Advanced Medical Life Support

Chapter 3

IV Access and Medication Administration

Introduction
Being able to administer fast-acting medications appropriately is a key intervention of the advanced caregiver.

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Topics
Medication Administration
Medication Administration Methods

Venous Access
Delivering Medication by Injection

Other Methods of Administration

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C ASE S TUDY
Situation
Your ALS unit is dispatched to a call for a person down. Fire department EMT-Ds are on scene quickly and inform you that they have a patient in cardiac arrest.

Upon your arrival, EMTs have countershocked the patient 6 times, and he remains in V-fib. They continue CPR.
Your partner delivers another shock, which converts the rhythm to asystole. You intubate, and your partners first IV attempt is unsuccessful.

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C ASE S TUDY
Situation
History & Findings
EMTs report that the patient collapsed suddenly after dinner.

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Administering Medicines
The 5 Rights

Right medication? Right dose? Right route? Right patient? Right time?
Parenteral medicines can have prompt, profound effects. Giving them warrants a competent caregiver who pays careful attention to details.
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Important to Note...
Remember to document whatever you do or attempt to do, whether successful or not:
IV attempt (s)
Location Catheter size Fluid type & volume given Type of tubing setup

Medication(s) Given
Substance Date & time Dose & concentration Route Site Effects/complications
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Medication Administration Methods

Intravenous
Rapid, predictable absorption with few complications

Intramuscular
Subcutaneous Endotracheal

Also predictable, but slower absorption rate than IV

Intentionally slower absorption for prolonged effects

Drug-specific indications in emergency situations

(continued)
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Administration Methods (continued)

Intraosseous
Common pediatric route if other access impossible

Inhalation

Quick absorption of respiratory-active medications

Constant, prolonged effects (specific substances only) Used only for specific substances in stable patients
(continued)
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Transdermal

Oral

Administration Methods (continued)

Sublingual
Topical application/injection of specific substances Topical absorption of specific substances

Rectal

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Venous Access
Consider:

Standing orders

Need to give meds or fluid challenge

Perceived patient stability

Patient benefits/risks
Consultation with medical direction
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Important to Note...
Any procedure that exposes you to blood or body fluids is a threat to your well-being.
Use BSI precautions -every time!

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Types of IV Cannulas
Catheter-over-needle (most common) Needle-over-catheter Anchored steel needle (Butterfly)
Less trauma during introduction More likelihood of trauma due to movement Most often used in pediatrics
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Cannulating a Vein
Catheter-Over-Needle Technique
Catheter over needle inserted together
A B

Catheter advanced over needle

Needle removed
C D

Catheter in place

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Cannulating a Vein
Catheter-Through-Needle Technique
Needle inserted
A

Catheter through needle

B

Needle pulled back

C D

Needle guard attached

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Major Peripheral Veins

Choose Sites Closest to Central Circulation
Cephalic Axillary Basilic Median cephalic Median basilic Radial Ulnar

Long saphenous

Medial malleolus

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Peripheral Venipuncture
Procedure (Sterile Precautions)
Take BSI precautions, and explain your intentions to the patient. Apply a constricting band, and cleanse the site. Insert the needle and catheter, bevel-side-up. Advance slightly to ensure placement, then ease the catheter into the vein.

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Peripheral Venipuncture
Procedure (continued)
Remove the needle. Insert a syringe or Luer adapter as necessary to withdraw blood and verify placement in the vein. Discard the needle safely...
...and attach the tubing to the catheter.

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Peripheral Venipuncture
Procedure (continued)
Open the stop-cock on the IV line. Check again to ensure that the line is patent, by watching for a steady flow. There should be no swelling at the site.
Finally, secure the site. Apply antiseptic ointment and a barrier.

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External Jugular Access

Anatomic View

External jugular vein

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External Jugular Access

Higher Risks, but Best Big-Bore Solution
The external jugular vein appears roughly from the angle of the jaw downward to the middle of the clavicle, and blood flow is away from the head. Pressurize the vein by raising the patients legs and by tamponading the distal end of the veins visible portion (as at right). Cleanse the site. Cannulate the vein, check the needle placement, connect the tubing, and stabilize the catheter.

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Complications of IV Therapy
Extravasation of IV fluids
Use of plain steel needles Insertion of catheters near joints

Hematoma
Infection Phlebitis
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IV Solutions
HYPOtonic solutions
Lower solute concentration than cells -- so, water flows into cells

HYPERtonic solutions
Higher solute concentration than cells -- so, water flows out of cells

ISOtonic solutions
Solute concentration = intracellular values
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IV Administration Sets
MICROdrippers
Designed to minimize delivered volumes. (usually 60gtt/ml)

MACROdrippers
Designed to maximize delivered volumes. (usually 10-15 gtt/ml)
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IV Flow Rates
To calculate the flow (drip rate) of an IV:
VOLUME (ml) x DRIP SIZE (gtt/ml) FLOW (gtt/min) = TIME (minutes)

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IV Push Administration
Risks vs. Benefits

Faster delivery to target tissues More reliable administration Greater dangers of miscalculation or failure to observe details
Accept the responsibility for your medicine!

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IV Push Administration
Procedure (Sterile Precautions)
Take BSI precautions, and explain your intentions to the patient ( if possible). Establish an IV. Choose the medicine, calculate the dose and concentration, review its benefits and risks, and check the expiration date and the clarity of the solution. Cleanse the injection port on the IV tubing.

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IV Push Administration
Procedure (continued)
Maintaining careful aseptic technique, insert the needle into the injection port. Use care not to jam the needle back through the tubing. Depending on the correct rate of administration for the medicine you have chosen, either pinch the tubing above the port, or open the IV wide-open...

...and inject the medication at a rate that is appropriate for the specific medicine and the desired effects. Watch the patient!

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IV Drip Administration
Risks vs. Benefits

Specific medications only Used to maintain therapeutic levels over time Monitor constantly/control risks:
Runaway drips Concentration errors Clogged & pinched lines (positional IVs) Infiltrates (beware of catecholamines)

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IV Drip Administration
Procedure (Sterile Precautions)
Take BSI precautions, and explain your intentions to the patient ( if possible). Establish an IV. Choose the medicine and the correct preparation, and review its benefits and risks. Calculate the dose, concentration, and drip rate. Double-check the expiration dates on the medicine and the IV bag. Cleanse an injection port on the bag, inject the medicine into the bag, and label the bag.

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IV Drip Administration
Procedure (continued)
Maintaining careful aseptic technique, connect the IV bag containing the medication to its own tubing set (usually a microdripper). Connect it to the primary IV tubing, turn off the flow in the primary tubing and adjust the flow of medication through the secondary tubing. Monitor the patient!

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Delivering Medications By Injection

Specific medications only Can provide sustained absorption over time Effectiveness depends on circulatory status. (Poor choice in shock!)

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Direct Injection Techniques

General Anatomy
Subcutaneous Intradermal Intramuscular

Epidermis Dermis Subcutaneous Muscle

15o

45o

90o

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Intramuscular Injection
General Anatomy

Epidermis

Dermis

90

Subcutaneous tissue

INTRAMUSCULAR Route Specific medications 1-1/2-inch, 18 to 23-gauge needle 1-5 ml (gluteus, quadriceps) 1-3 ml (deltoid)

Muscle
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Intramuscular Injection
Deltoid Anatomy
Acromial process

Deltoid muscle

The deltoid injection site is in the mass of the deltoid muscle. Aim at the lateral midline of the humerus, about 1/3 of the way from its proximal end. You can use the imaginary triangle (pictured) to help with visualization.
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Intramuscular Injection
Gluteal Site
Posterior superior

iliac spine Gluteus medius

Gluteal artery
Gluteus minimus Gluteus maximus Greater trochanter of femur

There are two ways to locate the gluteal injection site. One is to draw an imaginary line between the posterior superior iliac spine (pictured) to the greater trochanter of the femur, and inject on the lateral side of that line...

Sciatic nerve

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Intramuscular Injection
Gluteal Site (continued)
Vertical line

Preferred site Gluteal artery Horizontal line Hip Sciatic nerve

The other is to divide the buttock into quadrants as shown, and inject in the upper outer quadrant.

Fold separating the buttocks

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Intramuscular Injection
Procedure (Sterile Precautions)
Check the medication. Explain the procedure to the patient, and take appropriate BSI precautions. Cleanse the injection site on the medication container. Insert the needle into the site, and inject an amount of air that roughly equals the volume of medicine you plan to withdraw.

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Intramuscular Injection
Procedure (continued)
Cleanse the injection site. Use a circular motion, beginning at the center of the circle and gradually working your way outward. If the skin is especially dirty, consider prepping the area two or three times. Uncap the needle. Purge the air from the syringe, then pinch the injection area slightly and plunge the needle in (like a dart) at a 90degree angle. Draw back slightly on the plunger and check for blood. If no blood, you can safely inject the medication.

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Intramuscular Injection
Procedure (continued)
Remove the needle and syringe, and discard them safely. Massage the injection site for a few seconds, then cover the area with a sterile dressing. Finally, monitor the patient.

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Subcutaneous Injection
General Anatomy

Epidermis

45

Dermis

Subcutaneous tissue

SUBCUTANEOUS Route Specific medications Very small volumes (0.5-1 ml) Small, short needle (23-27 ga)
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Muscle

Subcutaneous Injection
Procedure (Sterile Precautions)
Check the medication. Explain the procedure to the patient, and take appropriate BSI precautions. Cleanse the injection site on the medication container (if there is one). Insert the needle into the site, and withdraw the medication.

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Subcutaneous Injection
Procedure (continued)
Cleanse the injection site. Use a circular motion, beginning at the center of the circle and gradually working your way outward. If the skin is especially dirty, consider prepping the area two or three times. Uncap the needle. Purge the air from the syringe, then pinch the injection area slightly and insert the needle at a 45-degree angle. Draw back slightly on the plunger and check for blood. If no blood, you can safely inject the medication.

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Subcutaneous Injection
Procedure (continued)
Remove the needle and syringe, and discard them safely. Massage the injection site for a few seconds, then cover the area with a sterile dressing. Finally, monitor the patient.

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C A S E S T U D Y F O L L O W-U P
Situation
Your ALS unit is dispatched to a call for a person down. Fire department EMT-Ds are on scene quickly and inform you that they have a patient in cardiac arrest.

Upon your arrival, EMTs have countershocked the patient 6 times, and he remains in V-fib. They continue CPR.
Your partner delivers another shock, which converts the rhythm to asystole. You intubate, and your partners first IV attempt is unsuccessful.

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C A S E S T U D Y F O L L O W-U P
Situation
Treatment
CPR continued via EMTs; epi administered endotracheally. Patient reverts to v-fib. You countershock, repeat epi and administer ET lidocaine.

External jugular vein inserted & resuscitation continued.

Patient regains pulse en route, w/ BP of 90/50. He remains apneic & you continue ET ventilations.
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C A S E S T U D Y F O L L O W-U P
Treatment Outcome
Patient placed on a ventilator; suffers 2nd cardiac arrest in CCU the following day. Patient dies in CCU despite vigorous resuscitation effort.

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