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.

5. SAEMS PRE- HOSPITAL PROTOCOLS 75 SCOPE OF PRACTICE ADMINISTRATIVE 2.9
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.

8. PROTOCOL ON-LINE MEDICAL DIRECTION
EMT-I OR EMT-P GIVES YOU AN ORDER THAT IS ATTENDING THE SAME PATIENT
STANDING ORDERS
ALLERGIC REACTION
CHEST PAIN
Hypoglycemia
HYPERTERMIA
NAUESA AND VOMITING
SEIZURE

9. QA PROCESS EMT-BASIC IV ACCESS QA FORM
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:

10. IV LOG

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

89. CASE REVIEW MEDICAL DIRECTION DIRECTION FROM PARAMEDIC STANDING ORDER
TMC

90. DOCUMENTATION & GUIDELINES

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…….

92. CLINCIAL REQUIREMENTS

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