Emergency Care In The Streets - Ch. 8

Front 1

access port

Back 1

a sealed hub on an administration set designed for sterile access to the IV fluid

Front 2

acidosis

Back 2

a pathologic condition resulting from the accumulation of acids in the body

Front 3

administration set

Back 3

- tubing that connects to the IV bag access port and the catheter to deliver IV fluid
- moves fluid from the IV bag into the patient's vascular system
- they remain sterile as long as they are in the packaging
- once the piercing spike is exposed and the seal is broken the set must be used immediately
- the package indicates the number of drops per milliliter of fluid to pass through the orifice and into the drip chamber
- come in microdrip (60gtt/ml) for medication administration or pediatric fluid delivery - easy to control fluid flow because they use a needlelike orifice
- also come in macrodrip (10 or 15 gtt/ml) with a large opening for rapid fluid replacement

Front 4

alkalosis

Back 4

pathologic condition resulting from the accumulation of bases in the body

Front 5

ampules

Back 5

small glass containers that are sealed and the contents sterilized

Front 6

anion

Back 6

- an ion that contains an overall negative charge
- major anions in the body are bicarbonate, chloride and phosphorous

Front 7

antecubital

Back 7

the anterior aspect of the elbow

Front 8

anticoagulant

Back 8

a substance that prevents blood from clotting

Front 9

antidiuretic hormone

Back 9

(ADH) - a hormone produced by the pituitary gland that signals the kidneys to prevent excretion of water

Front 10

antiseptics

Back 10

chemicals used to cleanse an area before perfoming an invasive procedure, such as starting an IV; not toxic to living tissues; examples include isopropyl alcohol and iodine

Front 11

aseptic technique

Back 11

a method of cleansing used to prevent contamination of a site when performing an invasive procedure, such as starting an IV

Front 12

ataxia

Back 12

a staggered walk or gait

Front 13

aural

Back 13

pertaining to the ear

Front 14

bivalent

Back 14

an ion that contains two charges

Front 15

blood tubing

Back 15

- a special type of macrodrip administration set designed to facilitate rapid fluid replacement by manual infusion of multiple IV bags or IV-blood replacement combinations
- a macrodrip set that facilitates rapid fluid replacement by manual infusion of multiple IV bags or IV and blood replacement combinations
- most have dual piercing spikes that allow two bags of fluid to be used simultaneously for the same patient
- the central drip chamber has a filter to filter the blood during transfusions

Front 16

bolus

Back 16

a term used to describe "in one mass"; in medication administration, a single dose given by the IV or IO route; may be a small or large quantity of the drug

Front 17

Bone Injection Gun (B.I.G.)

Back 17

a spring-loaded device that is used for inserting an IO needle into the proximal tibia in adult and pediatric patients

Front 18

buccal

Back 18

between the cheek and gums

Front 19

butterfly catheter

Back 19

- a rigid, hollow, venous cannulation device identified by its plastic "wings" that act as anchoring points for securing the catheter
- easiest venipuncture device to insert
- useful for scalp veins in infants and in small, difficult veins in geriatric patients for obtaining blood samples
- small, short needles
- may easily cause infiltration
- possible blood cell damage when drawing blood through the butterfly catheter
- small-gauge needles limit fluid flow

Front 20

cannulation

Back 20

the insertion of a catheter, such as into a vein to allow for fluid flow

Front 21

carpopedal spasms

Back 21

hand or foot spasms; usually the result of hyperventilation or hypocalcemia

Front 22

catheter shear

Back 22

- occurs when a needle is reinserted into the catheter, and it slices through the catheter, creating a free-floating segment
- occurs when part of the catheter is pinched against the needle and the needle slices through the catheter creating a free-floating segment
- the segment can travel through the circulatory system and possibly cause an embolism

Front 23

cation

Back 23

- an ion that contains an overall positive charge
- major cations in the body are sodium, potassium, calcium and magnesium

Front 24

Celsius scale

Back 24

a scale for measuring temperature in which water freezes at 0 degrees and boils at 100 degrees

Front 25

colloid solutions

Back 25

- solutions that contain molecules (usually proteins) that are too large to pass out of the capillary membranes and, therefore, remain in the vascular compartment
- large proteins give them a high osmolarity
- draw fluid from interstitial and intracellular compartments to vascular compartments
- reduce edema (pulmonary or cerebral)
- can cause dramatic fluid shifts and must be administered in a controlled setting
- rarely used in a prehospital setting
- examples are albumin, dextran, Plasmanate, and hetastarch (Hespan)

Front 26

concentration

Back 26

the total weight of a drug contained in a specific volume of liquid

Front 27

concentration gradient

Back 27

the natural tendency for substances to flow from an area of higher concentration to an area of lower concentration, within or outside the cell

Front 28

contaminated stick

Back 28

the puncturing of an emergency care provider's skin with a needle or catheter that was used on a patient

Front 29

crystalloid solutions

Back 29

solutions of dissolved crystals (for example, salts or sugars) in water; contain compounds that quickly dissociate in solution

Front 30

D5W

Back 30

an intravenous solution made up of 5% dextrose in water

Front 31

dehydration

Back 31

depletion of the body's systemic fluid volume

Front 32

depolarization

Back 32

the rapid movement of electrolytes across a cell membrane that changes the cell's overall charge, this rapid shifting of electrolytes and cellular charges in the main catalyst for muscle contractions and neural transmissions

Front 33

desired dose

Back 33

the amount of a drug that the physician orders for a patient; the drug order

Front 34

diaphysis

Back 34

the shaft of the long bone

Front 35

diffusion

Back 35

a process in which molecules move from an area of higher concentration to an area of lower concentration

Front 36

diluent

Back 36

a solution (usually water or normal saline) used for diluting a medication

Front 37

disinfectants

Back 37

chemicals used on nonliving objects to kill organisms; toxic to living tissues; examples include Virex, Cidex, and Microcide

Front 38

drip chamber

Back 38

the area of the administration set where fluid accumulates so that the tubing remains filled with fluid

Front 39

drug reconstitution

Back 39

injecting sterile water or saline from one vial into another vial containing a powdered form of the drug

Front 40

electrolytes

Back 40

- charged atoms or compounds that result from the loss or gain of an electron, these are ions that the body uses to perform certain critical metabolic functions
- inorganic molecules give rise to them
- they have an ability to conduct water when they dissociate in water into their charged components
- reactive and dnagerous if left to circulate in the body
- body uses the energy stored in these charged partilces
- help to regulate everything form water levels to cardiac function and muscle contractions
- water stabilizes the electrolyte charges so that the electrolytes can aid in the metabolic functions that are necessary
- each electrolyte has a unique property or value to the body

Front 41

enteral route

Back 41

a route of medication administration that involves the medication passing through a portion of the gastrointestinal tract

Front 42

epiphyseal plate

Back 42

the growth plate of a bone; a major site of bone development during childhood

Front 43

epiphyses

Back 43

the ends of the long bone

Front 44

external jugular (EJ) vein

Back 44

- large neck vein that is lateral to the carotid artery
- runs downward and obliquely backward behind the angle of the jaw until it pierces the deep fascia of the neck just above the middle of the clavicle
- it ends in the subclavian vein (where a valves retards backflow of blood)
- it is fairly large and usually easy to cannulate, but it is close to the skin so it rolls if it is not anchored
- it is also near other vessels that could be damaged (carotid artery)

Front 45

extracellular fluid (ECF)

Back 45

- the water outside the cells; accounts for 15% of body weight
- divided into interstitial fluid and intravascular fluid

Front 46

EZ-IO

Back 46

a hand-held, battery-powered driver to which a speical IO needle is attached; used for insertion of the IO needle into the proximal tibia of children and adults

Front 47

vascular access is often needed for:

Back 47

- hemodynamically unstable patients who are in need of IV fluids, various medications or both

Front 48

techniques for gaining vascular access:

Back 48

- cannulation of a peripheral extremity vein
- external jugular vein cannulation
- IO infusion

Front 49

water in the human body:

Back 49

- provides the environment in which the chemical reactions necessary to life take place
- serves as a transport medium for nutrients, hormones and waste materials

Front 50

total body water (TBW)

Back 50

- constitutes 60% of the weight of an adult male
components include:
- intracellular fluid (ICF)
- extracellular fluid (ECF) - (interstitial fluid and intravascular fluid)

Front 51

intracellular fluid

Back 51

- the water contained inside the cells
- normally accounts for 45% of body weight

Front 52

interstitial fluid

Back 52

- the water bathing the cells
- accounts for about 10.5% of the body weight
- includes special fluids like cerebrospinal fluid and intraocular fluid

Front 53

intravascular fluid

Back 53

- (plasma) - the water within the blood vessels
- carries RBCs, WBCs, and vital nutrients
- normally accounts for 4.5% of body weight

Front 54

fluids in the body are composed of:

Back 54

- solutions (composed of dissolved elements and water)
- a solution is a mixture of solvent and solute

Front 55

solvent

Back 55

- the fluid that does the dissolving or the solution that contains the dissolved components

Front 56

solute

Back 56

- the dissolved particles contained in the solvent
- water is the universal solvent and dissolves a variety of solutes (electrolytes and nonelectrolytes)

Front 57

milliequivalent (mEq)

Back 57

- unit of measurement for electrolytes
- represents the chemical combining power of the ion an is based on the number of available ionic charges in an electrolyte solution
- 1 mEq of a cation is able to react completely with 1 mEq of an anion

Front 58

monovalent

Back 58

- singly charged cation or anion
- one positive or negative charge
- sodium is a monovalent cation and chloride is a monovalent anion

Front 59

bivalent

Back 59

- doubly charged cation or anion
- two positive or negative charges
- calcium is a bivalent cation

Front 60

sodium

Back 60

- monovalent cation
- principal extracellular cation needed to regulate the distribution of water throughout the body
- in intravascular and interstitial fluids
- maintains adequate cellular perfusion (where sodium goes, water follows)

Front 61

potassium

Back 61

- monovalent cation
- 98% of all body's potassium is found inside the cells
- it is the body's principal intracellular cation
- plays a major role in neuromuscular function and in the conversion of glucose into glycogen

Front 62

sodium-potassium pump

Back 62

- cellular potassium levels are regulated by insulin
- the pump is helped by the presence of insulin and epinephrine

Front 63

hypokalemia

Back 63

- low potassium levels in the serum (blood plasma)
- can lead to descreased skeletal muscle function, gastrointestinal disturbances, and alterations of cardiac function

Front 64

hyperkalemia

Back 64

- high postassium levels in the serum (blood plasma)
- can lead to hyperstimulation of neural cell transmission (resulting in cardiac arrest)

Front 65

calcium

Back 65

- a bivalent cation
- principal cation needed for bone growth
- plays an important part in the functioning of heart muscle, nerves and cell membranes and is necessary for proper blood clotting

Front 66

hypocalcemia

Back 66

- low serum calcium levels
- can lead to overstimulateion of nerve cells
signs and symptoms include:
- skeletal muscle cramps, abdominal cramps, carpopedal spasms, hypotension and vasoconstriction

Front 67

hypercalcemia

Back 67

- high serum levels of calcium
- can lead to decreased stimulation of nerve cells
signs and symptoms include:
- skeletal muscle weakness, lethargy, ataxia, vasodilation, and hot, flushed skin

Front 68

magnesium

Back 68

- a bivalent cation
- important role as a coenzyme in the metabolism of proteins and carbohydrates
- acts in a manner similar to calcium in controlling neuromuscular irritability

Front 69

bicarbonate

Back 69

(HCO3-)
- levels are determining factor between acidosis and alkalosis in the body
- the primary buffer used in all circulating body fluids

Front 70

chloride

Back 70

- monovalent anion
- primary determinant of stomach pH
- also regulates extracellular fluid levels

Front 71

phosphorus

Back 71

- important in adenosine triphosphate (ATP) - the body's most powerful energy source

Front 72

nonelectrolytes

Back 72

- solutes that contain no electrical charge
- include glucose and urea
- normal concentration of glucose in blood is 70 to 110mg per 100 mL

Front 73

fluid and electrolyte movement

Back 73

- move according to some basic chemical and biologic tenets
- unequal concentrations on different sides of a cell membrance will move to balance themselves equally on both sides

Front 74

balance across a cell membrance

Back 74

- balance of compounds on either side of the cell membrance
- balance of charges (carried by atoms) on either side of the cell membrane

Front 75

concentration gradient

Back 75

- when concentrations of charges or compounds are greater on one side of the cell membrane than on the other side
- natural tendency for materials is to flow from and area of higher concentration to an area of lower concentration (concentration gradient)
- categorized by the type of material that flows down them
- chemical compounds flow down chemical gradients
- electrical currents for down electrical gradients
- flowing down a gradient will depend on if it can pass through a material
- if it can travel freely across it is kinetically favorable (less energy)
- some require active transport because of the size or an incompatible charge

Front 76

diffusion

Back 76

- when compounds or charges on one side of a cell membrance move across it to an area of low concentrations
- spread evenly

Front 77

filtration

Back 77

- a type of diffusion commonly used byt the kidneys to clean blood
- water carries dissolved compounds across the cell membranes of the tubules of the kidney and the tubule traps the dissolved compounds and lets the water pass through
- this cleans the blood of wastes and removes the trapped compounds from circulation so they can be flushed out of the body
- anti-diuretic hormone (ADH) - prevents the losss of water from the kidneys by causing its reabsorption in the tubules

Front 78

active transport

Back 78

- the cell must maintain an imbalance of compounds across its membrane to achieve some metabolic purpose - in the sodium-potassium pump, the cell uses sodium outside the cell and potassium inside the cell for depolarization - to maintain this imbalance the cell must use energy in the form of ATP and actively transport compounds across its membrane
- active transport demands a high-energy expenditure
- its benefits outweigh the initial use of ATP
- example - pumping sodium out of the cell and potassium into the cell, also moves glucose into the cell at the same time

Front 79

osmosis

Back 79

- the concentration or the number of solute particles is chiefly influenced by a semipermeable membrane
- water will flow across the membrane from the solution of lower solute concentration to the solution of higher solute concentration
- net effect is to equalize the solute concentrations on both sides of the membrane

Front 80

tonicity

Back 80

- the effects of osmotic pressure on a cell
- reflects the concentration of sodium in a solution and the movement of water in relation to the soiudm levels in and outside the cell

Front 81

abnormal states of fluid and electrolyte imbalance

Back 81

- include dehydration and overhydration
- healthy body maintains a balance between intake and output of fluids and electrolytes - keeps internal environment constant
- a healthy person loses ~ 2 to 2.5L of fluid a day through urine output and through the lungs (exhalation) and skin - these losses are replaced by the intake of fluids and nutrients that are partially converted to water when metabolized
- illness can cause imbalance of hydration

Front 82

homeostasis

Back 82

- the internal environment's resistance to change

Front 83

dehydration

Back 83

- inadequate total systemic fluid volume
- usually chronic in eldeerly or the very young and can take days to manifest
- fluid is lost from the vascular compartment and the body reacts by shifting interstitial fluid into the vascular area
- fluid also shifts from the intracellular to the extracellular compartments - total systemic fluid deficit
signs and symptoms include:
- decreased level of consciousness, postural hypotension, tachypnea, dry mucous membranes, tachycardia, poor skin turgor and flushed, dry skin
causes of dehydration include:
diarrhea, vomiting, gastrointestinal drainage, hemorrhage, and insufficient fluid or food intake

Front 84

overhydration

Back 84

- when the body's total systemic fluid volume increases
- fluid fills the vascular compartment and filters intot he interstitial compartment and is forced from the engorged interstitial compartment into the intracellular compartment (fluid back-up can lead to death)
signs and symptoms:
shortness of breath, puffy eyelids, edema, polyuria, moist crackles (rales) and acute weight gain
causes of overhydration:
unmonitored IVs, kidney failure, and prolonged hypoventilation

Front 85

hypertonic cell

Back 85

- net water movement out
- cell shrinks
- high solute concentration in the ECF

Front 86

hypotonic cell

Back 86

- net water moves in
- cell can lyse or burst
- low solute concentrationin the ECF

Front 87

IV Fluid Composition

Back 87

- use of fluids can alter a patient's condition and facilitate treatment
- each bag must be safe and sterile
- compounds and ions dissolved in the solutions are identical to those found in the body
- sodium is 0.9%, so altering the IV solution can move water into or out of a fluid compartment

Front 88

types of IV solutions

Back 88

- isotonic
- hypotonic
- hypertonic
- crystalloid
- colloid

IV fluids use combinations of these to create the desired effects inside the body

Front 89

isotonic solution

Back 89

- example, normal saline (0.9% sodium chloride), Lactated Ringer's (LR) solution, D5W
- have almost the same osmolarity (concentration of solute) as serum and other body fluids
- they expand contents of the intravascular compartment without shifting fluid to or from other compartments
- they do not change the shape of a cell - important when dealing with hypotensive or hypovolemic patients
- must be careful to avoid fluid overloading - hypertensive patients or patients with congestive heart failure are at the greatest risk

Front 90

Lactated Ringers (LR) solution

Back 90

- generally used in the field for patients hwo have lost large amounts of blood
- contains lactate which is metabolized in the liver to form bicarbonate (key buffer that combats the intracellular acidosis associated with severe blood loss)
- should not be given to patients with liver problems - they can't metabolize the lactate

Front 91

D5W

Back 91

- 5% dextrose in water
- a unique isotonic solution
- as long as it remains in the bag it is considered isotonic until it is administered and then it becomes hypotonic when the dextrose is metabolized

Front 92

hypotonic solutions

Back 92

- has an osmolarity less than that of serum
- when fluid is placed in the vascular compartment it begins diluting the serum so that the serum osmolarity is less than that of the interestitial fluid
- water is pulled from the vasuclar compartment into the interstitial fluid compartment and causes the cells to swell and possibly burst from the increased intracellular osmotic pressure
- hydrate the cells while depleting the vascular compartment - may be needed for a patient who is receiving dialysis because dialysis dehydrates the cells
- cause a sudden fluid shift in the intravascular space to the cells - can lead to cardiovascular collapse and increase intracranial pressure from shifting fluid into brain cells
- should not be used on stroke or head trauma patients
- should not be used on patients with burns, trauma, malnutrition, or liver disease - risk of third spacing - an abnormal fluid shift into the interstitial compartment

Front 93

hypertonic solution

Back 93

- has a higher osmolarity than that of serum (more ionic concentration)
- pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment
- cells may collapse from the increased extracellular osmotic pressure
- shift body fluids into the vascular paces and help stabilize blood pressure, increase urine output, and reduce edema
- rarely used in prehospital
- sometimes used to describe solutions with high concentrations of proteins (have the same effect of fluid as sodium)
- can cause fluid overloading especially with patients with impaired heart or kidney function
- should not be given to diabetic ketoacidosis patients or others who are at risk of cellular dehydration

Front 94

crystalloid solutions

Back 94

- are dissolved crystals (salts or sugars) in water
- have the ability to cross membranes and alter fluid levels makes them the best for injured patients who need body fluid replacement
- must support blood pressure after blood loss ( 3-to-1 replacement rule)
- cannot carry oxygen so 20ml/kg boluses should be given to maintain perfusion but not to raise blood pressure to normal (can cause hemostasis or the body's ability to clot by decreasing the proportion of hemoglobin)

Front 95

3-to-1 replacement rule

Back 95

- 3 ml of isotonic crystalloid solution is needed to replace 1 ml of patient blood
- approx. 2/3 of the infused isotonic crystalloid solution will leave the vascular spaces in about 1 hour

Front 96

oxygen-carrying solutions

Back 96

- best fluid to replace lost blood is whole blood
- whole blood contains hemoglobin (carries oxygen to the body's cells)
- O-negative blood (universal donor) may be used outside a hospital but because of refrigeration/storage requirements it is impractical
- synthetic blood substitutes - can carry oxygen - are being researched and field-tested - show potential to treat patients with blood loss

Front 97

intravenous (IV)

Back 97

within a vein

Front 98

intravenous (IV) therapy

Back 98

- involves cannulation of a vein with a catheter to access the patient's vascular system
- one of the most invasive procedures performed by a paramedic
- IV equipment must be sterile
- develop a routine to ensure proper technique

Front 99

peripheral vein cannulation

Back 99

- involves cannulating veins of the periphery veins that can been seen and/or palpated (hands, arms, lower extremity, external jugular vein)

Front 100

assembling IV equipment

Back 100

- gather and prepare all equipment before starting and IV
- working as a team can be helpful if a patient is critical

Front 101

choosing an IV solution

Back 101

- Is the patient's condition critical?
- Is the patient's condition stable?
- Does the patient need fluid replacement?
- Will the patient need medications?
- prehospital IV solutions are usually normal saline and LR solution (both isotonic crystalloids)
- D5W is often reserved for administering medication (dextrose has the potential to alter fluid and electrolyte levels in the body)
- IV bags are wrapping in plastic and are guaranteed sterile until the posted date - the solution must be used within 24 hours after opening
- each bag has 2 ports - an injection port for medication and an access port for connecting the administration set
- a pigtail protects the sterile access port and must be used immediately once it is removed
- IV bags come in various sizes (50ml - 1000ml)

Front 102

preparing an administration set

Back 102

- choose the appropriate solution, verify the expiration date and check for clarity of the solution
- choose the appropriate administration set (macrodrip or microdrip)
- remove pigtail by pulling on it and then remove the cover from the piercing spike (it is sterile)
- slide the spike into the IV bag port until you see fluid enter the drip chamber
- allow the solution to run freely from the drip chamber and into the tubing to prime the line and flush out the air
- twist the protective cover on the opposite end of the IV tubing to allow the air to escape (don't remove it) and turn the roller clamp to stop the flow
- check the drip chamber is half-filled, if it is too low squeeze the chamber, if it is too high turn the bag over and squeeze the chamber to empty it
- hang the bag in an appropriate location with the tubing accessible

Front 103

Volutrol

Back 103

- (Buretrol) used for fluid control in pediatric and certain geriatric patients
- a microdrip set that allows you to fill 100ml or 200ml calibrated drip chamber with a specific amount of fluid and administer only that amount
- a proximal roller clamp allows the Volutrol drip chamber to be shut off/added to the IV bag

Front 104

choosing an IV site

Back 104

- avoid areas of the vein that contain valves (small bumps in the vein), a catheter won't pass through easily and it could cause damage
- locate the vein section with the straightest apprearance
- choose a vein with a firm, round appearance or that is springy when palpated
- avoid areas where the vein crosses over joints
- avoid edematous extremities and any extremity with a dialysis fistula or on the side a mastectomy was done
- areas that remain open should be used for life-threatening conditions, otherwise start distally
- start distally, work proximally (fluid can enter the tissue below an open wound)
- large veins can roll side to side, so manual traction should be used (hand, wrist, forearm, and antecubital)
- the patient might provide IV history
- avoid areas with trauma, injury or infection, an arteriovenous shunt for renal dialysis, or the side of masectomy
- look for track marks (sign of sclerosis caused by frequent cannulation, drug abuse)
- some protocols allow leg cannulation, use caution because they are at greater risk of venous thrombosis and pulmonary embolism

Front 105

choosing an IV catheter

Back 105

- should reflect the purpose of the IV, the age of the patient, and the location of the IV
- over-the-needle and butterfly catheters are the most common
- there are also through-the-needle catheters but they are rarely used prehospital

Front 106

over-the-needle catheter

Back 106

- preferred for infusing IV fluids or medications in adults and children
- they are more readily secured, less cumbersome and they allow for greater patient movement
- they are less likely to puncture the vein than a butterfly catheter
- more comfortable once in position
- radiopaque for easy identification during x-ray
- risk of sticking the paramedic with contaminated needle as it is withdrawn
- more difficult to insert than other devices
- possibility of catheter shear
- come in different gauges and lengths
- 14 to 22 gauge, 18 or 20 the most common, 14 and 16 for fluid replacement
- 1-1/4" and 2-1/4" the most common lengths
- select the size that will fit the vein or that will be most appropriate and comfortable for your patient
- pediatric patients should use 20, 22, 24 or 26 gauge
- newer catheters have been designed to minimize the risk of a contaminated stick, some retract automatically

Front 107

inserting the IV catheter

Back 107

- beveled side of the catheter should be up
- maintain adequate traction on the vein
- apply a constricting band above the site (~6" to 10" above) so the blood fills the veins, it should be snug but not tight and only left in place long enough to complete the IV insertion, blood sample (if needed) and attach the line
- don't leave the band on while assembling equipment
- Penrose drain, blood pressure cuff or surgical hose can also be used as a band
- prep the site with an alcohol or iodine swab (inside to outside)
- twist the catheter (don't advance it) to break the seal and examine for imperfections (there could be burrs on the edge)
- apply downward or lateral traction to the vein with free hand and hold the catheter in the dominant hand
- using a 45 degree angle advance the catheter through the skin until the vein is pierced
- a flash of blood should be seen in the flash chamber, then drop to a 15 degree angle and advance the catheter a few more cm
- if only a drop or two flashes, advance the catheter gently
- slide the sheath off of the needle and apply pressure to the vein just proximal to the end of the catheter to prevent blood from leaking
- remove the needle, trigger the sheilding device and dispose of it in the sharps container
- attached the prepared IV line, remove the constricting band, and open the IV line
- look for signs of swelling or infiltration around the site
- if fluid doesn't flow check the band has been removed
- if infiltration occurs discontinue the IV and remove the catheter while holding pressure over the site to prevent bleeding

Front 108

securing the line

Back 108

- check that the catheter is in position and that the IV is flowing properly
- tear the tape before you start the IV
- double back the tubing to create a loop that will act as a shock absorber
- cover the insertion site with sterile gauze and secure with tape or other device
- adjust the flow rate and monitor the patient

Front 109

documentation and communication

Back 109

4 things
- the gauge of the needle
- the site (left forearm, left external jugular)
- type of fluid you are administrating
- the rate at which the fluid is running

Front 110

Saline Locks

Back 110

- "buff caps"
- are a way to maintain an active IV site without running fluids through the vein
- used primarily for patients who don't need additional fluids but may need rapid medication delivery
- attaches to the end of an IV catheter and is filled with approx. 2ml of normal saline to keep blood from clotting at the end
- it is a seal access site, so the saline remains in the port without entering the vein (prevents clotting)
- also known as (INT) intermittent sites because they eliminate the need to reestablish an IV each time a patient needs medication or fluid

Front 111

Discontinuing the IV line

Back 111

- shut off the flow from the IV with the roller clamp
- gently peel the tape back toward the IV site and stabilize the catheter as you remove it
- do not remove the tubing from the catheter
- using a piece of gauze place it over the site and hold down while pulling back on the catheter
- apply pressure to control bleeding

Front 112

Changing an IV Bag

Back 112

- do not allow an IV bag to become completely empty (change it when 25ml is left)
- it is a sterile process, replace any equipment that becomes contaminated
- don't allow the set to become empty and keep the drip chamber filled (prevent air from entering the vein)
- stop the flow of fluid by using the roller clamp
- prepare the IV bag by removing the pigtail from the piercing spike port
- inspect the new bag for clarity, discoloration, the expiration date and the correct fluid
- remove the piercing spike form the depleted bag and insert it into the port on the new bag (don't touch the spike)
- make sure the drip chamber is filled and then open the roller clamp and adjust the rate

Front 113

External Jugular Vein Cannulation

Back 113

- all other means of cannulation should be exhausted (there are more risks than other peripheral veins)
- risks include a carotid artery can be inadvertently punctured, a rapidly expanding hematoma from infiltration, or an air embolism
- place the patient supine with the head down to fill the jugular vein
- turn the patient's head to the side opposite the intended venipuncture site
- ALWAYS feel for a pulse (don't hit a carotid artery)
- appropriately cleanse the site
- occlude the jugular vein with your finger distally to the site (facilitates back flow of blood and also the vein to become more visible)
- Align the catheter in the direction of the vein pointed toward the shoulder
- make the puncture midway between the angle of the jaw and the midclavicular line
- stabilize the vein with your finger on it just above the clavicle
- proceed as normal and don't let air enter the vein
- tape the line securely but don't wrap anything around the neck

Front 114

Factors Affecting IV Flow Rates

Back 114

Check these after completing IV administration and whenever there is a flow problem:
- check the IV fluid (thick and cold fluids will infuse slowly)
- check the administration set (macrodrips are used for rapid delivery and microdrips deliver more controlled flow)
- check the height of the bag (the IV bag must be hung as high as possible)
- check the type of catheter used (the larger the catheter the more fluid can be delivered)
- check the constricting band (don't leave it on after completing the IV)

Front 115

local reactions of IVs

Back 115

- infiltration, thrombophlebitis, occulsion, vein irritation, hematoma, nerve, tendon, or ligament damage, and aterial puncture
- most require discontinuation of the IV and reestablishment of the IV in the opposite extremity

Front 116

systemic complications of IVs

Back 116

- can evolve from reactions or complications associated with IV insertion
- usually involve other body systems and can be life-threatening
- if an IV line is established and patent, do not remove it because it may be needed for treatment
- potential complications include allergic reactions, circulatory overload, pyrogenic reactions, air embolus, vasovagal reactions and catheter shear

Front 117

Infiltration

Back 117

- the escape of fluid into the surrounding tissue
- causes a localized area of edema
Causes of Infiltration include:
- when the IV passes completely through the vein and out the other side
- the patient moves excessively
- the tape used to secure the IV becomes loose or dislodged
- the catheter is inserted at too shallow an angle and enters only the fascia surrounding the vein (most common with large veins in the upper arm and neck)

Front 118

Signs and Symptoms of Infiltration

Back 118

- edema at the catheter site
- continued IV flow after occlusion of the vein above the insertion site
- patient complains of tightness and pain around the site

Front 119

Treating Infiltration

Back 119

- discontinue the IV and reestablish it in the opposite extremity, or in a more proximal location on the same extremity
- apply direct pressure over the swollen area to reduce further swelling and bleeding in the area
- avoid wrapping tape around the extremity (could create a constricting band)

Front 120

Thrombophlebitis

Back 120

- inflammation of the vein and the prescence of a clot
- most frequently caused by lapses in aseptic technique
- commonly encountered in patients who abuse drugs as well as in patients who are receiving long-term IV therapy in a hospital or hsopice setting or with vein-irritating solutions (dextrose or other hypertonic solutions)
- it can also be produced by mechanical factors (excessive motion of the IV needle or catheter after it has been placed)

Front 121

Signs and Symptoms of Thrombophlebitis

Back 121

- manifests by pain and tenderness along the veina nd redness and edema at the venipuncture site
- usually do not appear until after several hours of IV therapy, unlikely to see it in the field (unless interhospital transport)

Front 122

Treating Thrombophlebitis

Back 122

- stop the infusion and discontinue the IV at that site
- warm compresses may provide some relief

Front 123

Prevention of Thrombophlebitis

Back 123

- use a providone-iodine prep to scrub and disinfect skin and then do a final wipe with alcohol swab
- make sure the site is dry
- wear gloves
- cover the puncture site with a sterile dressing
- anchor the catheter and tubing securely to prevent motion in the vein

Front 124

Occulsion

Back 124

- a physical blockage of a vein or catheter
- if the flow rate is not sufficient to keep fluid moving out of the catheter tip, blood will enter the catheter and a clot could form and occlude the flow
- may also occur if the IV bag nears empty and the patient's blood pressure overcomes the flow (causes fluid backup in the line)

Front 125

Signs and symptoms of an occlusion

Back 125

- a decreasing dirp rate or the presence of blood in the IV tubing
- in a positional IV site, fluid flows at different rates (depending on the position) and the differences can cause occlusions

Front 126

Treating an Occlusion

Back 126

- select and assemble a sterile 10ml syring and large gauge needle
- select an injection port closest to the IV and swab it with an alcohol swab
- insert the needle into the injection port and pinch the line between the port and the bag
- gently pull back on the plunger to disrupt the occlusion and reestablish the flow
- if flow is reestablished check the rate (make sure it is sufficient)
- if unable to reestablish flow, discontinue the IV and reestablish it in the opposite extremity or proximally in the same extremity

Front 127

Vein Irritation

Back 127

- from the IV fluid
- patients will complain immediately that the solution is bothering them (tingling, stinging, itching, and burning)
- observe the patient closely in case an allergic reaction to the fluid develops
- caused by too-rapid infusion rate
- if redness develops at the IV site (a sign of thrombophlebitis) discontinue the IV and save the equipment for later analysis
- reestablish the IV in the other extremity with new equipment

Front 128

Hematoma

Back 128

- an accumulation of blood in the tissues surrounding an IV site
- often results from vein perforation or improper catheter removal
- blood can be seen rapidly pooling around the IV site - leads to tenderness and pain
- patients with a predisposition are those with vascular diseases (including Diabetes) and those on blood thinners (Coumadin) and corticosteroids

Front 129

How to correct a Hematoma

Back 129

- if one occurs while attempting an IV, stop and apply pressure to help minimize bleeding
- if it develops after, evaluate the IV flow and hematoma, if it seems controlled and the flow is not affected, monitor it and leave the line in place
- if a hematoma develops during the removal of an IV, apply pressure to the site

Front 130

Nerve, Tendon or Ligament Damage with IVs

Back 130

- improper identification of anatomic structures around the IV sites can lead to perforation of the tendons, ligaments, and nerves
- selecting sites near joints increases the risk
- patients will experience sudden and severe shooting pain
- numbness or tingling in the extremity after the incident is common
- immediately remove the catheter and select another site

Front 131

arterial puncture

Back 131

- when an artery is punctured during cannulation of a vein
- risk is especially high when cannulating an external jugular vein
- bright blood will spurt back through the catheter
- the color and the flow will alert you to the error
- immediately withdraw the catheter and apply pressure for at least 5 mins or until bleeding stops
- always check for a pulse in any vessel that you intend to cannulate
- usually veins are near the skin surface and arteries are deeper
- an anomaly seen is where the two are transposed and the arteries are very superficial

Front 132

Allergic Reactions

Back 132

- associated with IV therapy they are often minor
- anaphylaxis (life-threatening) is possible and must be treated aggressively
- can result from a person's unexpected sensitivity to an IV fluid or medication (allergy could be unknown to patient)

Front 133

Signs and Symptoms of an Allergic Reaction

Back 133

- itching (pruritus), shortness of breath, edema of face and hands, urticaria (hives), bronchospasm, and wheezing

Front 134

Treating an Allergic Reaction

Back 134

- discontinue the IV and remove the solution
- leave the catheter in place as an emergency medication route
- attach a saline lock, if available
- contact medical control and keep the airway open
- monitor ABCs and vital signs
- keep the solution or medication for evaluation

Front 135

Pyrogenic Reactions

Back 135

- the presence of foreign proteins in the infusion solution or administration set, capable of producing fever
- characterized by an abrupt temperature elevation (as high as 106 degrees)
- symptoms include: severe chills, backache, headache, weakness, nausea and vomiting
- occasionally vascular collapse occurs (shows signs of shock)
- reaction usually begins withing 30 mins after infusion starts

Front 136

Treating Pyrogenic Reactions

Back 136

- if any any signs of such a reaction are observed, stop the infusion immediately
- start a new IV in the other arm with a fresh infusion solution
- remove the first IV
- treat for shock if there are any signs

Front 137

Prevention of Pyrogenic Reactions

Back 137

- inspect the IV bag carefully before use
- if the bag has any leaks or if the fluid looks discolored or cloudy, use another bag

Front 138

Circulatory Overload

Back 138

- healthy adults can handle 2-3 extra liters of fluid
- cardiac, pulmonary, or renal dysfunction patients do not tolerate excess fluid
- most common cause is failure to readjust the drip rate after flushing an IV line immediately after insertion
- always monitor IV, or use Volutrol administration set for patients who are at risk, if available

Front 139

Signs and Symptoms of Circulatory Overload

Back 139

- include dyspnea, jugular vein distention and hypertension
- crackles (rales) are often heard when evaluating breath sounds
- acute peripheral edema can be an indication

Front 140

Treatment of Circulatory Overload

Back 140

- slow the IV rate to keep the vein open
- raise the patient's head to ease respiratory distress
- administer high-flow oxygen and monitor vital signs and breathing
- contact medical control (certain drugs can reduce circulatory volume)

Front 141

Air Embolus

Back 141

- healthy adults can tolerate as much as 200ml of air introduced into the circulatory system
- for people who are injured or ill, any air can present a problem

Front 142

Prevention of an Air Embolus

Back 142

- properly flushing an IV line will elminate the likelihood
- be sure to replace empty IV bags with full ones

Front 143

Signs and Symptoms of Air Embolus

Back 143

- respiratory distress with unequal breath sounds
- cyanosis (even in the presence of high-flow oxygen), signs of shock, loss of consciousness, and respiratory arrest

Front 144

Treatment of an Air Embolus

Back 144

- place patient on their left side with their head down to trap any air in the right atrium or right ventricle
- admin of 100% oxygen and rapid transport
- assist ventilation, if necessary

Front 145

Vasovagal Reactions

Back 145

- also called "vagaling down"
- vasculature dialation caused by anxiety concerning needles or the sight of blood
- causes a drop in blood pressure and patient collapse
- can present with anxiety, diaphoresis, nausea, and syncopal episodes

Front 146

Treatment of Vasovagal Reactions

Back 146

Treat for shock:
- place patient in shock position
- apply high-flow oxygen
- monitor vital signs
- establish an IV in case fluid resuscitation is needed

Front 147

Treatment of catheter shear

Back 147

- involves surgical removal of sheared tip
- if suspected, place the patient in a left lateral recumbent position with the legs down and the head up to catheter tip out of the pulmonary circulation

Front 148

radiopaque

Back 148

- catheter hubs are appear white in an x-ray
- aids in the diagnosis of this problem
- never rethread a catheter, always get a new one

Front 149

Signs and Symptoms of Catheter Shear

Back 149

- patients with pulmonary artery occlusion have sudden dyspnea, shortness of breath, and possibly diminished breath sounds
- mimic an air embolus, and can be treated the same way
- patients need continued IV access, an IV should be started in another extremity

Front 150

Treatment of catheter shear

Back 150

- involves surgical removal of sheared tip
- if suspected, place the patient in a left lateral recumbent position with the legs down and the head up to catheter tip out of the pulmonary circulation

Front 151

radiopaque

Back 151

- catheter hubs are appear white in an x-ray
- aids in the diagnosis of this problem
- never rethread a catheter, always get a new one

Front 152

Signs and Symptoms of Catheter Shear

Back 152

- patients with pulmonary artery occlusion have sudden dyspnea, shortness of breath, and possibly diminished breath sounds
- mimic an air embolus, and can be treated the same way
- patients need continued IV access, an IV should be started in another extremity

Front 153

Obtaining Blood Samples

Back 153

- obtain them at the same time you start an IV
- equipment needed includes: 15 or 20ml syringe, 18 or 20 gauge needle, and a self-sealing blood tube
- tubes come in red, blue, green and lavender (fill in that order - RED BLOOD GIVES LIFE)
- 2 procedures - live needle and Vacutainer

Front 154

red blood tube

Back 154

- contains no additives and is intended to clot if blood typing is needed

Front 155

blue blood tube

Back 155

- contains the preservative EDTA and is used to help determine a patient's prothrombin time and partial thromboplastin time (calculates a patient's clotting time)

Front 156

green blood tube

Back 156

- filled with heparin to prevent clotting and is used to evaluate the patient's electrolyte and glucose levels

Front 157

lavender blood tube

Back 157

- are filled with sodium citrate and are often used for a complete blood count, including hematocrit and hemoglobin values

Front 158

obtaining a blood sample with a live needle

Back 158

- after the catheter is in place, occlude the catheter and remove the constricting band
- attach a 15 or 20ml syringe to the hub of the IV and draw the necessary amount of blood
- don't leave the constricting band on while drawing blood (can cause waste products to build up in the blood - could skew results)
- detach the syringe, attach the IV tubing and start the infusion
- attach a 18 or 20 gauge needle to the syringe and fill the blood tubes with the blood
- dispose of the needle and syringe in sharps
- Be cautious with this technique - using a live needle

Front 159

obtaining a blood sample with a Vacutainer

Back 159

- apply a constricting band and locate a suitable vein (typically antecubital)
- prep the vein and cleanse the area as normal
- insert the needle (already attached to the Vacutainer) into the vein
- remove the constricting band and insert the blood tubes into the Vacutainer
- remove the needle from the vein and apply direct pressure
- dispose of needle in sharps
- label the tubes with patient's name, the date, time and your name
- gently turn them back and forth to mix the anticoagulants and blood
- don't shake the red tube after it has clotted
- tubes must be 3/4 full

Front 160

Vacutainer

Back 160

- a cyclinderical device that attaches to an 18 or 20 gauge sampling needle
- the blood tubes are inserted into it after the needle has entered the vein

Front 161

Intraosseous Infusion

Back 161

- a technique of administering fluids, blood and blood products, and medications into the intraosseous space of a long bone (usually proximal tibia)

Front 162

diaphysis

Back 162

- the shaft of long bones

Front 163

epiphysis

Back 163

- the ends of long bones

Front 164

epiphyseal plate

Back 164

- growth plate of long bones

Front 165

intraosseous (IO) space

Back 165

- collectively comprises the spongy cancellous bone of the epiphyses and the medullary cavity of the diaphysis
- its vasculature drains into the central circulation by a network of venous sinuses and canals
- shock, cardiac arrest, or another hemodynamically compromising condition can cause peripheral veins to collapse - makes IV access difficult
- IO space remains patent unless there is trauma
- referred to as a "noncollapsible vein"
- quickly absorbs IV fluids and medications and rapidly gets them to the central circulation
- anything given IV, can be given IO

Front 166

IO infusion

Back 166

- indicated when you are are unable to obtain IV access in a critically ill or injured patient
- historically IO was reserved for children under 6 when IV access could not be obtained with 3 attempts or 90 seconds

Front 167

Equipment for IO Infusion

Back 167

- manually inserted IO needles
- the FAST1
- EZ-IO
- Bone Injection Gun (BIG)
- all require specialized training and thorough familiarly with each device's features, functionality, and clinical application

Front 168

Manual IO needles

Back 168

- Jamshedi needle and Cook catheter
- were the original devices used for establishing IO access in children and are still widely used in the prehospital setting
- consist of a solid boring needle (trocar) inserted through a sharpened hollow needle
- the IO needle is pushed into the bone with a screwing, twisting action
- once the needle pops through the bone, the solid needle to removed, leaving the hollow steel needle in place
- the IV tubing is attached to the catheter
- they are long, rest at a 90 degree angle to the bone, and are easily dislodged
- they require full and careful immobilization to maintain adequate flow
- stabilize them the same as a impaled object

Front 169

FAST1

Back 169

- First Access for Shock and Trauma
- first IO device approved for adults (not used in children)
- 4 design elements allow for the placement in the sternum - an infusion tube and subcutaneous portal, an introducer, a target/strain relief patch, and a protective dome
- the sternum is used because of its ease of locating the manubrium and the easier penetration

Front 170

EZ-IO

Back 170

- features a hand-held battery-powered driver
- a special IO needle is attached to the driver and inserted into the proximal tibia of adults and children when IV access is difficult
- it is universal with different sized needles

Front 171

Bone Injection Gun (BIG)

Back 171

- a spring-loaded device that is used to insert an IO needle into the proximal tibia of adult and pediatric patients
- comes in adult/ped sizes

Front 172

Performing an IO Infusion

Back 172

- requires proper anatomic landmark identification - proximal tibia - located medial to the bony protuberance below the knee (tibial tuberosity)
- distal tibia or distal femur may also be acceptable locations
- check the IV fluid for the correct fluid, clarity and expiration date
- select the IO needle, syringe, saline, and extension set (a three way stopcock may facilitate easier fluid admin)
- connect the admin set to the bag and prepare the drip chamber and tubing
- prepare syring and extension tubing
- cut or tear the tape
- take BSI precautions
- find the appropriate IO location and cleanse the site
- stabilize the tibia and place a folded towel under the knee
- insert the needle at 90 degrees to the leg until there is a pop
- unscrew the cap and remove the stylet from the needle
- attach the syringe and extension set, pull back on the syring to aspirate and ensure proper placement
- slowly inject saline and watch for extravasation and stop the infusion if it is seen
- if the bone fractures, remove the IO and switch to the other leg
- connect the admin set and adjust the flow rate (fluid doesn't flow as fast as an IV)
- crystalloid boluses should be given with a syringe in children and a pressure infuser device in adults
- secure the needle with tape and support it with a bulky dressing (not all the way around the leg)
- dispose of needle in sharps

Front 173

Potential Complications of IO Infusion

Back 173

- risk for complications is relatively low if the proper technique is used
- same potential risks as IV - thrombophlebitis, local irritation, allergic reaction, circulatory overload, and air embolism
- in addition, extravasation, osteomyelitis, through-and-through insertion and pulmonary embolism can occur

Front 174

extravasation

Back 174

- occurs when the IO needle does not rest in the IO space, but instead rests outside the bone - can happen when the bone is missing or fractured
- fluid will collect in the soft tissues
- risk can be reduced by proper insertion (90 degree angle)
- should be suspected if the infusion does not run freely or if the posterior aspect of the leg rapidly becomes edematous
- discontinue the infusion immediately and reattempt in the other leg
- undetected, it could result in compartment syndrome

Front 175

Osteomyletis

Back 175

- inflammation of the bone and muscle caused by infection
- occurs in fewer than 0.6% of IOs

Front 176

Children and IOs

Back 176

- failure to properly identify the landmark of an IO can damage the growth plate and result in long-term bone growth abnormalities in children

Front 177

structural complications of IO

Back 177

- too forceful of an IO insertion or a needle that is to large for the patient's age or size can cause fractures

Front 178

through-and-through insertion

Back 178

- occurs when the IO needle passes through both sides of the bone
- to avoid this, stop the needle when you feel a pop
- if you feel a pop-pop it has likely passed through both sides
- remove the need and attempt in the other leg

Front 179

pulmonary embolism (PE)

Back 179

- can occur if the particles of the bone, fat or marrow find their way into the systemic circulation and lodge in a pulmonary artery
- suspect if the patient experiences shortness of breath, pleuritic chest pain, and cyanosis

Front 180

Contraindications to IO Infusion

Back 180

- IV lines are preferred and IO should only be used when there isn't easy access to an IV
- fracture of the bone intended for IO
- osteoporosis
- osteogenesis imperfecta
- bilateral knee replacements

Front 181

Calculating Fluid Infusion Rates

Back 181

- the flow rate should be adjusted according to the patient's clinical condition or as dictated by medical control
MUST KNOW:
- the volume to be infused
- the period over which it is to be infused
- the properties of the admin set being used (how many gtt/mL it delivers)

Front 182

KVO/TKO

Back 182

- Keep Vein Open/ To Keep Open
- the flow rate for medication admin
- should be slow enough to keep the vein open