chapter 8: vascular access and medication administration Flashcards
medical asepsis
the practice of preventing contamination of the patient by using aseptic techniqie
aseptic technique
method of cleansing intended to prevent contamination of a site when performing an invasive procedure
vascular access
cannulation of a peripheral extremity vein
standing orders
a form of indirect medical control, in which the paramedic performs certain predefined procedures without any consultation
direct medical control
some EMS system medical directors may not allow paramedics to perform certain procedures before making contact with the medical director or a designated physician
sterile technique
the destruction of all living organisms and is achieved by using heat, gas, or chemicals
antiseptics
used to cleanse an area before performing an invasive procedure
the most common antiseptics are rubbing alcohol and iodine
disinfectants
toxic to living tissues, you should never use them on a patient
ex) virex, cidex, microside
the first rule of routine precautions
treat any body fluid as being potentially infectious
sharps
any contaminated item that can cause injury
total body water
constitutes 60% of the weight of an adult
intracellular fluid
the water contained inside the cells; 45% of body weight
extracellular fluid
the water outside the cells; 15% of body weight
interstitial fluid
the water bathing the cells; 10.5% of body weight
intravascular fluid
the water within the blood vessels, carries red blood cells, white blood cells and vital nutrients; ~4.5% of body weight
solvent
the fluid that does the dissolving
solute
the dissolved particles contained in the solvent
sodium
the principal extracellular cation needed to regulate the distribution of water throughout the body in the IV and interstitial fluid compartments
potassium
the principal intracellular cation, plays a major role in neuromuscular function and in the conversion of glucose into glycogen
calcium
principal cation needed for bone growth
magnesium
has an important role as a coenzyme in the metabolism of proteins and carbohydrates
bicarbonate
the primary buffer used in all circulating body fluids
bicarbonate levels are the determining factor between acidosis and alkalosis in the body
chloride
a primary determinant of stomach pH
it also regulates ECF levels.
phosphorous
an important component in adenosine triphosphate, the body’s powerful energy source
nonelectrolytes
solutes that have no electrical charge
diffusion
the process of particles moving from an area of higher concentration to an area of lower concentration along a concentration gradient
filtration
another type of diffusion commonly used by the kidneys to clean blood
antidiuretic hormone ADH
prevents the loss of water from the kidneys by causing its reabsorption into the tubules while the hormone aldosterone is responsible for sodium reabsorption
tonicity
the concentration of a solution or ability to draw or give water
osmosis
the movement of a solvent such as water from an area of low solute concentration to an area of high concentration through a selectively permeable membrane
homeostasis
the internal environments resistance to change
dehydration
inadequate total systematic fluid volume
overhydration
when the body’s total systemic fluid volume increases
3 basic types of IV solutions
crystalloids, colloids, blood products
crystalloid solution
dissolved crystals in water
- best choice for fluid replacement
- 3 to 1 replacement rule
isotonic solutions
- normal saline 0.9% sodium chloride - lactated ringer - d5W (5% dextrose in water) - has almost the same osmolarity as serum and other body fluids
hypotonic solutions
- osmolarity less than serum
- dilutes serum
- hydrate the cells
hypertonic solution
- osmolarity higher than serum
- stabilize blood pressure
- increase urine output
- reduce edema
- rarely used in prehospital setting
colloid solutions
- very high osmolarity
- reduce edema
oxygen- carrying solutions
- best fluid to replace lost blood is whole blood
- o- neg blood (universally compatible)
- synthetic blood substitutes
intravenous (IV)
within a vein
intravenous therapy
cannulation of a vein with a catheter to access the patients vascular system
(one of the most invasive techniques that you will perform)
two ports of an IV bag
- injection port
- access port
choosing a solution
- is the patients condition stable or critical
- does the patient need fluid replacement
- will the patient need medications
in the prehospital setting the choice of IV solution is usually limited to 2 isotonic crystalloids
- normal saline
- lactated ringer
administration set
moves fluid from the IV bag into the patients vascular system
2 primary sizes of administration sets
- microdrip set: allows 60 drops/mL (ideal for pediatrics)
- macrodrip: allows 10, 15, 20 drops/mL (best used for rapid fluid replacement)
preparing an administration set
- verify the expiry date of the solution
- check for solution clarity
- prepare to spike the bag
blood tubing
a macrodrip administration set that is designed to facilitate rapid fluid replacement by manual infusion of multiple IV bags or IV and blood replacement combinations
Volutrol
allows you to fill 100- OR 200- mL calibrated drip chamber with a specific amount of fluid and administer only that amount
choosing an IV site
- locate the vein section with the straightest appearance
- choose a vein that has a firm, round appearance, or is springy when palpated
- avoid areas where the vein crosses over joints
- avoid edematous extremities and any extremity with a dialysis fistula or on the side a mastectomy was done
- avoid areas of overlying cellulitis
(avoid valves, and rolling veins)
start distally, work proximally
criteria
- purpose of the IV
- age of the patients
- location of the IV
- available vessels for venipuncture
needle types
- over the needle catheters
a teflon catheter inserted over a hollow needle - butterfly catheters
a hollow, stainless steel with 2 plastic wings to facilitate its handling - through the needle catheters
plastic catheters inserted through a hollow needle
(rarely used in the prehospital setting
contaminated stick
when a paramedic punctures their own skin with the same catheter that was used to cannulate the vein of a patient
inserting the IV catheter
- each paramedic has a unique technique to insert an IV
- keep the beveled side of the catheter up
- maintain adequate distal traction of the vein
- apply a tourniquet above the site
- remove tourniquet after the IV insertion, obtain blood samples and attach the line
- have tape or securing devices ready
penrose drain
a blood pressure cuff; or in a pinch, a surgical hose
prep the site
- alcohol or iodine swab
- apply gentle downward or lateral traction
- clean the site with iodine first in a circular motion, starting with small circles and moving to larger circles
- use the alcohol to clean the iodine
insertion angle
45 degrees
- advance the catheter into the vein until the vein is pierced (flash of blood in the flash chamber)
inserting the IV catheter
- immediately drop the angle down 15 degrees
- advance the catheter a few more cms to ensure the catheter sheath is in the vein
- slide the sheath off the needle and into the vein
- apply pressure to the vein just proximal to the end of the indwelling catheter
- remove the needle
- dispose of it in the sharps container
securing the line
tape the area
- tear the tape before you start the IV
- double back the tubing
- cover the insertion site with sterile gauze
- avoid circumferential taping around the extremity
steps of changing an IV bag
- stop the flow of fluid
- prepare the new IV bag
- insert the piercing spike
- ensure that the drip chamber is appropriately filled
steps for discontinuing the IV line
- shut off the flow
- peel back the tape toward the IV site
- stabilize the catheter while you loosen the tape
- do not remove the IV tubing
- place a 10 x 10 cm piece of gauze over the site
- gently pull the catheter and the IV line
factors affecting IV flow rates
- check the IV fluid
- check the administration set
- check the height of the IV bag (must be hung high)
- check the type of catheter used
- check the tourniquet
infiltration
the escape of fluid into the surrounding tissue, which causes a localized area of edema
thrombophlebitis
inflammation of a vein and the presence of a clot
occlusion
the physical blockage of a vein or catheter
vein irritation
usually caused by a too-rapid infused rate
hematoma
an accumulation of blood in the tissues surrounding an IV site
(resulting from vein perforation or improper catheter removal)
nerve tendon and ligament damage
- improper identification of anatomic structures
- selecting an IV site near joints
- sudden and severe shooting pain
- immediately remove the catheter and select an other IV site
systematic complication
- allergic reaction
- pyrogenic reactions
- circulatory overload
- air embolus
- vasovagal reactions
- catheter shear
intraosseous (IO)
within the bone
intraosseous infusion
technique for administering fluids, blood and blood products, and medications into the IO space of a long bone, usually the proximal tibia
manually inserted IO needles
- original devices
- solid boring needle inserted through a sharpened hollow the needle
- pushed into the bone with a screwing, twisting action
- solid needle is removed, leaving the hollow needle in place
- requires immobilization
FAST1
- first IO device approved for use in adults
- placement in the sternum
EZ-IO
- hand held, lithium battery powered medical drill to which a special needle is attached
- used to insert an IO needle into the proximal humerus or tibia or distal tibia of adults and children
- different sized needle
bone injection gun
- spring loaded device
- used to insert an IO needle into the proximal tibia
- comes in adult and peds sizes
extravasation
- needle rests outside the bone
- IV fluid will collect in the soft tissues
- discontinue the infusion immediately
osteomyelitis
- inflammation of the bone and muscle
- caused by an infection
- fewer than 0.6% of IO insertions
calculating fluid infusion rates
gtt/min= volume to be infused x gtt/ml of admin divided by total time of infusion in mins
calculating medical doses
volume to be administered = desired dose x volume on hand divided by dose on hand
converting lbs to kgs
divide the patients weight in pounds by 2 then subtract 10% of that number
step 1: 120 lbs divided by 2 = 60
step 2: 60 x 10% = 6
step 3: 60 - 6= 54kg
methods for determining the appropriate dose of medication for a pediatric patient
- length based tape measures
- tables or charts specific to pediatric patients
enteral medications
given through some portion of the gastrointestinal tract
oral medication administration
- capsules, time-released capsules, lozenges, pills tablets, elixirs, emulsions, suspensions, and syrups
- absorbed at a slow rate
syringe and needles
- prepackaged in colour coded packs with a needle
- plunger, body, flange and tip
- hypodermic needle lengths vary from 1 - 5 cm
the gauge refers to
the diameter
what end of the needle attaches to the syringe
the proximal end
what end of the needle is beveled
the distal end
ampules
breakable sterile glass containers that are designed to carry a single dose of a medication
vials
small glass or plastic bottles with a rubber-stopper top; they may contain single or multiple doses of a medication
prefilled syringes
- packaged tamper-proof boxes
- designed for ease of use
intradermal medication administration
- small amount of medication into the dermal layer
- avoid areas that contain superficial blood
- slow rate of absorption and minimal systemic distribution
subcutaneous medication adminstration
- loose connective tissue between the dermis and the muscular layer
ex) insulin
intramuscular medication admininstration
- penetrating a needle through the dermis and subcutaneous tissue into the muscular layer
- allows for a larger volume of medication
IV bolus medication administration
- places the drug directly into the circulatory system
- fastest route of medication
- no room for error
- bolus is a single dose
stopcocks
- allows multiple lines to be connected
- can control from which direction the flow is coming from
- “off” points to the direction that is being blocked
- allows for precise dosage to be delivered
saline locks
- used for patients who are not in need of IV fluid but may need medication therapy
- adding medication to an IV bag
IV infusion pumps
- medication maintenance infusion
- allow you to set the parameters of medication administration
IO medication administration
- critically ill or injured children and adults when IV access is difficult or impossible to obtain
- larger syringe to infuse the fluid
- pressure infuser device should be used when infusing fluids in adults
percutaneous medication administration
- applied and absorbed through the skin and mucous membranes
- absorption is predictable
transdermal medication administration
- surface of the skin
sublingual
under the tongue
buccal medication administration
- between the cheeks and gums
- tablets
ocular medication administration
- directly into the eye
- drops or ointments
aurul medication administration
mucous membranes of the ear canal
nasal spray
- rapidly absorbed
- mucosal atomizer device
nebulizer and metered dose inhaler
- respiratory emergencies
- oxygen, beta 2 agonist bronchodilators, ipratropium bromide
- patient with a history of respiratory problems will usually have a MDI
tracheal medication administration
- if IV or IO access is unavailable as a last resort
- you must administer 2 to 2.5 times the standard IV dose
- only 4 medications can be administered this way
(lidocaine, epinephrine, atropine, naloxone)
