IV Therapy and Medication Administration

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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
• MedicalNS TraumaLR and/or NS Med dripD5W
• Administration set with extension tubing
• Macro drip (10-15 gtts/cc) for all IVs
• Micro drip (60 gtts/cc) for medication drip
• Catheter
• Age gt12 and need for fluid resus16 or 18 g
• Age lt12 and/or no need for fluid resus20-24 g
• Age lt6may 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 systemic

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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 Rights

• 1. Right patient
• 2. Right dose
• 3. Right medication
• 4. 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!

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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 ccs will you give?
• The equation will look like this

5mg x 2cc X cc 10 mg
1 x 2 X cc 2
X 1 cc
You will give 1cc!
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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
  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 41 ratio)

60
4
1
15
3
45
2
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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)
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Drip calculations

• Desired 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 patient

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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

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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 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 11000
• 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 BPlt100, 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 lt60 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 11000 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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