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Baloney > Emergency Medicine - Injection and IV Therapies > Flashcards

Emergency Medicine - Injection and IV Therapies Flashcards

1
Q

What are peripheral injections?

A

Intradermal
Subcutaneous
Intramuscular

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2
Q

Injection procedures?

A

See Core NPLEX

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3
Q

Sites for IM injections?

A

Deltoid - adults and some kids over 2

Vastus lateralis (thigh) - preferred for kids under 2

Gluteus maximus - for larger quantities or thicker solutions

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4
Q

IM injection procedure?

A
  • Wash hands / glove up / prep skin w/ alcohol swab
  • Place injecting needle on syringe / remove cap
  • Stablize skin w/ one hand and hold syringe like dart or pencil w/ other
  • Enter skin quickly at 90 degree angle
  • Stop 1/2 to 1 cm prior to hub of needle
  • Aspirate! Inject material slowly then withdraw needle and re-cap
  • Hold cotton ball to injection site / dispose of needle in sharps / bandage pt
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5
Q

Angle for IM/SQ/ID needles?

A

IM - 90 degree (perpendicular)
SQ - 30-45 degree (oblique)
ID - 5-10 degree (flat)

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6
Q

What pH should IV solution be?

A

pH of 5 to 9 (human blood is pH 7.35 - 7.45)

  • Acidic range - ok to 5 or higher
  • Alkaline range - do not exceed 9 pH
  • Pt comfort max at 6.6 - 7.6
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7
Q

What is osmolarity of human plasma? What osmolarity for solution to be isotonic?

A

Osmolarity is the concentration of solute in a volume of solution

Human plasma osmolarity is around 300 so Isotonic solutions will be 300

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8
Q

Osmolarity range for low, moderate and certain risk of phlebitis?

A

150-450 - low risk
450-600 - moderate risk
600+ - 100% risk of some phlebitis

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9
Q

How to correct IV if phlebitis due to hyperosmolar solution?

A 
Slow the IV
Increase solution by diluting
Buffering additions (bicarbonate or HCl)
Use largest vein available
Watching catheter tip placement
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10
Q

What is isotonic, hypotonic, hypertonic?

A

Isotonic - 250-375 mOsm/L
Hypotonic - Below 250 mOsm/L
Hypertonic: Above 375 mOsm/L

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11
Q

What solutions are isotonic?

A

Isotonic at 250 - 375 mOsm/L

  • Normal saline (0.9% sodium chloride / NS)
  • 5% dextrose in water
  • Ringer’s Lactate (balanced electrolyte solution)
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12
Q

What does it mean that solutions are isotonic? Does it cause fluid shift between compartments? Is there a risk of circulatory overload?

A

Do not cause fluid shifts between compartments

  • may cause circulatory overload - overexpanded vascular compartment and dilution of cellular component of blood
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13
Q

Which solutions are hypotonic?

A

Solution below 250 mOsm/L

- 0.45% Sodium chloride (1/2 NS)

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14
Q

What is risk with Hypotonic solution? Does it cause fluid shift between compartments? What happens to serum sodium?

A

Solution below 250 mOsm/L

  • Lowers plasma osmolarity so fluid leaves blood compartment and goes to cellular compartment
  • Hydrates cells, lowers serum sodium
  • Can cause hypotension
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15
Q

Which solutions are hypertonic?

A

Solution above 375 mOsm/L

- D10 and D20 solutions

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16
Q

What is risk with hypertonic solution?

A

Solution above 375 mOsm/L

  • D10 and D20 infusions
  • Most vitamin/mineral infusions given - may be 500 to 2000+ mOsm/L
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17
Q

What is risk with Hypertonic solution? Does it cause fluid shift between compartments? Can it cause circulatory overload? What does it do to vein walls?

A

Solution above 375 mOsm/L

  • Shifts fluid into the plasma compartment - this dehyrdrates them temporarily
  • Can cause circulatory overload
  • IRRITATES VEIN WALLS - MAY BE PAINFUL
  • Give at slow rate - 1 to 5 ml? min
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18
Q

If an IV solution irritates veins, is it hypotonic, isotonic, or hypertonic?

A

Hypertonic

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19
Q

Does an isotonic solution shift fluid between compartments?

A

No

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20
Q

Does a hyptonic solution shift fluid between compartments?

A

Yes - it lowers plasma osmolarity so fluid leaves blood compartment to go to fluid compartment

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21
Q

Does a hypertonic solution shift fluid between compartments?

A

Yes - it shifts fluid to the plasma compartment - this DEHYDRATES them temporarily and may cause circulatory overload

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22
Q

What rate to give a hypertonic solution? How many ml/min?

A

Slow rate of 1 to 5 ml/min

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23
Q

What are peripheral injection complications?

A 
Abscess
Broken needle
Hematoma
Post-treatment pain
Shock / Syncope (from solution or vaso-vagal rxn)
Anapylaxis
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24
Q

Is an abscess a pre or post injection infection? What is it caused by? How to treat?

A

Post-injection infection d/t contaminated infusate or dirty stick

Case - Pt had an IM injection yesterday and now a swollen, warm nodule there

Antibiotic, heat and I&D possible

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25
Q

How to prevent complication from a broken needle?

A

Inspect before inject
Don’t flex needle during use
Don’t bury needle to hub

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26
Q

What does a post-injection hematoma indicate about veins? How to slow down? Who to have caution with?

A

Hematoma = leaky veins post-injection

Slow it down with post injection pressure

Watch anticoagulant patients

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27
Q

What are local complications of IV?

A 
Hematoma
Thrombosis
Infiltration / Extravasation
Local infection
Venous spasm
Hypersensitivity
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28
Q

Who is at risk for hematoma from IV?

A

Fragile veins

Elderly patient

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29
Q

What devices to use to prevent hematoma from IV? What education? What bandage?

A

Use small gauge device - catheter whenever possible
Educate high risk patients
Pressure bandage

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30
Q

What is a thrombosis? What population is it common in?

A

Clot due to endothelial trauma

Hospitalized patients more likely

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31
Q

Is thrombosis common in short term infusions?

A

No, it is more likely in long term infusions like hospitalized patients

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32
Q

Is technique a cause of thrombosis?

A

Yes, vein damage due to poor technique could cause thrombosis

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33
Q

Is thrombosis more likely in pH other than human pH or high osmolarity?

A

Yes, more likely w/ high osmolarity solution

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34
Q

What flow rate reading would indicate thrombosis?

A

Watch for slow / stopped flow rate

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35
Q

What to do if thrombosis?

A

Disconnect line - - apply ice / pressure

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36
Q

What are sequelae of phlebitis? What to do if phlebitis occurs?

A

Vein may stay ropy for 10 - 40 days after
Vein may sclerose

Tx: Prevention - - flush with NS - - Disconnect line - - Apply ice

37
Q

What is infiltration? What is extravasation?

A

Infiltration is the inadvertent administration of a non vesicant (non-blistering) fluid or medication into the surrounding tissues.

Extravasation is the inadvertent administration of a vesicant (blistering) fluid or solution into the surrounding tissue.

38
Q

What are signs / sx of infiltration and extravasation?

A

Fluid flows into subcutaneous tissues
Area swollen, cool, typically painful
Flow rate slows

39
Q

What would you suspect if an area with IV swells, cools, hurts and the flow rate slows?

A

Flow rate slows for thrombosis but also for infiltration and extravasation
Swelling, cooling, pain w/ slow flow rate suggests infiltration / extravasation

40
Q

Light pressure or heavy pressure to treat infiltration / extravasation?

A

Light pressure

41
Q

Besides light pressure, name a hydrotherapy and homeopathic treatment for infiltration / extravasation?

A

Ice

Apis

42
Q

What is treatment for local infection from IV?

A

Same as infiltration / extravasation

  • light pressure
  • ice
  • Apis homeopathic
43
Q

What physiological mechanism creates a venous spasm due to an IV?

A

Smooth muscle in vein wall acted upon by autonomic nervous system creates venous spasm

44
Q

What kind of a pH or temperature of solution would cause venous spasm?

A

Irritating or hyperosmotic pH = venous spasm

COLD temperature = venous spasm

45
Q

What type of pain indicates venous spasm from IV?

A

Pain at the site that TRAVELS UP THE ARM

46
Q

Should you slow the rate or speed it up to treat a venous spasm from an IV?

A

Slow the flow rate

47
Q

Should you disconnect the line or flush it with a venous spasm?

A

Flush the line

48
Q

What should you do about the pH if venous spasm occurs?

A

Check the pH and adjust solution

49
Q

Do you apply ice or heat for venous spasm?

A

Heat on arm

50
Q

Could the arm position have anything do with venous spasm?

A

Yes - you should check the arm position

51
Q

What are common Drug / Nutrient interactions for IVs?

A

Betablockers with Magnesium - Caution

CCBs wth EDTA or Magnesium (both are like CCBs functionally) - CAN LEAD TO HEART BLOCK - Caution

Rauwolfia alkaloid of Reserpine causes slower autonomic response - so if IV of Mg or Ca or EDTA makes you hypotensive, the normal autonomic response to sudden hypotension (Mg, Ca, EDTA) will be SLOW or impossible

52
Q

What do you do for emergency response to IV?

A

Assess CAB

53
Q

What is speed shock? Should you disconnect the line? What could you do instead? What antidotes would you consider for speed shock from calcium or magnesium?

A

IV push infusion too quickly and person passes out (Often Magnesium)

Do not disconnect the line

Stop the infusion

Infuse NS (0.9% normal saline)

Treat acute sx

Administer antidote if necessary - Ca antidotes Mg, Mg antidotes Ca

54
Q

Do you call EMS for complications from IV?

A

If anaphylaxis, yes

If local symptoms, not really but on NPLEX if option is given, usually call EMS

55
Q

What if someone faints or becomes syncopal? Why might they faint? Di you disconnect the line? What could you do instead? How to wake them up?

A

Fear of needles may cause syncope

Do not disconnect the line

SLOW (stop) infusion rate

If unconscious, lay them down

If conscious, lay them down, talk to them and have them move their feet

Smelling salts to wake them

56
Q

What types of infusions commonly cause Hypoglycemia?

A

Most common in high dose IV vitamin C and EDTA chelation

57
Q

What can you patients do during high dose Vitamin C and EDTA chelation IVs to prevent hypoglycemia?

A

Patients can eat

58
Q

How to reverse hypoglycemia?

A

D5W as a base solution for prevention

Slow push of D-50 (50% dextrose) 5-50 mL D50 will reverse

59
Q

In an IV if someone has edema, hypertension, pulmonary edema (SOB and crackles) do you suspect heart failure? What is it more likely to be?

A

You do not suspect heart failure w/ edema, HTN, pulmonary edema w/ crackles and rales in someone having an IV

You suspect fluid overload with an ISOTONIC solution

60
Q

How do you treat fluid overload from an IV of an isotonic solution? Do you disconnect the line? Do you slow the infusion or stop it? Do you use ice or heat? What is a really really good idea?

A

Do not disconnect the line

Slow the infusion

Use heat to dilate peripheral circulation

Administer O2 is a really really good idea

61
Q

What are 2 common result of hypertonic IV therapies?

A

Fluid overload - fluid shifts from cells to plasma

Dehydration often results from hypertonic

62
Q

What are signs and symptoms of dehydration?

A

Bounding pulse - - increased blood pressure - - headache - - dizziness

63
Q

What is suggested by post-IV hypertension?

A

Post IV hypertension is usually secondary to fluid overload

64
Q

How to prevent dehydration and post-IV hypertension?

A

Patients should come hydrated to the IV - should drink during and after IV

If hypertension occurs, may have to watch patient in office until BP stabilizes

65
Q

How to rehydrate IV-dehydrated patients? Do you want a small gauge (large) or large gauge (small) catheter?

A

To rehydrate, always take the largest catheter offered

Smaller the gauge, the bigger the catheters - so pick 20GA over 24GA

66
Q

How to rehydrate IV-dehydrated patients? Do you want a hypotonic or isotonic solution? Is sterile water okay?

A

To rehydrate, use an isotonic solution

  • 0.9% normal saline
  • Ringers Lactate
  • D5W
  • Maybe 0.45 saline “1/2 normal”

NEVER NEVER NEVER Sterile water

67
Q

Why should you never never never infuse sterile water into a patient?

A

Sterile water IV will cause hemolysis and kill the patient

68
Q

wrt Rehydration, what is the normal fluid replacement requirement for one day?

A

1500 to 2000 mL (1.5 to 2 L) per day

69
Q

How many hours to compensate for acute dehydration d/t fever, vomiting, diarrhea?

A

Acute dehydration can be compensated for in a 4 to 8 hr period

70
Q

What are common nursing orders for rehydration?

A

500 to 1000 mL saline, D5W or Ringers lactate at 125 - 250 mL/hr acutely for 1 to 2 hrs, then slow the rate to not more than 125 mL/hr

71
Q

What is a risk of rehydration? Hint: It is the same risk as for any isotonic solution

A

Fluid overload
Sx of edema, hypertension, pulmonary edema including dyspnea and crackles

Treat by slowing fluid infusion, heat to dilate peripheral circulation, O2 administration, and diuretics in severe cases

72
Q

What is D5W? Is D5W isotonic or hypertonic? Do you use more or less than 2 liters a day?

A

D5W - 5% dextrose in water is Isotonic - 1.5 to 2 liters a day is given

Good for a base to mix solutions in
Used in cancer therapies

73
Q

What are D10/D20/D50? Are they isotonic or hypertonic? What are they used for? What effect do they have on potassium?

A

D10/20/50 are hypertonic and are use for glucose support. They lower potassium

74
Q

Is 0.45 % sodium chloride saline hypotonic, isotonic or hypertonic?

A

0.45% saline is hypotonic

75
Q

Is 0.9% sodium chloride saline hypotonic, isotonic or hypertonic?

A

0.9% saline is isotonic

76
Q

Are 3% saline and 5% sodium chloride saline hypotonic, isotonic or hypertonic?

A

3% and 5% saline are hypertonic

77
Q

Is a mix of D5W and 0.9% NaCl hypotonic, isotonic or hypertonic?

A

D5 plus 0.9% Sodium Chloride is Isotonic

78
Q

Is a mix of 2.5% or 5% dextrose and 0.2% and 0.45% hypotonic, isotonic or hypertonic?

A

D2.5 or D5W plus 0.2% or 0.45% NaCal is Hypertonic

79
Q

Is sterile water hypotonic, isotonic or hypertonic? Is it good for mixing low osmolarity solutions or high osmolarity solutions? Why should you never infuse sterile water alone?

A

Sterile water is hypotonic and good for mixing high osmolarity solutions

Never infuse sterile water alone because RBC hemolysis results

80
Q

Are electrolyte solutions like Ringer’s and Ringer’s Lactate hypotonic, isotonic or hypertonic? What is Ringer’s used for?

A

Ringer’s solution: Isotonic electrolyte replenisher used for dehydration

Ringer’s Lactate aka Hartmann’s Solution is very similar to the Extra-cellular fluid electrolytes

81
Q

In which two conditions is Ringer’s Lactate contraindicated? What is impaired in these two conditions?

A

RL is CI in Addisons and Liver Disease because Lactate metabolism is impaired

82
Q

Wrt Chelation, what must you be careful with when infusing EDTA?

A

CCB and EDTA will have additive cardiac blockade effects

Use with caution and titrate up dose slowly in patients w/ CCB meds

83
Q

What conditions demand caution when doing IV chelation?

A 
Renal insufficiency
Liver disease
Anticoagulation
Congestive Heart failure
Pregnancy
84
Q

Is IV chelation permitted with pregnancy?

A

IV chelation is contraindicated with pregnancy

85
Q

Is IV chelation CI with mild to moderate or severe renal insufficiency? Can dosing and frequency play a role?

A

IV chelation CI with severe renal insufficiency and caution with mild to moderate renal insufficiency (use lower dose and just once a week)

86
Q

Is IV chelation CI with mild to moderate or severe liver disease? Is IV chelation CI with active Hep B or Hep C?

A

IV chelation CI with severe lover disease and caution requiring close monitoring with mild to moderate liver enzyme elevation (use lower dose and just once a week)

Active Hep B or Hep C are relative contraindications

87
Q

Is IV chelation CI with Anticoagulation therapy?

A

Prothrombin times must be monitored closely because EDTA MAY CHANGE CLOTTING TIME

88
Q

Is IV chelation CI with Congestive Heart Failure? What should be monitored? What should be assessed every 4 weeks?

A

IV chelation is cautioned with CHF
All cardiac parameters must be monitored closely (baseline EKG, etc)
Calcium levels should be assessed every 4 weeks

Baloney (37 decks)

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