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2001 04-april-ems-iv therapy-meds
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2001 04-april-ems-iv therapy-meds

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  • Crystalloid-multiple preparations, isotonic (no real fluid shifts in avg pt, similar tonicity to blood plasma), hypotonic (less solute so will move into cells), hypertonic (high solute concen so fluid leave cells) Colloid-contains proteins or other molecules that remain in the intravascular space for long periods, tend to attract water NS and LR—2/3 of fluid lost to interstitial space within 1 hour of admin
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    • 1. IV Therapy and MedicationAdministrationCFD April QA TrainingHome
    • 2. 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 effectsHome
    • 3. Crystalloids-Fluids used in the field Normal Saline (1000 cc) 0.9% Sodium Chloride Isotonic solution Lactated Ringers (1000cc) Isotonic solution containing electrolytes such asNaCl, KCl, CaCl, and sodium lactate D5W (250cc) Hypotonic solution containing glucose to providecalories for metabolism Glucose moves into cells rapidlyHome
    • 4. Equipment needed IV solution Medical—NS; Trauma—LR and/or NS; Med drip—D5W Administration set with extension tubing Macro drip (10-15 gtts/cc) for all IV’s Micro drip (60 gtts/cc) for medication drip Catheter Age >12 and need for fluid resus—16 or 18 g Age <12 and/or no need for fluid resus—20-24 g Age <6—may consider IntraosseousHome
    • 5. Equipment needed (cont) Gloves Tape and bioclusive dressing Tourniquet Alcohol/betadine pad Use betadine in cases of suspected ETOH usewhere a crime may be involved (DUI) Ensure no allergies when using betadine Arm board Sharps containerHome
    • 6. IV Complications Infiltration Fluid outside vessel causing swelling, pain, little orno IV flow Catheter shear Piece of catheter separates Air embolism Air enters blood stream (10-100 cc have beenfatal) Infection Localized or systemic Home
    • 7. Saline lock vs. IV Saline lock Potential need for single medadministration IV Multiple meds and/or D50, fluid adminHome
    • 8. 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 andshould only be used cautiously as a last resort.Home
    • 9. Fluid bolus Maintain blood pressure between 90-100 mmHg systolic Give 250 cc boluses one at a time Closely monitor blood pressure, lungsounds and patient status prior to givingadditional bolusesHome
    • 10. Medication AdministrationHome
    • 11. Five Right’s1. Right patient2. Right dose3. Right medication4. Right route5. Right timeHome
    • 12. 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 anddispose of ampule pieces in sharps container Remember, always use aseptic technique and removeair from syringe prior to injecting! Home
    • 13. 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 oradd saline to vial and mix thoroughlyHome
    • 14. Med Math The basics… use like units use common sense find a formula/system that works for youHome
    • 15. 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 = 99kgHome
    • 16. 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? Howmany g?mcg - move decimal point 3 places to the right = 100,000 mcgg - move decimal point 3 places to the left = 0.1 gHome
    • 17. Basic calculationsDesired 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 = XHHome
    • 18. Example You are ordered to give 5 mg Valium IV. The labelstates there is 10 mg in 2cc (10mg/2cc). How manycc’s will you give? The equation will look like this:5mg x 2cc = X cc10 mg1 x 2 = X cc2X = 1 ccYou will give 1cc! Home
    • 19. Calculations based on weightDesired 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 = XHHome
    • 20. Example You are to give 0.5 mg/kg IV push. Your patientweighs 80 kg. The drug comes packaged:100mg/10cc. How many mg will you give? Howmany cc’s 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 = 4cc100 mgHome
    • 21. Drip calculations“Clock” method (used only for 4:1 ratio)43 1601530452If your dose is 1 mg/min, your drip rate is 15 gtt/min.If the order is greater than 4 mg/min, add themtogether. A dose of 6 mg/min is 90 gtt/min (4 + 2 =6so 60 + 30 = 90) Home
    • 22. Drip calculationsDesired dose x Size of bag x gtt set = gtt/minAmount of drug on hand The order is for 5 mg/min. You have a 500 cc bag of NS, a 60 gtt/ccadministration set, and 2 g of drug on hand. How many gtt/min will youadminister?5 mg/min x 500 cc x 60 gtt/cc = 75 gtt/min2000 mgNote: If the dose is weight based, determine the total dose prior tobeginning the equation or multiply everything by the number of kg.Home
    • 23. 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 minutesHome
    • 24. 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)Home
    • 25. Medication delivery through the airway Inhalation Takes effect in 2-3 min Given by hand held nebulizer (HHN) ormetered dose inhaler (MDI) Endotracheal Takes effect in 2-3 min Must double IV dose and flush with saline Narcan, Epinephrine, Lidocaine, AtropineHome
    • 26. 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 needleHome
    • 27. Standing Orders vs. Physician Order Standing Order Able to give med or start procedure if patientmeets certain preset criteria Physician Order Must request med or procedure from on linedoctor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 togiveHome
    • 28. Things to look for… Onset of Action-time between administration and first effectsseen Duration of Action-time after administration until effects are lastseen Side effect-undesirable and often unavoidable effect thatoccurs. Effects are not the original reason for administering thedrug. Interaction-good or bad effects that occur with administration ofmultiple drugs. Can increase or decrease effects of one or bothmeds. Synergism-action of a combination of drugs that is greater thanone drug alone Allergy-systemic reaction to a drug involving the immuneresponse Untoward effect-side effect that becomes harmful to the patientHome
    • 29. Documentation Medication Dose Time Route Person who administered Effects List good, bad, expected, and unexpected effectsHome
    • 30. Glossary of Terms Absorption-process of drug moving from site ofintroduction into circulation Contraindication-factor that does not allowadministration of drug Dependence-state where absence or less of drugcauses 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 totemporarily increase blood levelsHome
    • 31. Glossary (cont.) Maintenance dose-amount of drug needed tomaintain steady blood levels Peak level-highest blood level from any given dose Therapeutic action-wanted and intended effects of adrug Tolerance-decreased response to drug after repeatedadministration. May require increased dose. Toxic level-blood levels are such that they mayproduce adverse effectsHome
    • 32. Prehospital Medications The following is a list of drugs given inthe TEMS region. Limited information isincluded for a number of the drugs butdue to space constraints, everythingcould not be listed. Please review allmedications you are responsible foradministeringHome
    • 33. Oxygen Standing order: EMT, ST, CT, PM Dose: 2-15 LPM via nasal cannula,non-rebreather, bag-valve-mask Indications: Any patient with reducedoxygen levels or increased need foroxygen.Home
    • 34. Activated Charcoal (Actidose) Physician order: EMT, ST, CT, PM Dose: Adult (50 g), Pediatrics (25-30 g) given bymouth Action: Binds and absorbs ingested toxin and is thenexcreted. Indication: Overdose or poisoning when induction ofvomiting is not indicated Contraindications: Unable to swallow or maintainairway. Not useful in cyanide, methanol, causticacids or alkalis, heavy metals, or lithium poisonings. Side Effects: NoneHome
    • 35. Oral Glucose Standing Order: EMT, ST, CT, PM Dose: One tube Action: Increases blood glucose Indication: Consider if patient has an alteredlevel of consciousness and/or knownhypoglycemia Contraindications: Difficulty swallowing orunable to protect own airway. Side Effects: NoneHome
    • 36. Epinephrine-SQ (Adrenalin) Patient Assisted Med: EMT Physician Order: ST Standing Order: CT, PM Dose: 0.01 mg/kg (up to .3 mg) SQ 1:1000 Action: Improves force of ventricular contractions and heart,bronchdilatation, peripheral vasoconstriction, and histamineantagonist 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 ageand or cardiac history!Home
    • 37. Albuterol (Proventil, Ventolin) Patient Assisted Med: EMT Standing Order: ST, CT, PM Dose: PAM (1-2 puffs from MDI only), 2.5 mgHHN repeated once Action: Relaxes smooth muscle of bronchial treeand peripheral vasculature Indication: Relief of bronchospasm, wheezing Contraindications: Tachycardic dysrhythmias Side Effects: Anxiety, restlessness, palpitations,increased blood pressureHome
    • 38. 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 causingdecreased workload of the heart and decreased oxygendemand by decreasing preload and afterload. Indications: Chest pain, CHF Contraindications: Viagra use in past 24 hours, systolicBP<100, 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.Home
    • 39. Aspirin (ASA) Physician order: ST Standing Order: CT, PM Dose: 324 mg (four 81mg chewable) Action: Antiplatelet and vasodilatory actions allowedto occur through alterations in enzyme production. Indication: Chest pain Contraindications: ASA intake in past 24 hours Side effects: Bleeding, GI upsetHome
    • 40. 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 thehistamine response Indications: Allergic and EPS/dystonic reactions Contraindications: Acute asthma attack, taking MAOinhibitors, narrow angle glaucoma Side Effects: Drowsiness, hypotension, drying ofsecretions, sedationHome
    • 41. 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 receptorsites Indications: Narcotic overdose, altered level of consciousnessor unconsciousness with unknown origin Contraindications: Use cautiously in drug dependant patientsas administration can cause withdrawals Side Effects: projectile vomiting and/or cardiac dysrhythmiaswith rapid admin, withdrawals, diaphoresis Note-Narcan’s effects are shorter acting than the narcotic’s somonitor patient closely.Home
    • 42. 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 inthe metabolism of carbohydrates Indications: Prior to the administration of D50 as part of theunconscious protocol, Wernicke’s encephalopathy Contraindications: None Side Effects: Hypotension from rapid admin, anxiety, nauseaand vomiting, diaphoresis, red streaks following up the veinHome
    • 43. 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 <60 mg/dl, alteredlevel of consciousness and/or seizure of unknownorigin Contraindications: Intercranial hemorrhage Side Effects: No systemic effects but may developnecrosis from infiltration locally.Home
    • 44. 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/kgover 24 hours Calcium chloride-Ca channel blocker overdose, crush syndrome,hyperkalemia, hypocalcemia PO: CT, PM 8-16 mg/kg slow IV pushHome
    • 45. 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 ETHome
    • 46. 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 1:1000 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 totalHome
    • 47. 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, returnof circulation after long arrest, known severe acidosis PO: CT and PM 1 mEq/kg IV pushHome
    • 48. CT and PM meds (cont.) Solumedrol (Methylprednisolone)-anaphylaxis, severe asthma PO: CT and PM 125 mg IVHome

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