IntravenousTherapy74Thirtyyearsago…Rampart,Squad51.Wehavea20yearoldmalemotorcycleriderinvolvedinamotorvehiclecollisioncomplainingofneck,backandlegpain.Hepresentswithcompoundfracturestobothfemursandhassignificantbloodloss.WearerequestinganorderfortwolargeboreIV’sandRinger’sLactate.ObjectivesIdentifythereasonsIVtherapyisperformedintheprehospitalsettingIdentifythefluidscommonlyadministeredStatethebasisoffluidandelectrolytebalanceIdentifyfactorsaffectingwaterlossExplaintherecommendedusesofIVsolutionsIdentifycommoncomplicationsandreactionsCalculateaflowrateDemonstrateproperskincleansingandasepticvenipuncturetechniqueDemonstrateproperIVcannulationtechniqueWhydowecannulate?FluidadministrationMedicationadministrationTomaintainlife(electrolytes,blood…)DowedothemtobeEHSNSprotocolcompliant?IVfluidsNormalsaline(0.9%NS)LactatedRinger’s(LR)AlsoknownasHartman’ssolutionorRLD5W?NSD5?NSD5RL(D5LR)IsotonicSolutionsCharacteristicsSametonicityasplasmaOsmoticpressureisthesameastheinsideofthecellFluidneverleavesorentersthecellApproximateosmolarityis240–340mOsm/LWillincreasecirculatingvolume,whichmayleadtofluidvolumeexcessoroverload.Solutions2.5%dextrose/0.45%NaCl0.9%NaClLactatedRingers2.5%dextrosein?lactatedringers6%dextanand0.9%NaCl10%dextranand0.9%NaClNormalSaline MostcommonlyadministeredIVfluidprehospitallyIVfluidofchoiceforEHSNSprotocolsWhy?LactatedRingersComposedofmultipleelectrolytesinsalineHasfallenoutoffavorasoneofmainIVfluidsfortreatmentoftraumatichypovolemiainpastdecadeWhy?HypotonicSolutionsCharacteristicsMaycausebloodcellstoswellandburstMaycausechangesordamageendothelialcellsExertlessosmoticpressurethanthefluidintheextracellularcompartmentFluidisdrawnintothecellsApproximateosmolarity<240mOsm/lSolutions0.45%NaCl10%dextranand5%dextrose(slightlyhypotonic)HypertonicSolutionsCharacteristicsMaycausebloodcellstoshrinkMaycausedame/changestoendothelialcellsExertmoreosmoticpressurethentheextracellularfluidFluidisdrawnfromthecellintothevascularspaceApproximateosmolarity>340mOsm/lSolutions5%dextrose/0.2%NaCl5%dextrose/0.9%NaClD5WD10WD50W5%NaHCO310%,15%and20%Mannitol6%dextranand0.9%NaClAdministrationSetsThecalibrationoftheadministrationsetmustbeknowninordertocalculatetheflowoftheIVfluidscorrectly.Macrodripsets10,15or20gtts/mlMicrodrip(minidrip)60gtts/mlWheredowecannulate?HandForearmNeckFootEquipmentRequiredSolutionAdministrationsetIVcannulaTourniquetAlcoholswabGlovesSharpsbinOpsiteandgauzeTapeIfperformingaLockLock,syringeandsalineCatheterspecificsColor Size Int

Dia/Length MaxFlowGrey 16G 1.4mm/45mm 180mls/minGreen 18G 1.0mm/45mm 80mls/minPink 20G 0.8mm/32mm 54mls/minBlue 22G 0.6mm/25mm 31mls/minThelengthanddiameterwillaffecttheamountoffluidabletobeinfusedthroughthecatheterLargerdiameterandshorterlengthgivesmorefluidSmalldiameterandlonglengthgiveslessfluidTypesofcathetersJelcoCathelonInsyteTypesofcathetersProtectiveProtectivePlusAdministrationSets10gtts/ml15gtts/ml60gtts/mlBloodsetsVeinSelectionBasedon:ConditionPalpatetoconfirmtypeofvesselShouldbesoftandspongyStraightwithnoturnsorbumpsLocationIstheptrightorlefthandedIstheextremityinjuredAvoidjoints(stabilization)Doesthepthaveashunt(fistula)PurposeFluidreplacement,Medicationroute,Safetyline(lock)DictatesflowrateandtypeoffluidtobeinfusedTrytouselargeveinsforlargequantitiesoffluidDurationWhattypeofpatient(trauma,cardiacoroutpatient)PatientcomfortoverlongperiodoftimeProlongedtherapymayrequiremultiplepuncturesForlongdurationsusedistalveinsfirstFluidReplacementBloodReplacedataratioof3:1ofIVfluidtobloodbeingreplacedMinimumdailyrequirements1st10kg 100ml/hr2nd10kg 50ml/hr3rd10kg 20ml/hr4th10kg 10ml/hr5th10kg 10ml/hrExample 50kgpatient100ml/hr+50ml/hr+20ml/hr+10ml/hr+10ml/hr=190ml/hrContraindicationsDistaltoafracturesiteinalimbThroughdamagedorabradedskinBurnsmaybeanexceptionifthereisnootheraccessiblesiteInanarmaffectedbyaradicalmastectomy,edema,bloodclotorinfectionInanarmwithafistulafordialysisoraperipherallyinsertedcontrolcatheter(PICCLine)ProcedureObtainconsentandexplainrationaleforIVtherapyAssessthattheptmeetsthecriteriafortheprocedureEnsurethattherearenocontraindicationsfortheprocedureObserveuniversalprecautionsforbodysubstanceexposuresPrepareallnecessaryequipmentPositionthepatientApplyatourniquet3–5inchesabovetheselectedsitePatientmaymakeafisttoassistinengorgingtheveinSelectthemostappropriatevenipuncturesiteConditionLocationPurposeDurationPreparethept’sarmusingalcoholswabProcedureInsertneedlethroughskinShouldbeatan30°angleLowerangle(15°)andenterveinObserveflashbackEnterveina‘littlebitmore’EntercatheterintoveinReleasetourniquetWithdrawneedleanddiscardinsharpscontainer,tamponadetheveintoavoidbloodspillAttachivtubingandopenflowvalveobservingforinfiltrationCoverwithOpsiteorothersteriledressing,tapeinplaceIVAccessComplicationsLocalcomplicationsHematomasInfiltrationNecrosisThrombophlebitisSystemiccomplicationsPulmonaryedemaSpeedshockPyrogenicreactionPulmonaryembolismbloodAirCathetershearLocal-HematomasCauses:Symptoms:Preventativeactions:PuncturedveinBruisingTendernessSwellingPropertechniquesLocal-InfiltrationCauses:Symptoms:Preventativeactions:PoorinsertiontechniquesImpropertapingOveractivepatientIVslowsorstopsSwellingorhardnessFeelingofcoldnessLeakingatthesiteArmboards,propertapingRoutinechecksofIVflowandsiteLocal-NecrosisCauses:Symptoms:Preventativeactions:IrritationoftissuesfrominfiltrateddrugorfluidSwelling,tendernessInflammationorbruisingRoutinechecksReportanychangesLocal-ThrombophlebitisCauses:Symptoms:Preventativeactions:TraumatoendotheliumfromchemicalmeansPain,redness,swellingalonginfectedveinGeneralizedsymptomssuchasfever,malaise,rapidpulseAvoidinsertionoverjointSelectveinswithadequatebloodflowforinfusionsofhypertonicsolutionsSystemic–PulmonaryEdemaCauses:Symptoms:Preventativeactions:CirculatoryoverloadfromtoorapidinfusionwhenpatienthasimpairedrenalorcardiacfunctionJVD,↑BP,↑Resps,dyspnea,agitationWatchrateOxygen,sitptuprightSlowIVandcontactOLMCSystemic–SpeedShockCauses:Symptoms:Preventativeactions:IVrunningtorapidlyRapidinjectionofadrug↓BP,rapidpulseLaboredresps,cyanosisFaint,↓LOCUsecontrolledvolumeinfusionsetUponinitiation,ensurefreeflowingpriortorateadjustmentSystemic–PyrogenicReactionCauses:Symptoms:Preventativeactions:ContaminatedIVsolutionsSymptomsgenerallyoccurafterIVbegun↑temp,chills,headache,N/V,circulatorycollapseCheckIVfluidsforcloudinessandparticlesUsefreshopenIV’sSystemic–PE(Blood/Embolus)Causes:Symptoms:Preventativeactions:UnfilteredbloodPartiallydissolveddrugParticulatematterinIVsolutionDyspnea,cyanosis,pain,anxiety,tachycardia,tachypneaInfusebloodthroughfilterDissolvedrugscompletelyUsegoodjudgmentwhensyringingIV’sSystemic–PE(Air)Causes:Symptoms:Preventativeactions:FailuretocleartubingofairAllowingairtoenterthesystemCyanosis,↓BP,weak,tachycardia,↓LOC,non-specificchestorABDpainDon’tletIVrundryCleartubingproperlyChecksyringepriortoinjectingIfoccursplaceptonleftsideandcontactOLMCTroubleshootingIfbloodbeginstoflowbackintheIVtubingChecklocationofthebagtoinsureitisinagravityflowlocationInsureallvalvesareopenIfcontinues,reassesssiteandassurearterialcannulationhasnotoccurredIfyourIVdoesnotrun…Startatthetop,workyourwaybacktothepatientIsthebagempty?ChecktheIVsetclampstoinsuretheyareopenChecktubingforkinksChecksiteforanyproblemsBloodbackingupInfiltrationDoyouneedtoflushthesiteIsyourtourniquetstillone!ExternalJugular(EJ)cannulationEJ’sOftenusedinseverecasesofshock,unresponsivenessandcardiacarrestsincetheyareHUGEandrelativelyeasytocannulate.Whyaretheynotcommonlyusedinthosewhoareconscious?Whyaretheynotagoodchoiceforpatientsofmultisystemtrauma?EJcannulationprocedurePlacepatientsupine/slightreverseTrendelenburgWhy???TurnpatientsheadslightlytooppositesideCleansewithantisepticusinguniversalprecautionsCreatetourniqueteffectwithfingersbyapplyinglightpressuretotheinferioraspectsoftheEJbeingcannulated.ProcedureAimneedletowardsipsilateralnippleInsertneedleandenterveinObserveflashbackWithdrawneedleandattachIVtuningCoversitewithsteriledressingEJcannulationCalculatingflowratesDripsets Factor10gtt/ml(macro) 10drops=1ml 615gtt/ml 15drops=1ml 420gtt/ml 20drops=1ml 360gtt/ml(micro) 60drops=1ml 1Volumetobeadministered(ml)Timetobeinfused(min)XDripset(gtts/ml)=Drops/min(gtts/min)CalculationsYourpatientistorec