Basic EMT IV Therapy

1. Basic EMT IV Therapy Dawn Daniels RN, CCRN Tucson Medical Center Pre-hospital Program

2. Agenda for the day……. • Base Hospital & ADHS/BEMS policy review • Anatomy & physiology • Identifying the purposes of IV infusions • IV solutions • Setting up an IV • IV catheters • Selecting the IV site • Starting the IV • Complications • Trouble-shooting • Removing the IV line • Case Reviews • Drip calculations

3. Prerequisites: • Certified EMT-Basic, under Medical Direction Course Competencies • This course is designed to develop the following course competencies: • Identify the need for fluid resuscitation in pediatric and adult victims • Identify and describe the vascular anatomy and venous access for the pediatric or adult victims • Identify and differentiate isotonic, hypotonic, and hypertonic solutions; • Select fluids, set up and manage equipment • Identify and demonstrate aseptic and safety techniques • Identify and describe indications and contraindications for intravenous site selection • Perform all peripheral intravenous cannulation techniques, monitor infusion • Demonstrate 100% accuracy in intravenous techniques in selected scenarios • Demonstrate 85% proficiency on a written examination.

4. R9-25-505. Protocol for IV Access by an EMT-B A. In this Section, unless the context otherwise requires, “EMS provider agency” means the emergency medical services provider or the ambulance service for whom the EMT-B is acting as an EMT-B. B. An EMT-B is authorized to perform IV access only after completing training that meets all requirements established in Exhibit 1. C. Before performing IV access, an EMT-B trained in IV access shall have received prior written approval from the EMT-B’s EMS provider agency and from an administrative medical director who agrees to provide medical direction for the EMT-B. D. An EMT-B shall perform IV access only under “on line” medical direction, under standing orders approved by the administrative medical director, or under the direction of a currently certified EMT-I or EMT-P who is also attending the patient upon whom the EMT-B is to perform the procedure. E. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B’s IV access attempts. F. An EMT-B trained in this optional procedure shall have a minimum of 5 IV starts per year. If less than 5, the EMT-B shall participate in a supervised base hospital clinical experience in which to obtain the minimum of 5 IV starts.

5. SAEMS PRE- HOSPITAL PROTOCOLS 75 SCOPE OF PRACTICE ADMINISTRATIVE 2.9 I. PURPOSE This protocol defines the scope of authority afforded to prehospital providers in the performance of their duties with and without on-line medical direction. This protocol will enable the pre-hospital provider to understand all skills allowed without on-line medical direction, specialized skills allowed with proof of training and skills allowed only AFTER on-line medical direction has concurred. II. DEFINITIONS A. STANDARD PERMISSIVE SKILLS Standard permissive skills are defined as skills that MAY be performed by pre-hospital personnel after approved initial training WITHOUT on-line medical direction. No telemetry or verbal orders are needed prior to the initiation of these skills for stabilization. Verification of on-going competency skill assessments must be obtained every two (2) years.

6. B. EXPANDED SCOPE OF PRACTICE: NON PERMISSIVE Expanded practice is defined as skills allowed by prehospital personnel with advanced training in the specific area. Prior approval of administrative medical direction authority is required. These skill MAY require on-line medical direction at the discretion of the medical direction authority.

7. GUIDELINES • Pre-Hospital Intravenous Access by EMT-Basic guidelines: • One (1) hour yearly review of curriculum related to Intravenous Therapy. • Five (5) successful IV starts in 6 month period (Jan. thru end of June----July thru end of December). • Use of QA form related to EMT-B IV Access for each encounter and attached it to the Patient Care Report. • Ongoing use of EMT-B IV Therapy form. Form to be reviewed randomly by Pre-Hospital Manager and QA/QI Officer, and at end of 6 months. Cycle describe above. • EMT-B will be limited to three (3) attempts at IV access peripherally per patient for this incident. • EMT-B will not initiate IV access on any patient less than 6 years of age. • It is an expectation that any problems related to this advanced skill will immediately be brought to the immediate attention of the Pre-Hospital Manager.

8. PROTOCOL • ON-LINE MEDICAL DIRECTION • EMT-I OR EMT-P GIVES YOU AN ORDER THAT IS ATTENDING THE SAME PATIENT • STANDING ORDERS • ALLERGIC REACTION • CHEST PAIN • Hypoglycemia • HYPERTERMIA • NAUESA AND VOMITING • SEIZURE

9. QA PROCESS • EMT-BASIC IV ACCESS QA FORM • Incident #: _________________ Date: _______________ • EMT #: _________________ Name: ______________(EMT-B) • Agency: ________________ • Patient Age: _________________ Sex: M F • BLS on scene time: ________ • IV start time: _________ • IV start on scene: Y/N IV start enroute: Y/N • Type of fluid: ______________________ • Total volume infused: _______________ • Medical Control Authorization: Circle One • On-Line base hospital patch time: _________ Standing Orders ( attach SO form) Paramedic/IEMT Direction • Ambulance on scene time: ____________ • ALS on scene time: ____________ • ALS meds given by IV Y/N Time given: __________ • EMT IV attempts: ______ • If greater than 2 give reason: _____________________________________________________________ • _____________________________________________________________ • Complications: Y/N SUCCESSFUL/UNSUCCESSFUL • Describe: • _____________________________________________________________ • _____________________________________________________________ • Patient Outcome: • _____________________________________________________________

10. IV LOG

11. Anatomy

12. Introduction • Knowing the anatomy will aid you in performing your skills, even when you cannot see the veins. • After this block of instruction you should be able to differentiate between veins and arteries, and show where these items can be found.

13. Some questions we’ll need to answer • What is skin? • What is an artery? • Where are arteries found? • What is a vein? • Where are veins found? • What is blood? • Question:

14. Skin • Covers the entire body and acts as a protective layer between the body and the environment. • The main functions of the skin are: • Protection from harmful influences • Control of body temperature • Conveyance of sensory impressions • Some areas of the bodies skin are highly sensitive and the insertion of a needle in one area may cause a great deal of pain, while another area may be practically painless.

15. Besides epithelial cells and connective tissue cells, the skin also contains delicately entwined nerves and blood vessels.

16. Blood Vessels • With the exception of capillaries, the walls of the blood vessels consist of three layers, though the thickness or construction of the individual layers can vary according to the vessel type.

17. Blood Vessels • The outer layer consists of connective tissue and facilitates the fitting of the vessel into its environment. • The middle layer is composed of smooth muscle containing elastic fibers. • The inner layer consists of thin connective tissue. It is covered by a layerof single-layered endothelial cells.

18. Arteries • The arteries are blood vessels which transports blood away from the heart. • They are different in construction from the veins in that they have an additional layer of an elastic membrane situated between the inner and middle wall layers.

20. Depending on the task and the location of the artery, its middle layer may be dominated by smooth muscle or elastic fibers. Arteries

21. Arteries • When the heart pumps blood into the arteries during the expulsion phase (systole), their high proportion of elastic fibers permits them to distend. • During the relaxation phase (diastole) of the heart, they contract again, transporting blood on further. • Arteries with muscle predominating are able to widen (vasodilation) or narrow (vasoconstriction) their diameter through contraction, thus enabling the amount of blood contained within them to increase or decrease with the demands of the body. • Arterioles are the smallest arteries.

22. The veins are the blood vessels which transport blood towards the heart. The wall layers of the veins are thinner than those of the arteries, yet contain more connective tissue. The muscle layer is less marked. The diameter of veins are larger than that of arteries. Veins

23. Veins • As a result of the thin layer of muscle the veins are not able to move blood themselves. They are aided by the surrounding musculature around them. • In order to prevent the blood from flowing back, some of the veins, especially those within the extremities, are equipped with venous valves. • When the blood is flowing towards the heart, the venous valves lie flat against the venous wall. If the blood congests or starts to flow back, the valves close.

24. Capillaries • Capillaries are the smallest blood vessels in the body • They are connected to the arterioles and into the venules, thus representing the link between arteries and veins.

25. Capillaries • In contrast to arteries and veins, capillaries have neither a middle or outer wall layer. They only have an inner layer, constructed of connective tissue and endothelial cells. • The diameter of capillaries is very small because of they are so small they circulate in single file.This fact, and the thinness of their wall layer promote their ability to exchange material and Water with their environment. • The oxygen and nutrients contained within the blood are pressed out of them as a result of the blood pressure and passed off to the intercellular cavities. • Carbon dioxide and metabolic products are absorbed by the blood in the exchange

26. Blood • 4-5x thicker than water • Liquid connective tissue • Adults = 7% of patients weight • 4-6 Liters of blood • Children = 9% of patients weight

27. Physical Characteristics of Blood • Color range • Oxygen-rich blood is scarlet red • Oxygen-poor blood is dull red • pH must remain between 7.35–7.45 • Blood temperature is slightly higher than body temperature (100.4)

28. Functions of Blood • Transportation – oxygen, nutrients, hormones, heat, electrolytes. • Carries away from the body tissues - Waste matter - CO2 • Protection – Vital role in our immune system; clotting mechanisms that prevent blood loss • Regulation – pH, body temperature, water content

29. Components of Blood • PLASMA – is the yellowish fluid of the blood and consists primarily of water (92%) and plasma proteins (7%) • Proteins – albumin and fibrinogen • FORMED ELEMENTS – solid component of the blood consisting of red blood cells, white blood cells, and platelets • BLOOD = 55% plasma

30. Blood Plasma • Composed of approximately 92 percent water • Contains: • Nutrients, salt solution • Respiratory gases • Hormones • Proteins, Waste products

31. Plasma Proteins • Albumin – regulates osmotic pressure • Clotting proteins – help to stem blood loss when a blood vessel is injured • Antibodies – help protect the body from antigens

32. Formed Elements“Types of Cells” • Erythrocytes = Red Blood Cells • Leukocytes = White Blood Cells • Thrombocytes = Platelets

33. Erythrocytes “Red Blood Cells” • The main function is to carry oxygen • Anatomy of circulating erythrocytes • Cells without a nucleus • Produced continuously in the bone marrow from stem cells at a rate of 2-3 million cells per second. ─ Hemoglobin 95% of a red cell • Approximately 120 days life span • Outnumber white blood cells 1000:1

34. Leukocytes“White Blood Cells” • These are complete cells, with a nucleus • Crucial in the body’s defense against disease. Ingest pathogens & destroy • Produce antibodies • Can respond to chemicals released by damaged tissues

35. Thrombocytes“Platelets” • Cell fragments without nuclei that release blood clotting chemicals • Life span of 5-9 days • Needed for the clotting process • Platelets and clotting proteins work together.

36. So….Why should we allow EMT’s to start IV’s??

37. Purpose of starting IV’s • To deliver fluids • To deliver medications

38. Cellular Physiology • Body Fluid • 1. Total body water = 60% of body weight • Intracellular = 45% of body weight • Extracellular = 15% of body weight • 2. Electrolytes • Cations = positive charge • sodium • potassium • magnesium • calcium

39. Anions = negative charge • Bicarbonate • chloride • Principles of electrolyte balance • Water follows sodium • Potassium > intracellular • Sodium > extracellular • Changes in ion concentration effect muscle and nerve function

40. 3. Protein • Albumin • Plasma • Other • 4. Fluid loss • Blood loss • Plasma loss • Nausea/vomiting/diarrhea • Sweating

41. Movement of Body Fluids • Osmosis – the flow of fluid across a semi permeable membrane (cell wall) from a lower solute concentration to a higher concentration.

42. Isotonic – IV fluids that approximate the osmolaity of blood plasma. I.e.: 0.9% Normal Saline (note the biconcave shape of the cells as they circulate in blood.) Hypotonic – IV solutions that have a lower osmolarity than blood plasma thus drawing fluids into the cell. I.e.: D5W. (note the cells are visibly swollen and have lost their biconcave shape, and at 100 mOs, most have swollen so much that they have ruptured, leaving what are called red blood cell ghosts. In a hypotonic solution, water rushes into cells.) Hypertonic – IV fluids that have a higher osmolality than normal blood plasma thus drawing fluids out of the cells and they get irritated when infused.I.e.: D50 (note water has flowed out of the cells, causing them to collapse and assume the spiky appearance you see.)

43. Types of IV Solutions • 0.9% Sodium Chloride • Lactated Ringers • D5W

44. 0.9% Sodium Chloride • Also called normal saline • Isotonic solution of sodium chloride in water • 9 grams of sodium chloride per liter • Indications • Restore loss of water and sodium chloride • Fractures • Trauma • Dehydration • Hypoglycemia • Non-traumatic hypoperfusion • Contraindications • Use with caution in CHF and pulmonary edema

45. Lactated Ringers • Source of water, electrolytes, and calories • Indications • To replenish fluid and calories, and restore loss of electrolytes • Trauma • Burns • OB • Non-traumatic hypotension • dehydration • Contraindications • Use with caution in CHF, pulmonary edema, and liver disease

46. D5W • Hypotonic solution of dextrose in water (50 grams of dextrose per liter) • Indications • Directed by MD • Contraindications • Head injury • Children

47. Combinations of Normal Saline, Lactated Ringers, and D5W are often common. All fluids come in 250cc, 500cc, and 1000cc bags.

48. Setting Up An IV

49. Assemble and prepare the necessary equipment You will need: The correct IV solution The correct administration set An IV catheter An IV start pack Tourniquet Alcohol prep Opsite or equivalent Tape

50. Inspect the container and solution • Check the label and the expiration date • Look for tears in the bag • Assess the clarity of the solution; if it isnot clear – DO NOT USE IT! • Look at the pull-tab and make sure that it is intact