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 Introduce medications

Immediate drug absorption and effects

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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 D5W (250cc)

Hypotonic solution containing glucose to provide calories for metabolism

Glucose moves into cells rapidly

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Equipment needed IV solution

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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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 embolism Air enters blood stream (10-100 cc have been

fatal) Infection

Localized or systemicHome

Saline lock vs. IV Saline lock

Potential need for single med administration

IV Multiple meds and/or D50, fluid admin

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Acceptable IV sites Arm

Multiple veins in hand and arm Neck

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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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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Medication Administration

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Five Right’s

1. Right patient2. Right dose3. Right medication4. Right route 5. Right 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

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! 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

Prepackaged (style with two pieces) remove caps and screw pieces together dispel air and use as standard syringe

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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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

10% or “Midnight” rule Half of 220 = 110 10% of 110 = 11 Subtract 11 from 110 = 99kg

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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)

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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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 mg1 x 2 = X cc

2X = 1 cc

You will give 1cc! Home

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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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 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)

4

3 1

60

15

30

45 2

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 60 + 30 = 90) Home

Drip calculationsDesired 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 500 cc x 60 gtt/cc = 75 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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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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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) Endotracheal

Takes effect in 2-3 min Must double IV dose and flush with

saline Narcan, Epinephrine, Lidocaine, Atropine

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Intramuscular and Subcutaneous

Intramuscular Takes effect in 10-20 min Delivery

90 degree angle, 1 ½ 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 response

Untoward effect-side effect that becomes harmful to the patientHome

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 levelsHome

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,

non-rebreather, 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: NoneHome

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-Narcan’s effects are shorter acting than the

narcotic’s 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, 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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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

Diazepam (Valium)-sedation or seizure control PO: CT, SO: PM 2-5 mg IV for adults, 0.2-0.3 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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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 PO: CT, PM 2-3 mg of 1:1000 in nebulizer

Furosemide (Lasix)-rales, CHF PO: CT, SO: PM 40 mg IV or 0.5-1.0 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 0.5-0.75 mg/kg repeat dose with pulse up to 3mg/kg total

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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

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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