U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234-6100 INTRAVENOUS INFUSIONS AND RELATED TASKS SUBCOURSE MD0553 EDITION 200 DEVELOPMENT This subcourse is approved for resident and correspondence course instruction. It reflects the current thought of the Academy of Health Sciences and conforms to printed Department of the Army doctrine as closely as currently possible. Development and progress render such doctrine continuously subject to change. ADMINISTRATION Students who desire credit hours for this correspondence subcourse must enroll in the subcourse. Application for enrollment should be made at the Internet website: http://www.atrrs.army.mil. You can access the course catalog in the upper right corner. Enter School Code 555 for medical correspondence courses. Copy down the course number and title. To apply for enrollment, return to the main ATRRS screen and scroll down the right side for ATRRS Channels. Click on SELF DEVELOPMENT to open the application; then follow the on-screen instructions. For comments or questions regarding enrollment, student records, or examination shipments, contact the Nonresident Instruction Branch at DSN 471-5877, commercial (210) 221-5877, toll-free 1-800-344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail [email protected], or write to: NONRESIDENT INSTRUCTION BRANCH AMEDDC&S ATTN: MCCS-HSN 2105 11TH STREET SUITE 4191 FORT SAM HOUSTON TX 78234-5064 Be sure your social security number is on all correspondence sent to the Academy of Health Sciences. CLARIFICATION OF TERMINOLOGY When used in this publication, words such as "he," "him," "his," and "men" 'are intended to include both the masculine and feminine genders, unless specifically stated otherwise or when obvious in context. USE OF PROPRIETARY NAMES The initial letters of the names of some products may be capitalized in this subcourse. Such names are proprietary names, that is, brand names or trademarks. Proprietary names have been used in this subcourse only to make it a more effective learning aid. The use of any name, proprietary or otherwise, should not be interpreted as endorsement, deprecation, or criticism of a product; nor should such use be considered to interpret the validity of proprietary rights in a name, whether it is registered or not. TABLE OF CONTENTS Lesson Paragraph INTRODUCTION 1 INITIATE AN INTRAVENOUS INFUSION AND MANAGE A PATIENT WITH AN INTRAVENOUS INFUSION ..................... 1-1--1-8 Exercises 2 OBTAIN A BLOOD SPECIMEN .................................................. 2-1--2-4 Exercises 3 INITIATE TREATMENT FOR ANAPHYLACTIC SHOCK ............ 3-1--3-3 Exercises APPENDIX, UNIVERSAL BODY SUBSTANCE PRECAUTIONS MD0553 i CORRESPONDENCE COURSE OF THE U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL SUBCOURSE MD0553 INTRAVENOUS INFUSIONS AND RELATED TASKS INTRODUCTION The medical soldier caring for patients provides a valuable service to his comrades. He must meet high standards with integrity, dignity, calm thinking, and careful study. The purpose of this subcourse is to provide you with a working knowledge of the procedures discussed herein; however, you must receive guidance and hands-on supervision to become proficient at the procedures described. Subcourse Components: The subcourse instructional material consists of three lessons and an appendix as follows: Lesson 1, Initiate an Intravenous Infusion and Manage a Patient with an Intravenous Infusion. Lesson 2, Obtain a Blood Specimen. Lesson 3, Initiate Treatment for Anaphylactic Shock. Appendix, Universal Body Substance Precautions. Here are some suggestions that may be helpful to you in completing this subcourse: --Read and study each lesson carefully. --Complete the subcourse lesson by lesson. After completing each lesson, work the exercises at the end of the lesson, marking your answers in this booklet. --After completing each set of lesson exercises, compare your answers with those on the solution sheet that follows the exercises. If you have answered an exercise incorrectly, check the reference cited after the answer on the solution sheet to determine why your response was not the correct one. MD0553 ii Credit Awarded: Upon successful completion of the examination for this subcourse, you will be awarded 5 credit hours. To receive credit hours, you must be officially enrolled and complete an examination furnished by the Nonresident Instruction Section at Fort Sam Houston, Texas. You can enroll by going to the web site http://atrrs.army.mil and enrolling under "Self Development" (School Code 555). A listing of correspondence courses and subcourses available through the Nonresident Instruction Section is found in Chapter 4 of DA Pamphlet 350-59, Army Correspondence Course Program Catalog. The DA PAM is available at the following website: http://www.usapa.army.mil/pdffiles/p350-59.pdf. MD0553 iii LESSON ASSIGNMENT LESSON 1 Initiate an Intravenous Infusion and Manage a Patient With an Intravenous Infusion. TEXT ASSIGNMENT Paragraphs 1-1 through 1-8. LESSON OBJECTIVES After completing this lesson, you should be able to: 1-1. Identify the purpose of initiating an intravenous infusion. 1-2. Identify fluids used in intravenous infusions. 1-3 Identify when an intravenous infusion should be initiated. 1-4. Identify the procedures for initiating an intravenous infusion. 1-5. Identify the procedures for performing a F.A.S.T.1 TM (First Access For Shock and Trauma) procedure. 1-6. Identify complications from intravenous infusions and how they can be prevented and treated. SUGGESTION After completing the assignment, complete the exercises of this lesson. These exercises will help you achieve the lesson objectives. MD0553 1-1 LESSON 1 INITIATE AN INTRAVENOUS INFUSION AND MANAGE A PATIENT WITH AN INTRAVENOUS INFUSION INITIATE AN INTRAVENOUS INFUSION 1-1. GENERAL As a soldier medic, you will be providing medical care in a variety of situations. The method you will use to control hemorrhage in a casualty will likely depend on the tactical situation. Once hemorrhage has been controlled, the casualty may need fluid resuscitation to combat hypovolemic (low volume of fluid in the circulatory system) shock or to help prevent hypovolemic shock. This lesson will concentrate on the battlefield methods. It is imperative that all bleeding has been stopped before any attempt to start an intravenous infusion is performed. NOTE: In this subcourse, the abbreviation "IV" can mean either "intravenous" or "intravenous infusion." 1-2. FLUID RESUSCITATION a. The goal of managing hypovolemic shock is to increase tissue perfusion and oxygenation status. Treatment is directed at providing adequate oxygenation and ventilation. STOPPING THE BLEEDING must be the priority before any fluid resuscitation is attempted. (1) Circulation and hemorrhage control priorities include controlling severe hemorrhage immediately, obtaining intravenous access, and assessing tissue perfusion. (2) If the casualty has a significant injury, initiate a single 18-gauge catheter in a peripheral vein and place a saline lock on it. If no significant injury exists, parenteral fluids are not required; however, the casualty should be encouraged to drink oral fluids as he will likely be somewhat dehydrated. NOTE: Sometimes, a casualty who has had been wounded may not need intravenous fluids at the time of initial treatment, but may need them at a later time. It is usually a good idea to prepare for administering IV fluids while the vein is still strong and easy to find. This is done by inserting the needle/catheter into the vein, removing the needle, and inserting a saline lock adapter into the catheter hub. The adapter seals off the catheter until you are ready to administer fluids intravenously. MD0553 1-2 b. If you are unable to initiate peripheral IV access, consider initiating a sternal intraosseous (IO) line. Although there are many other IO methods available, the sternal kit known as F.A.S.T.1TM has been chosen. NOTE: Intraosseous means "within the bone." (1) The sternum is protected by body armor and the cortex of the bone is much thinner than the tibia. Many injuries are to the lower extremities. (2) If the patient no longer has a sternum, he will not likely benefit from an IO infusion. (3) Indications for the need of an IO infusion include: (a) Inadequate peripheral access. (b) Need for rapid access for medications, fluid, or blood. (c) Failed attempts at peripheral or central venous access. 1-3. SOLUTIONS USED IN INTRAVENOUS THERAPY a. Resuscitation Solutions. Different types of IV fluids can be used for different medical conditions. These solutions are generally categorized as colloid or crystalloid. (1) Colloids. Colloids contain protein, sugar, or other high molecular weight molecules and are used to expand intravascular volume. Examples include: (a) Whole blood (most common) (see figure 1-1). (b) Packed red blood cells (PRBC). (c) Fresh frozen plasma (FFP). (d) Plasma protein fraction (PPF). (e) Hypertonic saline and dextran (HSD). (f) Hextend® (a 6 percent hetastarch solution in a balanced electrolyte solution). MD0553 1-3 Figure 1-1. Blood products. (Left--whole blood. Right--plasma.) (2) Crystalloids. Crystalloids are solutions that do not contain protein or other large molecules. Sodium (Na+) is the primary osmotic agent. These fluids do not remain in the vascular spaces very long. Examples include: (a) Normal saline (NS) (0.9 percent sodium chloride [NaCl] solution). (b) Ringer's lactate (RL). b. Fluid Distribution. Fluids are distributed throughout the body in several different spaces and the body continually works to maintain equilibrium within these spaces. The average adult male has approximately 42 liters of fluid within the body. The fluid is distributed as follows: (1) Intracellular space. Fluids within the cells amount to about two-thirds of the body's weight. (2) Extracellular space. Fluids outside the cells amount to about one-third of the body's weight. (a) Interstitial space. About eighty percent of the extracellular fluid is in spaces between tissues. (b) Vascular space. About twenty percent of the extracellular fluid is in the circulatory system. MD0553 1-4 c. Fluids. (1) One thousand milliliters (ml) of Ringer's lactate (about 2.4 pounds) will expand the intravascular volume by 200 to 250 ml within one hour. Sodium is the primary osmotic agent in RL and will not remain in the vascular system very long. It diffuses out into the interstitial space and eventually into the intracellular space. This fluid is better for treating dehydration. (2) Five hundred milliliters of Hextend® (about 1.3 pounds) will expand the intravascular volume by 800 ml within one hour and will sustain this expansion for up to eight hours. Hextend® contains large sugar molecules that remain in the vascular system for a much longer time than RL. Hextend® also pulls additional fluid from the interstitial spaces and holds this fluid in the vascular space for a longer period of time. Hextend® is better for treating hypovolemia secondary to blood loss than RL. d. Resuscitation Indicators. (1) The blood pressure is commonly used to determine who needs fluid resuscitation. However, stethoscopes and blood pressure cuffs are rarely available or useful to the front line soldier medic in the typically noisy and chaotic battlefield environment. (2) A palpable radial pulse and normal mentation (mental ability) are adequate and tactically relevant resuscitation endpoints to either start or stop fluid resuscitation. Both can be adequately assessed in noisy and chaotic situations without mechanical devices. (3) Casualties should only be resuscitated to a systolic blood pressure of 80 millimeters of mercury (mmHg). This blood pressure is adequate to perfuse all vital organs and, yet, not high enough to cause a possible re-bleed of a vessel that has already clotted. Re-bleeding can occur with a systolic blood pressure as low as approximately 93 mmHg. (4) The systolic blood pressure may be approximated by palpating pulses in specific areas: (a) A palpable carotid pulse indicates a systolic blood pressure of at least 60 mmHg. (b) A palpable femoral pulse indicates a systolic blood pressure of at least 70 mmHg. (c) A palpable radial pulse indicates a systolic blood pressure of at least 80 mmHg. MD0553 1-5