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Title: Venous Access and Medication Administration

1
Chapter 9
2
Metric System
• Definitions of units
• Meter - unit for linear measurement
• Liter - unit for capacity or volume
• Gram - unit for weight

3
Metric System
• Units of the metric system can be divided or
multiplied by 10, 100, or 1000 parts to form
secondary units that differ from each other by 10
or some multiple of 10
• Subdivisions of these basic units are made by
moving decimal point to left
• Multiples of the basic unit are indicated by
moving decimal point to right

4
Metric Units
• Meter (m) is the unit from which the other metric
units are derived
• Centimeters (cm) and millimeters (mm) are the
primary linear measurements used in medicine

5
Metric Units
• Liter (L) is the unit of capacity or volume
• Fractional parts of a liter are expressed in
milliliters (mL) or cubic centimeters (cc)
• A liter is equal to about 1000 mL or 1000 cc

6
Metric Units
• Gram (g) is the metric unit of weight used in
weighing drugs and various pharmaceutical
preparations
• The gram equals the weight of 1 mL of distilled
water at 4C
• A kilogram (kg) is equal to 1000 grams or 2.2
pounds
• A milligram (mg) is equal to one thousandth of a
gram
• A microgram (mcg) is equal to one millionth of a
gram

7
Metric Equivalents
• 1.0 g 0.001 kg
• 1.0 g 1000 mg
• 1.0 L 1000 mL

8
Metric Style of Notation
• Units are not to be capitalized (gram, not Gram)
• Periods should not be used with unit
abbreviations (mL, not m.L. or mL.)
• A single space should be left between the
quantity and the symbol (24 kg, not 24kg)
• Abbreviations should not be pluralized (kg, not
kgs)

9
Metric Style of Notation
• As a rule, fractions should not be used, only
decimal notation (0.25 kg, not 1/4 kg)
• Numerical quantities less than 1 should have a 0
placed to the left of the decimal point (0.75 mg,
not .75 mg)

10
Apothecary System
• Considered less precise and less convenient than
metric system
• Primary unit of volume in the apothecary system
is the minim (m)
• Conversion of pounds to kilograms
• One kilogram is equal to 2.2 pounds

11
Household System
• Household measures include the glass, cup,
tablespoon, teaspoon, drop, quart, and pint
• Measurements are only approximations

12
Temperature Conversions
• Normal body temperature is 37 Celsius
• To convert a Celsius reading to Fahrenheit,
• To convert from Fahrenheit to Celsius, subtract
32 from Fahrenheit reading and then multiply by
5/9

13
Drug Calculations
14
Calculation Methods
• Choose a calculation method that is precise and
reliable
• To perform drug calculations
• Convert all units of measure to the same unit and
system
• Assess the computed dosage to determine whether
it is reasonable
• Use one method of dose calculation consistently

15
Conversion of All Units of Measure
• Units of measure should be converted to same
units as medication label

16
Assessment of the Computed Dosage
• Many emergency drugs are supplied in units that
contain enough drug for a normal adult dose
• After performing the computation, determine
whether it is reasonable

17
Methods of Calculation
• Many drug calculations can be performed almost
intuitively because many drugs are packaged to
• Equations are necessary only when calculations
become complicated

18
Method 1 Desire over Have
• Requires that information be substituted in the
following formula, which must be memorized for
accuracy of computation
• D/H x Q X
• D Desired dose to be administered
• H Known dose on hand
• Q Volume or unit of measure to be administered

19
Method 2 Ratios and Proportions
• A ratio compares two numbers and is the same as a
fraction
• When used to calculate drug doses, a ratio refers
to the weight or quantity of a drug in solution
• A proportion is an equation made up of two ratios
• Shows the relationship between two different
ratios, and states that the two ratios are equal

20
Method 2 Ratios and Proportions
• To use this method, the equation must be set up
ensuring the same units of measure are stated in
the same sequence
• The units of measure must be equivalent
throughout the equation
• Dose on hand Volume on hand Desired dose
Desired volume

21
Method 2
• 100 mg 10 mL 40 mg X mL
• Multiply the means and extremes.
• means
• / \
• 100 mg 10 mL 40 mg X mL
• \____________________/
• extremes
• Solve the proportion by dividing both sides of
the equation by the number before X (100).
• 100X 400 4 mL
• 100 100
• Multiply the means and extremes. The products
will be equal if proportion is true.
• 100 x 4 400
• 10 x 40 400 Sum parts are equal.

22
Method Three Dimensional Analysis
• Useful for complex drug calculations that require
multiple conversions of a similar basic
dimensional unit so that all units of measure are
converted to like units (e.g., milligrams)
• Based on same principle as the basic formula, but
does not require memorization of the desire over
have equation
• All conversion factors are set up in one equation
and separated by multiplication signs

23
Calculating IV Flow Rates
• To calculate IV flow rates, the paramedic must
know
• The volume to be infused
• The period of time (in minutes) over which the
fluid is to be infused
• The number of drops per mL that infusion set
delivers (drop factor)

24
Calculating Infusion Rates
• The infusion rate can then be calculated using
the following equation
• Drops/min
• Volume to be infused x Drops/mL of infusion set
• Total time of infusion in minutes

25
Calculating IV Infusions
• To calculate IV infusions, the paramedic must
know
• The prescribed dose
• The concentration of the drug in 1 mL of solution
• The drop factor of the IV infusion set
• Drops/min Prescribed dose X Drop factor
• Concentration of drug in 1 mL of solution

26
Dosages for Infants and Children
• Doses of many medications are administered in the
same proportion to body weight as those for
• Other medications are given in greatly reduced
doses due to differences in the child's ability
to metabolize the drug
• Memory aids are useful
• Consult advice of medical direction

27
Safety Considerations
• When preparing or giving medicines, concentrate
on the procedure and avoid distractions
• Ensure that medication orders received are
clearly understood
• Repeat all orders back to medical direction for
• If in the emergency department or other patient
care areas, make certain that you have a written
order for every medication you administer

28
Safety Considerations
• Verify the patient's name on the armband or
identification tag and verify that the patient
has no allergy to the medication
• Five patient rights of drug administration
• Correct and thorough documentation (sixth patient

29
Safety Considerations
• Make a habit of reading the label of the medicine
and comparing it to the medication order at least
• When removing the drug from the drug kit or
supply area
• When preparing the medication for administration
• Just before administering it to the patient

30
Safety Considerations
• Always verify the route of administration
• Make certain that the information on the
medication label corresponds exactly to the
prescriber's order
• Never give a medicine from an unlabeled container
or from a container on which the label is not
legible
• If uncertain of your drug calculation, have a
coworker check your calculation or contact
medical direction for verification

31
Safety Considerations
• Handle multi-dose vials carefully and with
aseptic technique so that medicines are not
wasted or contaminated
• When preparing multiple injections, always label
the syringe immediately
• Keep the medication container with the syringe
• Do not rely on memory to determine which solution
is in which syringe

32
Safety Considerations
• Never administer an unlabeled medication prepared
by another person
• In doing so, you accept the responsibility for
accuracy, dose, and correct medication
• Never administer a medication that is outdated or
that appears discolored, cloudy, or in any other
way unusual or tampered with

33
Safety Considerations
• If the patient or your coworkers express doubt or
concern about a medication or dose, recheck to
make certain that there is no error before
• Be aware that patient has right to refuse
medication
• Carefully monitor the patient for any adverse
effects for at least 5 minutes after
• A longer observation time may be required for
intramuscular and oral medications

34
Safety Considerations
• Document all medications given
• Should include the name of the drug, the dosage,
and the time and route of administration
• When recording parenteral medications, note the
site of injection
• Patient's response, adverse as well as intended,
should be recorded

35
Safety Considerations
• Follow governmental guidelines and local EMS
policies regarding the return and disposal of any
unused medication

36
Medication Errors
• Common causes of medication errors
• A wrong medication dose was ordered by the
prescriber
• Drug calculations were in error
• Drugs were administered via wrong route
• The wrong patient received the drug

37
Medication Errors
• If an incident involving a medication error
occurs
• Accept professional responsibility for his or her
actions
• Immediately advise medical direction or the
prescriber
• Assess and carefully monitor the patient for
effects of the drug
• Document the medication error as required by
local and state drug administration policies and
those of the medical direction institution

38
Medication Errors
• If an incident involving a medication error
occurs
• Modify personal practice to avoid a similar error
in the future
• Follow EMS agency procedures for documentation
and quality improvement activities

39
Medical Asepsis
• The removal or destruction of disease-causing
organisms or infected material
• Sterile technique (surgical asepsis)
• Clean technique

40
Antiseptics and Disinfectants
• Antiseptics and disinfectants are chemical agents
used to kill specific groups of microorganisms
• Disinfectants
• Used only on nonliving objects
• Toxic to living tissue
• Antiseptics
• Applied only to living tissue
• More dilute to prevent cell damage
• Some chemical agents have both antiseptic and
disinfectant properties

41
Universal Precautions
• Universal precautions should be part of every
patient encounter
• When administering drugs, observe hand washing
and gloving procedures if indicated
• Face shields indicated during administration of
endotracheal drugs

42
• Enteral medications refer to those drugs
administered and absorbed through the GI tract
• These include
• Oral
• Gastric

43
Oral Route
• Most frequently used method
• Position patient upright or sitting
• If medication is in a suspension, shake the stock
bottle or unit dose before it is poured
• A drug not packaged as a unit dose should be
measured in a medicine cup or syringe

44
Gastric Tube
• Most drugs that can be administered orally can
also be administered via a gastric tube
(orogastric tube OG, nasogastric NG tube)
• Activated charcoal is an emergency drug

45
Gastric Tube
• Before administering a drug through this route
• Verify correct tube placement by injecting 30 to
50 mL of air into the tube
• Auscultate epigastric region for sound of air
movement
• Once correct position is confirmed, administer
the drug through the tube
to flush drug and help maintain tube patency

46
• Some drugs (e.g., suppositories) are designed for
• Other drugs can be given through the rectal route
when vascular access cannot be established
• Emergency drugs that can be administered rectally
include
• Diazepam (Valium)
• Lorazepam (Ativan)

47
• Carefully restrain child
• Draw drug dose into a syringe and remove needle.
• Introduce lubricated syringe just beyond external
sphincter
• Inject solution into rectum
• Squeeze buttocks together with manual pressure

48
Parenteral Routes
• Parenteral drugs are administered outside the GI
tract
• Usually refer to injections
• Parenteral routes include
• Subcutaneous
• Intramuscular
• Intravenous
• Intraosseous

49
Parenteral Routes
• Drugs administered by injection are usually
considered irretrievable
• Associated risks include
• Lipodystrophy
• Cellulitis or abscess formation
• Necrosis
• Skin sloughing
• Nerve injury
• Prolonged pain
• Periostitis

50
• To decrease risks of hazards
• Use aseptic technique
• Ensure accurate drug dosage
• Use proper rate of injection
• Use proper site for injection

51
Syringes and Needles
• Choice of syringe and needle depends on
• Characteristics of the fluid (e.g., aqueous,
oil-based)
• Volume of medication

52
Syringes
• Common syringe sizes range from 1 mL tuberculin
and insulin syringes to 60 mL irrigation syringes

53
Syringes Needles
• Tuberculin syringes
• Marked in 0.01 mL gradients
• Insulin syringes
• Marked off in 1unit increments
• Needles
• Vary in length and gauge
• A larger gauge means a smaller needle

54
Parenteral Medication Containers
• Single-dose ampules
• Glass containers that hold one dose of a
medication for injection, after which the ampule
• Multi-dose vials
• Glass containers equipped with rubber stoppers
that permit several medication doses to be
withdrawn for injection
• Prefilled syringes

55
Preparing Medication for Injection
• Assemble the necessary equipment
• Compute desired volume of medication to be

56
Preparing Medication for Injection
• If using a vial
• Clean rubber stopper with alcohol
• Using needle chosen for the injection, inject a
volume of air into the vial equivalent to the
amount of solution to be withdrawn
• Withdraw volume required and remove syringe from
vial
• Gently advance plunger of syringe to expel air
from solution

57
Preparing Medication for Injection
• If using an ampule
• Lightly tap or shake ampule to dislodge any
solution from neck of container
• Wrap neck of ampule with an alcohol swab or gauze
• Grasp ampule, snap off top, and discard top in
appropriate container

58
Preparing Medication for Injection
• Carefully insert 18-gauge needle into solution
without allowing it to touch edges of ampule
• Draw solution into syringe
• Carefully remove 18-gauge needle and discard in
appropriate
• Attach needle to be used for injection
• Gently advance plunger of syringe to expel air

59
Mixing Medications From Two Vials
• Use only one syringe to mix the drugs
• Aspirate volume of air equivalent to the first
drugs dosage
• Inject the air into vial A, ensuring the needle
does not touch the solution
• Withdraw the needle
• Aspirate air equivalent to the second drugs dose
and inject the volume of air into vial B
• Withdraw the required medication from vial B

60
Mixing Medications From Two Vials
• Apply a new sterile needle to the syringe and
insert it into vial A
• Be careful not to push the plunger or expel the
drug from the syringe into the vial
• Withdraw desired amount of the drug from vial A
into syringe
• Apply a new sterile needle

61
Mixing Medications From One Vial and One Ampule
• Withdraw desired drug dose from vial first
• Use same syringe and needle to withdraw
medication from the ampule
• Apply a new sterile needle

62
Prefilled Syringes
• Calculate the desired volume of medication to be
• Pop off the protective caps from the syringe
barrel and medication cartridge
• Screw cartridge into syringe barrel
• Gently advance plunger of syringe to expel any air

63
Preparing the Injection Site
• Prepare area by cleansing the area with alcohol,
iodine swabs, or both (per local protocol), using
aseptic technique
• Thoroughly scrub the site with alcohol to remove
dirt, dead skin, and other surface contaminants
• Disinfect the site with overlapping concentric
circles, moving outward from the site
• Allow the site to dry

64
epidermis
• Commonly used site for allergy testing and for
• Syringe used is usually a tuberculin syringe
• Volume injected is usually less than 0.5 mL
• Common sites for intradermal injections
• Medial surface of forearm
• Back

65
Angle of Injections
66
• Choose injection site and cleanse skin surface
• Hold skin taut with one hand
• With other hand, hold syringe with needle bevel
up at a 10- to 15-degree angle from injection
site
• Gently puncture skin until bevel is completely
under skin surface and inject medication
• Observe raised wheal
• Withdraw needle

67
Subcutaneous Injection
• Given to place medication below the skin into the
subcutaneous layer
• Volume usually less than 0.5 mL
• Administered through a ½- or 5/8-inch, 23- or
25-gauge needle

68
Subcutaneous Injection Procedure
• Choose the injection site
• Elevate subcutaneous tissue by pinching
injection site
• With needle bevel up, insert needle at a
45-degree angle in one quick motion

69
Subcutaneous Injection Procedure
• Pull back slightly on plunger (aspirate) to
ensure needle placement
• After the injection, withdraw needle at same
angle it was inserted
• Use alcohol swab to massage site

70
SC Injection Common Sites
71
Intramuscular Injection
• Route used when a drug is too irritating to be
given subcutaneously or when a greater volume or
faster absorption is desired
• Up to 5 mL may be given by IM injection
(buttocks)
• Type of needle used depends on
• Site of the injection
• Condition of the tissue
• Size of the patient
• Nature of the drug to be injected
• 1 ½ inch, 19 or 21-gauge needle usually used

72
Intramuscular Injection
• Procedure for IM injection same as those
previously described, but the needle is inserted
at a 90-degree angle and the skin is held taut,
not pinched

73
IM Injection - Deltoid
• Located in upper arm
• Forms a triangular shape
• Used primarily for vaccinations with small
volumes of injection because the muscle is small
• Care should be taken to avoid hitting radial
nerve
• Patient should be sitting upright or lying flat
and should be told to relax the arm muscles

74
IM Injection Dorsogluteal
• Consists of several gluteal muscles
• Gluteus medius most commonly used

75
Dorsogluteal Method 1
• Divide buttocks on one side into imaginary

76
Dorsogluteal Method 2
• Locate posterior superior iliac spine and greater
trochanter of femur
• Draw an imaginary line between the two landmarks
• Injection given up and out from this line

77
IM Injection Dorsogluteal
• Large, well-developed muscles can accommodate an
injection up to 5 mL
• But anything over 3 mL may be uncomfortable for
the patient
• Patient should lie prone with toes pointing
inward to promote muscle relaxation

78
IM Injection - Vastus Lateralis and Rectus
Femoris
• Lie side by side in the thigh
• Vastus lateralis is preferred injection site for
children
• Rectus femoris most often used for self-injection
because of its accessibility
• Up to 5 mL may be injected into a well developed
• Acceptable volumes for injection vary with
patient age and muscle size

79
IM Injection Ventrogluteal
• Accessible when patient lies in a supine or
lateral recumbent position
• May be used for all patients
• Site is free of large nerves and fat tissue
• In the adult, may accommodate up to 5 mL of a drug

80
Intravenous Therapy
body's circulation
• Indications
• Obtain specimens for laboratory determinations
• Route of choice for fluid replacement is through
a peripheral vein in an extremity

81
Choice of IV Catheters
• Three main types of IV catheters
• Hollow needles
• Butterfly type
• Indwelling plastic catheters over a hollow needle
• Angiocath or Jelco
• Indwelling plastic catheters inserted through a
hollow needle
• Intracath

82
Peripheral IV Insertion
• Common sites used
• Hands and arms, including antecubital fossae (AC
space)

83
Peripheral IV Insertion
• Alternate sites
• Long saphenous veins
• External jugular veins
• Incidence of embolism and infection is higher at
these alternate sites

84
Peripheral IV Insertion
• Avoid puncture sites where there is injury or
disease to an extremity
• Trauma
• Dialysis fistula
• History of mastectomy

85
Peripheral IV Procedure
• Explain procedure to conscious patients
• Assemble necessary equipment
• Inspect prescribed fluid for contamination,
appearance, and expiration date
• Prepare infusion set
• Attach infusion set to bag of solution

86
Peripheral IV Procedure
• Clamp tubing and squeeze reservoir on infusion
set until it fills half way
• Open clamp, and flush air from tubing
• Close clamp

87
Peripheral IV Procedure
• Select the catheter
• Large-bore catheter (14 to 16 gauge) should be
used for fluid replacement
• Smaller-bore catheter (18 to 20 gauge) should be
used for keep open lines
• Prepare other equipment

88
Peripheral IV Procedure
• Apply gloves for personal and patient protection
• Select puncture site
• Apply tourniquet above antecubital space
• Prepare the puncture site, cleansing the area
with alcohol or iodine wipes (per protocol)
• Ascertain allergy to iodine before procedure

89
Peripheral IV Procedure
• Stabilize vein by applying distal pressure and
tension to point of entry

90
Peripheral IV Insertion
• With bevel of the needle up in adults (down in
infants and children), pass through skin and into
vein from side or directly on top

91
Peripheral IV Procedure
point where blood return in the hub of the needle
was first encountered
• Slide catheter over needle and into vein

92
Peripheral IV Procedure
• Withdraw needle while stabilizing catheter
• Apply pressure on proximal end of catheter to
stop escaping blood
• Obtain blood samples if needed

93
Peripheral IV Procedure
• Release tourniquet and attach IV tubing

94
Peripheral IV Procedure
• Open tubing clamp and allow fluid infusion to
begin at prescribed flow rate

95
Peripheral IV Procedure
• Cover puncture site with antibiotic ointment and
dressing
• Anchor tubing
• Secure catheter
• Document procedure

96
Central Venous Access
• May be within scope of paramedic practice in some
EMS systems
• Requires special training and authorization from
medical direction
• Should never be considered as a means of rapid
fluid replacement in the prehospital setting

97
Central Venous Access
• Sites include
• Femoral vein
• Internal jugular vein
• Subclavian vein

98
Central Venous Access
• Steps
• Prepare for cannulation as for peripheral veins
• Patient's body position and paramedic's knowledge
of anatomy and familiarity with the procedures
are important for success of this procedure

99
Femoral Vein Anatomy
100
Femoral Vein Cannulation
101
Internal Jugular Vein Anatomy
102
Internal Jugular Vein Cannulation
• Posterior approach

103
Internal Jugular Vein Cannulation
• Central approach

104
Internal Jugular Vein Cannulation
• Anterior approach

105
Subclavian Vein Anatomy
106
Subclavian Vein Cannulation
107
Central Venous Access
• Availability when peripheral vessels collapse
measurements (in-hospital procedure)

108
Central Venous Access
• Excessive time (5-10 minutes) for placement
• Sterile technique (gloves, drape, wipes)
• Special equipment (catheter, large needle,
syringe)
• Skill deterioration
• High complication rate (pneumothorax, arterial
injury, abnormal placement)
• Chest x-ray should be obtained immediately after
placement to ensure correct position and evaluate
for complications

109
Central Venous Access
• Inability to initiate procedure while other
patient care activities are in progress
• Central placement is not generally considered to
be a useful prehospital technique
• Lower flow rates generally than with peripheral
cannulation

110
Local Complications
• Pain and irritation
• Infiltration and extravasation
• Phlebitis
• Thrombosis and thrombophlebitis
• Hematoma formation
• Venous spasm
• Vessel collapse
• Cellulitis
• Nerve, tendon, ligament, and limb damage

111
Systemic Complications
• Contamination and infection
• Hypersensitivity reactions
• Sepsis
• Speed shock
• Emboli (blood clot, air, and catheter)

112
Infiltration Causes
• Dislodgement of catheter or needle cannula from
intima of vein wall during venipuncture
• Puncture of distal vein wall during venipuncture
• Leakage of solution into surrounding tissue from
cannulas insertion site
• Poorly secured IV
• Poor vein or site selection
• Irritating solution or medication that inflames
the intima of the vein and causes it to weaken
• Improper cannula size
• High delivery rate or pressure of the solution or
medication

113
Infiltration Signs Symptoms
• Coolness of skin around IV site
• Swelling at the IV site, with or without pain
• Sluggish or absent flow rate
• Infusion continues to infuse when pressure is
applied to the vein above the tip of the cannula
• No backflow of blood into IV tubing when clamp
fully opened and solution container lowered below
IV site

114
Infiltration Management
• Lower fluid reservoir to dependent position to
check for presence of backflow of blood into the
tubing
• Absence of backflow suggests infiltration
• Discontinue IV infusion
• Remove needle or catheter
• Apply a pressure dressing to the site
• Choose an alternative puncture site and initiate
IV therapy with new equipment
• Document incident

115
Air Embolism
• Uncommon but can be fatal
• Caused by air entering the bloodstream via the
catheter tubing
• Risk is greatest when a catheter is passed into
the central circulation, where negative pressure
may actually pull air in

116
Air Embolism
• Air can enter the circulation on catheter
insertion or when tubing is disconnected to
replace solutions or new extension tubing
• If enough air enters the heart chamber, it can
impede the flow of blood, leading to shock

117
Air Embolism
• Signs and symptoms
• Hypotension
• Cyanosis
• Weak and rapid pulse
• Loss of consciousness
• Management
• Close the tubing
• Turn patient on left side with head down
• Check tubing for leaks
• Notify medical direction

118
Complications Central Veins
• Complications - femoral vein
• Local complications
• Systemic complications
• Complications from internal jugular and
subclavian cannulation
• Local complications
• Systemic complications

119
IV Medications
• An IV injection may be given by
• A previously established IV infusion line
• Heparin or saline lock
• Implantable port (e.g., Port-A-Cath, Hickman
catheter)
• Directly into the vein with a sterile needle or
butterfly device
• IV injections generally consist of a small amount
of medication (usually less than 5 mL)
• Called IV push or IV bolus medications

120
IV Infusion
• An IV infusion is administered by
• Adding a drug to an infusing IV solution
• Diluting the drug in a larger volume of fluid and
administering the drug through an in-line device
• Burette, Volutrol, infusion pump
• Intermittent infusion
• IV piggyback or secondary set

121
IV Injection Procedure
• To administer an IV injection
• Inject slowly (over 1-3 minutes)
• Rate depends on type of medication and patient
response
• Give through one-way valves on IV tubing or by
clamping the tubing above the injection site
• Following injection, continue infusion of fluids

122
• Compute volume of drug to be added to fluid
reservoir
• Draw up prescribed dose in a syringe
• If prefilled syringe used, note volume of
medication in syringe and dose to be used
• Cleanse rubber sleeve of fluid reservoir
• Puncture rubber sleeve and inject medication into
fluid reservoir

123
• Withdraw needle and discard needle and syringe
• Gently agitate reservoir to mix
• Label fluid reservoir with
• Resultant concentration of medication in
reservoir
• Date, time, and name of paramedic who prepared
infusion
• Calculate rate in drops per minute as prescribed

124
Volume-Control IV Devices
• Permit a more accurate delivery of IV medications
• Work by electronic flow-rate regulators
• Used to regulate precise doses of drugs that can
antidysrhythmics)

125
Intermittent Infusions
• Also called IV piggybacks
• Administered via a setup that is secondary to the
primary IV infusion
• Piggyback medication is hung in tandem and
connected to primary setup

126
Intermittent Infusion
• Prepare the prescribed medication and add it to
the secondary fluid
• Bleed the air out of the second administration
set and attach a 1-inch, 18-gauge needle
• Cleanse the medication port of the primary
infusion tubing
• Insert the needle of the piggyback medication
• Tape the needle securely to the medication port

127
Intermittent Infusion
• Calculate the flow rate of the secondary infusion
in drops per minute
• Lower the primary infusion reservoir so that its
center of gravity is lower than the secondary
infusion reservoir
• Open the piggyback line flow clamp, and adjust
the flow rate to the desired dose

128
Intermittent Infusion
• Clamp the tubing of the primary infusion to allow
the piggyback medication to infuse
• Following the administration of the piggyback
medication, the primary infusion is restarted,
and the piggyback equipment is discarded
• Always label bag with the medication

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Drug Pump
• Used by patients who need a slow injection of
medication in the home
• Usually consist of a syringe with a battery
attachment that regulates the injection of
medication
• Used to administer medication SC or can be
attached to indwelling vascular devices
• Port-A-Cath
• Hickman catheter

130
In-Dwelling Vascular Devices
• Heparin Lock

131
In-Dwelling Vascular Devices
• Single-, dual-, and triple-lumen right atrial
catheters

132
In-Dwelling Vascular Devices
• Port-A-Cath

133
Intraosseous Medications
• IO infusion is relatively safe and effective in
children
• Used for vascular access when peripheral
cannulation is unavailable

134
Intraosseous Medications
• Fluids and drugs infused through IO access pass
quickly from the marrow cavities to the systemic
circulation
• Normal saline, lactated Ringer's solution, D5W,
plasma, blood, and most ALS medications may be
infused quickly through this route

135
Intraosseous Medications
• IO infusion generally should be considered only
in unconscious children and only when reliable
venous access cannot be achieved rapidly
• Example scenarios include
• Cardiopulmonary arrest
• Peripheral vascular collapse (as in shock, major
trauma, or burns)
• Critically ill children in whom vascular access
is impaired by obesity or edema
• Life-threatening status asthmaticus

136
Intraosseous Infusion
• Site selection
• Tibia site of choice in children
• Femur alternative choice
• Equipment
• Method of insertion
• Contraindications
• Potential complications

137
Percutaneous Medications
• Refer to those drugs absorbed through the mucous
membrane or skin
• Topical drugs
• Sublingual drugs
• Buccal drugs
• Inhaled drugs
• Endotracheal drugs
• Drugs for the eye, nose, and ear

138
Topical Drugs
• Medications can be applied to any clean, dry area
of upper arm or hair-free portion of chest
• Nitropaste is applied in 1-2 inch increments
• Transdermal nitroglycerin patches are
adhesive-backed and available in solid or
semisolid form
• Always wear gloves to prevent self-absorption of
the drug

139
Sublingual Drugs
• Nitrates are the most frequently prescribed SL
drugs
• Used to treat angina pectoris
• Place tablet under patient's tongue where it is
dissolved
• Drinking fluids should be avoided while drug is
being absorbed
• Swallowing the drug may diminish or delay effects

140
Buccal Drugs
• Buccal drugs are held between the patients cheek
and gum where they dissolve
• Drinking fluids should be avoided while the drug
is being absorbed
• Example glucose gel preparations

141
Inhaled Drugs
• Oxygen
• Nitrous oxide (Nitronox)
• Bronchodilators
• Corticosteroids
• Antibiotics
• Mucokinetic agents
• Aerosols

142
Aerosols
• Aerosols are liquid or solid particles of a
substance dispersed in gas or solution
• Effectiveness of therapy depends on
• Number of droplets that can be suspended in the
gas or solution
• Particle size
• Rate and depth of patient breathing
• Rapid onset
• Reduced systemic side effects

143
Nebulizers
• Aerosols are produced by devices called
nebulizers
• Intermittent positive pressure breathing (IPPB)
devices (designed for in-hospital use)
• Metered-dose inhalers (pressure cartridges)
• Hand-held nebulizers

144
Metered-Dose Inhaler (MDI)
• Most commonly used device in aerosol therapy
• Convenient
• Delivers a measured dose with each push of the
cartridge
• Typically prescribed for self-treatment of asthma

145
Hand-Held Nebulizers
• Disposable nebulizer kits usually include a
mouthpiece or aerosol mask, oxygen tubing, and
reservoir tubing
• Device is attached to a nonhumidified portable or
on-board oxygen source to create an aerosol mist

146
Endotracheal (ET) Drugs
• ET route may be used when IV access cannot be
established
• Drugs typically administered via this route
include
• Lidocaine (Xylocaine)
• Atropine
• Naloxone (Narcan)

147
• Ensure proper tube placement by direct
visualization and auscultation
• Ensure adequate oxygenation and ventilation of
the patient's lungs
• Prepare the medication (per medical direction)
• 2 to 2 ½ times the IV dose and dilute to 10 mL
with normal saline
• Or prepare a 10 mL normal saline flush, as per
protocol
• Hyperventilate the patient's lungs

148
149
Drugs for the Eye, Nose, and Ear
• Eye medications
• Usually in the form of drops or ointments
• Nose drops
• Nasal sprays
• Ear medications
• Usually in the form of drops

150
Pediatric Guidelines
• Try to establish a positive relationship
• Accept the childs fearful or anxious behavior as
a natural response
• Be honest when a medication or procedure will be
unpleasant or painful
• If appropriate, allow the child to help
• Use only mild physical restraint if it is
required, and explain to the child why it is
necessary
• Enlist assistance of parents or other caregivers
when situation allows

151
Pediatric Guidelines
• When parenteral medications are required, make
certain the injection site is well stabilized and
that the injection is given quickly
• Two or more persons should be available to hold
children over 4 years of age despite promises
that they will be still
• The younger and smaller the child, the narrower
the margin for error

152
Obtaining a Blood Sample
• Venous blood samples may be obtained in the field
for
• Glucose testing
• Laboratory tests performed in the hospital
• If possible, obtain sample at time IV is
established
• If they are obtained from the IV, always collect
them before the infusion of any fluids
• Blood sample vacutainer
• Blood sample needle/syringe

153
Blood Sample - Vacutainer
154
Disposal of Contaminated Items
• Needles should not be capped before disposal, nor
bent or broken
• Should be discarded with syringe intact into a
clearly marked, appropriate container
• Discard according to policy when full