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Intravenous Access
Tips and Tricks for the Tricky IV ….In the Not
So Tricky Situation
Presenters:
Dr. Adam Dukelow, Christine Hardie, Justine
Jewell
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The right stuff!
Attitude not Equipment!
Confidence:
Do not say "I'm going to
try and start your IV."
Boldly state "I am going to
start your IV."
The patient will be encouraged
by your confidence,
and you might believe
it better yourself!
.
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Goal
•
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To increase the IV cannulation success rate
within the SWORBHP region.
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Objectives
Upon completion of this webinar the
paramedic should:
Identify situations that may decrease the odds of
a successful IV
• Appreciate the various techniques offered to
increase successful IV cannulation
• Volunteer to share tips, tricks and experiences
that could assist others improve their IV success
rate
• Demonstrate increased proficiency in prehospital IV initiation
• Identify the various components of a CVAD
•
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Case Study-Actual Call
Dispatch to a residence code 4, 61 y/o Resp. Distress.
O/A/A pt lethargic not responding appropriately according
to VON at scene.
PMHx: seizure disorder, depression
Medications: Dilantin, Soflax, lansoprazole (Prevacid)
NKA
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Physical Exam
C/C: Decreased LOC (none verbalized by pt)
Pt non-verbal, not responding appropriately.
A-patent
B-spontaneous/not labored
C-CNO radial pulse
GCS: E-spontaneous M-localizes V-none
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Physical Exam Cont.
Vital signs:
HR: 140 R/F
BP: 61/45
RR: 16
BGL: 10.7
Temp: 36.5
Remarkable physical assessments reported:
• Cool extremities, CNO radial pulse
• Stroke assessment is negative
• Crackles to left side of chest, good a/e on right
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Discussion
Primary Problem?
• Altered LOC
• Hypotension
Differential diagnosis?
• AEIOU-TIPS
Suggested treatments?
ABC* management
Oxygen
Cardiac monitoring
IV access/fluid bolus
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Complicating Factors
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No visible/palpable veins
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BP reported to be “normal” for patient
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Disbelieving the automatic BP reading (pt does not have
associated signs)
•
Short transport time
•
BP not relayed to IV certified medic
•
Ruin potential IV sites for hospital staff
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Intravenous and Fluid Therapy
Medical Directive-Auxiliary
A Primary Care Paramedic may provide the treatment prescribed in this
auxiliary medical directive if certified to the PCP Autonomous IV level.
Indications
Actual or potential need for intravenous medication OR fluid therapy
Conditions
IV
Fluid Bolus
Age: ≥ 2
Age: ≥ 2
SBP: Hypotension
Contraindication
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IV
Fluid Bolus
Suspected fracture proximal
to the access site
Signs of fluid overload
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Intravenous and Fluid Therapy
Medical Directive-Auxiliary
Consider 0.9% NaCl maintenance infusion:
Infusion
AGE
≥2 years to <12
IV
AGE
≥ 12 years
IV
15 ml/hr
30-60 ml/hr
*PCP’s certified in “PCP Assist IV” are authorized to cannulate a peripheral IV
at the request and under the direct supervision of an ACP. PCP IV Assist
paramedics are not authorized to administer IV therapy.
Certified “PCP Autonomous IV” paramedics are authorized to administer IV
therapy according to the applicable medical directives.
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“The Facts”
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Patients are being under treated in the field.
•
Data from Apr-Mar 11/12
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19 767 documented attempts in SWORBHP region
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Success rate is less than 60%
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Almost 8000 unsuccessful attempts!
• Any break in the skin poses a risk for infection
• Patients are not receiving the fluid they require
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The Challenges
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• The
Patient
• The
Setting
• The
Medic
• The
Equipment
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You Wish!
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The Patient
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The sick patient
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Bariatric
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Skin
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I can’t see the vein!
Trust your fingers even more than your eyes
• A tendon may seem like the vein you were
hoping for, but palpating it through a range
of motion may prove that it is not
• If the vein is hard, or scarred, try for another
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Gravity is your friend, Poor
positioning is not
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Hang the patient's arm down as low as
possible to assist in venous filling.
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If the patient is hypovolemic or in shock, you
may need to lay the patient flat
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Finger Tourniquet or Less
•
Decrease the chance of
"blowing" the vein by
using only finger
tamponade to
tourniquet the vein
OR
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No tourniquet at all
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Plan Ahead
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Smaller is sometimes better
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Be willing to use a small cannula.
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Flow rates
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Not so common Veins
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Consider
uncommonly used
veins: Digits, medial
wrists, basilic veins
on the ulnar aspect
of the forearms
•
Be sure that your
proposed unusual
location is approved
by local policies and
is truly needed due
to circumstances
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Make the blood go where you
want it to go
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Always disinfect the insertion site in the
direction of the venous flow so as to improve
the filling of the vein by pushing the blood
past the one-way valves
•
Clean vigorously and widely in case a better
vein presents itself nearby and to have the
tape and dressing adhere tightly to clean dry
skin
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Know When To Quit
• This
does not mean don’t try!!!
• Not
being a "quitter" is admirable
when persistence is necessary to
achieve a reasonable goal.
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Know When To Quit
• If
the patient relationship is being
damaged.
• If
vascular access has quite reasonably
become a matter for the physician/RN
requiring special skills or permitted
locations.
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The Setting
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Lighting
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Positioning
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Audience
•
Distractions
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Moving With the Moving Target
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When dealing with
limb motion, or
motion from the
mobile environment,
lock the arm in
extension and block
flexion at the elbow.
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•
It may be necessary to
tuck the distal part of
the limb under your
own axilla to control
motion.
Incorrect
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Correct
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The Medic
• Distraction
• The
audience
• Feeling
• Other?
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rushed
Overcoming the Obstacles
• Focus
• Delegate
• Take
• Talk
the time to
find a site
• Confidence
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to partner
to patient
• Other?
The Equipment
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New equipment
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Lack of training
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Attitude
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Seek assistance!
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Types of IV Cathaters
•
Three types most common types within
SWORBHP region
Nexiva
• Autoguard
• Introcan
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BD Nexiva
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Video Nexiva
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BD Insyte Autoguard
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B Braun Introcan
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Central Vascular Access Devices (CVAD)
aka “Central Lines (CVC)”
What is a CVAD?
A hollow, flexible tube inserted
into a large vein of the body….
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Tip Placement
Ideal tip of a adult
CVAD is
recommended to sit
in the SVC
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PICC
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Peripheral Inserted Central Catheter
Most common
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Tunneled Catheter
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Implanted
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Non-tunneling
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Short Term Central Catheters
Flushing CVC
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Competency skill to flush
and draw blood from CVADs
Always flush lines with a
push - stop turbulent
motion…
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• Use
ONLY 10cc
syringe
• diameters = less
psi
ACP-CVAD-Medical Directive
An Advanced Care Paramedic may provide the treatment
prescribed in the auxiliary medical directive if certified and
authorized.
Indications
• Actual or potential need for intravenous medication OR
fluid therapy
AND
• IV access is unobtainable
AND
• Cardiac arrest OR near arrest state
Conditions
• Other: Patient has a pre-existing, accessible central venous
catheter in place
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QUESTIONS?
SHARE YOUR TIPS AND TRICKS!
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References:
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BARD Inc. (2005). Your Port Advantage. Retrieved from:
http://www.portadvantage.com/patient/about_implanted_ports.html
Frey, A., Hammerscmidt, M., Mulholland, J. (2000). Peripheral IV's for Beginners.
Nursing, 12, 2000.
Hadaway, L. (2006). Principles of Flushing Vascular Access Devices: Variable Syringe
Diameter Size and Resulting Pressure Chart (for BD Standard Disposable Syringes).
Produced by Becton/Dickson Co., USA. page 26.
Hadaway, L.C., Millam, D.A. (2005). On the road to success. Nursing 2005, p. 1-14.
Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Lippincott
Williams & Wilkins. Journal of Infusion Nursing.
LHSC Nursing Practice Manual (2012)- Intravascular Devices: Care Use & Maintenance
of Peripheral Intravascular Devices. Retrieved from:
http://www.lhsc.on.ca/priv/pm/PFHI8Y6eAhQAADQyQQI.htm
Registered Nurses’ Association of Ontario (2005). Nursing Best Practice Guideline:
Care and Maintenance to Reduce Vascular Access Complications. Toronto, Canada:
Registered Nurses’ Association of Ontario.
Trimble, T. (2008). "I.V. Starts: Improving Your Odds!”, retrieved from: [email protected]
Emergency Health Services Branch, Ministry of Health and Long-Term Care (2011).
ALS advanced life support patient care standards November 2011 (Version 3.0).
Toronto: Queen’s Printer for Ontario
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