1. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Division 1 Introduction to Advanced Prehospital Care

2. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Chapter 7 Intravenous Access and Medication Administration Part 2 Intravenous Access, Blood Sampling, and Intraosseous Infusion

3. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Topics Types of Intravenous Access Equipment for Intravenous Access IV Drug Administration Venous Blood Sampling Intraosseous Infusion

4. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous (IV) Access Indications Fluid and blood replacement Drug administration Obtaining venous blood specimens for lab analysis

5. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Types of IV Access Peripheral venous access Central venous access

6. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Peripheral IV Access Sites

7. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Central Venous Access Veins located deep in the body Internal jugular, subclavian, and femoral Peripherally inserted central catheter (PICC) lines Larger veins that will not collapse in shock

8. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Fluids

9. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Colloids Colloids remain in the circulatory system for a long time. –Plasma protein fraction (Plasmanate) –Salt-poor albumin –Dextran –Hetastarch (Hespan)

10. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Crystalloids Primary out-of-hospital solutions Isotonic solutions Hypertonic solutions Hypotonic solutions

11. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Prehospital Fluids Lactated Ringer solution Normal saline solution 5% dextrose in water

12. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Other Fluids Blood Oxygen-carrying solutions –Perfluorocarbons –Hemoglobin-based oxygen-carrying solutions (HBOCs)

13. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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

14. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey IV Solution Containers

15. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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.

16. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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 from blood products from entering the body Measured volume –Delivers specific volumes of fluids

17. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey IV Administration Sets (2 of 2) 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.

18. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Macrodrip and Microdrip Administration Sets

19. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Secondary IV Administration Set

20. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Measured Volume Administration Set

21. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Paramedics may administer crystalloid solutions en route to the emergency department.

22. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey In-Line Intravenous Fluid Heaters IV fluids can be heated to near body temperature with heating devices.

23. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Cannulas Over-the-needle catheter Hollow-needle catheter Plastic catheter inserted through a hollow needle

24. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Over-the-Needle Catheter

25. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Hollow-Needle Catheter

26. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Catheter Inserted Through the Needle

27. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Peripheral IV Access

28. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Place the constricting band. © Scott Metcalfe

29. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Cleanse the venipuncture site. © Scott Metcalfe

30. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Insert the intravenous cannula into the vein. © Scott Metcalfe

31. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Withdraw any blood samples needed. © Scott Metcalfe

32. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Connect the IV tubing. © Scott Metcalfe

33. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Turn on the IV and check the flow. © Scott Metcalfe

34. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Secure the site. © Scott Metcalfe

35. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Label the IV solution bag. © Scott Metcalfe

36. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Peripheral Intravenous Access in an External Jugular Vein

37. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Place the patient in a supine or Trendelenburg position.

38. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Turn the patient’s head to the side opposite of access, and cleanse the site.

39. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Occlude venous return by placing a finger on the external jugular just above the clavicle.

40. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Point the catheter at the medial third of the clavicle and insert it, bevel up, at a 10 – 30° angle.

41. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Enter the jugular while withdrawing on the plunger of the attached syringe.

42. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Access With a Measured Volume Administration Set

43. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Prepare the tubing.

44. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Open the uppermost clamp and fill the burette chamber with approximately 20 mL of fluid.

45. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Close the uppermost clamp and open the flow regulator.

46. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Access with Blood Tubing

47. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Insert the flanged spike into the spike port of the blood and/or normal saline solution.

48. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Squeeze the drip chamber until it is one-third full and blood covers the filter.

49. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Attach blood tubing to the intravenous cannula or into a previously established IV line.

50. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Open the clamp(s) and/or flow regulator(s) and adjust the flow rate.

51. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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

52. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey IV Access Complications Pain Local infection Pyrogenic reaction Allergic reaction Catheter shear Inadvertent arterial puncture Circulatory overload Thrombophlebitis Thrombus formation Air embolism Necrosis Anticoagulants

53. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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.

54. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Bolus Administration

55. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Prepare the equipment.

56. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Prepare the medication.

57. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Check the label.

58. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Select and clean an administration port.

59. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Pinch the line.

60. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Administer the medication.

61. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Adjust the IV flow rate.

62. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Monitor the patient.

63. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intravenous Infusion Administration

64. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Select the drug.

65. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Draw up the drug.

66. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Select IV fluid for dilution.

67. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Clean the medication addition port.

68. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Inject the drug into the fluid.

69. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Mix the solution.

70. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Insert an administration set and connect to the main IV line with needle.

71. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Heparin/Saline Lock

72. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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

73. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Electromechanical Infusion Devices Infusion controllers Infusion pumps

74. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Infusion Pump

75. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Syringe-Type Infusion Pump

76. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Drawing Blood

77. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Blood Tubes

78. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey

79. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Vacutainer and Luer Lock

80. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Obtaining a blood sample with a 20 mL syringe

81. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Luer Sampling Needle

82. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Remove any IV that will not flow or has fulfilled its need.

83. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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.

84. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Anterior Tibia

85. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Pediatric and adult intraosseous needle placement sites.

86. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Manual Intraosseous Needle

87. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Bone Injection Gun (B.I.G.) WAISMed., Ltd.

88. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey FAST1 – Sternal IO Employs an introducer to insert an infusion tube into the top bone of the sternum

89. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey EZ-IO Battery-powered IO driver and needle set

90. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intraosseous Medication Administration

91. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Select the medication and prepare the equipment.

92. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Palpate the puncture site and prep with an antiseptic solution.

93. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Make the puncture.

94. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Aspirate to confirm proper placement.

95. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Connect the IV fluid tubing.

96. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Secure the needle appropriately.

97. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Administer the medication. Monitor the patient for effects.

98. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Intraosseous Access Complications Fracture Infiltration Growth plate damage Complete insertion Pulmonary embolism Infection Thrombophlebitis Air embolism Circulatory overload Allergic reaction

99. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 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

100. Bledsoe/Porter/Cherry, Essentials of Paramedic Care, Second Edition Update © 2011 by Pearson Education, Inc. Upper Saddle River, New Jersey Summary Types of Intravenous Access Equipment for Intravenous Access IV Drug Administration Venous Blood Sampling Intraosseous Infusion