1. Module: Session: Advanced Care Paramedicine Intravenous Therapy 7 4

2. Thirty years ago… Rampart, Squad 51. We have a 20 year old male motorcycle rider involved in a motor vehicle collision complaining of neck, back and leg pain. He presents with compound fractures to both femurs and has significant blood loss. We are requesting an order for two large bore IV’s and Ringer’s Lactate.

3. Objectives Identify the reasons IV therapy is performed in the prehospital setting Identify the fluids commonly administered State the basis of fluid and electrolyte balance Identify factors affecting water loss Explain the recommended uses of IV solutions Identify common complications and reactions Calculate a flow rate Demonstrate proper skin cleansing and aseptic venipuncture technique Demonstrate proper IV cannulation technique

4. Why do we cannulate? Fluid administration Medication administration To maintain life (electrolytes, blood…) Do we do them to be EHSNS protocol compliant?

5. IV fluids Normal saline (0.9% NS) Lactated Ringer’s (LR)  Also known as Hartman’s solution or RL D 5 W ½ NS D 5 ½ NS D 5 RL (D 5 LR)

6. Isotonic Solutions Characteristics Same tonicity as plasma Osmotic pressure is the same as the inside of the cell Fluid never leaves or enters the cell Approximate osmolarity is 240 – 340 mOsm/L Will increase circulating volume, which may lead to fluid volume excess or overload. Solutions 2.5% dextrose/0.45% NaCl 0.9% NaCl Lactated Ringers 2.5% dextrose in ½ lactated ringers 6% dextan and 0.9% NaCl 10% dextran and 0.9% NaCl

7. Normal Saline Most commonly administered IV fluid prehospitally IV fluid of choice for EHSNS protocols Why?

8. Lactated Ringers Composed of multiple electrolytes in saline Has fallen out of favor as one of main IV fluids for treatment of traumatic hypovolemia in past decade Why?

9. Hypotonic Solutions Characteristics May cause blood cells to swell and burst May cause changes or damage endothelial cells Exert less osmotic pressure than the fluid in the extracellular compartment Fluid is drawn into the cells Approximate osmolarity < 240 mOsm/l Solutions 0.45% NaCl 10% dextran and 5% dextrose (slightly hypotonic)

10. Hypertonic Solutions Characteristics May cause blood cells to shrink May cause dame/changes to endothelial cells Exert more osmotic pressure then the extracellular fluid Fluid is drawn from the cell into the vascular space Approximate osmolarity > 340 mOsm/l Solutions 5% dextrose/0.2% NaCl 5% dextrose/0.9% NaCl D 5 W D 10 W D 50 W 5% NaHCO 3 10%, 15% and 20% Mannitol 6% dextran and 0.9% NaCl

11. Administration Sets The calibration of the administration set must be known in order to calculate the flow of the IV fluids correctly.  Macrodrip sets 10, 15 or 20 gtts/ml  Microdrip (minidrip) 60 gtts/ml

12. Where do we cannulate? Hand Forearm Neck Foot

13. Equipment Required Solution Administration set IV cannula Tourniquet Alcohol swab Gloves Sharps bin Op site and gauze Tape If performing a Lock  Lock, syringe and saline

14. Catheter specifics ColorSizeInt Dia/LengthMax Flow Grey16 G1.4 mm/45 mm180 mls/min Green18 G1.0 mm/45 mm80 mls/min Pink20 G0.8 mm/32 mm54 mls/min Blue22 G0.6 mm/25 mm31 mls/min The length and diameter will affect the amount of fluid able to be infused through the catheter  Larger diameter and shorter length gives more fluid  Small diameter and long length gives less fluid

15. Types of catheters Jelco Cathelon Insyte

16. Types of catheters Protective Protective Plus

17. Administration Sets 10 gtts/ml 15 gtts/ml 60 gtts/ml Blood sets

18. Vein Selection Based on:  Condition Palpate to confirm type of vessel  Should be soft and spongy Straight with no turns or bumps  Location Is the pt right or left handed Is the extremity injured Avoid joints (stabilization) Does the pt have a shunt (fistula)  Purpose Fluid replacement, Medication route, Safety line (lock) Dictates flow rate and type of fluid to be infused Try to use large veins for large quantities of fluid  Duration What type of patient (trauma, cardiac or outpatient) Patient comfort over long period of time Prolonged therapy may require multiple punctures For long durations use distal veins first

19. Fluid Replacement Blood  Replaced at a ratio of 3:1 of IV fluid to blood being replaced Minimum daily requirements  1 st 10 kg100 ml/hr  2 nd 10 kg50 ml/hr  3 rd 10 kg20 ml/hr  4 th 10 kg10 ml/hr  5 th 10 kg10 ml/hr  Example50 kg patient 100 ml/hr + 50 ml/hr + 20 ml/hr + 10 ml/hr + 10 ml/hr = 190 ml/hr

20. Contraindications Distal to a fracture site in a limb Through damaged or abraded skin  Burns may be an exception if there is no other accessible site In an arm affected by a radical mastectomy, edema, blood clot or infection In an arm with a fistula for dialysis or a peripherally inserted control catheter (PICC Line)

21. Procedure Obtain consent and explain rationale for IV therapy Assess that the pt meets the criteria for the procedure Ensure that there are no contraindications for the procedure Observe universal precautions for body substance exposures Prepare all necessary equipment Position the patient Apply a tourniquet 3 – 5 inches above the selected site  Patient may make a fist to assist in engorging the vein Select the most appropriate venipuncture site  Condition  Location  Purpose  Duration Prepare the pt’s arm using alcohol swab

22. Procedure Insert needle through skin  Should be at an 30° angle Lower angle (15°)and enter vein Observe flashback Enter vein a ‘little bit more’ Enter catheter into vein Release tourniquet Withdraw needle and discard in sharps container, tamponade the vein to avoid blood spill Attach iv tubing and open flow valve observing for infiltration Cover with Op site or other sterile dressing, tape in place

23. IV Access

24. Complications Local complications  Hematomas  Infiltration  Necrosis  Thrombophlebitis Systemic complications  Pulmonary edema  Speed shock  Pyrogenic reaction  Pulmonary embolism blood Air  Catheter shear

25. Local - Hematomas Causes: Symptoms: Preventative actions: Punctured vein Bruising Tenderness Swelling Proper techniques

26. Local - Infiltration Causes: Symptoms: Preventative actions: Poor insertion techniques Improper taping Over active patient IV slows or stops Swelling or hardness Feeling of coldness Leaking at the site Armboards, proper taping Routine checks of IV flow and site

27. Local - Necrosis Causes: Symptoms: Preventative actions: Irritation of tissues from infiltrated drug or fluid Swelling, tenderness Inflammation or bruising Routine checks Report any changes

28. Local - Thrombophlebitis Causes: Symptoms: Preventative actions: Trauma to endothelium from chemical means Pain, redness, swelling along infected vein Generalized symptoms such as fever, malaise, rapid pulse Avoid insertion over joint Select veins with adequate blood flow for infusions of hypertonic solutions

29. Systemic – Pulmonary Edema Causes: Symptoms: Preventative actions: Circulatory overload from too rapid infusion when patient has impaired renal or cardiac function JVD, ↑ BP, ↑Resps, dyspnea, agitation Watch rate Oxygen, sit pt upright Slow IV and contact OLMC

30. Systemic – Speed Shock Causes: Symptoms: Preventative actions: IV running to rapidly Rapid injection of a drug ↓BP, rapid pulse Labored resps, cyanosis Faint, ↓LOC Use controlled volume infusion set Upon initiation, ensure free flowing prior to rate adjustment

31. Systemic – Pyrogenic Reaction Causes: Symptoms: Preventative actions: Contaminated IV solutions Symptoms generally occur after IV begun ↑temp, chills, headache, N/V, circulatory collapse Check IV fluids for cloudiness and particles Use fresh open IV’s

32. Systemic – PE (Blood/Embolus) Causes: Symptoms: Preventative actions: Unfiltered blood Partially dissolved drug Particulate matter in IV solution Dyspnea, cyanosis, pain, anxiety, tachycardia, tachypnea Infuse blood through filter Dissolve drugs completely Use good judgment when syringing IV’s

33. Systemic – PE (Air) Causes: Symptoms: Preventative actions: Failure to clear tubing of air Allowing air to enter the system Cyanosis, ↓BP, weak, tachycardia, ↓LOC, non- specific chest or ABD pain Don’t let IV run dry Clear tubing properly Check syringe prior to injecting If occurs place pt on left side and contact OLMC

34. Troubleshooting If blood begins to flow back in the IV tubing  Check location of the bag to insure it is in a gravity flow location  Insure all valves are open  If continues, reassess site and assure arterial cannulation has not occurred If your IV does not run… Start at the top, work your way back to the patient Is the bag empty? Check the IV set clamps to insure they are open Check tubing for kinks Check site for any problems  Blood backing up  Infiltration Do you need to flush the site Is your tourniquet still one!

35. External Jugular (EJ) cannulation

36. EJ’s Often used in severe cases of shock, unresponsiveness and cardiac arrest since they are HUGE and relatively easy to cannulate. Why are they not commonly used in those who are conscious ? Why are they not a good choice for patients of multi system trauma ?

37. EJ cannulation procedure Place patient supine / slight reverse Trendelenburg Why ??? Turn patients head slightly to opposite side Cleanse with antiseptic using universal precautions Create tourniquet effect with fingers by applying light pressure to the inferior aspects of the EJ being cannulated.

38. Procedure Aim needle towards ipsilateral nipple Insert needle and enter vein Observe flashback Withdraw needle and attach IV tuning Cover site with sterile dressing

39. EJ cannulation

40. Calculating flow rates Drip setsFactor 10 gtt/ml (macro)10 drops = 1 ml6 15 gtt/ml15 drops = 1 ml4 20 gtt/ml20 drops = 1 ml3 60 gtt/ml (micro)60 drops = 1 ml1 Volume to be administered (ml) Time to be infused (min) XDrip set (gtts/ml) = Drops/min (gtts/min)

41. Calculations Your patient is to receive 1000 ml of normal saline (NS) over a 12 hour period using a microdrip (60 gtt/ml) administration set. The formula will now look like this: Volume to be administered (ml) Time to be infused (min) XDrip set (gtts/ml) = Drops/min (gtts/min) 1000 ml 720 min X60 gtts/ml = Drops/min (gtts/min) 83.333= Drops/min (gtts/min)

42. Now add medications A physician orders 2 mg/min of Lidocaine to your patient. She orders 2 g of lidocaine to be added to 500 ml NaCL. Using a 60 gtt/ml set, calculate the gtt/min.

43. Calculation [ ] = Mass Volume = 2.0 g 500 ml = 2000 mg 500 ml = 4 mg/ml Dose = DHDH XV = 2 mg/min 2000 mg = 1000 mgml/min 2000 mg = 0.5 ml/min X500 ml

44. Calculation Volume to be administered (ml) Time to be infused (min) XDrip set (gtts/ml) = Drops/min (gtts/min) 0.5 ml 1 min X60 gtts/ml = Drops/min (gtts/min) 30= Drops/min (gtts/min)

45. A Variation to the Same Volume (ml) On Hand (mg) XDrip set (gtts/ml) = Drops/min (gtts/min) = 30= Drops/min (gtts/min) XOrdered (mg/min) 500 ml 200 mg X60 gtt/ml X2 mg/min