EMS Medication Administration - Intravenous (IV) Route

EMS providers must have a thorough understanding of intravenous (IV) medication administration to ensure patient safety and effective treatment. 

Here are key points they should know:

1. Indications and Contraindications

• Indications: Providers should know the clinical conditions or scenarios where IV medication is necessary, such as pain management, cardiac arrest, anaphylaxis, and dehydration.
• Contraindications: Awareness of conditions or situations where IV medication might be harmful, such as allergies to the medication or pre-existing medical conditions that might complicate IV therapy.

2. Pharmacology

• Mechanism of Action: Understanding how the medication works in the body.
• Dosage and Administration: Correct dosing calculations based on the patient's age, weight, and condition. Knowledge of administration techniques, such as bolus or continuous infusion.
• Side Effects and Adverse Reactions: Recognizing potential side effects and being prepared to manage adverse reactions.

3. IV Access

• Venipuncture Technique: Proficiency in starting an IV line, including choosing the appropriate vein and using aseptic technique to prevent infection.
• Types of IV Catheters: Familiarity with different types of IV catheters (e.g., peripheral IVs, central lines) and their appropriate use.
• Securing the IV Site: Ensuring the IV site is secure to prevent dislodgement and complications.

4. Medication Preparation

• Aseptic Technique: Maintaining sterility while preparing and administering medications.
• Reconstitution: Knowledge of how to properly reconstitute medications that come in powdered form.
• Dilution: Understanding which medications need dilution and the correct fluids and concentrations to use.

5. Administration Techniques

• Bolus vs. Infusion: Knowing when to administer medication as a bolus (rapid administration) versus a continuous or intermittent infusion.
• Rate of Administration: Understanding the correct rate at which to administer various medications to avoid adverse reactions.
• Monitoring: Continuous monitoring of the patient’s vital signs and clinical status during and after administration.

6. Complications and Management

• Infiltration and Extravasation: Identifying and managing IV infiltration (when IV fluid leaks into surrounding tissue) and extravasation (leakage of medication into surrounding tissue).
• Phlebitis: Recognizing signs of phlebitis (inflammation of the vein) and taking appropriate action.
• Air Embolism: Understanding how to prevent and manage air embolism, a potentially life-threatening complication.

7. Documentation

• Accurate Record-Keeping: Documenting the medication name, dose, route, time of administration, patient’s response, and any adverse reactions.
• Reporting: Properly reporting any medication errors or adverse events.

8. Legal and Ethical Considerations

• Scope of Practice: Adhering to the legal scope of practice for their certification level (e.g., EMT, Advanced EMT, Paramedic).
• Informed Consent: Ensuring that patients (or their guardians) provide informed consent for IV medication administration whenever possible.
• Continuing Education: Engaging in ongoing education to stay updated on new medications, techniques, and best practices.

Conclusion

Effective IV medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous education, practice, and adherence to protocols are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Hantke, J (2022) IV Placement and Management. Appropedia. Accessed May 22, 2024.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medication Administration - Intravenous (IV) Catheter Complications

EMS Providers need to be aware of the potential complications associated with IV catheter placement, their presentations, and how to manage them.

Here’s an overview:

1. INFILTRATION

Definition: Leakage of IV fluid into the surrounding tissue.

Presentation:

• Swelling at the insertion site
• Coolness to the touch
• Pallor (pale skin)
• Discomfort or pain

Management:

• Discontinue the IV immediately.
• Elevate the affected limb.
• Apply a warm or cold compress based on patient comfort and solution infiltrated.

2. EXTRAVASATION

Definition: Leakage of vesicant (irritating) fluids into the surrounding tissue.

Presentation:

• Similar to infiltration, but with more severe symptoms
• Pain or burning at the site
• Blistering or tissue necrosis

Management:

• Stop the IV immediately.
• Elevate the limb and apply a cold compress.
• Notify medical control for further treatment recommendations, which may include specific antidotes.

3. OCCLUSION

Definition: Blockage of the IV catheter, preventing fluid flow.

Presentation:

• Difficulty or inability to infuse fluids
• Backflow of blood into the IV line

Management:

• Check for kinks or clamps on the tubing.
• Attempt to flush the catheter gently.
• If occlusion persists, discontinue and restart IV at a different site.

4. HEMATOMA

Definition: Collection of blood outside the vessel due to vein damage during insertion.

Presentation:

• Swelling and bruising at the insertion site
• Tenderness and discoloration

Management:

• Apply direct pressure to the site to stop bleeding.
• Apply a cold compress to reduce swelling.
• Avoid using the same site for subsequent IV attempts.

5. CATHETER SHEAR

Definition: A rare but serious complication where part of the catheter breaks off inside the vein.

Presentation:

• Sudden pain during insertion or movement of the catheter
• Potential for embolization of the catheter fragment

Management:

• Avoid using excessive force during insertion.
• If suspected, discontinue IV immediately and contact medical control for further instructions, which may include imaging to locate the fragment.

6. VASOVAGAL REACTIONS

Definition: Reflex reaction to pain or anxiety causing sudden drop in heart rate and blood pressure.

Presentation:

• Dizziness or lightheadedness
• Nausea
• Pale skin and sweating
• Fainting or near fainting

Management:

• Lay the patient flat and elevate the legs.
• Loosen any tight clothing.
• Provide reassurance and monitor vital signs.

7. PHLEBITIS

Definition: Inflammation of the vein.

Presentation:

• Redness and warmth along the vein
• Tenderness or pain at the site
• A palpable cord-like vein

Management:

• Discontinue the IV.
• Apply a warm compress.
• Use anti-inflammatory medications if appropriate.

8. INFECTION

Definition: Introduction of bacteria at the insertion site, potentially leading to local or systemic infection.

Presentation:

• Redness, warmth, and swelling at the site
• Purulent drainage
• Fever and chills (systemic infection)

Management:

• Discontinue the IV.
• Clean the site and cover with a sterile dressing.
• Notify medical control for possible antibiotic treatment.

PREVENTION TIPS

• Aseptic Technique: Always use aseptic technique during insertion.
• Proper Site Selection: Choose an appropriate site and avoid joints or areas with poor circulation.
• Securement: Secure the catheter well to prevent movement.
• Monitoring: Regularly check the IV site for signs of complications.

By recognizing and managing these complications promptly, EMS Providers can ensure patient safety and improve outcomes during IV therapy.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Hantke, J (2022) IV Placement and Management. Appropedia. Accessed May 22, 2024.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medication Administration - Intravenous (IV) Catheter Placement

IV catheter placement is a critical skill for EMS Providers who are at the level of AEMT or above, in most states. Proper technique ensures effective treatment and minimizes complications.

Here are the recommended steps for IV catheter placement:

Preparation

Gather Supplies:

• IV catheter (appropriate gauge)
• Tourniquet
• Antiseptic wipes (e.g., alcohol, chlorhexidine)
• Sterile gauze
• Adhesive dressing or securement device
• IV extension set or saline lock
• Saline flush
• Tape

Gloves and other personal protective equipment (PPE)

Patient Assessment:

Identify a suitable vein: Look for a prominent, straight vein.

Consider patient-specific factors: Age, condition, hydration status, and vein quality.

Explain Procedure:

Inform the patient about the procedure to gain their cooperation and reduce anxiety.

Insertion

Prepare the Site:

Apply the tourniquet above the chosen site to engorge the vein.

Palpate the vein to confirm its location and direction.

Cleanse the site thoroughly with antiseptic wipes in a circular motion, starting from the center and moving outward. Allow the site to dry.

Insert the Catheter:

Don gloves.

Hold the catheter at a 10-30 degree angle to the skin, bevel up.

Insert the needle into the vein, looking for a flashback of blood in the catheter chamber.

Advance the needle slightly to ensure the catheter tip is in the vein.

Advance the Catheter:

Slide the catheter off the needle into the vein while holding the needle stationary.

Release the tourniquet once the catheter is fully advanced.

Securing and Flushing

Remove the Needle:

Retract the needle completely, and dispose of it in a sharps container.

Secure the Catheter:

Connect the IV extension set or saline lock.

Flush the catheter with saline to ensure patency.

Secure the catheter with an adhesive dressing or a securement device to prevent dislodgement.

Tape the IV tubing in place if connected to a fluid bag.

Monitoring and Documentation

Monitor the Site:

Check for signs of infiltration, phlebitis, or infection.

Monitor the patient's response to the IV.

Documentation:

Record the size of the catheter, insertion site, time, date, and any complications or observations.

Troubleshooting

If Initial Attempt Fails:

Reassess vein selection and technique.

Try another site or use a smaller gauge catheter.

Consider alternative access methods, such as intraosseous (IO), if IV access remains difficult and is urgently needed.

Post-Insertion Care

Patient Comfort:

Ensure the patient is comfortable and the IV site is not causing pain or discomfort.

Educate the patient on how to care for the IV site if it will remain in place for an extended period.

By following these steps, EMS Providers at the appropriate level can effectively and safely place IV catheters, ensuring optimal patient care and minimizing potential complications.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Hantke, J (2022) IV Placement and Management. Appropedia. Accessed May 22, 2024.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medication Administration - Intravenous (IV) Catheter Gauges

Intravenous (IV) catheter gauges are critical tools for EMS (Emergency Medical Services) providers, and understanding their use is essential for effective patient care.

Here are the key points EMS Providers need to know about IV catheter gauges:

1. Gauge Size and Flow Rate

Gauge Number: The gauge number refers to the diameter of the IV catheter; a higher number indicates a smaller diameter.

Common Gauges Include:

• 14-16 gauge: Large bore for rapid fluid resuscitation or blood transfusions.
• 18 gauge: General use, including blood administration.
• 20 gauge: Suitable for most IV medications and fluids.
• 22-24 gauge: Smaller veins, pediatric patients, or the elderly.

Flow Rate: Larger catheters (lower gauge numbers) allow higher flow rates, essential in emergencies where rapid fluid or blood administration is required.

2. Clinical Indications

• 14-16 gauge: Trauma, major surgery, massive transfusion protocols.
• 18 gauge: Stable patients needing blood products, fluid resuscitation, or certain medications.
• 20 gauge: Routine IV access for medications and fluids.
• 22-24 gauge: Patients with fragile veins, such as children and the elderly, or when slower administration rates are acceptable.

3. Vein Selection

Larger Gauges: Preferable in larger, more central veins (antecubital fossa) to minimize complications and maximize flow rates.

Smaller Gauges: Suitable for smaller peripheral veins (hand, wrist) and for patients with fragile veins.

4. Insertion Technique

Skill and Experience: Proper insertion technique reduces complications like infiltration, phlebitis, and infection. Training and experience in venipuncture are crucial.

Stabilization: Secure the catheter to prevent dislodgement, especially in pre-hospital settings where patients may be moved frequently.

5. Complications

Infiltration and Extravasation: Fluid or medication leaks into surrounding tissue. Larger gauges have higher risks if not properly secured.

Phlebitis: Inflammation of the vein, more common with larger catheters or prolonged use.

Infection: Strict aseptic technique during insertion and maintenance is essential to prevent infections.

6. Special Considerations

Pediatric Patients: Use smaller gauges (22-24) to minimize trauma to delicate veins.

Geriatric Patients: Often have fragile veins; use smaller gauges and gentle techniques.

Medication Compatibility:

Some medications require specific gauge sizes to prevent damage to blood cells or ensure effective delivery.

7. Alternative Access

Intraosseous (IO) Access: In emergencies where IV access is difficult or impossible, intraosseous access may be used, particularly in cardiac arrest or severe trauma situations.

8. Documentation and Communication

Document the size of the catheter, insertion site, number of attempts, and any complications.

Communicate any issues encountered during IV insertion to the receiving medical facility.

9. Ongoing Education

Continuous education and practice are necessary to maintain proficiency in IV catheter insertion and management. This includes staying updated on the latest guidelines and best practices.

By understanding these key points, EMS Providers can make informed decisions about IV catheter selection and insertion, ultimately improving patient outcomes in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell