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ALS PHARMACOLOGY:
INTRAVENOUS FLUIDS &
DRUG CALCULATIONS
Amy Gutman MD
EMS Medical Director
[email protected]
www.teaems.com
OVERVIEW
Review of fluids &
electrolytes
Techniques of intravenous
& intraosseous infusions
Mathematical principles
used in pharmacology & to
calculate medication doses
Medication administration
routes
DISCLAIMERS
#1
I am a woman
I am bad at math
Do not extrapolate ALL
women are bad at math
#2
This is a boring lecture
This is a necessary
lecture
Do not extrapolate ALL
my lectures are boring
MEDICATION ADMINISTRATION ROUTES
Discussed Today
Intravenous (IV)
Intraosseous (IO)
Other Routes
Sublingual (SL)
Subcutaneous (SQ)
Parenteral (PO)
Rectal (PR)
Inhalation (IH)
Endotracheal (ET)
Transdermal (TD)
Intramuscular (IM)
Intranasal (IN)
NATIONAL EMS EDUCATION STANDARD
COMPETENCIES ~ PHARMACOLOGY
Provider integrates pharmacology knowledge to formulate a
treatment plan intended to mitigate emergencies & improve
the overall health of patient
Administer medications within scope of practice
Understand “six rights” of medication administration
Understand advantages, disadvantages & techniques for
establishing venous access
Review math concepts, including dose & rate calculations
Describe role of medical direction
MEDICAL DIRECTION
Medication administration governed by local protocols & /or
online medical direction
Standing Orders:
Off-line or indirect medical control of predefined procedures
Online (Direct) Medical Control:
Must contact physician prior to performing certain procedures
When in doubt, contact medical control
When an order is given, if unclear / inappropriate, ask MD to repeat
Repeat back to confirm name, dose & route of delivery
VASCULAR ACCESS
In ill or injured patients,
survival may depend on
ability to obtain access for
fluid & drug resuscitation
Peripheral extremity
Eternal jugular vein
Intraosseous
Harm can result from
improper technique or
insufficient pharmacology
knowledge
“RIGHTS” OF MED ADMINISTRATION
Right patient
Right drug
Right dose
Right route
Right time
Right documentation
MEDICATION ADMINISTRATION
Know prior to administration
Mechanism of action
Indications
Contraindications
Side effects
Routes of administration
Pediatric & adult doses
Dose calculations
Antidotes / reversal agents
DOCUMENTATION
Name of drug
Dose of drug
Time administered
Administration route
Person administering drug
Pt’s response to drug
DRUG CHECKS & LOGS
At beginning of each shift, check drugs, supplies & equipment
Not expired / damaged
Readily available in required quantities
Paramedic responsible for documentation & security of all
controlled substances
State, regional & local distribution, security, exchanges &
accountability policies
Double lock system in each vehicle & base storage
Drug log kept for at least 3 years
MD DEA number used to order narcotics
UNIVERSAL PRECAUTIONS
Treat all BBF as infectious
I don’t shake pt’s hands
without gloves (especially
kids)
PPE, gloves & eyewear
Include full facial protection if
possible splatter
CDC: hand-washing most
effective method to
prevent disease spread
ASEPSIS
Routine & thorough hand -washing
Hand-sanitizer before & after pt
contacts if no access to soap / water
Disinfect equipment between each
patient & every shift
Antiseptic prior to invasive
procedures
Check linen, equipment & supplies
prior to use for intactness,
cleanliness
CONTAMINATED MATERIALS CLEANING
OR DISPOSAL
After needle penetrates
skin, its contaminated
After needle unsheathed, its
a weapon
Immediately dispose of
sharps in a puncture-proof
container
Follow agency protocol for
disposal of infectious waste
& cleaning of contaminated
equipment
BASIC PHARMACOLOGY KNOWLEDGE
Specific protocol
Specifics to that medication or IVF:
Indications / Contraindications
Therapeutic effects
Side effects
Appropriate dose & re-dosage
Need (+/-) for medical control
Allergies:
Known by patient
Reliable source if not from patient
Medic-alert jewelry or tags
QUESTIONS?
INTRAVENOUS FLUIDS
CHOOSING APPROPRIATE IVF
Based upon presenting
& underlying illness or
injury
Even a small amount of
the poorly chosen fluid
may be harmful
Most agencies have
limited choices – easy
to familiarize yourself
with specifics of each
BODY COMPARTMENTS
CRYSTALLOIDS
Commonly used prehospitally
Normal saline, lactated ringers,
dextrose & saline or water
Made of water & electrolyte
solutions that easily cross a semi permeable membrane
Rapidly alter intravascular fluid
levels
Non-oxygen carrying
Given as a constant rate or bolus
Adult: 250cc
Pediatric: 20cc/kg
In trauma, consider permissive
hypotension
IV FLUIDS: HYPOTONIC
(HYPO-OSMOLAR)
0.45% Normal Saline
Dilutes serum by pulling water
from intravascular space to
interstitial space
Used for (i.e.) severe dehydration but with significant side
ef fects if given too fast or in large quantities
Hyponatremia if plasma sodium normal
Cells rupture from increased osmotic pressure
Cerebral edema & central pontine demyelinosis
Fluid shift from intravascular to intracellular space causes
cardiovascular collapse
Third spacing ~ abnormal shift into serum if not enough protein to
“hold” fluid in vascular space
IV FLUIDS: HYPERTONIC
(HYPER-OSMOLAR)
1 .8% - 10% saline, mannitol
Pulls fluid & electrolytes from
intracellular to extracellular compartment
Large volumes cause hypernatremia & severe dehydration
Cells collapse from increased extracellular osmotic pressure
A little goes a long way to increase BP & reduce cerebral
edema
IV FLUIDS: ISOTONIC
(ISO-OSMOLAR)
0.9% Normal Saline
Principal resuscitation fluid
Contains sodium, potassium, chloride in almost same
concentrations as “body water” or “plasma”
Plasma so stays almost entirely in the extracellular space
3-1 replacement rule: 3cc isotonic sol’n replaces 1 mL blood
Why?
IV THERAPY: COLLOIDS
Albumin, blood, dextran, hetastarch
Contain particles which do not readily
cross semi-permeable membranes
Volume stays almost within
intravascular space for prolonged
time compared to crystalloids
Because of gelatinous properties cause platelet
dysfunction interfering with fibrinolysis & coagulation
factors (factor VIII)
Can cause significant coagulopathy in large volumes
HBOC HEMOGLOBIN-BASED OXYGENCARRYING SOLUTIONS (HBOC)
Blood contains hemoglobin which
carries oxygen to cells
Impractical for prehospital unless
specialized critical care transport
Refrigeration & unique storage
“Non-cross matched blood”, or “type O”
expensive, rare, with potential
complications
Synthetic blood available, rarely
used outside trauma institutions
or military
PolyHeme, HemoPure
QUESTIONS?
CHOOSING THE RIGHT SITE:
ANATOMY & TECHNIQUES
CHOOSING AN IV CATHETER
Based on purpose, pt age, location
Over-the-needle catheters preferred
in prehospital setting
Readily secured
Minimally cumbersome
Allow some pt movement
No need to immobilize entire limb
Sized by diameter (gauge)
Smaller gauge = larger diameter
Choose largest-diameter catheter for
chosen vein
Safety needles retract after insertion
EQUIPMENT NEEDED
PPE (including eye
protection)
Tape & bio-occlusive
dressing
Tourniquet
Alcohol, betadine,
chlorhexadine
Arm board
Sharps container
EQUIPMENT NEEDED
IV solution
Medical: NS
Trauma: LR, NS
Medication drip: NS, D5W
Administration set w/ extension tubing
Macro drip (10-15 gtts/cc) for volume
Micro drip (60 gtts/cc) for medications
Catheter
>12 yo + fluid resuscitation: 16-18g, IO
<12 yo +/- fluid resuscitation: 20-24g, IO
<6 yo: 20-24g, IO
IV SOLUTION CONTAINERS
Clear plastic bags
Labeling:
Fluid type
Expiration date
Do not use after
expiration date, appears
cloudy, discolored, with
visible particulate, or
packaging damaged
INTRAVENOUS CANNULAS
Over-The-Needle
Hollow-Needle
IV ADMINISTRATION
SETS
Macrodrip
10 gtts = 1 mL, for large
amounts of fluid
Microdrip
60 gtts = 1 mL, for
restricted amounts of fluid
Measured volume &
secondary infusion sets
Blood tubing
Filter prevent clots from
entering body
BLOOD TRANSFUSIONS
Blood type identified by obtaining
blood type & cross-match
Uncrossed matched blood is “O”, still requires a blood band which
identifies blood type & product hanging
Blood must be checked against bracelet & verified by medic even if
already checked by nursing
Blood administered through specific tubing supplied by hospital
Assess vitals q15 mins & monitor for hemolytic reactions
Tachycardia, hives, respiratory distress, CP
PERIPHERAL ACCESS
CHANGING INTRAVENOUS BAG OR BOTTLE
Prepare new bag / bottle
Occlude flow from depleted
bag or bottle
Remove spike from depleted
bag & insert into new bag
Open clamp to & titrate to
appropriate flow rate
FACTORS AFFECTING IV FLOW RATES
Thick fluids (colloids) infuse slowly
Cold fluids run slower than warm fluids
Height of IV bag must overcome gravity if not a pressure bag
The larger the diameter, the faster fluid can be delivered
Check for constricting band, BP cuf f
Evaluate for infiltration or trauma proximal to IV site
GERIATRIC CONSIDERATIONS
Puncturing vein may cause
massive hematomas
Tape may damage skin
Use smaller catheters (20,
22, 24 g)
Cardiovascularly sensitive
to rapid fluid shifts
Poor vein elasticity
IV ACCESS COMPLICATIONS
Pain
Infection / Phlebitis
Allergic reaction
Catheter shear
Arterial puncture
Circulatory overload
Air embolism
Necrosis
IV COMPLICATION ~
INFILTRATION
Escape of fluid into surrounding tissue
IV passes through vein
IV dislodged
Catheter inserted at too shallow an angle only entering fascia
SSX:
Edema at catheter site
Continued IV flow after proximal vein occlusion
Tightness, burning, pain at IV site
Treatment:
Discontinue IV
Reestablish in opposite extremity or more proximal location
Apply direct pressure
IV COMPLICATION ~ OCCLUSION
Vein, catheter or tubing blockage
1 st sign slow / no drip rate, blood in tubing
Causes:
Catheter position
High BP overcoming flow
Tourniquets!
I nject 1 cc saline into IV to increase pressure
to overcome obstruction & reestablish flow
If occlusion does not dislodge, discontinue IV
& re-establish in opposite extremity or
proximal to current site
IV COMPLICATIONS ~ HEMATOMA &
ARTERIAL PUNCTURE
Hematoma
Accumulation of blood in tissues
Causes: vein perforation, improper
catheter insertion or removal
Stop IV, apply direct pressure
Arterial puncture
Bright red spurting blood
Suspect if you have a great IV that
does not flow
Withdraw catheter, apply direct
pressure for 5 mins or bleeding stops
Always check for pulse in the “vein”
IV COMPLICATIONS ~ SYSTEMIC
Anaphylaxis
Sensitivity to IV fluid or medication
Treat according to allergic /
anaphylaxis protocol
Pyrogenic reactions
Pyrogens are foreign proteins capable
of producing fever secondary to
allergic reactions
Characterized by abrupt fever with
chills, backache, HA, N/V, weakness
Stop infusion immediately
Treat according to allergic /
anaphylaxis protocol
IV COMPLICATIONS ~ NECROSIS &
INFECTION
IV COMPLICATIONS ~ CIRCULATORY
OVERLOAD
Healthy adults can usually handle 2-3
extra liters of crystalloids
Pts with cardiorespiratory or renal
disease can’t tolerate hemodynamic
stress from increased circulatory volume
SSX:
Dyspnea, JVD, HTN, rales, hypoxia, edema
Treat: convert to saline lock, respiratory
distress protocol
IV THERAPY COMPLICATIONS ~ AIR
EMBOLUS
Flushing IV line & replacing empty IV
bags limits likelihood of air embolism
SSX:
Respiratory distress, unequal BS, cyanosis
Focal neurological symptoms
Shock & cardiorespiratory arrest
Treatment:
LLR plus Trendelenburg position
100% oxygen, treat specific symptoms
according to pertinent protocol
Rapid transport
IV COMPLICATIONS ~ CATHETER SHEAR
Part of catheter pinches
against needle & slices
through catheter creating
a free-flowing segment
SSX similar to air embolus
Treatment
Surgical removal of the tip
LLR & Trendelenburg
Do not rethread
CHOOSING THE RIGHT SITE
More than using a “BFN”
Have favorite site, favorite
“Jelco”, favorite technique
Have a back-up
And back-up to your back-up
Practice, practice, practice
ANTECUBITAL VEIN
DORSAL “DIGITAL” VEINS
EXTERNAL JUGULAR
ACCESSING EXTERNAL JUGULAR VEIN
INTRAOSSEOUS
Administering fluids, blood products
& drugs into IO space
Long bones consist of a shaft
(diaphysis), ends (epiphyses) &
growth plate (epiphyseal plate )
IO space spongy cancellous
epiphyseal & diaphysis medullary
cavity.
When in shock, peripheral veins
collapse making IV access dif ficult
IO space always patent to rapidly
absorb fluids & drugs, similar to a
central line
GENERAL IO CONTRAINDICATIONS
Cannot locate landmarks
Fractures at / above site
Amputations distal to site
Previous surger y at site
Infection at site
Local vascular compromise
Previous attempt in same site
Osteogenesis imper fecta
Occasionally dif ficult in
combative & the obese
IO INFUSION
Identify landmarks &
anatomy
Have all equipment
ready prior to starting
Manufacturer-specific
device & equipment
IV tubing
Medications
SYYAMA J, ET AL. IO VS IV ACCESS WHILE
WEARING PPE IN A HAZMAT SCENARIO. P E C 2 0 07
OBJECTIVE
Determine time difference to obtain IO vs IV wearing HazMat
PPE
METHODS
22 EMT-Ps placed anterior tibial EZ-IOs & antecubital IVs
Measured: time to skin access, vascular access & fluid infusion
CONCLUSIONS
With provider & mannequin in PPE, needle to skin time,
vascular access time, & fluid infusion time all favored EZ-IO
HUMERAL IO
HUMERAL APPROACH
Humerus adducted
Palpate midshaft proximally until
reach humeral head
At shoulder greater tubercle protrusion is the insertion site
With opposite hand “pinch” anterior & inferior aspects of
humeral head to confirm position of greater tubercle
Stabilize arm, place IO at 90 degrees to skin
Humeral cortex less dense than tibia so minimal force required
DISTAL TIBIA IO
DISTAL TIBIAL APPROACH
Landmarks are anterior
distal tibia & medial
malleolus (middle
ankle bone protrusion)
Medial insertion site, 2
finger widths proximal
to medial malleolus
“Big Toe = IO”
PROXIMAL TIBIA IO
PROXIMAL TIBIA APPROACH
Tibial tuberosity is round
protrusion distal to patella
From tuberosity, move 1 in
medially to tibial plateau
From tibial plateau, move
proximally 0.5 in towards
patella
This is thinnest portion of
tibial bony cortex
STERNAL IO
STABILIZE THE IO
STABILIZE THE BABY
CENTRAL VENOUS ACCESS
Large, deep veins do not
collapse until late shock
Internal jugular, subclavian,
femoral
Though IO “peripheral”, it’s flow
rate & placement in marrow
makes it function essentially as
central access
CENTRAL ACCESS DEVICE
Surgically implanted device
permitting repeated access
to central venous circulation
Generally located on
anterior chest near the 3 rd 4 th rib lateral to sternum
Accessed with a special
needle specific to the device
Requires special training
DIALYSIS FISTULA
Dilated vein acts like
artery due to AV graft
Do not access!
Most common
complication is
bleeding
Direct pressure +/proximal tourniquet
QUESTIONS?
MATHEMATICAL PHARMACOLOGY
PRINCIPALS
ASK YOURSELF…DO YOU FIND THIS FUNNY?
IF SO…YOU CAN SKIP THIS SECTION
IF YOU THINK THE ANSWERS ARE
OBVIOUS…REMEMBER THAT MATH IS HARDER AT
0 DARK THIRT Y
IV MEDICATION PACKAGING
Vials
Single, multi-dose
Draw air into syringe,
inject into vial, withdraw
drug
Ampules
Tap neck area to drain fluid
Using 4X4, snap neck of
vial, withdraw drug
Dispose ampule pieces in
sharps container
Prefilled Syringes
Remove caps, screw pieces
together
Dispel air & use as standard
syringe
Dry Powder meds
Depress plunger in vial to mix
with prepackaged saline
Mix thoroughly until
particulate completely
absorbed
METRICS
Decimal system based on
multiples of 10 measuring
length (meter), volume (liter),
weight (gram)
Prefixes indicate fraction of
base used
Micro = 0.00001
Milli = 0.001
Centi = 0.01
Kilo = 1,000
Drugs packaged in dif fering
units of weight & volume so
conversion often required
BASICS OF DOSE CALCULATION
Desired dose (amount of
drug)
Drug concentration (total
weight of drug contained
in specific volume)
Volume on hand (volume
of solution containing
drug)
PEDIATRIC DRUG DOSAGES
Most weight-based
Length-based
resuscitation tape
Pediatric wheel charts
EMS field guide /
Smartphone app
Once weight known,
calculations same as
for adults
METRIC CONVERSIONS
1 gram (g) = 1000 milligrams (mg)
1 mg = 1000 micrograms (mcg)
1 liter (L) = 1000 milliliters (ml)
If going from large to small value,
move decimal point to right
If going from small to large value,
move decimal point to left
1 Kg = 1000 g
1 Kg = 1,000,000 mg
1 Kg = 1,000,000,000 mcg
POUNDS TO KILOGRAMS
Kg x 2.2 = pounds (lbs)
1 Kg = 2.2 lbs
3 am: (lbs/2) – 10% = kg
To convert kg to lbs:
Kg x 2.2 = lbs
(Kg x 2) + 10% = lbs
CALCULATION EXAMPLE
You want to give 5mg valium. Label states 10 mg in
2cc (10mg/2cc). How many cc’s do you give?
5mg x 2cc =
X cc
10 mg
Therefore…1 cc of valium = 5mg of valium
Phenergan ordered for 12.5 mg
Supplied in 25 mg/ 2cc
Therefore 12.5 mg Phenergan in 1cc
CALCULATING FLUID INFUSION RATES
Adjust flow rate according to condition & protocol
You must know:
Volume to be infused
Period over which it is to be infused
Properties of the administration
Therefore, flow rate is:
Volume to be infused x gtt/mL of administration set/total time
of infusion in minutes = gtt/min
WEIGHT-BASED CALCULATIONS
Desired dose (D) x Patient’s kg Weight (W) = Volume to be
Administered (X)
Known dose on hand (H)
CALCULATION EXAMPLE
You are giving 0.5 mg/kg IVP to an
80kg patient. Drug is prepackaged
in 100mg/10cc
To determine total dose:
0.5mg x 80kg = 40mg
To determine total volume:
40 mg x 10cc = 4cc total volume
100 mg
DRIP RATE CALCULATIONS
Desired Dose x Volume of IV Bag x Administration Set gtt = gtt / min
Amount of Drug
Desired dose x Size of bag x gtt set = gtt/min
Order is for 5 mg/min. You have 500cc NS, a 60
gtt/cc admin set & 2g of drug. How many gtt/min?
5mg/min x 500cc x 60gtt/ cc = 75gtt / min
2000mg
SIMPLER DRIP RATE
CALCULATION
Volume x administration set / time
(cc x gtt) / minutes
You want to give a 500cc bolus using
a 15 gtt set over 1 hour
(500cc x 15gtt) / 60 mins = 125 gtts/min
QUESTIONS?
REFERENCES
Caroline’s Emergency Care in the
Streets 7 th Edition (Principles of
Pharmacology, Medication
Administration & Emergency
Medications). Jones & Bar tlett. 2013
Pharmacology Drug Dosage
Calculations. Shelby County EMS
Training Division 2010
Linscott et al. Emergency Care. IV
Access, Blood Sampling & IO
Infusions. Brady 2009.
Photo credits (IV inser tion, EJ
cannulation) Scott Metcalf MD©
SUMMARY
P RE H OSP I TALMD@ G MAI L.C OM / W W W.EMS.C OM
Find formula or system that
works for you
Use Smartphone but phones die!
Back-up with paper, pen & brain
IVF classes, pathophysiology &
indications
Techniques, equipment &
indications for vascular access
“6 rights” of drug administration
including basics of BLS & ALS
medication utilization
When in doubt contact medical
control