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Medication Administration
November 2009 CE
Advocate Condell Medical Center
Objectives prepared by: Mike Higgins, FF/PM
Grayslake Fire Department
Power point prepared by Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
 1. Identify the six rights of drug administration
correctly
 2. Identify medical control’s role in drug
administration
 3. Identify knowledge of proper use of standard
precautions
 4. Identify knowledge of proper disposal of
contaminated equipment
 5. Identify the importance of maintaining a
sterile and clean environment
Objectives
 6. Accurately calculate the drug dosage for a pt
with weight stated in pounds, converting weight
to kilograms
 7. Identify the various routes used to administer
medication
 8. Identify the proper technique for drawing up
meds from an ampule
 9. Identify the proper technique for drawing up
meds from a vial
 10. Identify the proper administration of a
medication from a prefilled syringe
Objectives
 11. Identify the proper administration of sub-
lingual medications
 12. Verbalize the proper administration of rectal
medications
 13. Identify the proper administration of IV
piggy-back medications
 14. Identify the proper administration of in-line
nebulizer medications
 15. Identify the proper administration of
endotracheal medications
Objectives
 16. Identify proper documentation of medication
administration
 17. Demonstrate the proper administration of
subcutaneous medications
 18. Demonstrate the proper administration of
intramuscular medications
 19. Demonstrate proper administration of
intravenous medications / IO meds
 20. Demonstrate the insertion of the EZ-IO
correctly
6 Right of Medication
Administration
 The RIGHT patient
 In the field this is the patient lying in front of
you
 When doing clinical in the hospital, it is
extremely important to check wrist bands for
identifying the right patient
 The RIGHT drug
 Check all medications 3 times prior to
administration
 Did you grab the correct medication?
6 Rights
 The RIGHT dose
 Most field medications can be easily
calculated in your head
 Double check if you are ever unsure of the
dose
 The RIGHT time
 In the field the time is now
6 Rights
 The RIGHT route
 IV/IO
 Injected
 IM
 SQ
 Inhaled
 IVPB
6 Rights
 The RIGHT documentation
 Drug name
 Dose – verify order in mg
 Dose often stated in ‘amps”, “tab”
 Route of delivery
 Time administered
 Person administering the medication
 Use skill check box
 Patient response to the medication
Allergies
 Important to screen all patients for their
allergy status prior to medication
administration
 If you are in doubt regarding an allergic
reaction versus side effect (ie: abdominal
distress), contact medical control for
clarification
Facts and Allergies
 Lidocaine and Novocain
 These are different “caine” families so allergy
to one does not cross over to the other
 Morphine sulfate
 This is NOT a sulfa drug
 Lasix – furosemide
 There is a low risk of patients allergic to sulfa
drugs having a reaction to Lasix
 Monitor the patient receiving Lasix if they
have a sulfa allergy
Medical Control
 You operate under the license of the
Medical Director
 You are still individually responsible for
having knowledge of the medications you
are delivering
 Inappropriate delivery of medications,
even when the patient does not suffer
harm, may result in legal ramifications
Medical Control
 Medical control is available as an on-line
resource
 Clarification regarding indications
 Clarification regarding dosage
 Clarification regarding orders received from a
physician on the scene
 In an acute care center, clinic, doctor’s
office, you cannot accept orders unless that
physician is willing to go with to the hospital
Standard Precautions
 Establishing routes for drug administration
creates the potential exposure to blood and
body fluids
 Decrease risk of exposure by following standard
precautions
 Gloves
 Goggles
 Mask
 The best standard precaution often forgotten:
 HANDWASHING
Sterile vs Clean Environment
 Sterile – free from all forms of life
 Generally uses extensive heat or chemicals
 Difficult in the field to maintain sterile
environments
 Most packages are sterile until opened
 Clean environment
 Minimize risk of infection
 Careful handling of equipment to prevent
contamination
Disposal of Equipment
 Minimize tasks done in a
moving ambulance
 Need to decrease risk of EMS exposure
 Immediately dispose of sharps in a sharps
container
 Rigid, puncture-resistant container
 Recap needles only as a last resort
 Use one handed technique
Metric System
 Pharmacology’s principle system of
measurement
 Widely used in science and medicine
 3 fundamental units
 Grams – weight or mass
 Liters – volume
 Meters – distance
 To avoid use of multiple zero’s , usually change
the prefixes (ie: kilo, centi, milli, micro)
Drug Administration and
Mathematical Skills
 To properly prepare and administer
medications, need understanding of:
 Multiplication
 Division
 Fractions
 Decimal fractions
 Proportions
 Percentages
Converting Pounds to Kilograms
 Many medications are dosed based on
patient weight
 Adults – acceptable to be “close
enough”
Can round off the adult weight
 Pediatrics – must practice a more
precise formula
Less room for error in calculation
Pounds to Kilograms
 1 kilogram = 2.2 pounds
 In the field, usually acceptable to take the
adult patient’s weight in pounds and
divide in half to be close enough to the
kilograms
 In peds, need to take the weight in
pounds and divide by 2.2
Exercise
 Convert 150 pounds to kilograms
 150/2.2 can be written as 150  2.2
 As a fraction, top number (numerator) is
divided by the bottom number (denominator)
 150 = dividend
 2.2 = divisor
 The divisor must always be a whole
number
 Answer = quotient
Exercise
2.2 150
 Need to make 2.2 a whole number
 In the metric system, you are multiplying by
“10”
 When multiplying with any derivative of 10,
count the zeros and move the decimal that
many numbers to the right
 What you do with the divisor, you must do with
the dividend (actions inside and outside the box
must match)
Example – 150# = ? kilograms
2.2 150 = 22 1500
68.1
22 1500.0
132
180
176
40
22
18
Medication By Patient Weight
 Most typical order is Lidocaine (mg/kg)
and pediatric drugs (mg/kg)
 Calculate the patient’s kilogram
Divide pounds by 2.2
Acceptable to divide the adult weight
by 2
 Multiply the kilogram by the number of
mg per kilogram
 Then you need to calculate the volume
(ml) to draw up in the syringe
Example
 Give your 132 pound patient 1.5mg/kg Lidocaine
 Lidocaine is packaged as 100 mg/5ml
 Steps to calculate
 Convert pounds to kilograms
 Based on the kilograms, calculate the number
of mg required
 Multiply kilograms by mg/kg required
 Calculate the ml volume to draw up
Answer
 132  2.2 = 1320  22 = 60 kg
 1.5 mg/kg = 1.5 mg x 60 kg = 90mg
 Now, draw up 90 mg (Lidocaine comes 100
mg/5ml)
 Formula #1: x ml = desired dose x vol on hand
dose on hand
 Formula #2: mg in bottle = mg ordered
ml in bottle x ml
Formula #1
 Formula #1: x ml = desired dose x vol on hand
dose on hand
x ml = 90 mg x 5 ml
100 mg
x ml = 450 (this fraction means 450  100)
100 (top number divided by bottom number)
x ml = 4.5 ml
Formula #2
 Formula #2: mg in bottle = mg ordered
ml in bottle x ml
100 mg = 90 mg
5 ml x ml
(cross multiply) 100 x = 450
(divide by 100 to get 100 x = 450
x by itself) 100 100
(divide top by bottom #) 450 / 100 = 450100
4.5 ml is answer
Do Brain Check
 Give 90 mg Lidocaine
 Lidocaine packaged 100 mg / 5 ml
 Your answer was to give 4.5 ml
 Brain check
 90 mg is slightly smaller than the total
amount of 100 mg
 4.5 ml is slightly smaller than 5 ml
 So our math must be correct
Routes of Medication
Administration
 4 basic categories
 Percutaneous
 Applied or absorbed thru the skin
 Pulmonary
 Absorbed via inhalation or injection
 Enteral
 Absorbed thru the gastrointestinal (GI) tract
 Parenteral
 Administration outside the GI tract
 Generally includes the use of needles
Percutaneous Medication Routes
 Meds absorbed through skin or mucous membranes
 Sublingual route
 Medication absorbed through the mucous
membrane under the tongue
 Sub = below; lingual = tongue
 Area extremely vascular
 Moderate to rapid rate of absorption
 Avoids the digestive tract
Mucous Membranes cont’d
 Nasal route
 Uses a medication atomization device (MAD)
 Coming soon to Region X
 Relatively rapid absorption rate in the absence of
IV access
 MAD provides a fine mist that allows
even and widespread distribution of
medication across the nasal mucosa
 The Region is preparing to
incorporate use of the MAD device in
the near future
Pulmonary Medication Route
 To administer medications into the
pulmonary system via inhalation or
injection
 Generally include gases, fine mists, or
liquids
 Most medications used for bronchodilation
for respiratory emergencies
 Inhalation also used for humidification
Nebulizer
 Uses pressurized oxygen to disperse a
liquid into a fine aerosol spray or mist
 Inhalation carries the aerosol to the lungs
Enteral Route - Rectally
 Medication absorbed through the GI tract
 Extreme vascularity promotes rapid drug
absorption
 Absorption more predictable
 Medications administered rectally do not pass
through the liver so are not subject to
alteration in the liver
 Advantageous for the unconscious patient
Parenteral Route
 Any drug administration outside of the GI
tract
 Typically, this route involves the use of
needles
 Medication is injected into the circulation or
into tissues
 Some parenteral forms (ie: IVP) are the
most rapid for drug delivery
Syringes
 Plastic or glass tube for drawing up
medications
 Range of sizes
 Medications are given in dosages by
weight (ie: mg)
 Syringes represent volume (ie: ml)
 Weights (ie: mg) must be mathematically
converted to volume (ie: ml)
Syringe Markings
 Plunger
 Barrel
 Hash marks
 Use most
appropriate
sized syringe for
higher accuracy
TB Syringe
Medications in Ampules
 Breakable vessel with liquid medication
 Cone-shaped top with thin neck
 Thin neck is the vulnerable
point for intentionally breaking
open the ampule
 Contains a single dose of med
Withdrawing From an Ampule
 Confirm the medication and dosage
 Hold the ampule upright
 Tap the top to dislodge trapped liquid
 Place gauze (or alcohol wipe package) around
thin nick
 Snap top off away from you
 Place tip of needle into ampule and withdraw
liquid
 Dispose of ampule into sharps container
Medications in Vials
 Plastic or glass containers with self-sealing
rubber top
 Rubber top prevents leakage from punctures
 May contain single or multiple doses
 Liquid is vacuum packaged
Withdrawing From a Vial
 Confirm the medication and dosage
 Prepare the syringe and needle based on
volume of liquid to draw up
 Use 1 ml TB syringe for any dose < 1 ml
 Because of the vacuum, draw up the same
amount of air as volume to be removed
 Cleanse rubber top with an alcohol wipe
 Insert needle straight into rubber top
Vial cont’d
 Inject the air from the syringe into the vial
 Withdraw the desired volume of liquid
 Watch to keep tip of needle in liquid
 Helpful to draw a small amount of extra fluid to
accommodate removing air bubbles
 Hold syringe with needle pointing upward
 Tap side of syringe with finger to
displace bubbles to distal end of
syringe
 Expel air bubbles and confirm exact
volume required in syringe
Medications in Prefilled Syringes
 Tamperproof containers packaged with
medication already in the syringe
 Generally contain
standard dosages
 May require assembly
Prefilled Syringe
 Confirm the medication and dosage
 Assemble syringe
 Pop off protective caps
 Twist glass tube containing liquid
into syringe
 Glass tube becomes the plunger
 Expel excess air
 Confirm dosage volume required
 Lidocaine cap is twisted to unlock and then
remove the cap
Nonconstituted Medications
 Extends viability and storage of time for
drugs with short shelf life or instability in
liquid form
 Consists of 2 vials
 Powdered medication
 Liquid mixing
solution
Reconstituting Medications
 Confirm medication and dosage
 Prepare syringe with liquid
 Cleanse off top of powder vial
 Inject liquid into powder vial
 Gently roll vial between palms to dilute powder
 Check that ALL particles have dissolved
 Redraw up liquid into syringe, expel excess air
Medication
Administration
Medication Administration
 Just because you administer medications
now, does not mean your technique is
accurate
 The first rule in medicine:
Primum non Nocere
Hippocrates
First, do no harm!
Sublingual Medication Route
 Use Standard Precautions
 Confirm medication and
dosage 3 times
 Have patient lift their tongue
 Place the tablet between the tongue and
the floor of the oral cavity
 Instruct the patient to allow the pill to
dissolve
In-line Nebulizer Administration
Route
 For administration of Albuterol
when the patient is no longer
able to ventilate effectively to
inhale the medication into their lungs
 Can begin to bag the patient and force the
medication into the lungs even prior to
intubation
 Set the equipment up and ventilate via a
mask while waiting for intubation
Endotracheal
Administration
Route
Discouraged route but not
forbidden
Studies have failed to demonstrate adequate
absorption of medication via this route
If used, double the calculated IVP dosage
Hyperventilate to distribute the medication
Acceptable for: Lidocaine, Epinephrine,
Atropine, and Narcan (ie: LEAN)
Rectal Medication
 Confirm medication and dosage 3 times
 Via syringe
 Use a small diameter syringe based on size of
patient
 Lubricate tip of syringe
 Turn the patient onto their side
 Insert tip of syringe into rectum
 Inject medication
 Remove syringe and hold cheeks together
 Permits retention and absorption
Rectal
Administration
 Via IV catheter
 In place of a syringe tip being placed into the
rectum, can place an IV catheter on the
needleless syringe and then inject the
medication
 Reduces the diameter of the equipment used
 Helpful alternative especially in the
pediatric population
Parenteral Medication Routes
 Intradermal injection
 Subcutaneous injection
 Intramuscular injection
 Intravenous injection
 Intraosseous injection
Preparing The Syringe
 Pull medication into the syringe
 Tap the side of the barrel to displace air
bubbles to the distal tip
 Express out the excess air bubbles
 Confirm accuracy of medication dosage
 Rubber edge of the plunger lines up with the
dosage marking on the barrel
 Then draw up an additional 0.1 ml of air for SQ
or IM injections
 The air plug pushes the med farther into the
site preventing leakage of med
Preparing the Site
 Wipe the intended site with alcohol
 Start wiping from the center moving
outward
 Let the site air dry
 Introducing alcohol into the site causes
irritation
 Do not blow on the site to hasten drying –
causes contamination
SQ Route
 Layer of connective tissue between skin and
muscle
 Less blood supply than IM so slower absorption
rate
 Slow onset of action but long duration of drug
action due to less blood supply
 Maximum volume of medication is 1 ml
 Preferred needle size is 25 – 27 G; 3/8 - 5/8 inch
 Preferred is 450 angle (900 angle acceptable if
using ½ inch needle)
Subcutaneous Medication
Routes
 Sites
 Deltoid
 Abdominal
 Thighs
 Buttocks
SQ Technique
 Prepare the syringe and needle
 Identify the site
 Cleanse the site
 Pinch a fold of skin up
 Quickly dart the needle into the fold at a 450 angle
 900 angle is an alternative especially with ½” needle
 Release the fold
 Aspirate checking for blood return
 Inject steadily
 Quickly withdraw the needle and discard
 Massage the site to enhance absorption
Aspiration Before Injection
 Purpose
 To check for inadvertent entry into a vessel
 If you did not check you could be giving an IVP
drug instead of a SQ or IM
 More common for vessel entry during an
IM
 If blood is returned, remove needle and
prepare a new syringe and needle
Pediatric SQ Injections
 Most common site is posterior upper arm
 Next site used is the anterior aspect of the
thigh
 Limited volume up to 1 ml of volume SQ
 Use 450 angle injected into pinched skin
 Site has limited use in poor perfusion state
IM Route
 Muscle is extremely vascular and allows for
systemic delivery throughout the whole body
and a moderate absorption rate
 Absorption is relatively predictable
 When using the buttock, important to avoid the
sciatic nerve
 If you strike the sciatic nerve, the patient
could develop chronic pain
 Typical needle size is 21 – 23 G; 1 – 11/2”
 Use 900 angle
 Volume limitation dependent on the site used
Intramuscular Medication Route
 Sites
 Deltoid
 Buttock
 Dorsal gluteal
 Ventrogluteal
 Thigh
 Vastus lateralis
 Rectus femoris
IM Sites
 Deltoid
 Easily reached
 Smaller sized muscle limits volume used
 2 ml maximum
 Site is 2 - 3 finger breadths below the acromial
process (AC) and above the armpit crease
 Area often identified as a triangle
IM routes cont’d
 Buttocks – dorsal gluteal
 Can inject up to 5 ml
 Minimal discomfort felt
 Must stay away from the
sciatic nerve
 Avoid this site in kids < 2 and in
emaciated patients
 Find the site in the upper,
outer quadrant of the buttock
 Must avoid the sciatic nerve
IM site cont’d - Ventrogluteal
 Volume 1 – 3 ml
 Good site for children <7months
 Place the palm over the
trochanter of the femur
 Make a V with the 2nd and 3rd
fingers
 The 3rd finger runs straight up
to the iliac crest
 The 2nd finger angles forward
to the anterior superior iliac crest
 The injection is made inside the V formed between
the 2nd and 3rd fingers
IM routes cont’d
 Thigh
 Vastus lateralis – side of
the thigh
 Rectus femoris – muscle
over the front of the thigh
 Can inject up to 5 ml
volume
 Practice often is to divide
larger volumes into 2
injections of smaller
volume
Thigh Injection Site
 To find the site
 Place one hand at the top of the thigh at the
groin
 Place one hand on the distal (lower) thigh
above the knee
 The area between the 2 hands can be used
 Anterior surface of the thigh at the midline is
the rectus femoris
 Lateral to the midline is the vastus lateralis
Pediatric IM Injection
 Thigh is preferred site in peds
 Especially used in infants and young
toddlers
 Large muscle mass
 No proximal nerves or blood
vessels
 Limited subcutaneous fat layer
 More developed muscle than other
sites
 Can accommodate larger volumes than other
pediatric injection sites
IM Technique
 Prepare syringe and needle
 Identify site
 Prepare site – let alcohol air dry
 Pull the skin taut
 Dart the needle in at 900
 The quicker the dart like insertion, the less
painful
 Slowly and steadily inject the medication
 Quickly withdraw needle and properly discard
 Massage site – enhances absorption
Intravenous Administration Route
 Quickest route to deliver medication directly into
the bloodstream
 Fastest absorption rate
 Dependent on adequate perfusion
 Many medications are in prefilled syringes
 Pop off protective caps
 Assemble syringe
 Expel air
 Confirm dosage
 Administer medication
 Watch for response
IVP Medication
 Confirm medication 3
times for accuracy
 Prepare syringe
 Consider need for a flush
 Secure medication syringe
into an IV port as close to
the IV site as possible
 Pinch off the IV tubing
 Inject the medication at the prescribed
speed for the medication
Needleless IV Tubing
 Standard IV tubing to minimize the event
of needle stick
 Port wiped with alcohol
 Needle twisted onto port
 Must pinch tubing above
injection site
 Fluid will move in direction
of least resistance
IVPB Administration Route
 To administer a medication over
a longer period of time
 All IV bags hanging need to be
labeled
 The bags can be hung at the
same height
 The IV bags will both drip
independently of the other IV bag
 Secure the IVPB into a port as
close to the IV site as possible
Disposal of Contaminated
Equipment
 As soon as possible
dispose of equipment into
sharps container
 After giving an injection,
snap the protective cover
over the needle
 After starting the IV, the
needle should be covered
as it is retracted after the
injection
Side Effects and Complications
 Remember for all injections
 Once delivered, cannot get the medication back
 Be very sure of 5 “rights’
Patient
Drug
Dose
Route
Time
 Once administered, monitor for known side effects
and any other changes to the patient
Documentation of Medication
Administration
 Time
 Drug name
 Drug dosage in mg
 Route
 Patient response
EZ-IO
 Indications
 Shock, arrest, impending arrest
 Unconscious/unresponsive to verbal stimuli
 2 unsuccessful IV attempts or 90 seconds
duration of a peripheral attempt
EZ IO
 Contraindications
 Fracture of the tibia or femur
 Infection at insertion site
 Previous orthopedic procedure
 Knee replacement
 Previous IO within 48 hours
 Pre-existing medical condition
 Tumor near site, peripheral vascular disease
 Inability to locate landmarks
 Excessive tissue at insertion site
EZ IO Needles
 Adult patients
 88 pounds or over (40 kg)
 15 G; 25 mm blue needle
 Pediatric patients
 7 - 88 pounds (3 kg – 39 kg)
 15 G; 15 mm pink needle
 Think “pink” for “peds”
EZ IO Equipment
 10 ml syringe filled with 0.9 NS
 5 ml of NS in syringe for peds patient
 EZ connect tubing
 Material to cleanse site
 EZ IO driver
 EZ IO needle in it’s case
 Primed IV tubing
 1000 ml bag for adults
 250 ml IV bag for geriatric and pediatric
patients
 Pressure bag (B/P cuff is no pressure bag)
EZ IO drill
with storage
case
EZ IO Site
 Most common site:
proximal tibia
 Palpate the tibial tuberosity
 Bump below the patella
 Identify 2-3 finger widths below the patella
 Move 1 finger width medially (toward the
big toe)
 In smaller children often will not be able
to palpate the tibial tuberosity
EZ IO - Technique
 Prime EZ connect tubing
 Takes 1 ml to prime tubing
 Leave syringe attached
 Attach needle to driver
 Insert needle at 900 angle into site
 Release trigger once decreased resistance is
felt
 Remove driver from needle
 Remove stylet by rotating counterclockwise
EZ IO Technique cont’d
 Connect EZ primed tubing to needle
 May notice backflow of bone marrow
 Blood will NOT pump out of needle
 Using syringe, aspirate then flush with
remaining NS to confirm placement
 Needle stands up on own
 Flushes easily
 No infiltration felt
EZ IO Technique cont’d
 Remove syringe
 Attach primed IV tubing
 Secure pressure bag to permit flow of fluid
 Begin infusion
 Secure tubing to leg
 Apply wristband
 Monitor site for infiltration
 Can administer any IVP medication that
would normally be given IV push
EZ IO Documentation
 Same information for starting an IV
 Time
 Solution
 Size IV bag
 Site
 Person actually performing the puncture
Case Study #1
 Your patient weighs 150 pounds
 They need to receive 1.5 mg / kg
Lidocaine
 Lidocaine packaged as 100 mg/5 ml
 How much Lidocaine needs to be drawn
up and given?
Case Study #1
 Calculate pounds to kilograms
 150  2.2 = 68.1 rounded to 68 kg
 Calculate total mg of medication
 To receive 1.5 mg per kg
 Multiply 1.5 x 68 = 102mg
 Calculate how much medication to deliver
 Use formula of your choice
Case Study #1
 Formula #1
 X ml = desired dose x vol on hand
dose on hand
X ml = 102 mg x 5 ml
100mg
X ml = 510
100
X ml = 510  100
X ml = 5.1 ml (in the adult rounded to 5 ml)
Case Study #1
 Formula #2
 100 mg = 102 mg
5 ml x ml
100 x = 510
100x = 510
100 100
x = 510  100
X = 5.1 ml (rounded to 5 ml)
Case Study #2
 Your 45 year-old patient is having an
allergic reaction with airway involvement
 The vital signs are stable
 What medications are indicated?
 How do you administer each of the
medications?
Case Study #2
 Epinephrine 1:1000 – 0.3 mg SQ
 Bronchodilator, vasoconstrictor
 Short needle (3/8 - 5/8”)
 450 angle
 Pinch up the skin
 Benadryl 50 mg IVP slowly or IM
 Antihistamine
 Long needle (1” up to 1 1/2”)
 900 angle
 Pull the skin taut before injecting
Case Study #2
 Always aspirate to check for inadvertent
entry into a vein
 If blood is noted, withdraw needle
 Prepare a new needle and syringe
 Injecting the blood can cause irritation
 With blood in the syringe, may not be able
to detect aspiration of new blood at new
site
Case Study #3
 You are on the scene of a full arrest
 You cannot find peripheral veins
 What is you next alternative?
 How do you confirm needle placement?
Case Study #3
 EZ IO needle is indicated
 Confirmation of needle placement
 Needle stands up by itself
 Able to flush the needle easily through the EZ
connect tubing
 Fluid flows with a pressure bag attached
 No infiltration is noted
EZ IO Needle
 Needle always flushed via the EZ connect
tubing
 NEVER flush the needle directly – too much
pressure
Case Study #4
 You have an 8 month-old infant with a
blood sugar of 45
 The patient responds weakly to verbal
stimuli
 What medication is necessary?
 How do you prepare the medication?
 How do you administer the medication?
Case Study #4 - Hypoglycemia
 Ages > 16 – Dextrose 50%
 Ages 1 – 15 – Dextrose 25%
 Age < 1 years-old - Dextrose 12.5%
 Diluted strength due to vein irritation
 Calculate the dosage
 Draw up equal amounts normal saline and
D25% to make a 1:1 dilution
 Administer slowly due to vein irritation
Case Study #4
 Dextrose is given IVP
 Wipe off the injection port with alcohol
 Push on the needleless syringe and twist to
connect
 Pinch off the tubing above the injection port
 Slowly and steadily administer the medication
 Evaluate the site for infiltration
 Evaluate the patient’s response
Case Study #5
 You are on the scene for a 5 year old having a
seizure
 Patient weighs 50 pounds
 History of seizure disorder
 Glucose level of 80
 You are unable to establish a peripheral IV
 What do you do for the airway?
 What medication is indicated?
 How do you administer the medication?
Case Study #5
 Airway control – bag the patient
 In active seizure, the respiratory status of the
patient is difficult to evaluate and assume the
patient is not ventilating well
 Medication and route
 Valium 0.5 mg/kg (max 10 mg) rectally
Case Study #5
 Calculate dose
 50 pounds  2.2 = 22.7 = 23 kg
 Multiple 0.5 mg x 23 kg = 11.5 mg = 12 mg
 Max dose is 10 mg
 Valium comes 10 mg per 2 ml
 Make sure syringe is needleless
 Insert syringe into buttocks
 Inject medication and remove syringe
 Hold cheeks together
Pediatric Resources
 What resources are available to calculate a
pediatric dosage?
 Back of the SOP’s
 Medical Control
 Broselow tape
 Valium listed as diazepam
 Narcan listed as Naloxone
 Normal saline listed as crystalloid
Bibliography
 Bledsoe, B., Clayden, D., Papa, F. Prehospital
Emergency Pharmacology 5th Edition. Brady. 2001.
 Bledsoe, B., Porter, R., Cherry, R., Paramedic Care:
Principles and Practices. Brady. 2009
 Edmunds, M. Introduction to clinical Pharmacology.
Elsevier. 2006.
 Marenson, D. Pediatric Prehospital Care. Brady. 2002.
 Region X SOP’s March 2007, Amended January 1,
2008
 Sanders, M. Paramedic Textbook. Rev 3rd edition.
Mosby. 2007
 wps.prenhall.com
 www.vidacare.com

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rev-nov-2009-medication-administration.ppt

  • 1. Medication Administration November 2009 CE Advocate Condell Medical Center Objectives prepared by: Mike Higgins, FF/PM Grayslake Fire Department Power point prepared by Sharon Hopkins, RN, BSN, EMT-P
  • 2. Objectives Upon successful completion of this module, the EMS provider will be able to:  1. Identify the six rights of drug administration correctly  2. Identify medical control’s role in drug administration  3. Identify knowledge of proper use of standard precautions  4. Identify knowledge of proper disposal of contaminated equipment  5. Identify the importance of maintaining a sterile and clean environment
  • 3. Objectives  6. Accurately calculate the drug dosage for a pt with weight stated in pounds, converting weight to kilograms  7. Identify the various routes used to administer medication  8. Identify the proper technique for drawing up meds from an ampule  9. Identify the proper technique for drawing up meds from a vial  10. Identify the proper administration of a medication from a prefilled syringe
  • 4. Objectives  11. Identify the proper administration of sub- lingual medications  12. Verbalize the proper administration of rectal medications  13. Identify the proper administration of IV piggy-back medications  14. Identify the proper administration of in-line nebulizer medications  15. Identify the proper administration of endotracheal medications
  • 5. Objectives  16. Identify proper documentation of medication administration  17. Demonstrate the proper administration of subcutaneous medications  18. Demonstrate the proper administration of intramuscular medications  19. Demonstrate proper administration of intravenous medications / IO meds  20. Demonstrate the insertion of the EZ-IO correctly
  • 6. 6 Right of Medication Administration  The RIGHT patient  In the field this is the patient lying in front of you  When doing clinical in the hospital, it is extremely important to check wrist bands for identifying the right patient  The RIGHT drug  Check all medications 3 times prior to administration  Did you grab the correct medication?
  • 7. 6 Rights  The RIGHT dose  Most field medications can be easily calculated in your head  Double check if you are ever unsure of the dose  The RIGHT time  In the field the time is now
  • 8. 6 Rights  The RIGHT route  IV/IO  Injected  IM  SQ  Inhaled  IVPB
  • 9. 6 Rights  The RIGHT documentation  Drug name  Dose – verify order in mg  Dose often stated in ‘amps”, “tab”  Route of delivery  Time administered  Person administering the medication  Use skill check box  Patient response to the medication
  • 10. Allergies  Important to screen all patients for their allergy status prior to medication administration  If you are in doubt regarding an allergic reaction versus side effect (ie: abdominal distress), contact medical control for clarification
  • 11. Facts and Allergies  Lidocaine and Novocain  These are different “caine” families so allergy to one does not cross over to the other  Morphine sulfate  This is NOT a sulfa drug  Lasix – furosemide  There is a low risk of patients allergic to sulfa drugs having a reaction to Lasix  Monitor the patient receiving Lasix if they have a sulfa allergy
  • 12. Medical Control  You operate under the license of the Medical Director  You are still individually responsible for having knowledge of the medications you are delivering  Inappropriate delivery of medications, even when the patient does not suffer harm, may result in legal ramifications
  • 13. Medical Control  Medical control is available as an on-line resource  Clarification regarding indications  Clarification regarding dosage  Clarification regarding orders received from a physician on the scene  In an acute care center, clinic, doctor’s office, you cannot accept orders unless that physician is willing to go with to the hospital
  • 14. Standard Precautions  Establishing routes for drug administration creates the potential exposure to blood and body fluids  Decrease risk of exposure by following standard precautions  Gloves  Goggles  Mask  The best standard precaution often forgotten:  HANDWASHING
  • 15. Sterile vs Clean Environment  Sterile – free from all forms of life  Generally uses extensive heat or chemicals  Difficult in the field to maintain sterile environments  Most packages are sterile until opened  Clean environment  Minimize risk of infection  Careful handling of equipment to prevent contamination
  • 16. Disposal of Equipment  Minimize tasks done in a moving ambulance  Need to decrease risk of EMS exposure  Immediately dispose of sharps in a sharps container  Rigid, puncture-resistant container  Recap needles only as a last resort  Use one handed technique
  • 17. Metric System  Pharmacology’s principle system of measurement  Widely used in science and medicine  3 fundamental units  Grams – weight or mass  Liters – volume  Meters – distance  To avoid use of multiple zero’s , usually change the prefixes (ie: kilo, centi, milli, micro)
  • 18. Drug Administration and Mathematical Skills  To properly prepare and administer medications, need understanding of:  Multiplication  Division  Fractions  Decimal fractions  Proportions  Percentages
  • 19. Converting Pounds to Kilograms  Many medications are dosed based on patient weight  Adults – acceptable to be “close enough” Can round off the adult weight  Pediatrics – must practice a more precise formula Less room for error in calculation
  • 20. Pounds to Kilograms  1 kilogram = 2.2 pounds  In the field, usually acceptable to take the adult patient’s weight in pounds and divide in half to be close enough to the kilograms  In peds, need to take the weight in pounds and divide by 2.2
  • 21. Exercise  Convert 150 pounds to kilograms  150/2.2 can be written as 150  2.2  As a fraction, top number (numerator) is divided by the bottom number (denominator)  150 = dividend  2.2 = divisor  The divisor must always be a whole number  Answer = quotient
  • 22. Exercise 2.2 150  Need to make 2.2 a whole number  In the metric system, you are multiplying by “10”  When multiplying with any derivative of 10, count the zeros and move the decimal that many numbers to the right  What you do with the divisor, you must do with the dividend (actions inside and outside the box must match)
  • 23. Example – 150# = ? kilograms 2.2 150 = 22 1500 68.1 22 1500.0 132 180 176 40 22 18
  • 24. Medication By Patient Weight  Most typical order is Lidocaine (mg/kg) and pediatric drugs (mg/kg)  Calculate the patient’s kilogram Divide pounds by 2.2 Acceptable to divide the adult weight by 2  Multiply the kilogram by the number of mg per kilogram  Then you need to calculate the volume (ml) to draw up in the syringe
  • 25. Example  Give your 132 pound patient 1.5mg/kg Lidocaine  Lidocaine is packaged as 100 mg/5ml  Steps to calculate  Convert pounds to kilograms  Based on the kilograms, calculate the number of mg required  Multiply kilograms by mg/kg required  Calculate the ml volume to draw up
  • 26. Answer  132  2.2 = 1320  22 = 60 kg  1.5 mg/kg = 1.5 mg x 60 kg = 90mg  Now, draw up 90 mg (Lidocaine comes 100 mg/5ml)  Formula #1: x ml = desired dose x vol on hand dose on hand  Formula #2: mg in bottle = mg ordered ml in bottle x ml
  • 27. Formula #1  Formula #1: x ml = desired dose x vol on hand dose on hand x ml = 90 mg x 5 ml 100 mg x ml = 450 (this fraction means 450  100) 100 (top number divided by bottom number) x ml = 4.5 ml
  • 28. Formula #2  Formula #2: mg in bottle = mg ordered ml in bottle x ml 100 mg = 90 mg 5 ml x ml (cross multiply) 100 x = 450 (divide by 100 to get 100 x = 450 x by itself) 100 100 (divide top by bottom #) 450 / 100 = 450100 4.5 ml is answer
  • 29. Do Brain Check  Give 90 mg Lidocaine  Lidocaine packaged 100 mg / 5 ml  Your answer was to give 4.5 ml  Brain check  90 mg is slightly smaller than the total amount of 100 mg  4.5 ml is slightly smaller than 5 ml  So our math must be correct
  • 30. Routes of Medication Administration  4 basic categories  Percutaneous  Applied or absorbed thru the skin  Pulmonary  Absorbed via inhalation or injection  Enteral  Absorbed thru the gastrointestinal (GI) tract  Parenteral  Administration outside the GI tract  Generally includes the use of needles
  • 31. Percutaneous Medication Routes  Meds absorbed through skin or mucous membranes  Sublingual route  Medication absorbed through the mucous membrane under the tongue  Sub = below; lingual = tongue  Area extremely vascular  Moderate to rapid rate of absorption  Avoids the digestive tract
  • 32. Mucous Membranes cont’d  Nasal route  Uses a medication atomization device (MAD)  Coming soon to Region X  Relatively rapid absorption rate in the absence of IV access  MAD provides a fine mist that allows even and widespread distribution of medication across the nasal mucosa  The Region is preparing to incorporate use of the MAD device in the near future
  • 33. Pulmonary Medication Route  To administer medications into the pulmonary system via inhalation or injection  Generally include gases, fine mists, or liquids  Most medications used for bronchodilation for respiratory emergencies  Inhalation also used for humidification
  • 34. Nebulizer  Uses pressurized oxygen to disperse a liquid into a fine aerosol spray or mist  Inhalation carries the aerosol to the lungs
  • 35. Enteral Route - Rectally  Medication absorbed through the GI tract  Extreme vascularity promotes rapid drug absorption  Absorption more predictable  Medications administered rectally do not pass through the liver so are not subject to alteration in the liver  Advantageous for the unconscious patient
  • 36. Parenteral Route  Any drug administration outside of the GI tract  Typically, this route involves the use of needles  Medication is injected into the circulation or into tissues  Some parenteral forms (ie: IVP) are the most rapid for drug delivery
  • 37. Syringes  Plastic or glass tube for drawing up medications  Range of sizes  Medications are given in dosages by weight (ie: mg)  Syringes represent volume (ie: ml)  Weights (ie: mg) must be mathematically converted to volume (ie: ml)
  • 38. Syringe Markings  Plunger  Barrel  Hash marks  Use most appropriate sized syringe for higher accuracy TB Syringe
  • 39. Medications in Ampules  Breakable vessel with liquid medication  Cone-shaped top with thin neck  Thin neck is the vulnerable point for intentionally breaking open the ampule  Contains a single dose of med
  • 40. Withdrawing From an Ampule  Confirm the medication and dosage  Hold the ampule upright  Tap the top to dislodge trapped liquid  Place gauze (or alcohol wipe package) around thin nick  Snap top off away from you  Place tip of needle into ampule and withdraw liquid  Dispose of ampule into sharps container
  • 41. Medications in Vials  Plastic or glass containers with self-sealing rubber top  Rubber top prevents leakage from punctures  May contain single or multiple doses  Liquid is vacuum packaged
  • 42. Withdrawing From a Vial  Confirm the medication and dosage  Prepare the syringe and needle based on volume of liquid to draw up  Use 1 ml TB syringe for any dose < 1 ml  Because of the vacuum, draw up the same amount of air as volume to be removed  Cleanse rubber top with an alcohol wipe  Insert needle straight into rubber top
  • 43. Vial cont’d  Inject the air from the syringe into the vial  Withdraw the desired volume of liquid  Watch to keep tip of needle in liquid  Helpful to draw a small amount of extra fluid to accommodate removing air bubbles  Hold syringe with needle pointing upward  Tap side of syringe with finger to displace bubbles to distal end of syringe  Expel air bubbles and confirm exact volume required in syringe
  • 44. Medications in Prefilled Syringes  Tamperproof containers packaged with medication already in the syringe  Generally contain standard dosages  May require assembly
  • 45. Prefilled Syringe  Confirm the medication and dosage  Assemble syringe  Pop off protective caps  Twist glass tube containing liquid into syringe  Glass tube becomes the plunger  Expel excess air  Confirm dosage volume required  Lidocaine cap is twisted to unlock and then remove the cap
  • 46. Nonconstituted Medications  Extends viability and storage of time for drugs with short shelf life or instability in liquid form  Consists of 2 vials  Powdered medication  Liquid mixing solution
  • 47. Reconstituting Medications  Confirm medication and dosage  Prepare syringe with liquid  Cleanse off top of powder vial  Inject liquid into powder vial  Gently roll vial between palms to dilute powder  Check that ALL particles have dissolved  Redraw up liquid into syringe, expel excess air
  • 49. Medication Administration  Just because you administer medications now, does not mean your technique is accurate  The first rule in medicine: Primum non Nocere Hippocrates First, do no harm!
  • 50. Sublingual Medication Route  Use Standard Precautions  Confirm medication and dosage 3 times  Have patient lift their tongue  Place the tablet between the tongue and the floor of the oral cavity  Instruct the patient to allow the pill to dissolve
  • 51. In-line Nebulizer Administration Route  For administration of Albuterol when the patient is no longer able to ventilate effectively to inhale the medication into their lungs  Can begin to bag the patient and force the medication into the lungs even prior to intubation  Set the equipment up and ventilate via a mask while waiting for intubation
  • 52. Endotracheal Administration Route Discouraged route but not forbidden Studies have failed to demonstrate adequate absorption of medication via this route If used, double the calculated IVP dosage Hyperventilate to distribute the medication Acceptable for: Lidocaine, Epinephrine, Atropine, and Narcan (ie: LEAN)
  • 53. Rectal Medication  Confirm medication and dosage 3 times  Via syringe  Use a small diameter syringe based on size of patient  Lubricate tip of syringe  Turn the patient onto their side  Insert tip of syringe into rectum  Inject medication  Remove syringe and hold cheeks together  Permits retention and absorption
  • 54. Rectal Administration  Via IV catheter  In place of a syringe tip being placed into the rectum, can place an IV catheter on the needleless syringe and then inject the medication  Reduces the diameter of the equipment used  Helpful alternative especially in the pediatric population
  • 55. Parenteral Medication Routes  Intradermal injection  Subcutaneous injection  Intramuscular injection  Intravenous injection  Intraosseous injection
  • 56. Preparing The Syringe  Pull medication into the syringe  Tap the side of the barrel to displace air bubbles to the distal tip  Express out the excess air bubbles  Confirm accuracy of medication dosage  Rubber edge of the plunger lines up with the dosage marking on the barrel  Then draw up an additional 0.1 ml of air for SQ or IM injections  The air plug pushes the med farther into the site preventing leakage of med
  • 57. Preparing the Site  Wipe the intended site with alcohol  Start wiping from the center moving outward  Let the site air dry  Introducing alcohol into the site causes irritation  Do not blow on the site to hasten drying – causes contamination
  • 58. SQ Route  Layer of connective tissue between skin and muscle  Less blood supply than IM so slower absorption rate  Slow onset of action but long duration of drug action due to less blood supply  Maximum volume of medication is 1 ml  Preferred needle size is 25 – 27 G; 3/8 - 5/8 inch  Preferred is 450 angle (900 angle acceptable if using ½ inch needle)
  • 59. Subcutaneous Medication Routes  Sites  Deltoid  Abdominal  Thighs  Buttocks
  • 60. SQ Technique  Prepare the syringe and needle  Identify the site  Cleanse the site  Pinch a fold of skin up  Quickly dart the needle into the fold at a 450 angle  900 angle is an alternative especially with ½” needle  Release the fold  Aspirate checking for blood return  Inject steadily  Quickly withdraw the needle and discard  Massage the site to enhance absorption
  • 61. Aspiration Before Injection  Purpose  To check for inadvertent entry into a vessel  If you did not check you could be giving an IVP drug instead of a SQ or IM  More common for vessel entry during an IM  If blood is returned, remove needle and prepare a new syringe and needle
  • 62. Pediatric SQ Injections  Most common site is posterior upper arm  Next site used is the anterior aspect of the thigh  Limited volume up to 1 ml of volume SQ  Use 450 angle injected into pinched skin  Site has limited use in poor perfusion state
  • 63. IM Route  Muscle is extremely vascular and allows for systemic delivery throughout the whole body and a moderate absorption rate  Absorption is relatively predictable  When using the buttock, important to avoid the sciatic nerve  If you strike the sciatic nerve, the patient could develop chronic pain  Typical needle size is 21 – 23 G; 1 – 11/2”  Use 900 angle  Volume limitation dependent on the site used
  • 64. Intramuscular Medication Route  Sites  Deltoid  Buttock  Dorsal gluteal  Ventrogluteal  Thigh  Vastus lateralis  Rectus femoris
  • 65. IM Sites  Deltoid  Easily reached  Smaller sized muscle limits volume used  2 ml maximum  Site is 2 - 3 finger breadths below the acromial process (AC) and above the armpit crease  Area often identified as a triangle
  • 66. IM routes cont’d  Buttocks – dorsal gluteal  Can inject up to 5 ml  Minimal discomfort felt  Must stay away from the sciatic nerve  Avoid this site in kids < 2 and in emaciated patients  Find the site in the upper, outer quadrant of the buttock  Must avoid the sciatic nerve
  • 67. IM site cont’d - Ventrogluteal  Volume 1 – 3 ml  Good site for children <7months  Place the palm over the trochanter of the femur  Make a V with the 2nd and 3rd fingers  The 3rd finger runs straight up to the iliac crest  The 2nd finger angles forward to the anterior superior iliac crest  The injection is made inside the V formed between the 2nd and 3rd fingers
  • 68. IM routes cont’d  Thigh  Vastus lateralis – side of the thigh  Rectus femoris – muscle over the front of the thigh  Can inject up to 5 ml volume  Practice often is to divide larger volumes into 2 injections of smaller volume
  • 69. Thigh Injection Site  To find the site  Place one hand at the top of the thigh at the groin  Place one hand on the distal (lower) thigh above the knee  The area between the 2 hands can be used  Anterior surface of the thigh at the midline is the rectus femoris  Lateral to the midline is the vastus lateralis
  • 70. Pediatric IM Injection  Thigh is preferred site in peds  Especially used in infants and young toddlers  Large muscle mass  No proximal nerves or blood vessels  Limited subcutaneous fat layer  More developed muscle than other sites  Can accommodate larger volumes than other pediatric injection sites
  • 71. IM Technique  Prepare syringe and needle  Identify site  Prepare site – let alcohol air dry  Pull the skin taut  Dart the needle in at 900  The quicker the dart like insertion, the less painful  Slowly and steadily inject the medication  Quickly withdraw needle and properly discard  Massage site – enhances absorption
  • 72. Intravenous Administration Route  Quickest route to deliver medication directly into the bloodstream  Fastest absorption rate  Dependent on adequate perfusion  Many medications are in prefilled syringes  Pop off protective caps  Assemble syringe  Expel air  Confirm dosage  Administer medication  Watch for response
  • 73. IVP Medication  Confirm medication 3 times for accuracy  Prepare syringe  Consider need for a flush  Secure medication syringe into an IV port as close to the IV site as possible  Pinch off the IV tubing  Inject the medication at the prescribed speed for the medication
  • 74. Needleless IV Tubing  Standard IV tubing to minimize the event of needle stick  Port wiped with alcohol  Needle twisted onto port  Must pinch tubing above injection site  Fluid will move in direction of least resistance
  • 75. IVPB Administration Route  To administer a medication over a longer period of time  All IV bags hanging need to be labeled  The bags can be hung at the same height  The IV bags will both drip independently of the other IV bag  Secure the IVPB into a port as close to the IV site as possible
  • 76. Disposal of Contaminated Equipment  As soon as possible dispose of equipment into sharps container  After giving an injection, snap the protective cover over the needle  After starting the IV, the needle should be covered as it is retracted after the injection
  • 77. Side Effects and Complications  Remember for all injections  Once delivered, cannot get the medication back  Be very sure of 5 “rights’ Patient Drug Dose Route Time  Once administered, monitor for known side effects and any other changes to the patient
  • 78. Documentation of Medication Administration  Time  Drug name  Drug dosage in mg  Route  Patient response
  • 79. EZ-IO  Indications  Shock, arrest, impending arrest  Unconscious/unresponsive to verbal stimuli  2 unsuccessful IV attempts or 90 seconds duration of a peripheral attempt
  • 80. EZ IO  Contraindications  Fracture of the tibia or femur  Infection at insertion site  Previous orthopedic procedure  Knee replacement  Previous IO within 48 hours  Pre-existing medical condition  Tumor near site, peripheral vascular disease  Inability to locate landmarks  Excessive tissue at insertion site
  • 81. EZ IO Needles  Adult patients  88 pounds or over (40 kg)  15 G; 25 mm blue needle  Pediatric patients  7 - 88 pounds (3 kg – 39 kg)  15 G; 15 mm pink needle  Think “pink” for “peds”
  • 82. EZ IO Equipment  10 ml syringe filled with 0.9 NS  5 ml of NS in syringe for peds patient  EZ connect tubing  Material to cleanse site  EZ IO driver  EZ IO needle in it’s case  Primed IV tubing  1000 ml bag for adults  250 ml IV bag for geriatric and pediatric patients  Pressure bag (B/P cuff is no pressure bag)
  • 83. EZ IO drill with storage case
  • 84. EZ IO Site  Most common site: proximal tibia  Palpate the tibial tuberosity  Bump below the patella  Identify 2-3 finger widths below the patella  Move 1 finger width medially (toward the big toe)  In smaller children often will not be able to palpate the tibial tuberosity
  • 85. EZ IO - Technique  Prime EZ connect tubing  Takes 1 ml to prime tubing  Leave syringe attached  Attach needle to driver  Insert needle at 900 angle into site  Release trigger once decreased resistance is felt  Remove driver from needle  Remove stylet by rotating counterclockwise
  • 86. EZ IO Technique cont’d  Connect EZ primed tubing to needle  May notice backflow of bone marrow  Blood will NOT pump out of needle  Using syringe, aspirate then flush with remaining NS to confirm placement  Needle stands up on own  Flushes easily  No infiltration felt
  • 87. EZ IO Technique cont’d  Remove syringe  Attach primed IV tubing  Secure pressure bag to permit flow of fluid  Begin infusion  Secure tubing to leg  Apply wristband  Monitor site for infiltration  Can administer any IVP medication that would normally be given IV push
  • 88. EZ IO Documentation  Same information for starting an IV  Time  Solution  Size IV bag  Site  Person actually performing the puncture
  • 89. Case Study #1  Your patient weighs 150 pounds  They need to receive 1.5 mg / kg Lidocaine  Lidocaine packaged as 100 mg/5 ml  How much Lidocaine needs to be drawn up and given?
  • 90. Case Study #1  Calculate pounds to kilograms  150  2.2 = 68.1 rounded to 68 kg  Calculate total mg of medication  To receive 1.5 mg per kg  Multiply 1.5 x 68 = 102mg  Calculate how much medication to deliver  Use formula of your choice
  • 91. Case Study #1  Formula #1  X ml = desired dose x vol on hand dose on hand X ml = 102 mg x 5 ml 100mg X ml = 510 100 X ml = 510  100 X ml = 5.1 ml (in the adult rounded to 5 ml)
  • 92. Case Study #1  Formula #2  100 mg = 102 mg 5 ml x ml 100 x = 510 100x = 510 100 100 x = 510  100 X = 5.1 ml (rounded to 5 ml)
  • 93. Case Study #2  Your 45 year-old patient is having an allergic reaction with airway involvement  The vital signs are stable  What medications are indicated?  How do you administer each of the medications?
  • 94. Case Study #2  Epinephrine 1:1000 – 0.3 mg SQ  Bronchodilator, vasoconstrictor  Short needle (3/8 - 5/8”)  450 angle  Pinch up the skin  Benadryl 50 mg IVP slowly or IM  Antihistamine  Long needle (1” up to 1 1/2”)  900 angle  Pull the skin taut before injecting
  • 95. Case Study #2  Always aspirate to check for inadvertent entry into a vein  If blood is noted, withdraw needle  Prepare a new needle and syringe  Injecting the blood can cause irritation  With blood in the syringe, may not be able to detect aspiration of new blood at new site
  • 96. Case Study #3  You are on the scene of a full arrest  You cannot find peripheral veins  What is you next alternative?  How do you confirm needle placement?
  • 97. Case Study #3  EZ IO needle is indicated  Confirmation of needle placement  Needle stands up by itself  Able to flush the needle easily through the EZ connect tubing  Fluid flows with a pressure bag attached  No infiltration is noted
  • 98. EZ IO Needle  Needle always flushed via the EZ connect tubing  NEVER flush the needle directly – too much pressure
  • 99. Case Study #4  You have an 8 month-old infant with a blood sugar of 45  The patient responds weakly to verbal stimuli  What medication is necessary?  How do you prepare the medication?  How do you administer the medication?
  • 100. Case Study #4 - Hypoglycemia  Ages > 16 – Dextrose 50%  Ages 1 – 15 – Dextrose 25%  Age < 1 years-old - Dextrose 12.5%  Diluted strength due to vein irritation  Calculate the dosage  Draw up equal amounts normal saline and D25% to make a 1:1 dilution  Administer slowly due to vein irritation
  • 101. Case Study #4  Dextrose is given IVP  Wipe off the injection port with alcohol  Push on the needleless syringe and twist to connect  Pinch off the tubing above the injection port  Slowly and steadily administer the medication  Evaluate the site for infiltration  Evaluate the patient’s response
  • 102. Case Study #5  You are on the scene for a 5 year old having a seizure  Patient weighs 50 pounds  History of seizure disorder  Glucose level of 80  You are unable to establish a peripheral IV  What do you do for the airway?  What medication is indicated?  How do you administer the medication?
  • 103. Case Study #5  Airway control – bag the patient  In active seizure, the respiratory status of the patient is difficult to evaluate and assume the patient is not ventilating well  Medication and route  Valium 0.5 mg/kg (max 10 mg) rectally
  • 104. Case Study #5  Calculate dose  50 pounds  2.2 = 22.7 = 23 kg  Multiple 0.5 mg x 23 kg = 11.5 mg = 12 mg  Max dose is 10 mg  Valium comes 10 mg per 2 ml  Make sure syringe is needleless  Insert syringe into buttocks  Inject medication and remove syringe  Hold cheeks together
  • 105. Pediatric Resources  What resources are available to calculate a pediatric dosage?  Back of the SOP’s  Medical Control  Broselow tape  Valium listed as diazepam  Narcan listed as Naloxone  Normal saline listed as crystalloid
  • 106. Bibliography  Bledsoe, B., Clayden, D., Papa, F. Prehospital Emergency Pharmacology 5th Edition. Brady. 2001.  Bledsoe, B., Porter, R., Cherry, R., Paramedic Care: Principles and Practices. Brady. 2009  Edmunds, M. Introduction to clinical Pharmacology. Elsevier. 2006.  Marenson, D. Pediatric Prehospital Care. Brady. 2002.  Region X SOP’s March 2007, Amended January 1, 2008  Sanders, M. Paramedic Textbook. Rev 3rd edition. Mosby. 2007  wps.prenhall.com  www.vidacare.com