1. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 10, Part 2 Intravenous Access, Blood Sampling, and Intraosseous Infusion

2. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Part 2 Topics Types of Intravenous Access Equipment for Intravenous Access IV Drug Administration Venous Blood Sampling Intraosseous Infusion

3. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous (IV) Access Indications Fluid and blood replacement Drug administration Obtaining venous blood specimens for lab analysis

4. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Types of IV Access Peripheral venous access Central venous access

5. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Peripheral IV access sites

6. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Central Venous Access Veins located deep in the body Internal jugular, subclavian, femoral Peripherally inserted central catheter (PICC) lines Larger veins that will not collapse in shock

7. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Fluids

8. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Colloids Colloids remain in the circulatory system for a long time. –Plasma protein fraction (plasmanate) –Salt poor albumin –Dextran –Hetastarch (Hespan)

9. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Crystalloids Primary out-of-hospital solutions Isotonic solutions Hypertonic solutions Hypotonic solutions

10. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Prehospital Fluids Lactated Ringer’s Normal saline solution 5% dextrose in water

11. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Other Fluids Blood Oxygen-carrying solutions –Perfluorocarbons –Hemoglobin-based oxygen-carrying solutions (HBOCs) PolyHeme Hemopure

12. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Packaging of IV Fluids Most packaged in soft plastic or vinyl bags. Container provides important information: –Label lists fluid type and expiration date. –Medication administration port. –Administration set port.

13. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ IV solution containers

14. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Do not use any IV fluids after their expiration date; any fluids that appear cloudy, discolored, or laced with particulate; or any fluid whose sealed packaging has been opened or tampered with.

15. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ IV Administration Sets (1 of 2) Macrodrip –10 gtts = 1 mL, for giving large amounts of fluid Microdrip –60 gtts = 1 mL, for restricting amounts of fluid Blood tubing –Has a filter to prevent clots or debris from entering the body Measured volume –Delivers specific volumes of fluids

16. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ IV extension tubing –Extends original tubing. Electromechanical pump tubing –Specific for each pump. Miscellaneous –Some sets have a dial that can set the flow rates. IV Administration Sets (2 of 2)

17. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Macrodrip and microdrip administration sets

18. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Secondary IV administration set

19. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Measured volume administration set

20. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Paramedics may administer crystalloid solutions en route to the emergency department.

21. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ In-Line Intravenous Fluid Heaters IV fluids can be heated to near body temperature with heating devices.

22. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Cannulas Over-the-needle catheter Hollow-needle catheter Plastic catheter inserted through a hollow needle

23. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Over-the-needle catheter

24. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hollow-needle catheter

25. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Catheter inserted through the needle

26. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Peripheral IV Access

27. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Place the constricting band.

28. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cleanse the venipuncture site.

29. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Insert the intravenous cannula into the vein.

30. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Withdraw any blood samples needed.

31. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Connect the IV tubing.

32. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Secure the site.

33. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Label the IV solution bag.

34. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Peripheral Intravenous Access in an External Jugular Vein

35. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Place the patient in a supine or Trendelenburg position.

36. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Turn the patient’s head to the side opposite of access and cleanse the site.

37. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Occlude venous return by placing a finger on the external jugular just above the clavicle.

38. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Point the catheter at the medial third of the clavicle and insert it, bevel up, at a 10° – 30° angle.

39. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Enter the jugular while withdrawing on the plunger of the attached syringe.

40. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Access with a Measured Volume Administration Set

41. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Prepare the tubing.

42. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open the uppermost clamp and fill the burette chamber with approximately 20 mL of fluid.

43. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Close the uppermost clamp and open the flow regulator.

44. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Access with Blood Tubing

45. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Insert the flanged spike into the spike port of the blood and/or normal saline solution.

46. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Squeeze the drip chamber until it is one-third full and blood covers the filter.

47. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Attach blood tubing to the intravenous cannula or into a previously established IV line.

48. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open the clamp(s) and/or flow regulator(s) and adjust the flow rate.

49. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Factors Affecting IV Flow Rates Constricting band Edema at puncture site Cannula abutting the vein wall or valve Administration set control valves IV bag height Completely filled drip chamber Catheter patency

50. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ IV Access Complications Pain Local infection Pyrogenic reaction Catheter shear Inadvertent arterial puncture Circulatory overload Thrombophlebitis Thrombus formation Air embolism Necrosis Anticoagulants

51. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Changing an IV Bag or Bottle Prepare the new bag or bottle. Occlude the flow from depleted bag or bottle. Remove spike from depleted bag or bottle. Insert spike into the new IV bag or bottle. Open the clamp to appropriate flow rate.

52. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Bolus Administration

53. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Prepare the equipment.

54. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Prepare the medication.

55. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Check the label.

56. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Select and clean an administration port.

57. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pinch the line.

58. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Administer the medication.

59. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Adjust the IV flow rate.

60. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Monitor the patient.

61. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Infusion Administration

62. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Select the drug.

63. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Draw up the drug.

64. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Select IV fluid for dilution.

65. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Clean the medication addition port.

66. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Inject the drug into the fluid.

67. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Mix the solution.

68. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Insert an administration set and connect to the main IV line with needle.

69. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heparin/saline lock

70. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Venous Access Device Surgically implanted device that permits repeated access to the central venous circulation Generally located on anterior chest near the third or fourth rib lateral to the sternum Accessed with a special needle specific to the device Requires special training

71. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Electromechanical Infusion Devices Infusion controllers Infusion pumps

72. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Infusion pump

73. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Syringe-type infusion pump

74. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Drawing Blood

75. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Blood tubes

76. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

77. Vacutainer and Luer-Lok

78. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Obtaining a blood sample with a 20 mL syringe

79. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Luer sampling needle

80. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Remove any IV that will not flow or has fulfilled its need.

81. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intraosseous Infusion A rigid needle is inserted into the cavity of a long bone. Used for critical situations when a peripheral IV is unable to be obtained. Initiate after 90 seconds or three unsuccessful IV attempts.

82. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anterior tibia

83. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pediatric and adult intraosseous needle placement sites

84. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Manual intraosseous needle

85. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ EZ-IO Battery-powered IO driver and needle set

86. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bone Injection Gun (B.I.G.)

87. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ F.A.S.T.1 – Sternal IO Employs an introducer to insert an infusion tube into the top bone of the sternum

88. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intraosseous Medication Administration

89. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Select the medication and prepare equipment.

90. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Palpate the puncture site and prep with an antiseptic solution.

91. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Make the puncture.

92. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Aspirate to confirm proper placement.

93. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Connect the IV fluid tubing.

94. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Secure the needle appropriately.

95. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Administer the medication. Monitor the patient for effects.

96. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intraosseous Access Complications Fracture Infiltration Growth plate damage Complete insertion Pulmonary embolism Infection Thrombophlebitis Air embolism Circulatory overload Allergic reaction

97. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Contraindications to Intraosseous Placement Fracture to tibia or femur on side of access Osteogenesis imperfecta—congenital bone disease resulting in fragile bones Osteoporosis Establishment of a peripheral IV line

98. Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Part 2 Summary Types of Intravenous Access Equipment for Intravenous Access IV Drug Administration Venous Blood Sampling Intraosseous Infusion