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Medication Administration November 2009 CE Advocate Condell Medical Center Objectives prepared by: Mike Higgins, FF/PM Grayslake Fire Department Grayslake.

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Presentation on theme: "Medication Administration November 2009 CE Advocate Condell Medical Center Objectives prepared by: Mike Higgins, FF/PM Grayslake Fire Department Grayslake."— Presentation transcript:

1 Medication Administration November 2009 CE Advocate Condell Medical Center Objectives prepared by: Mike Higgins, FF/PM Grayslake Fire Department Grayslake Fire Department Power point prepared by Sharon Hopkins, RN, BSN, EMT-P

2 Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Identify the six rights of drug administration correctly 1. Identify the six rights of drug administration correctly 2. Identify medical control’s role in drug administration 2. Identify medical control’s role in drug administration 3. Identify knowledge of proper use of standard precautions 3. Identify knowledge of proper use of standard precautions 4. Identify knowledge of proper disposal of contaminated equipment 4. Identify knowledge of proper disposal of contaminated equipment 5. Identify the importance of maintaining a sterile and clean environment 5. Identify the importance of maintaining a sterile and clean environment

3 Objectives 6. Accurately calculate the drug dosage for a pt with weight stated in pounds, converting weight to kilograms 6. Accurately calculate the drug dosage for a pt with weight stated in pounds, converting weight to kilograms 7. Identify the various routes used to administer medication 7. Identify the various routes used to administer medication 8. Identify the proper technique for drawing up meds from an ampule 8. Identify the proper technique for drawing up meds from an ampule 9. Identify the proper technique for drawing up meds from a vial 9. Identify the proper technique for drawing up meds from a vial 10. Identify the proper administration of a medication from a prefilled syringe 10. Identify the proper administration of a medication from a prefilled syringe

4 Objectives 11. Identify the proper administration of sub- lingual medications 11. Identify the proper administration of sub- lingual medications 12. Verbalize the proper administration of rectal medications 12. Verbalize the proper administration of rectal medications 13. Identify the proper administration of IV piggy-back medications 13. Identify the proper administration of IV piggy-back medications 14. Identify the proper administration of in-line nebulizer medications 14. Identify the proper administration of in-line nebulizer medications 15. Identify the proper administration of endotracheal medications 15. Identify the proper administration of endotracheal medications

5 Objectives 16. Identify proper documentation of medication administration 16. Identify proper documentation of medication administration 17. Demonstrate the proper administration of subcutaneous medications 17. Demonstrate the proper administration of subcutaneous medications 18. Demonstrate the proper administration of intramuscular medications 18. Demonstrate the proper administration of intramuscular medications 19. Demonstrate proper administration of intravenous medications / IO meds 19. Demonstrate proper administration of intravenous medications / IO meds 20. Demonstrate the insertion of the EZ-IO correctly 20. Demonstrate the insertion of the EZ-IO correctly

6 6 Right of Medication Administration The RIGHT patient The RIGHT patient In the field this is the patient lying in front of you In the field this is the patient lying in front of you When doing clinical in the hospital, it is extremely important to check wrist bands for identifying the right patient When doing clinical in the hospital, it is extremely important to check wrist bands for identifying the right patient The RIGHT drug The RIGHT drug Check all medications 3 times prior to administration Check all medications 3 times prior to administration Did you grab the correct medication? Did you grab the correct medication?

7 6 Rights The RIGHT dose The RIGHT dose Most field medications can be easily calculated in your head Most field medications can be easily calculated in your head Double check if you are ever unsure of the dose Double check if you are ever unsure of the dose The RIGHT time The RIGHT time In the field the time is now In the field the time is now

8 6 Rights The RIGHT route The RIGHT route IV/IO IV/IO Injected Injected IM IM SQ SQ Inhaled Inhaled IVPB IVPB

9 6 Rights The RIGHT documentation The RIGHT documentation Drug name Drug name Dose – verify order in mg Dose – verify order in mg Dose often stated in ‘amps”, “tab” Dose often stated in ‘amps”, “tab” Route of delivery Route of delivery Time administered Time administered Person administering the medication Person administering the medication Use skill check box Use skill check box Patient response to the medication Patient response to the medication

10 Allergies Important to screen all patients for their allergy status prior to medication administration Important to screen all patients for their allergy status prior to medication administration If you are in doubt regarding an allergic reaction versus side effect (ie: abdominal distress), contact medical control for clarification If you are in doubt regarding an allergic reaction versus side effect (ie: abdominal distress), contact medical control for clarification

11 Facts and Allergies Lidocaine and Novocain Lidocaine and Novocain These are different “caine” families so allergy to one does not cross over to the other These are different “caine” families so allergy to one does not cross over to the other Morphine sulfate Morphine sulfate This is NOT a sulfa drug This is NOT a sulfa drug Lasix – furosemide Lasix – furosemide There is a low risk of patients allergic to sulfa drugs having a reaction to Lasix There is a low risk of patients allergic to sulfa drugs having a reaction to Lasix Monitor the patient receiving Lasix if they have a sulfa allergy Monitor the patient receiving Lasix if they have a sulfa allergy

12 Medical Control You operate under the license of the Medical Director You operate under the license of the Medical Director You are still individually responsible for having knowledge of the medications you are delivering You are still individually responsible for having knowledge of the medications you are delivering Inappropriate delivery of medications, even when the patient does not suffer harm, may result in legal ramifications Inappropriate delivery of medications, even when the patient does not suffer harm, may result in legal ramifications

13 Medical Control Medical control is available as an on-line resource Medical control is available as an on-line resource Clarification regarding indications Clarification regarding indications Clarification regarding dosage Clarification regarding dosage Clarification regarding orders received from a physician on the scene Clarification regarding orders received from a physician on the scene In an acute care center, clinic, doctor’s office, you cannot accept orders unless that physician is willing to go with to the hospital In an acute care center, clinic, doctor’s office, you cannot accept orders unless that physician is willing to go with to the hospital

14 Standard Precautions Establishing routes for drug administration creates the potential exposure to blood and body fluids Establishing routes for drug administration creates the potential exposure to blood and body fluids Decrease risk of exposure by following standard precautions Decrease risk of exposure by following standard precautions Gloves Gloves Goggles Goggles Mask Mask The best standard precaution often forgotten: The best standard precaution often forgotten:  HANDWASHING

15 Sterile vs Clean Environment Sterile – free from all forms of life Sterile – free from all forms of life Generally uses extensive heat or chemicals Generally uses extensive heat or chemicals Difficult in the field to maintain sterile environments Difficult in the field to maintain sterile environments Most packages are sterile until opened Most packages are sterile until opened Clean environment Clean environment Minimize risk of infection Minimize risk of infection Careful handling of equipment to prevent contamination Careful handling of equipment to prevent contamination

16 Disposal of Equipment Minimize tasks done in a moving ambulance Minimize tasks done in a moving ambulance Need to decrease risk of EMS exposure Need to decrease risk of EMS exposure Immediately dispose of sharps in a sharps container Immediately dispose of sharps in a sharps container Rigid, puncture-resistant container Rigid, puncture-resistant container Recap needles only as a last resort Recap needles only as a last resort Use one handed technique Use one handed technique

17 Metric System Pharmacology’s principle system of measurement Pharmacology’s principle system of measurement Widely used in science and medicine Widely used in science and medicine 3 fundamental units 3 fundamental units Grams – weight or mass Grams – weight or mass Liters – volume Liters – volume Meters – distance Meters – distance To avoid use of multiple zero’s, usually change the prefixes (ie: kilo, centi, milli, micro) To avoid use of multiple zero’s, usually change the prefixes (ie: kilo, centi, milli, micro)

18 Drug Administration and Mathematical Skills To properly prepare and administer medications, need understanding of: To properly prepare and administer medications, need understanding of: Multiplication Multiplication Division Division Fractions Fractions Decimal fractions Decimal fractions Proportions Proportions Percentages Percentages

19 Converting Pounds to Kilograms Many medications are dosed based on patient weight Many medications are dosed based on patient weight Adults – acceptable to be “close enough” Adults – acceptable to be “close enough” Can round off the adult weight Can round off the adult weight Pediatrics – must practice a more precise formula Pediatrics – must practice a more precise formula Less room for error in calculation Less room for error in calculation

20 Pounds to Kilograms 1 kilogram = 2.2 pounds 1 kilogram = 2.2 pounds In the field, usually acceptable to take the adult patient’s weight in pounds and divide in half to be close enough to the kilograms In the field, usually acceptable to take the adult patient’s weight in pounds and divide in half to be close enough to the kilograms In peds, need to take the weight in pounds and divide by 2.2 In peds, need to take the weight in pounds and divide by 2.2

21 Exercise Convert 150 pounds to kilograms Convert 150 pounds to kilograms 150/2.2 can be written as 150  /2.2 can be written as 150  2.2 As a fraction, top number (numerator) is divided by the bottom number (denominator) As a fraction, top number (numerator) is divided by the bottom number (denominator) 150 = dividend 150 = dividend 2.2 = divisor 2.2 = divisor The divisor must always be a whole number The divisor must always be a whole number Answer = quotient Answer = quotient

22 Exercise Need to make 2.2 a whole number Need to make 2.2 a whole number In the metric system, you are multiplying by “10” In the metric system, you are multiplying by “10” When multiplying with any derivative of 10, count the zeros and move the decimal that many numbers to the right When multiplying with any derivative of 10, count the zeros and move the decimal that many numbers to the right What you do with the divisor, you must do with the dividend (actions inside and outside the box must match) What you do with the divisor, you must do with the dividend (actions inside and outside the box must match)

23 Example – 150# = ? kilograms =

24 Medication By Patient Weight Most typical order is Lidocaine (mg/kg) and pediatric drugs (mg/kg) Most typical order is Lidocaine (mg/kg) and pediatric drugs (mg/kg) Calculate the patient’s kilogram Calculate the patient’s kilogram Divide pounds by 2.2 Divide pounds by 2.2 Acceptable to divide the adult weight by 2 Acceptable to divide the adult weight by 2 Multiply the kilogram by the number of mg per kilogram Multiply the kilogram by the number of mg per kilogram Then you need to calculate the volume (ml) to draw up in the syringe Then you need to calculate the volume (ml) to draw up in the syringe

25 Example Give your 132 pound patient 1.5mg/kg Lidocaine Give your 132 pound patient 1.5mg/kg Lidocaine Lidocaine is packaged as 100 mg/5ml Lidocaine is packaged as 100 mg/5ml Steps to calculate Steps to calculate Convert pounds to kilograms Convert pounds to kilograms Based on the kilograms, calculate the number of mg required Based on the kilograms, calculate the number of mg required Multiply kilograms by mg/kg required Multiply kilograms by mg/kg required Calculate the ml volume to draw up Calculate the ml volume to draw up

26 Answer 132  2.2 = 1320  22 = 60 kg 132  2.2 = 1320  22 = 60 kg 1.5 mg/kg = 1.5 mg x 60 kg = 90mg 1.5 mg/kg = 1.5 mg x 60 kg = 90mg Now, draw up 90 mg (Lidocaine comes 100 mg/5ml) Now, draw up 90 mg (Lidocaine comes 100 mg/5ml) Formula #1: x ml = desired dose x vol on hand Formula #1: x ml = desired dose x vol on hand dose on hand dose on hand Formula #2: mg in bottle = mg ordered Formula #2: mg in bottle = mg ordered ml in bottle x ml ml in bottle x ml

27 Formula #1 Formula #1: x ml = desired dose x vol on hand Formula #1: x ml = desired dose x vol on hand dose on hand dose on hand x ml = 90 mg x 5 ml 100 mg 100 mg x ml = 450 (this fraction means 450  100) x ml = 450 (this fraction means 450  100) 100 (top number divided by bottom number) 100 (top number divided by bottom number) x ml = 4.5 ml x ml = 4.5 ml

28 Formula #2 Formula #2: mg in bottle = mg ordered Formula #2: mg in bottle = mg ordered ml in bottle x ml ml in bottle x ml 100 mg = 90 mg 100 mg = 90 mg 5 ml x ml 5 ml x ml (cross multiply) 100 x = 450 (divide by 100 to get 100 x = 450 x by itself) (divide top by bottom #) 450 / 100 = 450  ml is answer 4.5 ml is answer

29 Do Brain Check Give 90 mg Lidocaine Give 90 mg Lidocaine Lidocaine packaged 100 mg / 5 ml Lidocaine packaged 100 mg / 5 ml Your answer was to give 4.5 ml Your answer was to give 4.5 ml Brain check Brain check 90 mg is slightly smaller than the total amount of 100 mg 90 mg is slightly smaller than the total amount of 100 mg 4.5 ml is slightly smaller than 5 ml 4.5 ml is slightly smaller than 5 ml So our math must be correct So our math must be correct

30 Routes of Medication Administration 4 basic categories 4 basic categories Percutaneous Percutaneous Applied or absorbed thru the skin Applied or absorbed thru the skin Pulmonary Pulmonary Absorbed via inhalation or injection Absorbed via inhalation or injection Enteral Enteral Absorbed thru the gastrointestinal (GI) tract Absorbed thru the gastrointestinal (GI) tract Parenteral Parenteral Administration outside the GI tract Administration outside the GI tract Generally includes the use of needles Generally includes the use of needles

31 Percutaneous Medication Routes Meds absorbed through skin or mucous membranes Meds absorbed through skin or mucous membranes Sublingual route Sublingual route Medication absorbed through the mucous membrane under the tongue Medication absorbed through the mucous membrane under the tongue Sub = below; lingual = tongue Sub = below; lingual = tongue Area extremely vascular Area extremely vascular Moderate to rapid rate of absorption Moderate to rapid rate of absorption Avoids the digestive tract Avoids the digestive tract

32 Mucous Membranes cont’d Nasal route Nasal route Uses a medication atomization device (MAD) Uses a medication atomization device (MAD) Coming soon to Region X Coming soon to Region X Relatively rapid absorption rate in the absence of IV access Relatively rapid absorption rate in the absence of IV access MAD provides a fine mist that allows even and widespread distribution of medication across the nasal mucosa MAD provides a fine mist that allows even and widespread distribution of medication across the nasal mucosa The Region is preparing to incorporate use of the MAD device in the near future The Region is preparing to incorporate use of the MAD device in the near future

33 Pulmonary Medication Route To administer medications into the pulmonary system via inhalation or injection To administer medications into the pulmonary system via inhalation or injection Generally include gases, fine mists, or liquids Generally include gases, fine mists, or liquids Most medications used for bronchodilation for respiratory emergencies Most medications used for bronchodilation for respiratory emergencies Inhalation also used for humidification Inhalation also used for humidification

34 Nebulizer Uses pressurized oxygen to disperse a liquid into a fine aerosol spray or mist Uses pressurized oxygen to disperse a liquid into a fine aerosol spray or mist Inhalation carries the aerosol to the lungs Inhalation carries the aerosol to the lungs

35 Enteral Route - Rectally Medication absorbed through the GI tract Medication absorbed through the GI tract Extreme vascularity promotes rapid drug absorption Extreme vascularity promotes rapid drug absorption Absorption more predictable Absorption more predictable Medications administered rectally do not pass through the liver so are not subject to alteration in the liver Medications administered rectally do not pass through the liver so are not subject to alteration in the liver Advantageous for the unconscious patient Advantageous for the unconscious patient

36 Parenteral Route Any drug administration outside of the GI tract Any drug administration outside of the GI tract Typically, this route involves the use of needles Typically, this route involves the use of needles Medication is injected into the circulation or into tissues Medication is injected into the circulation or into tissues Some parenteral forms (ie: IVP) are the most rapid for drug delivery Some parenteral forms (ie: IVP) are the most rapid for drug delivery

37 Syringes Plastic or glass tube for drawing up medications Plastic or glass tube for drawing up medications Range of sizes Range of sizes Medications are given in dosages by weight (ie: mg) Medications are given in dosages by weight (ie: mg) Syringes represent volume (ie: ml) Syringes represent volume (ie: ml) Weights (ie: mg) must be mathematically converted to volume (ie: ml) Weights (ie: mg) must be mathematically converted to volume (ie: ml)

38 Syringe Markings Plunger Plunger Barrel Barrel Hash marks Hash marks Use most appropriate sized syringe for higher accuracy Use most appropriate sized syringe for higher accuracy TB Syringe

39 Medications in Ampules Breakable vessel with liquid medication Breakable vessel with liquid medication Cone-shaped top with thin neck Cone-shaped top with thin neck Thin neck is the vulnerable point for intentionally breaking open the ampule Thin neck is the vulnerable point for intentionally breaking open the ampule Contains a single dose of med Contains a single dose of med

40 Withdrawing From an Ampule Confirm the medication and dosage Confirm the medication and dosage Hold the ampule upright Hold the ampule upright Tap the top to dislodge trapped liquid Tap the top to dislodge trapped liquid Place gauze (or alcohol wipe package) around thin nick Place gauze (or alcohol wipe package) around thin nick Snap top off away from you Snap top off away from you Place tip of needle into ampule and withdraw liquid Place tip of needle into ampule and withdraw liquid Dispose of ampule into sharps container Dispose of ampule into sharps container

41 Medications in Vials Plastic or glass containers with self-sealing rubber top Plastic or glass containers with self-sealing rubber top Rubber top prevents leakage from punctures Rubber top prevents leakage from punctures May contain single or multiple doses May contain single or multiple doses Liquid is vacuum packaged Liquid is vacuum packaged

42 Withdrawing From a Vial Confirm the medication and dosage Confirm the medication and dosage Prepare the syringe and needle based on volume of liquid to draw up Prepare the syringe and needle based on volume of liquid to draw up Use 1 ml TB syringe for any dose < 1 ml Use 1 ml TB syringe for any dose < 1 ml Because of the vacuum, draw up the same amount of air as volume to be removed Because of the vacuum, draw up the same amount of air as volume to be removed Cleanse rubber top with an alcohol wipe Cleanse rubber top with an alcohol wipe Insert needle straight into rubber top Insert needle straight into rubber top

43 Vial cont’d Inject the air from the syringe into the vial Inject the air from the syringe into the vial Withdraw the desired volume of liquid Withdraw the desired volume of liquid Watch to keep tip of needle in liquid Watch to keep tip of needle in liquid Helpful to draw a small amount of extra fluid to accommodate removing air bubbles Helpful to draw a small amount of extra fluid to accommodate removing air bubbles Hold syringe with needle pointing upward Hold syringe with needle pointing upward Tap side of syringe with finger to displace bubbles to distal end of syringe Tap side of syringe with finger to displace bubbles to distal end of syringe Expel air bubbles and confirm exact volume required in syringe Expel air bubbles and confirm exact volume required in syringe

44 Medications in Prefilled Syringes Tamperproof containers packaged with medication already in the syringe Tamperproof containers packaged with medication already in the syringe Generally contain standard dosages Generally contain standard dosages May require assembly May require assembly

45 Prefilled Syringe Confirm the medication and dosage Confirm the medication and dosage Assemble syringe Assemble syringe Pop off protective caps Pop off protective caps Twist glass tube containing liquid into syringe Twist glass tube containing liquid into syringe Glass tube becomes the plunger Glass tube becomes the plunger Expel excess air Expel excess air Confirm dosage volume required Confirm dosage volume required Lidocaine cap is twisted to unlock and then remove the cap Lidocaine cap is twisted to unlock and then remove the cap

46 Nonconstituted Medications Extends viability and storage of time for drugs with short shelf life or instability in liquid form Extends viability and storage of time for drugs with short shelf life or instability in liquid form Consists of 2 vials Consists of 2 vials Powdered medication Powdered medication Liquid mixing solution Liquid mixing solution

47 Reconstituting Medications Confirm medication and dosage Confirm medication and dosage Prepare syringe with liquid Prepare syringe with liquid Cleanse off top of powder vial Cleanse off top of powder vial Inject liquid into powder vial Inject liquid into powder vial Gently roll vial between palms to dilute powder Gently roll vial between palms to dilute powder Check that ALL particles have dissolved Check that ALL particles have dissolved Redraw up liquid into syringe, expel excess air Redraw up liquid into syringe, expel excess air

48 Medication Administration

49 Just because you administer medications now, does not mean your technique is accurate Just because you administer medications now, does not mean your technique is accurate The first rule in medicine: The first rule in medicine: Primum non Nocere Hippocrates First, do no harm!

50 Sublingual Medication Route Use Standard Precautions Use Standard Precautions Confirm medication and dosage 3 times Confirm medication and dosage 3 times Have patient lift their tongue Have patient lift their tongue Place the tablet between the tongue and the floor of the oral cavity Place the tablet between the tongue and the floor of the oral cavity Instruct the patient to allow the pill to dissolve Instruct the patient to allow the pill to dissolve

51 In-line Nebulizer Administration Route For administration of Albuterol when the patient is no longer able to ventilate effectively to inhale the medication into their lungs For administration of Albuterol when the patient is no longer able to ventilate effectively to inhale the medication into their lungs Can begin to bag the patient and force the medication into the lungs even prior to intubation Can begin to bag the patient and force the medication into the lungs even prior to intubation Set the equipment up and ventilate via a mask while waiting for intubation Set the equipment up and ventilate via a mask while waiting for intubation

52 Endotracheal Administration Route Discouraged route but not forbidden Studies have failed to demonstrate adequate absorption of medication via this route If used, double the calculated IVP dosage Hyperventilate to distribute the medication Acceptable for: Lidocaine, Epinephrine, Atropine, and Narcan (ie: LEAN)

53 Rectal Medication Confirm medication and dosage 3 times Confirm medication and dosage 3 times Via syringe Via syringe Use a small diameter syringe based on size of patient Use a small diameter syringe based on size of patient Lubricate tip of syringe Lubricate tip of syringe Turn the patient onto their side Turn the patient onto their side Insert tip of syringe into rectum Insert tip of syringe into rectum Inject medication Inject medication Remove syringe and hold cheeks together Remove syringe and hold cheeks together Permits retention and absorption Permits retention and absorption

54 Rectal Administration Via IV catheter Via IV catheter In place of a syringe tip being placed into the rectum, can place an IV catheter on the needleless syringe and then inject the medication In place of a syringe tip being placed into the rectum, can place an IV catheter on the needleless syringe and then inject the medication Reduces the diameter of the equipment used Reduces the diameter of the equipment used Helpful alternative especially in the pediatric population Helpful alternative especially in the pediatric population

55 Parenteral Medication Routes Intradermal injection Intradermal injection Subcutaneous injection Subcutaneous injection Intramuscular injection Intramuscular injection Intravenous injection Intravenous injection Intraosseous injection Intraosseous injection

56 Preparing The Syringe Pull medication into the syringe Pull medication into the syringe Tap the side of the barrel to displace air bubbles to the distal tip Tap the side of the barrel to displace air bubbles to the distal tip Express out the excess air bubbles Express out the excess air bubbles Confirm accuracy of medication dosage Confirm accuracy of medication dosage Rubber edge of the plunger lines up with the dosage marking on the barrel Rubber edge of the plunger lines up with the dosage marking on the barrel Then draw up an additional 0.1 ml of air for SQ or IM injections Then draw up an additional 0.1 ml of air for SQ or IM injections The air plug pushes the med farther into the site preventing leakage of med The air plug pushes the med farther into the site preventing leakage of med

57 Preparing the Site Wipe the intended site with alcohol Wipe the intended site with alcohol Start wiping from the center moving outward Start wiping from the center moving outward Let the site air dry Let the site air dry Introducing alcohol into the site causes irritation Introducing alcohol into the site causes irritation Do not blow on the site to hasten drying – causes contamination Do not blow on the site to hasten drying – causes contamination

58 SQ Route Layer of connective tissue between skin and muscle Layer of connective tissue between skin and muscle Less blood supply than IM so slower absorption rate Less blood supply than IM so slower absorption rate Slow onset of action but long duration of drug action due to less blood supply Slow onset of action but long duration of drug action due to less blood supply Maximum volume of medication is 1 ml Maximum volume of medication is 1 ml Preferred needle size is 25 – 27 G; 3 / / 8 inch Preferred needle size is 25 – 27 G; 3 / / 8 inch Preferred is 45 0 angle (90 0 angle acceptable if using ½ inch needle) Preferred is 45 0 angle (90 0 angle acceptable if using ½ inch needle)

59 Subcutaneous Medication Routes Sites Sites Deltoid Deltoid Abdominal Abdominal Thighs Thighs Buttocks Buttocks

60 SQ Technique Prepare the syringe and needle Prepare the syringe and needle Identify the site Identify the site Cleanse the site Cleanse the site Pinch a fold of skin up Pinch a fold of skin up Quickly dart the needle into the fold at a 45 0 angle Quickly dart the needle into the fold at a 45 0 angle 90 0 angle is an alternative especially with ½” needle 90 0 angle is an alternative especially with ½” needle Release the fold Release the fold Aspirate checking for blood return Aspirate checking for blood return Inject steadily Inject steadily Quickly withdraw the needle and discard Quickly withdraw the needle and discard Massage the site to enhance absorption Massage the site to enhance absorption

61 Aspiration Before Injection Purpose Purpose To check for inadvertent entry into a vessel To check for inadvertent entry into a vessel If you did not check you could be giving an IVP drug instead of a SQ or IM If you did not check you could be giving an IVP drug instead of a SQ or IM More common for vessel entry during an IM More common for vessel entry during an IM If blood is returned, remove needle and prepare a new syringe and needle If blood is returned, remove needle and prepare a new syringe and needle

62 Pediatric SQ Injections Most common site is posterior upper arm Most common site is posterior upper arm Next site used is the anterior aspect of the thigh Next site used is the anterior aspect of the thigh Limited volume up to 1 ml of volume SQ Limited volume up to 1 ml of volume SQ Use 45 0 angle injected into pinched skin Use 45 0 angle injected into pinched skin Site has limited use in poor perfusion state Site has limited use in poor perfusion state

63 IM Route Muscle is extremely vascular and allows for systemic delivery throughout the whole body and a moderate absorption rate Muscle is extremely vascular and allows for systemic delivery throughout the whole body and a moderate absorption rate Absorption is relatively predictable Absorption is relatively predictable When using the buttock, important to avoid the sciatic nerve When using the buttock, important to avoid the sciatic nerve If you strike the sciatic nerve, the patient could develop chronic pain If you strike the sciatic nerve, the patient could develop chronic pain Typical needle size is 21 – 23 G; 1 – 1 1 / 2 ” Typical needle size is 21 – 23 G; 1 – 1 1 / 2 ” Use 90 0 angle Use 90 0 angle Volume limitation dependent on the site used Volume limitation dependent on the site used

64 Intramuscular Medication Route Sites Sites Deltoid Deltoid Buttock Buttock Dorsal gluteal Dorsal gluteal Ventrogluteal Ventrogluteal Thigh Thigh Vastus lateralis Vastus lateralis Rectus femoris Rectus femoris

65 IM Sites Deltoid Deltoid Easily reached Easily reached Smaller sized muscle limits volume used Smaller sized muscle limits volume used 2 ml maximum 2 ml maximum Site is finger breadths below the acromial process (AC) and above the armpit crease Site is finger breadths below the acromial process (AC) and above the armpit crease Area often identified as a triangle Area often identified as a triangle

66 IM routes cont’d Buttocks – dorsal gluteal Buttocks – dorsal gluteal Can inject up to 5 ml Can inject up to 5 ml Minimal discomfort felt Minimal discomfort felt Must stay away from the sciatic nerve Must stay away from the sciatic nerve Avoid this site in kids < 2 and in emaciated patients Avoid this site in kids < 2 and in emaciated patients Find the site in the upper, outer quadrant of the buttock Find the site in the upper, outer quadrant of the buttock Must avoid the sciatic nerve Must avoid the sciatic nerve

67 IM site cont’d - Ventrogluteal Volume 1 – 3 ml Volume 1 – 3 ml Good site for children <7months Good site for children <7months Place the palm over the trochanter of the femur Place the palm over the trochanter of the femur Make a V with the 2 nd and 3 rd fingers Make a V with the 2 nd and 3 rd fingers The 3 rd finger runs straight up to the iliac crest The 3 rd finger runs straight up to the iliac crest The 2 nd finger angles forward to the anterior superior iliac crest The 2 nd finger angles forward to the anterior superior iliac crest The injection is made inside the V formed between the 2 nd and 3 rd fingers The injection is made inside the V formed between the 2 nd and 3 rd fingers

68 IM routes cont’d Thigh Thigh Vastus lateralis – side of the thigh Vastus lateralis – side of the thigh Rectus femoris – muscle over the front of the thigh Rectus femoris – muscle over the front of the thigh Can inject up to 5 ml volume Can inject up to 5 ml volume Practice often is to divide larger volumes into 2 injections of smaller volume Practice often is to divide larger volumes into 2 injections of smaller volume

69 Thigh Injection Site To find the site To find the site Place one hand at the top of the thigh at the groin Place one hand at the top of the thigh at the groin Place one hand on the distal (lower) thigh above the knee Place one hand on the distal (lower) thigh above the knee The area between the 2 hands can be used The area between the 2 hands can be used Anterior surface of the thigh at the midline is the rectus femoris Anterior surface of the thigh at the midline is the rectus femoris Lateral to the midline is the vastus lateralis Lateral to the midline is the vastus lateralis

70 Pediatric IM Injection Thigh is preferred site in peds Thigh is preferred site in peds Especially used in infants and young toddlers Especially used in infants and young toddlers Large muscle mass Large muscle mass No proximal nerves or blood vessels No proximal nerves or blood vessels Limited subcutaneous fat layer Limited subcutaneous fat layer More developed muscle than other sites More developed muscle than other sites Can accommodate larger volumes than other pediatric injection sites Can accommodate larger volumes than other pediatric injection sites

71 IM Technique Prepare syringe and needle Prepare syringe and needle Identify site Identify site Prepare site – let alcohol air dry Prepare site – let alcohol air dry Pull the skin taut Pull the skin taut Dart the needle in at 90 0 Dart the needle in at 90 0 The quicker the dart like insertion, the less painful The quicker the dart like insertion, the less painful Slowly and steadily inject the medication Slowly and steadily inject the medication Quickly withdraw needle and properly discard Quickly withdraw needle and properly discard Massage site – enhances absorption Massage site – enhances absorption

72 Intravenous Administration Route Quickest route to deliver medication directly into the bloodstream Quickest route to deliver medication directly into the bloodstream Fastest absorption rate Fastest absorption rate Dependent on adequate perfusion Dependent on adequate perfusion Many medications are in prefilled syringes Many medications are in prefilled syringes Pop off protective caps Pop off protective caps Assemble syringe Assemble syringe Expel air Expel air Confirm dosage Confirm dosage Administer medication Administer medication Watch for response Watch for response

73 IVP Medication Confirm medication 3 times for accuracy Confirm medication 3 times for accuracy Prepare syringe Prepare syringe Consider need for a flush Consider need for a flush Secure medication syringe into an IV port as close to the IV site as possible Secure medication syringe into an IV port as close to the IV site as possible Pinch off the IV tubing Pinch off the IV tubing Inject the medication at the prescribed speed for the medication Inject the medication at the prescribed speed for the medication

74 Needleless IV Tubing Standard IV tubing to minimize the event of needle stick Standard IV tubing to minimize the event of needle stick Port wiped with alcohol Port wiped with alcohol Needle twisted onto port Needle twisted onto port Must pinch tubing above injection site Must pinch tubing above injection site Fluid will move in direction of least resistance Fluid will move in direction of least resistance

75 IVPB Administration Route To administer a medication over a longer period of time To administer a medication over a longer period of time All IV bags hanging need to be labeled All IV bags hanging need to be labeled The bags can be hung at the same height The bags can be hung at the same height The IV bags will both drip independently of the other IV bag The IV bags will both drip independently of the other IV bag Secure the IVPB into a port as close to the IV site as possible Secure the IVPB into a port as close to the IV site as possible

76 Disposal of Contaminated Equipment As soon as possible dispose of equipment into sharps container As soon as possible dispose of equipment into sharps container After giving an injection, snap the protective cover over the needle After giving an injection, snap the protective cover over the needle After starting the IV, the needle should be covered as it is retracted after the injection After starting the IV, the needle should be covered as it is retracted after the injection

77 Side Effects and Complications Remember for all injections Remember for all injections Once delivered, cannot get the medication back Once delivered, cannot get the medication back Be very sure of 5 “rights’ Be very sure of 5 “rights’  Patient  Drug  Dose  Route  Time Once administered, monitor for known side effects and any other changes to the patient Once administered, monitor for known side effects and any other changes to the patient

78 Documentation of Medication Administration Time Time Drug name Drug name Drug dosage in mg Drug dosage in mg Route Route Patient response Patient response

79 EZ-IO Indications Indications Shock, arrest, impending arrest Shock, arrest, impending arrest Unconscious/unresponsive to verbal stimuli Unconscious/unresponsive to verbal stimuli 2 unsuccessful IV attempts or 90 seconds duration of a peripheral attempt 2 unsuccessful IV attempts or 90 seconds duration of a peripheral attempt

80 EZ IO Contraindications Contraindications Fracture of the tibia or femur Fracture of the tibia or femur Infection at insertion site Infection at insertion site Previous orthopedic procedure Previous orthopedic procedure Knee replacement Knee replacement Previous IO within 48 hours Previous IO within 48 hours Pre-existing medical condition Pre-existing medical condition Tumor near site, peripheral vascular disease Tumor near site, peripheral vascular disease Inability to locate landmarks Inability to locate landmarks Excessive tissue at insertion site Excessive tissue at insertion site

81 EZ IO Needles Adult patients Adult patients 88 pounds or over (40 kg) 88 pounds or over (40 kg) 15 G; 25 mm blue needle 15 G; 25 mm blue needle Pediatric patients Pediatric patients pounds (3 kg – 39 kg) pounds (3 kg – 39 kg) 15 G; 15 mm pink needle 15 G; 15 mm pink needle Think “pink” for “peds” Think “pink” for “peds”

82 EZ IO Equipment 10 ml syringe filled with 0.9 NS 10 ml syringe filled with 0.9 NS 5 ml of NS in syringe for peds patient 5 ml of NS in syringe for peds patient EZ connect tubing EZ connect tubing Material to cleanse site Material to cleanse site EZ IO driver EZ IO driver EZ IO needle in it’s case EZ IO needle in it’s case Primed IV tubing Primed IV tubing 1000 ml bag for adults 1000 ml bag for adults 250 ml IV bag for geriatric and pediatric patients 250 ml IV bag for geriatric and pediatric patients Pressure bag (B/P cuff is no pressure bag) Pressure bag (B/P cuff is no pressure bag)

83 EZ IO drill with storage case

84 EZ IO Site Most common site: proximal tibia Most common site: proximal tibia Palpate the tibial tuberosity Palpate the tibial tuberosity Bump below the patella Bump below the patella Identify 2-3 finger widths below the patella Identify 2-3 finger widths below the patella Move 1 finger width medially (toward the big toe) Move 1 finger width medially (toward the big toe) In smaller children often will not be able to palpate the tibial tuberosity In smaller children often will not be able to palpate the tibial tuberosity

85 EZ IO - Technique Prime EZ connect tubing Prime EZ connect tubing Takes 1 ml to prime tubing Takes 1 ml to prime tubing Leave syringe attached Leave syringe attached Attach needle to driver Attach needle to driver Insert needle at 90 0 angle into site Insert needle at 90 0 angle into site Release trigger once decreased resistance is felt Release trigger once decreased resistance is felt Remove driver from needle Remove driver from needle Remove stylet by rotating counterclockwise Remove stylet by rotating counterclockwise

86 EZ IO Technique cont’d Connect EZ primed tubing to needle Connect EZ primed tubing to needle May notice backflow of bone marrow May notice backflow of bone marrow Blood will NOT pump out of needle Blood will NOT pump out of needle Using syringe, aspirate then flush with remaining NS to confirm placement Using syringe, aspirate then flush with remaining NS to confirm placement Needle stands up on own Needle stands up on own Flushes easily Flushes easily No infiltration felt No infiltration felt

87 EZ IO Technique cont’d Remove syringe Remove syringe Attach primed IV tubing Attach primed IV tubing Secure pressure bag to permit flow of fluid Secure pressure bag to permit flow of fluid Begin infusion Begin infusion Secure tubing to leg Secure tubing to leg Apply wristband Apply wristband Monitor site for infiltration Monitor site for infiltration Can administer any IVP medication that would normally be given IV push Can administer any IVP medication that would normally be given IV push

88 EZ IO Documentation Same information for starting an IV Same information for starting an IV Time Time Solution Solution Size IV bag Size IV bag Site Site Person actually performing the puncture Person actually performing the puncture

89 Case Study #1 Your patient weighs 150 pounds Your patient weighs 150 pounds They need to receive 1.5 mg / kg Lidocaine They need to receive 1.5 mg / kg Lidocaine Lidocaine packaged as 100 mg/5 ml Lidocaine packaged as 100 mg/5 ml How much Lidocaine needs to be drawn up and given? How much Lidocaine needs to be drawn up and given?

90 Case Study #1 Calculate pounds to kilograms Calculate pounds to kilograms 150  2.2 = 68.1 rounded to 68 kg 150  2.2 = 68.1 rounded to 68 kg Calculate total mg of medication Calculate total mg of medication To receive 1.5 mg per kg To receive 1.5 mg per kg Multiply 1.5 x 68 = 102mg Multiply 1.5 x 68 = 102mg Calculate how much medication to deliver Calculate how much medication to deliver Use formula of your choice Use formula of your choice

91 Case Study #1 Formula #1 Formula #1 X ml = desired dose x vol on hand X ml = desired dose x vol on hand dose on hand dose on hand X ml = 102 mg x 5 ml X ml = 102 mg x 5 ml 100mg 100mg X ml = 510 X ml = X ml = 510  100 X ml = 510  100 X ml = 5.1 ml (in the adult rounded to 5 ml) X ml = 5.1 ml (in the adult rounded to 5 ml)

92 Case Study #1 Formula #2 Formula #2 100 mg = 102 mg 100 mg = 102 mg 5 ml x ml 5 ml x ml 100 x = x = x = 510  100 x = 510  100 X = 5.1 ml (rounded to 5 ml) X = 5.1 ml (rounded to 5 ml)

93 Case Study #2 Your 45 year-old patient is having an allergic reaction with airway involvement Your 45 year-old patient is having an allergic reaction with airway involvement The vital signs are stable The vital signs are stable What medications are indicated? What medications are indicated? How do you administer each of the medications? How do you administer each of the medications?

94 Case Study #2 Epinephrine 1:1000 – 0.3 mg SQ Epinephrine 1:1000 – 0.3 mg SQ Bronchodilator, vasoconstrictor Bronchodilator, vasoconstrictor Short needle ( 3 / / 8 ”) Short needle ( 3 / / 8 ”) 45 0 angle 45 0 angle Pinch up the skin Pinch up the skin Benadryl 50 mg IVP slowly or IM Benadryl 50 mg IVP slowly or IM Antihistamine Antihistamine Long needle (1” up to 1 1 / 2 ”) Long needle (1” up to 1 1 / 2 ”) 90 0 angle 90 0 angle Pull the skin taut before injecting Pull the skin taut before injecting

95 Case Study #2 Always aspirate to check for inadvertent entry into a vein Always aspirate to check for inadvertent entry into a vein If blood is noted, withdraw needle If blood is noted, withdraw needle Prepare a new needle and syringe Prepare a new needle and syringe Injecting the blood can cause irritation Injecting the blood can cause irritation With blood in the syringe, may not be able to detect aspiration of new blood at new site With blood in the syringe, may not be able to detect aspiration of new blood at new site

96 Case Study #3 You are on the scene of a full arrest You are on the scene of a full arrest You cannot find peripheral veins You cannot find peripheral veins What is you next alternative? What is you next alternative? How do you confirm needle placement? How do you confirm needle placement?

97 Case Study #3 EZ IO needle is indicated EZ IO needle is indicated Confirmation of needle placement Confirmation of needle placement Needle stands up by itself Needle stands up by itself Able to flush the needle easily through the EZ connect tubing Able to flush the needle easily through the EZ connect tubing Fluid flows with a pressure bag attached Fluid flows with a pressure bag attached No infiltration is noted No infiltration is noted

98 EZ IO Needle Needle always flushed via the EZ connect tubing Needle always flushed via the EZ connect tubing NEVER flush the needle directly – too much pressure NEVER flush the needle directly – too much pressure

99 Case Study #4 You have an 8 month-old infant with a blood sugar of 45 You have an 8 month-old infant with a blood sugar of 45 The patient responds weakly to verbal stimuli The patient responds weakly to verbal stimuli What medication is necessary? What medication is necessary? How do you prepare the medication? How do you prepare the medication? How do you administer the medication? How do you administer the medication?

100 Case Study #4 - Hypoglycemia Ages > 16 – Dextrose 50% Ages > 16 – Dextrose 50% Ages 1 – 15 – Dextrose 25% Ages 1 – 15 – Dextrose 25% Age < 1 years-old - Dextrose 12.5% Age < 1 years-old - Dextrose 12.5% Diluted strength due to vein irritation Diluted strength due to vein irritation Calculate the dosage Calculate the dosage Draw up equal amounts normal saline and D25% to make a 1:1 dilution Draw up equal amounts normal saline and D25% to make a 1:1 dilution Administer slowly due to vein irritation Administer slowly due to vein irritation

101 Case Study #4 Dextrose is given IVP Dextrose is given IVP Wipe off the injection port with alcohol Wipe off the injection port with alcohol Push on the needleless syringe and twist to connect Push on the needleless syringe and twist to connect Pinch off the tubing above the injection port Pinch off the tubing above the injection port Slowly and steadily administer the medication Slowly and steadily administer the medication Evaluate the site for infiltration Evaluate the site for infiltration Evaluate the patient’s response Evaluate the patient’s response

102 Case Study #5 You are on the scene for a 5 year old having a seizure You are on the scene for a 5 year old having a seizure Patient weighs 50 pounds Patient weighs 50 pounds History of seizure disorder History of seizure disorder Glucose level of 80 Glucose level of 80 You are unable to establish a peripheral IV You are unable to establish a peripheral IV What do you do for the airway? What do you do for the airway? What medication is indicated? What medication is indicated? How do you administer the medication? How do you administer the medication?

103 Case Study #5 Airway control – bag the patient Airway control – bag the patient In active seizure, the respiratory status of the patient is difficult to evaluate and assume the patient is not ventilating well In active seizure, the respiratory status of the patient is difficult to evaluate and assume the patient is not ventilating well Medication and route Medication and route Valium 0.5 mg/kg (max 10 mg) rectally Valium 0.5 mg/kg (max 10 mg) rectally

104 Case Study #5 Calculate dose Calculate dose 50 pounds  2.2 = 22.7 = 23 kg 50 pounds  2.2 = 22.7 = 23 kg Multiple 0.5 mg x 23 kg = 11.5 mg = 12 mg Multiple 0.5 mg x 23 kg = 11.5 mg = 12 mg Max dose is 10 mg Max dose is 10 mg Valium comes 10 mg per 2 ml Valium comes 10 mg per 2 ml Make sure syringe is needleless Make sure syringe is needleless Insert syringe into buttocks Insert syringe into buttocks Inject medication and remove syringe Inject medication and remove syringe Hold cheeks together Hold cheeks together

105 Pediatric Resources What resources are available to calculate a pediatric dosage? What resources are available to calculate a pediatric dosage? Back of the SOP’s Back of the SOP’s Medical Control Medical Control Broselow tape Broselow tape Valium listed as diazepam Valium listed as diazepam Narcan listed as Naloxone Narcan listed as Naloxone Normal saline listed as crystalloid Normal saline listed as crystalloid

106 Bibliography Bledsoe, B., Clayden, D., Papa, F. Prehospital Emergency Pharmacology 5 th Edition. Brady Bledsoe, B., Clayden, D., Papa, F. Prehospital Emergency Pharmacology 5 th Edition. Brady Bledsoe, B., Porter, R., Cherry, R., Paramedic Care: Principles and Practices. Brady Bledsoe, B., Porter, R., Cherry, R., Paramedic Care: Principles and Practices. Brady Edmunds, M. Introduction to clinical Pharmacology. Elsevier Edmunds, M. Introduction to clinical Pharmacology. Elsevier Marenson, D. Pediatric Prehospital Care. Brady Marenson, D. Pediatric Prehospital Care. Brady Region X SOP’s March 2007, Amended January 1, 2008 Region X SOP’s March 2007, Amended January 1, 2008 Sanders, M. Paramedic Textbook. Rev 3 rd edition. Mosby Sanders, M. Paramedic Textbook. Rev 3 rd edition. Mosby wps.prenhall.com wps.prenhall.com


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