Advanced First Aid for USMC Personnel: IV Therapy CDR Charles J. Gbur Jr., MC, USNR Battalion Surgeon LCDR Richard M. Gallaway, NC, USNR HMC Peter V. Vallejo, (FMF), USNR 3 rd Battalion, 25 th Marines, 4 th Marine Division

This presentation is dedicated to all United States Naval personnel. past and present, who have provided care & comfort to our comrades in the United States Marine Corps and to all of those who have perished serving our country… Semper Fidelis

Background l Buddy Care l Early Treatment l Improved Survival l Limited Corpsman Assets l OMFTS –MOUT –The Littorals l New Doctrine

Indications for IV Therapy l Replace lost body fluids –Bleeding External or visibleExternal or visible Internal or suspectedInternal or suspected –Dehydration Heat relatedHeat related Diarrhea/VomitingDiarrhea/Vomiting –Multiple trauma

Types of IV fluid l Blood l Crystalloids –Saline: Salt water –Lactated Ringers: Mixed salt solution –Dextrose: Sugar water

Required Equipment l IV Catheter l IV Tubing l IV Solution –Tourniquet l Alcohol or Betadine Preparation l Dressing, Tape, Band-aids l Gloves

IV Equipment

IV Equipment: Field Ready

Equipment Preparation l Remove tubing and IV fluid from their protective coverings

Equipment Preparation l Remove the protective tab from the spike port

Equipment Preparation l Remove the protective cover from the spike (over the inspection bulb) of the IV tubing

Assembly of IV Equipment l Close the tubing by rotating the thumb lock to the closed position

Assembly of IV Equipment l Assemble the IV tubing to the IV fluid –Insert spike into spike port –Puncture seal with the spike by using a twisting, pushing motion until spike is fully inserted

Flushing the IV Tubing l Flush the line with the IV fluid –With the spike fully inserted squeeze the drip chamber between the index finger and thumb and immediately release. The chamber will fill with the IV fluid –Release the line clamp by rotating the thumb lock to the fully opened position.

Flushing the IV Tubing –Raise the IV fluid bag to allow for gravity flow –Allow the IV fluid to fill the line completely, eliminating any air within the line –Once the tubing is completely filled, clamp the line again by rotating the thumb clamp to the closed position –You are now ready to select an IV site

Sight Selection l Hand l Forearm l Antecubital Fossa (Elbow)*** –Usually easiest and most accessible l Upper Arm l Foot & Lower Leg –Least favorable, use as last resort

Sight Selection l Hand –Posterior (back of hand) may not accept large bore IV catheter or allow rapid volume infusion l Forearm –Sometimes difficult to locate vein –Good for rapid infusion of fluids and blood products as well as IV medications

Arm Veins

Sight Selection l Antecubital Fossa –Large vessels –Most accessible –Allows for rapid infusion –Accepts large bore IV catheter Disadvantage –Elbow must remain straight to allow for infusion

Sight Selection l Upper arm –Usually very large vessel –Sometimes difficult to access –Straight long vessel (no bends to occlude catheter)

Sight Selection l Foot and Upper leg –Used as a last resort –Usually more painful to patient –Furthest form the heart –Difficult to manage l Now you now are ready to attempt an IV

Sight Preparation l Identify vein l Clean 3 times with alcohol l Apply tourniquet above vein l Wear gloves Gloves are not worn during demonstration to allow better visualization of techniques

Sight Preparation l Place the tourniquet above the desired IV site –Should be snug to reduce venous flow –Makes for easier vein identification l Identify vein –Determine the most appropriate vein –Choose the site where the IV is to be inserted

Sight Preparation l Alcohol swab –Cleanse the area with an alcohol swab three times if able –Allow area to air dry or wipe excess away l Prepare to insert the IV

IV Insertion l Remove the Catheter from the package l Remove the protective covering from the Catheter

IV Insertion l Place the hub of the catheter between the thumb and index finger of one hand

IV Insertion l With the other hand grasp the arm lightly l Place the thumb over and below the vein that you intend to puncture

IV Insertion l Apply traction to the skin and vein to make those areas taught l Assure the bevel is in the upward position l Place the needle at the site at a 30° angle

IV Insertion l Pierce the skin with the needle l Continue with a forward motion forcing the needle into the vein, you should feel a “popping” sensation, at this point stop momentarily

IV Insertion l Check the hub for a blood return

IV Insertion l You may have to withdrawal the catheter partially and reattempt l With blood in the hub, release the arm with the hand holding traction

Advancing IV Catheter l While maintaining the grasp to the catheter with one hand, hold the colored portion of the catheter with the index finger and thumb

Advancing IV Catheter l Separate the two pieces by slowly advancing the catheter into the vein l Slowly withdraw the needle portion and discard it in a “sharp box”

Attaching IV tubing l Place thumb over the end of the catheter in the vein and apply pressure to stop blood flow out of the catheter

Attaching IV tubing l Remove the protective cap from the end of the IV tubing and insert the tubing end into the hub of the catheter

Release Tourniquet

Adjust Drip Rate

Apply Tape Securely Around Hub

l Securing the IV is very important. You do not want to have to restart an IV

Apply Tape Securely Around Hub l Apply a 4 inch strip of tape to the underside of the catheter hub l Make a chevron and attach it to the skin adjacent to the insertion point

Apply Tape Securely Around Hub l Place tape across the top of the bulb on the tubing to secure the tubing to the IV hub and the arm

Apply Tape Securely Around Hub l Loop the tubing and tape it into position on the arm. This helps to prevent inadvertent dislodgment of the IV

Dress the insertion site with a Band-Aid or gauze dressing

Calculating “Rate” l Open the line by using the thumb line lock l Volume depletion and heat casualty require more rapid infusion (“wide open”) l Head injury and heart conditions require less aggressive fluid resuscitation (very slow; 1 drop every 3 or 4 seconds)

Changing the Bag l Situations arise when a bag will have to be changed –Follow the steps when first spiking the bag. –Remove the protective tab from the new bag of fluid. –Remove the spiked end of the tubing from the expended bag. –Insert the spike into the port. –Squeeze and release the inspection bulb, allow to fill and hang the fluid. l New tubing is not required

Acknowledgements Battalion Aid Station 3 rd Battalion, 25 th Marines 4 th Marine Division Operation Agile Thrust/Restore Confidence 99 Fort Drum, New York HMCS R.K. Carr HM1 M. Joris HM2 N.E. Austin HM2 E.W. Barnett HM2 C.J. Mack HM2 T.J. Osugi HM2 P.G. Nutter HM2 E.A. Petersen HM3 F.C. Anselm HM3 G.S. Barker HM3 M. Moriarity HM3 J.P. Purkey HM2 B.D. Shaser HM3 S.B. Wilson

Points of Contact CDR Charles J. Gbur Jr., MC, USNR 3727 River Road Toledo, Ohio LCDR Richard M. Gallaway Jr., NC, USNR 7666 Quail Hollow Drive Seven Hills, Ohio