Venous Access and Medication Administration

1
Venous Access and Medication Administration
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
  (centigrade) or 98.6 Fahrenheit
• To convert a Celsius reading to Fahrenheit,
  multiply Celsius reading by 9/5 and then add 32
• 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
  supply one adult dose
• 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
  adults
• 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
  confirmation before administering a drug
• 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
  right of drug administration)

29
Safety Considerations

• Make a habit of reading the label of the medicine
  and comparing it to the medication order at least
  3 times before administration
• When removing the drug from the drug kit or
  supply area
• When preparing the medication for administration
• Just before administering it to the patient
  (before the container is discarded)

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
  administering the medication
• Be aware that patient has right to refuse
  medication
• Carefully monitor the patient for any adverse
  effects for at least 5 minutes after
  administration of any medication
• 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 Medication Administration

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

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
  administered by this route

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
• Follow with a small amount of water (about 30 mL)
  to flush drug and help maintain tube patency

46
Rectal Administration

• Some drugs (e.g., suppositories) are designed for
  rectal administration
• 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
Rectal Administration

• 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
• Intradermal
• 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
Parenteral Administration

• 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
• Route of administration
• 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
  is discarded
• 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
  administered

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
• Administer injection

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
• Administer the drug

62
Prefilled Syringes

• Calculate the desired volume of medication to be
  administered
• 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
Intradermal Injections

• Intradermal injection is made just below
  epidermis
• Commonly used site for allergy testing and for
  administration of local anesthetics
• 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
Intradermal Injection Procedure

• 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
• Appropriately discard equipment used

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
  quadrants
• Administer medication into upper outer quadrant

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
  adult
• 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

• IV cannulation is used to gain access to the
  body's circulation
• Indications
• Administer fluids
• Administer drugs
• 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

• Advance needle and catheter about 2 mm beyond the
  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

• Advantages
• Availability when peripheral vessels collapse
• Provision of access to central pressure
  measurements (in-hospital procedure)
• Safer vasopressor administration

108
Central Venous Access

• Disadvantages
• 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

• Disadvantages
• 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
• Administer high-concentration oxygen
• 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
  during drug administration
• Following injection, continue infusion of fluids

122
Adding Medication to IV Reservoir

• 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
Adding Medication to IV Reservoir

• Withdraw needle and discard needle and syringe
• Gently agitate reservoir to mix
• Label fluid reservoir with
• Name of medication added
• Amount of medication added
• 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
  readily cause toxicity (e.g., vasopressors,
  antidysrhythmics)
• Follow manufacturers instructions

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

• To administer
• 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

129
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
• Advantages
• 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)
• Epinephrine (Adrenalin)
• Atropine
• Naloxone (Narcan)

147
ET Drug Administration

• 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
ET Drug Administration
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
  administer the medication
• 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