IntravenousIntravenous TherapyTherapy

Department of EMS Professions Temple College IVIV TherapyTherapy OverviewOverview

I DefinitionsDefinitions && IndicationsIndications I FluidFluid ResuscitationResuscitation I EquipmentEquipment andand SuppliesSupplies I ChoosingChoosing FluidsFluids andand CathetersCatheters I ProcedureProcedure andand TechniqueTechnique TipsTips – Peripheral Venipuncture – Intraosseous Access I PotentialPotential ComplicationsComplications DefinitionsDefinitions

I IVIV // VenipunctureVenipuncture I CrystalloidsCrystalloids I PeripheralPeripheral // CentralCentral I ColloidsColloids I IntraosseousIntraosseous AccessAccess I HypertonicHypertonic I FluidFluid ResuscitationResuscitation I IsotonicIsotonic I MedicationMedication AccessAccess I DripDrip RatesRates I KVOKVO // TKOTKO IndicationsIndications forfor VenipunctureVenipuncture

I VolumeVolume I VenousVenous AccessAccess toto – Dehydration CirculationCirculation I Water – Blood collection

I Electrolytes I Labs – Blood Loss I Field Chemistry I Colloids – Medication I Crystalloids Administration FluidFluid ResuscitationResuscitation

I DehydrationDehydration andand I ShockShock VolumeVolume LossLoss ManagementManagement – Replace Lost Fluid or – Controversial Blood – Definitive therapy = – Often requires 2 -3 Surgery and blood times the amount replacement lost (2:1 rule) – EMS → judicious replacement – Improve end organ perfusion (BP at 90 - 100 mm Hg) EquipmentEquipment andand SuppliesSupplies

I FluidsFluids I SuppliesSupplies – Normal Saline – IV Catheters

(0.9% NaCl) I Over the needle – Lactated Ringers catheter (LR or RL) I Thru the needle catheter – 5% Dextrose in I Hollow needle / Water Butterfly needles (D 5W) I Intraosseous needle – Other

(D 5 1/2 NS) EquipmentEquipment andand SuppliesSupplies

I SuppliesSupplies (cont(cont ’’d)d) – Infusion Sets – “Tegaderm ” / I 10 or 15 gtt/cc “Venigard ” (large/macro drip) – Tape I 60 gtt/cc (small/micro drip) – Armboard (optional)

I “Select -3” – Labels – Alcohol and Betadine – Saline Lock – Restricting Band (optional) ChoosingChoosing FluidsFluids && CathetersCatheters

I CrystalloidCrystalloid FluidsFluids I ColloidColloid FluidsFluids – Volume replacement – Large proteins and ↑ CO/BP – Remain in vascular – Isotonic space – No proteins – Blood replacement – Moves into tissue products over short time – Plasma Substitutes (Hypertonic)

I Dextran

I Hetastarch ChoosingChoosing FluidsFluids && CathetersCatheters

I CathetersCatheters I VeinVein SelectionSelection – Over the needle – For most patients, preferred (or IO in choose most distal peds) – Hand, forearm, – Size depends on antecubital space, patient ’s needs and and external jugular vein size – Normal Anatomy – Large gauge and provides clues to short length for locations volume replacement – avoid injury, fistula, mastectomy side TheoryTheory ofof FluidFluid FlowFlow

I FlowFlow == diameterdiameter 4 // lengthlength – Larger catheters = higher flow – Short catheters = somewhat higher flow I OtherOther factorsfactors affectingaffecting flowflow – Tubing length – Size of Vein – Temperature and viscocity of fluid

I Warm fluids flow better than cold TipsTips onon IncreasingIncreasing FlowFlow

I UseUse aa largelarge veinvein – Large AC preferred for cardiac arrest, trauma, adenosine & D50 administration I UseUse aa short,short, largelarge borebore cathetercatheter – 11/4 ” 14 g I UseUse shortshort tubingtubing withwith largelarge dripdrip setset – Macrodrip (10 gtts/ml) and NO extension set I UseUse warmwarm fluidfluid withwith pressurepressure infuserinfuser VenipunctureVenipuncture Procedure:Procedure: TipsTips

I TalkTalk toto youryour I FlushFlush airair fromfrom tubingtubing patientpatient I SelectSelect thethe mostmost I PreparePrepare && AssembleAssemble distaldistal sitesite ifif atat allall equipmentequipment aheadahead ofof possiblepossible timetime oror directdirect thisthis – antecubital tasktask – saphenous I InspectInspect fluidfluid date,date, – external jugular appearance,appearance, andand sterilitysterility VenipunctureVenipuncture Procedure:Procedure: TipsTips

I StabilizeStabilize extremityextremity I RemoveRemove needleneedle && I StabilizeStabilize adjacentadjacent placeplace inin sharpssharps skinskin I CheckCheck forfor adequateadequate I RemoveRemove restrictingrestricting flowflow bandband I RECHECKRECHECK dripdrip raterate – before removing needle – after drawing blood VenipunctureVenipuncture Procedure:Procedure: TipsTips IntraosseousIntraosseous (IO)(IO) InfusionInfusion && VascularVascular AccessAccess

I CommonCommon IVIV sitessites forfor PediatricPediatric patientspatients – Peripheral extremities (hand, wrist, dorsal foot, antecubital) – Peripheral other (external jugular, scalp, intraosseous – Neonate (umbilical vein) I AnyAny drugdrug oror fluidfluid thatthat cancan bebe givengiven IVIV maymay bebe givengiven byby thethe IOIO routeroute I LittleLittle interferenceinterference duringduring ResuscitationResuscitation IntraosseousIntraosseous (IO)(IO) InfusionInfusion

Initial IV access sites IntraosseousIntraosseous (IO)(IO) InfusionInfusion

Potential IV sites IntraosseousIntraosseous (IO)(IO) InfusionInfusion

I IndicationsIndications – Required drug or fluid resuscitation due to an immediate life -threat (e.g. CPR, Shock) – At least 2 unsuccessful peripheral IV attempts I ContraindicationsContraindications – Placement in or distal to a fractured bone/pelvis – Placement at a burn site (relative) – Placement in a leg with a missed IO attempt –
difficulty in patients > 6 years of age IntraosseousIntraosseous (IO)(IO) InfusionInfusion

I PlacementPlacement LocationLocation – Anteromedial surface of the tibia – Approximately 1 -3 fingers (1 -3 cm) below the tibial tuberosity – generally safe location with large marrow cavity – avoid closer locations to knee due to growth plate IntraosseousIntraosseous (IO)(IO) InfusionInfusion IntraosseousIntraosseous (IO)(IO) InfusionInfusion

I ProcedureProcedure I ProcedureProcedure (contd)(contd)

I Same as peripheral IV I Insert needle at 90 °

I Place leg on firm surface. angle. Apply pressure Locate landmarks with firm twisting motion.

I Grasp the thigh and I Stop advancing once knee. Do not place hand needle resistance is behind insertion site. decreased

I Palpate landmarks and I Remove stylet. identify site of insertion. I Inject saline. Check for

I Clean site if time permits resistance or soft tissue swelling.

I Connect infusion set

I Stabilize IntraosseousIntraosseous (IO)(IO) InfusionInfusion

I ConsiderationsConsiderations – Gravity flow of IV fluids will typically be ineffective. Use pressure bags if continuous infusion is required – Fluid is best administered as a syringe bolus using an extension set or T -connector – PROTECT YOUR IO SITE! PotentialPotential ComplicationsComplications

I SepsisSepsis (infection)(infection) I CatheterCatheter fragmentfragment I HematomaHematoma embolismembolism I CellulitisCellulitis I InfiltrationInfiltration I ThrombosisThrombosis I AirAir embolismembolism I PhlebitisPhlebitis DemonstrationDemonstration && PracticePractice

II Questions?Questions?