Ada County Paramedics

Educational
Advanced EMTOutreach
introduction to
Vascular Access

VASCULAR ACCESS UPDATE

Objectives

 Describe the basic distribution of fluids in the body

 Discuss the basic role of Vascular access in EMS
 Identify the main types of IV solutions encountered by
EMS
 Identify the basic equipment used by EMS to establish
IV and IO access.
Basic Physiology of Fluid
KEY POINT:

 We will actually go into a LOT of detail on fluids and

shock later in the ..FLUIDS and SHOCK Lecture.
 
Water…Its good for you!

 Total Body Water (TBW): approx. 60-70% of total body

mass.
 Higher the younger you are
Quick Exercise

 Did you know that 1 kg of water = 1 liter of water?

 What is your weight in Kg?

 Weight in Kg x 0.6 = estimated TB H2O in liters
Distribution of Fluids

 Intracellular Fluid (ICF): The amount of water that’s

inside our cells accounts for 2/3rds of our TBW.
 Extracellular Fluid (ECF): The amount of water that
surrounds our cells accounts for 1/3 of our TBW. ECF
is also known as interstitial fluid because it’s the fluid
in between the cells.
 Mnemonic to help you remember which is 1/3rd and
2/3rd: ECF and ICF. E comes before I in the alphabet,
so E is 1/3rd and I is 2/3rd.
 ICF = 2/3 X TBW. For example, 2/3 x 41L = 27L
ECF = 1/3 X TBW. For example, 1/3 x 41L = 14L
Distribution of fluids
Extracellular Fluids

 ECF is also known as interstitial fluid because it’s the

fluid in between the cells.
 Sometimes called the “third Space”
 Tissue fluid: 2/3rd of ECF

 Blood plasma: 1/3rd of ECF

 Transcellular fluid: Often not calculated as a fraction of

the extracellular fluid, but it is about 2.5% of TBW.
How much blood?

 Blood is made up of blood cells and blood plasma.

 TBV = 8% x Body Weight (kg).
 Remember, we can calculate volume from mass without a
problem because that’s the beauty of the metric system
(1.0kg water = 1.0L water)
Another quick exercise

 Normally about 20% blood loss is an indication for IV

fluid resuscitation (in addition to other indicators of
shock, like your vital signs).
 So take 8% of your TBW… That’s your total blood
volume.
 Figure up :
 10% of total blood volume
 15% of total blood volume
 30% of total blood volume
 40% of total blood volume
 Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 2000 or more

Blood Loss Up to 15% 15-30% 30-40% >40%

(%BV)

HR 100 100 120 140 and up

BP Normal Normal Decreased Decreased

PP (mmhg) Normal-inc. Decreased Decreased Decreased

Refill Normal Positive Positive Positive

RR 14-20 20-30 30-40 >40

Urine OP ml/hr 30ml 20-30 5-15 Negligible

CNS Slightly anxious Mildly anxious Anxious & Confused-

confused lethargic

Fluid Crystalloid Crystalloid Crystalloid & Crystalloid &

replacement Blood Blood
3:1

Emergency War Surgery, NATO Handbook: part II

Remember that exercise?

 Figure up :
 <15% of total blood volume – Class 1 shock
 15%- 30% of total blood volume – Class II Shock
 30% - 40% of total blood volume – Class III Shock
 > 40% of total blood volume – Class IV Shock
Now do the same for a
child….
Ridley – 30 Pounds
 TBW in KG
 TBV = 8% x Body Weight
(kg).
 10% of total blood
volume
 15% of total blood
volume
 30% of total blood
volume
 40% of total blood
volume
COMMON SOLUTIONS
 PURPOSE:

 Four major indications for IV access:

 Replace fluids
 Administer Blood Products
 Route for administration of medications
 Anticipated need for any of above
Question?

 What is Bioavailability?
 What is the considered “Onset” of bioavailability of
medications administered via the IV route?
 What is the % of bioavailability of medications
administered via the IV route?
IV Solutions

 Solutions are comprised of fluid (the solvent) and

particles (the solute) dissolved in the fluid.
 Water is the body's primary fluid and is essential for
proper organ system functioning and survival.
Although people can live several weeks without food,
they can survive only a few days without water.
CLASSES OF IV FLUIDS:

 Colloids:  Crystalloids:
 High molecular  Water and
weight electrolytes
 Proteins that do  The electrolytes will
not diffuse across readily diffuse
the CM across from the
 Colloid osmotic
vascular space into
pressure the tissues
 Used is pre-
 Volume expanders
hospital
 $$$$ and short environment
shelf life
 Other Methods of Classification

IVFLUIDS

HYPOTONICFLUIDS ISOTIONICFLUIDS HYPERTONICFLUIDS

Key Point:

 Osmolarity and Tonicity

 The “Tonicity”: mainly refers to the Sodium and
Dextrose content
ISOTONIC FLUIDS

 Electrolyte composition
is similar to plasma

 When administered to
normally hydrated
patient, there is no
appreciable fluid or
electrolyte shift
HYPERTONIC FLUIDS

 Higher solute level than

plasma

 Cause fluid to shift from IC

to EC space
Hypotonic Fluids

 Lower solute level than

plasma

 Cause fluid to shift from

Extracellular to Intracellular
and Intersticial space
LACTATED RINGER’S SOLUTION /
HARTMANN’S SOLUTION
 Class:  Contains:
 Isotonic crystalloid
 Sodium (Na+) 130 mEq/L
 Description:
 One of the most frequently  Potassium (K +) 4 mEq/L
used IV fluids in hypovolemic
shock.  Calcium (Ca2+) 3 mEq/L
 Chloride (Cl-) 109 mEq/L
 Lactate
(Lactic acid) 28 mEq/L
 LACTATED RINGER’S SOLUTION /
HARTMANN’S SOLUTION
 Indications:
 Hypovolemia/KVO
 Contraindications:
 CHF, renal failure
 Administration:
 Crystalloidsdiffuse
out of the vascular
space in <1hr. 3:1
ratio
 0.9 PERCENT SODIUM
CHLORIDE / NORMAL
 Class: SALINE
 Isotonic crystalloid solution
 Description:
 Concentration of sodium is
near that of blood

 Contains:
 Sodium (Na+) 154 mEq/L
 Chloride (Cl-) 154 mEq/L
0.9 PERCENT SODIUM CHLORIDE /
NORMAL SALINE
 Indications:
 Heat problems
 Freshwater drowning
 Hypovolemia

 DKA

 KVO
 5% Dextrose in .9% Sodium
Chloride (D5NS)
 Class:
 Hypertonic crystalloid
 Indications:
 Heat disorders, freshwater
drowning, hypovolemia,
peritonitis
 Cautions:
 May cause venous
irritation
 5% Dextrose in Lactated Ringer’s
Solution (D5LR)
 Class:
 Hypertonic crystalloid
 Indications:
 Hypovolemia

 Hemorrhagic shock
 Some cases of acidosis
While we are talking about IV
fluids….
 From our friends in the military:
 Hetastarch
 Colloid
 Big Bang in a small package
 “Colloid Pulling Power”
 Hypertonic Saline
 Crystalloid
 “Pulls Fluid” Osmotic Pulling Power
Common IV equipment
Main routs of Vascular
Access
 Peripheral Lines Include:
 Hands
 Feet
 External Jugulars
 Central Lines Include:
 Femoral (Groin)
 Internal Jugular (neck)
 Subclavian
 Intraosseous
 Tib/Fib
 Ankle
 Sternum
 Humerous
A lot of changes…

 What we do now:
 Single Lumen Catheters
 Twin Catheters
 Central Lines
 Intraosseous:
 EZ-IO
 Pediatric / manual IO
Single Lumen IVs

 Traditional
 Quick
 Good for 24-72 hours
Multi-Lumen IVs

 Two (or more) lines in

one IV site
 Ableto give multiple
medications that are
not compatible
 Veryuseful in STEMI
and Acute CVA
patients
Peripheral IV Access Sites
Packaging of IV Fluids

 Most packaged in soft plastic or vinyl bags.

 Container provides important information:
 Label lists fluid type and expiration date.
 Medication administration port.
 Administration set port.
IV Solution
Containers
 Do not use:
any IV fluids after their expiration date;

any fluids that appear cloudy, discolored, or laced with particulate;

or any fluid whose sealed packaging has been opened or tampered

with;

Any fluids with red writing on the package

Just because there is no red
writing does not mean its
“safe” to give!
IV Administration Sets

 Macrodrip—10 gtts = 1 ml, for giving large

amounts of fluid.
 Microdrip—60 gtts = 1 ml, for restricting
amounts of fluid.
 Blood tubing—has a filter to prevent clots
from blood products from entering the
body.
 Measured volume—delivers specific
volumes of fluids.
IV Administration Sets (continued)
 IV extension tubing—extends original tubing.
 Electromechanical pump tubing—specific for each pump.
 Miscellaneous—some sets have a dial that can set the flow
rates.
Macrodrip and Microdrip Administration Sets
Secondary IV Administration Set
Measured Volume Administration Set
Intravenous Cannulas

 Over-the-needle catheter
 Hollow-needle catheter
 Plastic catheter inserted through a hollow needle
Over-the-Needle Catheter
Hollow-Needle Catheter
Catheter Inserted Through the Needle
Peripheral IV Access
Place the constricting band
Cleanse the venipuncture site
Insert the intravenous cannula into the
vein.
Withdraw any blood samples needed.
Connect the IV tubing.
Secure the site.
Label the IV solution bag.
 IV Access Complications

 Pain  Circulatory
 Local infection overload
 Pyrogenic reaction  Thrombophlebitis
 Catheter shear  Thrombus
formation
 Inadvertent arterial
puncture  Air embolism
 Necrosis
 Anticoagulants
Intraosseous
A lot of changes…

 What we do now:
 Single Lumen Catheters
 Twin Catheters
 Central Lines
 What is coming:
 EZ-IO
Single Lumen IVs

 Traditional
 Quick
 Good for 24-72 hours
Multi-Lumen IVs

 Two (or more) lines in

one IV site
 Ableto give multiple
medications that are
not compatible
 Veryuseful in STEMI
and Acute CVA
patients
Central Lines

 Better Access
 More complications
 More difficult
 Infection
 Compressible??
Intraosseous

 A rigid needle is inserted into the cavity of a long

bone.
 Used for critical situations when a peripheral IV is
unable to be obtained.
 Typically initiated after 90 seconds or 2-3 unsuccessful
IV attempts
Intraosseous

 Vasculature always
there, even in shock
 Lessdifficulty than
Central lines
 Only good for 24
hours
 Easier to train
 More costly
Traditional IO (Pediatric)
Traditional Intraosseous Needle
Traditional Intraosseous
Needle
Not so traditional …
EZ IO
IO Indications….

A life or limb threatening condition exists.

 -Severe Volume depletion (dehydration or
hemorrhage)
 -Circulatory collapse
 -Cardiac arrest
 -Medication route if no other access is
available
 A peripheral IV cannot or is unlikely to be
established.
 Delay in administration of fluids or
medications may increase risk to the
patient.
IO placement – All types

https://www.youtube.com/watch?v=0roDPk-
VpAo&feature=player_embedded
6 Common mistakes with IO

https://www.youtube.com/watch?v=YXfyL8kvFTg&feature=player_embedded
Central venous Access
JUST AN FYI BIT…
Some other kinds of vascular
access you will see in the
field…
 Central Lines
 PICC Line
 IVADD (Port-o-Caths)
Central Lines

 Better Access
 More complications
 More difficult
 Infection
 Compressible??
PICC

 “Peripherally inserted
central catheter”
 Can be single or multi
lumen.
 Used for extended home
TPN
 Home health care use
 Administration of meds
and fluids
 Used when repeated IV
sticks would be necessary
IVADs

 Portacath-Inserted in the
chest below the
clavicle.Access is gained
by puncturing the skin
then the synthetic port
 Permacath-Lasts
longer.Up to a year
 Passport-Placed in the
arm instead of
chest.Cheapest
IVAD
Can AEMTs access Central
Venus devices?
 In short: no…
 Key Concerns:
 Sterile Technique
 Heparin in line
 Damage to the CV device
 Specialized equipment.
Aterial-Venous Fistula’s

 A fistula is defined as an abnormal opening between

body parts. In the case of an arterio-venous fistula
(AVF), a surgeon creates a passageway or merge
between an artery and vein, thereby allowing for an
easier target vein to use for access.
 Most commonly used for dialysis patients
Injections
 Routes of Medication Administration

Parenteral medication: administration of a

medication by injection into body tissues

Subcutaneous (SC) – into tissue below dermis of

skin

Intramuscular (IM) – into the body muscle

Intravenous (IV) – into a vein

Intradermal (ID)– into the dermis just under the

epidermis
What is an injection?

Injections are sterile solutions,

emulsions or suspensions.

They are prepared by dissolving,

emulsifying or suspending an active
ingredient and any other substances in
water for injection.

Injecting is the act of giving medication

by use of syringe and needle to obtain
the desired therapeutic effect taking into
account the patients safety and comfort
How are drugs for injections presented?

Single dose preparations

a pre - prepared volume of measured drug, in a
syringe for single dose use
i.e. Flu vaccines, Pneumovax and B12.

Multidose preparations
multi-dose preparations contain a
antimicrobiacteral preservative, are used on
more than the one occasion and great care is
required for its administration but especially it’s
storage between successive withdrawals
i.e Insulin
 Why give drugs in injection form?

Injections usually allow rapid absorption

Can produce blood levels comparable to those

of intravenous bolus injections

Injections can be given from 1ml and up to 2

mils in the Deltoid and up to 3 mls in the
gluteal muscle in adults

Drugs that are altered or not absorbed by

other methods of administration
Needle length and size
For intramuscular injections e.g flu, pneumonia
and B12, the needle should be long enough to
penetrate the muscle and still allow a quarter of
the needle to remain external to the skin

When choosing the needle it is important to

assess the amount of muscle, subcutaneous fat
and weight of the patient - which in the majority
of cases will be a blue needle
Syringes

 Three main parts:

– Barrel – chamber that holds the medication
– Plunger – part within the barrel that moves back
and forth to withdraw and instill medication
– Tip – part that the needle is attached to
 Calibration:
– Syringe sizes from 1 ml to 50 ml
– Measure to a 1/10th or 1/100th depending on
calibration
Needles
 Shaft of the needle
– Length chosen depends on the depth to
which medication will be instilled
– Tip of shaft is beveled or slanted to pierce
the skin more easily

 Gauge:width of the needle (18 – 27

gauge) – a smaller number indicates a
larger diameter and larger lumen inside
the needle
Considerations when choosing a syringe
and needle

 Type of medication
 Depth of tissue penetration required
 Volume of medication
 Viscosity of medication
 Size of the client
Parenteral Administration

 Equipment
 Syringes
 Syringe consists of a barrel, a plunger, and a tip.
 Outside of the barrel is calibrated in milliliters,
minims, insulin units, and heparin units.
 Types
 Tuberculin syringe
 Insulin syringe
 Three-milliliter syringe
 Safety-Lok syringes
 Disposable injection units
Parts of a syringe

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)

Parts of a syringe.
Dose?

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Calibration of U100 insulin syringe.

Dose?

Reading the calibrations of a 3-mL syringe.

TB Syringe

Safety-Glide syringe.
The pointy end

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Parts of a needle.
 Equipment for the administration of injections

Clean tray/area in which to place drug and equipment

21g needle to ease reconstitution and drawing up

(Filter Straw if from a glass ampoule

Syringe of appropriate size

Swabs saturated with isopropyl alcohol 70%

Sterile topical swab if drug is presented in ampoule form

Drug to be administered

Patients prescription to check dose, route and timing

Notes available to record administration in accordance with law

Gloves
 Asepsis and reducing the risk of infection

Good hand washing

Good hand drying

Aseptic technique

Good observation and questioning

of the client

Skin preparation if required

INTRADERMAL INJECTIONS
INTRADERMAL INJECTIONS

 Most often used for PPD

 Site: the inner aspect of the forearm
 Needle size is 25 - 27 gauge, 1/2 to 5/8 inch
 Insert needle at 15o angle
 Injection made just below the outer layer of skin
 If injection does not form a wheal or if bleeding is
noted, the injection was probably too deep and should
be repeated
INTRADERMAL INJECTIONS

 Review the provider’s order for accuracy

 Ask the patient/parent if the patient is allergic to the
medication
 Wash your hands and gather supplies, equipment
 Select proper needle size, length and gauge
INTRADERMAL INJECTIONS

 Explain procedure to patient/parent

 Ask for assistance with children
 Position patient appropriately
 Prepare injection site with alcohol - air dry
 Support skin with thumb
 With bevel up, completely insert bevel at a 15 o angle
INTRADERMAL INJECTIONS

 Inject medication gently, place a cotton ball over the

site after needle removal
 A visual wheal will be produced at the site
 Dispose of needle as per policy
 Wash hands
 Document procedure and patient’s response
INTRADERMAL INJECTIONS
Correct Technique
 Tip of needle can be seen
directly beneath the surface of
the skin
 Resistance should be felt
when medication is
injected
 Tense white wheal 5-10
mm in diameter appears at the
point of the needle
Incorrect
Technique
 Little resistance and a
shallow bulge
 Needle inserted too deep
- will cause an induration
that is difficult to measure
and interpret
Subcutaneous
injection
SQ Injections

 Many immunizations are given SQ

 Insulin and Lovinox are some of the most common
drugs in the subcutaneous injections for clinical use
 Epi and Brethine used to be the most common in EMS
 SQ is seldom used anymore in EMS
 IM is believed to be more reliable in critical patients due
to poor perfusion of SQ space.
Sites for SQ Administration
 SUBCUTANEOUS INJECTION

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)

Subcutaneous injection. Angle and needle length depend on the

thickness of skinfold.
INTRAMUSCULAR
INJECTION
IM Injections

 Surprisingly common in EMS

 EPI IM for anaphylaxis
 Most other auto injectors are IM
 Other meds when IV access is not practical (and IO is
not practical , desirable , or available)
 Narcan
 Anti-emetics
 Pain meds
 Anti-convulsants
Intramuscular injections

 Gauge-20-22
 Length-1-1 ½ inches
 Angle-90 degrees
 Darting motion
 ASPIRATE
Intramuscular injections
 Intramuscular Injections
 Involves inserting a needle into the muscle tissue to administer
medication
 Site Selection
 Gluteal sites
 Vastus lateralis muscle
 Rectus femoris muscle
 Deltoid muscle
 Z-track Method
 Used to inject medications that are irritating to the tissues
INTRAMUSCULAR INJECTION
IM INJECTION SITES

 Deltoid
 Up to 2 ml

 Dorsogluteal
 Up to 3 ml

 Ventrogluteal
 Up to 2 ml
 Vastus lateralis
 Up to 3 ml
DELTOID MUSCLE
GLUTEUS MAXIMUS
Locating right dorsogluteal site. Giving IM
injection in left dorsogluteal site.

(C, D, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
GLUTEUS MEDIUS
Locating IM injection for ventrogluteal
site.

(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
VASTUS LATERALIS
Giving IM injection in vastus lateralis site on

adult.

(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)

Giving IM injection in vastus lateralis site on adult.

 Intramuscular Injections and Pain

The needle
The technique
The speed of the injection
The solution and composition of the drug
The volume of the drug
The approach and attitude of person
administering the injection
Comparison of ID, SQ and
IM

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Angles of insertion for intramuscular (90°), subcutaneous (45°), and

intradermal (15°).
QUESTIONS?
THANK
YOU!