1. IV Therapy and Medication Administration
CFD April QA Training
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2. 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
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3. 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
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4. 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
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5. 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
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6. 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 ( cc have been fatal)
Infection
Localized or systemic
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7. Saline lock vs. IV Saline lock IV
Potential need for single med administration IV
Multiple meds and/or D50, fluid admin
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8. 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.
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9. 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
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10. Medication Administration
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11. Five Right’s 1. Right patient 2. Right dose 3. Right medication
4. Right route
5. Right time
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12. 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!
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13. 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
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14. Med Math The basics… use like units use common sense
find a formula/system that works for you
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15. 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
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16. Metric conversions 1 gram (g) = 1000 milligrams (mg)
1 mg = micrograms (mcg)
1 liter (L) = 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
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17. 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
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18. 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 = X cc 2
X = 1 cc
You will give 1cc!
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19. 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
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20. 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 kg = mg to be given
Your equation to determine cc will look like this:
40 mg x 10 cc = 4cc
100 mg
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21. 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 = 90)
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22. 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 cc x gtt/cc = 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.
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23. 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
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24. 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)
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25. 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
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26. Intramuscular and Subcutaneous
Takes effect in min
Delivery
90 degree angle, 1 ½ inch minimum needle
Subcutaneous
Takes effect in min
45 degree angle, 1/2-1 inch needle
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27. 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
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28. 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
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29. Documentation Medication Dose Time Route Person who administered
Effects
List good, bad, expected, and unexpected effects
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30. 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
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31. 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
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32. 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
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33. 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.
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34. 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
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35. 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
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36. Epinephrine-SQ (Adrenalin)
Patient Assisted Med: EMT
Physician Order: ST
Standing Order: CT, PM
Dose: 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!
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37. 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
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38. 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.
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39. 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
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40. 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
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41. 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.
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42. 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
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43. 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.
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44. 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
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45. 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, 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
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46. 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 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
mg/kg repeat dose with pulse up to 3mg/kg total
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47. 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
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48. CT and PM meds (cont.)
Solumedrol (Methylprednisolone)-anaphylaxis, severe asthma
PO: CT and PM
125 mg IV
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