Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
hsi02657_ch16_182-208.indd Page 182 5/1/07 7:37:52 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 16 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). hsi02657_ch16_182-208.indd Page 183 5/1/07 7:37:56 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 184 5/17/07 2:42:09 PM epg 184 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 185 5/1/07 7:37:57 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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 Medication Administration and IV 185 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 hsi02657_ch16_182-208.indd Page 186 5/1/07 7:37:58 PM epg 186 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 187 5/1/07 7:37:59 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 188 5/1/07 10:26:48 PM epg 188 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 189 5/1/07 7:38:04 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 190 5/1/07 7:38:04 PM epg 190 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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 hsi02657_ch16_182-208.indd Page 191 5/1/07 7:38:05 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 192 5/1/07 7:38:06 PM epg 192 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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 hsi02657_ch16_182-208.indd Page 193 5/1/07 7:38:06 PM epg Step-by-Step /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 42 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 hsi02657_ch16_182-208.indd Page 194 5/1/07 7:38:11 PM epg 194 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 195 5/1/07 7:38:16 PM epg Step-by-Step /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 45 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 hsi02657_ch16_182-208.indd Page 196 5/1/07 7:38:24 PM epg 196 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 197 5/1/07 7:38:27 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 198 5/1/07 7:38:31 PM epg Step-by-Step /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 49 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 hsi02657_ch16_182-208.indd Page 199 5/1/07 7:38:37 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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 hsi02657_ch16_182-208.indd Page 200 5/1/07 7:38:41 PM epg 200 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 201 5/1/07 7:38:44 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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 hsi02657_ch16_182-208.indd Page 202 5/1/07 7:38:49 PM epg 202 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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 hsi02657_ch16_182-208.indd Page 203 5/1/07 7:38:52 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 204 5/1/07 7:38:56 PM epg 204 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 58 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 205 5/1/07 10:26:49 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Chapter 16 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. hsi02657_ch16_182-208.indd Page 206 5/1/07 7:39:02 PM epg 206 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 Foundations of Communication, Assessment, and Critical Care 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. hsi02657_ch16_182-208.indd Page 207 5/17/07 2:42:26 PM epg /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 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. hsi02657_ch16_182-208.indd Page 208 5/1/07 7:39:04 PM epg 208 Part 2 /Volumes/108/MHIY023/mhhsi_1848T%0/hsi1ch16 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.