Intravenous Therapy

1. Intravenous Therapy 7 4

2. Thirty years ago… • Rampart, Squad 51. • We have a 20 year old male motorcycle rider involved in a motor vehicle collision complaining of neck, back and leg pain. • He presents with compound fractures to both femurs and has significant blood loss. • We are requesting an order for two large bore IV’s and Ringer’s Lactate.

3. Objectives • Identify the reasons IV therapy is performed in the prehospital setting • Identify the fluids commonly administered • State the basis of fluid and electrolyte balance • Identify factors affecting water loss • Explain the recommended uses of IV solutions • Identify common complications and reactions • Calculate a flow rate • Demonstrate proper skin cleansing and aseptic venipuncture technique • Demonstrate proper IV cannulation technique

4. Why do we cannulate? • Fluid administration • Medication administration • To maintain life (electrolytes, blood…) • Do we do them to be EHSNS protocol compliant?

5. IV fluids • Normal saline (0.9% NS) • Lactated Ringer’s (LR) • Also known as Hartman’s solution or RL • D5W • ½ NS • D5 ½ NS • D5RL (D5LR)

6. Characteristics Same tonicity as plasma Osmotic pressure is the same as the inside of the cell Fluid never leaves or enters the cell Approximate osmolarity is 240 – 340 mOsm/L Will increase circulating volume, which may lead to fluid volume excess or overload. Solutions 2.5% dextrose/0.45% NaCl 0.9% NaCl Lactated Ringers 2.5% dextrose in ½ lactated ringers 6% dextan and 0.9% NaCl 10% dextran and 0.9% NaCl Isotonic Solutions

7. Normal Saline • Most commonly administered IV fluid prehospitally • IV fluid of choice for EHSNS protocols • Why?

8. Lactated Ringers • Composed of multiple electrolytes in saline • Has fallen out of favor as one of main IV fluids for treatment of traumatic hypovolemia in past decade • Why?

9. Characteristics May cause blood cells to swell and burst May cause changes or damage endothelial cells Exert less osmotic pressure than the fluid in the extracellular compartment Fluid is drawn into the cells Approximate osmolarity < 240 mOsm/l Solutions 0.45% NaCl 10% dextran and 5% dextrose (slightly hypotonic) Hypotonic Solutions

10. Characteristics May cause blood cells to shrink May cause dame/changes to endothelial cells Exert more osmotic pressure then the extracellular fluid Fluid is drawn from the cell into the vascular space Approximate osmolarity > 340 mOsm/l Solutions 5% dextrose/0.2% NaCl 5% dextrose/0.9% NaCl D5W D10W D50W 5% NaHCO3 10%, 15% and 20% Mannitol 6% dextran and 0.9% NaCl Hypertonic Solutions

11. Administration Sets • The calibration of the administration set must be known in order to calculate the flow of the IV fluids correctly. • Macrodrip sets • 10, 15 or 20 gtts/ml • Microdrip (minidrip) • 60 gtts/ml

12. Where do we cannulate? • Hand • Forearm • Neck • Foot

13. Equipment Required • Solution • Administration set • IV cannula • Tourniquet • Alcohol swab • Gloves • Sharps bin • Op site and gauze • Tape • If performing a Lock • Lock, syringe and saline

14. Catheter specifics Color Size Int Dia/Length Max Flow Grey 16 G 1.4 mm/45 mm 180 mls/min Green 18 G 1.0 mm/45 mm 80 mls/min Pink 20 G 0.8 mm/32 mm 54 mls/min Blue 22 G 0.6 mm/25 mm 31 mls/min • The length and diameter will affect the amount of fluid able to be infused through the catheter • Larger diameter and shorter length gives more fluid • Small diameter and long length gives less fluid

15. Types of catheters • Jelco • Cathelon • Insyte

16. Types of catheters • Protective • Protective Plus

17. Administration Sets • 10 gtts/ml • 15 gtts/ml • 60 gtts/ml • Blood sets

18. Vein Selection • Based on: • Condition • Palpate to confirm type of vessel • Should be soft and spongy • Straight with no turns or bumps • Location • Is the pt right or left handed • Is the extremity injured • Avoid joints (stabilization) • Does the pt have a shunt (fistula) • Purpose • Fluid replacement, Medication route, Safety line (lock) • Dictates flow rate and type of fluid to be infused • Try to use large veins for large quantities of fluid • Duration • What type of patient (trauma, cardiac or outpatient) • Patient comfort over long period of time • Prolonged therapy may require multiple punctures • For long durations use distal veins first

19. Fluid Replacement • Blood • Replaced at a ratio of 3:1 of IV fluid to blood being replaced • Minimum daily requirements • 1st 10 kg 100 ml/hr • 2nd 10 kg 50 ml/hr • 3rd 10 kg 20 ml/hr • 4th 10 kg 10 ml/hr • 5th 10 kg 10 ml/hr • Example 50 kg patient • 100 ml/hr + 50 ml/hr + 20 ml/hr + 10 ml/hr + 10 ml/hr = 190 ml/hr

20. Contraindications • Distal to a fracture site in a limb • Through damaged or abraded skin • Burns may be an exception if there is no other accessible site • In an arm affected by a radical mastectomy, edema, blood clot or infection • In an arm with a fistula for dialysis or a peripherally inserted control catheter (PICC Line)

21. Procedure • Obtain consent and explain rationale for IV therapy • Assess that the pt meets the criteria for the procedure • Ensure that there are no contraindications for the procedure • Observe universal precautions for body substance exposures • Prepare all necessary equipment • Position the patient • Apply a tourniquet 3 – 5 inches above the selected site • Patient may make a fist to assist in engorging the vein • Select the most appropriate venipuncture site • Condition • Location • Purpose • Duration • Prepare the pt’s arm using alcohol swab

22. Procedure • Insert needle through skin • Should be at an 30° angle • Lower angle (15°)and enter vein • Observe flashback • Enter vein a ‘little bit more’ • Enter catheter into vein • Release tourniquet • Withdraw needle and discard in sharps container, tamponade the vein to avoid blood spill • Attach iv tubing and open flow valve observing for infiltration • Cover with Op site or other sterile dressing, tape in place

23. IV Access

24. Complications • Local complications • Hematomas • Infiltration • Necrosis • Thrombophlebitis • Systemic complications • Pulmonary edema • Speed shock • Pyrogenic reaction • Pulmonary embolism • blood • Air • Catheter shear

25. Causes: Symptoms: Preventative actions: Punctured vein Bruising Tenderness Swelling Proper techniques Local - Hematomas

26. Causes: Symptoms: Preventative actions: Poor insertion techniques Improper taping Over active patient IV slows or stops Swelling or hardness Feeling of coldness Leaking at the site Armboards, proper taping Routine checks of IV flow and site Local - Infiltration

27. Causes: Symptoms: Preventative actions: Irritation of tissues from infiltrated drug or fluid Swelling, tenderness Inflammation or bruising Routine checks Report any changes Local - Necrosis

28. Causes: Symptoms: Preventative actions: Trauma to endothelium from chemical means Pain, redness, swelling along infected vein Generalized symptoms such as fever, malaise, rapid pulse Avoid insertion over joint Select veins with adequate blood flow for infusions of hypertonic solutions Local - Thrombophlebitis

29. Causes: Symptoms: Preventative actions: Circulatory overload from too rapid infusion when patient has impaired renal or cardiac function JVD, ↑BP, ↑Resps, dyspnea, agitation Watch rate Oxygen, sit pt upright Slow IV and contact OLMC Systemic – Pulmonary Edema

30. Causes: Symptoms: Preventative actions: IV running to rapidly Rapid injection of a drug ↓BP, rapid pulse Labored resps, cyanosis Faint, ↓LOC Use controlled volume infusion set Upon initiation, ensure free flowing prior to rate adjustment Systemic – Speed Shock

31. Causes: Symptoms: Preventative actions: Contaminated IV solutions Symptoms generally occur after IV begun ↑temp, chills, headache, N/V, circulatory collapse Check IV fluids for cloudiness and particles Use fresh open IV’s Systemic – Pyrogenic Reaction

32. Causes: Symptoms: Preventative actions: Unfiltered blood Partially dissolved drug Particulate matter in IV solution Dyspnea, cyanosis, pain, anxiety, tachycardia, tachypnea Infuse blood through filter Dissolve drugs completely Use good judgment when syringing IV’s Systemic – PE (Blood/Embolus)

33. Causes: Symptoms: Preventative actions: Failure to clear tubing of air Allowing air to enter the system Cyanosis, ↓BP, weak, tachycardia, ↓LOC, non-specific chest or ABD pain Don’t let IV run dry Clear tubing properly Check syringe prior to injecting If occurs place pt on left side and contact OLMC Systemic – PE (Air)

34. Troubleshooting • If blood begins to flow back in the IV tubing • Check location of the bag to insure it is in a gravity flow location • Insure all valves are open • If continues, reassess site and assure arterial cannulation has not occurred • If your IV does not run… • Start at the top, work your way back to the patient • Is the bag empty? • Check the IV set clamps to insure they are open • Check tubing for kinks • Check site for any problems • Blood backing up • Infiltration • Do you need to flush the site • Is your tourniquet still one!

35. External Jugular (EJ) cannulation

36. EJ’s • Often used in severe cases of shock, unresponsiveness and cardiac arrest since they are HUGE and relatively easy to cannulate. • Why are they not commonly used in those who are conscious ? • Why are they not a good choice for patients of multi system trauma ?

37. EJ cannulation procedure • Place patient supine / slight reverse Trendelenburg • Why ??? • Turn patients head slightly to opposite side • Cleanse with antiseptic using universal precautions • Create tourniquet effect with fingers by applying light pressure to the inferior aspects of the EJ being cannulated.

38. Procedure • Aim needle towards ipsilateral nipple • Insert needle and enter vein • Observe flashback • Withdraw needle and attach IV tuning • Cover site with sterile dressing

39. EJ cannulation

40. Calculating flow rates Drip sets Factor 10 gtt/ml (macro) 10 drops = 1 ml 6 15 gtt/ml 15 drops = 1 ml 4 20 gtt/ml 20 drops = 1 ml 3 60 gtt/ml (micro) 60 drops = 1 ml 1 Volume to be administered (ml) X Drip set (gtts/ml) Drops/min (gtts/min) = Time to be infused (min)

41. Calculations • Your patient is to receive 1000 ml of normal saline (NS) over a 12 hour period using a microdrip (60 gtt/ml) administration set. The formula will now look like this: Volume to be administered (ml) X Drip set (gtts/ml) Drops/min (gtts/min) = Time to be infused (min) 1000 ml X 60 gtts/ml Drops/min (gtts/min) = 720 min Drops/min (gtts/min) 83.333 =

42. Now add medications • A physician orders 2 mg/min of Lidocaine to your patient. She orders 2 g of lidocaine to be added to 500 ml NaCL. Using a 60 gtt/ml set, calculate the gtt/min.

43. Calculation [ ] Mass Volume Dose D H X V = = X 500 ml 2.0 g 500 ml 2 mg/min 2000 mg = = 2000 mg 500 ml 1000 mgml/min 2000 mg = = 4 mg/ml 0.5 ml/min = =

44. Calculation Volume to be administered (ml) X Drip set (gtts/ml) Drops/min (gtts/min) = Time to be infused (min) 0.5 ml X 60 gtts/ml Drops/min (gtts/min) = 1 min Drops/min (gtts/min) 30 =

45. A Variation to the Same Volume (ml) X Ordered (mg/min) Drops/min (gtts/min) X Drip set (gtts/ml) = On Hand (mg) 500 ml X 2 mg/min Drops/min (gtts/min) X 60 gtt/ml = 200 mg Drops/min (gtts/min) 30 =