Pharmacology and Fluid Therapy PART 2 Flashcards
Methoxyflurane (Penthrox®) -generic name-trade name-class
Generic name:-Methoxyflurane Trade name: -Penthrox® Classification Analgesic gas -
Methoxyflurane (Penthrox®) -MOA
Active ingredient is methoxyflurane, works by decreasing the CNS and making patients less responsive to pain. Research is unsure how this drug effects the CNS.
Methoxyflurane (Penthrox®) -indications-contraindications
Indications -Moderate to severe pain related to trauma Contraindications -Inadequate understanding/patient cooperation -Decreased level of consciousness -Psychosis -Pre-eclampsia -Moderate to severe renal and/or liver impairment -Hypersensitivity/ family history of malignant hyperpyrexia without negative personal test -Significant cardiovascular compromise -Raised intracranial pressure
Methoxyflurane (Penthrox®) -precautions-side effects
Precautions -Used with care in patients with underlying hepatic conditions -Previous exposure to halogenated hydrocarbon anesthetic (methoxyflurane when used as an anesthetic agent) especially if the interval is less than 3 months. -May increase the potential for hepatic injury. Side Effects -Altered level of consciousness -Cough
Methoxyflurane (Penthrox®) -route-dose-pharmacokinetics
Route -Inhalation Dose -Self-administered -One bottle containing 3 mL of Penthrox® to be vaporized is a supplied inhaler -Maximum dose is 6 mL in a 48-hour period Pharmacokinetics -Onset 1 to 3 minutes -Duration 1 hour -Half-life unavailable
Methoxyflurane (Penthrox®) -how supplied SKIP FOR NOW-special notes
How Supplied -Bottle containing 3 mL Penthrox® Special Notes -When disposing Penthrox®, the inhaler and medication is to be placed in plastic bags provided, sealed and disposed
Salbutamol -generic name-trade name-class
Generic name: -Salbutamol Trade name: -Ventolin® Classification -Bronchodilator
Salbutamol - MOA
-Beta adrenergic agonist.-Predominant Beta 2 effects: relax bronchiole smooth muscle and cause bronchodilation
Salbutamol -indications-contraindications
Indications -Bronchospasms due to exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and Asthma Contraindications -Hypersensitivity, symptomatic tachycardia
Salbutamol -precautions-side effects
Precautions -Caution with cardiac patients Side Effects -Palpitations, tachycardia, increased blood pressure, anxiety -Headache, dizziness -Sweating, trembling
Salbutamol -route-dose-pharmacokinetics
Route -Inhalation Dose -Adult: 2.5–5 mg -Pediatric: 1.25–2.5 mg with 2–4 mL of NaCl Pharmacokinetics -Onset: 5–15 min -Peak effects: 30 min–2 hours -Duration: 3–4 hours
Salbutamol -how supplied SKIP FOR NOW-special considerations
How Supplied - Metered dose inhaler: 100 mcg/ metered spray -Nebules: 2.5 mg/2.5 mL Special Considerations -Monitor blood pressure, pulse and electrocardiogram (ECG)
Anti-microbial -what is it-how much of it can be given over what period of time
is an agent used to kill microbes or prevent the replication of microbes in an infected host most, if not all, can be given intravenously over 15–20 minutes
what is the procedure for PCP and anti microbial infusion
- Ask the attending MD or RN to complete the administration of the IV anti-microbial before setting out on the transfer2. A dosage sticker must be affixed to the IV mini-bag indicating: -The name of the anti-microbial. -The dose and the time of preparation. 3. The anti-microbial will be given by constant IV infusion using an infusion control device at a predetermined rate according to the local pharmacy protocol
what is the procedure for PCP and anti microbial infusion during transport
Vital signs every 15 minutes. Discontinue if any unexplained symptoms or signs of hypersensitivity develop. (If there is any doubt concerning the etiology of any new signs or symptoms during the transport, contact the referring physician.) Discontinue if any signs or symptoms of anaphylaxis develop. Treat anaphylaxis as per protocol. If the patient’s condition deteriorates, arrange for an ALS intercept.
Heparin
directed primarily towards preventing development of intravascular thrombosis and the treatment of thromboembolitic disorders such as acute myocardial infarction, pulmonary embolism, and deep venous thrombosis
2 classes of anticoagulant drugs
parenteral (administered via IV) oral agents
The patient receiving IV Heparin must meet certain criteria before being infused -what does not meet the criteria
Anyone who has a known hypersensitivity to Heparin, is actively bleeding, is in shock, is suffering from some form of severe bleeding disorder (hemophilia)
If any adverse reactions are going to occur, such as anaphylaxis, they usually begin within
the first several minutes to 1 hour of the infusion
why does a pt on heparin need to be closely monitored
This drug classification is potentially dangerous, capable of causing severe, possibly fatal hemorrhaging
Possible Complications of heparin
Localized bleeding Irritation at the IV site Hemorrhaging Hypersensitivity (chills, urticaria, fever, anaphylaxis, bronchospasm) Elevated blood pressure Chest pain Impaired renal function
Management of heparin
Observe for bleeding (GI urinary, epistaxis, etc.) and discontinue the infusion if present and significant. Vital signs are to be recorded every 15 minutes, watching for any signs and symptoms of shock. Ensure that you have an accurate baseline of all vital signs before the transport begins. A record of the patient’s vital signs over the last several hours or days will provide you with some criteria to gather your baseline data. Stop Heparin if unexplained hypotension occurs. If there is any doubt about the origin of any new signs or symptoms during transport, contact the medical control physician for further orders.
Drug Interactions with heparin
very stable medication when mixed in normal saline, D5W or Ringer’s Lactate for a period of up to 24 hourshas to be given in a separate IV site if other medications are also being infusedHeparin will interact with salicylates (ASA), nonsteroidal anti-inflammatory drugs, NSAIDs, and will interfere with platelet aggregation. Heparin will also antagonize the action of insulin.
Potassium
Potassium is an electrolyte that is frequently administered intravenously to maintain a serum level
what should the serum level of potassium be betweenwhat is considered a low serum level and symptoms what serum level is too low and what can happen
between 3.5 and 5.3 mmol/Lbelow 3.0 mmol/L may be associated with symptoms such as weakness and malaise. below 2.5 mmol/L, lethal arrhythmias may occur
what can potassium added to an iv bag be infused up to in a patient with normal renal function
up to 40 mEq/hr
Sudden boluses of potassium may cause lethal arrhythmias meaning…
the rate of infusion of a potassium drip cannot be increased rapidly if the patient develops hypotension
To prevent a rapid infusion of potassium, the following must be adhered to:
must be administered via an IV pump. ensure that a medication sticker is affixed to the IV bag which identifies potassium as the medication being infused, as well as the dose of potassium. The rate of administration must be in writing and is not to be exceeded under any circumstances. If the patient has the potential to develop hypotension enroute, a second IV line is to be established. The patient may complain of burning along the vein where potassium is infusing; however, this is a common symptom the pre-hospital care provider should ensure the infusion is not exceeding the specified rate, and should provide reassurance to the patient. Under no circumstances is the flow rate of potassium-containing solution to be increased.
Oxytocin
a naturally occurring hormone that is secreted by the posterior pituitary gland. When secreted, it causes contraction of the uterine smooth muscles and lactation.
When postpartum hemorrhage cannot be controlled with breastfeeding or fundal massage, an IV infusion containing
10 – 20 units of synthetic oxytocin (Syntocinon®) may be administered
Possible Complications of oxytocin
Hypotension Dysrhythmias Tachycardia Seizures Coma Nausea Vomiting Uterine rupture from overstimulation of uterus
Management of oxytocin
Monitor vital signs. Due to the fact that excessive oxytocin can cause overstimulation of the uterus, uterine tone must be monitored throughout transport. If there is any doubt about the origin of any new signs or symptoms during transport, contact the medical control physician for further orders.
Drug Interactions with oxytocin
Syntocinon® can cause hypertension when administered with a vasoconstrictor such as norepinephrine.
Total Parenteral Nutrition (TPN)
the most common site for administration is via a central venous catheter due to the high concentration of the solution TPN is given to patients that have a long-term need for intravenous feeding, cannot receive adequate nutrition to meet their physiologic needs, do not have a functioning gastrointestinal (GI) tract or have a condition that has them on total bowel rest
possible patients that may receive TPN:
Hypercatabolic states (burns, trauma, sepsis) Gastrointestinal diseases Renal failure Congenital GI abnormalities Short bowel syndrome due to surgery
Standard dosing for an adult of TPN
is 2 liters per day of standard solution
Adverse reactions related to TPN’s components:
Water: -Fluid overload Insulin and dextrose:-Hypoglycemia or hyperglycemia Heparin: -Hemorrhage Electrolytes: -Abnormal levels of sodiumchloride, potassium, and magnesium Vitamins: -Deficiency in vitamin D-excess of vitamin A Dextrose:-Respiratory distress-liver dysfunction Allergic reaction
TPN Administration
When administering TPN via the central line, maintain sterility to help prevent infection. The line that is used for TPN administration should not be used for any other purpose. The TPN infusion must be transported on an infusion pump, and the prescribed rate must never be exceeded.
Acetylcysteine (Mucomyst®)
is an antidote for acetaminophen poisoning.
Acetylcysteine (Mucomyst®) classification
Its classification is Antitode (Mucolytic).
Acetylcysteine (Mucomyst®) Dosage
Loading dose: Dilute 150 mg/kg in 250 mL D5W; infuse over one hour Second infusion (repeat): Dilute 50 mg/kg in 500 mL D5W, infuse over four hours Third infusion (repeat): Dilute 100 mg/kg in 1000 mL D5W; infuse over sixteen hours or as directed
EMS Contraindications for Acetylcysteine (Mucomyst®)
No contraindications when used to treat acetaminophen overdose Hypersensitivity to acetylcysteine when used for indications other than treating acetaminophen overdose
Cautions for Acetylcysteine (Mucomyst®)
Encephalopathy, due to hepatic failure Asthma, chronic pulmonary disease, or sensitivity to acetylcysteine; administer loading dose slowly and be prepared to treat anaphylactoid reactions Pregnancy/Breast Feeding: Contact pharmacy for most recent information
what is an iatrogenic response
is an adverse condition that is inadvertently induced in a patient by a treatment given.
what is an iatrogenic overdose
an overdose of medication by a medical personnel It can be a result of wrong dosing or wrong route of administration.
Blood serves the following functions:
Supplies oxygen and nutrients for energy production and for tissue maintenance, growth, and repair Transports cellular waste, including carbon dioxide, to the organs for elimination Provides a defense against infection by transporting antibodies Regulates and equalizes body temperature Helps to maintain the acid-base balance Regulates fluid and electrolyte balance
Blood is made up of 2 basic components:
Cellular or formed elementsPlasma
Plasma
is a sticky straw-coloured fluid approximately 90% water. Dissolved within the plasma are over 100 different solutes including proteins, nutrients, electrolytes, and respiratory gases. Plasma makes up about 55% of the volume of blood.
Erythrocytes
(red blood cells) constitute approximately 45% of the blood’s volumehave a dedicated role in the transportation of respiratory gases.
Leukocytes
white blood cellsmake up less than 1% of the entire blood volumeplay a major role in defense against infection and disease.
Platelets
(also less than 1% of blood volume) are necessary for the clotting process and circulate in the vasculature, inactive until a blood vessel ruptures or is damaged
Blood is group classified based
on the types of antigens present or absent on the surfaces of the red blood cell
Pre-transfusion testing includes the following
Blood typing Antibody detection (and antibody identification if antibody screen is positive) Crossmatching
ABO Group -A -B -AB -O * name antigen and the frequency in population
-A 40% -B 11% -A and B 4% -None 45%
A patient’s antibodies will do what to red blood cells that have corresponding antigen on their surface
A patient’s antibodies will hemolyze (break down or destroy red blood cells) transfused red blood cells that have the corresponding antigen on their surface.
Historically, patients whose blood group was unknown and who required an urgent transfusion were provided with
Group O Rh negative red blood cells (RBC) until the patient’s blood group was determined
In situations where the blood group is unknown:
The Transfusion Medicine Laboratory (TML) will usually issue O Rh negative RBC’s for females of child bearing potential (less than 45 years of age) until the patient’s blood group is confirmed. All males and females past child bearing potential, can receive O Rh positive RBC’s until the patient’s blood group is confirmed
Crossmatching
is the process of determining the compatibility of blood from a donor with that of the recipient before transfusion
Whole blood
contains all components of blood the clotting factors and platelets quickly lose their function during storage A unit contains approximately 450 mL of whole blood plus 63 mL of anticoagulant
Indications of whole blood
indicated in blood loss not commonly available from blood banks, and therefore red blood cells are more commonly used for treatment of anemia and acute blood loss One unit of whole blood can increase the patient’s hemoglobin by approximately 10g/L
Infusion Rate of whole blood
The initial transfusion should be slow (5 mL/min for 15 minutes) while assessing the patient for adverse reactions In the absence of any reactions, the product can be infused as quickly as the patient can tolerate it. The transfusion must be completed with the 4-hour window
whole blood Compatibility
Normal saline
whole blood Special Considerations
Whole blood must be ABO-identical to the recipient’s blood group. (Group O is not universal donor for whole blood.)
whole blood Administration Set
The administration set must be a blood tubing set that has a 170–260 micron blood filter.
whole blood Storage and Shelf Life
Whole blood cannot be left at room temperature for longer than 4 hours. As soon as collection from the donor is complete, whole blood must be stored at 1–6° C the red blood cells will retain their function for up to 21–35 days
Whole Blood – Overview -major uses-storage and shelf life-administration
Major Uses -To replace: -Fibrinogen: in patients actively bleeding who have a low fibrinogen level Storage and Expiration -Frozen -Shelf life: 1 year -Once thawed, expires after 4 hours stored at 20–24°C Administration -Blood tubing required -Transfuse as rapidly as tolerated
Red Blood Cells
along with normal saline are more commonly used than whole blood for acute blood loss A unit of red blood cells is 240–340 mL and will be more viscous than whole blood most red blood cell components today have an additive solution mixed with the red blood cells (e.g., AS-3). With an additive solution, red blood cells will have the same flow rate as whole blood Red blood cells have minimal amounts of plasma (and ABO antibodies) so you can give ABO-compatible blood rather than only ABO identical
Red Blood Cells indications
Red blood cells units are administered to patients requiring increased oxygen-carrying capacity by increasing the circulating red blood cell mass.
Infusion Rate
The initial infusion should be slow for the first 15 minutes to assess for adverse reactions, then administered as quickly as the patient tolerates A slower rate should be considered for patients at risk for overload. A unit of red blood cells must be administered within 4 hours.
red blood cells Compatibility
Normal Saline
red blood cells special considerations
In massive transfusions, if possible warm blood with approved blood warmer prior to transfusion to prevent hypothermia.
cAdministration Set
The administration set must be a blood tubing set that has a 170–260 micron blood filter. If administering at a fast rate, 16–18 gauge cathlon is required in small vein patients a 20–22 gauge may be used.
red blood cells shelf life
Depending on the anticoagulant and additive solution used, red blood cell units have a shelf life of 21–42 days.
red blood cells Storage
Red blood cells must be stored at 2–6° C. During inter-facility transfers, the blood should be stored in a Canadian Blood Services styrofoam box with ice packs.
Red Blood Cells – Overview
Major Uses-Bleeding or anemic non-bleeding patients with signs and symptoms of impaired tissue oxygen delivery: –Tachycardia –Shortness of breath –Dizziness Storage and Expiration -2–6° C in approved refrigerator only -Shelf life: Maximum 42 days Administration-Blood tubing required -Initiate transfusion slowly for first 15 minutes unless massive blood loss -Transfuse over no more than 4 hours -Typically over 1½–2 hours with slower rates for patients at risk for circulatory overload
Fresh Frozen Plasma
-Fresh frozen plasma (FFP) is separated from whole blood by centrifugation or sedimentation and must be frozen within 8 hours of collection -A unit of fresh frozen plasma (FFP) contains approximately 250 mL (minimum 100 mL) of anticoagulated plasma.
Fresh Frozen Plasma Indications
Fresh frozen plasma (FFP) is separated from whole blood by centrifugation or sedimentation and must be frozen within 8 hours of collection A unit of fresh frozen plasma (FFP) contains approximately 250 mL (minimum 100 mL) of anticoagulated plasma. Fresh frozen plasma is indicated for patients requiring plasma coagulation factors, patients on Coumadin requiring emergency invasive procedures before Vitamin K can reverse its effects, or patients with plasma protein deficiencies.
Infusion Rate Fresh Frozen Plasma
Recommended infusion time is 30 minutes to 120 minutes but must be infused within 4 hours.
Compatibility Fresh Frozen Plasma
Normal Saline
Special Considerations Fresh Frozen Plasma
FFP should be thawed in a water bath at 30–37° C (in a watertight protective plastic over wrap using gentle agitation); this may take 20–30 minutes. Once thawed, FFP must be used immediately and cannot be refrozen.
Administration Set
The administration set must be a blood tubing set that has a 170–260 micron blood filter.
Storage and Shelf Life
FFP can be stored up to 12 months at temperatures -18° C and for 24 hours at 1–6° C once thawed.
Fresh Frozen Plasma – Overview
Major Uses -Liver disease coagulopathy –Massive transfusion –Plasma exchange procedures for certain diseases (e.g., TTP/HUS*) Frozen Storage and Expiration -Shelf life: 1 year; Once thawed, expires after 5 days stored at 1–6° C Administration -Blood tubing required Initiate transfusion slowly for first 15 minutes unless massive blood loss -Transfuse over no more than 4 hours -Typically over 30 minutes–2 hours
Cryoprecipitate
produced by Canadian Blood Services from fresh frozen plasma An insoluble precipitate, cryoprecipitate, is separated from the plasma and refrozen One unit of cryoprecipitate contains 80IU of Factor VIII and 150 mg of fibrinogen in 5–15 mL of plasma.
Indications of cryoprecipitate
Cryoprecipitate is indicated in patients requiring a source of fibrinogen or Factor VIII. It can only be used as a source of Factor VIII when virally inactivated fractionation products or recombinant Factor VIII (used for Hemophilia A) are not available.
Infusion Rate of cryoprecipitate
Recommended infusion time is 10–30 minutes per dose but must be complete within 4 hours.
Compatibility of cryoprecipitate
Normal saline
Administration Set of cryoprecipitate
The administration set must be a blood tubing set that has a 170–260 micron blood filter.
Storage and Shelf Life
Cryoprecipitate can be stored up to 12 months at temperatures of -18° C and for 4 hours at 20-24° C.
Cryoprecipitate – Overview
Major Uses-To replace: -Fibrinogen: in patients actively bleeding who have a low fibrinogen level Storage and Expiration-Frozen -Shelf life: 1 year; Once thawed, expires after 5 days stored at 1–6° C Administration-Blood tubing required -Transfuse as rapidly as tolerated
4.1 Rights of Transfusion
- Patient - Is this the right patient? 2. Product - Is this the right product? Check the blood for any clots, leaks, or discolouration Check the expiry date 3. Amount - Is this the right amount? 4. Rate - Is it set at the right rate? 5. Time - Is it the right time?
monitoring of a patient receiving blood products:
Only transport those patients receiving blood products that have been stable for last 24 hours Ensure that vital sign assessment is performed 15 minutes after the initiation of transfusion Repeat vitals every 30 minutes, including a temperature Repeat vitals more often for patients who are at greater risk of overload or experienced previous reactions Ensure that a physician’s order is present specifying the infusion rate and that the rate is no faster than 2 hours per unit All infusions must be complete within 4 hours of initiation A pressure infuser cannot be utilized unless a physician is present during transport Only normal saline can be infused through the same IV line as a blood product All blood tubing must be changed every 2–4 units of blood
Steps Upon Completion of Transfusion
Disconnect blood tubing once infusion is complete, as used tubing can be a breeding ground for bacteria Dispose of used blood tubing and bags in a biohazard bag and return to the hospital Continue to assess patient for symptoms of reactions for 6 hours post transfusion
Documentation
include the following on your PCR: Start and finish time of each bag Type of product being infused Blood unit number Rate the transfusion was run at Volume transfused during transport Vital signs and assessment findings Any reactions and treatment provided
List Potential Complications of Blood and Blood Product Transfusions
Adverse effects, generally referred to as transfusion reactions, are infrequent and vary in severity. Death due to transfusion is rareAIDS has occurred following transfusion, but blood donors are now tested
Adverse reactions can be classified as one of the following:
Immediate transfusion reactions Delayed transfusion reactions
deaths from blood transfusion
The majority of deaths are due to severe intravascular hemolysis (the destruction of red blood cells) following the administration of ABO mismatched blood Viral hepatitis is the second most common cause of death related to blood transfusion; the association with transfusion may not be recognized, and the hepatitis may develop many months after the transfusion
Immediate Transfusion Reactions
Reactions that occur during or within 24 hours of the infusion of blood products They include the following: Acute hemolytic transfusion reactions Febrile reactions Allergic reactions Air embolism Overload Chills Hypothermia
Acute Hemolytic Transfusion Reactions
rare usually due to the transfusion of ABO incompatible blood following the improper identification of the recipient, either when the crossmatch specimen is taken or when the blood donor is transfused
Signs of acute intravascular hemolysis include
fever, chills, hypotension, hemoglobinuria (the presence of hemoglobin in the urine which may cause a reddish discoloration of the urine), flank pain, and shortness of breath
disseminated intravascular coagulation (DIC)
results in abnormal bleeding such as around an IV site
Febrile Reactions
during transfusion is the most common adverse reaction following a transfusion
Febrile Reactions may be due to
Destruction of transfused red blood cells Destruction of transfused white blood cells Bacterial contamination of the blood Reaction to proteins
Urticaria during blood transfusion
(hives) fairly common. Unless extremely severe or accompanied by bronchospasm or other signs of impending anaphylaxis, the development of urticaria is not serious Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline.
Anaphylaxis
A life-threatening anaphylactic reaction (hypotension, bronchospasm, flushing, and laryngeal edema) rarely occurs during a transfusion of blood Treatment consists of discontinuing the transfusion of the blood product, keeping the IV line open with normal saline, providing high flow O2, etc.
Air Embolism
The use of closed plastic systems for the collection of whole blood and for the preparation of blood components has virtually eliminated air embolism as a complication of blood transfusion deaths have occurred when air has been deliberately introduced into the blood bag, or the administration set, to increase the rate of blood flow to the patient
Delayed Transfusion Reactions
a delayed reaction occurs after 24 hours and in some cases is not identified until much later.
Delayed Transfusion Reactions include
Hepatitis Sepsis Iron overload Delayed hemolytic reaction Post transfusion purpura Transfusion-associated graft-versus-host disease
Transfusion Associated Circulatory Overload (TACO)
The infusion of blood products can cause fluid overload and resultant pulmonary edema Circulatory overload occurs when the rate of infusion is excessive for that patient’s cardiovascular status especially in the elderly or very young
Transfusion Associated Circulatory Overload (TACO) symptom
These patients complain of shortness of breath (which can also be present with anaphylactic and acute hemolytic reactions)
Transfusion Associated Circulatory Overload (TACO) treatment
Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline The patient should also be placed on high flow O2 and placed as high as possible in the sitting position.
Chills and treatment
Chills may occur as a result of a febrile reaction or in patients with a normal temperature In either case the transfusion should be discontinued Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline
Hypothermia and treatment
Hypothermia may occur if cold blood is rapidly transfused Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline
Possible Transfusion Reaction -Fever, chills, or rigors (shaking)
Bacterial contamination Acute hemolytic transfusion reaction Transfusion related acute lung injury (TRALI) Febrile non-hemolytic transfusion reaction
Possible Transfusion Reaction -Urticaria and other allergic symptoms
Anaphylaxis Minor allergic reaction
Possible Transfusion Reaction -dyspnea
Transfusion related acute lung injury (TRALI) Transfusion associated circulatory overload (TACO) Anaphylaxis Bacterial contamination Acute hemolytic transfusion reaction
Possible Transfusion Reaction -Hypotension
Transfusion associated circulatory overload (TACO)
Possible Transfusion Reaction -Hemolysis, hemoglobinuria
Acute hemolytic transfusion reaction
Possible Transfusion Reaction -Pain
Acute hemolytic transfusion reaction IV site Lumbar Transfusion associated circulatory overload (TACO) Chest
Possible Transfusion Reaction -Nausea and vomiting
Acute hemolytic transfusion reaction Acute anaphylaxis Febrile non-hemolytic transfusion reaction
Risk and Description -Minor Allergic Reaction
1 in 100 Mild allergic reaction to an allergen in the blood component/product.
Risk and Description -Anaphylaxis
1 in 40,000 Potentially fatal reaction caused by an allergen that the patient has been sensitized to.
Risk and Description-Febrile Non-Hemolytic Transfusion Reaction
1 in 300 Mild, usually self-limiting, reaction associated with donor white blood cells or cytokines in the blood component/product. Usually presents with fever and/or rigors.
Risk and Description-Bacterial Sepsis (platelet pool)
1 in 10,000 will become symptomatic 1 in 60,000 will be fatal Potentially fatal reaction caused by bacteria inadvertently introduced into the blood component/product or originating from the donor. More common in platelets due to room temperature storage.
Risk and Description-Bacterial Sepsis (red blood cells)
1 in 250,000 will become symptomatic 1 in 500,000 will be fatal More common in platelets due to room temperature storage.
Risk and Description-Acute Hemolytic Transfusion Reaction
1 in 40,000 Potentially fatal reaction caused by blood group incompatibility. Can also be caused by chemical hemolysis (e.g. incompatible solutions) or mechanical hemolysis (e.g. improper storage). Can result in renal failure, shock, and coagulopathy.
Risk and Description-Transfusion Related Acute Lung Injury (TRALI)
1 in 12,000 Acute hypoxemia with evidence of new bilateral lung infiltrates on X-ray and no evidence of circulatory overload. Patients often require ventilatory support.Usually occurs within 1–2 hours of start of transfusion and rarely after 6 hours. Usually resolves within 24–72 hours, with death occurring in 5–10%. Cause not fully understood. Postulated to be related to donor or recipient antibodies acquired through pregnancy or transfusion.
Risk and Description-Transfusion Associated Circulatory Overload (TACO)
1 in 100 Circulatory overload from excessively rapid transfusion and/or in patients at greater risk for overload (e.g. very young, elderly, impaired cardiac function). Preventative measures include slower transfusion rates and pre-emptive diuretics for patients at risk.
Risk and Description-Hypotensive Reaction
Rare Bradykinin mediated hypotension. Characterized by profound drop in blood pressure, usually seen in patients on ACE inhibitors unable to degrade bradykinin in blood component/product.
Macro
10 gtts/mL, 15 gtts/mL and 20 gtts/mL.
Micro
60 gtts/mL
TKO (to keep vein open)
is always 30 mL/hr
When performing drip rate calculations when do u round up
f the number in the tenths is above zero the number would be rounded up. For example 22.1 mL should be rounded up to 23 mL.
Calculate Drip Rate
volume x set——————- =rate time
Calculations for Intravenous Infusions
volume x set = time x rate
To Calculate Volume:
rate x time—————- =volume set
medication infusion calculation
pres. d x dripfactor————————— = rateconcentration of drug in 1 ml
1 inch is how many cm
2.54 cm
how many ml in an ounce
30ml
how many ml in 1 teaspoon
5ml
how many mg in 1 g
1000mg
how many grams in a decagram
10g
how many grams in a kilogram
1000g
Concentration refers to how many of a given item is present in something elseWhen we are dealing with medication it refers to
how much medication is in 1 mL of solutionIf the medication is stated as mg in an amount of fluid, this can be easily determined by dividing the number of mg by the number mL of fluid
Drug concentration is sometimes listed as a percentage
This refers to how many grams of drug are present in 100 mLThe concentration can be determined by converting grams to mg and dividing by 100
drug calculation formula
ml in vial x desired dose———————————- mg in vial
The ratio and proportion method
Dose on hand × Desired volume = Volume on hand × Desired dose
examples Enteral
Oral medication administration Rectal medication administration
examples Parenteral
Subcutaneous medication administration Intramuscular medication administration Intravenous (IV) medication administration including IV infusion pump use Intraosseous medication administration Endotracheal medication administration Inhalation medication administration
examples Percutaneous
Transdermal medication administration Sublingual medication administration Buccal medication administration Intranasal medication administration
Medication Preparation
begins with you checking the medication to ensure that it is the correct drug, that the drug is not cloudy or discoloured, and that the expiry date has not passed You then have to determine the correct dose and concentration for that medication
ampoule
a sterile glass container that is designed to carry a single dose of a medication. An example of a medication supplied in an ampoule is epinephrine
Medication Preparation: Vials
A vial is a glass or plastic container with a rubber-stopper top. They may be either single or multi-dose. An example of a medication supplied in a vial is Narcan®.
safe scene practices that include the following:
- If the patient is responsive or if there is another reliable source of information confirm that the patient is not allergic to the drug that has been ordered2. Read the label carefully as you take the vile or syringe from its box and again before you give the drug note the concentration printed on the label and the drugs date of expiry3. Check with your partner to ensure the correct medication is being administered4. Check the defects in the vile, preloaded syringe or ampoule and make sure the fluid inside is not cloudy discoloured or precipitated• Check whether the container itself appears to be cracked or damaged5. If more than one drug is going to be administered to make sure that the drugs are compatible6. Monitor the patient for possible adverse side effects7. Dispose of the syringe and needle safely do not try to recap the needle
If an online physician consultation is required:
- Make sure the physician understands the situation2. Make sure you understand the physician orders clearly3. Always repeat any orders Word for Word back to the physician before administering medication to confirm state in the name of the drug the dose and the route
- Enteral route of administration refers to
any route in which the medications are absorbed through the gastrointestinal tract.
oral administration
Oral medication administrations are given to the patient to take by mouth. Depending on the medication they can be either swallowed whole or chewed.
oral administration Absorption
Since medication taken orally is absorbed by the stomach and intestines, onset of action is delayed sometimes as long as 30-90 minutes.
oral administration Advantages
• Convenient• Sterility is not needed
oral administration disAdvantages
• Unpleasant taste for patient• Nausea may result due to gastric mucosa irritation• Patient must be conscious to reduce the risk of aspiration• Digestive juices may destroy medication
oral administration Example
is ASA.
Rectal Medication Administration
are inserted into the patient’s rectum. Depending on the medication it may be in liquid form or in a firm base that is designed to melt at body temperature.
Rectal Medication absorption
Since medication administered rectally is absorbed by the highly vascular rectal mucosa, onset of action is rapid.
Rectal medication Advantage and disadvantage
An option for patients that cannot tolerate the medication orallyCan be uncomfortable for the patient.
Rectal medication equipment
• Water-soluble lubricant• Syringe• NPA, ET tube, plastic sheath off IV cathlon or 1 mL syringe
Rectal medication Example
Acetaminophen
Subcutaneous Medication Administration
are given in the loose connective tissue located between the dermis and the muscle layer. Volumes up to 1 mL can be injected subcutaneously.45 degree angle
Subcutaneous Medication Absorption
- Since the subcutaneous space does not have a rich blood supply, medications injected into this space have a slower onset of action and prolonged duration of action.
Subcutaneous Medication AdvantageDisadvantage
- No need for patient to be conscious can be used with both conscious and unconscious patients.- Pain and irritation at site
Subcutaneous Medication Equipment
• 24 to 26 gauge safety needle• 1 to 3 mL syringe
Subcutaneous Medication example
epinephrine
Intramuscular Medication Administration
are given directly into the muscle. Volumes up to 5 mL can be injected intramuscularly.90 degree angle
Intramuscular Medication absorption
- Since muscle is more vascular than subcutaneous tissue, medications injected into the muscle have a quicker onset of action than subcutaneous injections.
Intramuscular Medication advantages
• No need for patient to be conscious—can be used with both conscious and unconscious patients.• Rapid absorption
Intramuscular Medication Disadvantages
• Pain and irritation at injection site• When administering medication intramuscularly, there is potential for nerve damage so it is important to choose appropriate site and needle size for the patient.
Intramuscular Medication Equipment
• 21 to 22 gauge, 1½ to 2 inch safety needle• 1 to 5 mL syringe
Intramuscular Medication example
epinephrine
Intravenous Medication Administration
administration introduces the medication directly into the circulatory system. The medication is injected with a syringe into a needless port on an existing peripheral intravenous line.
Intravenous Medication absorption
- Since this route bypasses most barriers to drug absorption, this is the route for fastest onset of action.
Intravenous Medication Advantages and disadvantages
Advantages• Direct control of drug concentration in the blood• Rapid onsetDisadvantage- Risk of high drug concentrations if injected too fast
Intravenous Medication Equipment
- Luer-lock syringe of appropriate size for concentration of medication.
Intravenous Medication example
D50W.
Intravenous (IV) Infusion Pumps
pump is a mechanical device which infuses fluid by positive pressure. It controls the flow rate with more precision than traditional gravity.
Check the functioning of the pump’s alarm system
• On and off switch• Variable volume• Silencer
The alarm system may activate for any of the following reasons:
• End of infusion• Occlusion• Air in line• Battery low• Broken/disconnected tubing• Excessive pressure build-up within the system
Infusion Rate
- Each pump will have a rate of flow (mL/hr) which can be adjusted.
Volume to be Infused
- As a general guideline, set the volume to be infused at 30-50 mL less than what is in the IV bag or volutrol. Examples:• New 500 mL bag added to present IV - set amount to be absorbed at 450 mL• 50 mL in volutrol - set amount to be absorbed at 40 mL- Your alarm will then sound before total amount in IV bag has been infused.
Assessment of Total Infusion System
• Correct intravenous solution• Clamps open or closed as appropriate• Alarm system turned on• Rate of flow• Volume to be infused• Compare the amount to be infused to the amount in the bag or volutrol• Mechanical problems• Occlusion• Air in tubing, etc.• Connections - luer lock/regular• Intravenous site• Last tubing change
Intraosseous Medication Administration
introduces the medication directly into the intraosseous space of a long bone- The vessels in the intraosseous space drain directly into the central circulation by a network of venous sinuses and canals
Intraosseous Medication absorption
- Onset of action is comparable to intravenous as the medication is introduced directly into the circulatory system.
Intraosseous Medication Advantage and disadvantage
Advantage- Rapid onset of actionDisadvantage- May be difficult to infuse due to resistance
Intraosseous Medication equipment
• Safety syringe of appropriate size for concentration of medicationo Ensure the use of a large enough syringe to be able to infuse against the resistance met• 3 way stop-cock• Extension set
Intraosseous Medication example
- Any medication that can be administered intravenous can also be administered intraosseous.
Endotracheal Medication Administration
administration is done only as a last resort when intravenous or intraosseous access cannot be established- It involves the medication being administered down the endotracheal tube and then the patient being ventilated to disperse the medication across the alveoli.
Endotracheal Medication absorption
- Since the region within the respiratory tract is very vascular, the onset of action is usually within 2–3 minutes. - It is important to administer 2–2.5 times the standard intravenous dose to insure that the medication is adequately dispersed.
Endotracheal Medication advantage and disadvantage
Advantage- Useful when IV or IO is unobtainableDisadvantage- Medications that are not water soluble can cause damage to lung tissue
Endotracheal Medication equipment
safety syringe
select medications that can be administered using the endotracheal tube.
You can remember them by the mnemonic NAVEL:• Naloxone• Atropine• Ventolin / Vasopressin• Epinephine• Lidocaine
Inhalation Route of Administration
refers to when medications are inhaled by the patient and absorbed through the respiratory tract
Inhalation Route Absorption
- Since the region within the respiratory tract is very vascular, the onset of action is usually within 2–3 min.
Inhalation Route advantage and disadvantage
Advantage- Continuous drug dosingDisadvantage• Irritation of mucosa may occur• Low ambient temperature may affect gases ability to vaporize (nitrous oxide).
Inhalation Route examples
• Nebulizer• Metered-dose inhaler• Nitrous oxide
Nebulizer Medication Administration
- A nebulizer is when liquid medication is aerosolized to aid in inhalation. -The nebulizer is attached to an oxygen or compressed air source.
Nebulizer Medication Equipment
• Nebulizer mask with oxygen tubing• Oxygen cylinder compressed air source
Examples of medication that may be administered using a nebulizer are:
• Ventolin• Atrovent
Metered-Dose Inhaler (MDI) Medication Administration
- A metered-dose inhaler delivers a set dose of medication to a patient for inhalation. -They are most often prescribed to patients for use at home.
Metered-Dose Inhaler (MDI) Medication Equipment
• Metered-dose inhaler• Spacer device (useful for small children)
Metered-Dose Inhaler (MDI) Medication example
Ventolin
Nitrous Oxide Medication Administration
- Nitrous oxide is administered in a gaseous form via inhalation.
Nitrous Oxide Medication equipment
• Nitrous oxide cylinder• Mask or mouthpiece
Percutaneous Route of Administration
refers to when medications are applied to and absorbed through the skin and mucus membranes
percutaneous routes:
• Transdermal• Sublingual• Buccal• Intranasal
Transdermal Medication Administration
- Transdermal medication administration is when medication is applied topically on the surface on the patient’s skin.
Transdermal Medication absorption
- Since the medication absorption is slow with transdermal administration, this is a useful route for medication that requires slow, sustained release.
Transdermal Medication advantage and disadvantages
Advantage - Continuous dosing Disadvantages• Effective only for lipid-soluble medication.• Local irritation may occur.
Transdermal Medication Equipment
- No equipment is needed to facilitate administration of a medication this route.
Transdermal Medication example
- An example of medication that may be administered transdermal is a Nitroglycerin patch.
Sublingual Medication Administration
- Sublingual medication administration is when medication is placed under a patient’s tongue and allowed to absorb.
Sublingual Medication absorption
- Since the region under the tongue is very vascular, the rate of absorption is very quick.
Sublingual Medication advantage
- Direct delivery to general circulation.
Sublingual Medication Disadvantages
• Irritation to oral mucosa• Patient must be conscious.• Useful only for highly lipid-soluble medication.
Sublingual Medication example
Nitroglycerin.
Buccal Medication Administration
- Buccal medication administration is when medication is applied to the region between the cheek and gums and allowed to absorb.
Buccal Medication Absorption
- Since the region between the cheek and gums is very vascular, the rate of absorption is quite quick.
Buccal Medication advantage
- Direct delivery to general circulation
Buccal Medication disadvantage
• Irritation to gastric mucosa• Only useful for highly lipid-soluble medications
Buccal Medication Equipment
• Applicator (tongue depressor)• It is important to remember that this route of administration is only safe for those patients that have an intact gag reflex
Buccal Medication example
oral glucose
Intranasal Medication Administration
- Intranasal medication administration is when medication is administered directly into the nasal mucosa.
Intranasal Medication Absorption
- Since the region within the nasal mucosa is very vascular, the onset of action is very rapid- Intranasal route has a faster onset than intramuscular and therefore has become more popular in recent years in the prehospital setting.
Intranasal Medication advantages
• Rapid onset of action• Allows medication administration when IV not available
Intranasal Medication Disadvantage
- Specialized device required
Intranasal Medication equipment
- Syringe with mucosal atomizer device attached
Intranasal Medication examples
Lorazepam and Midazolam.
A medication error
the failure to complete a planned action as it was intended; or when an incorrect plan is used at any point in the process of providing medications to patients
Common sources of medication errors include:
• Prescriber ordered wrong dose of medication• Drug calculation was performed incorrectly• Drugs were administered wrong route• Drugs that had similar packaging or names• Drug given to the wrong patient• Drugs that are not commonly used
medication error Prevention
• Reduce reliance on memory: Checklists, protocols, computerized tools• Error-proof processes: “6 rights” of medication administration• Standardize tasks: Always perform a task the same way every time• Reduce the amount of hand-offs: Draw up your own medication
The following is the process to follow if a medication error occurs:
- Accept responsibility for the error.2. Inform medical direction of the error immediately.3. Assess and monitor the patient for any adverse effects.4. Document the error.5. Make changes in your personal practice to ensure that error does not occur again.6. Follow your agencies policies on documentation and reporting requirements for medication errors.
mandatory reporting requirements of any critical incident that causes serious adverse health effects to Saskatchewan health. This includes:
• Surgical events• Product or device events• Patient protection events• Care management events• Environmental events• Criminal events
When storing medication there are several factors that we must consider:
• We must identify the manufacturer’s recommendations regarding storage.• We must identify whether the medication is a controlled substance.In general, medications should be kept out of direct sunlight, away from humidity, and stored in temperatures between 15 and 30 °C.
Controlled Medication Storage
- must be either stored on person (drug pouch) or in a securely locked non-identifying cabinet that cannot be moved or be easily damaged. - A detailed Controlled Medication Log must be kept identifying the amount of drug on hand, medication used for patient care and any leftover medication that was disposed of- When signing for medication you must have two signatures, one for the person that has counted, administered or disposed of the medication, and the other signature of a witness.
6 rights of medication
- Right patiento Verify that it is the right patient confirm the patients name and compare it with wristband or triage tag2. Right medicationo Read the drug label at least three times before administration to ensure you have the right medication read it when it is still in the drug box, when you prepare the drug for ministration is coming to show your partner and ask which drug you’re holding in order to confirm, and before actually administering the drug to the patient3. Right dose4. Right route5. Right time 6. Right documentationo Name of drugo Dose o Time you administered the drugo Route of administrationo Name of paramedic who administered it
, transport of these patients coincides with the scheduled time for their oral medication administration. - A PCP can assist these patients to self-administration their medication as long as both of the following criteria have been met:
• There is a written order by a physician for the medication.• The medication ordered is one that normally would be self-administered by the patient in a home setting.
When giving fluid therapy to patients, always consider the following five questions:
• Why am I giving fluids?• How will I give fluids?• What type of fluid will I use?• How much fluid?• How will I monitor?
Why am I giving fluids?
Your reasons for giving fluids may include:- Resuscitation- Deficit replacement- Ongoing losses- Maintenance
How will I give fluids?
- Parenteral – Intravenous
What type of fluid will I use?
- Normal Saline- Ringers Lactate- D5W or D10W
How much fluid should I give?
- This will be based on your patient’s clinical presentation.
How will I monitor?
- This will be accomplished through continuous reassessment of your patient and their vital signs.
Electrolytes
, circulate through the body and help to regulate everything from water levels in the body to cardiac activity and muscle contractions- Electrolytes can either have a negative or positive charge
The major electrolytes found in the body are:
• Sodium• Potassium• Calcium• Magnesium• Bicarbonate• Chloride• Phosphorus
Sodium
the principle extracellular cationrequired to help regulate the volume of total water as well as the distribution of water throughout the bodyimportant for proper nerve and muscle functionIf levels are high it can lead to edema, lethargy, and weaknessIf the levels are low, it can result in pulmonary or cerebral edema
Potassium
the principle intracellular cation establishing resting membrane potential most dangerous of any electrolyte imbalancetoo low can result in decreased skeletal muscle function, GI disturbances, and cardiac arrhythmia. High levels lead to hyperstimulation of neural cell transmission which may lead to cardiac arrhythmias including cardiac arrest.
Calcium
the principle cation that is required for bone growth. role in heart muscle function, muscle contraction, nerve transmission, and blood clotting. Levels that are too low can result in skeletal muscle cramps, abdominal cramps, carpopedal spasms, hypotension, and vasoconstriction. High levels can result in the patient displaying signs of skeletal muscle weakness, lethargy, ataxia (involuntary lack of coordination or muscle control), cardiac arrhythmia, vasodilation, and flushed skin.
Magnesium
the second most common intracellular cation.It plays an important role in the metabolism of proteins and carbohydrates. essential for normal neuromuscular activity, synaptic transmission, and myocardial function.Low levels may result in the patient presenting with weakness, irritability, tetany, delirium, convulsions, confusion, anorexia, nausea, emesis, and cardiac arrhythmia. High levels may result in the patient presenting with hypotension, muscular weakness, nausea, vomiting, and altered mental function.
Bicarbonate
the second most prevalent extracellular anion. It is the primary buffer used in all circulating body fluids. Bicarbonate levels determine acidosis or alkalosis in the body.
Chloride
the most prevalent anion in extracellular fluid and is strongly linked to sodium.o if sodium is either retained or excreted the same action will occur with chloride.contributes to the formation of stomach acids and helps to regulate fluid balance and pH. Low levels may result in the patient presenting with muscle spasms, metabolic acidosis, shallow respiration, hypotension, and tetany.High levels may result in the patient presenting with lethargy, weakness, metabolic acidosis, and rapid, deep breathing.
Phosphorus
important component in adenosine triphosphate (ATP), which is a source of energy for the body
Fluid and Electrolyte Movement
- Water and electrolytes move within the body according to the principle of balance- When the concentration of charge or compounds are greater on one side of the cell membrane, a gradient is created- The tendency is for materials to move from areas of higher concentration to areas of lower concentration in an attempt to balance things out
There are different means of movement within the body:
• Diffusion• Facilitated Diffusion• Osmosis• Active Transport• Filtration
Diffusion
- the passive movement of solute from an area of higher concentration to an area of lower concentration. - If it is classed as simple diffusion, it occurs without the help of membrane transport proteins. - The movement of oxygen is classed as simple diffusion.
Facilitated Diffusion
- Facilitated diffusion is a type of passive diffusion that requires assistance of an integral membrane protein to move a solute across the membrane when it is too highly charged to cross alone.- It can be either channel mediated facilitated diffusion as is with the movement of potassium or it may be carrier mediated facilitated diffusion as is with glucose across the plasma membrane.
Osmosis
- Osmosis is a form of diffusion that involves the movement of water across a semipermeable membrane. - The water moves from the side with the lesser number of particles and greater concentration of water, to the side of the membrane with the greater number of particles and lesser concentration of water.
Active Transport
- Active transport is not a passive process as it requires energy to occur. - When a solute must move against its concentration gradient (from lower to higher), they cannot do this alone. - The primary source of energy is adenosine triphosphate (ATP). - An example of active transport is the sodium-potassium pump.
Filtration
- Filtration is the passage of materials through a membrane by a physical force such as gravity.- In the body filtration is also achieved by means of a physical pump, the heart, which effects the rate of filtration by effecting the pressure of the blood through the blood vessels.
Intravenous Solutions
When choosing the fluid to administer, it is important to know the type of fluid it is and the effect it has on the body. There are 5 basic types of IV fluid:1. Isotonic2. Hypotonic3. Hypertonic4. Crystalloid5. Colloid
Isotonic Solution
- has the same concentration of solute as serum and bodily fluids.- will not cause the cells to either swell or shrink- works by expanding the contents of intravascular space without shifting fluid to or from other compartments
- Examples of isotonic solutions
normal saline and lactated ringers.
Hypotonic Solution
- has a concentration of solute less than that of serum which results in a fluid shift- Since the concentration of solute is less than that of the interstitial fluid, hypotonic fluid placed in the intravascular space causes fluid to move from the vascular compartment into the interstitial compartment. - causes cells to swell and possibly burst.- work to hydrate the cells while depleting intravascular compartments. - should not be used for fluid replacement but rather to maintain a lifeline.
example of a hypotonic solution
D5W once administered
Hypertonic Solution
- has a concentration of solute greater than that of serum which results in a fluid shift.- Since the concentration of solute is greater than that of the interstitial fluid, hypertonic solution placed in the intravascular space causes fluid to move from the interstitial and intracellular compartments to the vascular compartment. - causes cells to shrink and possibly collapse.- Hypertonic solutions work to help stabilize blood pressure, increase urine output, and reduce edema. - These types of fluid are rarely used prehospital.
An example of a hypertonic fluid
D5 in lactated ringers.
Crystalloid Solutions
- are dissolved crystals in water- have the ability to cross membranes and alter fluid levels so it makes them a good choice for prehospital patients that require fluid replacement. - When administering crystalloid solutions for fluid replacement it is important to remember the 3 to 1 rule. - For every 1 mL of fluid lost, the patient requires 3 mL of crystalloid solution because within one hour, two thirds of the fluid will leave the vascular space.
Examples of crystalloid solutions
normal saline and lactated ringers
Colloid Solutions
- contain molecules that are too large to cross the capillary membranes and therefore remain in the vascular compartment.- high osmolarity. - fluid is drawn from interstitial compartments and intracellular compartments into vascular compartments.- it is important to closely monitor a patient receiving a colloid solution. - reducing edema while expanding the vascular compartment. - rarely administered prehospital.
Examples of colloid solutions
albumin, dextran, and pentaspan
Fluid Replacement Products
• Lactated Ringer’s • Normal Saline • 5% Dextrose in Water (D5W) • Colloids o Dextran o Pentaspan
Lactated Ringer’s-classification-description
Classification- Isotonic Crystalliod SolutionDescription - Sterile water with multiple electrolytes: o Sodium (Na) - 130mEq/L. o Potassium (K) - 4mEq/L. o Calcium (Ca) - 30mEq/L. o Chloride - 109mEq/L. o Lactate - 28mEq/L.
Lactated Ringer’s-indications-contraindications-precautions
Indications - This solution is indicated for use in adults and pediatric patients as a source of electrolytes, calories and water for hydration- Significant burns and hypovolemia.Contraindications- DON’T USE: Heart failure, renal failure, or suspected hyperkalemia-pts with ;liver problemsPrecautions- Monitor closely for signs of circulatory overload
Normal Saline -class-description
Classification - Isotonic crystalloidDescription - 0.9% Solution Sodium Chloride
Normal Saline -indications-contraindications
Indications - Hypovolemia, heat exhaustion/stroke, DKAContraindications- Hypersensitivity, heart failure
Normal Saline -precautions
- Use caution in patients with renal impairment to avoid volume overload - Use with Caution if signs of heart failure, CHF or crackles- Shock in peds manifested as: o Tachycardia - Poor skins signs - ALOC o Weak distal pulse - Delayed Cap Refill - Low Blood Pressure
5% Dextrose in Water (D5W) -class-description
Classification- isotonic solutionDescription- 5% Dextrose Injection, USP solution is sterile and nonpyrogenic. - It is a parenteral solution containing dextrose in water for injection intended for intravenous administration. - Each 100 mL of 5% Dextrose Injection, USP, contains dextrose, hydrous 5 g in water for injection.
5% Dextrose in Water (D5W) -indications-contraindications-precautions
Indications- hypoglycaemia Contraindications- D5W should not be used as a fluid replacement for hypovolemic states-hyperglycemia Precautions - May produce venous irritation
Pentaspan-class-description
Classification- Colloid solution- plasma volume expanderDescription- (10% Pentastarch in 0.9% Sodium Chloride Injection)
Pentaspan-indications-contraindications
Indications- the management of shock due to hemorrhage, surgery, sepsis, burns or other trauma Contraindications- patients with sepsis. - patients with severe liver disease - patients with known hypersensitivity to hydroxyethyl starch, or with bleeding disorders, or with congestive heart failure where volume overload is a potential problem - renal disease with oliguria or anuria not related to hypovolemia.
Pentaspan-precautions
- Caution should be used when the risk of pulmonary edema and/or congestive heart failure is increased - Special care should be exercised in patients who have impaired renal clearance since this is the principal route by which pentastarch is eliminated - patients allergic to corn because such patients can also be allergic to PENTASPAN - possibility of circulatory overload - not a substitute for red blood cells or coagulation factors in plasma
Dextran-class-description
Classification- Colloid solution- plasma volume expanderDescription - 10% LMD in 0.9% Sodium Chloride Injection
Dextran-indications-contraindications
Indications- treat hypovolemia and/or hemorrhage from trauma, burns, surgeries, or other causes if ABO compatibility tests are not possible in timeContraindication - patients with heart failure, as rapid administration may prove dangerous due to the plasma volume expansion effects, potentially leading to circulatory overload and acute decompensation- patients with untreated bleeding disorders- patients with underlying renal disease, failure to clear dextran can lead to worsening of renal function- include severe liver disease, preexisting edema, asthma, diabetes, epilepsy, and seizures
Dextran-Precautions
- Hypersensitivity Reactions- Delayed Reactions- Increased Risk Of Toxicity In Patients With Underlying Conditions
WHEN ARE Volume expanders USED
used when a patient has lost fluid as a result of hemorrhage, diarrhea, vomiting, heat exhaustion, or burns
The most effective way to increase a patient’s intravascular fluid levels
administer colloid solutions
PCP scope of practice, if volume expansion needs to occur
crystalloid fluid will need to be administered
When administering a crystalloid solution to increase intravascular volume it is important to not only remember
the rule of 3:1 but also that crystalloid solution cannot carry oxygen
Vascular Access (Peripheral Intravenous) -purpose
Purpose -Provides access to the circulation to administer drug therapy or fluids. Equipment -PPE-Appropriate size catheter -Tourniquet-Swabs-Gauze-Tape-Drip-Set -IV bag with solution Sharp Container
Vascular Access (Peripheral Intravenous) technique according to SCOP
- PPE2. Choice of insertion site: 3. Procedurea. Explain the procedure, including why IV therapy is necessary.b. Select the appropriate size cannula.c. Prepare equipment and cannulation site.d. Stabilize vein and insert needle bevel up.e. Confirm IV placement by flashback and advance further into thevein. f. Advance catheter over the needle and into the vein.g. Retract needle while stabilizing the vein.
Vascular Access (Peripheral Intravenous) Choice of insertion site: according to SCOP
- General drug administrationi. Small to medium gauge cannula (i.e. adult: 18 – 20 G, child: 22 – 24G). ii. Best most distal available vein.iii. Use non-dominant limb when possible. iv. Avoid joints. 2. Likely need for fluid replacementi. Large gauge cannula sited in a large vein (i.e. adult: 16 – 18 G, child: 20 – 22 G). ii. In significant trauma a 16 G cannula is sufficient to facilitate rapidfluid replacement. 3. Difficult IV access/poor vein presentation i. Consider the lower limbs, or external jugular vein.ii. Consider IO access (Note: a small gauge cannula provides more reliable access than the IO route).
Vascular Access (Peripheral Intravenous) Indications according to scop
- For volume expansion in patients with the clinical diagnosis of shock (hypovolemic, neurogenic or anaphylactic). Patients with suspected cardiogenic shock will have an intravenous initiated TKO, with OLMC required to establish the rate of flow for PCP and ICP. 2. To obtain an intravenous route for administration of essential emergency drugs. Examples include, but not limited to the following circumstances: a. Cardiac arrest.b. Diabetic shock.c. Anaphylactic shock.d. Unconsciousness of unknown etiology or significanttrauma.
Vascular Access (Peripheral Intravenous) contraindications according to scop
- Whenever possible avoid sites of burns, infection or localized cellulitis.
Vascular Access (Peripheral Intravenous) precautions according to scop
Precautions 1. Because of the increased risk of phlebitis in IVs started in the pre-hospital scene, strict attention must be placed on an aseptic technique and secure taping of the IV. 2. The following sites are not to be used for IV access:a. Lower limbs when pelvis, abdominal or thoracic trauma issuspected.b. Distal to a complex limb injury.c. Limb with a fistula present.d. An area of phlebitis or cellulitis.e. When a limb has potential or existing lymphedema (e.g. the same side as lymph node clearance).
A peripheral intravenous saline lock may be used in those patients where
IV access has been obtained for the purpose of administering IV medications
. A saline lock is not to be used for
patients who require or may require bolus IV fluid therapy for hypotension.
Each dose of IV medication administered during a cardiac arrest
is followed by a bolus of IV fluid (to accelerate its entry to the central circulation) as follows: a. Under the age of six years: 5 mL (including IO infusions) b. Between six and twelve years: 10 mLc. Over the age of 12 years: 20 mL
The IVs should be established enroute unless:
a. There is delay in extrication of the patient.b. Airway management during transportation will not allow for IV initiation.c. In patients with “controlled hemorrhage” where ongoing blood loss will not be a problem. d. Transport time of greater than 30 minutes in length.e. Crystalloids will be the fluid administered. The decision as to which fluid will be utilized
- Solvent: - Solute:
- Solvent: the fluid that does the dissolving- Solute: the dissolved particles contained in the solvent
Dehydrationoverhydration
dehydration-define does inadequate total systematic fluid volumeoverhydration-when the body’s total systematic fluid volume increases
Dehydration signs and symptoms
Signs and symptoms include decreased level of consciousness, orthostatic hypotension, tachypnea, dry mucous membranes, tachycardia, poor skin turgor, flushed dry skin
dehydration causes
include diarrhea, vomiting, gastrointestinal drainage, haemorrhage and insufficient fluid or food intake
overhydration signs and symptoms
include shortness of breath, puffy eyelids, edema, polyuria, moist crackles and acute weight gain
overhydration causes
o Causes include monitored IV lines, kidney failure and prolonged hyporventilation
intracellular fluid
-is the water contained inside the cells it normally accounts for 45% about 28 L of body weight
Extra cellular fluid
The water outside the cells accounts for 15% of body weight about 14 L and is further divided into two types of fluids interstitial fluid and intravascular fluid
interstitial fluid
The water bathing the sales accounts for approximately 10.5% of the body weight about 10 L include special fluid collections such as cerebrospinal fluid and intraocular fluid
Intravascular fluid
plasmaThe water within the blood cells carry his red blood cells white blood cells and vital nutrientsNormally accounts for approximately 4.5% of body weight or 4 L
tonicity
The concentration of a solution or ability to draw or give water
Intravenous Access Sites
start as distal as possible and work your way upThis allows for subsequent cannulation attempts on the same extremity if there is a failed cannulationIf you attempt an IV distal to a previous attempted site, you risk leaking of fluid into the surrounding tissue at the previous site and resulting damage
When choosing a site, it is important to keep the following criteria in mind:
Find a section of vein that is straight and will accommodate the full length of the cathlon.Look for a vein that is full and round in appearance and that does not “roll.”Avoid valves if possible as a cannula will not pass through easily and if you push through with the needle you may cause damage to the valve.Avoid starting near joints.Avoid any injuries, edema, fistulas, or same side as a previous mastectomy.
Peripheral Intravenous Access Sites-Upper Extremity
-The three main veins of the antecubital fossa (the cephalic, basilic, and median cubital) are frequently used
when are the three main veins of the antecubital fossa ideal sites
when large amounts of fluid must be administered
the most commonly used vein
The accessory cephalic vein
when may the veins in the dorsal hand be utilized
if large bore access (18 gauge or larger) is not required
Peripheral Intravenous Access Site-Lower Extremity
- Insertion can be quite painful, and the catheter may cause more discomfort than if it were started in the hand or forearm- IV catheters placed in the feet are more likely to become infected, not flow properly, and produce phlebitis-The great saphenous vein
which lower extremity veins can be used
-The lesser saphenous vein -The great saphenous vein -Any vein in the foot large enough to accept the IV catheter may be used, if necessary
Alternate Intravenous Route
when an IV in an extremity cannot be established, is an external jugular vein cannulization. In Saskatchewan, this skill is only to be performed by licensed Advanced Care Paramedics.
external jugular vein cannulization-indications
For the administration of fluids or medications in patients where other peripheral IV (intravenous) attempts have been unsuccessful.
external jugular vein cannulization-location
The external jugular veinIt is a painful site, reserved for patients with decreased or a total loss of consciousness.
external jugular vein cannulization-The external jugular vein
it can accommodate up to a 12g needleformed below the ear and behind the angle of the mandible where it passes downward and obliquely backward, across the surface of the sternomastoid muscle. It then pierces the deep fascia of the neck just above the middle of the clavicle.
external jugular vein cannulization-contraindications
- Infection over the insertion site- Lack of anatomic landmarks due to neck size, shape, or deformities- Patients unable to tolerate a Trendelenberg position- Unsuccessful contralateral attempt at insertion with resultant hematoma- Coagulopathies: In these cases, other more easily compressible sites should be considered.
external jugular vein cannulization-precautions
- Puncture the vein as close to the angle of the jaw as possible, to avoid injuring the lung and causing a pneumothorax.- Ensure IV set is clear of all air and connections are tight.
Local hematoma jugular vein-prevention-management
prevention • Going too deep might lacerate the deep wall of the vein or too superficially the superficial wall of the vein• To prevent this, take care to strictly follow the axis of the vein during insertion management -Local pressure (but never circumferentially applied)
Laceration of the deeper internal jugular vein-prevention-management
-preventionDo not insert the needle deeply for this procedure. -managementLocal pressure (but never circumferentially applied)
Infection jugular vein-prevention-management
-preventionAseptic procedureNever insert through infected skin -managementAppropriate antibiotics
Air embolism jugular vein-prevention-management
prevention• Maintain a Trendelenberg position• Have the patient exhale while advancing the catheter if conscious• Maintain a “closed” systemmanagement -Place the patient in a left lateral recumbent, head down position to minimize the chances of an air embolism to the brain.
Preparing an Infusion Site
- 6 rights of medication- Check color and clarity of solution- Check expiration date- Insert spike into port- Hang bag on pole- Compress drip chamber until it is ½ full- Prime- Select the vein- Apply tourniquet 4-6 inches above IV site - Check for presence of radial pulse- Use most distal site in non dominant arm- Palpate vein and note resilient, soft bouncy feeling- Cleanse area for 30 secs
how to select vein
o Cephalic, basilic and median are preferred in adults o Dorsal hand veins are fragile and should be avoided in older ptso Avoid: areas of tenderness, redness, rash, pain or infection; interferes with daily activities; use of assisted devices; extremity affected by CVA, paralysis, dialysis shunt or mastectomy; sites distal to previous venipunctures; sclerosed, hardened or phlebitis veins; areas with infiltration or venous valves
Initiating an IV
- Cleanse area for 30 secs- Using thumb of non dominant hand stretch the skin below the site- Holding needle bevel up firmly insert the needle in vein in one smooth motion at a 45 degree angle and then immediately drop angle to 15 degrees- Check flashback chamber for blood return- Advance the device 2-3mm - Remove the tourniquet- Remove needle while advancing the catheter up to the hub or until you meet resistance- Attach the IV tubing to the IV catheter - Secure
Performing Venipuncture
same as initiating IVbut also:- Advance the catheter off the needle - Stablizie catheter and remove tourniquet - Apply firm gentle pressure to vein 1 inch from insertion site- Connect saline lock or primary administration set - Slowly flush
Dressing the Infusion Site
- use transparent dressing- apply 1 edge of dressing and smooth over- leave the area between iv tubing and catheter hub uncovered- place 1 inch piece of tape over administration set or extension tubing- do not apply tape to transparent dressing- label dressing
to secure the catheter using gauze
- place a piece of tape over the catherter hub- do not apply tape over insertion site- tape 2x2 sterile gauze over insertion site and catheter site do not cover connection between tubing and catherter hub - fold 2x2 gauze in half and cover it with tape slide this between the tubing and catheter hub - once secured open line clamp
Troubleshooting Intravenous Infusions
- Check flow rate- If the infusion rate is set properly but alrm is sounding check for kinks in tubing- Assess IV device; look for bleeding at iv sight- Check insertion site for color changes, swelling and drainage- Palpate around site - Check for phlebitis; if found stop infusion
To document and IV insertion you need to include the following:
- The gauge of the needle2. The IV attempts versus successes3. The site example left forearm4. The type of fluid you are administering5. The rate at which the fluid is running
when to Change an IV bag
- Change the bag with approximately 50 mL of fluid is left
The steps for changing an IV bag are as follows
- Stop the flow of fluid from depleted bag by closing the roller clamp2. Prepare the new IV bag by removing the pigtail from the piercing spike port - inspect the new bag of IV fluid for clarity and discolouration and to ensure that expiry date has not passed3. Remove the piercing spike from the depleted bag and inserted into the port on the new bag4. Ensure the drip chamber is appropriately filled and then open the roller clamp and adjust the fluid rate accordingly
Discontinuing the IV line
- Shut off the flow from the IV line with a roller clamp2. Gently peel the tape back to where the IV site and stabilize a catheter while you loosen the remaining tape3. Do not remove the IV tubing from the hub of the catheter4. For the 10 x 10 piece of gauze and place it over the site holding it down while you pull back on the hub of the catheter5. Gently pull the catheter in the IV line from the patient’s pain while applying pressure to control bleeding
following components are necessary for IV therapy:
• Solution containers• Administration sets• Needles and cannulas• IV fluids
IV fluids are packaged in two types of containers and are labeled indicating…
glass bottles and plastic bagslabeled indicating the solution and strength, and they have a graduated scale and an expiry date
Administration Sets
The administration set is in a sterile package consisting of: -the tubing, -a drip chamber, -a flow adjustment valve- piercing pin-an injection site
Tubing
- The tubing is made of a clear pliable plastic which facilitates visualization of the solution in order to check for air bubbles and foreign particles- The pliability of the tubing allows for movement- The top of the tube has a piercing pin for insertion into the solution bag or bottle- At the bottom end of the tube is an adapter that fits into the IV catheter placed in one of the patient’s extremities.
Drip chamber
- The drip chamber is located beneath the piercing pin- controls the rate of fluid administration which is monitored by counting the drops falling into the chamber- The drop size varies according to the type of set used
There are two basic types of infusion sets:
macrodrip (standard) infusion set microdrip infusion set
macrodrip (standard) infusion set
is designed for rapid fluid replacementdesigned to deliver a total of 10, 15, or 20 gtts (drops) /mL
The microdrip infusion set
is not designed to replace lost fluid; rather, to maintain a to keep open (TKO) rate and/or to provide a route for drug administrationThe microdrip set is designed to deliver 60 gtts (drops) /mL.
the injection site
Near the bottom end of the tube is a junctionA syringe can be attached at this site for administration of drugs
The most commonly used sizes in the field
18 and 20 gauge
There are two types of IV needles available
Steel, and Over-the-Needle
the steel needle
(also called the Butterfly), has been around a long time but has become less popular since the introduction of the plastic catheter over the needle system
Over-the-Needle
- the catheter over the needle which allows a steel needle to puncture the skin and gain access to the veino Once the placement is confirmed in the vein, the plastic catheter is slid over top of the steel needle and secured in the veino The steel needle is then withdrawn from the vein and the plastic catheter remains in place
Steel (Butterfly) -advantages
• Easiest to insert• Useful for scalp veins in infants and in small, difficult veins in geriatric patients• Small guage short needles
Steel (Butterfly) -disadvantages
• May easily cause infiltration• Possible blood cell damage when drawing blood• Small gauge needles limit fluid flow
over the needle-advantages
• Less likely to puncture the vein• More comfortable for patient once in position• Radiopaque for easy identification during x-ray
over the needle-disadvantages
• More difficult to insert• Risk of sticking paramedic with contaminated needle as it is withdrawn • Possibility of catheter shear
The most common solutions utilized in the field are
5% dextrose in water (D5W), Ringers lactate and normal saline
5% Dextrose in Water (D5W)/10% Dextrose in Water
- This hypotonic solution contains 5 grams or 10 grams of glucose for each 100 mL of water.- Because it is absorbed from the circulatory system into the body tissues quite rapidly, it is not used for fluid replacement but is used commonly for diabetics and maintaining a lifeline.
Ringers Lactate
- This isotonic solution contains sodium chloride, lactate, potassium, and calcium. - It is used for fluid replacement because it remains in the vascular space.- It is commonly referred to as a volume expander and is the fluid of choice for trauma patients.
Normal Saline
- This is an isotonic solution of 0.9% sodium chloride.- It most closely resembles body fluids in density and osmotic pressure.- It is an adequate temporary solution for fluid replacement during hemorrhage or fluid loss due to burns, peritonitis, or excessive diarrhea. - It is also referred to as a volume expander.
Phlebitis-description-signs and symptoms -treatment
Description- Inflammation of the vein. It is caused by mechanical trauma or chemical irritation to the vein.Signs and Symptoms- Burning pain along the vein; edema; redness; increased skin temperature over the course of the vein.Treatment1. Discontinue the IV.2. Apply warm packs to provide some relief.3. Notify emergency physician.4. Record procedure and reasons.
Thrombophlebitis-description/prevention-causes-signs and symptoms-treatment
Description- Caused by local damage to the venous wall, and resultant inflammation and thrombus formation. This can be prevented by checking the site daily for signs, changing the IV (intravenous) site every 72 hours, ensuring all connections are tight, and using an aseptic technique.causeso The IV needle passes completely through the van and out the other sideo The patient moves excessivelyo The tape used to secure the IV line becomes looser dislodgedo Catheter is inserted to shallow and angle and enters only the fascia surrounding the veinSigns and Symptoms- Pain; erythema; swelling; a palpable cord along the course of the cannulated vein.Treatment1. Discontinue the IV.2. Apply warm packs to provide some relief.3. Notify emergency physician.4. Record procedure and reasons.
Infiltration (Interstitial)-description-signs and symptoms -treatment
Description- Infiltration is the escape of fluid into the subcutaneous tissue due to dislodgement of the needle.Signs and Symptoms- Reduced rate of flow (an early sign); pain at the site; swelling of the subcutaneous tissues; skin becomes cold.Treatment1. Discontinue the infusion.2. Apply cold packs (early) or warm packs (later) to aid absorption.3. Re-establish an IV at another site.4. Notify emergency physician.5. Record procedure and reasons.
Circulatory Overload-description/causes-signs and symptoms -treatment
Description- Circulatory Overload occurs when the intravascular fluid compartment contains more fluid than normal. This is usually due to infusion rates being too rapid, resulting in cardiac failure and pulmonary edema. Monitoring flow rate is essential in preventing circulatory overload. Flow rates must not be increased for an infusion that is behind schedule.Signs and Symptoms- Patient discomfort; rapid pulse; venous distention; increased B/P; coughing; shortness of breath; increased respiration; syncope, shock; pulmonary edema - dyspnea, cough, cyanosis, frothy sputum, gurgling sounds on respiration.Treatment1. Slow the IV to a “keep open” rate.2. Administer oxygen.3. Raise the patient to a sitting position.4. Notify the emergency physician for further instructions.5. Record procedure and reasons.
Air Embolism & Catheter Embolus-descriptions/causes-signs and symptoms -treatment
Description- Air embolism occurs when air enters the circulatory system. Causes include: patient movement, occur with the insertion of an IV catheter, during manipulation of the catheter or catheter site when the device is removed, or when IV lines associated with the catheter are disconnected. -Catheter embolism is when the tip of the catheter is sheared off; it may potentially embolize and travel proximal in the circulation. This is always caused by poor technique during the insertion of the IV, when the needle is withdrawn from the catheter and then reinserted.Signs and Symptoms- Shock; chest pain, cyanosis; tachycardia; respiratory distress, rapid loss of consciousness.Treatment1. Immediately close adjustment valve.2. Clamp off tubing, with a hemostat or other clamp, as close to the infusion site as possible. Ensure the catheter is firmly attached to the tubing.3. Place patient on the left side with the head down. This will allow the air embolus to fill the right atrium and let the blood still pass to the right ventricle, so that the heart will keep pumping.4. Administer oxygen.5. Initiate a second IV.6. Contact the emergency physician for further instructions.7. Record procedure.
Pyrogenic Reaction-description-signs and symptoms -treatment
Description- An infection or bacteria (pyrogens) in the solution.Signs and Symptoms- Usually occur about 1/2 hour after IV is started or container is changed. Chills and fever; - malaise; headache; nausea and vomiting; backache; shock – with a possibility of circulatory collapse.Treatment1. Stop the infusion by closing the flow adjustment valve.2. Discontinue the IV.3. Treat for shock.4. Contact the physician for further instructions.5. Record procedure and reasons.
Speed Shock
Description- A sudden adverse physiologic reaction to IV medications or drugs that are administered too quickly.Signs and Symptoms- Flushed face; headache; a tight feeling in the chest; irregular pulse; loss of consciousness; cardiac arrest.Treatment1. Slow infusion.2. Administer oxygen.3. Watch for the development of cardiac arrest.4. Contact the physician for further instructions.5. Record procedure and reasons.
Hypersensitivity
Description- An immediate or delayed adverse response which may occur following medication administration. Always confirm the patient’s allergies prior to administering any medications.Signs and Symptoms- Vary. Mild rash or anaphylactic shock; urticaria; laryngeal and glottis swelling; upper respiratory obstruction; hypotension; shock.Treatment1. Stop the medication administration immediately.2. Administer oxygen.3. Administer epinephrine if indicated.
Blood tubing
is a macro drip administration set that is designed to facilitate rapid fluid replacement by manual infusion of multiple IV bags or IV and blood replacement combinationso The central drip chamber has a special filter design to filter the blood during transfusions
Volutrol
: a macro Dripset that allows you to fill a 100 or 200 mL calibrated drip chamber with a specific amount of fluid and administer only that amount to avoid fluid overload
what gauge catheter is a good size for adults who do not need fluid replacement
an 18 or 20 gauge catheter is usually a good size for adults who do not need fluid replacement metacarpal veins of the hand can usually accommodate 18 or 20 gauge catheters
what gauge catheter is a good size for when the patient requires fluid replacement or may receive blood products
- A 14 or 16 gauge catheter should be used when the patient requires fluid replacement and certainly should be used in any patient who may receive blood products or undergo a surgery in the hospitalo You should be able to insert a 14 or 16 gauge catheter into an anti-cubital vein an average adult
Occlusion-description-signs- treatment/reestablishment of line
description- The physical blockage of a vein or cathetersigns - The first sign of occlusion is decreasing drip rate her presence of blood and IV tubing- Occlusion may develop if the IV bag nearest empty in the patient’s blood pressure overcomes the flow causing fluid back up in the linereestablishment of line- follow these steps to determine whether the IV line should be reestablished1. Select and assemble a sterile 10 mL syringe and large gauge needle2. Suction injection port closest to the IV site and swab with alcohol3. Insert the needle into injection port4. Pinch the line between the injection port and IV bag5. Gently pull back on the plunger to disrupt the occlusion and reestablish flow never push the inclusion into the patient6. If the flow is reestablish ensure that the rate is sufficient7. If you are unable to reestablish flow discontinue the IV line and reestablish on opposite
Hematoma-description-signs-treatment
description- A haematoma is an accumulation of blood in the tissue surrounding an IV site often results from the vein perforation or improper catheter removalsigns - Blood can be seen rapidly pooling around the IV site leading to tenderness and painTreatment o If a haematoma develops while you were attempting to insert a catheter stop and apply direct pressureo If a haematoma develops after successful catheter insertion evaluate the IV flow in the haematoma o if it appears to be controlled and the flow is not affected monitor and leave it o if the haematoma develops as a result of discontinuing the IV line apply direct pressure with gauze
Vasovagal -description-treatment
description- Some patients have anxiety concerning needles with a side of blood which may cause vasculature dilation leading to a drop in blood pressure and faintingTreatment o Treat them for shock1. Place patient in shock position2. Apply high flow oxygen if necessary and indicated3. Monitor vitals4. Establish an IV line in case fluid resuscitation is needed
It is important that you perform a check of the following items after every intravenous initiation and when a flow rate issue is encountered:
• Is the tourniquet on?• Is the tubing clamped or kinked?• Is the intravenous now interstitial?• What is the cathlon size? The larger the cathlon the faster the flow.• Is the bag too low?• What is the administration set? Micro versus macro• What is the fluid? Thicker and colder fluids will run slower.
If any of these occur, the following procedure should be followed:
- Shut off the IV flow by closing the flow adjustment valve.2. Remove tape and dressing (if any) from the infusion site.3. Hold a cotton swab or sterile 4 × 4 above the entry site. Apply pressure as soon as needle is withdrawn. Do not apply pressure while the catheter is being withdrawn as the vein can be traumatized.4. Remove the catheter by pulling straight out in line with the vein. Immediately check the needle or catheter to ensure intactness. If the catheter is not intact or it appears that a section or piece has broken off, immediately apply a tourniquet at the most proximal location on the limb, position the patient on the left side with head lower than feet, administer oxygen, and transport to the nearest hospital.5. Immediately apply pressure to the site for about 1 minute.6. Apply a band-aid over the site.7. Record procedure. Including any sign and symptoms noted, treatment done and time procedure performed.
drip rate calculation equation:
Volume × Set = Time × Rate*Remember with drip rate calculations we always round up!
Monitor an Existing IV
- Check fluid level — the solution container should not run dry. The container is changed when 50 mL of the solution is left. Reading fluid levels must be done at eye level. If a plastic bag is in use, milk the bag by pulling the sides taut and then releasing before you read the fluid.2. Check for total infusion to see if it is on schedule. If too much or not enough solution is left in the bag for the amount of time expired, recalculate the drip rate.3. Check the drip chamber. Is there flow and is the rate correct?4. Check tubing for patency, kinking, or obstructions.5. Check the IV site. Visualization of the infusion site is important in order to detect signs of complications.• Skin—colour and temperature should be normal• Pain—should be pain free• Swelling—should be free of swelling6. Check patient’s arm.• Is the IV still properly affixed?• Is there good circulation?7. Assess the patient’s comfort. The patient should not experience pain or discomfort in association with the IV.8. Take vital signs at regular intervals. • This will help detect signs of complication early• Take blood pressure on the opposite arm9. Record all observations as well as the time they were observed.
If you cannot stabilize the flow rate, the following checks should be made in the order listed.
- Check the bag for adequate fluid.2. Check the infusion site for complications.3. Check the tubing for kinks.4. Reposition the patient’s arm. A bent arm may cause an obstruction of the flow.5. Adjust the height of the bag.6. Make sure the flow adjustment valve is working.
Changing an Existing IV Solution Container
- The IV solution container must be changed when 25 mL of the solution is left in the bag.- It is important to change the container before the solution is completely used to prevent air from entering the vein. - If air enters the vein, an air embolus could occur
Changing an Existing IV Solution Container procedure
- Carefully inspect the new solution container prior to changing the IV container2. Stop the flow of the existing IV.3. Remove the tubing from the old container without touching the spike and keep fingers behind the flange. 4. Insert the spike into the port of the new container while holding the neck of the port tightly to prevent slipping and possible contamination. 5. Invert the new container and hang it on the IV pole.6. Ensure the drip chamber is half full by squeezing the drip chamber and releasing if necessary. 7. Release clamp or open flow adjustment valve.8. Re-establish the correct drip rate.9. Record the procedure including the time the bag was changed.
. The following criteria should be assessed: when assessing new solution container
• Compare the label on the bag to the physician’s order to ensure the correct solution has been selected. The name of the solution should be read aloud. • Ensure the outer wrapper is intact — the bag is considered unsterile if it is out of the wrapper more than 24 hours. • Inspect the solution. The solution must be clear, colourless, and particle free. When inspecting, hold the container up to the light. Select a different container if there is doubt. • Check for leaks by squeezing the bag — leaks in the bag will cause the fluid to become contaminated. • Check the expiry date.
. Conditions in which intraosseous infusions can be used include:
• Obtaining blood samples for type and cross match• Clinical states such as:o Cardiac arresto Shock, widespread burnso Massive trauma• Other conditions such as:o Obesityo Peripheral edemao History of IV drug useo History of IV therapy time
The following points must be taken into consideration when using intraosseous infusions:
• Attempts to start a peripheral IV must be unsuccessful or peripheral IV sites are unavailable.• The preferred use is with the pediatric patient, but is NOT limited to that group.- Studies indicate that the absorption and distribution of fluids and medications appear to be very similar to that of intravenous routes- There is NO limitation as to what type of fluid or medication can be administered via intraosseous infusions
Vascular Access (Intraosseous) -indications
The ACP may attempt an intraosseous infusion in the following circumstances: 1. Children under the age of six years in a cardiac arrest where a peripheral vein is not visible (including the external jugular vein), or an IV has been unsuccessful on two attempts or 90 seconds has elapsed and a vein has not been successfully cannulized. 2. Children under the age of six years who are hypotensive where a peripheral vein is not visible (including the external jugular vein), or an IV has been unsuccessful on two attempts or 90 seconds has elapsed and a vein has not been successfully cannulized. 3. In adults where peripheral vein cannulation has been unsuccessful on two attempts or 90 seconds has elapsed and a vein has not been successfully cannulized.
Vascular Access (Intraosseous) this procedure may be initiated at the scene only in the following circumstances:
- If the patient is in cardiac arrest. 2. If there is a delay in the extrication of the patient. 3. Airway management during transportation will not allow for intraosseous initiation. 4. In those patients with “controlled hemorrhage” where ongoing blood loss will not be a problem (i.e. isolated soft tissue injury that can be controlled by pressure). 5. If the transport time is greater than 30 minutes in length.
Vascular Access (Intraosseous) -contraindications
- Fracture of the bone selected for IO insertion (consider alternatesite). 2. Previous significant orthopedic procedures (IO within 24 hours; prosthesis). 3. Infection at the site selected for insertion (consider alternate site). 4. Excessive tissue at insertion site, with absence of anatomical landmarks (consider alternate site).
Vascular Access (Intraosseous) -precautions
- Remember that securing an airway, maintaining adequate ventilation, and controlling hemorrhage have priority over the initiation of an intraosseous infusion. 2. Osteomyelitis, growth plate injury (in pediatric patients), and extravasation of fluid with compression of popliteal vessels or the tibial nerve may occur. 3. Do not perform more than one attempt in each tibia. 4. Medication may be administered IO. 5. Do not use hypertonic saline through an IO.
Equipment Required for IO Infusion
• Alcohol and betadine swabs• Sterile normal saline• IV administration set/pump• 3-way stopcock• Tape• Gloves• 10 mL syringe• 60 mL syringe• Intraosseous needle (Pediatric: 18-20 gauge) (Adult 13-18 gauge)• IV tubing extension set- It is advisable to use a needle suited to intraosseous inserts thereby avoiding problems and complications. - It is important to use the proper gauge needle in order to avoid fractures and/or plugging.
IO Sites
• Proximal tibia (most common site)• Distal femur• Medial and lateral malleolus• Proximal humerus• Sternum (requires a special needle)• Greater trochanter
Proximal Tibia
- The proximal tibia is the most common site of choice. - The precise location is one to two finger breadths (2.0 cm) below the tibial tuberosity. - The leg should be externally rotated with the needle inserted on the anteromedial surface with the needle tip directed towards the foot. - The epiphyseal plate can be damaged with improper site location and/or needle angle; therefore, caution is advised in site selection.
Medial Malleolus
- The medial malleolus may be a preferred site for morbidly obese patients.- The precise location when using the medial malleolus is one to two finger breadths (2.0 cm) above the medial malleolus (Figure 1). - The leg should be externally rotated with the needle directed slightly cephalad.
The following is a list of the steps that will be followed during the initiation of an intraosseous infusion:
- An indication for the initiation of the intraosseous has been identified.2. Equipment is assembled, including the proper size needle for that patient.3. Patient and site are prepared.4. Insert the IO needle.5. Remove the stylet from the needle and attach the syringe and extension set to the IO needle and attempt to aspirate blood and bone marrow.6. Slowly inject saline to ensure proper placement. Observe for signs of extravasation into surrounding tissue. If present discontinue infusion.7. Immediately connect stopcock to extension set and set the drip rate as appropriate.8. Secure the needle.9. Monitor and document the procedure.
- Equipment is assembled, including the proper size needle for that patient.
• Equipment is prepared.• Proper PPE is donned.• IV bag is charged and connected to a 3-way stopcock.• Antimicrobial swabs and tape are prepared.• Syringe is filled with 5 mL of saline.
- Patient and site are prepared.
• Ensure the patient/caregiver are informed of procedure.• Leg is stabilized using a towel roll.• Appropriate site is selected (proximal tibia or distal tibia).• Cleanse site with antimicrobial swab utilizing a circular in to out technique.
- Insert the IO needle.
• Insert the needle at a 90-degree angle to the leg making sure that you penetrate the skin and periosteum.• If using proximal tibia, insert anteromedial towards foot, if utilizing distal tibial insert anteroposterior slightly towards the head.• If using a manual needle begin to advance the needle with a “boring” technique.• If using an EZ-IO, pull the trigger and steady the drill to allow the device to do the work.
Osteomyelitis solution/reason
Very rare. Seen in patients with an infusion length of 24 hours or greater.
Subcutaneous abscess solution/reason
Related to extravasation of fluid. Be sure to monitor the site and surrounding area for swelling and treat accordingly.
fractures solution/reason
Related to excessive force and/or too large of needle gauge.
Fat embolism solution/reason
Rare. Presents as a pulmonary embolism with acute shortness of breath, chest pain and cyanosis.
Epiphyseal plate injury solution/reasosn
Rare. Poor insertion technique and/or improper site selection.
Incomplete penetration leading to fluid leakage into the surrounding tissue solution/reason
Remove the needle and restart in the opposite leg.
Leakage of fluid into surrounding tissue from a nearby previous site solution/reason
Remove the needle and restart in the opposite leg. Do not reuse the same leg for second or subsequent attempts.
Penetration of the posterior wall of the bone with fluid leakage into the surrounding tissue solution/reason
Remove the needle and restart in the opposite leg. Reexamine needle size and depth.
Fluid leakage from the site into surrounding tissue solution/reason
This is due to a poor fit of the needle in the bone. This is the most common complication and firm external pressure over the bone may resolve the leak. If not, remove the needle and restart in the opposite leg. Slight leakage at the site is common – only when the leakage is significant do you consider change.
blood product monitoring
wears pepperforms rights of transfusionensures physician orders monitor patient according to protocolmanage patient appropriately-must be stable for 30mins-can hang a new bag-charge the line with salon e first and then infuse the blood and then saline lock
IV Med Admin
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprepares equipment; blunt, syringe, alcohol pad draws up med in na clean wayconfirms absence of medication allergiesverbalizes 6 rights of medprepares patientcleanses med IV portensure latency of iv line by observing flow and ensure there are no signs of infiltrationattach syringe to port and administer medicationflush line and check for infiltration
SQ
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprepares equipment; blunt, syringe, alcohol pad draws up med in na clean wayconfirms absence of medication allergiesverbalizes 6 rights of medprepares patientPERFORMS SQ INJECTION PROPERLY;thumb and index finger pink skininject needle at a 45 degree angleinject by plunging depressor
IM
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprepares equipment; blunt, syringe, alcohol pad draws up med in na clean wayconfirms absence of medication allergiesverbalizes 6 rights of medprepares patientinject patient at a 90 degree angleinject med by depressing plunger
SL
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprime spray confirms absence of medication allergiesverbalizes 6 rights of medhave patient open mouth and put tongue on roof of mouthadminister depress the spray nozzle
buccal
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedopen oral glucose and retrieve applicator confirms absence of medication allergiesverbalizes 6 rights of medprepares patient in a way to secure airwayuse applicator and put glucose near molar teethdo not apply excessive amounts and monitor for airway
oral
wear ppeexamine med for expiry date, correct med and the solution is not cloudy or damagedconfirms absence of medication allergiesverbalizes 6 rights of medask pt to sit in comfortable positionprovide tablets and water
MDI
wear ppeexamine med for expiry date, correct med and the solution is not cloudy or damagedprepare medconfirms absence of medication allergiesverbalizes 6 rights of medadministers inhaled med properlyensure patient exhalesplace mouth piece in between teethduring inhalation depress canister
Rectal
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprepares equipment; suppository, lubeprepares suppository in a aseptic wayconfirms absence of medication allergiesverbalizes 6 rights of medprepares patientperform rectal admin appropriately insert lubricated suppository 1 inchhold butt together
IN
wear ppeexamine med for expirary date, correct med and the solution is not cloudy or damagedprepares equipment; syringe, MAD and gauzedraws up med in a aseptic wayconfirms absence of medication allergiesverbalizes 6 rights of medprepares patientperform IN admin appropriately
