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Medication Administration
and IV
3. List four possible causes of this child’s seizure.
4. What test should you perform on this infant before
any medications are administered, and why?
5. What are the possible routes of medication administration for this patient (list in order of your preference and explain).
Are You Ready?
As you arrive on the scene of an “unknown medical
emergency,” a hysterical woman runs out of her house
carrying an infant who appears blue and is actively
seizing. You yell to your partner, “Seizing kid,” as you
open the side door of the ambulance and grab the
pediatric kit and O2 bag. Your partner takes the baby
from the mother and steps up into the ambulance as
you open the O2 bag.
1. What is your general impression of this patient?
2. What is your first priority?
182
Active Learning
Some people are great at math, and then there are
the rest of us. There is a certain amount of common
sense that goes into calculating drug dosages, but
for the most part it is based on simple formulas and
calculations.
1. Equivalents
Before you begin calculating drug dosages, there
are several things that you will need to commit to
memory:
a.
pound(s) (lb) make up 1 kilogram
(kg).
b. 1 kg is equal to
gram(s) (g).
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c. 1 g is equal to
milligram(s) (mg).
microgram(s)
d. 1 mg is equal to
(mcg).
e. 1 liter (L) is equal to
milliliter(s)
(mL).
f. 1 cubic centimeter (cc) is equal to
mL.
g. 1 teaspoon (tsp) is equal to
mL.
mL.
h. 1 tablespoon (T) is equal to
i. 1 fluid ounce (fl oz) is equal to
mL.
mg.
j. 1 grain (gr) is equal to
k. 1 deciliter (dL) is equal to
L.
l. 1 centimeter (cm) is equal to
meter(s) (m).
m. 1 milligram (mg) is equal to
g.
n. 1 mcg is equal to
g.
2. Calculation Methods
There are several ways to determine how much
of a medication you are supposed to administer
to a patient. No matter what method you choose
to use, if performed properly, they should all
come up with the same answer. Following are
three methods for determining the appropriate
dose based on information that you have available to you.
Method 1
The first method is based on the following formula:
Volume on hand Volume to be
Ordered (or calculated) dose
administered (X)
Concentration (in units
of mg, mcg, g, etc.)
Example: Medical control orders you to administer 5 mg of morphine sulfate IV to your 84-year-old
female patient who has signs and symptoms of a
hip fracture. The morphine in your formulary
contains 10 mg in 1 mL. How many milliliters of
morphine sulfate do you need to administer to this
patient in order to deliver 5 mg?
You have the following information:
Order:
On hand:
5 mg morphine sulfate IV
10 mg/1 mL
Fill in the formula:
X
1 mL 5 mg
10 mg
Medication Administration and IV
183
Cancel any common values (volumes or concentrations) that exist on the top and on the bottom, and
multiply across the top.
X
1mL 5 mg
10 mg
1 5 mL
10
5 mL
10
0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
Method 2
This second method involves ratio and proportion.
The symbol for proportion is ::, and the symbol for
ratio is : .
Using the same problem as in method 1, start
with the known ratio on the left side of the proportion:
10 mg : 1 mL ::
Place the unknown ratio on the right side of the
proportion in the same sequence as the ratio
on the left side of the proportion. This ratio is
usually the physician order or the dosage that
you are permitted to administer based on standing orders:
10 mg : 1 mL :: 5 mg : X mL
First, multiply the extremes ( the far outside
values: 10 mg and X mL) and place the result
on the left side of the equation. Second, multiply the means (the numbers on either side of
the proportion symbol: 1 mL and 5 mg) and
place this value on the right side of the expression:
10X 1 5
Multiply:
10X 5
Divide both sides by the number in front of
the X:
10X
5
10
10
X 0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
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Method 3
The third method is referred to as the cross
multiplication method. This method sets the problem up using fractions. The first fraction is the
concentration, and the second fraction is the physician’s order over the volume of medication being
administered.
10 mg
5 mg
1 mL
X mL
Cross multiply the fractions by multiplying numerators by the denominator on the opposite side.
Express the results as an algebraic equation the
same as used in the proportion method.
10X 5 1
5
X 0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
3. Fluid Volume over Time
To calculate a volume to be infused over a specific
time frame, you need the following information:
• The volume to be administered
• The delivery of volume of the administration
set (drops [gtt]/mL)
• The total time to infuse the fluid (always
expressed in minutes)
Example: The physician orders the administration
of 400 mL of 0.9% sodium chloride solution
over 1½ hours using a 10 gtt/mL (macro-drip)
administration set. At what drip rate will you set
the infusion?
Volume to be infused: 400 mL
Administration set size: 10 gtt/mL
Total time of infusion: 90 minutes
The following formula should be used when calculating this type of problem:
Drip rate Volume to be infused Drip chamber size
(gtt>min)
Total time of infusion (minutes)
400 mL 10 gtt/ mL
90 min
Simplify:
400 mL 10 gtt/ mL
90 min
400 gtt
9 min
44.4 gtt/ min
Drip rate This same formula can be used to find out how
long it would take to administer the entire contents of an IV bag using a specific drip rate.
• Place the drip rate on the left side of the equation.
• The total volume of the IV bag multiplied by
the drip chamber size is the numerator on the
right side of the equation.
• The total time of infusion is the denominator
on the right side of the equation.
• Solve the equation for X (the time needed to
administer the entire contents of an IV bag).
Example: You have a 250-mL bag of 5% dextrose in
water (D5W) and have been ordered to infuse it at
90 gtt/min using a 60-gtt/mL administration set. How
long will it take to infuse this amount of fluid?
Volume to be infused:
250 mL
Administration set size: 60 gtt/mL
Total time of infusion:
X minutes
Ordered gtt/min:
90 gtt/min
Set up the formula with the information that you
have on hand:
90 gtt/ min 250 mL 60 gtt/ mL
X Time
Multiply each side of the equation by X. Milliliters
cancel one another.
X(90 gtt/ min)(X Time) 15,000 gtt
Divide each side by 90 gtt/min:
X Time 167 min
It will take 167 minutes, or 2 hours and 47 minutes, to infuse the 250-mL bag of D5W.
4. IV Infusions
There are also several methods for determining
IV drip rates for patients receiving IV infusions.
The following methods are examples of how this
can be done.
Formula Method
This method finds the ordered dosage over time
based on the patient’s weight.
Example: You have a resuscitation patient who
has a return of spontaneous circulation (ROSC)
after you defibrillate her out of ventricular fibrillation. You reassess the patient and discover that
she is in a normal sinus rhythm, but she is hypotensive. Fluid boluses do not affect the patient’s
blood pressure, so you decide to start the patient
on a dopamine infusion at 10 mcg/kg/min per
your protocols. The patient weighs 132 pounds.
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You have premixed dopamine IV bags that contain
200 mg of dopamine in 250 mL of D5W. Your policy for administration of dopamine mandates the
use of a 60-gtt/mL IV tubing. How many drops per
minute will need to be delivered in order to
achieve the 10 mcg/kg/min dosage?
First convert the patient’s weight in pounds into
kilograms:
132 lb 2.2 lb/ kg 60 kg
Next insert the information that you have on hand into
the formula below, and you will get
X
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Clock Method—Dopamine Clock
The clock method is a way in which paramedics
can simplify calculating how many drops per minute they need to infuse once they have determined
the dosage of the medication that they need to
administer. It helps determine drops per minute
based on the concentration of medication per a
specific volume of fluid and the number of drops
per volume of the administration set.
Example: Dopamine comes in premixed bags
with various concentrations of medication. For
IV bag volume (mL)
Concentration ordered (mg, mcg, g)
Administration set (gtt)
Amount of drug in IV bag
1 min
1 mL
250 mL
10 mcg/kg
60 gtt
200 mg
1 min
1mL
Because the concentration ordered is weight based,
the 10 mcg needs to be multiplied by the patient’s
weight in kilograms (60 kg):
10 60 600 mcg
250 mL
600 mcg
60 gtt
X
200 mg
1 min
1 mL
Next convert the amount of drug in the bag from
milligrams to micrograms because the order is in
micrograms:
200 mg 200,000 mcg
250 mL
600 mcg
60 gtt
X
200,000 mcg
1 min
1 mL
Simplify the problem (cancel out zeros and units):
250 mL
60 gtt
600 mcg
200,000 mcg
1 min
1 mL
25
6
6 gtt
20
1 min
1
Now multiply:
X
25
6
6 gtt
20
1 min
1
900 gtt
X
20 min
X
Simplify the problem:
X
90 gtt
2 min
Reduce the fraction:
45 gtt
45 gtt/ min
1 min
the sake of this example, we will say that the
premixed bag contains 800 mcg/mL of fluid. If
you are using a 60-gtt/mL administration set
(which is typical for the administration of dopamine), the clock tells us that for every 60 gtt or
1 mL of fluid, the patient will receive 800 mcg
of the solution. The 800 mcg and the 60 gtt/min
go at the top of the clock (at 12:00). To complete
the clock, you need to use basic division and
addition. We need to fill in the clock at the 3:00,
6:00, and 9:00 positions. In order to do this, we
need to divide both the 800 mcg and the 60 gtt
by 4: 800 divided by 4 is 200, and 60 divided by
4 is 15. The 3:00 position is filled in by 200 mcg/
mL and 15 gtt/mL. Add another 200 mcg/mL and
15 gtt/mL, respectively, to these numbers to get
the correct volume and drip rate for the 6:00
position (400 mcg/mL and 30 gtt/mL). To complete the clock and fill in the 9:00 position, add
another 200 mcg/mL and 15 gtt/mL, respectively,
to the 6:00 calculation (obtaining 600 mcg/mL
and 45 gtt/mL).
Dosage: 10 mcg/kg/min 10 mcg/60 kg/min 600 mcg/min
Premix IV bag: 200 mg/250 mL 200,000 mcg/
250 mL
Concentration: 800 mcg/mL
IV administration set: 60 gtt/mL
You are looking for the drip rate for dopamine in
drops per minute. To accomplish this, you need
to make sure that you are dealing with like values
in your clock. For example, the volume that you
are using in your administration set needs to
match that of your concentration (if the volume
of the administration set is measured in milliliters,
then the concentration of the medication needs
to be measured in a like volume [mL]). Once this
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has been confirmed, you are ready to set up your
clock:
Apply the information that you have to the equation:
250 mL 60 gtt/ mL 2 mg/ min
1,000 mg
Simplify: Milliliters cancel one another and milligrams cancel one another, leaving gtt/min.
Drops per minute 800 mcg
Drops per minute 30 gtt/ min
60
600 mcg
45
gtt/min
15
200 mcg
Clock Method—Lidocaine Clock
30
400 mcg
Since you are going to deliver 600 mcg/min, look
at the clock to determine how many drops per
minute you will need to deliver that amount of
dopamine: 45 gtt/min will give you the desired
600 mcg/min.
Find the ordered dosage over time: The information that is needed from the problem is
• The ordered dose
• The size of the drip chamber
• The amount of drug on hand
• The total volume on hand (the volume of the
IV bag being used)
The physician orders a 2-mg/min maintenance
infusion of lidocaine for a patient who was experiencing ventricular tachycardia. You have a
premixed solution of lidocaine that has 1 g of
lidocaine in 250 mL of normal saline. You have a
60-gtt/mL administration set. At what drip rate
will you set this infusion?
Physician’s order:
Administration set size:
Amount of drug on hand:
Volume on hand:
Run the infusion at 30 drops per minute to infuse
2 mg of lidocaine per minute (check your work on
the following lidocaine clock).
2 mg/min
60 gtt/mL
1g
250 mL
The following formula should be used when calculating these types of problems:
Volume on hand Drip chamber
Ordered dose
Drops per minute Amount of drug on hand
First, convert grams to milligrams to allow for consistency between the requested dosage and the
concentration of medication on hand:
1g 1,000 mg
Lidocaine drips are typically 1 g of lidocaine
in 250 mL or 2 g of lidocaine in 500 mL of D5W.
These drips are not weight based, but instead
are based on milligrams per minute (mg/min).
The first thing that needs to be done is to convert
the grams of lidocaine to milligrams so that the
drip rate will reflect the established mg/min infusion rate.
• 1 g 1,000 mg
Next divide the volume found in the IV bag by the
concentration of the lidocaine to obtain the ratio
of mg:mL.
• 1,000 ÷ 250 4 mg/mL
• 2000 mg ÷ 500 4 mg/mL
Now simply apply this ratio to a clock:
4 mg
60
3 mg
45
gtt/min
15
1 mg
30
2 mg
5. Calculation Problems
Using any of the preceding methods, solve the following dosage calculation problems.
a. You have been instructed by medical control to
administer an initial dosage of 0.1 mg/kg of IV
adenosine to your 33-lb pediatric patient followed by a rapid fluid bolus. Based on the available packaging of adenosine (depicted in the
photo at the top of page 187), you will need to
administer
mL.
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b. You are working up a patient who is in ventricular fibrillation. The patient has been defibrillated
following the administration of 1 mg of epinephrine 1:10,000, CPR is in progress, and the patient
is now ready for her first round of lidocaine at
1.5 mg/kg. The patient weighs 132 lb. Based on
the order and the lidocaine that you carry in your
formulary (depicted below), you will need to
administer
mL of lidocaine.
c. You are treating an infant who is suffering
from a symptomatic bradycardia at a heart rate
of 40 beats per minute. The patient has not
responded to oxygen therapy, ventilation, or
epinephrine administration. Your base hospital physician has ordered you to administer
0.02 mg/kg to this 22-lb child. You should
administer
mL of atropine
(depicted below) to the patient.
Medication Administration and IV
187
d. You have a 27-year-old (80 kg) male patient
who has suffered second- and third-degree
burns over 56% of his body. You are transporting the patient to the burn center, which is just
under 1 hour away. The patient has received
a considerable amount of morphine, which
barely seems to be taking the edge off of the
pain. You calculate your fluid infusion for the
patient based on the Parkland formula and
realize that you will need to infuse 1,120 mL
per hour for the first 8 hours. You will need
to deliver
drops per minute in
order to administer 1,120 mL/hour.
e. You are monitoring a 500-mL bag of normal
saline that is dripping at a rate of 120 gtt/min
through a 10-gtt/mL administration set. It
will take
min for the bag to
finish.
f. You have been given an order to infuse a
300-mL fluid bolus to your patient over 45
minutes with a 10-gtt/mL administration set.
You will need to set the drip rate at
gtt/min in order to accomplish
this goal.
g. The physician orders 3 mcg/kg/min of
dopamine to be administered to your patient
in cardiogenic shock. You place 200 mg of
dopamine into a 250-mL bag of D5W to mix
the infusion. You have a 60-gtt/mL administration set, and your patient weighs 165 lb. You
will run the infusion at the rate of
gtt/min.
h. You have been given an order for dobutamine
for your hypotensive CHF patient. The order
is 15 mcg/kg/min. Your protocol states that
you are to use a dobutamine infusion consisting of 250 mg in 500 mL of normal saline. The
patient weighs 165 lb. You will need to administer
gtt/min if you are using
a 60-gtt/mL administration set.
i. Your preceptor is quizzing you about dosage
calculations, and he states that he wants you
to administer dopamine in the alpha range to
a hypothetical 65-year-old, 88-lb patient. You
remember that alpha effects are seen at 20 mcg/
kg/min, and you have been drilled and drilled
that you are supposed to always use a microdrip (60 gtt/min) administration set when
administering IV piggyback medications and
that your local protocols require 200 mg of
dopamine to be mixed into a 250-mL bag of
D5W. Your preceptor wants to know how many
drops per minute you will need to administer
to this patient in order to see the desired
effects. The answer you give is
gtt/min.
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j. You have achieved a return of spontaneous
circulation on a ventricular fibrillation cardiac
arrest patient following your second defibrillation. Your partner boluses the patient with
lidocaine and asks that you prepare a lidocaine drip. Your protocols require that you
begin a lidocaine infusion at 2 mg/min. You
carry premixed lidocaine (2 g in 500 mL).
Using a 60-gtt/mL administration set, you will
set the lidocaine infusion at a drip rate of
gtt/min to deliver 2 mg/min.
You Are There: Reality-Based Cases
Case 1
As you are inspecting your ambulance at the beginning of your shift, an elderly man shuffles up to the
back of the ambulance and says, “Excuse me young
man, may I have some help? I am having chest pain
and I really don’t feel well.” You pull out the gurney
from the back of the ambulance and ask the gentleman
to sit down so that you can check him out. The patient
complies, and as you are about to begin your assessment, your partner walks up to the ambulance. The
two of you immediately go to work.
You assess the patient as your partner hooks him
up to the ECG monitor and the pulse oximeter (his
oxygen saturation is 92% on room air) and then
places the patient on O2 at 10 L by non-rebreather
mask. The patient’s vital signs are BP of 188/96, HR
of 112, and irregular and slightly labored respirations of 28. The ECG shows the rhythm in Figure 16-1. The patient presents with cool, pale, moist
skin and speaks in five- to six-word sentences. He is
alert and oriented and follows basic commands. He
states that he is having a heavy sensation in his
chest, very similar to the pressure that he felt when
he had an MI 2 months ago. The pressure (6 on a
scale of 10) is nonradiating and is associated with
FIGURE 16-1
nausea. The onset of this episode was 30 minutes
ago while walking.
The patient states that he had a stent placed, but
he doesn’t know which artery it was placed in. He
takes digoxin, atenolol, Coumadin, Glucophage, and
Lipitor. He has no allergies to medications.
You discover that the patient has jugular venous
distention (JVD), slight supraclavicular retractions
with his ventilations, trace pedal edema, and faint
crackles in the bilateral bases of his lungs. He has had
no recent illnesses and has had no sputum production. He states that he has had trouble breathing when
he sleeps at night, so he has been sleeping in a recliner
in his living room. He also states that he has trouble
breathing when he walks.
As you establish an IV, your partner administers
one metered dose of sublingual nitroglycerin and
325 mg of aspirin. Your partner states that he would
like to complete the MONA algorithm and asks if you
would like to contact medical control to get an order
for morphine sulfate or if you would like him to make
the call.
1. What is your general impression of the patient?
2. What is your first priority in the treatment of this
patient?
3. Describe your basic treatment of the patient prior
to administration of medications.
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4. What do you need to know about the patient before
you can administer medications?
5. What do you need to know about a medication
prior to administering that medication?
6. What are the five “rights” of medication administration?
7. What is likely the single most important thing that
a paramedic can do following medication administration to prevent unnecessary exposure to contaminated items?
8. Explain why your partner was able to administer
nitroglycerin and aspirin but needed to contact
medical control in order to administer morphine
sulfate.
9. During the process of obtaining a history, what is
an important question to ask the patient regarding
medications—other than the names of the medications and any known allergies that the patient may
have to medications—that can have a dramatic
impact on the patient’s current condition?
Test Yourself
1. You are called to an apartment building by law
enforcement officials who have discovered a man
Medication Administration and IV
189
whom they believe to be delusional. The patient
tells you that he has been hearing people talking
all day long, like “a radio playing in my head.” In
the kitchen you find several bottles of Abilify, an
antipsychotic medication; all the bottles are full,
and the prescriptions were filled several months
ago. You should suspect
a. a medication overdose.
b. a manic depressive disorder.
c. a traumatic head injury.
d. a medication underdose.
2. In regard to medication administration, what is a
contraindication?
3. When administering a medication, you should
check the patient’s vital signs
a. after administering the medication.
b. before and after administering the medication.
c. every 10 minutes after administering the medication.
d. before administering the medication.
4. Next to a patient’s bathroom sink, you find a prescription sleep aid, an over-the-counter (OTC) pain
reliever, an herbal remedy, and a toothpaste that
contains fluoride. Which of the following must be
documented in your report?
a. The prescription and OTC medications
b. The prescription medication only
c. The prescription, OTC medication, and herbal
remedy
d. The prescription, OTC medication, herbal remedy, and toothpaste
5. Like medications, IV catheters and tubing have
expiration dates.
True
False
6. Your patient is in hypovolemic shock and requires
immediate fluid replacement therapy. While preparing to administer the IV, you drop the needle
and it falls to the ground. What should you do?
a. Retrieve a new needle.
b. Wipe off the needle with a clean, dry piece of
gauze.
c. Wipe the needle with an antiseptic.
d. Use your breath to steam the surface of the
needle.
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7. Sharps should be disposed of in
a. a plastic bag clearly marked “Caution.”
b. any public trash receptacle.
c. a jar containing alcohol.
d. a biohazard receptacle.
8. _________ drugs need to be accounted for at the
beginning and end of your shift, should be kept
secure throughout your shift, and require detailed
custody logs.
9. In accordance with your local protocols, you should
frequently inspect your ambulance’s medication
supply. List three specific factors you should note
when performing this task.
10. Although needle-less systems do not require needles, they are compatible with traditional needles.
True
False
11. Your partner has been experiencing chronic bumps
and raised, red areas on her hands. When she went
on vacation for 2 weeks, the symptoms gradually
disappeared, but a week after returning to work,
the symptoms have returned. She is always very
careful to wear gloves when handling medications
and during any patient contact. You should suspect
a. a reaction to handling a medication.
b. contact dermatitis contracted from a patient.
c. a fungal infection.
d. a latex allergy.
12. Which of the following statements regarding injectable medications is true?
a. Most injectable medications should not be frozen.
b. Most injectable medications have a very short
shelf life.
c. Most injectable medications can only be stored
in glass bottles.
d. Most injectable medications cannot be exposed
to light.
medication is being administered. Briefly describe
these three steps.
15. You have responded to a remote location for a
patient in hemorrhagic shock. En route to the hospital you are attempting to obtain IV access to begin
fluid resuscitation, but the road that you are traveling on is bumpy, and you are unable to safely perform the procedure. To minimize the possibility of
an accidental needle stick, you would likely
a. wait until you reach the main highway before
reattempting to obtain IV access.
b. have the driver pull over, and obtain IV access
while the ambulance is stopped.
c. concentrate on alternative forms of treatment
until you reach the hospital.
d. continue to carefully attempt to obtain IV
access until you are successful.
16. A drug in your supply expires December 2012.
What is the last date that you can administer the
drug?
a. December 1, 2012
b. November 1, 2012
c. December 31, 2012
d. November 31, 2012
17. How are the majority of health-care workers accidentally exposed to blood during their occupational training?
a. Eye splashes
b. Non-intact skin exposure
c. Mucous membrane exposure
d. Needle sticks
18. Most patients who regularly take prescription
medication are compliant with their prescribed
dosing regimen.
True
False
13. List the three acceptable methods for sterilization
of medical equipment.
19. Who can authorize the administration of medication?
a. The team leader
b. The patient
c. The online physician
d. The most senior paramedic
14. EMS providers can emulate pharmacies by using
a three-step system to confirm that the correct
20. You are called to a “man down” in a supermarket.
When you arrive, the adult male patient is unresponsive and apneic. The ECG monitor reveals that the
patient is in cardiac arrest. You need to administer
epinephrine, but you cannot confirm the patient’s
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medical history or allergies because none of the
immediate bystanders know the man. You should
a. administer the epinephrine immediately.
b. provide care without administering any medications.
c. use the man’s cell phone to contact a family
member.
d. use the store’s public address system to ask
any friends or family to come forward.
Need to Know
The following represent the Key Objectives of Chapter 16:
1. Describe the safe and appropriate administration of
medications based upon the selected route.
With administration of medications comes a great
deal of responsibility. The process of administering
medications needs to be methodical, well thought
out, and based on sound judgment. There is no
room for complacency in medication administration, for when the paramedic becomes complacent,
mistakes are made, and when it comes to medication administration, mistakes can be lethal.
All medication administration decisions need
to be based on the results of assessments that
include past medical history, any known allergies to medications (specific medications [e.g.,
morphine] or general classifications of medications [sulfa-based medications]), physical examination, and vital signs (e.g., heart rate, blood
pressure, respiratory rate, temperature, ECG tracing, pulse oximetry). Paramedics must have a
basic knowledge of any medications that they
may administer, including indications, contraindications (absolute or relative), potential side
Medication Administration and IV
191
effects or complications, precautions, any possible interactions with other medications, and the
expected therapeutic effects, based on their scope
of practice and the formulary of their provider.
Is the paramedic able to administer the medication based on standing orders, or does the medication administration require consultation with
medical control?
Because most medication dosages are based
on a patient’s weight, the paramedic must be able
to perform drug calculations so that the patient
does not receive an overdose or an underdose of
a medication. Since some medications do not
come packaged as ready to administer, paramedics
need to know how to prepare medications for
administration. For example, glucagon comes in
two vials. One of the vials contains a powder, and
the other vial contains a liquid. The powder needs
to be combined with the liquid and thoroughly
dissolved before it can be administered. Similarly, some medications need to be mixed with
an IV solution in an IV bag before they can be
administered as an IV drip (infusion). If given
such a medication undiluted as an IV bolus, the
patient could experience undesired effects.
Standard medication administration must
follow safe administration techniques via the
appropriate administration route while maintaining asepsis. Contaminated disposable medication
administration equipment needs to be disposed of
in the appropriate disposal container, and reusable
medication administration equipment needs to be
cleaned and maintained per the manufacturer’s
instructions.
Any preexisting medication administration
device that is used by paramedics must be approved
by the EMS agency and the EMS provider that the
paramedic works for. Any medication administration device that the paramedic is not familiar with
or specifically trained how to use should not be
used by the paramedic.
Other than ensuring that the five rights of
medication administration are followed and the
patient is not allergic to the medication that you
are administering, perhaps the most important
step in medication administration is to reassess
the patient following the administration of a medication to see if it had the desired or any undesired
effects. Make sure that the medication administration is clearly and accurately documented on your
patient care report. This report is a part of the
patient’s medical record and may be referred to by
medical personnel to direct them in further treatment of the patient.
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Need to Do
The following medication administration skills are explained and illustrated in a step-by-step manner, via skill
sheets and/or Step-by-Steps in this text and on the accompanying DVD:
Skill Name
Skill Sheet Number
and Location
Step-by-Step Number
and Location
Intravenous Access
42 – Appendix A and DVD
42 – This chapter and DVD
Intravenous Access Using Saline Lock
43 – DVD
43 – DVD
Phlebotomy
44 – DVD
N/A
Intraosseous Access and Drug
Administration
45 – Appendix A and DVD
45 – This chapter and DVD
Umbilical Vein Cannulation
46 – DVD
N/A
Central Line Access for Fluids and Drug
Administration
47 – DVD
N/A
Intravenous Drug Bolus
48 – Appendix A and DVD
48 – This chapter and DVD
Intravenous Drug Infusion
49 – Appendix A and DVD
49 – This chapter and DVD
Intramuscular Drug Administration
50 – Appendix A and DVD
50 – This chapter and DVD
Intranasal Drug Administration
51 – DVD
N/A
Nebulized Drug Administration
52 – Appendix A and DVD
52 – This chapter and DVD
Subcutaneous Drug Administration
53 – Appendix A and DVD
53 – This chapter and DVD
Sublingual Drug Administration
54 – DVD
N/A
Endotracheal Drug Administration
55 – DVD
N/A
Eye Drop Drug Administration
56 – DVD
N/A
Oral Drug Administration
57 – DVD
N/A
Rectal Drug Administration
58 – Appendix A and DVD
58 – This chapter and DVD
Autoinjector Drug Administration Device
59 – DVD
N/A
NREMT Intravenous Therapy
89 – DVD
N/A
NREMT Pediatric Intraosseous Infusion
91 – DVD
N/A
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Intravenous Access
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions. Establish a patent IV line within
6 minutes.
Indications: Patients who require or may potentially require administration of fluids or intravenous
medications.
Red Flags: Prep the site with aseptic or medically clean technique as field conditions permit. Avoid starting
an IV on the same arm as a dialysis shunt. IV infiltration, especially when medications are being administered,
can cause serious and irreversible tissue damage. Avoid using areas of burned skin or heavy vein scarring.
Steps:
1. Use appropriate standard precautions.
2. Select proper fluid and check its expiration date
and clarity.
3. Select proper IV tubing.
4. Close roller clamp.
5. Remove tab from IV bag and cap from spike
end of IV tubing. Insert spike into IV bag
administration port (Figure SBS 42-1).
SBS 42-2
11. Cleanse area with alcohol prep.
12. Control site by pulling skin firmly, taking care to
keep your fingers out of the needle path.
13. Insert needle at less than a 45-degree angle with
the bevel up (Figure SBS 42-3).
SBS 42-1
6. Squeeze the drip chamber until IV solution
reaches fluid line or the drip chamber is half full.
7. Run fluid through the tubing until fluid fills
tubing and air bubbles are removed.
8. Gather equipment (IV needle, tourniquet, tape,
gauze, alcohol prep, etc.).
9. Apply tourniquet proximal to desired site.
10. Select site (Figure SBS 42-2). (Possible sites
include between knuckles, dorsal thumb, back of
hands, forearms, or antecubital fossa.)
SBS 42-3
14. Advance needle in a smooth motion.
—Continued
193
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15. Monitor for flashback, and verbalize when
flashback is visualized.
16. Advance catheter into vein while retracting
needle until it locks.
23. Inspect and palpate for infiltration at IV site.
24. Secure site and tubing with tape or a commercial
device (Figure SBS 42-6).
17. Avoid catheter shear by not reinserting needle
into catheter.
18. Remove tourniquet if blood sample is not required.
19. Hold hub, and tamponade vein to prevent
bleeding (Figure SBS 42-4).
SBS 42-6
Critical Criteria:
SBS 42-4
20. Remove needle from hub and place in a sharps
container.
21. Connect administration set to catheter hub.
22. Open roller clamp and observe for free flow
through drip chamber (Figure SBS 42-5).
SBS 42-5
• Use appropriate standard precautions.
• Maintain aseptic or medically clean technique
throughout procedure.
• Avoid catheter shear by not reinserting needle
into catheter.
• Observe for infiltration.
• Establish a patent IV line within 6 minutes.
• Dispose of sharps in an appropriate container.
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Intraosseous Access and Drug Administration
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A patient who requires intravascular access for medication administration and/or volume
resuscitation and for whom IV access is not readily available.
Red Flags: Long-bone deformity distal to access site on same bone; unable to locate landmarks.
Steps:
1. Use appropriate standard precautions.
8. Stabilize IO catheter and remove needle.
2. Select appropriate device and prepare
equipment.
9. Dispose of sharps in appropriate sharps container.
3. Locate intraosseous (IO) site (Figure SBS 45-1).
(Possible sites include tibia, distal femur,
humerus, sternum, or iliac crest.)
SBS 45-1
4. Cleanse site with alcohol and/or iodine.
5. Place IO device against bone.
6. Insert needle straight into bone at a 90-degree
angle (Figure SBS 45-2).
10. Attach syringe to IO needle.
11. Aspirate bone marrow and administer saline
flush (Figure SBS 45-3).
SBS 45-3
12. Inspect site for infiltration. If swollen, remove
needle and apply pressure.
13. Attach administration set, and run fluid wide open.
14. Ensure free flow and no swelling, and adjust to
desired rate.
15. Secure device (Figure SBS 45-4).
SBS 45-2
7. Stop at proper depth or when resistance is no
longer felt (“popping” sensation).
SBS 45-4
—Continued
195
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Drug Administration
22. Push medication at proper rate, and flush tubing
after administration.
16. Ensure that five patient rights of drug
administration are met.
23. Monitor patient for desired and adverse effects.
17. Draw medication using aseptic technique.
Critical Criteria:
18. Dispose of needle in a sharps container.
19. Cleanse port with alcohol prep.
20. Attach syringe to port.
21. Occlude line between fluid and port by
pinching line or adjusting three-way stopcock
(Figure SBS 45-5).
• Use appropriate standard precautions.
• Use intraosseous needle in a safe manner.
• Immediately dispose of sharps in appropriate
container.
• Observe for infiltration at site.
• Ensure that five rights of medication
administration are followed.
SBS 45-5
Step-by-Step
48
Intravenous Drug Bolus
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A patient who requires a medication bolus delivered intravenously.
Medications given through the IV route are rapid acting. Deliver medications at appropriate
rate and at appropriate time intervals. Always observe for infiltration.
Red Flags:
Steps:
1. Use appropriate standard precautions.
4. Ensure IV flows without infiltration.
2. Explain procedure to a conscious patient.
5. Ensure that five patient rights of drug
administration are met.
3. Ensure patient is not allergic to the medication.
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6. Assemble pre-filled syringe, or draw medication
into syringe (Figure SBS 48-1).
Medication Administration and IV
197
12. Withdraw needle from IV tubing and dispose in
sharps container.
13. Flush IV tubing, and set flow to desired rate
(Figure SBS 48-4).
SBS 48-1
7. Expel air from syringe.
8. Cleanse IV port with alcohol prep.
9. Attach syringe to IV port (Figure SBS 48-2).
SBS 48-4
14. Thoroughly document medication administration.
15. Monitor patient for desired and adverse effects.
Critical Criteria:
SBS 48-2
10. Occlude IV line between port and IV bag, or
close roller clamp.
11. Push medication at the proper rate (Figure
SBS 48-3) while observing for infiltration.
SBS 48-3
• Use standard precautions.
• Check for patient allergies and medication
reactions.
• Ensure that five rights of medication
administration have been met.
• Cleanse the IV port prior to injection.
• Immediately dispose of sharps in an appropriate
container.
• Monitor patient for changes in condition.
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Intravenous Drug Infusion
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A patient who requires medications continuously delivered intravenously.
Red Flags: Medications given through the IV route are rapid acting. Pay close attention to the rate of
administration. Always observe for infiltration of primary IV.
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient.
3. Ensure patient is not allergic to the medication.
4. Ensure IV flows without infiltration.
5. Ensure that five patient rights of drug
administration are met.
6. Calculate drug dosage in drips per minute
(gtt/min).
9. Mark bag with drug name and concentration,
date and time of administration, and initials of
person preparing and administering infusion.
10. Dispose of any sharps in appropriate container.
11. Cleanse IV port with alcohol prep.
12. Connect infusion IV set to main IV and stop flow
of main IV (Figure SBS 49-3).
7. Prepare IV solution or spike premixed bag
(Figure SBS 49-1).
SBS 49-3
SBS 49-1
8. Fill drip chamber, and flush tubing (Figure
SBS 49-2).
SBS 49-2
198
13. Secure line with tape (Figure SBS 49-4).
SBS 49-4
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14. Adjust to proper drip rate.
15. Thoroughly document medication administration.
16. Monitor patient for desired and adverse effects.
Critical Criteria:
• Use standard precautions.
• Check for patient allergies and medication
reactions.
Step-by-Step
Medication Administration and IV
199
• Ensure that five rights of medication
administration have been met.
• Cleanse medication port prior to insertion.
• Dispose of sharps immediately after use.
• Ensure that infusion is set at proper rate.
• Monitor patient for desired and adverse effects.
50
Intramuscular Drug Administration
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A patient whose condition requires the administration of a medication through the
intramuscular route. A patient who does not have vascular access, and the required medication can be
administered intramuscularly.
Red Flags: May not be effective in poorly perfused tissue.
Steps:
1. Use appropriate standard precautions.
6. Expel air from syringe.
2. Explain procedure to a conscious patient.
7. Locate administration site (deltoid, thigh, or
buttocks).
3. Ensure patient is not allergic to the medication.
4. Ensure that five patient rights of drug
administration are met.
5. Using a 20-gauge or smaller needle, draw
medication into syringe (Figure SBS 50-1).
SBS 50-1
8. Cleanse site with alcohol prep.
9. Stabilize skin with fingers, or pinch to raise skin
slightly (Figure SBS 50-2).
SBS 50-2
—Continued
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10. Insert needle at 90-degree angle, and quickly
advance into muscle.
11. Attempt to aspirate for blood (Figure SBS 50-3).
If blood returns, withdraw needle and try a
different site.
SBS 50-4
15. Thoroughly document medication administration.
16. Monitor for redness and swelling.
17. Monitor patient for desired and adverse effects.
Critical Criteria:
SBS 50-3
12. Slowly inject medication.
13. Withdraw needle from patient, and dispose of
needle and syringe in appropriate sharps
container.
14. Apply sterile gauze and direct pressure to site
(Figure SBS 50-4).
Step-by-Step
• Use standard precautions.
• Check for patient allergies.
• Ensure that five rights of medication
administration have been met.
• Insert needle at 90-degree angle.
• Aspirate for blood prior to medication
administration.
• Immediately dispose of sharps in appropriate
container.
52
Nebulized Drug Administration
Conditions: The candidate should perform this skill on a simulated patient in a sitting or supine position
(stretcher, chair, or bed) under existing indoor, ambulance, or outdoor lighting, temperature, and weather
conditions.
Indications:
A patient whose condition requires the administration of a medication through the nebulized
route.
Red Flags: Equipment used to nebulize medications can vary significantly. Practice with your local
system’s equipment until you are comfortable with assembly and use.
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Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient.
3. Ensure the patient is not allergic to the medication.
Medication Administration and IV
201
10. Adjust flow of oxygen to nebulizer to create a
steady mist of medication (6–8 L/min).
11. Instruct patient to seal lips around mouthpiece, and direct him or her to breathe slowly
and deeply (Figure SBS 52-4).
4. Ensure that five patient rights of drug
administration are met.
5. Place medication in nebulizing chamber (Figure
SBS 52-1).
SBS 52-4
SBS 52-1
6. Screw on chamber cover.
12. Alternately, attach set to an in-line adapter, and
ventilate with a bag-mask at 12–20 breaths/min
timed with patient’s inspiratory effort (Figure
SBS 52-5).
7. Attach oxygen tubing to nebulizer chamber, and
attach tubing to oxygen source (Figure SBS 52-2).
SBS 52-5
SBS 52-2
8. Assemble administration set according to
manufacturer’s instructions, ensuring nebulizer
chamber remains upright.
13. Alternately, attach nebulizer to simple mask
(Figure SBS 52-6) and adjust the flow of
oxygen to create a steady mist of medication
(6–8 L/min).
9. Attach T-piece to nebulizing chamber (Figure
SBS 52-3).
SBS 52-6
14. Refill chamber per local protocol.
SBS 52-3
—Continued
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15. Thoroughly document medication
administration.
• Assist ventilations as necessary.
• Keep in-line nebulizer chamber upright.
16. Monitor patient for desired and adverse
effects.
Critical Criteria:
• Use standard precautions.
• Ensure that five rights of medication
administration are met.
Step-by-Step
53
Subcutaneous Drug Administration
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A patient whose condition requires the administration of a medication through the
subcutaneous route.
Red Flags: May not be effective in poorly perfused tissue.
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient.
3. Ensure patient is not allergic to the medication.
4. Ensure five patient rights of drug administration
are met.
5. Using a 22-gauge or smaller needle, draw
medication into syringe (Figure SBS 53-1). May
give maximum of 1 mL of fluid.
SBS 53-1
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Medication Administration and IV
203
6. Expel air from syringe.
7. Locate administration site (upper arm, abdomen,
or thigh).
8. Cleanse site with alcohol prep.
9. Pinch skin to lift it slightly (Figure SBS 53-2).
SBS 53-4
14. Withdraw needle, and dispose of needle and
syringe in appropriate sharps container.
SBS 53-2
10. Insert needle at a 45-degree angle.
11. Smoothly advance needle into subcutaneous
tissue (Figure SBS 53-3).
15. Place gauze over injection site, and apply direct
pressure.
16. Thoroughly document medication
administration.
17. Monitor administration site for redness and
swelling.
18. Monitor the patient for desired and adverse
effects.
Critical Criteria:
•
•
•
•
•
•
•
•
SBS 53-3
12. Attempt to aspirate for blood with syringe
(should be difficult). If blood returns, withdraw
and try a different site.
13. Inject the medication (Figure SBS 53-4).
Use standard precautions.
Check for patient allergies.
Check expiration date of medication.
Ensure that five rights of medication
administration have been met.
Insert needle at 45-degree angle.
Immediately dispose of sharps in appropriate
container.
Aspirate for blood prior to medication
administration.
Monitor for desired and adverse effects.
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Step-by-Step
Rectal Drug Administration
Conditions: The candidate should perform this skill on a simulated pediatric patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions.
Indications: A pediatric patient whose condition requires the administration of a medication via the rectal
route.
Red Flags: Feeding tube or syringe must be inserted deep enough into rectal space in order to deliver
medication. Forceful insertion can perforate the bowel wall. Remove needle prior to insertion of syringe into rectum.
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient or
parents.
3. Ensure patient is not allergic to the medication.
8. Lubricate administration device or suppository
and finger with water-soluble jelly only.
9. Gently insert into anus (Figure SBS 58-2). If
using a suppository, insert with gloved finger.
4. Ensure that five patient rights of drug
administration are met.
5. Draw up medication using aseptic technique
(Figure SBS 58-1).
SBS 58-2
10. Advance past both sphincter muscles.
11. Slowly deliver medication.
12. Remove syringe and hold buttocks together
(Figure SBS 58-3).
SBS 58-1
6. Remove and dispose of needle in appropriate
sharps container.
7. Choose administration option:
a. Attach an extension: large-bore IV catheter
without needle or cut 3.0 ET tube.
b. Use a tuberculin (TB) syringe without needle.
c. Insert a suppository with gloved finger.
204
SBS 58-3
13. Dispose of syringe in appropriate container.
14. Thoroughly document medication administration.
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15. Monitor patient for desired and adverse effects
(Figure SBS 58-4).
Medication Administration and IV
205
Critical Criteria:
• Use standard precautions.
• Check for patient allergies and medication
reactions.
• Ensure that five rights of medication
administration have been met.
• Lubricate administration device or suppository
and finger before administration.
• Pinch buttocks closed after administration.
• Immediately dispose of sharps in appropriate
container.
• Monitor patient for desired and adverse effects.
SBS 58-4
Connections
ᔢ Chapter 15, Pharmacology, in the textbook contains additional information on medication
indications, contraindications, precautions, and
special considerations. See Box 15-6 in the textbook for a description of the patient “rights”
that are identified in the DOT curricula.
ᔢ Chapter 10, Therapeutic Communications and
History Taking, in the textbook describes techniques that can be helpful in obtaining information from patients.
ᔢ Chapter 9, Safety and Scene Size-Up, in the
textbook includes additional information on
BSI precautions.
ᔢ Chapter 17, Documentation and Communication,
in the textbook details information on performing a radio consultation and what elements of
medication administration documentation are
important to capture on the patient care report.
ᔢ Link to the companion DVD for a chapter-based
quiz, audio glossary, animations, games and
exercises, and, when appropriate, skill sheets
and skill Step-by-Steps.
Street Secrets
ᔢ Shortcuts Drug dosage calculations can be a
nightmare for many paramedics. The need to perform them in any situation—let alone a situation
in which one is caring for a critical patient who
has a very low blood pressure—can send the most
confident paramedic into a meltdown. The following simple formulas are shortcuts that will give
you a close estimate of the number of drops per
minute that you need to administer to a patient
receiving a dopamine infusion. These shortcuts
are based on the use of a 60-gtt/mL IV administration set. This method should not be used in a testing environment because it is not 100% accurate.
Shortcut 1 is for use with a dopamine IV bag that
has a concentration of 1,600 mcg/mL and is used
to obtain a 5-mcg/min dose.
(Weight in kg 10) (2) 1 drip rate in gtt/min
for patient receiving 5-mcg/min dose.
Example: The patient weighs 80 kg.
80 10 8
8 2 16
16 1 15 gtt/min
Shortcut 2 is for use with a dopamine IV bag that
has a concentration of 800 mcg/mL and is used to
obtain a 5-mcg/min dose.
(Weight in kg 5) (2) 2 drip rate in gtt/min for
patient receiving 5-mcg/min dose.
Example: The patient weighs 60 kg.
60 5 12
12 2 24
24 2 22 gtt/min
Note: The paramedic should always ensure the
patency of the IV by aspirating prior to injecting
any medication. This is crucial because drugs
injected into the tissues instead of the bloodstream could have a detrimental effect on the
patient.
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d. Another possibility for the administration of some
medications is the intranasal route, but the absorption rate is not as rapid, and there is no possibility
for addressing fluid deficits or hypoglycemia.
The Drug Box
There are no specific drugs related to this chapter content.
Answers
Are You Ready?
1. The patient is critically ill. The infant is seizing and blue
(cyanotic). This alone is evidence of a life-threatening
emergency.
2. Airway, airway, airway! Followed by breathing and circulation.
3. Any four of the following: fever, hypoglycemia, head
injury, ingestion (poisoning), hypoxia, arrhythmia,
epilepsy, hypovolemia, and electrolyte imbalance.
4. You should perform a blood sugar test. If the patient is
hypoglycemic and you stop the seizure with an anticonvulsant, you may not remember to check the patient’s
blood sugar, and a blood sugar level low enough to cause
seizures can cause significant damage if left untreated.
5. Administration of medications needs to be in compliance with local EMS policies and protocols, but for the
sake of this exercise general guidelines are as follows:
a. The first choice would be IV administration of medications because of the relative ease of establishing
an IV, the relatively minimal invasiveness of the
procedure, and the rapid onset of action of medications administered intravenously. You also have a
route to administer IV fluids in the setting of hypovolemia.
b. The second choice would be based on the type of
medication being administered. If you are delivering
an anticonvulsant such as a benzodiazepine, the rectal
route should be considered next. This route does not
allow for correction of hypovolemia or hypoglycemia.
c. If the patient is hypoglycemic and/or hypovolemic,
another more invasive, yet very effective, means of
delivering medications to a critical patient is via the
intraosseous route (Figure 16-2).
Active Learning
1. a. 2.2 lb; b. 1,000 g; c. 1,000 mg; d. 1,000 mcg; e. 1,000
mL; f. 1 mL; g. 5 mL; h. 15 mL; i. 30 mL; j. 65 mg;
k. 1/10 or 0.1 L; l. 1/100 or 0.01 m; m. 1/1,000 or 0.001 g;
n. 1/1,000,000 or 0.000001 g
5.
a. In order for you to administer 0.1 mg/kg of adenosine to this 33-lb (15 kg) patient, you will need to
administer 0.5 mL.
b. In order to administer 1.5 mg/kg of lidocaine to this
132-lb cardiac arrest patient, you will need to
deliver 4.5 mL.
c. To administer a 0.02-mg/kg dose of atropine to this
22-lb (10 kg) child, you must administer 2 mL of
atropine.
d. In order to deliver 1,120 mL/hour, you will need to
deliver 187 gtt/min.
e. The 500-mL bag of normal saline dripping at a
rate of 120 gtt/min through a 10-gtt/mL administration set will be completed in 41.66 or about
42 minutes.
f. In order to administer 300 mL of fluid over 45 minutes via a 10-gtt/min administration set, you will
need to set your drip rate at 67 gtt/min.
g. Drops per minute = 16.8 gtt/min. Run the infusion
at 17 drops per minute to infuse 3 mcg/kg/min of
dopamine to your patient.
h. For your 165-lb patient to receive 15 mcg/kg/min
of dobutamine from an IV bag that contains 250 mg
of dobutamine in 500 mL of normal saline, using a
60-gtt/min administration set, the patient needs to
get a 135-gtt/min infusion.
i. In order for your 88-lb patient to receive 20 mcg/
kg/min of dopamine (200 mg/250 mL D5W) via a
micro-drip administration set, you will need to
administer 60 gtt/min.
j. In order to deliver 2 mg/min, you will need to set
the IV drip rate of the 60-gtt/mL administration set
at 30 gtt/min.
You Are There: Reality-Based Cases
Case 1
1. The patient is sick: he has chest pain and shortness of
breath, and he is hypertensive, tachycardic, and tachypneic. He has an oxygen saturation of 92% on room air,
and he speaks in five- to six-word sentences. He has JVD,
pedal edema, supraclavicular retractions, and crackles
in the bilateral bases of his lung fields.
FIGURE 16-2 The intraosseous route is an effective alternative
to the intravenous route of medication and fluid administration.
2. The first priority in this patient, or any patient for that
matter, is airway, breathing, and circulation.
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Chapter 16
3. Perform complete primary and secondary examinations
including vital signs, ECG, and pulse oximetry; take a
medical history, including medications and allergies to
medications.
4.
• Does the patient have any allergies to medications?
• Will the patient’s current hemodynamic status allow
for the administration of the chosen medication?
• Will the administration of the chosen medication
negatively impact the patient’s medical condition(s)?
(For example, if the patient has a history of ulcers,
will the administration of aspirin have a negative
impact on the patient?)
• Will the administration of the chosen medication
interact negatively with any of the medications that
the patient takes on a regular basis?
5. Prior to administering any medication, a paramedic
should be aware of its indications, contraindications, precautions, side effects, interactions, and therapeutic effects.
The paramedic should also be familiar with the appropriate route of administration for that particular medication,
as well as the appropriate rate of administration.
6.
•
•
•
•
•
The
The
The
The
The
right
right
right
right
right
patient
medication
dosage
route
time
7. Immediately dispose of sharps in an approved container.
Never re-cap sharps!
8. There could be several reasons why a paramedic may
administer some medications and not others. It is likely
that the nitroglycerin and aspirin were administered
according to standing orders. (Standing orders are preestablished medication orders that paramedics may
administer based on specific parameters. A complete
assessment, history, and physical examination must be
performed prior to medication administration by standing orders.) For some medications and procedures, a
paramedic must consult with a physician prior to
administering the medications or performing the procedures.
9. Determine whether the patient has been compliant with
his or her prescribed medications. (Is there any chance
the patient is taking either too much or too little of the
prescribed medication? An overdose or an underdose of
medication can have a dramatic impact on the patient’s
condition.)
Test Yourself
1. d
The unopened pill bottles in the patient’s kitchen are a
good indication that he has not been taking his prescribed medication. Medications such as antipsychotics
(which help control delusions) must be taken continually to maintain their effectiveness.
Medication Administration and IV
207
2. A contraindication is a reason that a medication should
not be considered. Common contraindications include
sensitivity, pregnancy, and certain diseases.
3. b
Prior to administering any medication you should collect enough information through history taking and from
the physical examination to ensure a correct diagnosis
is made so the proper therapy is selected. Postadministration follow-up procedures include reassessing and
monitoring the patient for effects.
4. c
When looking for medications in a patient’s home you
should be alert for prescription medication, OTC medications, herbal preparations, drug paraphernalia, and
any signs of medication abuse or misuse.
5. True
Check all expiration dates on a regular basis. To make
it easier to check for expiration, mark the box clearly
with the expiration date or circle the date on the container.
6. a
The fallen needle must be replaced with a new, sterile
needle. Before performing an administration, it is a good
idea to collect extra supplies in case something becomes
contaminated or is not appropriate for use.
7. d
Used needles and syringes should be disposed of in an
appropriate biohazard receptacle. These storage devices
may be red or yellow and often carry warning labels.
8. Narcotic
9. Answers may include: ensure that all necessary medications have not expired. Confirm that all medications
have been stored and handled in accordance with their
manufacturers’ recommendations. Make sure the appropriate supplies are available to prepare and administer
every medication in the formulary (an adequate number
and selection of syringes, needles, IV solutions, IV
administration sets, etc.).
Every agency will have its own guidelines regarding
the management of medications. Some services require
a thorough count and expiration date check with the
change of every shift, while other services may require
weekly, monthly, or random spot checks. Make sure
you are informed of, and abide by, your agency’s
guidelines.
10. False
Attempting to use a needle in a needle-less system will
contaminate or damage it.
11. d
Given the location of your partner’s rash, and knowing
that her symptoms cleared when she was away from
her job and then returned, you should suspect an
allergic reaction to her latex gloves. Between 5% and
17% of all health-care workers are estimated to be
allergic to latex.
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Foundations of Communication, Assessment, and Critical Care
12. a
When familiarizing yourself with your service’s formulary, you should read the accompanying literature from
the medication package box (called the package insert)
to determine if there are any special storage or handling
requirements.
13. Extreme heat from steam under pressure (autoclaving),
dry heat, and ethylene oxide gas.
Sterilization kills all biotic material, including bacterial
spores. Human tissue and some equipment cannot be
sterilized.
14. To confirm that the correct medication has been selected
for administration, you can first repeat the drug name
and dosage when received during consultation; then
carefully read the medication name before taking it out
of the box; and finally ask another member of the patient
care team to verify the name on the medication container.
This three-step approach is a good, systematic way to
make sure you are administering the correct medication.
Although it may not always be practical to follow all
three steps in the field, you should always check to confirm that the right medication has been selected for
administration.
15. b
Minimize the possibility of an accidental needle stick
by performing all injections or IVs while the ambulance
is stationary. If patient transport has begun, gather and
prepare the equipment while the ambulance is moving.
When ready, ask the driver to pull over and stop for a
minute while you perform the venipuncture. Once the
flash of blood is seen in the needle chamber, if the road
surface is relatively smooth, the driver can go while you
finish securing the line.
16. c
For expiration dates that only list the month and year,
the last day of the month is considered the expiration
date.
17. d
A 1998 survey of 3,162 emergency medicine residents
found that over 50% reported having at least one occupational exposure to blood during their training, and
over 70% of the exposures were from a needle stick or
sharp object.
18. False
A study observed that over three-fourths of all people
taking a prescription medication were not taking it
according to the directions.
19. c
Administration of medication requires authorization
from medical direction. This permission may take the
form of off-line written protocol and standing orders, or
it may require real-time, online physician direction via
telephone, radio, or satellite consultation.
20. a
Although it is important to know whether a patient is taking medication or has any known allergies, this information should not delay treatment during life-threatening
events.