Medication Administration Chapter 14 PDF

Chapter 14 {#chapter-14.ChapterNumber} ========== Medication Administration {#medication-administration.ChapterTitle} ========================= {#section.ChapterTitle} Unit Summary This chapter begins with an overview of fluids and electrolytes---balanced and imbalanced---and the processes of o...

Chapter 14 {#chapter-14.ChapterNumber} ========== Medication Administration {#medication-administration.ChapterTitle} ========================= {#section.ChapterTitle} Unit Summary This chapter begins with an overview of fluids and electrolytes---balanced and imbalanced---and the processes of osmosis and diffusion. Next, it discusses the various types of IV solutions used in the prehospital setting and the techniques of IV therapy and intraosseous infusion. It describes the mathematical principles used in pharmacology and for calculating medication doses (bolus and maintenance infusion). Paramedics administer medication in different forms. The chapter concludes with a discussion of routes for administering medications. National EMS Education Standard Competencies **Pharmacology** Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies and improve the overall health of the patient. ***Medication Administration*** - Routes of administration (see Chapter 13, *Principles of Pharmacology*) - Self-administer medication (p 871) - Peer-administer medication (p 871) - Assist/administer medications to a patient (pp 798, 834--841, 843--875) - Within the scope of practice of the paramedic, administer medications to a patient (pp 798, 834--841, 843--875) Knowledge Objectives 1. Describe the role of medical direction in medication administration. (p 798) 2. Discuss the benefits of performing a Medication Administration Cross-Check© (MACC) before administering a medication. (p 799) 3. Explain the importance of properly documenting medication administration. (p 798) 4. Discuss paramedicsʼ responsibilities related to security of medications stocked on the ambulance. (p 799) 5. Explain the difference between aseptic, clean, and sterile techniques. (p 800) 6. Describe the use of standard precautions related to medication administration. (p 801) 7. Discuss the signs and symptoms that can occur with changes in the body's fluid status. (pp 801--803) 8. List commonly used intravenous (IV) fluid compositions and types of IV solutions. (pp 803--806) 9. Discuss the techniques for performing IV therapy. (pp 806--821) 10. Discuss the factors to consider when choosing an IV solution. (p 807) 11. Discuss the factors to consider when choosing an administration set. (pp 808--809) 12. Discuss the factors to consider when choosing an IV site. (pp 809--812) 13. List the types of IV catheters. (p 847) 14. Describe special considerations when performing IV therapy on a pediatric or older adult patient. (pp 820--821) 15. List the factors to check if the IV flow rate is incorrect. (p 821) 16. Describe complications that can occur as a result of IV therapy. (pp 821--825) 17. Discuss transport considerations for a patient undergoing a blood transfusion. (p 827) 18. Discuss the advantages, disadvantages, and techniques for establishing an intraosseous (IO) IV line. (pp 827--834) 19. List the types of IO devices available. (pp 829--831) 20. Discuss the potential complications of IO infusion. (pp 831--834) 21. Discuss the systems of weights and measures used when administering medication. (pp 837--840) 22. Explain the principles of drug dose calculations, including desired dose, concentration on hand, volume on hand, volume to administer, and IV drip rate. (pp 839--843) 23. Discuss the advantages, disadvantages, and techniques of oral medication administration. (pp 843--844) 24. Discuss the advantages, disadvantages, and techniques of rectal medication administration. (pp 844--845) 25. Discuss the advantages, disadvantages, and techniques of intradermal medication administration. (pp 852--853) 26. Discuss the advantages, disadvantages, and techniques of subcutaneous medication administration. (pp 853--854) 27. Discuss the advantages, disadvantages, and techniques of intramuscular medication administration. (pp 855--857) 28. Discuss the advantages, disadvantages, and techniques of IV medication administration. (pp 857--864) 29. Discuss the advantages, disadvantages, and techniques of IO medication administration. (pp 864--865) 30. Discuss the advantages, disadvantages, and techniques of transdermal medication administration. (pp 865--867) 31. Discuss the advantages, disadvantages, and techniques of sublingual medication administration. (p 867) 32. Discuss other methods of medication administration, including the buccal, ocular, and aural routes. (pp 867--869) 33. Discuss the advantages, disadvantages, and techniques of intranasal medication administration. (p 869) 34. Discuss the advantages, disadvantages, and techniques of inhaled medication administration. (pp 869--875) 35. Discuss the rates at which medication is absorbed through various routes. (p 878) Skills Objectives 1. Demonstrate how to spike an IV bag. (p 815) 2. Demonstrate how to obtain vascular access. (pp 815--817, Skill Drill 14-1) 3. Demonstrate how to obtain a blood sample. (pp 825--827) 4. Demonstrate how to gain IO access. (pp 832--833, Skill Drill 14-2) 5. Demonstrate how to administer oral medication to a patient. (pp 843--844) 6. Demonstrate how to administer medication via a gastric tube. (p 844) 7. Demonstrate how to draw medication from an ampule. (pp 848--849, Skill Drill 14-3) 8. Demonstrate how to draw medication from a vial. (pp 850--851, Skill Drill 14-4) 9. Demonstrate how to administer a subcutaneous medication to a patient. (p 854, Skill Drill 14-5) 10. Demonstrate how to administer an intramuscular medication to a patient. (pp 856--857, Skill Drill 14-6) 11. Demonstrate how to administer a medication via the IV bolus route. (p 858, Skill Drill 14-7) 12. Demonstrate how to administer a medication via IV piggyback. (pp 861--863, Skill Drill 14-8) 13. Demonstrate how to perform an IO infusion. (pp 865--866, Skill Drill 14-9) 14. Demonstrate how to administer a sublingual medication to a patient. (p 868, Skill Drill 14-10) 15. Demonstrate how to administer an intranasal medication to a patient. (p 870, Skill Drill 14-11) 16. Demonstrate how to assist a patient with a metered-dose inhaler. (p 872, Skill Drill 14-12) 17. Demonstrate how to assist a patient with a small-volume nebulizer. (p 874, Skill Drill 14-13) 18. Demonstrate how to access nontunneling and implemented vascular access devices. (pp 875--878) Readings and Preparation - Review all instructional materials including Chapter 14 of *Nancy Caroline's Emergency Care in the Streets*, Ninth Edition, and all related presentation support materials. Support Materials - Lecture PowerPoint presentation - Case Study PowerPoint presentation - Skill Drill PowerPoint presentations - - - - - - - - - - - - - - Skill Evaluation Sheets - - - - - - - - - - - - - - Various size IV solution bags, drip chambers, and IV catheters for demonstration Enhancements - Direct students to visit Navigate. - Students should see actual medication administration items while covering material in this chapter. If this is not possible, multimedia presentations should be used at a minimum. **Content connections:** Chapter 13, *Principles of Pharmacology*, Chapter 14, *Medication Administration*, and Chapter 15, *Emergency Medications* make up the pharmacology suite of information. Information from all three chapters is applicable. **Cultural considerations:** It is important to note that some religious beliefs do not permit introduction of fluids, medications, and blood products. When in doubt on what to do in this instance, contact medical control for help. Teaching Tips - The practical skills associated with medication administration require a solid foundation of anatomy, physiology, and knowledge of fluid dynamics. This can be enhanced through multimedia demonstration, models, and actual equipment when available. Unit Activities **Writing activities:** Assign students an IV fluid product. Students should discuss the fluid's tonicity and what types of chief complaints would benefit from its use. Additionally, students should discuss what chief complaint types would not benefit from its use. **Student presentations:** Students may present their written assignment. Alternatively, group assignments may be presented. **Group activities:** After dividing students into groups, assign them one of the 10 rights of medication administration. The group will prepare a presentation on how the right should be accomplished as well as the wrong way to accomplish the same task. **Visual thinking:** Display actual IV fluid containers on a table or display board. Provide students with statements about the fluid, such as tonicity, colloid versus crystalloid, etc. The students will then select the proper IV fluid container that meets that specification. Pre-Lecture ### You are the Paramedic "You are the Paramedic" is a progressive case study that encourages critical-thinking skills. ### Instructor Directions 1. Direct students to read the "You are the Paramedic" scenario found throughout Chapter 12. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. 3. You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. **Lecture** I. Introduction A. It is your responsibility to administer the appropriate medications and the appropriate dosage when needed, and to determine the most effective route by which to administer them. 2\. Significant harm to the patient can result from: i\. Improper technique ii\. Insufficient knowledge of medication II\. Medical Direction A. Gaining approval from medical direction 1\. Online (direct) medical control 2\. If you are not confident with medication administration: a\. Use your protocols, a drug formulary, a flip guide, a smartphone or tablet application, or any other available resource. b\. Consider medical control. 3\. Online medical control is not just for approval of medications. a\. General consultation of treatment modalities with which you are not confident 4\. When in doubt, contact medical control. III\. Ensuring Correct and Safe Medication Administration A. Ensure medications are administered accurately and safely. 1\. Use standing orders or online medical direction. 2\. Avoid human factors that cause errors. 3\. Use a tool to verify the drug dose, name, route, rate of administration, indication for administration, contraindications, drug concentration, and volume to be administered. B. Document the following: 1\. Dose administered a\. Total quantity administered during that administration b\. Units of measure for that drug c\. Volume administered to the patient 2\. Name of medication 3\. Route 4\. Rate a\. Bolus, infusion, or other administration method 5\. Time of administration 6\. Who administered the drug 7\. Who helped perform the medication check 8\. Patient's response IV\. Local Drug Distribution System A. Ensure all equipment on the ambulance is fully functional before responding to an EMS call. 1\. Verification performed during your check at the beginning of your shift 2\. Check all medications to make sure they are: a\. Not expired b\. Not damaged c\. Readily available in right quantity B. You are responsible for documentation and security of all controlled substances carried on your vehicle. 1\. Follow policies and procedures of your local drug distribution, security, and accountability system. V. Medical Asepsis A. The practice of preventing contamination from pathogens by using aseptic technique. 1\. Method of cleansing that prevents contamination of a site a\. Accomplished through: i\. Sterilization of equipment ii\. Antiseptics iii\. Disinfectants B. Clean technique versus sterile technique 1\. Sterile technique refers to the deconstruction of all living organisms using heat, gas, or chemicals. 2\. For a sterile field to exist: a\. Wear a mask and sterile sleeves or a gown that covers you from the wrist to 2 inches (5 cm) proximal of the elbow. b\. Wear sterile gloves using numerical sizes. c\. Place sterile drapes around procedural area. d\. Only sterile items and personnel may enter the sterile field. 3\. It may not be feasible to maintain a sterile environment in the field. a\. Practice medical asepsis to reduce risk of contamination and infection. C. Antiseptics and disinfectants 1\. Antiseptics are used to cleanse an area before performing an invasive procedure. a\. Capable of destroying pathogens b\. Not toxic to living tissues c\. Most common examples: i\. Isopropyl alcohol (rubbing alcohol) ii\. Iodine iii\. 2% chlorhexidine gluconate (ChloraPrep) 2\. Disinfectants are toxic to living tissue. a\. Use only on nonliving objects VI\. Standard Precautions and Contaminated Equipment Disposal A. Standard precautions 1\. Treat any bodily fluid as being potentially infectious. B. Disposal of contaminated equipment 1\. After an IV catheter or needle has penetrated a patient's skin, it is contaminated. a\. Accidental needlesticks are a leading cause of disease transmission in healthcare settings. b\. Dispose immediately and properly. c\. Sharps: Any contaminated item that can cause injury i\. Include: \(a) IV/IM/subcutaneous needles and catheters \(b) Scalpels \(c) Broken ampules or vials \(d) Anything that can penetrate/lacerate skin 2\. Immediately dispose of all sharps in a puncture-proof sharps container with a biohazard logo. a\. Should be readily accessible i Place at least two in the back of the ambulance. ii\. Have a small sharps container in your jump kit. VII\. Cellular Fluid Composition and Status A. Body fluid composition 1\. The human body is composed mostly of water. a\. Provides environment necessary for life b\. Body maintains balance between intake and output of fluids and electrolytes. i\. Injured or ill body may be unable to maintain homeostasis. c\. A healthy person loses approximately 2--2.5L of fluid daily. i\. Through urine output, lungs (exhalation), and the skin B. Dehydration 1\. Inadequate total systemic fluid volume 2\. Signs and symptoms: a\. Decreased level of consciousness b\. Postural hypotension c\. Tachypnea d\. Dry mucous membranes e\. Decreased urine output f\. Tachycardia g\. Poor skin turgor h\. Flushed, dry skin 3\. Causes: a\. Diarrhea b\. Vomiting c\. Gastrointestinal drainage d\. Infections e\. Metabolic disorders f\. Hemorrhage g\. Environmental emergencies h\. High-caffeine diet i\. Insufficient fluid intake C. Overhydration 1\. Occurs when the body's total systemic fluid volume increases 2\. May occur in patients: a\. With impaired kidney function b\. Who have been administered more fluid than their body can excrete c\. Younger than 1 month (kidneys are not fully developed) 3\. Signs and symptoms: a\. Shortness of breath b\. Puffy eyelids c\. Edema d\. Polyuria e\. Moist crackles (rales) f\. Acute weight gain 4\. Causes: a\. Unmonitored IVs (pediatrics) b\. Kidney failure c\. Water intoxication in endurance sports d\. Prolonged hypoventilation VIII\. IV Fluid Composition A. Each bag of IV solution is individually sterilized. 1\. Compounds and ions are identical to the ones in the body. a\. Altering IV concentration can move water into or out of any fluid compartment in the body. 2\. Operation of electrolytes a\. A patient's electrolytes can become altered from: i\. Excessive vomiting ii\. Diarrhea iii\. Dietary issues iv\. Medications v\. Blood loss, or a variety of other injuries b\. Understanding the role of each electrolyte aids in selecting the appropriate IV solution. B. Types of IV solutions 1\. Can be categorized as crystallized or colloid, or as isotonic, hypotonic, or hypertonic 2\. Crystalloid solutions b\. Able to cross membranes and alter fluid levels c\. Best choice for prehospital care of injured patients needing body fluid replacement d\. Optimal replacement fluid is as near to whole as possible. e\. Crystallized solutions cannot carry oxygen. 3\. Colloid solutions b\. Molecules remain in the vascular system. c\. High osmolarity i\. Draw fluid from the interstitial and intracellular compartments into the vascular compartments d\. Reduce edema e\. Could cause dramatic fluid shifts f\. Short duration of action g\. Low cost-to-benefit ratio 4\. IV solutions are also categorized by their tonicity. a\. Isotonic solution: The same concentration of sodium as the cell i\. Water does not shift. ii\. No change in the cell shape b\. Hypertonic solution: A greater concentration of sodium than the cell i\. Water is drawn out. ii\. The cell may collapse from the increased extracellular osmotic pressure. c\. Hypotonic solution: A lower concentration of sodium than the cell i\. Water flows into the cell. ii\. The cell swells and could possibly burst from increased intracellular osmotic pressure. 5\. Isotonic solutions a\. Example: Normal saline (0.9% sodium chloride) b\. Expand the contents of the intravascular compartment c\. Use care to avoid fluid overloading. d\. Lactated Ringer (LR) solution is generally used for patients who have significant blood loss. i\. Contains lactate ii\. Should not be given to patients with liver problems iii\. May be potentially detrimental if given during blood transfusions iv\. Contraindicated for: \(a) Mannitol, methylprednisolone, nitroglycerin, nitroprusside, norepinephrine, procainamide, and propranolol infusions e\. D~5~W is a unique isotonic solution. i\. Is considered isotonic in the bag ii\. Becomes hypotonic once administered iii\. Usually administered during medication infusions 6\. Hypotonic solutions a\. Begins to dilute serum once in the vascular compartment b\. Water pulled from vascular compartment into interstitial fluid compartment c\. Hydrate the cells while depleting the vascular compartment i\. May treat hypoglycemic conditions d\. Can cause a sudden fluid shift from intravascular space to the cells i\. May lead to cardiovascular collapse and increased intracranial pressure ii\. Dangerous for patients with stroke, head trauma, burns, malnutrition, or liver disease iii\. Third spacing: Abnormal shift into the serous linings e\. 0.45% sodium chloride, commonly referred to as half-normal saline i\. Not common in prehospital setting ii\. May be encountered during interfacility transports for patients who have normal sodium levels but need fluid replenishment 7\. A hypertonic solution a\. Higher osmolarity and ionic concentration than serum b\. Pulls fluid and electrolytes from the intracellular and intestinal compartments to intravascular compartment c\. Cells may collapse from increased extracellular osmotic pressure. d\. Helps stabilize blood pressure, increase urine output, and reduce edema e\. Rarely used in prehospital setting but commonly encountered during interfacility transports f\. "Hypertonic" is often used to refer to solutions with high concentrations of proteins. i\. Proteins have same effect on fluid as sodium. g\. Careful monitoring to avoid fluid overloading i\. Should not be given to: \(a) Diabetic ketoacidosis patients \(b) Patients at risk of cellular dehydration h\. 3% sodium chloride may be used per your EMS protocols for interfacility transport. i\. Used as a temporizing measure to draw out fluid in an effort to reduce intracranial pressure until the patient can be taken into neurosurgery 8\. Oxygen-carrying solutions a\. Whole blood is the best replacement for lost blood. i\. Impractical in the prehospital setting \(a) Requires refrigeration and unique storage b\. Synthetic blood substitutes are being researched and field-tested. IX\. Techniques and Administration A. IV therapy involves cannulation of a vein with a catheter to access a patient's vascular system. 1\. Peripheral vein cannulation involves cannulating veins of the periphery. 2\. The most important point to remember is to keep the IV equipment sterile. B. Assembling your equipment 1\. Gather and prepare your equipment before starting an IV line. 2\. The following equipment will be available: a\. Latex-free tourniquet b\. Antiseptic wipe or solution c\. Gauze pads d\. Tape or adhesive bandage e\. Transparent polyurethane dressing f\. Appropriate-size IV catheter g\. IV extension set h\. A saline flush i\. IV fluid and administration set appropriate for the patient's condition j\. Sharps container C. Choosing an IV solution 1\. Ask yourself: a\. Is the patient's condition critical? b\. Is the patient's condition stable? c\. Does the patient need fluid replacement? d\. Will the patient need medications? e\. Does the patient have any preexisting conditions (eg, kidney failure) that may preclude or change the standard IV therapy choice? 2\. IV solution is usually limited to two isotonic crystalloids. a\. Normal saline b\. LR solution 3\. IV solution bags are wrapped in a sterile bag and guaranteed sterile until the expiration date. a\. Solution must be used within 24 hours once opened. b\. Each bag has two ports: i\. Injection port for medication ii\. Access port for connecting the administration set c\. Removable pigtail protects sterile access port d\. IV bags come in different fluid volumes. D. Choosing an administration set 1\. An administration set moves fluid from the IV bag into the patient's vascular system. a\. Contains a piercing spike protected by a plastic cover i\. The set must be used or discarded once the spike is exposed and the seal surrounding the cap is broken. 2\. Two sizes: a\. Microdrip set: Allows 60 gtt (drops) per milliliter (mL) i\. Ideal for medication administration or pediatric fluid delivery ii\. Easy to control fluid flow b\. Macrodrip set: Allows 10 or 15 gtt/mL i\. Ideal for rapid fluid replacement 3\. Preparing an administration set a\. Verify the expiration date, and check the solution for clarity. b\. Prepare to spike the bag. 4\. Steps for spiking the bag are as follows: a\. Ensure the proper solution is clear and not expired and the protective tail port covers are in place. b\. Ensure you have chosen the correct administration set drip rating, the tubing is not tangled, and protective covers are present on both ends, and check that the flow clamp is up almost to the drip chamber and closed. c\. Remove the protective covering at the end of the IV bag and the piercing spike. d\. Slide the spike into the IV bag port until it is seated against the bag. e\. Squeeze the drip chamber to the fill line on the chamber. f\. Run fluid into the line to flush the air out of the tubing. g\. Twist the protective cover of the opposite end of the IV tubing to let the fluid flow until air bubbles are removed from the line, then either turn the roller clamp wheel to stop the flow or set the drip rate per the required dose. h\. Check the drip chamber fluid level to ensure it is half-filled. i\. If the fluid level is too low, squeeze the chamber until it fills. ii\. If the fluid level is too full, with the roller clamp in the off position, invert the bag and the chamber and squeeze the chamber to empty the fluid back into the bag. i\. Hang the bag in an appropriate location, where the ends of the IV tubing is easily accessible. 5\. Other administration sets a\. Blood tubing is a macrodrip administration. i\. Designed to facilitate rapid fluid replacement by manual infusion of multiple IV bags or IV blood replacement combinations b\. Volutrol (Buretrol or burette) is a microdrip set i\. Fills 100- or 200-mL calibrated drip chamber ii\. Able to administer only the amount wanted iii\. Proximal roller clamp allows shutoff of the drip chamber from the bag. E. Choosing an IV site 1\. Avoid areas of the vein that contain valves and bifurcations. 2\. Follow criteria to choose a vein: a\. Locate the vein section that looks the straightest. b\. Choose a vein that looks firm, round, and springs when palpated. c\. Avoid veins that cross over joints. d\. Avoid edematous, injured, infected, or paralyzed extremities and any extremity with dialysis fistula or on the side where a mastectomy was performed. 3\. Limit IV access to distal areas of extremities. a\. Start distally. b\. Work proximally. 4\. Any introduced fluid immediately below an open wound can enter tissue and cause damage. 5\. Bulging veins can roll from side to side. a\. Apply manual traction to lock it in place. i\. Pull skin over vein taut with thumb of free hand. ii\. Flex patient's hand. iii\. Stabilize wrist. iv\. Applying lateral traction can stabilize veins in forearm and antecubital areas. v\. Stabilizing and cannulating the EJ vein requires a different approach. 6\. Consider the patient's opinion when selecting an IV site. a\. Avoid extremity if it shows signs of: i\. Trauma ii\. Injury iii\. Infection b\. Look for track marks. i\. Signs of sclerosis 7\. Hospitals prefer IV lines located in nonarticulating areas such as the top of the hand or forearm. 8\. Some protocols allow IV cannulation of leg veins. a\. Can increase risk of venous thrombosis and pulmonary embolism F. Choosing an IV catheter 1\. Catheter selection should reflect the purpose of the IV line, the patient's age, and location for the line. 2\. Over-the-needle catheters a\. Teflon catheter inserted over a hollow needle b\. Use automatic needle retraction after insertion to decrease risk of contamination. i\. Locking slide mechanism or spring-loaded slide mechanism c\. Sizes determined by their diameter (gauge) i\. The smaller the gauge, the larger the diameter. d\. Choose the largest-diameter catheter for the vein you have chosen. i\. 18- or 20-gauge catheter is usually a good size for adults. 3\. Butterfly catheters a\. Hollow, stainless steel needle with two plastic wings b\. Most common in phlebotomy c\. Sometimes used for IV placement in scalp veins for pediatric patients 4\. Intracatheter a\. A tube that enters the bloodstream with the puncturing needle b\. Can be used in the hospital setting for medication administration, blood samples, and hemodynamic monitoring c\. Rarely used in prehospital setting G. Inserting the IV catheter 1\. Considerations for any technique: a\. Keep the beveled side of the catheter up. b\. Maintain adequate traction on the vein. 2\. Use a constricting band above the site. a\. Remove the band while assembling IV equipment. b\. The most common constricting band is a latex-free IV tourniquet. c\. If visualizing or palpating IV site is difficult: i\. Replace the constricting bands with a device that applies more pressure, such as: \(a) A Penrose drain \(b) A blood pressure cuff 3\. Prep the site according to your local or agency protocols. 4\. Inspect the needle for burrs or other imperfections. 5\. Loosen the catheter hub with a twisting motion to break the seal. 6\. Apply gentle lateral traction on the skin over the vein, while holding the catheter bevel side up in your dominant hand. 7\. Insert at a 35--45° angle. 8\. Push the catheter through the skin until the vein is pierced. 9\. Drop angle to 15° and advance catheter a few centimeters. 10\. Slide sheath off needle into vein until the hub touches the skin. 11\. Apply pressure to the vein proximal to the end of the indwelling catheter. 12\. Remove needle. 13\. Activate the shielding device. 14\. Dispose of needle in a sharps container. H. Vein Identification Assistive Devices 1\. Help visualize a patient's vasculature in the event of a challenging IV start a\. Near-infrared technology devices b\. Ultrasonographically guided devices c\. Portable vein transilluminators i\. Most economically feasible in prehospital setting I. Securing the line 1\. Tape the area to secure the catheter and tubing. a\. Double back the tubing to create a loop. 2\. Cover the insertion site with sterile gauze, and secure with tape. a\. Avoid circumferential taping around any extremity. 3\. Establish vascular access. 4\. To correctly establish vascular access, see Skill Drill 14-1. J. Changing an IV bag 1\. Never allow an IV fluid bag to become completely empty. a\. Change when 25 mL of fluid is left. 2\. Replace the equipment if it becomes contaminated. 3\. To change an IV fluid bag: a\. Stop the flow of fluid by closing the roller clamp. b\. Prepare the new IV bag. c\. Remove the piercing spike and insert it into the port on the new bag. d\. Ensure the drip chamber is filled and open the roller clamp, adjusting the fluid rate accordingly. K. Discontinuing the IV line 1\. Use the roller clamp to shut off the flow. 2\. Peel tape back toward the IV site. 3\. Stabilize the catheter. 4\. Do not remove IV tubing from hub of catheter. 5\. Pull catheter and IV line from patient's vein. 6\. Apply pressure to control bleeding. 7\. Apply a bandage or tape the gauze in place. L. Alternative IV sites and techniques 1\. Saline locks (buff caps) a\. Maintain active IV site without running fluids through vein b\. Composed of: i\. Male Luer-lock connecter \(a) Attaches to hub of an IV catheter ii\. Female Luer-lock connecter \(a) Can connect to syringes or an IV administration set c\. Attached to the end of an IV catheter d\. Filled with approximately 2 mL of saline i\. Keeps blood from clotting e\. Also called intermittent sites (INT) 2\. EJ vein cannulation a\. EJ vein runs down and obliquely backward behind the jaw i\. Pierces deep fascia of the neck ii\. Large and easy to cannulate iii\. Can roll if not anchored b\. Exhaust all other means of cannulating a peripheral vein before attempting EJ vein cannulation. i\. Risks include: \(a) Inadvertent puncture of carotid artery \(b) Rapidly expanding hematoma \(c) Air embolism c\. Steps to cannulate EJ vein: i\. Place patient in supine, head-down position. ii\. Cleanse the site. iii\. Occlude the jugular vein with your finger. iv\. Align the catheter in the direction of the vein. v\. Puncture midway between the jaw and midclavicular line. \(a) Stabilize the vein. vi\. Proceed cannulation as if for a peripheral vein. \(a) Prevent air from entering catheter. vii\. Tape line securely, avoiding circumferential dressings. M. Pediatric IV therapy considerations 1\. Adult IV solutions and equipment can be used on pediatric patients with some exceptions. 2\. Catheters a\. The best gauges for over-the-needle catheters used on pediatric patients are 20, 22, 24, and 26. b\. Butterfly catheters are ideal. i\. Can be used in the same location as over-the-needle catheters ii\. Can be used in visible scalp veins 3\. IV locations a\. Explain your actions to child and parent. b\. Youngest patients have fewer choices for an IV site. i\. Hand veins are painful but remain the location of choice for peripheral IV lines. c\. Critical to protect IV site i\. Ensure the catheter hub and tubing connection are covered with a clear dressing so they can be continually assessed. ii\. If there is a fear of the child pulling the catheter out, then consider wrapping the tubing and catheter with roller gauze. d\. Technique for starting pediatric IV line: i\. Use penlight to illuminate veins through back of hand. ii\. Once site is located, graze surface with fingernail to mark location. iii\. Proceed with IV insertion. e\. Scalp vein cannulation is aesthetically unpleasant and can be difficult. i\. Does not allow for rapid fluid resuscitation ii\. Tape a paper cup over the site to avoid direct pressure. N. Older adult IV therapy considerations 1\. Smaller catheters may be preferable. 2\. Puncturing the vein may cause massive hematomas. 3\. Tape may cause skin damage. 4\. Use smaller catheters (20, 22, 24 gauge). 5\. Be careful using macrodrips. a\. Can allow rapid infusion of fluids, leading to fluid overload 6\. Locations a\. Consider poor vein elasticity. b\. Avoid spidery veins because they rupture easily. c\. Do not use varicose veins. i\. They are completely closed off. X. Factors Affecting IV Flow Rates A. Perform the following checks after completing an IV administration and whenever a problem occurs: 1\. IV fluid. a\. Thick fluids infuse slowly and may be diluted to help speed. b\. Cold fluids run slower than warm fluids. 2\. Administration set a\. Macrodrips deliver fluid rapidly. b\. Microdrips deliver controlled flow. 3\. Height of the IV bag a\. Bag must be high enough to overcome gravity. 4\. Type of catheter used a\. The larger the diameter, the faster fluid can be delivered. 5\. Constricting band a\. Remove from arm after completing establishment. 6\. Entire line to ensure it is not clamped at any point a\. Occasionally, the roller clamp or the clamp from an extension set is left closed. 7\. Positioning of the IV line XI\. Potential Complications of IV Therapy A. Problems with IV therapy can be: 1\. Local reactions (infiltration and thrombophlebitis) 2\. Systemic complications (allergic reactions, circulatory overload, air embolus, vasovagal reactions, and catheter shear) B. Local complications 1\. Infiltration a\. Causes localized area of edema b\. Causes include: i\. Dislodgement of catheter ii\. Puncture of the distal vein wall iii\. Solution leakage into surrounding tissue iv\. Poorly secured line v\. Poor vein or site selection vi\. Irritating solution or medication vii\. Improper cannula size viii\. High delivery rate or pressure of the solution or medication c\. Signs and symptoms include: i\. Swelling at the site ii\. Sluggish or absent flow rate iii\. Continued IV flow after occlusion of the vein above the insertion site iv\. Absence of backflow of blood into the tubing with open clam and lowered solution v\. Patient complaints of tightness, burning, pain around the IV site d\. If infiltration occurs: i\. Discontinue the IV line. ii\. Reestablish IV line in another site with new equipment. iii\. Document and report condition. 2\. Catheter occlusion a\. Physical blockage of a vein or catheter b\. The first sign is a decreasing drip rate or blood in the IV tubing. c\. May develop due to: i\. Position of catheter within the vein ii\. Patient's blood pressure overcoming the flow (may occur if IV bag nears empty) d\. If occlusion is suspected: i\. Do not attempt to flush a catheter. ii\. Remove the catheter. iii\. Assess the integrity of the catheter. iv\. Apply a dry, sterile dressing to the site. 3\. Vein spasm a\. Patients report the solution is bothering them. b\. Signs and symptoms include: i\. Sluggish or stopped infusion rate ii\. Severe pain radiating up the extremity iii\. Blanching of the skin over the site iv\. Redness over and around the site c\. If venous spasm occurs: i\. Slow the infusion rate until the spasm subsides. ii\. Remove the catheter if the spasm persists. 4\. Phlebitis and thrombophlebitis a\. Phlebitis may result from: i\. Administration of irritating IV solutions (chemical phlebitis) ii\. Injury to the vein's lining by catheter (mechanical phlebitis) iii\. Infection (bacterial phlebitis) b\. Signs and symptoms include: i\. Pain and tenderness along affected vein ii\. Redness and swelling iii\. Warmth radiating from site c\. If signs of phlebitis develop: i\. Discontinue the IV line and save the equipment for later analysis. ii\. Reestablish the IV line in another extremity with new equipment. d\. Thrombophlebitis may occur in: i\. Association with venous cannulation ii\. Patients who misuse drugs iii\. Patients who receive long-term IV therapy iv\. Conjunction with vein-irritating solutions e\. Signs and symptoms include: i\. Slowed or stopped infusion rate ii\. Aching or burning sensation iii\. Warmth and red skin around the site iv\. Swelling of the extremity v\. Throbbing pain in the limb f\. If thrombophlebitis is suspected: i\. Stop the infusion and discontinue the IV at that site. ii\. Warm compresses may provide some relief. 5\. Hematoma a\. An accumulation of blood in the tissues surrounding an IV site b\. Often caused by: i\. Vein perforation ii\. Improper catheter removal c\. Signs and symptoms include: i\. Bruising over and around insertion site ii\. Pain at the site iii\. Swelling and hardness at the site iv\. Inability to flush IV line v\. Inability to advance cannula completely into vein during insertion d\. Common in patients with a history of: i\. Vascular diseases ii\. Taking certain medication iii\. Drinking alcohol e\. Stop and apply direct pressure if a hematoma develops while inserting a catheter. f\. Evaluate the IV flow if a hematoma develops after inserting a catheter. i\. Monitor the IV site, and leave the line in place if the hematoma is controlled and flow is not affected. g\. Apply pressure if a hematoma develops as a result of discontinuing the IV. 6\. Nerve, tendon, or ligament damage a\. Often caused by: i\. Improper venipuncture technique ii\. Improper identification of anatomic structures around the IV site iii\. Improper securing and stabilization of the cannula and line after insertion iv\. Extravasation of the solution b\. Injury results in sudden and severe shooting pain to the patient. i\. IV site near joints increases risk c\. Remove the catheter and select another IV site. 7\. Arterial puncture a\. Risk is high near an EJ vein. b\. Bright red blood will spurt back through the catheter. i\. Patients with high BP levels may have rapid backflow into the bag. c\. Withdraw the catheter, and apply direct pressure for at least 5 minutes or until bleeding stops. C. Systemic complications 1\. Allergic reactions a\. Can occur as response to IV solution, preservatives, or medications b\. Signs and symptoms have wide range across several systems c\. Stop the infusion, discontinue the IV, and select a new IV site. 2\. Pyrogenic reactions a\. Pyrogens are foreign proteins capable of producing fever. b\. Characterized by abrupt temperature elevation with: i\. Severe chills ii\. Backache iii\. Headache iv\. Weakness v\. Nausea vi\. Vomiting c\. Reaction begins within 30 minutes after IV infusion has been started. d\. Stop the infusion immediately. i\. Start a new IV line in the other arm with a fresh infusion solution. ii\. Remove the first IV. e\. Can be avoided by inspecting IV bag before use 3\. Circulatory overload and speed shock a\. Excessive fluid administration can lead to pulmonary edema. i\. Problems occur in patients with cardiac, pulmonary, or renal dysfunction. b\. Commonly caused by failure to readjust drip rate after flushing an IV line after insertion c\. The signs and symptoms include: i\. Anxiety ii\. Dyspnea iii\. Jugular vein distention iv\. Hypertension v\. Crackles heard when evaluating breath sounds vi\. A bounding pulse d\. To treat: i\. Slow the IV rate to keep the vein open. ii\. Place patient in a semi-Fowler position. iii\. Administer high-flow oxygen. iv\. Monitor vital signs and breathing adequacy. v\. Consider CPAP use. e\. Speed shock occurs when a medication or solution is rapidly introduced into the circulation. i\. Signs and symptoms include dizziness, facial flushing, anxiety, pounding headache, chills, dyspnea, tachycardia, and possible cardiac arrest. ii\. Halt infusion or medication. iii\. Ensure IV line is patent and monitor. 4\. Air embolus a\. Occurs when air enters the bloodstream. b\. Properly flushing an IV line will help eliminate the likelihood of an air embolism. c\. Replace empty IV bags with full ones. d\. Signs and symptoms: i\. Sudden hypotension ii\. Pallor leading to cyanosis iii\. Cool and clammy skin iv\. Weak, thready, rapid pulse v\. Chest, shoulder, and low back pain vi\. Diminished levels of consciousness vii\. Respiratory arrest e\. To treat: i\. Place patient on the left side with head down. ii\. Administer 100% oxygen. iii\. Transport to closest facility. iv\. Assist ventilations if needed. 5\. Vasovagal reactions a\. Anxiety concerning needles or sight of blood may cause vasculature dilation. b\. May lead to a drop in blood pressure and patient collapse c\. Patients can present with: i\. Anxiety ii\. Diaphoresis iii\. Nausea iv\. Dizziness or light-headedness d\. Treatment includes: i\. Place patient in supine position. ii\. Apply high-flow oxygen. iii\. Monitor vital signs. iv\. Establish an IV line. 6\. Catheter shear a\. Occurs when part of the catheter is pinched against the needle and the needle slices through the catheter, creating a free-floating fragment. b\. Signs and symptoms: i\. Sudden, severe pain at site ii\. Reduced or absent blood return iii\. Diminished breath sounds iv\. Dyspnea v\. Hypotension vi\. Tachycardia vii\. Chest pain viii\. Cyanosis ix\. Loss of consciousness c\. If you suspect a catheter shear: i\. Put patient in left lateral recumbent position (legs down and head elevated). ii\. Obtain an IV site in the other extremity and transport. XII\. Obtaining Blood Samples A. Obtain blood samples at the same time you start an IV line. B. The following equipment will be needed: 1\. 15- or 20-mL syringe 2\. 18- or 20-gauge needle 3\. Self-sealing blood tubes a\. Blood tubes should be filled in the following order (mnemonic: Red Blood Gives Life): i\. Red: Contains no additives; intended to clot if blood typing is needed ii\. Blue: Contains citrate; determines patient's prothrombin time, partial thromboplastin time and international normalized ratio iii\. Green: Contains heparin; used for some plasma-based determinations iv\. Lavender: Contains EDTA; determines complete blood count C. After the IV catheter is in place, occlude the catheter and remove constricting band. 1\. Attach a 15- or 20-mL syringe to the hub of the IV and draw necessary blood. 2\. Remove the constricting band while drawing blood. 3\. Remove syringe after blood has been obtained. 4\. Attach IV tubing and begin infusion. D. If IV therapy is not indicated but blood samples are required, use a Vacutainer. 1\. 18- or 20-gauge sampling needle 2\. Steps: a\. Apply a constricting band and locate vein. b\. Cleanse the site. c\. Insert the needle into the vein. d\. Remove the constricting band and insert blood tubes. e\. Remove the needle and apply direct pressure. f\. Dispose of the needle. g\. Label all the tubes (patient's name, date, time, your name). 3\. Turn blood tubes back and forth to mix the anticoagulant and blood evenly. a\. Do not shake the red tube, which is meant to clot. 4\. Blood tubes must be at least three-fourths full to be viable for testing. XIII\. Blood Transfusions A. Blood type is identified by obtaining a type and cross-match from the patient's bloodwork. 1\. Bracelet will be placed on patient to identify blood type. 2\. Blood to be transfused must be checked against bracelet and verified by two ALS providers. 3\. Verification includes the: a\. Patient's complete name b\. Patient's medical record number c\. Product being transfused d\. Unit number of the product being transfused e\. ABO and Rh type of the product f\. Expiration date of the unit 4\. In emergency medical settings, the patient's ABO blood type and Rh factor may not be known. a\. Hospital will have type O blood available for transfusion. b\. If your crew is expected to switch out units during transport, then verify the ABO type and Rh factor before leaving. c\. Accepted blood must be used within 4 hours or returned to the blood bank. 5\. Any time you accept a transport involving a blood transfusion, ensure patient has at least one available vascular site that does not have blood running. a\. If a transfusion reaction occurs, then any IV lines that have blood transfusing should be discontinued. B. Blood being transfused is administered through specific blood tubing and mixed with normal saline. 1\. Assess vital signs every 5 minutes. 2\. Monitor the patient for signs of a transfusion reaction. a\. Headache b\. Change in mental status c\. Flushing of the skin d\. Nausea and vomiting e\. Difficulty breathing f\. Chills g\. Tachycardia h\. Hypotension i\. Fever XIV\. Intraosseous Infusion A. Intraosseous means within the bone. 1\. IO infusion is a technique of administering fluids, blood and blood products, and medications into the IO space of the proximal tibia, humeral head, or sternum. 2\. Long bones consist of a shaft (diaphysis), the ends (epiphyses), and the growth plate (epiphyseal plate). 3\. The IO space comprises the spongy cancellous bone of the epiphyses and the medullary cavity of the diaphysis. 4\. When a patient is in a hemodynamically compromised condition, peripheral veins often collapse. a\. IV access is difficult if not impossible. b\. IO space remains patent. i\. Quickly absorbs IV fluids and medications ii\. Anything that can be given via the IV route can be given via the IO route. B. IO Sites 1\. Three common sites you will use for IO insertion are the sternum, humerus, and proximal tibia. 2\. To locate the humeral IO site, manipulate arm and palpate humeral head: a\. Place patient's hand over his or her abdomen. b\. Place the ulnar aspect of one of your hands vertically over the axilla near the humeral head that will be used for insertion. c\. Place the ulnar aspect of your other hand laterally along the midline of the upper portion of the patient's humerus. d\. Place your thumbs together, palpating up the surgical neck to the humeral head. e\. Identify the sternal IO site by palpating the sternal notch and using the IO device's adhesive target. i\. The device location is near the chest compression landmarks; however, the device does not impede chest compressions. 3\. The flat bone of the proximal tibia is located medial to the tibial tuberosity, the bony protuberance just below the knee. a\. You must feel the leg to know the difference between the first and second landmarks. b\. To locate the proximal tibia IO site, palpate the tibial tuberosity, then: i\. For adults, palpate 0.8 inch (2 cm) medially. ii\. For pediatric patients, palpate 0.4 to 0.8 inch (1 to 2 cm) distally to avoid the epiphyseal plate. 4\. For the distal tibia IO site, use palpation as well. a\. Identify the medial malleolus, then: i\. For adults, palpate 0.8 to 1.2 inch (2 to 3 cm) above that site. ii\. For pediatric patients, palpate 0.4 inch (1 to 2 cm) above the medial malleolus. C. Equipment for IO infusion 1\. Manually inserted IO needles a\. Consist of solid boring needle (trocar) inserted through a sharpened hollow needle b\. Pushed into bone via screwing and twisting i\. Once needle pops through bone, solid needle is removed. \(a) Hollow steel needle remains. c\. Long needles that rest at a 90° angle to the bone d\. Easily dislodged and require careful immobilization 2\. FAST (First Access for Shock and Trauma) devices a\. Do not use in children. b\. Design elements allow for IO placement in sternum c\. Can be used during cardiac arrest i\. While chest compressions can coincide with FAST IO use, mechanical CPR devices must be paused during the insertion phase. ii\. Mechanical CPR can continue once the FAST device is stabilized. d\. FASTR device is updated with many components already assembled to expediate insertion process i\. Safety lock removed before insertion ii\. Requires less pressure for insertion e\. Remain in place for maximum of 24 hours i\. Remove by firmly grasping the insertion tube and pulling in one continuous motion until dislodged. 3\. The EZ-IO a\. Features hand-held battery-powered driver with an attached IO needle b\. Inserts IO needle into proximal or distal tibia of adults and children and humeral head in adults c\. Determining factor in needle size selection is the amount of subcutaneous tissue present over the insertion site. d\. To remove the device, attach a 10-mL syringe to the IO's Luer lock and twist clockwise. 4\. The Bone Injection Gun (BIG) a\. Spring-loaded device b\. Inserts IO needle into proximal tibia of adults and children and humeral head in adults c\. Uses the safety lock as the stabilization device once the device has been inserted d\. To remove the device, use the stabilization device as the removal tool. 5\. New Intraosseous (NIO) device a\. Placed in the proximal tibia of an adult patient i\. The humeral head is an alternative site for this device. b\. The spring-loaded device contains neither drill nor battery. i\. Inserted by unlocking a safety cap ii\. While applying downward pressure with the dominant hand, the fingers of the other hand are used to pull trigger wings up to deploy the device. iii\. The device is then pulled up in a rotating motion while the needle stabilizer is held against the skin. iv\. Once the introducing trocar is removed, any Luer-lock tubing can be attached. c\. A pediatric version, NIO Pediatric (NIO-P), is also available. i\. This device has an adjustable dial, allowing the provider to adjust by age or depth. ii\. It is only approved for placement in the proximal tibia. D. Performing IO infusion 1\. To perform IO infusion using an EZ-IO device, follow the steps in Skill Drill 14-2. E. Potential complications of IO infusion 1\. Same potential complications as with IV therapy, as well as others 2\. Infiltration occurs when the IO needle rests outside the bone, rather than inside IO space. a\. Suspect if infusion does not run freely or site becomes edematous. i\. Discontinue infusion immediately. ii\. Reattempt in the opposite leg. 3\. Osteomyelitis is inflammation of the bone and muscle caused by an infection. 4\. Failure to identify the proper anatomic landmark can damage the growth plate. 5\. Improper technique can cause fracture. a\. Too forceful b\. Too large of an IO needle 6\. Through-and-through insertion occurs when the IO needle passes through both sides of the bone. a\. Stop inserting when you feel a pop. 7\. A pulmonary embolism (PE) can occur if particles of bone, fat, or marrow find their way into the systemic circulation. a\. Suspect if patient experiences acute shortness of breath, pleuritic chest pain, and cyanosis. F. Contraindications to IO infusion 1\. Functional IV line is available. 2\. Fracture of the bone intended for IO cannulation 3\. Osteoporosis 4\. Osteogenesis imperfecta (congenital disease resulting in fragile bones) 5\. Bilateral knee replacements 6\. Prosthetic limb XV\. Medication Administration A. Understand how medications affect the human body before administering them. 1\. Become familiar with: a\. Mechanism of action b\. Indications c\. Contraindications d\. Adverse effects e\. Routes of administration f\. Pediatric and adult doses g\. Antidotes for adverse reactions 2\. The first rule of medicine is to do no harm. a\. Ensure that a particular drug is clearly indicated to treat the patient's condition. b\. Understand basic math to calculate appropriate doses. B. Mathematical principles used in pharmacology 1\. Mathematics review a\. Fractions represent a portion of a whole number. b\. Decimals distinguish numbers that are greater than zero from numbers that are smaller than zero. i\. Whole numbers are on the left side of the decimal. ii\. Fractions of numbers are on the right side of the decimal. iii\. Convert fractions to decimals by dividing the numerator by the denominator. c\. Dividing or multiplying by 10 can easily be done by remembering a calculation method. i\. When dividing, move the decimal point to the left. ii\. When multiplying, move the decimal point to the right. d\. Percentages are part of 100 and use the % symbol. i\. Written as a fraction with the denominator being 100 ii\. Convert decimals to percentages by moving the decimal over two places. 2\. The metric system is a decimal system based on multiples of ten. a\. Measures length, volume, weight i\. Meter (m): Length ii\. Liter (L): Volume iii\. Gram (g): Weight b\. Prefixes demonstrate the fraction of the base being used. i\. Micro- = 0.00001 ii\. Milli- = 0.001 iii\. Centi- = 0.01 iv\. Kilo- = 1,000.0 c\. Medications are supplied in a variety of weights and volumes. i\. You will be required to convert weights to volumes. d\. Drugs are packaged in various units of weight and volume. i\. Usually comprise only a fraction of packaged form ii\. Conversion required to fulfill drug requests 3\. Volume conversion a\. The prehospital setting uses two measurements of volume: milliliters and liters. i\. 1 L equals 1,000 mL. ii\. Converting mL to L: Divide the smaller volume by 1,000 or move the decimal point three places to the left. iii\. Converting L to mL: Multiply L by 1,000 or move the decimal point three places to the right. 4\. Weight conversion a\. To convert a larger unit of weight to a smaller one, multiply the larger by 1,000 or move the decimal point three places to the right. b\. To convert a smaller unit of weight to a larger one, divide the larger by 1,000 or move the decimal point three places to the left. c\. 1 g equals 1,000 mg. d\. 1 mg equals 1,000 mcg. 5\. Converting pounds to kilograms a\. For patients who do not know their weight in pounds or who are unresponsive: i\. Estimate the patient's weight in pounds. ii\. Convert pounds to kilograms. b\. Two formulas for converting pounds to kilograms: i\. Divide the patient's weight in pounds by 2.2. ii\. Divide the patient's weight in pounds by 2 and subtract 10% of that number. 6\. Temperature conversion a\. Normal body temperature is 98.6° Fahrenheit or 37° Celsius. b\. To convert Fahrenheit to Celsius: i\. Subtract 32 then multiply by 0.555 (5/9). c\. To convert Celsius to Fahrenheit: i\. Multiply by 1.8 (9/5) then add 32. C. Calculating medication doses 1\. Based on three factors: a\. Desired dose (amount of drug ordered by the physician) i\. Expressed as standard dose or specific number of micrograms, milligrams, or grams b\. Drug concentrations (total weight of the drug contained in a specific amount of volume) i\. Volume on hand: Volume of solution that the drug is contained in \(a) The weight of the drug present in 1 mL will tell you its concentration. \(1) Total weight of the drug/Total volume in milliliters = Weight per milliliter \(b) If the label lists the concentration of a drug as a percentage (number of grams present in 100 mL): \(1) Divide the numerator and denominator by 100. c\. Volume to be administered i\. Desired dose (mg)/Concentration of drug on hand (mg/mL) = Volume to be administered D. Weight-based drugs 1\. Some medication doses are based on the patient's weight in kilograms. a\. Add one step to the formula: Convert the patient's weight in pounds to kilograms XVI\. Calculating Fluid Infusion Rates A. Adjust the flow rate of the IV or IO catheter according to the patient's condition or as dictated by medical control. 1\. You must know: a\. Volume to be infused b\. Period over which it is to be infused c\. Properties of the administration 2\. To calculate the flow rate: \ [\$\$\\frac{Volume\\ to\\ be\\ infused\\ \\times \\frac{\\text{gtt}}{\\text{mL}}\\text{of\\ administration\\ set}}{\\text{Total\\ time\\ of\\ infusion\\ in\\ minutes}} = gtt/min\$\$]{.math.display}\ XVII\. Calculating the Dose and Rate for a Medication Infusion A. Non-weight-based medication infusions 1\. Usually ordered to be administered over a specified period (typically per minute) 2\. To calculate, know the following information: a\. Desired dose b\. Properties of the administration set you are using c\. If you are using an infusion pump 3\. Use the same formula to calculate a drug dose as previously discussed. a\. Then calculate the desired dose to be administered continuously. i\. You must know the number of drops per milliliter (gtt/mL). \(a) Microdrip: 60 gtt/mL \(b) Macrodrip: 10 or 15 gtt/mL \ [\$\$\\frac{mL\\ per\\ minute\\ \\times Drops\\ per\\ milliliter}{\\text{Total\\ time\\ in\\ minutes}} = Continuous\\ infusion\\ rate\$\$]{.math.display}\ B. Weight-based medication infusions 1\. To calculate the IV drop rate, use the previously discussed formula, but factor in the patient's weight in kilograms. XVIII\. Pediatric Drug Doses A. There are many methods to determine the right dose of medication for pediatric patients. 1\. Length-based resuscitation tape measures 2\. Pediatric wheel charts 3\. EMS field guide with tables or charts 4\. Smartphone apps B. Most drugs used in pediatric emergency medicine are based on the child's weight in kilograms. 1\. Calculations are the same for pediatric medicine as they are for adults. XIX\. Enteral Medication Administration A. Given through the digestive or intestinal tract B. Oral medication administration 1\. Forms include: a\. Capsules b\. Time-released capsules c\. Lozenges d\. Pills e\. Tablets f\. Elixirs g\. Emulsions h\. Suspensions i\. Syrups 2\. Drugs are absorbed at a slow rate (30 to 90 minutes). a\. PO medication may need to be started early. 3\. To administer, you may use: a\. Medicine cup b\. Medicine dropper c\. Teaspoon d\. Oral syringe e\. Nipple 4\. Check for indications, contraindications, and precautions, and review the rights of medication administration. 5\. When administering an oral medication: a\. Take standard precautions. b\. Determine need for medication. c\. Obtain history, including allergies. d\. Follow standing orders or contact medical control. e\. Check the medication to ensure it is correct, not cloudy or discolored, and not past its expiration date. f\. Determine the appropriate dose. g\. Instruct patient to swallow a pill or tablet with water. h\. Monitor the patient's condition and document the medication given, route, time of administration, and response of the patient. C. Orogastric and nasogastric tube medication administration 1\. Gastric tubes are occasionally inserted in the prehospital setting to: a\. Decompress stomach b\. Perform gastric lavage c\. Establish a route for enteral medication administration 2\. Common during interfacility transports 3\. Most common solution administered is tube feeding D. Rectal medication administration 1\. Medication absorption is rapid and predictable. a\. Bypass the first-pass metabolism 2\. Some medications available in suppository form. a\. Drug mixed in a firm base that melts at body temperature and is shaped to fit the rectum. 3\. To administer drugs rectally: a\. Take standard precautions. b\. Determine the need for the medication. c\. Obtain a history, including drug allergies. d\. Follow standing orders or contact medical control. e\. Determine the appropriate dose and ensure: i\. It is the right medication ii\. No cloudiness or discoloration iii\. Medicine has not expired f\. Use a water-soluble gel for lubrication, and insert into the rectum 1 to 1.5 inches (3 to 4 cm). g\. Modifications may be needed for liquid form. i\. You may use: \(a) Nasopharyngeal airway \(b) Small endotracheal tube \(c) Large-bore IV \(d) Commercial device ii\. Lubricate the end of the delivery device, and insert 1 to 1.5 inches (3 to 4 cm) into rectum. iii\. Tell patient not to bear down. iv\. Push medication through tube with needleless syringe. v\. Remove and dispose of the tube. h\. Monitor the patient and document medication, route, time of administration, and response of the patient. XX\. Parenteral Medication Administration A. Any route other than the gastrointestinal tract 1\. Includes: a\. Intradermal b\. Subcutaneous c\. IM d\. IV e\. IO f\. Percutaneous 2\. Medications are absorbed into the central circulation faster and at a predictable rate. **B. Syringes and needles** 1\. A variety of needles and syringes are used. a\. May be prepackaged with a needle attached b\. May be packaged separately 2\. Syringes consist of: a\. Plunger b\. Body or barrel c\. Flange d\. Tip 3\. Most syringes are marked with 10 calibrations per milliliter on one side. a\. Other side is marked minims. b\. Vary from 1 mL to 60 mL 4\. Hypodermic needles consist of: a\. Hub b\. Shaft c\. Bevel 5\. Hypodermic needles vary from 3/8 to 2 inches in length (0.9 cm to 5 cm) for standard injections. a\. Gauge refers to diameter. i\. Smaller number = larger diameter ii\. Common needle gauge is 18 to 26 C. Packaging of parenteral medications 1\. Ampules a\. Breakable sterile glass containers b\. Carry single dose of medication c\. To correctly draw medication from an ampule, see Skill Drill 14-3. 2\. Vials a\. Glass or plastic bottles with a rubber stopper top b\. Contain single or multiple doses c\. Determine how much of the drug is needed and how much is in the bottle. d\. Removing the cover makes it no longer sterile. e\. Some medications in vials may need to be reconstituted. i\. Shake the vial vigorously. ii\. Mix-o-Vial: Single vial divided into two compartments by a rubber stopper f\. To correctly draw medication from a vial, see Skill Drill 14-4. 3\. Prefilled syringes a\. Packaged in tamper-proof boxes b\. Two types: i\. Separated into a glass drug cartridge and syringe ii\. Preassembled prefilled syringes c\. Single-dose medication cartridges inserted into a reusable syringe are available. 4\. Push-dose pressors a\. Some vasopressors are available for administration in a small bolus format. i\. Generally reserved for patients with transient hypotension or for EMS systems with short transport times b\. Epinephrine and phenylephrine (Neosynephrine) are currently available in push-dose format. c\. Using push-dose epinephrine involves mixing the appropriate concentration: i\. Use a 10-mL saline flush to waste 1 mL. ii\. Use a blunt-tip needle and draw out 0.1 mg (1 mL) of an epinephrine 1:10,000 (0.1 mg/mL) prefilled syringe. iii\. The result is a concentration of 0.1 mg or 100 mcg in 10 mL. D. Intradermal medication administration 1\. Intradermal injections involve administering a small amount of medication into the dermal layer. a\. Uses a 1-mL syringe and a 25- to 27-gauge, 3/8-inch to 1-inch (0.9-cm to 3-cm) needle. 2\. Avoid areas containing superficial blood vessels. a\. Most common locations used are anterior forearm and upper back. 3\. Medications have a slow absorption rate. a\. Minimal to no systemic distribution b\. Medication remains locally collected. 4\. To administer medication intradermally: a\. Take standard precautions. b\. Determine need for medication. c\. Obtain history, including drug allergies. d\. Follow standing orders or contact medical control. e\. Check the medication. f\. Advise patient of potential discomfort and explain procedure. g\. Assemble and check equipment needed. h\. Cleanse the area for injection using aseptic technique. i\. Pull skin taut with your nondominant hand. j\. Insert the needle at a 10° to 15° angle with the bevel up. k\. Slowly inject the medication. i\. Look for a wheal: A small bump indicating if the medication is pooling in the intradermal tissue l\. Remove the needle, and immediately dispose of it in a sharps container. m\. Monitor the patient's condition and document response. E. Subcutaneous medication administration 1\. Injections are given into the loose connective tissue between the dermis and muscle layer. a\. Use a 24- to 26- gauge ½-inch to 1-inch (1-cm to 3-cm) needle. b\. Common sites include upper arms, anterior thighs, and abdomen. 2\. To correctly administer a medication via the subcutaneous route, see Skill Drill 14-5. F. IM medication administration 1\. Injections are given by inserting a needle through the dermis and subcutaneous tissue and into the muscle layer. a\. Allows for more rapid absorption of medication b\. Potential to damage nerves c\. Common sites include: i\. Vastus lateralis muscle ii\. Rectus femoris muscle iii\. Gluteal area iv\. Deltoid muscle 2\. To correctly administer a medication via the IM route, see Skill Drill 14-6. G. IV bolus medication administration 1\. The IV route places drugs directly into the circulatory system. a\. Fastest route of administration b\. Bypasses most barriers to drug absorption 2\. Direct injection of drugs with a needle and syringe into IV line a\. Needleless systems now available b\. Syringe screws into the injection port of the administration set. 3\. A bolus is a single dose given by the IV route. a\. Small or large quantity of a drug b\. Delivered rapidly or slowly c\. Some medications require initial bolus, followed by continuous IV infusion. d\. To correctly administer a medication via the IV bolus route, see Skill Drill 14-7. 4\. Saline locks are used for patients who are not in need of IV fluid boluses but may need medication therapy. a\. To administer medication through a saline lock: i\. Take standard precautions. ii\. Determine the need for the medication. iii\. Obtain a history, including allergies and vital signs. iv\. Follow standing orders or contact medical control. v\. Check the medication. vi\. Explain the procedure to the patient. vii\. Assemble the needed equipment and draw up the medication. \(a) 20 mL of normal saline needed to use as a flush viii\. Cleanse the injection port with alcohol or remove the protective cap. ix\. Insert the needle into the port or screw the syringe onto the port. \(a) Clamp off the IV tubing to prevent backflow. x\. Pull back slightly on the syringe plunger and observe for blood return. \(a) If blood appears, watch for infiltration. \(b) If resistance is felt or patient reports discomfort, discontinue and establish a new site. xi\. Place the needle and syringe into the sharps container. xii\. Clean the port and insert the needle with the flush. xiii\. Flush and place the needle in the sharps container. xiv\. Store any unused medication properly. xv\. Monitor the patient's condition and document the findings. H. Adding medication to an IV bag 1\. Certain medications are added to the IV solution itself to be administered as a maintenance infusion. a\. Check the fluid in the IV bag for discoloration and ensure it has not expired. b\. Check the medication name and concentration. c\. Compute the volume of the drug to be added to the IV bag and draw up that amount in the syringe. d\. Cleanse the medication injection port. e\. Inject medication into the IV bag via rubber stopper. f\. Withdraw the needle and dispose in the sharps container. g\. Agitate the IV bag to ensure the medication is mixed in the solution. h\. Label the IV bag with the: i\. Name of the medication added ii\. Amount added iii\. Concentration in the IV bag iv\. Date and time v\. Your name i\. Attach IV administration set, and prepare the IV bag. 2\. IV piggyback a\. Primary line: IV administration set that is connected directly to the hub of the IV catheter b\. When performing continuous infusion, take the distal end of drip set and connect it to a port on the primary line. c\. Multiple lines can be piggybacked. i\. Label the lines to ensure there are no interactions. d\. Follow the steps in Skill Drill 14-8 to perform IV piggyback infusion. 3\. IV infusion pumps a\. Use an electromechanical infusion pump when: i\. Administering a medication maintenance infusion ii\. Delivering IV fluid maintenance infusions in children and older adults b\. Benefits include: i\. Deliver the rates set by the pump without deviating ii\. Calculate the amount of fluid infused and amount remaining c\. Problems include: i\. Lack of uniformity among manufacturers ii\. Air trapping in lines causes the pump to stop and an alarm to sound. d\. Deliver fluids via positive pressure. e\. Safety features include: i\. An alarm that indicates change in flow pressure ii\. Alarm that alerts you to presence of occlusion or depletion of medication f\. May be designed to accommodate: i\. IV tubing to regulate the flow of fluids ii\. Needleless syringe g\. May have multiple chambers for multiple medications i\. If number of medication lines outweighs available chambers, isotonic fluid may need to be transported on gravity alone. h\. Some pumps have medication databases that calculate medication rate by desired dose and patient's weight. i\. Volume to be infused is the amount of solution remaining to be infused. i\. IV infusion pumps come in a wide variety of configurations. I. IO medication administration 1\. Fluid does not flow well into the bone. a\. Use a large syringe to infuse fluid. i\. A pressure infuser device is a sleeve placed around the IV bag and inflated to force fluid from the IV bag. \(a) Use in adults 2\. Potential for compartment syndrome if fluid leaks out of bone 3\. To correctly administer a medication via the IO route, see Skill Drill 14-9. J. Percutaneous medication administration 1\. Medications are applied to and absorbed through the skin and mucous membranes. 2\. Transdermal medication administration a\. Applied topically b\. Useful for sustained release of certain medications c\. Delivery includes: patches, creams, lotions, pastes d\. Too much medication or thin/nonintact skin may increase the speed of absorption. e\. Thick skin, scar tissue, or peripheral vascular disease may decrease the speed of absorption. f\. To apply, perform the following steps: i\. Take standard precautions. ii\. Determine the need for medication. iii\. Obtain history, including drug allergies and vital signs. iv\. Follow standing orders or contact medical control. v\. Check the medication to ensure it is correct, unexpired, and is the appropriate amount. vi\. Explain the procedure to the patient. vii\. Clean and dry area for medication application. viii\. Apply the medication in accordance with the manufacturer's specifications. ix\. Monitor patient's condition and document the response. 3\. Sublingual medication administration a\. The sublingual area is highly vascular, and medication is rapidly absorbed here. b\. Drugs may also be injected under the tongue. c\. To correctly administer a sublingual medication, see Skill Drill 14-10. 4\. Buccal medication administration a\. The buccal region lies in between the cheek and gums. b\. Medication comes in the form of tablets or gel. c\. To administer medication via the buccal route: i\. Take standard precautions. ii\. Determine the need. iii\. Obtain history, including allergies and vital signs. iv\. Follow standing orders or contact medical control. v\. Check medication to ensure it is correct, unexpired, and the appropriate amount. vi\. Explain procedure to patient. vii\. Place medication in between the patient's cheek and gum (or ask patient to do so). viii\. Advise patient to allow the tablet to dissolve slowly rather than chew or swallow it. ix\. Monitor the patient's condition and document the response. 5\. Ocular medication administration a\. Drops or ointments are commonly administered via the ocular route. b\. Typically administered for pain relief, allergies, and infections c\. Medication administration via ocular route is rare in prehospital setting. i\. In the hospital and in some prehospital systems, providers use bottles to squeeze the prescribed amount of drops into the eye. ii\. A Morgan lens can be used for some ophthalmic medications, particularly local anesthetics. d\. To assist a patient with ocular medication administration: i\. Take standard precautions. ii\. Confirm prescription. iii\. Have patient tilt head and look up. iv\. Expose conjunctiva by gently pulling down on the lower eyelid, without touching the eyeball. v\. Administer medication by using an eye dropper. vi\. Advise patient to close eye for 1 to 2 minutes. vii\. Document medication name, dose, and administration time. 6\. Aural medication administration a\. Administered via the ear canal b\. To assist a patient with aural medication administration: i\. Take the standard precautions. ii\. Confirm prescription. iii\. Place the patient on side with affected ear facing up. iv\. Expose the ear canal by pulling the ear up and back (adults) or down and back (infants and children). v\. Administer medication with a medicine dropper. vi\. Document medication name, dose, and administration time. 7\. Intranasal medication administration a\. Intranasal medications include nasal spray for congestion or solutions to moisten the nasal mucosa. b\. Rapidly absorbed c\. Rapid onset of action d\. Performed with a mucosal atomizer device (MAD) i\. Attaches to a syringe ii\. Sprays medication into the nasal mucosa e\. Typically requires 2 to 2.5 times the dose of IV medications f\. Follow local protocol or consult with medical control. g\. To administer a medication via the intranasal route, follow the steps in Skill Drill 14-11. XXI\. Medications Administered by the Inhalation Route A. Nebulizer and metered-dose inhaler 1\. The most common medication administered via inhalation route is oxygen. 2\. Check your drug reference guide or the package prior to administration. 3\. A patient with a history of respiratory problems will likely have a metered-dose inhaler (MDI). a\. Administered by the patient, but the patient may ask for assistance. b\. Can be delivered through a mouthpiece held by the patient or by a mask c\. To correctly help a patient self-administer medication from an inhaler, see Skill Drill 14-12. 4\. Liquid bronchodilators may be aerosolized in a nebulizer for inhalation. a\. Most common method of administration of inhaled medications in the prehospital setting b\. May allow blow-by administration or a nebulized mask c\. To administer a medication via a small-volume nebulizer, see Skill Drill 14-13. 5\. If patients are breathing inadequately, they may be unable to effectively inhale medications. a\. Assist with bag-mask ventilation. b\. Attach a small-volume nebulizer to the ventilation device. c\. Place a short piece of corrugated tubing between the bag and mask or endotracheal tube. d\. When using CPAP, most manufacturers have a nebulizer that is designed to work with their device. XXII\. Long-Term Vascular Access Devices XXIII\. Rates of Medication Absorption A. Drugs are absorbed at a speed directly related to the route of delivery. 1\. Drugs injected into the bloodstream gain access the fastest. 2\. Oral medications take longer because they must be absorbed first. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor's presentation. Assessment in Action -------------------- Assessment in Action is available to students in the Navigate course. This practice activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Assignments ----------- **A.** Review all materials from this lesson and be prepared for a lesson quiz to be administered (**date to be determined by instructor**). **B.** Read Chapter 15, *Emergency Medications,* for the next class session.