Medication Administration and IV

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1 16 Medication Administration and IV 3. List four possible causes of this child s seizure. 4. What test should you perform on this infant before any medications are administered, and why? 5. What are the possible routes of medication administration for this patient (list in order of your preference and explain). Are You Ready? As you arrive on the scene of an unknown medical emergency, a hysterical woman runs out of her house carrying an infant who appears blue and is actively seizing. You yell to your partner, Seizing kid, as you open the side door of the ambulance and grab the pediatric kit and O 2 bag. Your partner takes the baby from the mother and steps up into the ambulance as you open the O 2 bag. 1. What is your general impression of this patient? 2. What is your first priority? 182 Active Learning Some people are great at math, and then there are the rest of us. There is a certain amount of common sense that goes into calculating drug dosages, but for the most part it is based on simple formulas and calculations. 1. Equivalents Before you begin calculating drug dosages, there are several things that you will need to commit to memory: a. pound(s) (lb) make up 1 kilogram (kg). b. 1 kg is equal to gram(s) (g).

2 Chapter 16 Medication Administration and IV 183 c. 1 g is equal to milligram(s) (mg). d. 1 mg is equal to microgram(s) (mcg). e. 1 liter (L) is equal to milliliter(s) (ml). f. 1 cubic centimeter (cc) is equal to ml. g. 1 teaspoon (tsp) is equal to ml. h. 1 tablespoon (T) is equal to ml. i. 1 fluid ounce (fl oz) is equal to ml. j. 1 grain (gr) is equal to mg. k. 1 deciliter (dl) is equal to L. l. 1 centimeter (cm) is equal to meter(s) (m). m. 1 milligram (mg) is equal to g. n. 1 mcg is equal to g. 2. Calculation Methods There are several ways to determine how much of a medication you are supposed to administer to a patient. No matter what method you choose to use, if performed properly, they should all come up with the same answer. Following are three methods for determining the appropriate dose based on information that you have available to you. Method 1 The first method is based on the following formula: Volume on hand Volume to be administered (X) Ordered (or calculated) dose Concentration (in units of mg, mcg, g, etc.) Example: Medical control orders you to administer 5 mg of morphine sulfate IV to your 84-year-old female patient who has signs and symptoms of a hip fracture. The morphine in your formulary contains 10 mg in 1 ml. How many milliliters of morphine sulfate do you need to administer to this patient in order to deliver 5 mg? You have the following information: Order: On hand: 10 mg/1 ml Fill in the formula: X 5 mg morphine sulfate IV 1 ml 5 mg 10 mg Cancel any common values (volumes or concentrations) that exist on the top and on the bottom, and multiply across the top. 1mL 5 mg X 10 mg 1 5 ml 10 5 ml ml You need to administer 0.5 ml of morphine sulfate to your patient. Method 2 This second method involves ratio and proportion. The symbol for proportion is ::, and the symbol for ratio is :. Using the same problem as in method 1, start with the known ratio on the left side of the proportion: 10 mg : 1 ml :: Place the unknown ratio on the right side of the proportion in the same sequence as the ratio on the left side of the proportion. This ratio is usually the physician order or the dosage that you are permitted to administer based on standing orders: 10 mg : 1 ml :: 5 mg : X ml First, multiply the extremes ( the far outside values: 10 mg and X ml) and place the result on the left side of the equation. Second, multiply the means ( the numbers on either side of the proportion symbol: 1 ml and 5 mg) and place this value on the right side of the expression: Multiply: 10X X 5 Divide both sides by the number in front of the X : 10X X 0.5 ml You need to administer 0.5 ml of morphine sulfate to your patient.

3 184 Part 2 Foundations of Communication, Assessment, and Critical Care Method 3 The third method is referred to as the cross multiplication method. This method sets the problem up using fractions. The first fraction is the concentration, and the second fraction is the physician s order over the volume of medication being administered. 10 mg 1 ml 5 mg X ml Cross multiply the fractions by multiplying numerators by the denominator on the opposite side. Express the results as an algebraic equation the same as used in the proportion method. 10X X 0.5 ml You need to administer 0.5 ml of morphine sulfate to your patient. 3. Fluid Volume over Time To calculate a volume to be infused over a specific time frame, you need the following information: The volume to be administered The delivery of volume of the administration set (drops [gtt]/ml) The total time to infuse the fluid (always expressed in minutes) Example: The physician orders the administration of 400 ml of 0.9% sodium chloride solution over 1½ hours using a 10 gtt/ml (macro-drip) administration set. At what drip rate will you set the infusion? Volume to be infused: 400 ml Administration set size: 10 gtt/ml Total time of infusion: 90 minutes The following formula should be used when calculating this type of problem: Drip rate Volume to be infused Drip chamber size (gtt>min) Total time of infusion (minutes) 400 ml 10 gtt / ml 90 min Simplify: Drip rate 400 ml 10 gtt / ml 90 min 400 gtt 9 min 44.4 gtt/ min This same formula can be used to find out how long it would take to administer the entire contents of an IV bag using a specific drip rate. Place the drip rate on the left side of the equation. The total volume of the IV bag multiplied by the drip chamber size is the numerator on the right side of the equation. The total time of infusion is the denominator on the right side of the equation. Solve the equation for X (the time needed to administer the entire contents of an IV bag). Example: You have a 250-mL bag of 5% dextrose in water (D 5 W) and have been ordered to infuse it at 90 gtt/min using a 60-gtt/mL administration set. How long will it take to infuse this amount of fluid? Volume to be infused: 250 ml Administration set size: 60 gtt/ml Total time of infusion: X minutes Ordered gtt/min: 90 gtt/min Set up the formula with the information that you have on hand: 90 gtt/ min 250 ml 60 gtt / ml X Time Multiply each side of the equation by X. Milliliters cancel one another. X(90 gtt/ min)(x Time) 15,000 gtt Divide each side by 90 gtt/min: X Time 167 min It will take 167 minutes, or 2 hours and 47 minutes, to infuse the 250-mL bag of D 5 W. 4. IV Infusions There are also several methods for determining IV drip rates for patients receiving IV infusions. The following methods are examples of how this can be done. Formula Method This method finds the ordered dosage over time based on the patient s weight. Example: You have a resuscitation patient who has a return of spontaneous circulation (ROSC) after you defibrillate her out of ventricular fibrillation. You reassess the patient and discover that she is in a normal sinus rhythm, but she is hypotensive. Fluid boluses do not affect the patient s blood pressure, so you decide to start the patient on a dopamine infusion at 10 mcg/kg/min per your protocols. The patient weighs 132 pounds.

4 Chapter 16 Medication Administration and IV 185 You have premixed dopamine IV bags that contain 200 mg of dopamine in 250 ml of D 5 W. Your policy for administration of dopamine mandates the use of a 60-gtt/mL IV tubing. How many drops per minute will need to be delivered in order to achieve the 10 mcg/kg/min dosage? First convert the patient s weight in pounds into kilograms: 132 lb 2.2 lb/kg 60 kg Next insert the information that you have on hand into the formula below, and you will get Clock Method Dopamine Clock The clock method is a way in which paramedics can simplify calculating how many drops per minute they need to infuse once they have determined the dosage of the medication that they need to administer. It helps determine drops per minute based on the concentration of medication per a specific volume of fluid and the number of drops per volume of the administration set. Example: Dopamine comes in premixed bags with various concentrations of medication. For X IV bag volume (ml) Concentration ordered (mg, mcg, g) Administration set (gtt) Amount of drug in IV bag 1 min 1 ml 250 ml 200 mg 10 mcg /kg 60 gtt 1 min 1mL Because the concentration ordered is weight based, the 10 mcg needs to be multiplied by the patient s weight in kilograms (60 kg): mcg X 250 ml 600 mcg 60 gtt 200 mg 1 min 1 ml Next convert the amount of drug in the bag from milligrams to micrograms because the order is in micrograms: 200 mg 200,000 mcg X 250 ml 600 mcg 60 gtt 200,000 mcg 1 min 1 ml Simplify the problem (cancel out zeros and units): X 250 ml 600 mcg 60 gtt 200,000 mcg 1 min 1 ml min Now multiply: 6 gtt 1 X gtt 1 min 1 X 900 gtt 20 min Simplify the problem: X Reduce the fraction: 90 gtt 2 min 45 gtt 1 min 45 gtt / min the sake of this example, we will say that the premixed bag contains 800 mcg/ml of fluid. If you are using a 60-gtt/mL administration set (which is typical for the administration of dopamine), the clock tells us that for every 60 gtt or 1 ml of fluid, the patient will receive 800 mcg of the solution. The 800 mcg and the 60 gtt/min go at the top of the clock (at 12:00). To complete the clock, you need to use basic division and addition. We need to fill in the clock at the 3:00, 6:00, and 9:00 positions. In order to do this, we need to divide both the 800 mcg and the 60 gtt by 4: 800 divided by 4 is 200, and 60 divided by 4 is 15. The 3:00 position is filled in by 200 mcg/ ml and 15 gtt/ml. Add another 200 mcg/ml and 15 gtt/ml, respectively, to these numbers to get the correct volume and drip rate for the 6:00 position (400 mcg/ml and 30 gtt/ml). To complete the clock and fill in the 9:00 position, add another 200 mcg/ml and 15 gtt/ml, respectively, to the 6:00 calculation (obtaining 600 mcg/ml and 45 gtt/ml). Dosage: 10 mcg/kg/min 10 mcg/60 kg/min 600 mcg/min Premix IV bag: 200 mg/250 ml 200,000 mcg/ 250 ml Concentration: 800 mcg/ml IV administration set: 60 gtt/ml You are looking for the drip rate for dopamine in drops per minute. To accomplish this, you need to make sure that you are dealing with like values in your clock. For example, the volume that you are using in your administration set needs to match that of your concentration (if the volume of the administration set is measured in milliliters, then the concentration of the medication needs to be measured in a like volume [ml]). Once this

5 186 Part 2 Foundations of Communication, Assessment, and Critical Care has been confirmed, you are ready to set up your clock: 600 mcg mcg 60 gtt/min mcg mcg Since you are going to deliver 600 mcg/min, look at the clock to determine how many drops per minute you will need to deliver that amount of dopamine: 45 gtt/min will give you the desired 600 mcg/min. Find the ordered dosage over time: The information that is needed from the problem is The ordered dose The size of the drip chamber The amount of drug on hand The total volume on hand (the volume of the IV bag being used) The physician orders a 2-mg/min maintenance infusion of lidocaine for a patient who was experiencing ventricular tachycardia. You have a premixed solution of lidocaine that has 1 g of lidocaine in 250 ml of normal saline. You have a 60-gtt/mL administration set. At what drip rate will you set this infusion? Physician s order: 2 mg/min Administration set size: 60 gtt/ml Amount of drug on hand: 1 g Volume on hand: 250 ml The following formula should be used when calculating these types of problems: Volume on hand Drip chamber Ordered dose Drops per minute Amount of drug on hand First, convert grams to milligrams to allow for consistency between the requested dosage and the concentration of medication on hand: 1g 1,000 mg Apply the information that you have to the equation: Drops per minute 250 ml 60 gtt / ml 2 mg/ min 1,000 mg Simplify: Milliliters cancel one another and milligrams cancel one another, leaving gtt/min. Drops per minute 30 gtt/ min Run the infusion at 30 drops per minute to infuse 2 mg of lidocaine per minute (check your work on the following lidocaine clock). Clock Method Lidocaine Clock Lidocaine drips are typically 1 g of lidocaine in 250 ml or 2 g of lidocaine in 500 ml of D 5 W. These drips are not weight based, but instead are based on milligrams per minute (mg/min). The first thing that needs to be done is to convert the grams of lidocaine to milligrams so that the drip rate will reflect the established mg/min infusion rate. 1 g 1,000 mg Next divide the volume found in the IV bag by the concentration of the lidocaine to obtain the ratio of mg:ml. 1, mg/ml 2000 mg mg/ml Now simply apply this ratio to a clock: 3 mg 45 4 mg 60 gtt/min 30 2 mg 15 1 mg 5. Calculation Problems Using any of the preceding methods, solve the following dosage calculation problems. a. You have been instructed by medical control to administer an initial dosage of 0.1 mg/kg of IV adenosine to your 33-lb pediatric patient followed by a rapid fluid bolus. Based on the available packaging of adenosine (depicted in the photo at the top of page 187), you will need to administer ml.

6 Chapter 16 Medication Administration and IV 187 b. You are working up a patient who is in ventricular fibrillation. The patient has been defibrillated following the administration of 1 mg of epinephrine 1:10,000, CPR is in progress, and the patient is now ready for her first round of lidocaine at 1.5 mg/kg. The patient weighs 132 lb. Based on the order and the lidocaine that you carry in your formulary (depicted below), you will need to administer ml of lidocaine. c. You are treating an infant who is suffering from a symptomatic bradycardia at a heart rate of 40 beats per minute. The patient has not responded to oxygen therapy, ventilation, or epinephrine administration. Your base hospital physician has ordered you to administer 0.02 mg/kg to this 22-lb child. You should administer ml of atropine (depicted below) to the patient. d. You have a 27-year-old (80 kg) male patient who has suffered second- and third-degree burns over 56% of his body. You are transporting the patient to the burn center, which is just under 1 hour away. The patient has received a considerable amount of morphine, which barely seems to be taking the edge off of the pain. You calculate your fluid infusion for the patient based on the Parkland formula and realize that you will need to infuse 1,120 ml per hour for the first 8 hours. You will need to deliver drops per minute in order to administer 1,120 ml/hour. e. You are monitoring a 500-mL bag of normal saline that is dripping at a rate of 120 gtt/min through a 10-gtt/mL administration set. It will take min for the bag to finish. f. You have been given an order to infuse a 300-mL fluid bolus to your patient over 45 minutes with a 10-gtt/mL administration set. You will need to set the drip rate at gtt/min in order to accomplish this goal. g. The physician orders 3 mcg/kg/min of dopamine to be administered to your patient in cardiogenic shock. You place 200 mg of dopamine into a 250-mL bag of D 5 W to mix the infusion. You have a 60-gtt/mL administration set, and your patient weighs 165 lb. You will run the infusion at the rate of gtt/min. h. You have been given an order for dobutamine for your hypotensive CHF patient. The order is 15 mcg/kg/min. Your protocol states that you are to use a dobutamine infusion consisting of 250 mg in 500 ml of normal saline. The patient weighs 165 lb. You will need to administer gtt/min if you are using a 60-gtt/mL administration set. i. Your preceptor is quizzing you about dosage calculations, and he states that he wants you to administer dopamine in the alpha range to a hypothetical 65-year-old, 88-lb patient. You remember that alpha effects are seen at 20 mcg/ kg/min, and you have been drilled and drilled that you are supposed to always use a microdrip (60 gtt/min) administration set when administering IV piggyback medications and that your local protocols require 200 mg of dopamine to be mixed into a 250-mL bag of D 5 W. Your preceptor wants to know how many drops per minute you will need to administer to this patient in order to see the desired effects. The answer you give is gtt/min.

7 188 Part 2 Foundations of Communication, Assessment, and Critical Care j. You have achieved a return of spontaneous circulation on a ventricular fibrillation cardiac arrest patient following your second defibrillation. Your partner boluses the patient with lidocaine and asks that you prepare a lidocaine drip. Your protocols require that you begin a lidocaine infusion at 2 mg/min. You carry premixed lidocaine (2 g in 500 ml). Using a 60-gtt/mL administration set, you will set the lidocaine infusion at a drip rate of gtt/min to deliver 2 mg/min. You Are There: Reality-Based Cases Case 1 As you are inspecting your ambulance at the beginning of your shift, an elderly man shuffles up to the back of the ambulance and says, Excuse me young man, may I have some help? I am having chest pain and I really don t feel well. You pull out the gurney from the back of the ambulance and ask the gentleman to sit down so that you can check him out. The patient complies, and as you are about to begin your assessment, your partner walks up to the ambulance. The two of you immediately go to work. You assess the patient as your partner hooks him up to the ECG monitor and the pulse oximeter (his oxygen saturation is 92% on room air) and then places the patient on O 2 at 10 L by non-rebreather mask. The patient s vital signs are BP of 188/96, HR of 112, and irregular and slightly labored respirations of 28. The ECG shows the rhythm in Figure The patient presents with cool, pale, moist skin and speaks in five- to six-word sentences. He is alert and oriented and follows basic commands. He states that he is having a heavy sensation in his chest, very similar to the pressure that he felt when he had an MI 2 months ago. The pressure (6 on a scale of 10) is nonradiating and is associated with nausea. The onset of this episode was 30 minutes ago while walking. The patient states that he had a stent placed, but he doesn t know which artery it was placed in. He takes digoxin, atenolol, Coumadin, Glucophage, and Lipitor. He has no allergies to medications. You discover that the patient has jugular venous distention (JVD), slight supraclavicular retractions with his ventilations, trace pedal edema, and faint crackles in the bilateral bases of his lungs. He has had no recent illnesses and has had no sputum production. He states that he has had trouble breathing when he sleeps at night, so he has been sleeping in a recliner in his living room. He also states that he has trouble breathing when he walks. As you establish an IV, your partner administers one metered dose of sublingual nitroglycerin and 325 mg of aspirin. Your partner states that he would like to complete the MONA algorithm and asks if you would like to contact medical control to get an order for morphine sulfate or if you would like him to make the call. 1. What is your general impression of the patient? 2. What is your first priority in the treatment of this patient? 3. Describe your basic treatment of the patient prior to administration of medications. FIGURE 16-1

8 Chapter 16 Medication Administration and IV What do you need to know about the patient before you can administer medications? 5. What do you need to know about a medication prior to administering that medication? 6. What are the five rights of medication administration? whom they believe to be delusional. The patient tells you that he has been hearing people talking all day long, like a radio playing in my head. In the kitchen you find several bottles of Abilify, an antipsychotic medication; all the bottles are full, and the prescriptions were filled several months ago. You should suspect a. a medication overdose. b. a manic depressive disorder. c. a traumatic head injury. d. a medication underdose. 2. In regard to medication administration, what is a contraindication? 7. What is likely the single most important thing that a paramedic can do following medication administration to prevent unnecessary exposure to contaminated items? 8. Explain why your partner was able to administer nitroglycerin and aspirin but needed to contact medical control in order to administer morphine sulfate. 9. During the process of obtaining a history, what is an important question to ask the patient regarding medications other than the names of the medications and any known allergies that the patient may have to medications that can have a dramatic impact on the patient s current condition? Test Yourself 1. You are called to an apartment building by law enforcement officials who have discovered a man 3. When administering a medication, you should check the patient s vital signs a. after administering the medication. b. before and after administering the medication. c. every 10 minutes after administering the medication. d. before administering the medication. 4. Next to a patient s bathroom sink, you find a prescription sleep aid, an over-the-counter (OTC) pain reliever, an herbal remedy, and a toothpaste that contains fluoride. Which of the following must be documented in your report? a. The prescription and OTC medications b. The prescription medication only c. The prescription, OTC medication, and herbal remedy d. The prescription, OTC medication, herbal remedy, and toothpaste 5. Like medications, IV catheters and tubing have expiration dates. True False 6. Your patient is in hypovolemic shock and requires immediate fluid replacement therapy. While preparing to administer the IV, you drop the needle and it falls to the ground. What should you do? a. Retrieve a new needle. b. Wipe off the needle with a clean, dry piece of gauze. c. Wipe the needle with an antiseptic. d. Use your breath to steam the surface of the needle.

9 190 Part 2 Foundations of Communication, Assessment, and Critical Care 7. Sharps should be disposed of in a. a plastic bag clearly marked Caution. b. any public trash receptacle. c. a jar containing alcohol. d. a biohazard receptacle. 8. drugs need to be accounted for at the beginning and end of your shift, should be kept secure throughout your shift, and require detailed custody logs. 9. In accordance with your local protocols, you should frequently inspect your ambulance s medication supply. List three specific factors you should note when performing this task. 10. Although needle-less systems do not require needles, they are compatible with traditional needles. True False 11. Your partner has been experiencing chronic bumps and raised, red areas on her hands. When she went on vacation for 2 weeks, the symptoms gradually disappeared, but a week after returning to work, the symptoms have returned. She is always very careful to wear gloves when handling medications and during any patient contact. You should suspect a. a reaction to handling a medication. b. contact dermatitis contracted from a patient. c. a fungal infection. d. a latex allergy. 12. Which of the following statements regarding injectable medications is true? a. Most injectable medications should not be frozen. b. Most injectable medications have a very short shelf life. c. Most injectable medications can only be stored in glass bottles. d. Most injectable medications cannot be exposed to light. 13. List the three acceptable methods for sterilization of medical equipment. 14. EMS providers can emulate pharmacies by using a three-step system to confirm that the correct medication is being administered. Briefly describe these three steps. 15. You have responded to a remote location for a patient in hemorrhagic shock. En route to the hospital you are attempting to obtain IV access to begin fluid resuscitation, but the road that you are traveling on is bumpy, and you are unable to safely perform the procedure. To minimize the possibility of an accidental needle stick, you would likely a. wait until you reach the main highway before reattempting to obtain IV access. b. have the driver pull over, and obtain IV access while the ambulance is stopped. c. concentrate on alternative forms of treatment until you reach the hospital. d. continue to carefully attempt to obtain IV access until you are successful. 16. A drug in your supply expires December What is the last date that you can administer the drug? a. December 1, 2012 b. November 1, 2012 c. December 31, 2012 d. November 31, How are the majority of health-care workers accidentally exposed to blood during their occupational training? a. Eye splashes b. Non-intact skin exposure c. Mucous membrane exposure d. Needle sticks 18. Most patients who regularly take prescription medication are compliant with their prescribed dosing regimen. True False 19. Who can authorize the administration of medication? a. The team leader b. The patient c. The online physician d. The most senior paramedic 20. You are called to a man down in a supermarket. When you arrive, the adult male patient is unresponsive and apneic. The ECG monitor reveals that the patient is in cardiac arrest. You need to administer epinephrine, but you cannot confirm the patient s

10 Chapter 16 Medication Administration and IV 191 medical history or allergies because none of the immediate bystanders know the man. You should a. administer the epinephrine immediately. b. provide care without administering any medications. c. use the man s cell phone to contact a family member. d. use the store s public address system to ask any friends or family to come forward. Need to Know The following represent the Key Objectives of Chapter 16: 1. Describe the safe and appropriate administration of medications based upon the selected route. With administration of medications comes a great deal of responsibility. The process of administering medications needs to be methodical, well thought out, and based on sound judgment. There is no room for complacency in medication administration, for when the paramedic becomes complacent, mistakes are made, and when it comes to medication administration, mistakes can be lethal. All medication administration decisions need to be based on the results of assessments that include past medical history, any known allergies to medications (specific medications [e.g., morphine] or general classifications of medications [sulfa-based medications]), physical examination, and vital signs (e.g., heart rate, blood pressure, respiratory rate, temperature, ECG tracing, pulse oximetry). Paramedics must have a basic knowledge of any medications that they may administer, including indications, contraindications (absolute or relative), potential side effects or complications, precautions, any possible interactions with other medications, and the expected therapeutic effects, based on their scope of practice and the formulary of their provider. Is the paramedic able to administer the medication based on standing orders, or does the medication administration require consultation with medical control? Because most medication dosages are based on a patient s weight, the paramedic must be able to perform drug calculations so that the patient does not receive an overdose or an underdose of a medication. Since some medications do not come packaged as ready to administer, paramedics need to know how to prepare medications for administration. For example, glucagon comes in two vials. One of the vials contains a powder, and the other vial contains a liquid. The powder needs to be combined with the liquid and thoroughly dissolved before it can be administered. Similarly, some medications need to be mixed with an IV solution in an IV bag before they can be administered as an IV drip (infusion). If given such a medication undiluted as an IV bolus, the patient could experience undesired effects. Standard medication administration must follow safe administration techniques via the appropriate administration route while maintaining asepsis. Contaminated disposable medication administration equipment needs to be disposed of in the appropriate disposal container, and reusable medication administration equipment needs to be cleaned and maintained per the manufacturer s instructions. Any preexisting medication administration device that is used by paramedics must be approved by the EMS agency and the EMS provider that the paramedic works for. Any medication administration device that the paramedic is not familiar with or specifically trained how to use should not be used by the paramedic. Other than ensuring that the five rights of medication administration are followed and the patient is not allergic to the medication that you are administering, perhaps the most important step in medication administration is to reassess the patient following the administration of a medication to see if it had the desired or any undesired effects. Make sure that the medication administration is clearly and accurately documented on your patient care report. This report is a part of the patient s medical record and may be referred to by medical personnel to direct them in further treatment of the patient.

11 192 Part 2 Foundations of Communication, Assessment, and Critical Care Need to Do The following medication administration skills are explained and illustrated in a step-by-step manner, via skill sheets and/or Step-by-Steps in this text and on the accompanying DVD: Skill Name Skill Sheet Number and Location Step-by-Step Number and Location Intravenous Access 42 Appendix A and DVD 42 This chapter and DVD Intravenous Access Using Saline Lock 43 DVD 43 DVD Phlebotomy 44 DVD N/A Intraosseous Access and Drug Administration 45 Appendix A and DVD 45 This chapter and DVD Umbilical Vein Cannulation 46 DVD N/A Central Line Access for Fluids and Drug Administration 47 DVD N/A Intravenous Drug Bolus 48 Appendix A and DVD 48 This chapter and DVD Intravenous Drug Infusion 49 Appendix A and DVD 49 This chapter and DVD Intramuscular Drug Administration 50 Appendix A and DVD 50 This chapter and DVD Intranasal Drug Administration 51 DVD N/A Nebulized Drug Administration 52 Appendix A and DVD 52 This chapter and DVD Subcutaneous Drug Administration 53 Appendix A and DVD 53 This chapter and DVD Sublingual Drug Administration 54 DVD N/A Endotracheal Drug Administration 55 DVD N/A Eye Drop Drug Administration 56 DVD N/A Oral Drug Administration 57 DVD N/A Rectal Drug Administration 58 Appendix A and DVD 58 This chapter and DVD Autoinjector Drug Administration Device 59 DVD N/A NREMT Intravenous Therapy 89 DVD N/A NREMT Pediatric Intraosseous Infusion 91 DVD N/A

12 Step-by-Step 42 Intravenous Access Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Establish a patent IV line within 6 minutes. Indications: Patients who require or may potentially require administration of fluids or intravenous medications. Red Flags: Prep the site with aseptic or medically clean technique as field conditions permit. Avoid starting an IV on the same arm as a dialysis shunt. IV infiltration, especially when medications are being administered, can cause serious and irreversible tissue damage. Avoid using areas of burned skin or heavy vein scarring. Steps: 1. Use appropriate standard precautions. 2. Select proper fluid and check its expiration date and clarity. 3. Select proper IV tubing. 4. Close roller clamp. 5. Remove tab from IV bag and cap from spike end of IV tubing. Insert spike into IV bag administration port (Figure SBS 42-1). SBS Cleanse area with alcohol prep. 12. Control site by pulling skin firmly, taking care to keep your fingers out of the needle path. 13. Insert needle at less than a 45-degree angle with the bevel up (Figure SBS 42-3). SBS Squeeze the drip chamber until IV solution reaches fluid line or the drip chamber is half full. 7. Run fluid through the tubing until fluid fills tubing and air bubbles are removed. 8. Gather equipment (IV needle, tourniquet, tape, gauze, alcohol prep, etc.). 9. Apply tourniquet proximal to desired site. 10. Select site (Figure SBS 42-2). (Possible sites include between knuckles, dorsal thumb, back of hands, forearms, or antecubital fossa.) SBS Advance needle in a smooth motion. Continued 193

13 194 Part 2 Foundations of Communication, Assessment, and Critical Care 15. Monitor for flashback, and verbalize when flashback is visualized. 16. Advance catheter into vein while retracting needle until it locks. 17. Avoid catheter shear by not reinserting needle into catheter. 18. Remove tourniquet if blood sample is not required. 19. Hold hub, and tamponade vein to prevent bleeding (Figure SBS 42-4). 23. Inspect and palpate for infiltration at IV site. 24. Secure site and tubing with tape or a commercial device (Figure SBS 42-6). SBS 42-6 SBS Remove needle from hub and place in a sharps container. 21. Connect administration set to catheter hub. 22. Open roller clamp and observe for free flow through drip chamber (Figure SBS 42-5). Critical Criteria: Use appropriate standard precautions. Maintain aseptic or medically clean technique throughout procedure. Avoid catheter shear by not reinserting needle into catheter. Observe for infiltration. Establish a patent IV line within 6 minutes. Dispose of sharps in an appropriate container. SBS 42-5

14 Step-by-Step 45 Intraosseous Access and Drug Administration Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient who requires intravascular access for medication administration and/or volume resuscitation and for whom IV access is not readily available. Red Flags: Long-bone deformity distal to access site on same bone; unable to locate landmarks. Steps: 1. Use appropriate standard precautions. 2. Select appropriate device and prepare equipment. 3. Locate intraosseous (IO) site (Figure SBS 45-1). (Possible sites include tibia, distal femur, humerus, sternum, or iliac crest.) 8. Stabilize IO catheter and remove needle. 9. Dispose of sharps in appropriate sharps container. 10. Attach syringe to IO needle. 11. Aspirate bone marrow and administer saline flush (Figure SBS 45-3). SBS Cleanse site with alcohol and/or iodine. 5. Place IO device against bone. 6. Insert needle straight into bone at a 90-degree angle (Figure SBS 45-2). SBS Inspect site for infiltration. If swollen, remove needle and apply pressure. 13. Attach administration set, and run fluid wide open. 14. Ensure free flow and no swelling, and adjust to desired rate. 15. Secure device (Figure SBS 45-4). SBS Stop at proper depth or when resistance is no longer felt ( popping sensation). SBS 45-4 Continued 195

15 196 Part 2 Foundations of Communication, Assessment, and Critical Care Drug Administration 16. Ensure that five patient rights of drug administration are met. 17. Draw medication using aseptic technique. 18. Dispose of needle in a sharps container. 19. Cleanse port with alcohol prep. 20. Attach syringe to port. 21. Occlude line between fluid and port by pinching line or adjusting three-way stopcock (Figure SBS 45-5). 22. Push medication at proper rate, and flush tubing after administration. 23. Monitor patient for desired and adverse effects. Critical Criteria: Use appropriate standard precautions. Use intraosseous needle in a safe manner. Immediately dispose of sharps in appropriate container. Observe for infiltration at site. Ensure that five rights of medication administration are followed. SBS 45-5 Step-by-Step 48 Intravenous Drug Bolus Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient who requires a medication bolus delivered intravenously. Red Flags: Medications given through the IV route are rapid acting. Deliver medications at appropriate rate and at appropriate time intervals. Always observe for infiltration. Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient. 3. Ensure patient is not allergic to the medication. 4. Ensure IV flows without infiltration. 5. Ensure that five patient rights of drug administration are met.

16 Chapter 16 Medication Administration and IV Assemble pre-filled syringe, or draw medication into syringe (Figure SBS 48-1). 12. Withdraw needle from IV tubing and dispose in sharps container. 13. Flush IV tubing, and set flow to desired rate (Figure SBS 48-4). SBS Expel air from syringe. 8. Cleanse IV port with alcohol prep. 9. Attach syringe to IV port (Figure SBS 48-2). SBS Thoroughly document medication administration. 15. Monitor patient for desired and adverse effects. SBS Occlude IV line between port and IV bag, or close roller clamp. 11. Push medication at the proper rate (Fig ure SBS 48-3) while observing for infiltration. Critical Criteria: Use standard precautions. Check for patient allergies and medication reactions. Ensure that five rights of medication administration have been met. Cleanse the IV port prior to injection. Immediately dispose of sharps in an appropriate container. Monitor patient for changes in condition. SBS 48-3

17 Step-by-Step 49 Intravenous Drug Infusion Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient who requires medications continuously delivered intravenously. Red Flags: Medications given through the IV route are rapid acting. Pay close attention to the rate of administration. Always observe for infiltration of primary IV. Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient. 3. Ensure patient is not allergic to the medication. 4. Ensure IV flows without infiltration. 5. Ensure that five patient rights of drug administration are met. 6. Calculate drug dosage in drips per minute (gtt/min). 7. Prepare IV solution or spike premixed bag (Figure SBS 49-1). 9. Mark bag with drug name and concentration, date and time of administration, and initials of person preparing and administering infusion. 10. Dispose of any sharps in appropriate container. 11. Cleanse IV port with alcohol prep. 12. Connect infusion IV set to main IV and stop flow of main IV (Figure SBS 49-3). SBS 49-3 SBS Fill drip chamber, and flush tubing (Fig ure SBS 49-2). 13. Secure line with tape (Figure SBS 49-4). 198 SBS 49-2 SBS 49-4

18 Chapter 16 Medication Administration and IV Adjust to proper drip rate. 15. Thoroughly document medication administration. 16. Monitor patient for desired and adverse effects. Critical Criteria: Use standard precautions. Check for patient allergies and medication reactions. Ensure that five rights of medication administration have been met. Cleanse medication port prior to insertion. Dispose of sharps immediately after use. Ensure that infusion is set at proper rate. Monitor patient for desired and adverse effects. Step-by-Step 50 Intramuscular Drug Administration Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient whose condition requires the administration of a medication through the intramuscular route. A patient who does not have vascular access, and the required medication can be administered intramuscularly. Red Flags: May not be effective in poorly perfused tissue. Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient. 3. Ensure patient is not allergic to the medication. 4. Ensure that five patient rights of drug administration are met. 5. Using a 20-gauge or smaller needle, draw medication into syringe (Figure SBS 50-1). 6. Expel air from syringe. 7. Locate administration site (deltoid, thigh, or buttocks). 8. Cleanse site with alcohol prep. 9. Stabilize skin with fingers, or pinch to raise skin slightly (Figure SBS 50-2). SBS 50-1 SBS 50-2 Continued

19 200 Part 2 Foundations of Communication, Assessment, and Critical Care 10. Insert needle at 90-degree angle, and quickly advance into muscle. 11. Attempt to aspirate for blood (Figure SBS 50-3). If blood returns, withdraw needle and try a different site. SBS Thoroughly document medication administration. 16. Monitor for redness and swelling. 17. Monitor patient for desired and adverse effects. SBS Slowly inject medication. 13. Withdraw needle from patient, and dispose of needle and syringe in appropriate sharps container. 14. Apply sterile gauze and direct pressure to site (Figure SBS 50-4). Critical Criteria: Use standard precautions. Check for patient allergies. Ensure that five rights of medication administration have been met. Insert needle at 90-degree angle. Aspirate for blood prior to medication administration. Immediately dispose of sharps in appropriate container. Step-by-Step 52 Nebulized Drug Administration Conditions: The candidate should perform this skill on a simulated patient in a sitting or supine position (stretcher, chair, or bed) under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient whose condition requires the administration of a medication through the nebulized route. Red Flags: Equipment used to nebulize medications can vary significantly. Practice with your local system s equipment until you are comfortable with assembly and use.

20 Chapter 16 Medication Administration and IV 201 Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient. 3. Ensure the patient is not allergic to the medication. 4. Ensure that five patient rights of drug administration are met. 5. Place medication in nebulizing chamber (Figure SBS 52-1). 10. Adjust flow of oxygen to nebulizer to create a steady mist of medication (6 8 L/min). 11. Instruct patient to seal lips around mouthpiece, and direct him or her to breathe slowly and deeply (Fig ure SBS 52-4). SBS Screw on chamber cover. 7. Attach oxygen tubing to nebulizer chamber, and attach tubing to oxygen source (Figure SBS 52-2). SBS Alternately, attach set to an in-line adapter, and ventilate with a bag-mask at breaths/min timed with patient s inspiratory effort (Figure SBS 52-5). SBS Assemble administration set according to manufacturer s instructions, ensuring nebulizer chamber remains upright. 9. Attach T-piece to nebulizing chamber (Figure SBS 52-3). SBS Alternately, attach nebulizer to simple mask (Figure SBS 52-6) and adjust the flow of oxygen to create a steady mist of medication (6 8 L/min). SBS 52-3 SBS Refill chamber per local protocol. Continued

21 202 Part 2 Foundations of Communication, Assessment, and Critical Care 15. Thoroughly document medication administration. 16. Monitor patient for desired and adverse effects. Assist ventilations as necessary. Keep in-line nebulizer chamber upright. Critical Criteria: Use standard precautions. Ensure that five rights of medication administration are met. Step-by-Step 53 Subcutaneous Drug Administration Conditions: The candidate should perform this skill on a simulated patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A patient whose condition requires the administration of a medication through the subcutaneous route. Red Flags: May not be effective in poorly perfused tissue. Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient. 3. Ensure patient is not allergic to the medication. 4. Ensure five patient rights of drug administration are met. 5. Using a 22-gauge or smaller needle, draw medication into syringe (Figure SBS 53-1). May give maximum of 1 ml of fluid. SBS 53-1

22 Chapter 16 Medication Administration and IV Expel air from syringe. 7. Locate administration site (upper arm, abdomen, or thigh). 8. Cleanse site with alcohol prep. 9. Pinch skin to lift it slightly (Figure SBS 53-2). SBS Insert needle at a 45-degree angle. 11. Smoothly advance needle into subcutaneous tissue (Figure SBS 53-3). SBS Withdraw needle, and dispose of needle and syringe in appropriate sharps container. 15. Place gauze over injection site, and apply direct pressure. 16. Thoroughly document medication administration. 17. Monitor administration site for redness and swelling. 18. Monitor the patient for desired and adverse effects. Critical Criteria: Use standard precautions. Check for patient allergies. Check expiration date of medication. Ensure that five rights of medication administration have been met. Insert needle at 45-degree angle. Immediately dispose of sharps in appropriate container. Aspirate for blood prior to medication administration. Monitor for desired and adverse effects. SBS Attempt to aspirate for blood with syringe (should be difficult). If blood returns, withdraw and try a different site. 13. Inject the medication (Figure SBS 53-4).

23 204 Part 2 Foundations of Communication, Assessment, and Critical Care Step-by-Step 58 Rectal Drug Administration Conditions: The candidate should perform this skill on a simulated pediatric patient under existing indoor, ambulance, or outdoor lighting, temperature, and weather conditions. Indications: A pediatric patient whose condition requires the administration of a medication via the rectal route. Red Flags: Feeding tube or syringe must be inserted deep enough into rectal space in order to deliver medication. Forceful insertion can perforate the bowel wall. Remove needle prior to insertion of syringe into rectum. Steps: 1. Use appropriate standard precautions. 2. Explain procedure to a conscious patient or parents. 3. Ensure patient is not allergic to the medication. 4. Ensure that five patient rights of drug administration are met. 5. Draw up medication using aseptic technique (Figure SBS 58-1). 8. Lubricate administration device or suppository and finger with water-soluble jelly only. 9. Gently insert into anus (Figure SBS 58-2). If using a suppository, insert with gloved finger. SBS Advance past both sphincter muscles. 11. Slowly deliver medication. 12. Remove syringe and hold buttocks together (Figure SBS 58-3). SBS Remove and dispose of needle in appropriate sharps container. 7. Choose administration option: a. Attach an extension: large-bore IV catheter without needle or cut 3.0 ET tube. b. Use a tuberculin (TB) syringe without needle. c. Insert a suppository with gloved finger. 204 SBS Dispose of syringe in appropriate container. 14. Thoroughly document medication administration.

24 Chapter 16 Medication Administration and IV Monitor patient for desired and adverse effects (Figure SBS 58-4). Critical Criteria: Use standard precautions. Check for patient allergies and medication reactions. Ensure that five rights of medication administration have been met. Lubricate administration device or suppository and finger before administration. Pinch buttocks closed after administration. Immediately dispose of sharps in appropriate container. Monitor patient for desired and adverse effects. SBS 58-4 Connections Chapter 15, Pharmacology, in the textbook contains additional information on medication indications, contraindications, precautions, and special considerations. See Box 15-6 in the textbook for a description of the patient rights that are identified in the DOT curricula. Chapter 10, Therapeutic Communications and History Taking, in the textbook describes techniques that can be helpful in obtaining information from patients. Chapter 9, Safety and Scene Size-Up, in the textbook includes additional information on BSI precautions. Chapter 17, Documentation and Communication, in the textbook details information on performing a radio consultation and what elements of medication administration documentation are important to capture on the patient care report. Link to the companion DVD for a chapter-based quiz, audio glossary, animations, games and exercises, and, when appropriate, skill sheets and skill Step-by-Steps. Street Secrets Shortcuts Drug dosage calculations can be a nightmare for many paramedics. The need to perform them in any situation let alone a situation in which one is caring for a critical patient who has a very low blood pressure can send the most confident paramedic into a meltdown. The following simple formulas are shortcuts that will give you a close estimate of the number of drops per minute that you need to administer to a patient receiving a dopamine infusion. These shortcuts are based on the use of a 60-gtt/mL IV administration set. This method should not be used in a testing environment because it is not 100% accurate. Shortcut 1 is for use with a dopamine IV bag that has a concentration of 1,600 mcg/ml and is used to obtain a 5-mcg/min dose. (Weight in kg 10) (2) 1 drip rate in gtt/min for patient receiving 5-mcg/min dose. Example: The patient weighs 80 kg gtt/min Shortcut 2 is for use with a dopamine IV bag that has a concentration of 800 mcg/ml and is used to obtain a 5-mcg/min dose. (Weight in kg 5) (2) 2 drip rate in gtt/min for patient receiving 5-mcg/min dose. Example: The patient weighs 60 kg gtt/min Note: The paramedic should always ensure the patency of the IV by aspirating prior to injecting any medication. This is crucial because drugs injected into the tissues instead of the bloodstream could have a detrimental effect on the patient.