1、Module:Session:Intravenous Therapy74Thirty years agonRampart,Squad 51.nWe have a 20 year old male motorcycle rider involved in a motor vehicle collision complaining of neck,back and leg pain.nHe presents with compound fractures to both femurs and has significant blood loss.nWe are requesting an orde
2、r for two large bore IVs and Ringers Lactate.Objectivesn Identify the reasons IV therapy is performed in the prehospital settingn Identify the fluids commonly administeredn State the basis of fluid and electrolyte balancen Identify factors affecting water lossn Explain the recommended uses of IV sol
3、utionsn Identify common complications and reactionsn Calculate a flow raten Demonstrate proper skin cleansing and aseptic venipuncture techniquen Demonstrate proper IV cannulation techniqueWhy do we cannulate?n Fluid administrationn Medication administrationn To maintain life(electrolytes,blood)n Do
4、 we do them to be EHSNS protocol compliant?IV fluidsn Normal saline(0.9%NS)n Lactated Ringers(LR)Also known as Hartmans solution or RLn D5Wn NSn D5 NSn D5RL(D5LR)Isotonic SolutionsCharacteristicsn Same tonicity as plasman Osmotic pressure is the same as the inside of the celln Fluid never leaves or
5、enters the celln Approximate osmolarity is 240 340 mOsm/Ln Will increase circulating volume,which may lead to fluid volume excess or overload.Solutionsn 2.5%dextrose/0.45%NaCln 0.9%NaCln Lactated Ringersn 2.5%dextrose in lactated ringersn 6%dextan and 0.9%NaCln 10%dextran and 0.9%NaClNormal Salinen
6、Most commonly administered IV fluid prehospitallyn IV fluid of choice for EHSNS protocolsn Why?Lactated Ringersn Composed of multiple electrolytes in salinen Has fallen out of favor as one of main IV fluids for treatment of traumatic hypovolemia in past decaden Why?Hypotonic SolutionsCharacteristics
7、n May cause blood cells to swell and burstn May cause changes or damage endothelial cellsn Exert less osmotic pressure than the fluid in the extracellular compartmentn Fluid is drawn into the cellsn Approximate osmolarity 340 mOsm/lSolutionsn5%dextrose/0.2%NaCln5%dextrose/0.9%NaClnD5WnD10WnD50Wn5%Na
8、HCO3n10%,15%and 20%Mannitoln6%dextran and 0.9%NaClAdministration Setsn The calibration of the administration set must be known in order to calculate the flow of the IV fluids correctly.Macrodrip setsn 10,15 or 20 gtts/ml Microdrip(minidrip)n 60 gtts/mlWhere do we cannulate?n Handn Forearmn Neckn Foo
9、tEquipment Requiredn Solutionn Administration setn IV cannulan Tourniquetn Alcohol swabn Glovesn Sharps binn Op site and gauzen Tape n If performing a LockLock,syringe and salineCatheter specificsColorSizeInt Dia/LengthMax FlowGrey16 G1.4 mm/45 mm180 mls/minGreen18 G1.0 mm/45 mm80 mls/minPink20 G0.8
10、 mm/32 mm54 mls/minBlue22 G0.6 mm/25 mm31 mls/minn The length and diameter will affect the amount of fluid able to be infused through the catheterLarger diameter and shorter length gives more fluidSmall diameter and long length gives less fluidTypes of cathetersn Jelcon Cathelonn InsyteTypes of cath
11、etersn Protectiven Protective PlusAdministration Setsn 10 gtts/mln 15 gtts/mln 60 gtts/mln Blood setsVein SelectionnBased on:ConditionnPalpate to confirm type of vesselShould be soft and spongynStraight with no turns or bumpsLocationnIs the pt right or left handednIs the extremity injurednAvoid join
12、ts(stabilization)nDoes the pt have a shunt(fistula)PurposenFluid replacement,Medication route,Safety line(lock)nDictates flow rate and type of fluid to be infusednTry to use large veins for large quantities of fluidDurationnWhat type of patient(trauma,cardiac or outpatient)nPatient comfort over long
13、 period of timenProlonged therapy may require multiple puncturesnFor long durations use distal veins firstFluid Replacementn BloodReplaced at a ratio of 3:1 of IV fluid to blood being replacedn Minimum daily requirements1st 10 kg100 ml/hr2nd 10 kg50 ml/hr3rd 10 kg20 ml/hr4th 10 kg10 ml/hr5th 10 kg10
14、 ml/hrExample50 kg patientn100 ml/hr+50 ml/hr+20 ml/hr+10 ml/hr+10 ml/hr=190 ml/hrContraindicationsn Distal to a fracture site in a limbn Through damaged or abraded skin Burns may be an exception if there is no other accessible siten In an arm affected by a radical mastectomy,edema,blood clot or inf
15、ectionn In an arm with a fistula for dialysis or a peripherally inserted control catheter(PICC Line)ProcedurenObtain consent and explain rationale for IV therapynAssess that the pt meets the criteria for the procedurenEnsure that there are no contraindications for the procedurenObserve universal pre
16、cautions for body substance exposuresnPrepare all necessary equipmentnPosition the patientnApply a tourniquet 3 5 inches above the selected sitePatient may make a fist to assist in engorging the veinnSelect the most appropriate venipuncture siteConditionLocationPurposeDurationnPrepare the pts arm us
17、ing alcohol swabProceduren Insert needle through skinShould be at an 30 angle n Lower angle(15)and enter veinn Observe flashbackn Enter vein a little bit moren Enter catheter into veinn Release tourniquetn Withdraw needle and discard in sharps container,tamponade the vein to avoid blood spilln Attac
18、h iv tubing and open flow valve observing for infiltrationn Cover with Op site or other sterile dressing,tape in placeIV Access Complications n Local complicationsHematomasInfiltrationNecrosisThrombophlebitisn Systemic complicationsPulmonary edemaSpeed shockPyrogenic reactionPulmonary embolismnblood
19、nAirCatheter shearLocal-Hematomas n Causes:n Symptoms:n Preventative actions:n Punctured veinn Bruisingn Tendernessn Swellingn Proper techniquesLocal-Infiltration n Causes:n Symptoms:n Preventative actions:n Poor insertion techniquesn Improper tapingn Over active patientn IV slows or stopsn Swelling
20、 or hardnessn Feeling of coldnessn Leaking at the siten Armboards,proper tapingn Routine checks of IV flow and siteLocal-Necrosisn Causes:n Symptoms:n Preventative actions:n Irritation of tissues from infiltrated drug or fluidn Swelling,tendernessn Inflammation or bruisingn Routine checksn Report an
21、y changesLocal-ThrombophlebitisnCauses:nSymptoms:nPreventative actions:nTrauma to endothelium from chemical meansnPain,redness,swelling along infected veinnGeneralized symptoms such as fever,malaise,rapid pulsenAvoid insertion over jointnSelect veins with adequate blood flow for infusions of hyperto
22、nic solutionsSystemic Pulmonary Edeman Causes:n Symptoms:n Preventative actions:nCirculatory overload from too rapid infusion when patient has impaired renal or cardiac functionnJVD,BP,Resps,dyspnea,agitationnWatch ratenOxygen,sit pt uprightnSlow IV and contact OLMCSystemic Speed Shockn Causes:n Sym
23、ptoms:n Preventative actions:n IV running to rapidlyn Rapid injection of a drugn BP,rapid pulsen Labored resps,cyanosisn Faint,LOCn Use controlled volume infusion setn Upon initiation,ensure free flowing prior to rate adjustmentSystemic Pyrogenic ReactionnCauses:nSymptoms:nPreventative actions:nCont
24、aminated IV solutionsnSymptoms generally occur after IV begunntemp,chills,headache,N/V,circulatory collapsenCheck IV fluids for cloudiness and particlesnUse fresh open IVsSystemic PE(Blood/Embolus)nCauses:nSymptoms:nPreventative actions:nUnfiltered bloodnPartially dissolved drugnParticulate matter i
25、n IV solutionnDyspnea,cyanosis,pain,anxiety,tachycardia,tachypneanInfuse blood through filternDissolve drugs completelynUse good judgment when syringing IVsSystemic PE(Air)nCauses:nSymptoms:nPreventative actions:nFailure to clear tubing of airnAllowing air to enter the systemnCyanosis,BP,weak,tachyc
26、ardia,LOC,non-specific chest or ABD painnDont let IV run drynClear tubing properlynCheck syringe prior to injectingnIf occurs place pt on left side and contact OLMCTroubleshootingnIf blood begins to flow back in the IV tubingCheck location of the bag to insure it is in a gravity flow locationInsure
27、all valves are openIf continues,reassess site and assure arterial cannulation has not occurrednIf your IV does not runnStart at the top,work your way back to the patientnIs the bag empty?nCheck the IV set clamps to insure they are opennCheck tubing for kinksnCheck site for any problemsBlood backing
28、upInfiltrationnDo you need to flush the sitenIs your tourniquet still one!External Jugular(EJ)cannulationEJsn Often used in severe cases of shock,unresponsiveness and cardiac arrest since they are HUGE and relatively easy to cannulate.n Why are they not commonly used in those who are conscious?n Why
29、 are they not a good choice for patients of multi system trauma?EJ cannulation proceduren Place patient supine/slight reverse Trendelenburgn Why?n Turn patients head slightly to opposite siden Cleanse with antiseptic using universal precautionsn Create tourniquet effect with fingers by applying ligh
30、t pressure to the inferior aspects of the EJ being cannulated.Proceduren Aim needle towards ipsilateral nipplen Insert needle and enter veinn Observe flashbackn Withdraw needle and attach IV tuningn Cover site with sterile dressingEJ cannulationCalculating flow ratesDrip setsFactor10 gtt/ml(macro)10
31、 drops=1 ml615 gtt/ml15 drops=1 ml420 gtt/ml20 drops=1 ml360 gtt/ml(micro)60 drops=1 ml1Volume to be administered(ml)Time to be infused(min)XDrip set(gtts/ml)=Drops/min(gtts/min)Calculations n Your patient is to receive 1000 ml of normal saline(NS)over a 12 hour period using a microdrip(60 gtt/ml)ad
32、ministration set.The formula will now look like this:Volume to be administered(ml)Time to be infused(min)XDrip set(gtts/ml)=Drops/min(gtts/min)1000 ml720 minX60 gtts/ml=Drops/min(gtts/min)83.333=Drops/min(gtts/min)Now add medicationsn A physician orders 2 mg/min of Lidocaine to your patient.She orde
33、rs 2 g of lidocaine to be added to 500 ml NaCL.Using a 60 gtt/ml set,calculate the gtt/min.Calculation=MassVolume=2.0 g500 ml=2000 mg 500 ml=4 mg/mlDose=DHXV=2 mg/min2000 mg=1000 mgml/min 2000 mg=0.5 ml/minX500 mlCalculationVolume to be administered(ml)Time to be infused(min)XDrip set(gtts/ml)=Drops/min(gtts/min)0.5 ml1 minX60 gtts/ml=Drops/min(gtts/min)30=Drops/min(gtts/min)A Variation to the SameVolume(ml)On Hand(mg)XDrip set(gtts/ml)=Drops/min(gtts/min)=Drops/min(gtts/min)30=Drops/min(gtts/min)X Ordered(mg/min)500 ml200 mgX60 gtt/mlX2 mg/min
