Operational Medicine 2001
Field Medical Service School
Student Handbook

INTRAVENOUS THERAPY

FMST 0412

17 Dec 99

TERMINAL LEARNING OBJECTIVES:

1.      Given a casualty in a combat environment (day and night), and the standard Field Medical Service technician supplies and equipment, perform the procedures for Intravenous therapy, per the references. (FMST.04.13)

ENABLING LEARNING OBJECTIVES:

1.      Without the aid of reference materials and from a list provided, select the proper definition of homeostasis, per student handbook.  (FMST. 04.13a)

2.      Without the aid of reference materials, identify the indications for initiating IV therapy, per student handbook.  (FMST.04.13b)

3.      Without the aid of reference materials and from a list provided, select the type of  IV fluid which matches the indications for its use, per student handbook.  (FMST. 04.13c)

4.      Without the aid of reference materials, identify the equipment required for initiating IV therapy, per student handbook (FMST. 04.13d)

5.      Without the aid of reference materials, identify the factors which influence selection of the most suitable vein and appropriate size needle/catheter to be used for venipuncture, per student handbook.  (FMST. 04.13e)

6.      Without the aid of reference materials, sequence the steps in IV fluid administration, per student handbook.  (FMST. 04.13f)

7.      Without the aid of reference materials, identify potential sources of local/systemic complications and methods of preventing complications of IV therapy, per student handbook (FMST. 04.13g)

8.      Without the aid of references, and given FMST Mike bag and a patient, start and manage an IV through live stick, per the student handbook.  (FMST. 04.13h)

OUTLINE:

A.  FLUID AND ELECTROLYTE BALANCES

1.      DEFINITIONS-The following terms and their definitions are essential to understand intravenous fluids and the basics of electrolyte inbalances.

a.       Homeostasis:  A state of physiological equilibrium produced by a balance of functions and chemical composition within the body.

b.  Electrolyte:  An element or compound that, when melted or dissolved in water or another solvent, dissociates into ions and is able to carry an electric current.

c.  Total body water (TBW):   Is the percentage of a person’s weight that consist of water.  The amount of body water varies with age, weight, sex and lean body mass.

1)  Water is essential for:

a)      Temperature regulation.

b)      Circulation.

c)      Digestion.

d)      Chemical reactions.

e)      Water Balance (when the amount of water taken into the body is equal to the quantities lost)

2.     BODY WATER:

a.       Water Intake.  Although the volume of water taken in each day varies, an average adult living in a moderate environment may take in 2500 ml; 60% (1500 ml) may be in the form of beverages.  Thirty percent (750 ml) may be from moist food; the remaining 10 percent (250 ml) will be obtained from metabolism of nutrients such as carbohydrates and fats.

b.      Regulation of Water Intake.  The primary regulator is thirst.  The feeling of thirst is usually accompanied by dryness of the mouth, due to the loss of extracellular water and decreased flow of saliva.  The thirst mechanism is usually triggered when the Total Body Water (TBW) supply decreases by 1-2 percent.  As the person drinks in response to feeling thirsty, the act of drinking and the resulting stomach distention seems to inhibit the mechanism.  Thus, the person stops drinking long before the water swallowed has been absorbed.  This prevents the person from drinking too much water; or drinking more water than what is required to replace the quantity lost.

c.       Water Output. Water can be lost by various routes.  The most common routes are urine, feces, sweat, and evaporation during respiration.  The average adult takes in 2500 ml of water every day; thus 2500 ml must be eliminated if water balance is to be maintained.  These percentages will vary according to environmental factors including temperature and humidity and with physical exercise.  In hot environments, a person can lose as much as 100 ml per hour during strenuous activities.  Another factor that will increase Total Body Water Loss is fever.

3.      DISTRIBUTION OF BODY FLUIDS: 

a.  Water and electrolytes of the body are not evenly distributed throughout the tissues.  Instead they are in compartments, which are filled with varying compositions.  Movement of water and electrolytes between these compartments is regulated, so that distribution of substances within the body remains stable.  (NOTE:  Consider this when determining area of injury.)

4.      REGULATION OF WATER INTAKE: 

a.  Health is usually maintained as long as the fluid volume and chemical composition of the fluid compartments stay within narrow safe limits.  Normally, a person’s fluid intake is counterbalanced by fluid loss.  Illness can upset this balance so that the body has too little or too much fluid.  The Field Medical Technician’s goal is to maintain Homeostasis. 

5.      INDICATIONS FOR IV THERAPY:

a.  Hypovolemia

1)  Hemorrhage or trauma.

2)  Diarrhea or Vomiting.

3)  Burns.

4)  Unable to tolerate fluids by mouth (maintain hydration when the patient is NPO).

b.  Pass medications. (Gets the medication into the blood faster than any other route of

     administration).

b.      Maintain adequate water intake.

c.       Illness or Injury:

e.   To maintain nutrition (when the patient is NPO.)

B.     INJURIES AND TREATMENT PROTOCOL

1.      Hypovolemia:  Sodium and water are lost in equal amounts from body.  Normal avenues of fluid and sodium loss are the skin, gastrointestinal system, and the urinary system.

a. Treatment:  Replace electrolytes and fluid loss.

2.   Dehydration:  Excessive loss of water, This condition occurs when water output exceeds water intake.

a.    Treatment:  Replace electrolytes and fluid loss.  1^st Choice - Ringers Lactate.  2^nd Choice:  Normal Saline.  Infuse 1-2 litters until tilt negative or normal urine output occurs.

3.   Heat Stroke:  Condition characterized by core body temperature of 47 C (103 F)

a.  Treatment:  In addition to primary treatment protocol, infuse Ringers Lactate

4.   Abnormal losses can occur through, burns, wound exudate, hemorrhage, vomiting, and diarrhea.

a. Treatment: Replace electrolytes and fluid loss.

5.   Multiple Major Trauma:  Involving the extremities, abdomen, or both.  Require at least one, preferably two, intravenous infusions.  Major trauma requires 2 large bore IV’s , normally a 16 ga catheter or larger.

a.  Treatment:

1) Utilize a large bore catheter (14-16 gauge).

2) Infuse Ringers Lactate  solution (Normal Saline as a second choice) and run wide open or KVO as indicated.

3) Try to use uninjured extremities.

4) Anticipate shock.

NOTE:  In expected uncontrolled internal hemorrage IV should be titrated to radial

pulse. 

6.   Hemorrhage:  Bleeding, the escape of blood from the blood vessels.

a.   Treatment:

1.   Preferred intravenous (resuscitation) fluid are provided with the following recommendations.

a)      1^st Choice - Blood products.

b) 2^nd Choice - Ringers Lactate

NOTE:  Blood products are not available until third echelon care or higher.

7.  Burns:

a.                    Treatment:

1) 1^st Choice - Plasma.

2) 2^nd Choice - Ringers Lactate

C.     ASSESSMENT OF FLUID AND ELECTROLYTE DISTURBANCES

1.      Tilt test: if systolic decreases and diastolic increases by 10-20mm Hg, and heart rate         increases 10-20 beats/minute the patient has positive tilt test indicative of dehydration.

2.      Assess peripheral pulse for quality, volume, and ease of obliteration.

3.  Assess respiratory status-rate, depth, and rhythm.  Changes in respiration which are not      accounted for by other conditions generally point to change in electrolyte balance.

D.  INTRAVENOUS SOLUTIONS

1.  Categories (two)

a.       Crystalloids:  Electrolyte solutions that diffuse into interstitial spaces.  A part of crystalloids are lost to extravascular space for every part that remains in the muscular system.

1)  Types of crystalloids:

a)      Normal Saline: Each liter contains 9.0 grams of sodium chloride (0.9% solution).

b) Ringers Lactate:

1) Most physiologically adaptable solution available to corpsman.

2) Ringers Lactate should be considered the fluid of choice for fluid resuscitation initiated by the Field Medical Technician.

3) Best initial IV therapy in all trauma and dehydration casualties in a field environment.

b.  Colloids:  Blood plasma serum albumin, and plasma substitutes (Dextran).

1) Types of Colloids:

a)      Blood plasma serum albumin, and plasma substitutes.

E.  WHOLE BLOOD

1.  Available in combat only in rear areas (echelon 3 is the first place blood is available):  i.e. Medical battalion; best solution and agent of choice for shock due to whole blood loss.  Replaces simultaneous loss of RBC’s and plasma; ordered only by a Medical Officer.  Blood must be typed and cross-matched prior to infusion.  In combat, type O-Negative (universal donor) is supplied and can be given without prior cross-matching.

a.  Whole blood is not suited for the following:

1) Shock without hemorrhage; plasma is better.

2) Shock accompanying burns.

2. Hazards of Whole Blood:

a.  Hemolysis (incompatibility reaction which causes destruction of RBCs).

b.      Bacterial contamination.

c.       Viral contamination (Human Immunodeficiency Virus and Hepatitis - Type B).

d.      Circulatory overload (known as speed shock).

f.  Pyrogenic or allergic reactions.

F.  HUMAN SERUM ALBUMIN (SEMI-SYNTHETIC HUMAN PLASMA)

1.      VERY hypertonic (a biological term denoting asolution which when bathing body cells causes a net flow of water across the semipermeable cell membrane out of the cell).  Normal body fluid but less water.

2.      Must be accompanied by (4) times its volume of 0.9% Saline solution of Ringer’s Lactate.

3.      One of the best and most physiologically compatible agents for the maintenance of blood           volume during shock.

4.      Not suited for burn victims.

5.      Metabolizes rapidly, causing Kidneys to excrete excessive fluids.

6.      Will rapidly restore blood volume.

7.  Dosage is 50-250 mg/kg of 25% Albumin.

G.  EQUIPMENT NEEDED FOR IV THERAPY

1.  Needle / Catheter

a.  Needle over catheter (introducer).

b.  Butterfly.

c.  Catheter over needle (standard IV).

2.  IV Solutions

a.  Inspect for:

1.  Expiration date.

2.  Physical damage to the container.

3.  Foreign bodies / particles in the solution.

4.  Evidence of contamination.

5.  Discoloration.

6.  NOTE:  Potassium and select other medications may turn the IV fluid bright yellow.

3.  Administration Set

a.       Check the length of tubing and make note of the drip factor rate for that set.  Micro drip used for medicine administration or when need to accurately monitor flow rate.  Deliver 60 gtt/cc, for bolus 10gtt/cc.

4.  Other Items

a.  Tape-You need both 1” and ½”.

b.  Tourniquet-A variety of things can be used to restrict venous blood flow, including:

1.  Penrose drains, rubber tubing a BP cuff and other items.

2.  Alcohol or Betadine prep pads.

3.  2x2’s and a bandage.

4.  An IV pole or something else to hold the IV bag 18 to 36 inches above the infusion site; and  an armboard if possible.

H.    VEIN SELECTION GUIDELINES

1.  WORK FROM DISTAL TO PROXIMAL IN LOOKING FOR A SUITABLE VEIN.

2.      USE THE UNINJURED SIDE.

3.      USE PATIENT’S non-dominant side if possible.

4.      Avoid using the feet if possible, the vessels there are usually more tortuous than in the arms, and are easier to thrombose.

5.      Avoid joints.

I.       WAYS TO ENCOURAGE VENOUS CONGESTION

1.  Tourniquet.

2.  B/P Cuff.

3.  Place limb lower than heart.

4.  Apply heat (with caution).

Note: Do not slap veins.

J.      INSERTION TECHNIQUE

1.  Direct - Into the vein.

2.  Indirect - Through skin first, then into the vein.

K.    DETERMINATION OF NEEDLE SIZE

1.  Purpose of instituting IV therapy.

2.  14 OR 16g for trauma patient or heat casualties.

3.  14-16g for patients undergoing surgery or receiving blood transfusion.  DO NOT use anything smaller than 16g for blood transfusions.

L.     PROCEDURE FOR INSERTION (Note: If in a combat situation steps 1-5 may be skipped due to time constraints)

1.  Introduce yourself.

2.  Inform the patient of the doctor’s order for IV therapy.

3.      Explain the procedure if necessary.

4.      Check for allergies:  i.e. betadine, alcohol, tape etc.

5.      Don non-sterile gloves (if possible, wash your hands).

6.      Prepare IV solution and administration set.

7.      Aseptically insert the tubing into the IV bag port and flush all air.

8.      Connect to extension set tubing if you’re using an extension set.

9.      Prepare the catheter for insertion.

10.  Aseptically loosen all joints/connections.

11.  Either return to the sterile interior of its packaging or place on a sterile field.

12.  Apply tourniquet 4-5 inches above the selected site.

13.  Stop venous flow only, not arterial flow.  Be sure to check for radial pulse to insure you  have an arterial flow.

14.  Prepare the insertion site.

15.  Use betadine prep pad if possible.  Alcohol pad may be used if betadine is unavailable.  (check allergies to iodine).

16.  Start at center of the chosen site and work outward in a spiral, to a diameter of approximately  2-3 inches.

17.  Once you have swabbed and area, do not go back over it.  The center of the area should be the most sterile part of the area swabbed.

18.  Prepare your tape - several pieces of 1” tape 4-6’ long and 1 piece of ½ tape 4-6” long.

19. Insert the needle, bevel up, in line with vein.

 M.  DIRECT TECHNIQUE/INDIRECT TECHNIQUE

1.  Direct technique:  Use a 30 degree angle to puncture the skin in one swift motion, lower the needle to parallel the vein, advance the needle and catheter.

2.  Indirect technique:

a.  Hold the intracath with needle along the side of the vein in the direction of the injection site.  Pierce the skin and insert the needle into subcutaneous tissue.  Decrease the angle of the intracatheter until it is parallel to the skin and slightly to one side of the vein wall.

b. Apply pressure with the needle in the direction of the vein and into it.  As soon as a “pop” is felt, check for flashback (blood return) or aspirate for blood return, if present proceed to next step.  If no blood, gently advance or withdraw the needle slightly, as required to get blood return.  If a hematoma develops or 3-4 minutes elapse without success, remove needle and apply direct pressure to the site with a 2x2 after removing the tourniquet (apply pressure 2-3 minutes).  Choose a new site and start over.

c.  Advance catheter slowly while withdrawing needle.  Insert the hub of the catheter, be careful not to touch the catheter itself, only the hub.

d.  Connect tubing to the hub of the catheter, using aseptic technique; open the line.

e.       Remove the tourniquet; the IV should flow freely.

f.        If flow slows or stops, try to reposition the catheter.  Also, check the factors affecting IV flow rate.

g.       If this doesn’t work, repeat procedure with new supplies or seek assistance.

h.       Secure catheter with tape and apply proper dressing.

i.  Set flow rate per indicated orders.  Application of a well padded armboard is strongly advised, especially for unconscious or restless patients.  Use of an armboard is required if you have chosen a site which is near a joint.

N.    LABEL DRESSING AND BOTTLE/BAG

1.  Label IV dressing with date, time, size of device used, and initials.

2.  Place a time tape and label on bag according to local instructions.

O.    FACTORS AFFECTING FLOW RATE

1.  Size of vein.

2.  Size of catheter or tubing.

3.  Height of IV solution above patient should be:

a.    18-36 inches above infusion site.

4.  Position of arm.

5.  IV tubing twisted or kinked, or patient lying on tubing.

P.      FLOW RATE CALCULATIONS

1.  Formula:

a.  Drops/min= number of ml to be infused each hour multiplied by the drop factor divided by 60 (number of minutes in an hour).

b.  The drop factor will be found on the administration set.

c.  Calculate flow rate.

d.  Calculate the number of ml to be given each hour.

d.      Divide 1000 by the number of hours the bottle is to run.

f.  Example:

1.  1000 divided by 8 hr + 125 ml/hr.

2.  Calculate the number of ml to be given each hour.

3.  Divide 125 by 60 minutes.

g.       Example:

1.  125ml/hr divided by 60 = 2.08 ml/min.

2.  Calculate number of drops/minute.

3.  Multiply ml/min by the drop factor.

h.  Example:

1.  2.08 x 20 =41.60 gtts/min.  Since you can not come this close, you can set the flow rate to 41 gtts/min.  The easiest way to do this is to set to 10gtts per 15 seconds.

2.  Now you have the data needed to set the flow rate and to make the time tape.  Once the flow rate has been set, place a piece of tape on the bag beside the ml used scale.  By using the number of ml per hour you can calculate how many ml should have been infused each hour.  The hour written at the bottom should be the time the IV should be completed.

Q.    DOCUMENTATION

1.  You have already labeled the site and the bag.  Now you need to document the procedure       wherever you’re recording this patient’s care.

2.  DD 1380- check the appropriate box, enter the type of IV , the date and time started.

3.  SF600- date and time, type of solution and amount, where the infusion site is, and the size of the needle/catheter, the rate of flow, and the name of the person who performed  the procedure. 

4.  Intake and Output (DD 792) if you are in a situation where it may be used.

R.  COMPLICATIONS OF IV THERAPY

1. Infiltration (local):  This is the escape of fluid from the vein into the  tissue when the           needle/catheter dislodges from the vein.

a.  SYMPTOMS:

1.  Edema.

2.  Localized pain.

3.  Coolness of the site.

4.  Flow stops or slows.

b.  Prevention:

1.  Secure needle/catheter properly.

2.  Limit movement of limb.

c.  Treatment:

1.  Discontinue IV.

2.  Select ALTERNATE SITE FOR INFUSION.

3.  Apply heat to the affected area.

4.  Elevate the limb.

2.      Phlebitis (local):  This is an inflammation of a vein due to bacterial, chemical or mechanical irritation.

a.    Symptoms:

1.  Pain.

2.  Redness.

3.  Warmth along the area.

4.  Vein feels hard or cordlike.

b.  Prevention:

1.  Rotate infusion sites according to local policy.

2.      Meticulous asepsis

c.  Treatment:

1.  Discontinue IV.

2.  Warm pack to the area.

3.  Antibiotics

3.   Nerve Damage (local):  Usually results when the arm is secured to tightly to the armboard, compressing nerves.

a.  Symptoms:

1.  Numbness of fingers and hand.

a.       Prevention:

1.  Ensure tape is not applied to tightly.

b.  Treatment:

1.  Reposition and loosen armboard.

            4.  Circulatory Overload (systemic):  Results from infusing IV fluid too rapidly.

      a.  Symptoms:

                       1.  Headache.

2.      Venous distention.

3.      Dyspnea.

4.      Increased blood pressure.

5.      Cyanosis.

b.      Prevention:

1.  Monitor and control flow rate.

c.   Treatment:

1.  Slow down the flow rate.

2.  Place patient in high Fowlers position.

5.   Air Embolism (systemic):  Air circulating in the blood when it gets introduced through the IV tubing.

a.   Symptoms:

1.  Cyanosis.

2.  Hypotension.

3.  Weak and rapid pulse.

4.  Shortness of breath.

b.   Prevention:

1.  Flush line thoroughly to remove air (prior to insertion).

2.  Monitor tubing during therapy.

3.  Ensure bag is replaced before it completely runs dry.

c.   Treatment:

1.  Position patient on left side in reverse trendelenburg, so that the air in the right  ventricles floats away from the pulmonary air flow tract.

2.  Administer oxygen.

3.  Notify M.O.

4.  Monitor vital signs.

6.   Pyogenic Contamination (systemic):  Bacterial contamination of IV tubing and/or fluid which causes infection.

a.   Potential Sources of Infection:

1.  IV solution.

2.  Administration set.

3.  Poor or dirty insertion technique.

b.   Symptoms:

1.  Fever/Chills.

2.  Headache.

3.  Urticaria.

4.  Shortness of breath.

c.   Prevention:

1.  Use aseptic technique.

2.  Replace tubing according to policy.

3.  Start new IV.

REFERENCE (S):

1.  Emergency Care and Treatment of the Sick and Injured

2.  Emergency War Surgery, NATO Handbook

3.  Clinical Nursing Skills and Techniques

4.  Advanced Trauma Life Support

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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