IV Therapy and Medication Administration

CFD April QA Training

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Intravenous Therapy

Fluid/electrolyte administration

Normal blood volume is 4.5-5L IV fluids do not replace blood or carry O2 Immediate drug absorption and effects

Introduce medications

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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
Hypotonic solution containing glucose to provide calories for metabolism Glucose moves into cells rapidly
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D5W (250cc)

Equipment needed

IV solution

MedicalNS; TraumaLR and/or NS; Med drip D5W

Administration set with extension tubing

Macro drip (10-15 gtts/cc) for all IVs Micro drip (60 gtts/cc) for medication drip
Age >12 and need for fluid resus16 or 18 g Age <12 and/or no need for fluid resus20-24 g Age <6may consider Intraosseous
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Catheter

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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IV Complications

Infiltration

Fluid outside vessel causing swelling, pain, little or no IV flow

Catheter shear

Piece of catheter separates

Air enters blood stream (10-100 cc have been fatal) Localized or systemic
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Air embolism

Infection

Saline lock vs. IV

Saline lock

Potential need for single med administration Multiple meds and/or D50, fluid admin

IV

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Acceptable IV sites

Arm

Multiple veins in hand and arm External jugular Long saphenous vein* Anteromedial aspect of the tibia (IO)
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Neck

Leg

*Leg and foot veins involve a very high incidence of complications and should only be used cautiously as a last resort.

Fluid bolus

Maintain blood pressure between 90100 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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Medication Administration

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Five Rights
1. 2. 3. 4. 5. Right Right Right Right Right patient dose medication route time

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IV medication packaging

Vials (Single or Multi-dose)

Draw equal amount of air into proper syringe Inject air into vial and withdraw medication 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

Ampules

Remember, always use aseptic technique and remove air from syringe prior to injecting! Home

IV medication packaging (cont)

Prefilled syringes

Tubex (glass syringe without plunger)

attach to plastic plunger based on device dispel air and use as standard syringe remove caps and screw pieces together dispel air and use as standard syringe Depress plunger in vial to mix with prepackaged saline or add saline to vial and mix thoroughly
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Prepackaged (style with two pieces)

Dry powder meds (lose efficacy when pre-mixed)

Med Math

The basics

use like units use common sense find a formula/system that works for you

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Making weight..

1 kilogram (kg) = 2.2 pounds (lb)

Actual conversion

Wt: 220 lb 220 divided by 2.2 = 100kg Half of 220 = 110 10% of 110 = 11 Subtract 11 from 110 = 99kg
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10% or Midnight rule

Metric conversions

1 gram (g) = 1000 milligrams (mg) 1 mg = 1000 micrograms (mcg) 1 liter (L) = 1000 milliliters (ml) You need to give 500 mcg. How many mg?

Mg - move decimal 3 places to the left = 0.5 mg OR 500 = half of 1000 so half of 1 = .5 mg

You need to give 100 mg. How many mcg? How many g?

mcg - move decimal point 3 places to the right = 100,000 mcg g - move decimal point 3 places to the left = 0.1 g
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Basic calculations
Desired dose (D) x Unit of measure or volume on hand (Q) Known dose on hand (H) = volume or unit of measure to be administered (X)

D
H

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Example

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

You will give 1cc!

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)

H
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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 ccs will you deliver? Your equation to determine mg will look like this: 0.5 mg/kg x 80 kg = 40 mg to be given Your equation to determine cc will look like this: 40 mg x 10 cc = 4cc 100 mg
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Drip calculations
Clock method (used only for 4:1 ratio)
60 4 45 3 2 30 1 15

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 Home =6 so 60 + 30 = 90)

Drip calculations
Desired dose x Size of bag x Amount of drug on hand gtt set = gtt/min 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? x 500 cc x 2000 mg 60 gtt/cc = 75 gtt/min

5 mg/min

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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Routes to administer medications

Enteral (via digestive tract)

Oral (by mouth, PO)

10-90 minutes to begin working Affected by digestion and absorption 3-5 min 5-30 minutes
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Sublingual (under the tongue, SL)

Rectal (via the rectum, RE)

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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Medication delivery through the airway

Inhalation

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

Intramuscular and Subcutaneous

Intramuscular

Takes effect in 10-20 min Delivery

90 degree angle, 1 inch minimum needle

Subcutaneous

Takes effect in 15-30 min Delivery

45 degree angle, 1/2-1 inch needle

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Standing Orders vs. Physician Order

Standing 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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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 Home response Untoward effect-side effect that becomes harmful to the patient

Documentation

Medication Dose Time Route Person who administered Effects

List good, bad, expected, and unexpected effects

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Glossary of Terms

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

Glossary (cont.)

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

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

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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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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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Epinephrine-SQ (Adrenalin)

Patient Assisted Med: EMT Physician Order: ST Standing Order: CT, PM Dose: 0.01 mg/kg (up to .3 mg) SQ 1:1000 Action: Improves force of ventricular contractions and heart, bronchdilatation, peripheral vasoconstriction, and histamine antagonist Indication: Anaphylaxis, severe asthma Contraindications: Hypovolemic shock, hypertension, cardiac insufficiency Side Effects: Anxiety, restlessness, hypertension, dysrhythmias Note- Physician order for any patient over 40 years of age and or cardiac history!
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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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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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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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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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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-Narcans effects are shorter acting than the narcotics so monitor patient closely.
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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, Wernickes encephalopathy Contraindications: None Side Effects: Hypotension from rapid admin, anxiety, nausea and vomiting, diaphoresis, red streaks following up the vein

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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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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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CT and PM meds (cont.)

Cardizem (Diltiazem)-Afib or Aflutter

PO: CT, SO: PM Dose: 0.25 mg/kg IV over 2 min

PO: CT, SO: PM 2-5 mg IV for adults, 0.2-0.3 mg/kg for peds PO: CT, PM 5-20 mcg/kg/min IV drip (400 mg/250cc) SO: CT, PM 1 mg IV every 3-5 min in cardiac arrest, doubled for ET

Diazepam (Valium)-sedation or seizure control

Dopamine (Intropin)-hypotension without hypovolemia

Epinephrine (Adrenalin)-cardiac arrest (IV, ET)

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CT and PM meds (cont.)

Epinephrine drip-profound symptomatic bradycardia

PO: CT, PM 2- 10 mcg/min IV drip (1mg/250cc)

PO: CT, PM 2-3 mg of 1:1000 in nebulizer PO: CT, SO: PM 40 mg IV or 0.5-1.0 mg/kg for adult and 1mg/kg for peds SO: CT(cardiac arrest only), PM 1.5 mg/kg initial dose and repeat for cardiac arrest up to 3mg/kg total 0.5-0.75 mg/kg repeat dose with pulse up to 3mg/kg total
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Epinephrine nebulized-pediatric upper airway obstruction

Furosemide (Lasix)-rales, CHF

Lidocaine (Xylocaine)-Vtach, Vfib, wide complex tachycardias

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
PO: CT, SO: PM 2mg slow IV push titrated to effect PO: CT and PM 1-3 mg slow IV for CHF and chest pain and 2-4 mg IV for burns

Midazolam Hydrochloride (Versed)-sedation, seizures

Morphine Sulfate-pain, CHF

Sodium Bicarbonate (Bicarb)-tricyclic antidepressant overdose, return of circulation after long arrest, known severe acidosis

PO: CT and PM 1 mEq/kg IV push

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CT and PM meds (cont.)

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

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