Upcoming SlideShare
×

965 views

Published on

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

2 Likes
Statistics
Notes
• Full Name
Comment goes here.

Are you sure you want to Yes No
• Be the first to comment

Views
Total views
965
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
36
0
Likes
2
Embeds 0
No embeds

No notes for slide

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
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
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
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!