Intravenous Therapy
Advanced Care Paramedicine
Module: 7
Session: 4
Thirty years ago…
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Rampart, Squad 51.
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We have a 20 year old male
motorcycle rider involved in a
motor vehicle collision
complaining of neck, back and
leg pain.
He presents with compound
fractures to both femurs and has
significant blood loss.
We are requesting an order for
two large bore IV’s and Ringer’s
Lactate.
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Objectives
 Identify the reasons IV therapy is performed in the
prehospital setting
 Identify the fluids commonly administered
 State the basis of fluid and electrolyte balance
 Identify factors affecting water loss
 Explain the recommended uses of IV solutions
 Identify common complications and reactions
 Calculate a flow rate
 Demonstrate proper skin cleansing and aseptic
venipuncture technique
 Demonstrate proper IV cannulation technique
Why do we cannulate?
 Fluid administration
 Medication administration
 To maintain life (electrolytes, blood…)
 Do we do them to be EHSNS protocol
compliant?
IV fluids
 Normal saline (0.9% NS)
 Lactated Ringer’s (LR)
 Also known as Hartman’s solution or RL
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D5W
½ NS
D5 ½ NS
D5RL (D5LR)
Isotonic Solutions
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Characteristics
Same tonicity as plasma
Osmotic pressure is the
same as the inside of the
cell
Fluid never leaves or
enters the cell
Approximate osmolarity is
240 – 340 mOsm/L
Will increase circulating
volume, which may lead to
fluid volume excess or
overload.
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Solutions
2.5% dextrose/0.45%
NaCl
0.9% NaCl
Lactated Ringers
2.5% dextrose in ½
lactated ringers
6% dextan and 0.9%
NaCl
10% dextran and 0.9%
NaCl
Normal Saline
 Most commonly administered IV fluid
prehospitally
 IV fluid of choice for EHSNS protocols
 Why?
Lactated Ringers
 Composed of multiple electrolytes in
saline
 Has fallen out of favor as one of main
IV fluids for treatment of traumatic
hypovolemia in past decade
 Why?
Hypotonic Solutions
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Characteristics
May cause blood cells to
swell and burst
May cause changes or
damage endothelial cells
Exert less osmotic
pressure than the fluid in
the extracellular
compartment
Fluid is drawn into the
cells
Approximate osmolarity <
240 mOsm/l
Solutions
 0.45% NaCl
 10% dextran and 5%
dextrose (slightly
hypotonic)
Hypertonic Solutions
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Characteristics
May cause blood cells to
shrink
May cause dame/changes
to endothelial cells
Exert more osmotic
pressure then the
extracellular fluid
Fluid is drawn from the cell
into the vascular space
Approximate osmolarity >
340 mOsm/l
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Solutions
5% dextrose/0.2% NaCl
5% dextrose/0.9% NaCl
D 5W
D10W
D50W
5% NaHCO3
10%, 15% and 20%
Mannitol
6% dextran and 0.9% NaCl
Administration Sets
 The calibration of the administration
set must be known in order to
calculate the flow of the IV fluids
correctly.
 Macrodrip sets
 10, 15 or 20 gtts/ml
 Microdrip (minidrip)
 60 gtts/ml
Where do we cannulate?
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Hand
Forearm
Neck
Foot
Equipment Required
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Solution
Administration set
IV cannula
Tourniquet
Alcohol swab
Gloves
Sharps bin
Op site and gauze
Tape
If performing a Lock
 Lock, syringe and saline
Catheter specifics
Color
Grey
Green
Pink
Blue
Size
16 G
18 G
20 G
22 G
Int Dia/Length
1.4 mm/45 mm
1.0 mm/45 mm
0.8 mm/32 mm
0.6 mm/25 mm
Max Flow
180 mls/min
80 mls/min
54 mls/min
31 mls/min
 The length and diameter will affect the amount of fluid
able to be infused through the catheter
 Larger diameter and shorter length gives more fluid
 Small diameter and long length gives less fluid
Types of catheters
 Jelco
 Cathelon
 Insyte
Types of catheters
 Protective
 Protective Plus
Administration Sets
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10 gtts/ml
15 gtts/ml
60 gtts/ml
Blood sets
Vein Selection
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Based on:
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Condition
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Palpate to confirm type of vessel
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Is the pt right or left handed
Is the extremity injured
Avoid joints (stabilization)
Does the pt have a shunt (fistula)
Purpose
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Straight with no turns or bumps
Location
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Should be soft and spongy
Fluid replacement, Medication route, Safety line (lock)
Dictates flow rate and type of fluid to be infused
Try to use large veins for large quantities of fluid
Duration
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What type of patient (trauma, cardiac or outpatient)
Patient comfort over long period of time
Prolonged therapy may require multiple punctures
For long durations use distal veins first
Fluid Replacement
 Blood
 Replaced at a ratio of 3:1 of IV fluid to blood being
replaced
 Minimum daily requirements
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1st 10 kg
2nd 10 kg
3rd 10 kg
4th 10 kg
5th 10 kg
 Example
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100 ml/hr
50 ml/hr
20 ml/hr
10 ml/hr
10 ml/hr
50 kg patient
100 ml/hr + 50 ml/hr + 20 ml/hr + 10 ml/hr + 10 ml/hr = 190
ml/hr
Contraindications
 Distal to a fracture site in a limb
 Through damaged or abraded skin
 Burns may be an exception if there is no other
accessible site
 In an arm affected by a radical mastectomy,
edema, blood clot or infection
 In an arm with a fistula for dialysis or a
peripherally inserted control catheter (PICC
Line)
Procedure
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Obtain consent and explain rationale for IV therapy
Assess that the pt meets the criteria for the procedure
Ensure that there are no contraindications for the procedure
Observe universal precautions for body substance exposures
Prepare all necessary equipment
Position the patient
Apply a tourniquet 3 – 5 inches above the selected site
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Select the most appropriate venipuncture site
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Patient may make a fist to assist in engorging the vein
Condition
Location
Purpose
Duration
Prepare the pt’s arm using alcohol swab
Procedure
 Insert needle through skin
 Should be at an 30° angle
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Lower angle (15°)and enter vein
Observe flashback
Enter vein a ‘little bit more’
Enter catheter into vein
Release tourniquet
Withdraw needle and discard in sharps container,
tamponade the vein to avoid blood spill
 Attach iv tubing and open flow valve observing for
infiltration
 Cover with Op site or other sterile dressing, tape in
place
IV Access
Complications
 Local complications
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Hematomas
Infiltration
Necrosis
Thrombophlebitis
 Systemic complications
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Pulmonary edema
Speed shock
Pyrogenic reaction
Pulmonary embolism
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blood
Air
 Catheter shear
Local - Hematomas
 Causes:
 Punctured vein
 Symptoms:
 Bruising
 Tenderness
 Swelling
 Preventative
actions:
 Proper techniques
Local - Infiltration
 Causes:
 Poor insertion
techniques
 Improper taping
 Over active patient
 IV slows or stops
 Symptoms:
 Swelling or hardness
 Feeling of coldness
 Leaking at the site
 Preventative actions:
 Armboards, proper
taping
 Routine checks of IV
flow and site
Local - Necrosis
 Causes:
 Symptoms:
 Preventative actions:
 Irritation of tissues
from infiltrated drug or
fluid
 Swelling, tenderness
 Inflammation or
bruising
 Routine checks
 Report any changes
Local - Thrombophlebitis
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Causes:
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Trauma to endothelium
from chemical means
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Symptoms:
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Pain, redness, swelling
along infected vein
Generalized symptoms
such as fever, malaise,
rapid pulse
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Preventative actions:
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Avoid insertion over joint
Select veins with adequate
blood flow for infusions of
hypertonic solutions
Systemic – Pulmonary Edema
 Causes:
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Circulatory overload from
too rapid infusion when
patient has impaired renal
or cardiac function
 Symptoms:
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JVD, ↑BP, ↑Resps,
dyspnea, agitation
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Watch rate
Oxygen, sit pt upright
Slow IV and contact OLMC
 Preventative actions:
Systemic – Speed Shock
 Causes:
 IV running to rapidly
 Rapid injection of a
drug
 Symptoms:
 ↓BP, rapid pulse
 Labored resps,
cyanosis
 Faint, ↓LOC
 Preventative actions:
 Use controlled volume
infusion set
 Upon initiation, ensure
free flowing prior to
rate adjustment
Systemic – Pyrogenic
Reaction
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Causes:
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Contaminated IV solutions
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Symptoms:
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Symptoms generally occur
after IV begun
↑temp, chills, headache,
N/V, circulatory collapse
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Preventative actions:
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Check IV fluids for
cloudiness and particles
Use fresh open IV’s
Systemic – PE
(Blood/Embolus)
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Causes:
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Unfiltered blood
Partially dissolved drug
Particulate matter in IV
solution
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Symptoms:
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Dyspnea, cyanosis, pain,
anxiety, tachycardia,
tachypnea
Preventative actions:
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Infuse blood through filter
Dissolve drugs completely
Use good judgment when
syringing IV’s
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Systemic – PE (Air)
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Causes:
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Failure to clear tubing of air
Allowing air to enter the
system
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Symptoms:
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Cyanosis, ↓BP, weak,
tachycardia, ↓LOC, nonspecific chest or ABD pain
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Preventative actions:
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Don’t let IV run dry
Clear tubing properly
Check syringe prior to injecting
If occurs place pt on left side
and contact OLMC
Troubleshooting
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If blood begins to flow back in the IV tubing
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If your IV does not run…
Start at the top, work your way back to the patient
Is the bag empty?
Check the IV set clamps to insure they are open
Check tubing for kinks
Check site for any problems
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Check location of the bag to insure it is in a gravity flow location
Insure all valves are open
If continues, reassess site and assure arterial cannulation has
not occurred
Blood backing up
Infiltration
Do you need to flush the site
Is your tourniquet still one!
External Jugular (EJ) cannulation
EJ’s
 Often used in severe cases of shock,
unresponsiveness and cardiac arrest since
they are HUGE and relatively easy to
cannulate.
 Why are they not commonly used in those
who are conscious ?
 Why are they not a good choice for patients
of multi system trauma ?
EJ cannulation procedure
 Place patient supine / slight reverse Trendelenburg
 Why ???
 Turn patients head slightly to opposite side
 Cleanse with antiseptic using universal precautions
 Create tourniquet effect with fingers by applying light
pressure to the inferior aspects of the EJ being
cannulated.
Procedure
 Aim needle towards ipsilateral nipple
 Insert needle and enter vein
 Observe flashback
 Withdraw needle and attach IV tuning
 Cover site with sterile dressing
EJ cannulation
Calculating flow rates
Volume to be administered (ml) X
Drip set (gtts/ml)
=
Time to be infused (min)
Drip sets
10 gtt/ml (macro)
15 gtt/ml
20 gtt/ml
60 gtt/ml (micro)
10 drops = 1 ml
15 drops = 1 ml
20 drops = 1 ml
60 drops = 1 ml
Drops/min
(gtts/min)
Factor
6
4
3
1
Calculations
 Your patient is to receive 1000 ml of normal saline
(NS) over a 12 hour period using a microdrip (60
gtt/ml) administration set. The formula will now look
like this:
Volume to be administered (ml) X
Drip set (gtts/ml)
=
Drops/min
(gtts/min)
=
Drops/min
(gtts/min)
=
Drops/min
(gtts/min)
Time to be infused (min)
1000 ml
X
60 gtts/ml
720 min
83.333
Now add medications
 A physician orders 2 mg/min of
Lidocaine to your patient. She orders
2 g of lidocaine to be added to 500 ml
NaCL. Using a 60 gtt/ml set, calculate
the gtt/min.
Calculation
[]
=
Mass
Volume
=
2.0 g
500 ml
Dose
=
D X V
H
=
2 mg/min X 500 ml
2000 mg
=
2000 mg
500 ml
=
=
4 mg/ml
=
1000 mgml/min
2000 mg
0.5 ml/min
Calculation
Volume to be administered (ml) X
Drip set (gtts/ml)
=
Drops/min
(gtts/min)
=
Drops/min
(gtts/min)
=
Drops/min
(gtts/min)
Time to be infused (min)
0.5 ml
X
60 gtts/ml
1 min
30
A Variation to the Same
Volume (ml) X Ordered (mg/min)
X
Drip set (gtts/ml) =
On Hand (mg)
500 ml
X
2 mg/min
X
60 gtt/ml
=
Drops/min
(gtts/min)
=
Drops/min
(gtts/min)
200 mg
30
Drops/min
(gtts/min)