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 - IV Solutions Part Two

EMS Providers must understand the different properties, uses, and potential complications associated with isotonic, hypertonic, and hypotonic solutions to provide optimal care in various clinical scenarios. 

Here’s a breakdown with examples, advantages, and disadvantages for each type of solution:

Isotonic Solutions

An isotonic solution has the same concentration of solutes (e.g sodium) as blood plasma, preventing significant fluid shifts between compartments. 

It stays in the bloodstream, increasing intravascular volume. 

Examples:

• Normal Saline (0.9% Sodium Chloride)

• Lactated Ringer’s Solution (LR)

• D5W (5% Dextrose in Water) - initially isotonic, but becomes hypotonic once dextrose is metabolized.

Advantages:

• Volume Expansion: Effective for increasing intravascular volume without causing significant fluid shifts between compartments.

• Versatility: Can be used in a wide range of conditions including dehydration, shock, and blood loss.

• Compatibility: Generally well-tolerated and compatible with most medications and other IV fluids.

Disadvantages:

• Risk of Fluid Overload: Can cause or exacerbate conditions like pulmonary edema or heart failure in patients with compromised cardiac function.

• Electrolyte Imbalances: Long-term use can lead to imbalances, particularly with Normal Saline, which may cause hyperchloremic acidosis.

Hypertonic Solutions

A hypertonic solution has a higher concentration of solutes (e.g., sodium) than blood plasma, causing water to move out of cells into the bloodstream. 

This helps increase intravascular volume and reduce swelling. 

Examples:

• 3% Sodium Chloride

• D5NS (5% Dextrose in Normal Saline)

• D10W (10% Dextrose in Water)

Advantages:

• Rapid Volume Expansion: Quickly draws fluid into the intravascular space from the interstitial and intracellular compartments, useful in cases of severe hyponatremia or cerebral edema.

• Elevating Blood Pressure: Helps increase blood pressure more rapidly in hypovolemic patients.

Disadvantages:

• Cellular Dehydration: Can cause cells to shrink due to osmotic fluid shifts, potentially leading to dehydration at the cellular level.

• Vascular Irritation: High osmolarity solutions can irritate veins, potentially causing phlebitis or damage to blood vessels.

• Risk of Hypernatremia: Overuse can lead to elevated sodium levels and associated complications.

Hypotonic Solutions

A hypotonic solution has a lower concentration of solutes (e.g., sodium) than blood plasma, causing water to move into cells. 

This helps hydrate cells and lower serum sodium levels.

Examples:

• 0.45% Sodium Chloride (Half Normal Saline)

• 0.33% Sodium Chloride

• D5W (after metabolism of dextrose)

Advantages:

• Hydration of Cells: Helps hydrate cells and correct intracellular dehydration, useful in conditions such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).

• Reduction of Serum Osmolality: Lowers serum osmolality, aiding in the correction of hypernatremia.

Disadvantages:

• Risk of Hyponatremia: Excessive administration can dilute plasma sodium levels, leading to hyponatremia.

• Cerebral Edema: In susceptible individuals, hypotonic solutions can exacerbate cerebral edema by increasing intracranial pressure.

• Not for Volume Expansion: Ineffective for patients needing rapid intravascular volume expansion as the fluid quickly shifts into cells and interstitial spaces.

Key Considerations for EMS Providers

• Isotonic Solutions:

• When to Use: Ideal for general fluid resuscitation, dehydration, shock, and blood loss. For example, a trauma patient with significant blood loss may benefit from Normal Saline or Lactated Ringer’s.

• When to Avoid: Caution in patients with renal or heart failure to prevent fluid overload.

• Hypertonic Solutions:

• When to Use: Useful in treating severe hyponatremia or cerebral edema. For example, a patient with a traumatic brain injury and signs of increased intracranial pressure may benefit from 3% Sodium Chloride.

• When to Avoid: Avoid in patients with dehydration or conditions where cellular dehydration would be detrimental.

• Hypotonic Solutions:

• When to Use: Effective for treating hypernatremia or cellular dehydration. For example, a patient in DKA with elevated blood glucose and dehydration may be treated with Half Normal Saline.

• When to Avoid: Not suitable for patients needing rapid intravascular volume expansion, and should be used cautiously in patients with potential for cerebral edema.

Summary

• Isotonic Solutions are versatile and suitable for most situations requiring volume expansion.

• Hypertonic Solutions are potent and used in specific scenarios like severe hyponatremia or cerebral edema.

• Hypotonic Solutions are effective for cellular hydration but must be used cautiously to avoid complications like hyponatremia and cerebral edema.

EMS Providers should choose the appropriate type of IV solution based on the patient’s clinical condition, understanding the benefits and risks associated with each to ensure 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

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 - IV Solutions Part One

EMS Providers must have a clear understanding of the different types of IV solutions, including crystalloids, colloids, and blood products, and their appropriate uses to ensure effective patient care in various medical scenarios. 

Here is an overview:

Crystalloid Solutions

Types:

• Normal Saline (0.9% Sodium Chloride): Isotonic solution commonly used for fluid resuscitation.

• Lactated Ringer’s Solution: Isotonic solution containing electrolytes, often used for trauma and burn patients.

• D5W (5% Dextrose in Water): Hypotonic solution, initially isotonic but becomes hypotonic once dextrose is metabolized.

Uses:

• Fluid Resuscitation: Effective for increasing intravascular volume in hypovolemia and dehydration.

• Electrolyte Replacement: Suitable for maintaining or correcting electrolyte imbalances.

• General Hydration: Used in various clinical situations requiring rehydration.

When Not to Use:

• Pulmonary Edema: Excessive fluid administration can worsen pulmonary congestion.

• Severe Hypoalbuminemia: Crystalloids do not replace lost proteins.

Colloid Solutions

Types:

• Albumin: Natural protein solution, often used for volume expansion in hypoalbuminemia.

• Hetastarch (HES): Synthetic starch solution used for volume expansion.

• Dextran: Synthetic polysaccharide used for volume expansion.

Uses:

• Hypovolemic Shock: Effective for rapid volume expansion due to their ability to remain in the intravascular space longer.

• Burns and Trauma: Can be used when crystalloids alone are insufficient to maintain hemodynamic stability.

When Not to Use:

• Coagulopathy: Some colloids can interfere with coagulation.

• Renal Failure: Certain colloids can exacerbate renal dysfunction.

• Allergic Reactions: Risk of anaphylaxis with synthetic colloids.

Blood Products

Types:

• Packed Red Blood Cells (PRBCs): Used to increase oxygen-carrying capacity in anemia or hemorrhage.

• Fresh Frozen Plasma (FFP): Contains clotting factors, used in coagulopathies.

• Platelets: Used for thrombocytopenia or platelet function disorders.

• Cryoprecipitate: Rich in fibrinogen, used in specific bleeding disorders.

Uses:

• Severe Hemorrhage: To restore oxygen-carrying capacity and hemostasis.

• Anemia: When hemoglobin levels are critically low and causing symptoms.

• Coagulopathies: When there is a need to replace clotting factors or platelets.

When Not to Use:

• Volume Expansion Alone: Blood products should not be used solely for volume expansion; crystalloids or colloids are more appropriate.

• Allergic Reactions: Risk of transfusion reactions or infections.

Key Considerations for EMS Providers

• Patient Assessment: Thorough assessment of the patient’s condition, including vital signs, history, and clinical presentation, is crucial to determine the appropriate IV solution.

• Guidelines and Protocols: Adherence to local EMS protocols and guidelines is essential. These protocols are often based on evidence-based practices and can provide clear indications for the use of specific IV solutions.

• Monitoring: Continuous monitoring of the patient’s response to the IV therapy is critical. Look for signs of improvement or deterioration, and be prepared to adjust the treatment plan accordingly.

• Dosage and Administration: Knowledge of the correct dosages and administration rates for each type of IV solution is necessary to avoid complications such as fluid overload or electrolyte imbalances.

• Communication: Effective communication with receiving hospital staff about the IV solutions administered and the patient's response to treatment is important for continuity of care.

Summary

• Crystalloids are generally the first choice for fluid resuscitation and hydration.

• Colloids are used for more aggressive volume expansion but have more potential side effects.

• Blood Products are reserved for situations requiring restoration of oxygen-carrying capacity and hemostasis.

EMS Providers should be well-versed in the indications, contraindications, and potential complications of each type of IV solution to make informed decisions in the field and provide the best possible care to their patients.

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