IV Therapy

Outline
• • • • • • Fluids Needles Technique Patient care Complications IO

Total Body Water
• • • • • 60% of body weight in kg 2/3 intracellular fluid 1/3 extracellular fluid ¾ interstitial fluid ¼ intravascular

• NS or LR expands extracellular volume (1/4 stays intravascular) • Water (D5W) diffuses through total body water (1/12 stays intravascular)

Expanders vs Water Solutions
• Volume expanders: expand intravascular volume in the presence of hemorrhagic shock, or volume depletion (dehydration, burns, severe N/V) • Water solutions: To obtain and keep intravenous access:
– Treat with IV meds – Assure later access

Types of Solutions • Isotonic: osmotic pressure equal to body fluid • Hypotonic: osmotic pressure less than body fluid • Hypertonic: osmotic pressure greater than body fluid .

Crystalloids • Dissolving sugars and salts in water • Dissolved ions cross the cell membrane. followed by solution • Only in intravascular space a short time • 3L of crystalloid necessary to replace 1 L of blood loss .

9% normal saline – 154 mEq of sodium ions – 154 mEq of chlorid ions – Provides no calories • Isotonic solution – same osmolarity as blood • Most widely used • Only solution that can be administered with blood products .Normal Saline • 0.

Lactated Ringers • Recommended by trauma surgeons • Similar electrolyte make-up as blood plasma – 130 mEq of sodium – 4 mEq of potassium – 3 mEq of calcium – 109 mEq of chloride – 28 mEq of lactate .

• Isotonic in container – hypotonic in blood – Glucose moves into the blood quickly • 170 calories per liter • Treatment for hypernatremia .D5W • Sugar solution – 5% dextrose in water • Pts that are hypovolemic are slightly hyperglycemic – no added glucose.

Colloids • Contain large molecules like protein • Do not pass readily through membranes • Examples: – Plasma protein fraction – Salt-poor albumin – Dextran – Hetastarch .

Tubing • 1 ml/min = – 60 drops/min (pediatric tubing) – 15 drops/min (regular tubing) – 10 drops/min (blood tubing) – See examples of each – Be able to tell the difference .

Blood Tubing • 10 gtts/min • Use with Normal Saline – Not with Lactated Ringers • Calcium will cause blood to clot • Which patients: – – – – Trauma AAA Suspected Internal bleeding Patients needing large volume replacement .

Cathalons • Bigger the number  smaller the needle – 25 gauge smallest – 10 gauge largest • Fluid replacement – at least an 18 gauge 16 or 14 better – But any access is better than none – Can dump a lot of fluid thru a 20 gauge .

IV sites .

Veins of the arm .

Central Line Placement • May see this in the ER .

Secure the site • Use an arm board with: – Pediatric pts – Possibly with burn pts • Use Koban. “bomb proof” – Combative pts – Anytime secure site is needed .

Technique • Watch video • Spike a bag • Start an IV .

External Jugular Vein • Indications: – no extremity access .

head down Turn patient’s head to side Point catheter toward ipsilateral shoulder “tourniquet” vein with one finger above the clavicle Apply traction above the angle of the jaw Puncture midway between angle of jaw and midclavicular line Do not let air enter the catheter.can cause air embolism .External Jugular Vein • • • • • • • Position: supine.

IV Complications • • • • • Flow clamp closed Needle not patent Tourniquet still in place Tubing kinked or pinched Local infiltration .

IV Complications • Do Not Drown your patients. TKO rates unless patient is in shock. – Can fluid overload: • • • • • Elderly Pediatrics CHF patients Pts taking Lasix without a urinary catheter Pts with kidney failure .

IV Complications • Extravasation: catheter not in the vein – Fluid flows into tissue – Pain and swelling – Discontinue and try again in another site .

IV Complications • Hematoma – Catheter penetrates vein • Blood leaks into surrounding tissue • Discoloration • Swelling • Pain • Discontinue use • Apply direct pressure .

IV Complications • Catheter shear – Results from pulling the catheter back over the needle during insertion – Catheter embolus is a potential result – Always withdraw both needle and catheter if you must withdraw. .

chills.IV Complications • Pyrogenic reaction – Rapid onset of fever. headache. or catheter – Discontinue IV . N/V – Reaction to IV fluid. backache.

IV Complications • Thrombophlebitis– Inflammation of the vein – Reddening and tenderness around the site – Discontinue IV • Apply warm compresses .

IV Complications • Air embolism – Air entering the vein from IV tubing – Be extremely careful when performing an EJ for this reason .

IV Complications • Arterial puncture: – Bright red blood = bad – Withdraw needle – apply direct pressure for 5 minutes – Always check site for pulse .

IV Complications • Pediatric fluid overloading – 20 ml/kg bolus for hypovolemia in kids .

IO it’s off to work I go… Intraosseos Infusions .IO.

Intraosseous Infusion • Indications – Pediatric patients – 1-2 unsuccessful IV attempts – Can be used in adult patients • Ex: sternal IOs for adults .

Intraosseous Infusion • Contraindications – Fracture in same extremity – Overlying cellullitis – Recent IO in same bone – Osteogenesis Imperfecta – inherited condition of brittle bones  fractures likely .

LR…) or medication that can be administered through an IV can be given through an IO – Flush all medications with 10 ml of fluid – ALS meds effective within seconds during CPR .Intraosseous Infusion • Fluids and Meds – Any fluid (NS.

Intraosseous Infusion • Can use bilateral IO access for fluid replacement • IO is not intended for long term use should be changed to an IV as soon as possible .

medial surface of the proximal tibia.Intraosseous Infusion • IO sites – Preferred site • Flat. two finger widths below the tibial tuberosity .

Alternative Sites • Distal tibia – Flat area just proximal to the midline of the medial malleolus .

Alternative Sites • Distal femur – 2-3 cm in the midline above the epicondyle .

Technique .

IO Complications • Osteomyelitis . never reported • Growth plate injury – uncommon .most common complication reported. • Fat embolism – theoretical.

IO Complications • Dislodgement.typically EMT neglect • Extravasation – discontinue infusion • Bending needles – avoided by proper technique • Plugging of needle – should not happen with stylet in place .

Flow Rates .

Blood Draw .

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