IV Therapy and Medication Administration CFD April QA Training Home

Intravenous Therapy Fluid/electrolyte administration Normal blood volume is 4.5-5L IV fluids do not replace blood or carry O2 Introduce medications Immediate drug absorption and effects Home

Crystalloids-Fluids used in the field Normal Saline (1000 cc) 0.9% Sodium Chloride Isotonic solution Lactated Ringers (1000cc) Isotonic solution containing electrolytes such as NaCl, KCl, CaCl, and sodium lactate D5W (250cc) Hypotonic solution containing glucose to provide calories for metabolism Glucose moves into cells rapidly Crystalloid-multiple preparations, isotonic (no real fluid shifts in avg pt, similar tonicity to blood plasma), hypotonic (less solute so will move into cells), hypertonic (high solute concen so fluid leave cells) Colloid-contains proteins or other molecules that remain in the intravascular space for long periods, tend to attract water NS and LR—2/3 of fluid lost to interstitial space within 1 hour of admin Home

Equipment needed IV solution Administration set with extension tubing Medical—NS; Trauma—LR and/or NS; Med drip—D5W Administration set with extension tubing Macro drip (10-15 gtts/cc) for all IV’s Micro drip (60 gtts/cc) for medication drip Catheter Age >12 and need for fluid resus—16 or 18 g Age <12 and/or no need for fluid resus—20-24 g Age <6—may consider Intraosseous Home

Equipment needed (cont) Gloves Tape and bioclusive dressing Tourniquet Alcohol/betadine pad Use betadine in cases of suspected ETOH use where a crime may be involved (DUI) Ensure no allergies when using betadine Arm board Sharps container Home

IV Complications Infiltration Catheter shear Air embolism Infection Fluid outside vessel causing swelling, pain, little or no IV flow Catheter shear Piece of catheter separates Air embolism Air enters blood stream (10-100 cc have been fatal) Infection Localized or systemic Home

Saline lock vs. IV Saline lock IV Potential need for single med administration IV Multiple meds and/or D50, fluid admin Home

Acceptable IV sites Arm Neck Leg Multiple veins in hand and arm External jugular Leg Long saphenous vein* Anteromedial aspect of the tibia (IO) *Leg and foot veins involve a very high incidence of complications and should only be used cautiously as a last resort. Home

Fluid bolus Maintain blood pressure between 90-100 mmHg systolic Give 250 cc boluses one at a time Closely monitor blood pressure, lung sounds and patient status prior to giving additional boluses Home

Medication Administration Home

Five Right’s 1. Right patient 2. Right dose 3. Right medication 4. Right route 5. Right time Home

IV medication packaging Vials (Single or Multi-dose) Draw equal amount of air into proper syringe Inject air into vial and withdraw medication Ampules Tap neck area to drain fluid Using alcohol prep or 4X4, snap neck of vial Withdraw proper amount of medication and dispose of ampule pieces in sharps container Remember, always use aseptic technique and remove air from syringe prior to injecting! Home

IV medication packaging (cont) Prefilled syringes Tubex (glass syringe without plunger) attach to plastic plunger based on device dispel air and use as standard syringe Prepackaged (style with two pieces) remove caps and screw pieces together Dry powder meds (lose efficacy when pre-mixed) Depress plunger in vial to mix with prepackaged saline or add saline to vial and mix thoroughly Home

Med Math The basics… use like units use common sense find a formula/system that works for you Home

1 kilogram (kg) = 2.2 pounds (lb) Making weight….. 1 kilogram (kg) = 2.2 pounds (lb) Actual conversion Wt: 220 lb 220 divided by 2.2 = 100kg 10% or “Midnight” rule Half of 220 = 110 10% of 110 = 11 Subtract 11 from 110 = 99kg Home

Metric conversions 1 gram (g) = 1000 milligrams (mg) 1 mg = 1000 micrograms (mcg) 1 liter (L) = 1000 milliliters (ml) You need to give 500 mcg. How many mg? Mg - move decimal 3 places to the left = 0.5 mg OR 500 = half of 1000 so half of 1 = .5 mg You need to give 100 mg. How many mcg? How many g? mcg - move decimal point 3 places to the right = 100,000 mcg g - move decimal point 3 places to the left = 0.1 g Home

Basic calculations D X Q = X H Desired dose (D) Known dose on hand (H) x Unit of measure or volume on hand (Q) = volume or unit of measure to be administered (X) D X Q = X H Home

Example You are ordered to give 5 mg Valium IV. The label states there is 10 mg in 2cc (10mg/2cc). How many cc’s will you give? The equation will look like this: 5mg x 2cc = X cc 10 mg 1 x 2 = X cc 2 X = 1 cc You will give 1cc! Home

Calculations based on weight Desired dose (D) x Weight in kg (W) Known dose on hand (H) X Unit of measure or volume on hand (Q) = volume or unit of measure to be administered (X) D x W x Q = X H Home

Example You are to give 0.5 mg/kg IV push. Your patient weighs 80 kg. The drug comes packaged: 100mg/10cc. How many mg will you give? How many cc’s will you deliver? Your equation to determine mg will look like this: 0.5 mg/kg x 80 kg = 40 mg to be given Your equation to determine cc will look like this: 40 mg x 10 cc = 4cc 100 mg Home

Drip calculations “Clock” method (used only for 4:1 ratio) 60 4 1 15 45 3 2 30 If your dose is 1 mg/min, your drip rate is 15 gtt/min. If the order is greater than 4 mg/min, add them together. A dose of 6 mg/min is 90 gtt/min (4 + 2 =6 so 60 + 30 = 90) Home

Drip calculations Desired dose x Size of bag x gtt set = gtt/min Amount of drug on hand The order is for 5 mg/min. You have a 500 cc bag of NS, a 60 gtt/cc administration set, and 2 g of drug on hand. How many gtt/min will you administer? 5 mg/min x 500 cc x 60 gtt/cc = 75 gtt/min 2000 mg Note: If the dose is weight based, determine the total dose prior to beginning the equation or multiply everything by the number of kg. Home

Routes to administer medications Enteral (via digestive tract) Oral (by mouth, PO) 10-90 minutes to begin working Affected by digestion and absorption Sublingual (under the tongue, SL) 3-5 min Rectal (via the rectum, RE) 5-30 minutes Home

Med routes (cont) Parenteral Inhalation (IH) Endotracheal (ET) Transdermal (TD) Time for effects variable based on medication Subcutaneous (SQ) Intramuscular (IM) Intravenous/Intraosseous (IV/IO) Home

Medication delivery through the airway Inhalation Takes effect in 2-3 min Given by hand held nebulizer (HHN) or metered dose inhaler (MDI) Endotracheal Must double IV dose and flush with saline Narcan, Epinephrine, Lidocaine, Atropine Home

Intramuscular and Subcutaneous Takes effect in 10-20 min Delivery 90 degree angle, 1 ½ inch minimum needle Subcutaneous Takes effect in 15-30 min 45 degree angle, 1/2-1 inch needle Home

Standing Orders vs. Physician Order Able to give med or start procedure if patient meets certain preset criteria Physician Order Must request med or procedure from on line doctor When giving report, ask for doctor before beginning Give report and paint clear picture of patient status Specifically request the medication and dose you want to give Home

Things to look for… Onset of Action-time between administration and first effects seen Duration of Action-time after administration until effects are last seen Side effect-undesirable and often unavoidable effect that occurs. Effects are not the original reason for administering the drug. Interaction-good or bad effects that occur with administration of multiple drugs. Can increase or decrease effects of one or both meds. Synergism-action of a combination of drugs that is greater than one drug alone Allergy-systemic reaction to a drug involving the immune response Untoward effect-side effect that becomes harmful to the patient Home

Documentation Medication Dose Time Route Person who administered Effects List good, bad, expected, and unexpected effects Home

Glossary of Terms Absorption-process of drug moving from site of introduction into circulation Contraindication-factor that does not allow administration of drug Dependence-state where absence or less of drug causes physical or emotional effects Excretion-elimination of drug or toxins Half life-time it takes for a drug level to reduce by half Loading dose-large amount of drug given to temporarily increase blood levels Home

Glossary (cont.) Maintenance dose-amount of drug needed to maintain steady blood levels Peak level-highest blood level from any given dose Therapeutic action-wanted and intended effects of a drug Tolerance-decreased response to drug after repeated administration. May require increased dose. Toxic level-blood levels are such that they may produce adverse effects Home

Prehospital Medications The following is a list of drugs given in the TEMS region. Limited information is included for a number of the drugs but due to space constraints, everything could not be listed. Please review all medications you are responsible for administering Home

Oxygen Standing order: EMT, ST, CT, PM Dose: 2-15 LPM via nasal cannula, non-rebreather, bag-valve-mask Indications: Any patient with reduced oxygen levels or increased need for oxygen. Home

Activated Charcoal (Actidose) Physician order: EMT, ST, CT, PM Dose: Adult (50 g), Pediatrics (25-30 g) given by mouth Action: Binds and absorbs ingested toxin and is then excreted. Indication: Overdose or poisoning when induction of vomiting is not indicated Contraindications: Unable to swallow or maintain airway. Not useful in cyanide, methanol, caustic acids or alkalis, heavy metals, or lithium poisonings. Side Effects: None Home

Oral Glucose Standing Order: EMT, ST, CT, PM Dose: One tube Action: Increases blood glucose Indication: Consider if patient has an altered level of consciousness and/or known hypoglycemia Contraindications: Difficulty swallowing or unable to protect own airway. Side Effects: None Home

Epinephrine-SQ (Adrenalin) Patient Assisted Med: EMT Physician Order: ST Standing Order: CT, PM Dose: 0.01 mg/kg (up to .3 mg) SQ 1:1000 Action: Improves force of ventricular contractions and heart, bronchdilatation, peripheral vasoconstriction, and histamine antagonist Indication: Anaphylaxis, severe asthma Contraindications: Hypovolemic shock, hypertension, cardiac insufficiency Side Effects: Anxiety, restlessness, hypertension, dysrhythmias Note- Physician order for any patient over 40 years of age and or cardiac history! Home

Albuterol (Proventil, Ventolin) Patient Assisted Med: EMT Standing Order: ST, CT, PM Dose: PAM (1-2 puffs from MDI only), 2.5 mg HHN repeated once Action: Relaxes smooth muscle of bronchial tree and peripheral vasculature Indication: Relief of bronchospasm, wheezing Contraindications: Tachycardic dysrhythmias Side Effects: Anxiety, restlessness, palpitations, increased blood pressure Home

Nitroglycerin (NTG) Patient Assisted Med: EMT Physician Order: ST Standing Order: CT, PM Dose: 0.4 mg SL every 3-5 min up total of 3 Action: Dilation of arterioles and peripheral veins causing decreased workload of the heart and decreased oxygen demand by decreasing preload and afterload. Indications: Chest pain, CHF Contraindications: Viagra use in past 24 hours, systolic BP<100, head injury, cerebral hemorrhage Side effects: Headache, hypotension, nausea and vomiting, dizziness, burning sensation under the tongue Note-Monitor blood pressure closely in-between tablets. Home

Aspirin (ASA) Physician order: ST Standing Order: CT, PM Dose: 324 mg (four 81mg chewable) Action: Antiplatelet and vasodilatory actions allowed to occur through alterations in enzyme production. Indication: Chest pain Contraindications: ASA intake in past 24 hours Side effects: Bleeding, GI upset Home

Diphenhydramine HCl (Benadryl) Physician Order: ST Standing Order: CT, PM Dose: 50mg IV or IM (adult) 1-2 mg/kg (peds) Action: Binds to histamine receptor sites blocking the histamine response Indications: Allergic and EPS/dystonic reactions Contraindications: Acute asthma attack, taking MAO inhibitors, narrow angle glaucoma Side Effects: Drowsiness, hypotension, drying of secretions, sedation Home

Naloxone (Narcan) Physician Order: ST Standing Order: CT, PM Dose: 2-4 mg IV titrated to effect Action: Reverses effects of narcotics by competing for receptor sites Indications: Narcotic overdose, altered level of consciousness or unconsciousness with unknown origin Contraindications: Use cautiously in drug dependant patients as administration can cause withdrawals Side Effects: projectile vomiting and/or cardiac dysrhythmias with rapid admin, withdrawals, diaphoresis Note-Narcan’s effects are shorter acting than the narcotic’s so monitor patient closely. Home

Thiamine (Betaxin, Vitamin B1) Physician Order: ST Standing Order: CT, PM Dose: 100 mg IV or IM Action: Combines with ATP to form a coenzyme necessary in the metabolism of carbohydrates Indications: Prior to the administration of D50 as part of the unconscious protocol, Wernicke’s encephalopathy Contraindications: None Side Effects: Hypotension from rapid admin, anxiety, nausea and vomiting, diaphoresis, red streaks following up the vein Home

Dextrose 50% (D50) Physician order: ST Standing Order: CT, PM Dose: 25 g in 50 cc for adult 0.25 g/kg of 25% solution for peds Action: Increases blood glucose. Indication: Blood glucose level <60 mg/dl, altered level of consciousness and/or seizure of unknown origin Contraindications: Intercranial hemorrhage Side Effects: No systemic effects but may develop necrosis from infiltration locally. Home

CT and PM Meds Adenosine (Adenocard)-narrow complex tachycardias, SVT PO: CT and SO: PM Dose: 6mg, 12mg, 12mg rapid IV push Atropine-asystole (SO: CT, PM)-1mg every 3-5 min up to 3mg Bradycardia (PO: CT and SO: PM) 0.5mg-1mg every 3-5 min up to a total of 0.04 mg/kg or 3mg Bretylium (Bretylol)-Pulseless Vtach/Vfib or Vtach PO: CT, PM 5mg/kg rapid IV push repeated in 5 min at 10mg/kg to a max of 30mg/kg over 24 hours Calcium chloride-Ca channel blocker overdose, crush syndrome, hyperkalemia, hypocalcemia PO: CT, PM 8-16 mg/kg slow IV push Home

CT and PM meds (cont.) Cardizem (Diltiazem)-Afib or Aflutter PO: CT, SO: PM Dose: 0.25 mg/kg IV over 2 min Diazepam (Valium)-sedation or seizure control 2-5 mg IV for adults, 0.2-0.3 mg/kg for peds Dopamine (Intropin)-hypotension without hypovolemia PO: CT, PM 5-20 mcg/kg/min IV drip (400 mg/250cc) Epinephrine (Adrenalin)-cardiac arrest (IV, ET) SO: CT, PM 1 mg IV every 3-5 min in cardiac arrest, doubled for ET Home

CT and PM meds (cont.) Epinephrine drip-profound symptomatic bradycardia PO: CT, PM 2- 10 mcg/min IV drip (1mg/250cc) Epinephrine nebulized-pediatric upper airway obstruction 2-3 mg of 1:1000 in nebulizer Furosemide (Lasix)-rales, CHF PO: CT, SO: PM 40 mg IV or 0.5-1.0 mg/kg for adult and 1mg/kg for peds Lidocaine (Xylocaine)-Vtach, Vfib, wide complex tachycardias SO: CT(cardiac arrest only), PM 1.5 mg/kg initial dose and repeat for cardiac arrest up to 3mg/kg total 0.5-0.75 mg/kg repeat dose with pulse up to 3mg/kg total Home

CT and PM meds (cont.) Magnesium Sulfate-Torsades de pointes, refractory Vfib, preeclampsia PO: CT, PM 1-2 g in 10cc IV over 1-2 min for arrest and 2-4 g in 50cc NS slow IV push Midazolam Hydrochloride (Versed)-sedation, seizures PO: CT, SO: PM 2mg slow IV push titrated to effect Morphine Sulfate-pain, CHF PO: CT and PM 1-3 mg slow IV for CHF and chest pain and 2-4 mg IV for burns Sodium Bicarbonate (Bicarb)-tricyclic antidepressant overdose, return of circulation after long arrest, known severe acidosis 1 mEq/kg IV push Home

CT and PM meds (cont.) Solumedrol (Methylprednisolone)-anaphylaxis, severe asthma PO: CT and PM 125 mg IV Home