFINITIONSA. STANDARD PERMISSIVE SKILLSStandard 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.
6HAZ-MAT drug antidote therapy by toxicology paramedics B. EXPANDED SCOPE OF PRACTICE: NON PERMISSIVEExpanded 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.ALSBLSHAZ-MAT drug antidote therapy by toxicology paramedicsActivated Charcoal AdministrationInter-facility IV infusion pump monitoringAutomatic transport ventilatorsImmunization AdministrationAdult I/ORapid Sequence IntubationCPAPPatient Assisted Nitroglycerin Tablets or SprayPatient Assisted Nitroglycerin TabletsEMT IV Access SkillsEndotracheal IntubationCombitube Insertion
7GUIDELINES 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.
8PROTOCOL ON-LINE MEDICAL DIRECTION EMT-I OR EMT-P GIVES YOU AN ORDER THAT IS ATTENDING THE SAME PATIENTSTANDING ORDERSALLERGIC REACTIONCHEST PAINHypoglycemiaHYPERTERMIANAUESA AND VOMITINGSEIZURE
9QA PROCESS EMT-BASIC IV ACCESS QA FORM Incident #: _________________ Date: _______________EMT #: _________________ Name: ______________(EMT-B)Agency: ________________Patient Age: _________________ Sex: M FBLS on scene time: ________IV start time: _________IV start on scene: Y/N IV start enroute: Y/NType of fluid: ______________________Total volume infused: _______________Medical Control Authorization: Circle OneOn-Line base hospital patch time: _________Standing Orders ( attach SO form)Paramedic/IEMT DirectionAmbulance 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/UNSUCCESSFULDescribe:Patient Outcome:
12IntroductionKnowing 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.
13Some 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:
14SkinCovers 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 influencesControl of body temperatureConveyance of sensory impressionsSome 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.
15Besides epithelial cells and connective tissue cells, the skin also contains delicately entwined nerves and blood vessels.
16Blood VesselsWith 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.
17Blood VesselsThe 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.
18ArteriesThe 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.
20ArteriesDepending on the task and the location of the artery, its middle layer may be dominated by smooth muscle or elastic fibers.
21ArteriesWhen 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.
22VeinsThe 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.
23VeinsAs 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.
24Capillaries 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.
25Capillaries 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 toexchange material and Water with theirenvironment.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
26Blood 4-5x thicker than water Liquid connective tissue Adults = 7% of patients weight4-6 Liters of bloodChildren = 9% of patientsweight
27Physical Characteristics of Blood Color rangeOxygen-rich blood is scarlet redOxygen-poor blood is dull redpH must remain between 7.35–7.45Blood temperature is slightly higher than body temperature (100.4)
28Functions of BloodTransportation – oxygen, nutrients, hormones, heat, electrolytes.Carries away from the body tissues- Waste matter- CO2Protection – Vital role in our immune system; clotting mechanisms that prevent blood lossRegulation – pH, body temperature, water content
29Components of BloodPLASMA – is the yellowish fluid of the blood and consists primarily of water (92%) and plasma proteins (7%)Proteins – albumin and fibrinogenFORMED ELEMENTS – solid component of the blood consisting of red blood cells, white blood cells, and plateletsBLOOD = 55% plasma
30Blood Plasma Composed of approximately 92 percent water Contains: Nutrients, salt solutionRespiratory gasesHormonesProteins, Waste products
31Plasma Proteins Albumin – regulates osmotic pressure Clotting proteins – help to stem blood loss when a blood vessel is injuredAntibodies – help protect the body from antigens
32Formed Elements “Types of Cells” Erythrocytes = Red Blood CellsLeukocytes = White Blood CellsThrombocytes = Platelets
33Erythrocytes “Red Blood Cells” The main function is to carry oxygenAnatomy of circulating erythrocytesCells without a nucleusProduced continuously in the bone marrowfrom stem cells at a rate of 2-3million cells per second.─ Hemoglobin 95% of a red cellApproximately 120 days life spanOutnumber white blood cells 1000:1
34Leukocytes “White Blood Cells” These are complete cells, with a nucleusCrucial in the body’s defense against disease. Ingest pathogens & destroyProduce antibodiesCan respond to chemicals released by damaged tissues
35Thrombocytes “Platelets” Cell fragments without nuclei that release blood clotting chemicalsLife span of 5-9 daysNeeded for the clotting processPlatelets and clotting proteins work together.
37Purpose of starting IV’s To deliver fluidsTo deliver medications
38Cellular Physiology Body Fluid 1. Total body water = 60% of body weightIntracellular = 45% of body weightExtracellular = 15% of body weight2. ElectrolytesCations = positive chargesodiumpotassiummagnesiumcalcium
39Anions = negative charge BicarbonatechloridePrinciples of electrolyte balanceWater follows sodiumPotassium > intracellularSodium > extracellularChanges in ion concentration effect muscle and nerve function
403. Protein 4. Fluid loss Albumin Plasma Other Blood loss Plasma loss Nausea/vomiting/diarrheaSweating
41Movement of Body Fluids Osmosis – the flow of fluid across a semi permeable membrane (cell wall) from a lower solute concentration to a higher concentration.
42Isotonic – 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.)
43Types of IV Solutions0.9% Sodium ChlorideLactated RingersD5W
440.9% Sodium Chloride Also called normal saline Isotonic solution of sodium chloride in water9 grams of sodium chloride per literIndicationsRestore loss of water and sodium chlorideFracturesTraumaDehydrationHypoglycemiaNon-traumatic hypoperfusionContraindicationsUse with caution in CHF and pulmonary edema
45Lactated Ringers Source of water, electrolytes, and calories IndicationsTo replenish fluid and calories, and restore loss of electrolytesTraumaBurnsOBNon-traumatic hypotensiondehydrationContraindicationsUse with caution in CHF, pulmonary edema, and liver disease
46D5WHypotonic solution of dextrose in water (50 grams of dextrose per liter)IndicationsDirected by MDContraindicationsHead injuryChildren
47All 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.
49Assemble and prepare the necessary equipment You will need:The correct IV solutionThe correct administration setAn IV catheterAn IV start packTourniquetAlcohol prepOpsite or equivalentTape
50Inspect the container and solution Check the label and the expiration dateLook for tears in the bagAssess 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
51Types of administration sets IV administration sets differ mainly in the drop factor(the rate of flow they produce)
52Minidrip/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.
53Standard/MacrodripDelivers gtts (drops) per cc (ml). Used on patients that require a large amount of IV fluid. i.e.: trauma, overdoses, burns, heat related emergencies.
54Blood tubingA “Y” shaped tubing that is also is a 10 gtts per cc set, but is used with NS for blood administration.
55Preparing the IV bag Remove the protective tab from the insertion port Close the flow clamp on the administration setRemove the protective cap from the administration setHolding the port carefully and firmly with one hand, insert the spike with the other handHang the bag and squeeze the drip chamber until it is half full
56Priming the IV tubingOpen 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.
58Selecting the IV catheter Two types of needless and catheters are commonly used in peripheral lines:Over-the-needle cathetersWinged-tip or scalp-vein needles
59IV catheters The higher the number, the smaller the gauge The larger the gauge, the more fluid that can be deliveredThe shorter the catheter the more fluid that can be delivered
60General rule of thumb for selection of size: Medical patient’sUse at least a 20 gauge catheterA 22 gauge can be used if the patient has small, fragile veinsPediatric patient’s (NOT USED on ages SIX and UNDER)Use gaugeTrauma patient’sUse at least an 18 gauge catheter
61Selecting the sitePeripheral 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 infusionsAvoid arms with injuries, burns, open sores. Call for medical direction for mastectomy side possibleStart with a vein at the most distal site so you can move upward as needed for additional insertion sites.
62EXCEPTION: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.
63The most favorable venipuncture sites are: - veins in the dorsum of the hand- antecubital vein- basilic vein- cephalic veinBe sure the vein can accommodate the catheter used.
64Factors affecting site selection Type of solutionCondition of veinDuration of therapyCannula sizePatient agePatient preferencePatient activityPresence of disease or prior surgery, i.e.: mastectomy or shunt (Call for medical direction)
65Patient preparationTALK TO YOUR PATIENT. Explain what you are going to doPrepare equipmentCheck solution for correct type, valid expiration date, and clarityPlace patient in supine position to decrease vasovagal reaction
66Select site and catheter Apply tourniquetCleanse site
67Hold skin taut, by placing thumb on non-dominant hand 1-2 inches below intended insertion site and gently pull skin
68Insert needle through the subcutaneous tissue at a degree angle beside or directly into the vein, bevel up
69Assess 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 veinA steady backflow of blood indicates a successful venipuncture
70Pull 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
71Release the tourniquet Gently place pressure over the vein above the catheter tip to prevent bleeding while removing the needle. Do not compress catheter!
73Arm boardsArm boards should be used to support areas of joint flexion or to restrain IV sites in extremely active patients or childrenArm boards should be padded to maintain comfort and prevent nerve or tissue damageNormal joint configuration should be maintained by supplemental paddingTape 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
74Complications of IV therapy The potential hazards of IV therapy range from minor to life threateningThey may be associated with the venipuncture or with the infusionLack of aseptic technique is a major cause of complications as it induces pathogens into the circulatory systemComplications may be local or systemic
76Site infections (Local contamination of insertion site) Signs and symptomsRedness, warmth, tenderness, and swelling at sitePossible purulent materialPossible causesFailure to maintain aseptic technique during starting or removing IV catheterActionsRemove IV and restart in unaffected armPrevention measuresMaintain strict aseptic technique of IV insertion
77Clotting (Blockage at the end of the device in the patient’s vein) Signs and symptomsTenderness at IV siteSluggish flow ratePossible causesIV rate too slow to maintain patency of catheterActivity of patient causes increase back-flow of bloodActionsRemove IV and restart in another areaPrevention measuresMaintain constant flow rateTightly secure all connections
78Hematoma (Raised, discolored area caused by leakage of blood at puncture site) Signs and symptomsTenderness at venipuncture siteArea around site appears “bruised”Inability to advance IVPossible causesVein “blown” or punctured through other wall at time of venipunctureLeakage of blood from needle displacementActionsRemove IV catheterApply pressure to areaPrevention measuresDo not advance needle further if resistance is met on venipunctureChoose a vein that can accommodate size of IV catheter
79Infiltration (Leakage of IV fluids into surrounding tissues) Signs and symptomsSwelling, tenderness above the IV site that may extend along the entire armDecreased skin temperature around the siteFluid continues to infuse even when vein is occludedBack-flow of blood is absentFlow rate is slower or stoppedPossible causesCatheter is dislodged from vein or vein is perforatedActionsRemove IV catheterApply ice (early) or warm (later) to aid absorptionElevate extremityRestart IV infusion above infiltration or in another limbPrevention measuresCheck IV site frequentlyDo not obscure area above site with tapeRestrict movement of limb by placing on arm board
80Phlebitis (Irritation along vein) Signs and symptomsArea along vein is red, tender, and warmVein is hard and cord-like when palpatedIrritation increases with infusionPossible causesHypertonic solutionsRepeated use of same vein for therapyMovement of catheter in veinCatheter is too large or flow rate too rapid for size of veinClotting at tip of catheterActionsRemove IV catheterApply warm packsRestart IV infusion is a different limbPrevention measuresUse large veins for hypertonic solution infusionChoose smallest IV needle for situation and size of veinStabilize the catheter to decrease movement in vein
82Catheter embolism Signs and symptoms Possible causes Actions Related to specific location of embolus: discomfort, decreased BP, cyanosis, weak pulse, respiratory distress, altered LOCPossible causesRethreading stylet into catheterActionsApply tourniquet above IV site to discourage further traveling of device into venous systemPrevention measuresWithdraw catheter and stylet together is venipuncture is unsuccessful
83Air Embolism Signs and symptoms Possible causes Actions Respiratory distressUnequal breath soundsWeak pulseDecreased BPLoss of consciousnessPossible causesDisconnect between catheter and tubing thus allowing air to be sucked inIV tubing that runs dry or is not purged of air properlySolution container emptyActionsDiscontinue IV infusionTurn patient to left side, head downAdminister oxygenPrevention measuresPurge tubing completely of air before infusion starts
84Circulatory overload Signs and symptoms Possible causes Actions Patient discomfortNeck vein engorgementIncreased blood pressureFluid in lungs; rales, shortness of breathPossible causesRoller clamp loosened to allow “run-away” IVMiscalculation of fluid requirementsActionsSlow or stop infusion rateRaise head of patient’s bedPrevention measuresDouble check IV rate ordered for size and condition of patientAdminister oxygen
85Systemic infection Signs and symptoms Possible causes Actions Fever, chills without apparent reasonNausea, vomitingmalaisePossible causesContaminated IV devices or solutionFailure to maintain aseptic technique during insertionActionsRemove IV catheterRestart in another areaPrevention measuresExamine fluid and containerMonitor vital signsMaintain aseptic techniqueSecure all connections
86What to do when infusion stops Check IV site for infiltrationCheck 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 clampCheck the tubingCheck the air ventIf one is required (i.e.: glass bottles)Check to be sure the spike is pushed in far enough into bagTry 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! **
87Changing 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
88Removing a peripheral IV line An IV should be removed if it infiltrates, fails to run or the site becomes infectedGather necessary suppliesBand-aid or tapeSterile gauze (2x2)Turn the flow clamp offGently remove all the tape from the catheter and skinHold the sterile gauze over the insertion site and withdraw the catheter with a gentle, brisk movement keeping it parallel to the skinCover the site with a band-aid or tapeDocument:Reason for removalTimeCatheter integrity
89CASE REVIEW MEDICAL DIRECTION DIRECTION FROM PARAMEDIC STANDING ORDER TMC
91Patient Care Report documentation should include: TimeSite/Location of IV# of attemptsGauge of catheterSolution typeRate of IVAbsence of problemsTotal volume infused at transfer of care1310 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…….