Ada County Paramedics
Educational Outreach
VASCULAR ACCESS UPDATE
Advanced EMT introduction to
Vascular Access
Objectives
 Describe the basic distribution of fluids in the body
 Discuss the basic role of Vascular access in EMS
 Id...
Basic Physiology of Fluid
KEY POINT:
 We will actually go into a LOT of detail on fluids and
shock later in the ..FLUIDS and SHOCK Lecture.
 
Water…Its good for you!
 Total Body Water (TBW): approx. 60-70% of total body
mass.
 Higher the younger you are
Quick Exercise
 Did you know that 1 kg of water = 1 liter of water?
 What is your weight in Kg?
 Weight in Kg x 0.6 = e...
Distribution of Fluids
 Intracellular Fluid (ICF): The amount of water that’s
inside our cells accounts for 2/3rds of our...
Distribution of fluids
Extracellular Fluids
 ECF is also known as interstitial fluid because it’s the
fluid in between the cells.
 Sometimes ca...
How much blood?
 Blood is made up of blood cells and blood plasma.
 TBV = 8% x Body Weight (kg).
 Remember, we can calc...
Another quick exercise
 Normally about 20% blood loss is an indication for IV
fluid resuscitation (in addition to other i...
Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 2000 or more
Blood Loss
(%BV)
Up to 15% 1...
Remember that exercise?
 Figure up :
 <15% of total blood volume – Class 1 shock
 15%- 30% of total blood volume – Clas...
Now do the same for a
child….
 TBW in KG
 TBV = 8% x Body Weight
(kg).
 10% of total blood
volume
 15% of total blood
...
COMMON SOLUTIONS
PURPOSE:
 Four major indications for IV access:
 Replace fluids
 Administer Blood Products
 Route for administration o...
Question?
 What is Bioavailability?
 What is the considered “Onset” of bioavailability of
medications administered via t...
IV Solutions
 Solutions are comprised of fluid (the solvent) and
particles (the solute) dissolved in the fluid.
 Water i...
CLASSES OF IV FLUIDS:
 Colloids:
 High molecular
weight
 Proteins that do
not diffuse across
the CM
 Colloid osmotic
p...
Other Methods of Classification
HYPOTONICFLUIDS ISOTIONICFLUIDS HYPERTONICFLUIDS
IVFLUIDS
Key Point:
 Osmolarity and Tonicity
 The “Tonicity”: mainly refers to the Sodium and
Dextrose content
ISOTONIC FLUIDS
 Electrolyte composition
is similar to plasma
 When administered to
normally hydrated
patient, there is ...
HYPERTONIC FLUIDS
 Higher solute level than
plasma
 Cause fluid to shift from IC
to EC space
Hypotonic Fluids
 Lower solute level than
plasma
 Cause fluid to shift from
Extracellular to Intracellular
and Interstic...
LACTATED RINGER’S SOLUTION /
HARTMANN’S SOLUTION
 Class:
 Isotonic crystalloid
 Description:
 One of the most frequent...
LACTATED RINGER’S SOLUTION /
HARTMANN’S SOLUTION
 Indications:
 Hypovolemia/KVO
 Contraindications:
 CHF, renal failur...
0.9 PERCENT SODIUM
CHLORIDE / NORMAL
SALINE Class:
 Isotonic crystalloid solution
 Description:
 Concentration of sodi...
0.9 PERCENT SODIUM CHLORIDE /
NORMAL SALINE
 Indications:
 Heat problems
 Freshwater drowning
 Hypovolemia
 DKA
 KVO
5% Dextrose in .9% Sodium
Chloride (D5NS)
 Class:
 Hypertonic crystalloid
 Indications:
 Heat disorders, freshwater
dr...
5% Dextrose in Lactated Ringer’s
Solution (D5LR)
 Class:
 Hypertonic crystalloid
 Indications:
 Hypovolemia
 Hemorrha...
While we are talking about IV
fluids….
 From our friends in the military:
 Hetastarch
 Colloid
 Big Bang in a small pa...
Common IV equipment
Main routs of Vascular
Access
 Peripheral Lines Include:
 Hands
 Feet
 External Jugulars
 Central Lines Include:
 Fe...
A lot of changes…
 What we do now:
 Single Lumen Catheters
 Twin Catheters
 Central Lines
 Intraosseous:
 EZ-IO
 Pe...
Single Lumen IVs
 Traditional
 Quick
 Good for 24-72 hours
Multi-Lumen IVs
 Two (or more) lines in
one IV site
 Able to give multiple
medications that are
not compatible
 Very us...
Peripheral IV Access Sites
Packaging of IV Fluids
 Most packaged in soft plastic or vinyl bags.
 Container provides important information:
 Label ...
IV Solution
Containers
Do not use:
any IV fluids after their expiration date;
any fluids that appear cloudy, discolored, or laced with particulat...
Just because there is no red
writing does not mean its
“safe” to give!
IV Administration Sets
 Macrodrip—10 gtts = 1 ml, for giving large
amounts of fluid.
 Microdrip—60 gtts = 1 ml, for rest...
 IV extension tubing—extends original tubing.
 Electromechanical pump tubing—specific for each pump.
 Miscellaneous—som...
Macrodrip and Microdrip Administration Sets
Secondary IV Administration Set
Measured Volume Administration Set
Intravenous Cannulas
 Over-the-needle catheter
 Hollow-needle catheter
 Plastic catheter inserted through a hollow need...
Over-the-Needle Catheter
Hollow-Needle Catheter
Catheter Inserted Through the Needle
Peripheral IV Access
Place the constricting band
Cleanse the venipuncture site
Insert the intravenous cannula into the
vein.
Withdraw any blood samples needed.
Connect the IV tubing.
Secure the site.
Label the IV solution bag.
IV Access Complications
 Pain
 Local infection
 Pyrogenic reaction
 Catheter shear
 Inadvertent arterial
puncture
 C...
Intraosseous
A lot of changes…
 What we do now:
 Single Lumen Catheters
 Twin Catheters
 Central Lines
 What is coming:
 EZ-IO
Single Lumen IVs
 Traditional
 Quick
 Good for 24-72 hours
Multi-Lumen IVs
 Two (or more) lines in
one IV site
 Able to give multiple
medications that are
not compatible
 Very us...
Central Lines
 Better Access
 More complications
 More difficult
 Infection
 Compressible??
Intraosseous
 A rigid needle is inserted into the cavity of a long
bone.
 Used for critical situations when a peripheral...
Intraosseous
 Vasculature always
there, even in shock
 Less difficulty than
Central lines
 Only good for 24
hours
 Eas...
Traditional IO (Pediatric)
Traditional Intraosseous Needle
Traditional Intraosseous
Needle
Not so traditional …
EZ IO
IO Indications….
A life or limb threatening condition exists.
 -Severe Volume depletion (dehydration or
hemorrhage)
 -Ci...
IO placement – All types
https://www.youtube.com/watch?v=0roDPk-
VpAo&feature=player_embedded
6 Common mistakes with IO
https://www.youtube.com/watch?v=YXfyL8kvFTg&feature=player_embedded
Central venous Access
JUST AN FYI BIT…
Some other kinds of vascular
access you will see in the
field…
 Central Lines
 PICC Line
 IVADD (Port-o-Caths)
Central Lines
 Better Access
 More complications
 More difficult
 Infection
 Compressible??
PICC
 “Peripherally inserted
central catheter”
 Can be single or multi
lumen.
 Used for extended home
TPN
 Home health...
IVADs
 Portacath-Inserted in the
chest below the
clavicle.Access is gained
by puncturing the skin
then the synthetic port...
IVAD
Can AEMTs access Central
Venus devices?
 In short: no…
 Key Concerns:
 Sterile Technique
 Heparin in line
 Damage to ...
Aterial-Venous Fistula’s
 A fistula is defined as an abnormal opening between
body parts. In the case of an arterio-venou...
Injections
Routes of Medication Administration
Parenteral medication: administration of a
medication by injection into body tissues
S...
What is an injection?
Injections are sterile solutions,
emulsions or suspensions.
They are prepared by dissolving,
emulsif...
How are drugs for injections presented?
Single dose preparations
a pre - prepared volume of measured drug, in a
syringe fo...
Why give drugs in injection form?
Injections usually allow rapid absorption
Can produce blood levels comparable to those
o...
Needle length and size
For intramuscular injections e.g flu, pneumonia
and B12, the needle should be long enough to
penetr...
Syringes
 Three main parts:
– Barrel – chamber that holds the medication
– Plunger – part within the barrel that moves ba...
Needles
 Shaft of the needle
– Length chosen depends on the depth to
which medication will be instilled
– Tip of shaft is...
Considerations when choosing a syringe
and needle
 Type of medication
 Depth of tissue penetration required
 Volume of ...
Parenteral Administration
 Equipment
 Syringes
 Syringe consists of a barrel, a plunger, and a tip.
 Outside of the ba...
Parts of a syringe
Parts of a syringe.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clin...
Dose?
Calibration of U100 insulin syringe.
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th e...
Dose?
Reading the calibrations of a 3-mL syringe.
TB Syringe
Safety-Glide syringe.
The pointy end
Parts of a needle.
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. ...
Equipment for the administration of injections
Clean tray/area in which to place drug and equipment
21g needle to ease rec...
Asepsis and reducing the risk of infection
Good hand washing
Good hand drying
Aseptic technique
Good observation and quest...
INTRADERMAL INJECTIONS
INTRADERMAL INJECTIONS
 Most often used for PPD
 Site: the inner aspect of the forearm
 Needle size is 25 - 27 gauge, 1...
 Review the provider’s order for accuracy
 Ask the patient/parent if the patient is allergic to the
medication
 Wash yo...
 Explain procedure to patient/parent
 Ask for assistance with children
 Position patient appropriately
 Prepare inject...
 Inject medication gently, place a cotton ball over the
site after needle removal
 A visual wheal will be produced at th...
INTRADERMAL INJECTIONS
Correct Technique
 Tip of needle can be seen
directly beneath the surface of
the skin
 Resistance...
Subcutaneous
injection
SQ Injections
 Many immunizations are given SQ
 Insulin and Lovinox are some of the most common
drugs in the subcutaneou...
Sites for SQ Administration
SUBCUTANEOUS INJECTION
Subcutaneous injection. Angle and needle length depend on the
thickness of skinfold.
(From Elkin, M...
INTRAMUSCULAR
INJECTION
IM Injections
 Surprisingly common in EMS
 EPI IM for anaphylaxis
 Most other auto injectors are IM
 Other meds when I...
Intramuscular injections
 Gauge-20-22
 Length-1-1 ½ inches
 Angle-90 degrees
 Darting motion
 ASPIRATE
Intramuscular injections
 Intramuscular Injections
 Involves inserting a needle into the muscle tissue to administer
med...
INTRAMUSCULAR INJECTION
IM INJECTION SITES
 Deltoid
 Up to 2 ml
 Dorsogluteal
 Up to 3 ml
 Ventrogluteal
 Up to 2 ml
 Vastus lateralis
 Up...
DELTOID MUSCLE
GLUTEUS MAXIMUS
Locating right dorsogluteal site. Giving IM
injection in left dorsogluteal site.
(C, D, from Elkin, M.K., Perry, A.G., Pot...
GLUTEUS MEDIUS
Locating IM injection for ventrogluteal
site.
(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing intervention...
VASTUS LATERALIS
Giving IM injection in vastus lateralis site on
adult.
Giving IM injection in vastus lateralis site on adult.
(C, from Elk...
Intramuscular Injections and Pain
The needle
The technique
The speed of the injection
The solution and composition of the ...
Comparison of ID, SQ and
IM
Angles of insertion for intramuscular (90°), subcutaneous (45°), and
intradermal (15°).
(From ...
QUESTIONS?
THANK
YOU!
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
2014 AEMT introduction to IV administration and MED administration
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2014 AEMT introduction to IV administration and MED administration

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Introduction to IV administration and MED administration for Advanced EMT students and Early paramedic Students. Several good videos are inbedded as well.

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2014 AEMT introduction to IV administration and MED administration

  1. 1. Ada County Paramedics Educational Outreach VASCULAR ACCESS UPDATE Advanced EMT introduction to Vascular Access
  2. 2. Objectives  Describe the basic distribution of fluids in the body  Discuss the basic role of Vascular access in EMS  Identify the main types of IV solutions encountered by EMS  Identify the basic equipment used by EMS to establish IV and IO access.
  3. 3. Basic Physiology of Fluid
  4. 4. KEY POINT:  We will actually go into a LOT of detail on fluids and shock later in the ..FLUIDS and SHOCK Lecture.  
  5. 5. Water…Its good for you!  Total Body Water (TBW): approx. 60-70% of total body mass.  Higher the younger you are
  6. 6. Quick Exercise  Did you know that 1 kg of water = 1 liter of water?  What is your weight in Kg?  Weight in Kg x 0.6 = estimated TB H2O in liters
  7. 7. Distribution of Fluids  Intracellular Fluid (ICF): The amount of water that’s inside our cells accounts for 2/3rds of our TBW.  Extracellular Fluid (ECF): The amount of water that surrounds our cells accounts for 1/3 of our TBW. ECF is also known as interstitial fluid because it’s the fluid in between the cells.  Mnemonic to help you remember which is 1/3rd and 2/3rd: ECF and ICF. E comes before I in the alphabet, so E is 1/3rd and I is 2/3rd.  ICF = 2/3 X TBW. For example, 2/3 x 41L = 27L ECF = 1/3 X TBW. For example, 1/3 x 41L = 14L
  8. 8. Distribution of fluids
  9. 9. Extracellular Fluids  ECF is also known as interstitial fluid because it’s the fluid in between the cells.  Sometimes called the “third Space”  Tissue fluid: 2/3rd of ECF  Blood plasma: 1/3rd of ECF  Transcellular fluid: Often not calculated as a fraction of the extracellular fluid, but it is about 2.5% of TBW.
  10. 10. How much blood?  Blood is made up of blood cells and blood plasma.  TBV = 8% x Body Weight (kg).  Remember, we can calculate volume from mass without a problem because that’s the beauty of the metric system (1.0kg water = 1.0L water)
  11. 11. Another quick exercise  Normally about 20% blood loss is an indication for IV fluid resuscitation (in addition to other indicators of shock, like your vital signs).  So take 8% of your TBW… That’s your total blood volume.  Figure up :  10% of total blood volume  15% of total blood volume  30% of total blood volume  40% of total blood volume
  12. 12. Class I Class II Class III Class IV Blood Loss (ml) Up to 750 750-1500 1500-2000 2000 or more Blood Loss (%BV) Up to 15% 15-30% 30-40% >40% HR 100 100 120 140 and up BP Normal Normal Decreased Decreased PP (mmhg) Normal-inc. Decreased Decreased Decreased Refill Normal Positive Positive Positive RR 14-20 20-30 30-40 >40 Urine OP ml/hr 30ml 20-30 5-15 Negligible CNS Slightly anxious Mildly anxious Anxious & confused Confused- lethargic Fluid replacement 3:1 Crystalloid Crystalloid Crystalloid & Blood Crystalloid & Blood Emergency War Surgery, NATO Handbook: part II
  13. 13. Remember that exercise?  Figure up :  <15% of total blood volume – Class 1 shock  15%- 30% of total blood volume – Class II Shock  30% - 40% of total blood volume – Class III Shock  > 40% of total blood volume – Class IV Shock
  14. 14. Now do the same for a child….  TBW in KG  TBV = 8% x Body Weight (kg).  10% of total blood volume  15% of total blood volume  30% of total blood volume  40% of total blood volume Ridley – 30 Pounds
  15. 15. COMMON SOLUTIONS
  16. 16. PURPOSE:  Four major indications for IV access:  Replace fluids  Administer Blood Products  Route for administration of medications  Anticipated need for any of above
  17. 17. Question?  What is Bioavailability?  What is the considered “Onset” of bioavailability of medications administered via the IV route?  What is the % of bioavailability of medications administered via the IV route?
  18. 18. IV Solutions  Solutions are comprised of fluid (the solvent) and particles (the solute) dissolved in the fluid.  Water is the body's primary fluid and is essential for proper organ system functioning and survival. Although people can live several weeks without food, they can survive only a few days without water.
  19. 19. CLASSES OF IV FLUIDS:  Colloids:  High molecular weight  Proteins that do not diffuse across the CM  Colloid osmotic pressure  Volume expanders  $$$$ and short shelf life  Crystalloids:  Water and electrolytes  The electrolytes will readily diffuse across from the vascular space into the tissues  Used is pre- hospital environment
  20. 20. Other Methods of Classification HYPOTONICFLUIDS ISOTIONICFLUIDS HYPERTONICFLUIDS IVFLUIDS
  21. 21. Key Point:  Osmolarity and Tonicity  The “Tonicity”: mainly refers to the Sodium and Dextrose content
  22. 22. ISOTONIC FLUIDS  Electrolyte composition is similar to plasma  When administered to normally hydrated patient, there is no appreciable fluid or electrolyte shift
  23. 23. HYPERTONIC FLUIDS  Higher solute level than plasma  Cause fluid to shift from IC to EC space
  24. 24. Hypotonic Fluids  Lower solute level than plasma  Cause fluid to shift from Extracellular to Intracellular and Intersticial space
  25. 25. LACTATED RINGER’S SOLUTION / HARTMANN’S SOLUTION  Class:  Isotonic crystalloid  Description:  One of the most frequently used IV fluids in hypovolemic shock.  Contains:  Sodium (Na+) 130 mEq/L  Potassium (K +) 4 mEq/L  Calcium (Ca2+) 3 mEq/L  Chloride (Cl-) 109 mEq/L  Lactate (Lactic acid) 28 mEq/L
  26. 26. LACTATED RINGER’S SOLUTION / HARTMANN’S SOLUTION  Indications:  Hypovolemia/KVO  Contraindications:  CHF, renal failure  Administration:  Crystalloids diffuse out of the vascular space in <1hr. 3:1 ratio
  27. 27. 0.9 PERCENT SODIUM CHLORIDE / NORMAL SALINE Class:  Isotonic crystalloid solution  Description:  Concentration of sodium is near that of blood  Contains:  Sodium (Na+) 154 mEq/L  Chloride (Cl-) 154 mEq/L
  28. 28. 0.9 PERCENT SODIUM CHLORIDE / NORMAL SALINE  Indications:  Heat problems  Freshwater drowning  Hypovolemia  DKA  KVO
  29. 29. 5% Dextrose in .9% Sodium Chloride (D5NS)  Class:  Hypertonic crystalloid  Indications:  Heat disorders, freshwater drowning, hypovolemia, peritonitis  Cautions:  May cause venous irritation
  30. 30. 5% Dextrose in Lactated Ringer’s Solution (D5LR)  Class:  Hypertonic crystalloid  Indications:  Hypovolemia  Hemorrhagic shock  Some cases of acidosis
  31. 31. While we are talking about IV fluids….  From our friends in the military:  Hetastarch  Colloid  Big Bang in a small package  “Colloid Pulling Power”  Hypertonic Saline  Crystalloid  “Pulls Fluid” Osmotic Pulling Power
  32. 32. Common IV equipment
  33. 33. Main routs of Vascular Access  Peripheral Lines Include:  Hands  Feet  External Jugulars  Central Lines Include:  Femoral (Groin)  Internal Jugular (neck)  Subclavian  Intraosseous  Tib/Fib  Ankle  Sternum  Humerous
  34. 34. A lot of changes…  What we do now:  Single Lumen Catheters  Twin Catheters  Central Lines  Intraosseous:  EZ-IO  Pediatric / manual IO
  35. 35. Single Lumen IVs  Traditional  Quick  Good for 24-72 hours
  36. 36. Multi-Lumen IVs  Two (or more) lines in one IV site  Able to give multiple medications that are not compatible  Very useful in STEMI and Acute CVA patients
  37. 37. Peripheral IV Access Sites
  38. 38. Packaging of IV Fluids  Most packaged in soft plastic or vinyl bags.  Container provides important information:  Label lists fluid type and expiration date.  Medication administration port.  Administration set port.
  39. 39. IV Solution Containers
  40. 40. Do not use: any IV fluids after their expiration date; any fluids that appear cloudy, discolored, or laced with particulate; or any fluid whose sealed packaging has been opened or tampered with; Any fluids with red writing on the package
  41. 41. Just because there is no red writing does not mean its “safe” to give!
  42. 42. IV Administration Sets  Macrodrip—10 gtts = 1 ml, for giving large amounts of fluid.  Microdrip—60 gtts = 1 ml, for restricting amounts of fluid.  Blood tubing—has a filter to prevent clots from blood products from entering the body.  Measured volume—delivers specific volumes of fluids.
  43. 43.  IV extension tubing—extends original tubing.  Electromechanical pump tubing—specific for each pump.  Miscellaneous—some sets have a dial that can set the flow rates. IV Administration Sets (continued)
  44. 44. Macrodrip and Microdrip Administration Sets
  45. 45. Secondary IV Administration Set
  46. 46. Measured Volume Administration Set
  47. 47. Intravenous Cannulas  Over-the-needle catheter  Hollow-needle catheter  Plastic catheter inserted through a hollow needle
  48. 48. Over-the-Needle Catheter
  49. 49. Hollow-Needle Catheter
  50. 50. Catheter Inserted Through the Needle
  51. 51. Peripheral IV Access
  52. 52. Place the constricting band
  53. 53. Cleanse the venipuncture site
  54. 54. Insert the intravenous cannula into the vein.
  55. 55. Withdraw any blood samples needed.
  56. 56. Connect the IV tubing.
  57. 57. Secure the site.
  58. 58. Label the IV solution bag.
  59. 59. IV Access Complications  Pain  Local infection  Pyrogenic reaction  Catheter shear  Inadvertent arterial puncture  Circulatory overload  Thrombophlebitis  Thrombus formation  Air embolism  Necrosis  Anticoagulants
  60. 60. Intraosseous
  61. 61. A lot of changes…  What we do now:  Single Lumen Catheters  Twin Catheters  Central Lines  What is coming:  EZ-IO
  62. 62. Single Lumen IVs  Traditional  Quick  Good for 24-72 hours
  63. 63. Multi-Lumen IVs  Two (or more) lines in one IV site  Able to give multiple medications that are not compatible  Very useful in STEMI and Acute CVA patients
  64. 64. Central Lines  Better Access  More complications  More difficult  Infection  Compressible??
  65. 65. Intraosseous  A rigid needle is inserted into the cavity of a long bone.  Used for critical situations when a peripheral IV is unable to be obtained.  Typically initiated after 90 seconds or 2-3 unsuccessful IV attempts
  66. 66. Intraosseous  Vasculature always there, even in shock  Less difficulty than Central lines  Only good for 24 hours  Easier to train  More costly
  67. 67. Traditional IO (Pediatric)
  68. 68. Traditional Intraosseous Needle
  69. 69. Traditional Intraosseous Needle
  70. 70. Not so traditional …
  71. 71. EZ IO
  72. 72. IO Indications…. A life or limb threatening condition exists.  -Severe Volume depletion (dehydration or hemorrhage)  -Circulatory collapse  -Cardiac arrest  -Medication route if no other access is available  A peripheral IV cannot or is unlikely to be established.  Delay in administration of fluids or medications may increase risk to the patient.
  73. 73. IO placement – All types https://www.youtube.com/watch?v=0roDPk- VpAo&feature=player_embedded
  74. 74. 6 Common mistakes with IO https://www.youtube.com/watch?v=YXfyL8kvFTg&feature=player_embedded
  75. 75. Central venous Access JUST AN FYI BIT…
  76. 76. Some other kinds of vascular access you will see in the field…  Central Lines  PICC Line  IVADD (Port-o-Caths)
  77. 77. Central Lines  Better Access  More complications  More difficult  Infection  Compressible??
  78. 78. PICC  “Peripherally inserted central catheter”  Can be single or multi lumen.  Used for extended home TPN  Home health care use  Administration of meds and fluids  Used when repeated IV sticks would be necessary
  79. 79. IVADs  Portacath-Inserted in the chest below the clavicle.Access is gained by puncturing the skin then the synthetic port  Permacath-Lasts longer.Up to a year  Passport-Placed in the arm instead of chest.Cheapest
  80. 80. IVAD
  81. 81. Can AEMTs access Central Venus devices?  In short: no…  Key Concerns:  Sterile Technique  Heparin in line  Damage to the CV device  Specialized equipment.
  82. 82. Aterial-Venous Fistula’s  A fistula is defined as an abnormal opening between body parts. In the case of an arterio-venous fistula (AVF), a surgeon creates a passageway or merge between an artery and vein, thereby allowing for an easier target vein to use for access.  Most commonly used for dialysis patients
  83. 83. Injections
  84. 84. Routes of Medication Administration Parenteral medication: administration of a medication by injection into body tissues Subcutaneous (SC) – into tissue below dermis of skin Intramuscular (IM) – into the body muscle Intravenous (IV) – into a vein Intradermal (ID)– into the dermis just under the epidermis
  85. 85. What is an injection? Injections are sterile solutions, emulsions or suspensions. They are prepared by dissolving, emulsifying or suspending an active ingredient and any other substances in water for injection. Injecting is the act of giving medication by use of syringe and needle to obtain the desired therapeutic effect taking into account the patients safety and comfort
  86. 86. How are drugs for injections presented? Single dose preparations a pre - prepared volume of measured drug, in a syringe for single dose use i.e. Flu vaccines, Pneumovax and B12. Multidose preparations multi-dose preparations contain a antimicrobiacteral preservative, are used on more than the one occasion and great care is required for its administration but especially it’s storage between successive withdrawals i.e Insulin
  87. 87. Why give drugs in injection form? Injections usually allow rapid absorption Can produce blood levels comparable to those of intravenous bolus injections Injections can be given from 1ml and up to 2 mils in the Deltoid and up to 3 mls in the gluteal muscle in adults Drugs that are altered or not absorbed by other methods of administration
  88. 88. Needle length and size For intramuscular injections e.g flu, pneumonia and B12, the needle should be long enough to penetrate the muscle and still allow a quarter of the needle to remain external to the skin When choosing the needle it is important to assess the amount of muscle, subcutaneous fat and weight of the patient - which in the majority of cases will be a blue needle
  89. 89. Syringes  Three main parts: – Barrel – chamber that holds the medication – Plunger – part within the barrel that moves back and forth to withdraw and instill medication – Tip – part that the needle is attached to  Calibration: – Syringe sizes from 1 ml to 50 ml – Measure to a 1/10th or 1/100th depending on calibration
  90. 90. Needles  Shaft of the needle – Length chosen depends on the depth to which medication will be instilled – Tip of shaft is beveled or slanted to pierce the skin more easily  Gauge: width of the needle (18 – 27 gauge) – a smaller number indicates a larger diameter and larger lumen inside the needle
  91. 91. Considerations when choosing a syringe and needle  Type of medication  Depth of tissue penetration required  Volume of medication  Viscosity of medication  Size of the client
  92. 92. Parenteral Administration  Equipment  Syringes  Syringe consists of a barrel, a plunger, and a tip.  Outside of the barrel is calibrated in milliliters, minims, insulin units, and heparin units.  Types  Tuberculin syringe  Insulin syringe  Three-milliliter syringe  Safety-Lok syringes  Disposable injection units
  93. 93. Parts of a syringe Parts of a syringe. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
  94. 94. Dose? Calibration of U100 insulin syringe. (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
  95. 95. Dose? Reading the calibrations of a 3-mL syringe.
  96. 96. TB Syringe Safety-Glide syringe.
  97. 97. The pointy end Parts of a needle. (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
  98. 98. Equipment for the administration of injections Clean tray/area in which to place drug and equipment 21g needle to ease reconstitution and drawing up (Filter Straw if from a glass ampoule Syringe of appropriate size Swabs saturated with isopropyl alcohol 70% Sterile topical swab if drug is presented in ampoule form Drug to be administered Patients prescription to check dose, route and timing Notes available to record administration in accordance with law Gloves
  99. 99. Asepsis and reducing the risk of infection Good hand washing Good hand drying Aseptic technique Good observation and questioning of the client Skin preparation if required
  100. 100. INTRADERMAL INJECTIONS
  101. 101. INTRADERMAL INJECTIONS  Most often used for PPD  Site: the inner aspect of the forearm  Needle size is 25 - 27 gauge, 1/2 to 5/8 inch  Insert needle at 15o angle  Injection made just below the outer layer of skin  If injection does not form a wheal or if bleeding is noted, the injection was probably too deep and should be repeated
  102. 102.  Review the provider’s order for accuracy  Ask the patient/parent if the patient is allergic to the medication  Wash your hands and gather supplies, equipment  Select proper needle size, length and gauge INTRADERMAL INJECTIONS
  103. 103.  Explain procedure to patient/parent  Ask for assistance with children  Position patient appropriately  Prepare injection site with alcohol - air dry  Support skin with thumb  With bevel up, completely insert bevel at a 15 o angle INTRADERMAL INJECTIONS
  104. 104.  Inject medication gently, place a cotton ball over the site after needle removal  A visual wheal will be produced at the site  Dispose of needle as per policy  Wash hands  Document procedure and patient’s response INTRADERMAL INJECTIONS
  105. 105. INTRADERMAL INJECTIONS Correct Technique  Tip of needle can be seen directly beneath the surface of the skin  Resistance should be felt when medication is injected  Tense white wheal 5-10 mm in diameter appears at the point of the needle Incorrect Technique  Little resistance and a shallow bulge  Needle inserted too deep - will cause an induration that is difficult to measure and interpret
  106. 106. Subcutaneous injection
  107. 107. SQ Injections  Many immunizations are given SQ  Insulin and Lovinox are some of the most common drugs in the subcutaneous injections for clinical use  Epi and Brethine used to be the most common in EMS  SQ is seldom used anymore in EMS  IM is believed to be more reliable in critical patients due to poor perfusion of SQ space.
  108. 108. Sites for SQ Administration
  109. 109. SUBCUTANEOUS INJECTION Subcutaneous injection. Angle and needle length depend on the thickness of skinfold. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
  110. 110. INTRAMUSCULAR INJECTION
  111. 111. IM Injections  Surprisingly common in EMS  EPI IM for anaphylaxis  Most other auto injectors are IM  Other meds when IV access is not practical (and IO is not practical , desirable , or available)  Narcan  Anti-emetics  Pain meds  Anti-convulsants
  112. 112. Intramuscular injections  Gauge-20-22  Length-1-1 ½ inches  Angle-90 degrees  Darting motion  ASPIRATE
  113. 113. Intramuscular injections  Intramuscular Injections  Involves inserting a needle into the muscle tissue to administer medication  Site Selection  Gluteal sites  Vastus lateralis muscle  Rectus femoris muscle  Deltoid muscle  Z-track Method  Used to inject medications that are irritating to the tissues
  114. 114. INTRAMUSCULAR INJECTION
  115. 115. IM INJECTION SITES  Deltoid  Up to 2 ml  Dorsogluteal  Up to 3 ml  Ventrogluteal  Up to 2 ml  Vastus lateralis  Up to 3 ml
  116. 116. DELTOID MUSCLE
  117. 117. GLUTEUS MAXIMUS
  118. 118. Locating right dorsogluteal site. Giving IM injection in left dorsogluteal site. (C, D, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
  119. 119. GLUTEUS MEDIUS
  120. 120. Locating IM injection for ventrogluteal site. (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
  121. 121. VASTUS LATERALIS
  122. 122. Giving IM injection in vastus lateralis site on adult. Giving IM injection in vastus lateralis site on adult. (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
  123. 123. Intramuscular Injections and Pain The needle The technique The speed of the injection The solution and composition of the drug The volume of the drug The approach and attitude of person administering the injection
  124. 124. Comparison of ID, SQ and IM Angles of insertion for intramuscular (90°), subcutaneous (45°), and intradermal (15°). (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
  125. 125. QUESTIONS?
  126. 126. THANK YOU!

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