The Basic of ALS Assistance - Albemarle Rescue Squadcarsrescue.org/wp-content/uploads/2012/Downloads/drugbox.pdf · The Basic of ALS Assistance ... – ALWAYS used in trauma and cardiac

The Basic ofThe Basic ofALS AssistanceALS Assistance

CharlottesvilleCharlottesville--AlbemarleAlbemarleRescue Squad, Inc.Rescue Squad, Inc.

IntroductionIntroduction•• As a CARS member, you are an integral part of a team As a CARS member, you are an integral part of a team

whose goal is to take care of a sick patient. Regardless whose goal is to take care of a sick patient. Regardless of your training level, you will be called upon at times to of your training level, you will be called upon at times to set up an IV line, an albuterol treatment, or to get drugs set up an IV line, an albuterol treatment, or to get drugs from the box. Therefore, a basic understanding of the from the box. Therefore, a basic understanding of the box will help the team out tremendously.box will help the team out tremendously.

•• The contents and organization of the box changed in The contents and organization of the box changed in October, 2001 with implementation of new protocols. October, 2001 with implementation of new protocols.

•• The additional information included here is never to be The additional information included here is never to be used independent of the direct supervision and request used independent of the direct supervision and request of a certified ALS provider.of a certified ALS provider.

DisclaimersDisclaimers

•• For the sake of clarity, gloves have not been For the sake of clarity, gloves have not been used in most of the photographs. It should be used in most of the photographs. It should be noted that you should noted that you should

ALWAYS WEAR GLOVESALWAYS WEAR GLOVESwhen taking care of patients.when taking care of patients.

•• This presentation presents you with the basics This presentation presents you with the basics of the drug box to help you be even more of the drug box to help you be even more helpful on an ALS call. Never do anything from helpful on an ALS call. Never do anything from this presentation without an AIC asking you to this presentation without an AIC asking you to do so.do so.

Table of ContentsTable of Contents

I. Basic drug box anatomyI. Basic drug box anatomyII.II. Setting up an IV lineSetting up an IV lineIII.III. Setting up a nebulizer treatmentSetting up a nebulizer treatmentIV.IV. Preparing medicationPreparing medication

–– Medication vialsMedication vials–– BristojetBristojet injectorsinjectors–– TubexTubex injectorinjector–– Glass ampulesGlass ampules–– Administer Nitroglycerin and Administer Nitroglycerin and NitropasteNitropaste..

V.V. Basic drug reviewBasic drug reviewVI.VI. Written TestWritten Test

Section I Section I -- Drug box anatomyDrug box anatomy

•• There are four basic compartments to the There are four basic compartments to the box: three drawers and the bottom of the box: three drawers and the bottom of the box.box.

•• The next few pages contain basic outlines The next few pages contain basic outlines of the drawers’ contents. Don’t try to of the drawers’ contents. Don’t try to memorize them, but get the basic layout.memorize them, but get the basic layout.

•• Section V will outline these contents in Section V will outline these contents in more detail, and will give you a chance to more detail, and will give you a chance to test you memory.test you memory.

Opening the box…Opening the box…(Okay, you think, this is dumb. How hard can it be? (Okay, you think, this is dumb. How hard can it be?

Actually, very if you don’t know a few things…)Actually, very if you don’t know a few things…)

•• Start by breaking the pharmacy’s red seal Start by breaking the pharmacy’s red seal tag by tearing it off. ONLY do this if the tag by tearing it off. ONLY do this if the released ALS AIC asks you to do so.released ALS AIC asks you to do so.

•• Then, unlatch the front and two side Then, unlatch the front and two side latches.latches.

•• Open the front flap.Open the front flap.•• The The pull out the top drawerpull out the top drawer a few inches.a few inches.•• Only then will you be able to open the large Only then will you be able to open the large

top, and the box opens like a tackle box.top, and the box opens like a tackle box.NOTE: The drug boxes are sealed in the NOTE: The drug boxes are sealed in the

pharmacy following a thorough check by a pharmacy following a thorough check by a pharmacist. Check for the intact seal each pharmacist. Check for the intact seal each time you look for the presence of the box.time you look for the presence of the box.

Step 1

Step 2

General LayoutGeneral Layout•• There are three drawers and a There are three drawers and a

bottom basin. bottom basin. •• Top drawer: IV catheters, needles Top drawer: IV catheters, needles

and syringes, and gray top tube.and syringes, and gray top tube.•• Middle drawer: Most medications.Middle drawer: Most medications.•• Bottom drawer: ‘Code’ (cardiac Bottom drawer: ‘Code’ (cardiac

arrest) drugs.arrest) drugs.•• Bottom basin: IV fluids, tubing, Bottom basin: IV fluids, tubing,

albuterol, a few more drugs, arm albuterol, a few more drugs, arm splints, sharps container and splints, sharps container and pharmacy complaint form.pharmacy complaint form.

Top DrawerTop Drawer

Injection materials2 – 1 cc syringes with needle, ‘Tb syringe’

2 – 3 cc syringes with needle2 – 5 cc syringe without needle2 – 10 cc syringe without needle

2 heparin locksAssorted needlesIV starting materials

2 pairs of gloves2 tourniquets

3 – 2x2’s3 – 4x4’s Random IV Materials

16 – Alcohol preps1 – Roll of Transpore tape (“IV tape”)

2 – 10 cc saline flush bottles1 – Blood sugar tube (see later)

IV Catheters2 – 14 g (orange)2 – 16 g (gray)3 – 18 g (green)3 – 20 g (pink)

2 – 22 g (yellow)2 – 24 g (blue)

Middle DrawerMiddle Drawer

2 -

Bena

dryl

50

mg/

1 cc

2 –

Vers

ed 5

mg/

1 cc

4 –

Epin

ephr

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1:1,

000

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1 –

Glu

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mg,

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Bott

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4 –

Mag

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2 –

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Mor

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Aspi

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1 –

Dop

amin

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Cl20

0 m

g/5

cc, t

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ix

1 –

Valiu

m10

mg/

2 cc

1 –

Lido

cain

e1

g/25

cc

1 –

Epin

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1:1,

000

30 m

g/30

cc

1 –

Solu

-med

rol1

25 m

g

3 –

Met

opro

lol5

mg/

5 cc

3 –

Adeo

nsin

e6

mg/

2 cc

3 –

Lasi

x40

mg/

4 cc

1 -

Nar

can

4 m

g/10

cc

Bottom DrawerBottom Drawer4

–At

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10 c

c

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Lido

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1:10

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Bottom of BoxBottom of Box

2 – Dextrose 50% 25 g/50 cc2 – Sodium Bicarbonate 50 mEq/50 cc

2 – Macrodrip tubing sets2 – Minidrip tubing sets

2 – 1,000 cc bags of Normal Saline2 – 250 cc bags of D5W

2 – T-port extension sets1 – Sharps container

1 – Albuterol hand held nebulizer set-up4 – Albuterol bullets1 – Ipatropium bullet

2 – 30 cc syringes

2 –

Arm

boa

rds

1 –Biohazard bag

1 –D

rug box contents list

1 –Problem

form

Section II Section II -- Intravenous LinesIntravenous Lines

•• IV lines are started for many reasons, IV lines are started for many reasons, including administering fluid to including administering fluid to hypovolemichypovolemic patients and as a route to patients and as a route to give medications.give medications.

•• The basic setThe basic set--up involves:up involves:–– The fluid to be infused, connected to … The fluid to be infused, connected to … –– Tubing, which is connected to an…Tubing, which is connected to an…–– Extension set...Extension set...–– Which connects to the IV catheter in the vein.Which connects to the IV catheter in the vein.

FluidsFluidsNormal Saline (NS) Normal Saline (NS) –– 1,000 cc/bag1,000 cc/bag

–– ALWAYS used in trauma and cardiac arrest. ALWAYS used in trauma and cardiac arrest. Often used for patients with chest pain and other Often used for patients with chest pain and other medical complaints. medical complaints.

–– The fluid is a salt, which is infused into the The fluid is a salt, which is infused into the bloodstream, part of which stays in the bloodstream, part of which stays in the vasculature. vasculature.

–– Consider it the Consider it the defaultdefault fluid.fluid.•• Dextrose 5% Dextrose 5% -- 250 cc/bag250 cc/bag

–– Used for mixing drips of medications.Used for mixing drips of medications.–– Does not stay in vasculature, so it cannot be Does not stay in vasculature, so it cannot be

used to resuscitate a hypotensive patient.used to resuscitate a hypotensive patient.•• The bottom line: ASK the AIC which fluid The bottom line: ASK the AIC which fluid

they want, but you will almost always use they want, but you will almost always use saline.saline.

5% Dextrose in water

aka “D5W”

0.9% Sodium Chlorideaka “Normal Saline”

TubingTubing•• The tubing connects the fluid bag to the The tubing connects the fluid bag to the

extension setextension set•• Drip chamber determines maximum flow rateDrip chamber determines maximum flow rate•• MacrodripMacrodrip, , akaaka ‘big drip’ or ’10‘big drip’ or ’10--drop’ tubingdrop’ tubing

–– 10 drops make 1 cc (1 ml)10 drops make 1 cc (1 ml)–– Has a wide drip chamber which makes big Has a wide drip chamber which makes big

drops, allowing drops, allowing quick delivery of high volumesquick delivery of high volumes•• MicrodripMicrodrip, , akaaka ‘little drip’ or ’60 drop’ tubing‘little drip’ or ’60 drop’ tubing

–– 60 drops make 1 cc (1 ml)60 drops make 1 cc (1 ml)–– Has a small, needleHas a small, needle--like dripper which allows like dripper which allows

counting of drops to counting of drops to titrate medication dripstitrate medication drips•• Again, ask the AIC which tubing they want.Again, ask the AIC which tubing they want.

Tubing AnatomyTubing AnatomyFrom the fluid bag down to the extension setFrom the fluid bag down to the extension set

•• Drip chamberDrip chamber–– Holds a reservoir of fluid preventing infusion Holds a reservoir of fluid preventing infusion

of air bubblesof air bubbles–– Allows observation of flow rateAllows observation of flow rate

•• Clamp Clamp –– Allows immediate cessation of flowAllows immediate cessation of flow–– Always check here if there is NO flow when Always check here if there is NO flow when

you ‘open up the line.’you ‘open up the line.’•• Flow regulatorFlow regulator

–– Manipulates flowManipulates flow•• Towards the fluid bag increases flow rate, Towards the fluid bag increases flow rate,

akaaka ‘opening up the line.’‘opening up the line.’•• Towards the patient decreases rate.Towards the patient decreases rate.

–– Comes packaged in the open position.Comes packaged in the open position.•• Drug portDrug port

–– RubberRubber--covered allows repeated needle covered allows repeated needle puncture for medication administrationpuncture for medication administration

Drip chamber

Flow regulator

Drug port

Off-clamp

Incr

ease

s flo

w

Decreases flow

Extension setExtension set•• Should be placed on all IV’sShould be placed on all IV’s•• Serves as a reversible, oneServes as a reversible, one--way way

connector between tubing and the IV connector between tubing and the IV catheter.catheter.

•• Allows the ER staff to draw blood and Allows the ER staff to draw blood and inject medications without resticking inject medications without resticking the patient.the patient.

•• Provides a very proximal medication Provides a very proximal medication port for medications that have very port for medications that have very short halfshort half--lives, lives, egeg adenosine.adenosine.

•• Some providers do not like to use it Some providers do not like to use it because of the twisting port used to because of the twisting port used to attach to the catheter. However, it is attach to the catheter. However, it is of tremendous benefit to the patient, of tremendous benefit to the patient, so use them so use them ☺☺

Disposable caps

Clamp

One-way valve

ExtensionTubing IV Tubin

g

To IV catheter

Choosing the IV catheterChoosing the IV catheter•• IV supplies are found in the top IV supplies are found in the top

drawer of the drug box.drawer of the drug box.•• The catheters come in different The catheters come in different

diameters and lengths. The diameters and lengths. The packages are color coded by size as packages are color coded by size as shown in the middle. You can see shown in the middle. You can see the catheters come as a big mess, the catheters come as a big mess, so knowing the colors saves lots of so knowing the colors saves lots of time.time.

•• The size, or gauge (g), is written in The size, or gauge (g), is written in the upper left corner of the the upper left corner of the package. This number represents package. This number represents 1/(diameter of catheter in inches), 1/(diameter of catheter in inches), so 14g is 1/14” in diameter, and is so 14g is 1/14” in diameter, and is the biggest catheter. Next to it is the biggest catheter. Next to it is marked the length of catheter.marked the length of catheter.

14 g - Orange 16 g – Gray18 g – Green20 g – Pink22 g – Blue

24 g - Yellow

Anatomy of IV cathetersAnatomy of IV catheters•• The plastic catheter is the connection The plastic catheter is the connection

between the IV tubing and the between the IV tubing and the patient’s vein. Most of the new patient’s vein. Most of the new catheters are catheters are clear; clear; they are not they are not defective.defective.

•• The contraption shown in to top figure The contraption shown in to top figure is how the catheteris how the catheter--overover--needle is needle is packaged. packaged.

•• PROCEUDRE: The protective cap is PROCEUDRE: The protective cap is removed, and after cleansing the skin removed, and after cleansing the skin with alcohol, the needlewith alcohol, the needle--catheter catheter combination is introduced through the combination is introduced through the patient’s skin, into a superficial vein. patient’s skin, into a superficial vein. Blood flows back through the needle, Blood flows back through the needle, and into the flash chamber. The and into the flash chamber. The catheter is threaded over the needle catheter is threaded over the needle and into the vein, and the needle and into the vein, and the needle withdrawn into the casing as shown in withdrawn into the casing as shown in bottom figure. The needle is removed bottom figure. The needle is removed and tubing attached.and tubing attached.

Flash chamber

Intravenous catheter

Needle

Withdrawn needle

Protective cap

““Setting up a line…”Setting up a line…”•• Hopefully, you now understand the Hopefully, you now understand the

parts of a functional IV: a fluid bag, parts of a functional IV: a fluid bag, tubing, extension set and a catheter.tubing, extension set and a catheter.

•• “Setting up a line” is a common “Setting up a line” is a common request of newer members, so you request of newer members, so you should know how to do this. This should know how to do this. This involves involves preconnectingpreconnecting the fluid, the fluid, tubing and extension set and letting tubing and extension set and letting the fluid run through the line, getting the fluid run through the line, getting rid of the air.rid of the air.

•• Start by opening the box and Start by opening the box and removing a removing a bag of fluid, tubing and an bag of fluid, tubing and an extension set.extension set. Your defaults should Your defaults should be normal saline and a be normal saline and a macrodripmacrodrip (10 (10 drop) tubing, unless your AIC tells you drop) tubing, unless your AIC tells you differently. However, ALWAYS ask differently. However, ALWAYS ask what the AIC wants set up.what the AIC wants set up.

Extension set Tubing set Normal

Saline

The fluid bagThe fluid bag•• Packaging for both D5W and Packaging for both D5W and

saline bags have only saline bags have only oneone right right way to be opened…way to be opened…and several wrong, and several wrong, though creative ways.though creative ways.

•• There is a precut edge in the There is a precut edge in the upper left corner. Pull the corner upper left corner. Pull the corner as shown down the length of the as shown down the length of the bag.bag.

•• Remove the bag and pull off the Remove the bag and pull off the blue cover.blue cover.

•• The medication port is just that, The medication port is just that, and is not to be removed.and is not to be removed.

•• At this point, hang the bag on the At this point, hang the bag on the hooks in the truck (by the precut hooks in the truck (by the precut hole in the bag) or have a hole in the bag) or have a bystander hold it.bystander hold it. Medication/ fluid

withdrawal port

Precut edge

Preparing the tubing and extension setPreparing the tubing and extension set

•• Open the tubing by pulling the package Open the tubing by pulling the package apart at the sides. It tears easily at the apart at the sides. It tears easily at the serrated edge. Also open the extension serrated edge. Also open the extension set.set.

•• The extension set comes with The extension set comes with everything as shown. The blue cap everything as shown. The blue cap should be removed by twisting off, the should be removed by twisting off, the one way valve one way valve mustmust then be tightenedthen be tightened11, , or it will leak or fall off. Leave the distal or it will leak or fall off. Leave the distal cap on until ready to connect to the cap on until ready to connect to the catheter to keep the tip clean.catheter to keep the tip clean.

•• Then attach the distal end of the tubing Then attach the distal end of the tubing to the one way valve of the extension to the one way valve of the extension set as shownset as shown22. Secure the two by . Secure the two by twisting cap as showntwisting cap as shown33..

Tighten (1)

Remove cap

Ensure clamp is off

Leave cap on

Extension set contents

3

2

Connecting the tubing to fluidConnecting the tubing to fluid•• Remove the cap that covers the drip Remove the cap that covers the drip

chamber (not shownchamber (not shown11). Then grip ). Then grip the nipple tightly with one handthe nipple tightly with one hand22 and and squeeze the drip chamber as shown squeeze the drip chamber as shown with the other handwith the other hand33, and push up , and push up into the bag with a twisting motion. into the bag with a twisting motion. The beveled edge will pierce the The beveled edge will pierce the membrane and allow fluid to flow membrane and allow fluid to flow into drip chamber. into drip chamber.

•• Remember that once you do this, Remember that once you do this, removing the tubing from that port removing the tubing from that port will lead to a high volume leakage of will lead to a high volume leakage of fluid onto the floor…this constitutes fluid onto the floor…this constitutes poor form.poor form.

3. Squeeze and twist up

2. Grip tightly

1. Remove cap

The drip chamber…The drip chamber…•• The drip chamber serves two main The drip chamber serves two main

purposes: purposes: –– to prevent air from going into the line andto prevent air from going into the line and–– to monitor fluid flow rate. to monitor fluid flow rate.

•• There is a line engraved into the drip There is a line engraved into the drip chamber which marks the proper fluid chamber which marks the proper fluid level. level.

•• If you do not put enough fluid in the If you do not put enough fluid in the chamber, e.g. if you forget to squeeze the chamber, e.g. if you forget to squeeze the chamber as you puncture the bag, air can chamber as you puncture the bag, air can get into the line and flows into the get into the line and flows into the patient’s venous system. This can be very patient’s venous system. This can be very dangerous if lots of air gets infused. To dangerous if lots of air gets infused. To correct, simply squeeze the chamber and correct, simply squeeze the chamber and flow out the bubbles.flow out the bubbles.

•• Too much fluid disallows you from Too much fluid disallows you from visualizing the drip rate, which is rather visualizing the drip rate, which is rather annoying. To correct this, tip the bag annoying. To correct this, tip the bag upside down allowing air to come to the upside down allowing air to come to the top of bag, then squeeze the chamber, top of bag, then squeeze the chamber, allowing bubbles to backflow into the allowing bubbles to backflow into the chamber.chamber.

Correct

Too much air! Too much fluid

Importantslide

Fill the tubing…Fill the tubing…•• Having filled the drip chamber with the appropriate Having filled the drip chamber with the appropriate

level of fluid, allow the tubing to fill with fluid.level of fluid, allow the tubing to fill with fluid.•• This happens by gravity, so the bag must be above This happens by gravity, so the bag must be above

the end of the tubing, ideally hanging from the the end of the tubing, ideally hanging from the ceiling.ceiling.

•• Watch the tubing fill and ensure there are no air Watch the tubing fill and ensure there are no air bubbles throughout the length of the tubing (2bubbles throughout the length of the tubing (2--3 3 small ones are acceptable). Continue flowing saline small ones are acceptable). Continue flowing saline onto the floor until all bubbles are gone.onto the floor until all bubbles are gone.

•• Shut off flow using the regulator as shown. Rolling Shut off flow using the regulator as shown. Rolling towards the bag increases flow, away from bag towards the bag increases flow, away from bag shuts it off.shuts it off.

•• If there is NO flow, check for a clamped clamp. If there is NO flow, check for a clamped clamp. Many good IV’s have been unnecessarily pulled Many good IV’s have been unnecessarily pulled because of clamps!because of clamps!

•• The regulator holder is a little appreciated feature. The regulator holder is a little appreciated feature. It can be clamped around the tubing just below the It can be clamped around the tubing just below the drip chamber to allow easy visibility and access…you drip chamber to allow easy visibility and access…you get bonus points if you do this!get bonus points if you do this!

•• Leave the end of the tubing in an easy to reach Leave the end of the tubing in an easy to reach place, like hung up by the bag or behind the pillow, place, like hung up by the bag or behind the pillow, NOT on the floor.NOT on the floor.

Clamp

Regulator

Regulator holder

Other preparationOther preparation•• You have now completed the official You have now completed the official

business of ‘setting up a line.’ To put business of ‘setting up a line.’ To put the catheter in and ‘start the line,’ you the catheter in and ‘start the line,’ you should be on top of a few things:should be on top of a few things:–– Get a tourniquet, gloves, alcohol preps, Get a tourniquet, gloves, alcohol preps,

2x2’s and 4x4’s ready (top drawer).2x2’s and 4x4’s ready (top drawer).–– Cut five pieces of Cut five pieces of transporetranspore tape, each tape, each

about as long as your middle finger. about as long as your middle finger. Cut one more piece down the middle as Cut one more piece down the middle as shown.shown.

–– Open an alcohol prep as shown by Open an alcohol prep as shown by tearing down the middle, not where it tearing down the middle, not where it says ‘open here.’ This makes the says ‘open here.’ This makes the alcohol prep stick out and easy to grab.alcohol prep stick out and easy to grab.

–– Four by fours and 2x2’s can also be Four by fours and 2x2’s can also be open by tearing down the middle.open by tearing down the middle.

The way to open an alcohol prep and tear tape.

4x4

2x2

Alcohol prepsIV catheter

Transpore tape

Tourniquet

Opening the catheter package

Once the catheter is in… Once the catheter is in… •• Usually you will just need to remove Usually you will just need to remove

the cap off the end of extension set the cap off the end of extension set and hand the end of the tubing to and hand the end of the tubing to the AIC. the AIC.

•• If they ask for extra assistance, this If they ask for extra assistance, this is what to do. Hold the end of the is what to do. Hold the end of the extension set as shown and insert it extension set as shown and insert it into the hub of the catheter. Then into the hub of the catheter. Then twist the lock onto the hub by twist the lock onto the hub by turning clockwise.turning clockwise.

•• NOTE: sometimes the lock sticks, NOTE: sometimes the lock sticks, making it hard to lock onto the hub. making it hard to lock onto the hub. Always loosen it by twisting it Always loosen it by twisting it around before attempting to attach around before attempting to attach to the catheter.to the catheter.

•• Open the line using the regulator.Open the line using the regulator.

Twist clockwise

Twist to loosen

TapingTaping•• The catheter and tubing must now be held The catheter and tubing must now be held

in place until secured. This is done using in place until secured. This is done using the tape you cut. Remember it is the tape you cut. Remember it is everyone’s job to protect the IV, so watch everyone’s job to protect the IV, so watch your step, and help the person taping.your step, and help the person taping.

•• Your end result should look like this. Your end result should look like this. –– The first piece of tape is cut in half The first piece of tape is cut in half

lengthwise and turned upside down, and lengthwise and turned upside down, and forms a U around the catheter. Not all forms a U around the catheter. Not all providers use this technique.providers use this technique.

–– The remainder go across the catheter and The remainder go across the catheter and 2x2.2x2.

–– ALWAYS fold the tubing over on itself and ALWAYS fold the tubing over on itself and tape as shown to leave slack in the line.tape as shown to leave slack in the line.

–– Do your best to leave the ports accessible.Do your best to leave the ports accessible.•• Remember that the bag of fluid must be Remember that the bag of fluid must be

kept above the level of the heart at all kept above the level of the heart at all times. If you must lower the bag, times. If you must lower the bag, egegputting it on the patient’s lap to unload the putting it on the patient’s lap to unload the ambulance, make sure the regulator is to ambulance, make sure the regulator is to off, or blood will backflow into the tubing.off, or blood will backflow into the tubing.

Arm board

Sticky down

Sticky down

Sticky upTowards catheter

Adjusting flowAdjusting flow & Troubleshooting& Troubleshooting

•• There are two basic rates that There are two basic rates that IV fluids are run in the IV fluids are run in the prehospital setting:prehospital setting:–– Slow: known as ‘KVO’ for Slow: known as ‘KVO’ for

‘keep vein open’ or ‘TKO’ for ‘keep vein open’ or ‘TKO’ for to keep open. This is about to keep open. This is about one drop every two seconds. one drop every two seconds. Adjust the regulator as you Adjust the regulator as you watch the drip chamber.watch the drip chamber.

–– Fast: known as ‘wide open.’ Fast: known as ‘wide open.’ Open the regulator all the way Open the regulator all the way and allow the IV to flow at its and allow the IV to flow at its maximal rate.maximal rate.

•• Always watch the IV site for Always watch the IV site for signs of infiltration, such as signs of infiltration, such as pain, redness and swelling.pain, redness and swelling.

Top ten reasons your IV is Top ten reasons your IV is not runningnot running

1.1. It is not in the vein. Instead, it is in It is not in the vein. Instead, it is in the interstitial space. This is known as the interstitial space. This is known as infiltration.infiltration.

2.2. The tourniquet is still on. This is very The tourniquet is still on. This is very common!common!

3.3. The blood pressure cuff is still on the The blood pressure cuff is still on the same arm and pumped up.same arm and pumped up.

4.4. The bag is below the level of the The bag is below the level of the heart.heart.

5.5. The tubing is clamped.The tubing is clamped.6.6. The extension set is clamped.The extension set is clamped.7.7. The regulator is set to off.The regulator is set to off.8.8. You are standing on the tubing.You are standing on the tubing.9.9. The cot is on the tubing.The cot is on the tubing.10.10. The drip chamber is overfilled, so The drip chamber is overfilled, so

drips are not visible.drips are not visible.

SharpsSharps•• A ‘sharp’ is any sharp object (IV needle, IM A ‘sharp’ is any sharp object (IV needle, IM

needle, glass ampule) that may be contaminated needle, glass ampule) that may be contaminated by blood or body fluids.by blood or body fluids.

•• Extreme caution must be exercised by all Extreme caution must be exercised by all members involved in patient care when a sharp is members involved in patient care when a sharp is present on a scene, as an inadvertent stick may present on a scene, as an inadvertent stick may lead to transmission of infectious diseases, such lead to transmission of infectious diseases, such as hepatitis. as hepatitis.

•• Place the retracted IV needle into a sharps Place the retracted IV needle into a sharps container.container.

•• Press down on the container as shown until it Press down on the container as shown until it snaps closed. snaps closed.

•• Do NOT close the container by squeezing it Do NOT close the container by squeezing it between your two hands, as sometimes a sharp is between your two hands, as sometimes a sharp is able to puncture the bottom of the container and able to puncture the bottom of the container and can pierce your hand.can pierce your hand.

•• There are also sharps containers on all There are also sharps containers on all ambulances that are easier to use (look for the ambulances that are easier to use (look for the big red box).big red box).

•• In contrast to this picture, In contrast to this picture, always wear gloves.always wear gloves.

ReviewReview

•• The steps in setting up a line includeThe steps in setting up a line include–– Open the packaging for the fluid bag, tubing and Open the packaging for the fluid bag, tubing and

extension setextension set–– Attach the tubing to the extension setAttach the tubing to the extension set–– Attach the tubing to the fluid, checking for proper Attach the tubing to the fluid, checking for proper

filling of drip chamber and absence of bubblesfilling of drip chamber and absence of bubbles–– Turn off the flow using the regulatorTurn off the flow using the regulator–– Cut tape, select catheters, open alcohol preps, etc.Cut tape, select catheters, open alcohol preps, etc.

•• Nice work! Just a few more words about some Nice work! Just a few more words about some new additions to the drug box…new additions to the drug box…

Heparin locksHeparin locks•• These little contraptions are also known as These little contraptions are also known as

‘‘hephep locks,’ since they are sometimes locks,’ since they are sometimes flushed with heparin to prevent clotting of flushed with heparin to prevent clotting of blood in the catheter.blood in the catheter.

•• They are used simply as an endThey are used simply as an end--cap for cap for the catheter. They obviate the need to the catheter. They obviate the need to run IV fluids to ‘keep the vein open.’ run IV fluids to ‘keep the vein open.’

•• They can be punctured repeatedly as They can be punctured repeatedly as necessary to inject medications. necessary to inject medications.

•• To attach a To attach a hephep lock:lock:–– Open the package shown and remove the Open the package shown and remove the

blue protector.blue protector.–– Fill the port with saline to remove the air.Fill the port with saline to remove the air.–– Connect the Connect the hephep lock with the hub of the lock with the hub of the

catheter and secure with tape.catheter and secure with tape.–– Flush with saline to remove stagnant blood Flush with saline to remove stagnant blood

in the catheter.in the catheter.

Alligator ClipsAlligator Clips•• Alligator clips are used to attach Alligator clips are used to attach

accessories that usually attach accessories that usually attach directly into the IV catheter into a directly into the IV catheter into a hephep lock. It contains two plastic lock. It contains two plastic clips which hug the clips which hug the hephep lock and a lock and a soft needle which punctures the soft needle which punctures the hephep lock membrane.lock membrane.

•• Begin by attaching the IV line as Begin by attaching the IV line as shown aboveshown above11..

•• Then squeeze the clipsThen squeeze the clips2 2 and push and push the needle through the membranethe needle through the membrane33. .

•• Secure with tape and allow the IV Secure with tape and allow the IV fluid to run in.fluid to run in.

2

3

1

Section III Section III -- NebulizersNebulizers•• Nebulizers are small containers into which we Nebulizers are small containers into which we

put drugs to be delivered to the lungs, like put drugs to be delivered to the lungs, like albuterol and atrovent. albuterol and atrovent.

•• When oxygen flows through the nebulizer, it When oxygen flows through the nebulizer, it aerosolizes the drug into small particles about 2 aerosolizes the drug into small particles about 2 microns in diameter, small enough to travel all microns in diameter, small enough to travel all the way into the patient’s lower airways. the way into the patient’s lower airways.

•• The nebulizer is connected to oxygen on one The nebulizer is connected to oxygen on one end. The other end may be connected to a end. The other end may be connected to a piecepiece--pipe and held by the patient, or rigged up pipe and held by the patient, or rigged up to an NRB, allowing hands free drug delivery. to an NRB, allowing hands free drug delivery.

Set upSet up1.1. Open the packet, found in the bottom Open the packet, found in the bottom

compartment of the drug box, in a compartment of the drug box, in a sealed bag. Attached or included in it sealed bag. Attached or included in it are four albuterol bullets and one are four albuterol bullets and one atrovent bullet. There are no saline atrovent bullet. There are no saline bullets in the drug box. bullets in the drug box.

2.2. The plastic nebulizer has two parts The plastic nebulizer has two parts which screw together. They usually which screw together. They usually come put together, but always need to come put together, but always need to be tightened. be tightened.

NOTE NOTE –– not all not all nebulizersnebulizers in the drug box in the drug box will look like this one, but the will look like this one, but the components are the same. Spare components are the same. Spare nebulizersnebulizers are kept with the NRB masks are kept with the NRB masks on all the ambulances.on all the ambulances.

Albuterol Atrovent

Salinebullet

Albuterol nebulizersetup

More nebulizer setup…More nebulizer setup…3.3. Connect one end of the oxygen tubing to the bottom Connect one end of the oxygen tubing to the bottom

of the nebulizer and the other end to an Oof the nebulizer and the other end to an O22 source, source, set from 4set from 4--10 LPM; the old school states 410 LPM; the old school states 4--6 LPM, 6 LPM, but the aerosol is more effective when set at 8but the aerosol is more effective when set at 8--10 10 LPM.LPM.

4.4. The drugs for the nebulizer include albuterol ‘bullets’ The drugs for the nebulizer include albuterol ‘bullets’ (four/box) and atrovent (one/box), used for the (four/box) and atrovent (one/box), used for the treatment of asthma. When you open the packet, treatment of asthma. When you open the packet, put the extra treatments in a pocket or somewhere put the extra treatments in a pocket or somewhere you will not lose them.you will not lose them.

5.5. Ask the provider which drug/s they will want to give. Ask the provider which drug/s they will want to give. For some patients we will start with both an For some patients we will start with both an albuterol and atrovent, for others we start with just albuterol and atrovent, for others we start with just albuterol.albuterol.

6.6. Open the bullet by twisting off the small plastic cap Open the bullet by twisting off the small plastic cap (insert). Turn it upside down and place the open (insert). Turn it upside down and place the open end into the round opening of the nebulizer. It is end into the round opening of the nebulizer. It is okay if the oxygen is flowing when you do this. okay if the oxygen is flowing when you do this. REMEMBER that once you do this to always keep the REMEMBER that once you do this to always keep the nebulizer upright, or you will lose all the drug into nebulizer upright, or you will lose all the drug into the patient’s lap, which is much less effective the patient’s lap, which is much less effective ☺☺

Assembling delivery devicesAssembling delivery devicesHandHand--held nebulizerheld nebulizer

The standard method of delivering nebulized The standard method of delivering nebulized drugs is by hand held nebulizer (HHN). The drugs is by hand held nebulizer (HHN). The nebulizer is attached to a Tnebulizer is attached to a T--connector, connector, which has a piecepipe which the patient which has a piecepipe which the patient holds in his mouth. The serrated tube holds in his mouth. The serrated tube shown serves as a reservoir for nebulized shown serves as a reservoir for nebulized particles to buildup between breaths.particles to buildup between breaths.

•• The TThe T--connectorconnector22 has two ends, with either has two ends, with either a bigger or smaller diameter opening, as a bigger or smaller diameter opening, as denoted by the circles. denoted by the circles.

–– The mouthpieceThe mouthpiece3 3 fits inside the large fits inside the large diameter end of the Tdiameter end of the T--connector. connector.

–– The piecepipeThe piecepipe1 1 fits outside the small diameter fits outside the small diameter end of the Tend of the T--connector. connector.

–– Connect the TConnect the T--connector to the round top of connector to the round top of the neb. the neb.

•• The patient holds the entire contraption in The patient holds the entire contraption in his/her hand. It is good for claustrophobic his/her hand. It is good for claustrophobic patients who need to feel in control.patients who need to feel in control.

1 2 3

Assembling delivery devicesAssembling delivery devicesNonNon--rebreatherrebreather maskmaskAnother option is to connect the Another option is to connect the

nebulizer to the mask portion nebulizer to the mask portion of the NRB. of the NRB.

•• Simply remove the reservoir Simply remove the reservoir bag and tubing from a NRB bag and tubing from a NRB by pulling them apart. This by pulling them apart. This leaves the mask and strap leaves the mask and strap with a hole which fits the top with a hole which fits the top of the nebulizer perfectly. of the nebulizer perfectly.

•• This is the method of choice This is the method of choice for patients who are very for patients who are very dyspneic, in whom you are dyspneic, in whom you are doing lots of treatment and doing lots of treatment and need the patient’s arms, or in need the patient’s arms, or in small children.small children.

Section IV Section IV –– Miscellaneous skillsMiscellaneous skills

•• InjectableInjectable medicationsmedications–– Assembling a syringeAssembling a syringe–– Medication vialsMedication vials–– BristoBristo--jet injectorsjet injectors–– TubexTubex injectorsinjectors–– Glass ampulesGlass ampules

•• Other skillsOther skills–– Administering NitroglycerinAdministering Nitroglycerin–– Applying Applying NitropasteNitropaste–– Obtaining a blood sampleObtaining a blood sample

SyringesSyringes•• All syringes are found in the top All syringes are found in the top

drawer, except the large 30drawer, except the large 30--cc cc syringe in the bottom of the box.syringe in the bottom of the box.–– The 1 cc and 3 cc syringes come with The 1 cc and 3 cc syringes come with

a needle already attached.a needle already attached.–– The 5, 10 and 30 cc syringes need to The 5, 10 and 30 cc syringes need to

have a needle attached to them.have a needle attached to them.–– The lower picture is one of the new The lower picture is one of the new

protective needles, which are being protective needles, which are being phasedphased--in. The orange cover is in. The orange cover is simply snapped over the needle simply snapped over the needle following use. They are still disposed following use. They are still disposed of in sharps containers.of in sharps containers.

Assembling a syringeAssembling a syringe1. Pinch

2. Twist off

•• Start by choosing the appropriate sized syringe. Start by choosing the appropriate sized syringe. You can figure this out by what volume of You can figure this out by what volume of medication you will be giving and choosing the medication you will be giving and choosing the smallest one that will fit that volume. So don’t smallest one that will fit that volume. So don’t chose a 3 cc syringe to give 40 mg of chose a 3 cc syringe to give 40 mg of lasixlasix, , since that is 4 cc, and you would have to draw since that is 4 cc, and you would have to draw up medication twice…this is again, suboptimal.up medication twice…this is again, suboptimal.

•• Open the package by tearing it over the end of Open the package by tearing it over the end of the syringe as shown. the syringe as shown.

•• Then pinch the protective cap while you twist Then pinch the protective cap while you twist the syringe off of it and pull it out of the the syringe off of it and pull it out of the package. This is a timepackage. This is a time--saving maneuver.saving maneuver.

•• Remove a needle (NOT an IV catheter) from Remove a needle (NOT an IV catheter) from the top drawer and open it as you did the the top drawer and open it as you did the syringe.syringe.

•• Then twist the syringe and needle together.Then twist the syringe and needle together.

Medication vialsMedication vials•• The majority of the The majority of the injectableinjectable medications in medications in

the box come packaged as vials. the box come packaged as vials. •• To prepare this for injection, it must be To prepare this for injection, it must be

drawn up into a syringe.drawn up into a syringe.•• Begin by snapping off the protective cap as Begin by snapping off the protective cap as

shown. The rubber cap this uncovers is shown. The rubber cap this uncovers is sterile and should be maintained as such.sterile and should be maintained as such.

•• Invert the vial, puncture the rubber cap with Invert the vial, puncture the rubber cap with a syringe, inject in air approximately the a syringe, inject in air approximately the volume of medication you wish to withdraw, volume of medication you wish to withdraw, and then withdraw the medication by pulling and then withdraw the medication by pulling back on the syringe. Then remove the back on the syringe. Then remove the syringe.syringe.

•• Hold the syringe with the needle up and Hold the syringe with the needle up and expel any air you may have drawn up.expel any air you may have drawn up.

•• NOTE NOTE –– all vials and needles are considered all vials and needles are considered sharps and should be disposed of the sharps sharps and should be disposed of the sharps container. Never throw them in the trash.container. Never throw them in the trash.

BristoBristo--jet injectorsjet injectors•• BristoBristo--jets are jets are premadepremade syringes filled with medication, syringes filled with medication,

made ready to inject with minimal preparation, often for made ready to inject with minimal preparation, often for cardiac arrest situations. We have the following drugs cardiac arrest situations. We have the following drugs as as bristobristo--jets:jets:–– Atropine Atropine –– speeds up the heart.speeds up the heart.–– Epinephrine 1:10,000 Epinephrine 1:10,000 –– constricts peripheral vessels.constricts peripheral vessels.–– LidocaineLidocaine –– stops abnormal rhythms.stops abnormal rhythms.–– Dextrose 50% Dextrose 50% -- ‘D50’ ‘D50’ –– simple sugar for diabetics.simple sugar for diabetics.–– Sodium bicarbonate Sodium bicarbonate –– a ‘base’ to treat metabolic acidosis.a ‘base’ to treat metabolic acidosis.–– Calcium chloride Calcium chloride –– an ion to treat certain drug overdoses.an ion to treat certain drug overdoses.

•• You may find these setYou may find these set--ups in a prepackaged box (D50, ups in a prepackaged box (D50, bicarbonate, bicarbonate, lidocainelidocaine) or free) or free--standing in the drawer standing in the drawer (epinephrine, atropine).(epinephrine, atropine).

Setting up the Setting up the bristobristo--jetjet1.1. If the drug comes in a box, open it. Your life If the drug comes in a box, open it. Your life

will be much easier if you follow the ‘open will be much easier if you follow the ‘open here’ label on the box. here’ label on the box.

2.2. Pick up the glass ampule with the drug in it in Pick up the glass ampule with the drug in it in one hand, and a one hand, and a bristobristo--jet injector in the other. jet injector in the other. Point the yellow caps to the ceiling, and pop Point the yellow caps to the ceiling, and pop them off together using your thumbs. (This is them off together using your thumbs. (This is a key maneuver if you want to look cool as an a key maneuver if you want to look cool as an EMT).EMT).

3.3. Screw the two ends together. Beware that the Screw the two ends together. Beware that the injector has two needles in it, one hidden by injector has two needles in it, one hidden by the yellow plastic cover; the other punctures the yellow plastic cover; the other punctures the blue cap to the ampule.the blue cap to the ampule.

4.4. An ALS provider will remove the yellow needle An ALS provider will remove the yellow needle cap, insert the needle into a drug port on the cap, insert the needle into a drug port on the IV, and inject the drug.IV, and inject the drug.

Twistclockwise

TubexTubex injectorsinjectors•• Another way of packaging the drug is with a Another way of packaging the drug is with a

syringe with a needle that does not have a syringe with a needle that does not have a handle to push the drug with. handle to push the drug with.

•• You may see epinephrine and You may see epinephrine and benadrylbenadryl pakagedpakagedthis way.this way.

•• The ‘syringe holder’ contains two parts which The ‘syringe holder’ contains two parts which twist over one another. The ‘injector’ slides twist over one another. The ‘injector’ slides through this contraption.through this contraption.

•• To prepare a medication for injection:To prepare a medication for injection:1.1. Hold the syringe holder as shown and place a Hold the syringe holder as shown and place a

tubextubex syringe into the hole as shown. syringe into the hole as shown. 2.2. Twist the two parts of the syringe holder around Twist the two parts of the syringe holder around

each other in a clockwise fashion.each other in a clockwise fashion.3.3. Then push the injector into the back of the syringe Then push the injector into the back of the syringe

and twist it clockwise.and twist it clockwise.

Syringe holder

Injector

Step 1

Step 2

Step 3

Glass ampulesGlass ampules

•• Some drugs, such as epinephrine, come Some drugs, such as epinephrine, come packaged as glass ampules, as shown.packaged as glass ampules, as shown.

•• To retrieve the medication from the To retrieve the medication from the bottle, you must first swirl the bottle to bottle, you must first swirl the bottle to move the fluid stuck in the cap into the move the fluid stuck in the cap into the ampule.ampule.

•• Then break the top off as shown. Always Then break the top off as shown. Always wear gloves and protect yourself using a wear gloves and protect yourself using a 2x2. Break the cap away from your body.2x2. Break the cap away from your body.

•• The ampule can then be turned upside The ampule can then be turned upside down (the fluid is kept in by hydrostatic down (the fluid is kept in by hydrostatic pressure). Insert a syringe and withdraw pressure). Insert a syringe and withdraw the medication by pulling on the syringe. the medication by pulling on the syringe. Do NOT inject air into the ampule, or the Do NOT inject air into the ampule, or the medication will go all over the floor. medication will go all over the floor.

Administering NitroglycerinAdministering Nitroglycerin•• Nitroglycerin is a common medication that Nitroglycerin is a common medication that

is used to treat chest pain of suspected is used to treat chest pain of suspected myocardial origin. myocardial origin.

•• There is a full bottle of it in the second There is a full bottle of it in the second drawer of the box; you should be familiar drawer of the box; you should be familiar with it.with it.

•• If asked to administer a tablet, open the If asked to administer a tablet, open the vial carefully, remove a tablet, and recover vial carefully, remove a tablet, and recover the vial. Place it in a location where you the vial. Place it in a location where you will not lose it, like back where you got it.will not lose it, like back where you got it.

•• Ask the patient to lift their tongue and Ask the patient to lift their tongue and place the tablet under the tongue as place the tablet under the tongue as shown. They are not to be chewed. They shown. They are not to be chewed. They can close their mouth after the medication can close their mouth after the medication has been placed.has been placed.

•• Effects include headache, hypotension, Effects include headache, hypotension, tachycardia. Always make SURE the tachycardia. Always make SURE the patient has not had Viagra in the past 24 patient has not had Viagra in the past 24 hours, which is an absolute contraindication hours, which is an absolute contraindication to giving them nitroglycerin.to giving them nitroglycerin.

Applying Applying NitropasteNitropaste•• NitropasteNitropaste is an alternate form of nitroglycerin is an alternate form of nitroglycerin

that is applied to the skin and very quickly that is applied to the skin and very quickly absorbed. It is dosed in inches. absorbed. It is dosed in inches.

•• To prepare it, WEAR GLOVES. Then open the To prepare it, WEAR GLOVES. Then open the package by twisting about the precut area package by twisting about the precut area (insert). (insert).

•• Apply the paste to the paper as shown. A Apply the paste to the paper as shown. A package is a package is a premeasuredpremeasured dose of 1”, so dose of 1”, so squeeze out the whole package if asked to squeeze out the whole package if asked to give 1”, two packets for 2”.give 1”, two packets for 2”.

•• Apply the paste and paper to the patient’s Apply the paste and paper to the patient’s skin. The preferred locations are the lateral skin. The preferred locations are the lateral aspect of the arm (less headache, no aspect of the arm (less headache, no interference with the 12interference with the 12--lead) and the left lead) and the left upper chest.upper chest.

•• Always tape the paper as shown.Always tape the paper as shown.•• Change your gloves following this procedure.Change your gloves following this procedure.•• To remove the paste, don gloves and use a To remove the paste, don gloves and use a

4x4 to wipe the paste from the patient’s skin.4x4 to wipe the paste from the patient’s skin.

Obtaining a blood sampleObtaining a blood sample•• This procedure is used to obtain a This procedure is used to obtain a

grey topped tube filled with patient grey topped tube filled with patient blood prior to the administration of blood prior to the administration of sugar (D50) for the determination of sugar (D50) for the determination of blood glucose prior to treatment. blood glucose prior to treatment. Always attempt to obtain a sample Always attempt to obtain a sample prior to giving ‘D50.’prior to giving ‘D50.’

•• The The vacutainervacutainer comes in a sealed comes in a sealed package as shown (top drawer).package as shown (top drawer).

•• Prepare as shown. Prepare as shown. •• The IV tubing is then attached to the The IV tubing is then attached to the

catheter as usual and D50 catheter as usual and D50 administered.administered.

IV catheter

Section V Section V -- Basic Drug ReviewBasic Drug ReviewIn this section, we will review where in the box each of these mIn this section, we will review where in the box each of these medicines are edicines are (organized by chief complaint) and some pearls to know for each.(organized by chief complaint) and some pearls to know for each.

•• AsthmaAsthma–– Albuterol Albuterol -- ProventilProventil–– IpatropiumIpatropium bromide bromide -- AtroventAtrovent–– MethylprednisoloneMethylprednisolone -- SoluSolu--MedrolMedrol

•• AnginalAnginal Chest PainChest Pain–– Aspirin Aspirin -- ASAASA–– Nitroglycerin tab Nitroglycerin tab -- NTGNTG–– Nitroglycerin paste Nitroglycerin paste -- NTPNTP–– Morphine sulfate Morphine sulfate –– MSO4MSO4–– MetoprololMetoprolol

•• Allergic ReactionAllergic Reaction–– Epinephrine Epinephrine -- EpiEpi–– DiphenhidramineDiphenhidramine -- BenadrylBenadryl

•• Cardiac Arrest Cardiac Arrest –– Vasopressin Vasopressin -- PitressinPitressin–– EpinephrineEpinephrine–– AtropineAtropine–– LidocaineLidocaine–– Magnesium sulfateMagnesium sulfate

•• Sick HeartsSick Hearts–– Adenosine Adenosine -- AdenocardAdenocard–– Atropine Atropine HClHCl–– Dopamine Dopamine HClHCl–– LasixLasix -- FurosemideFurosemide

•• Diabetic Diabetic EmergeniesEmergenies–– Dextrose 50% Dextrose 50% -- D50D50–– GlucagonGlucagon

•• SeizuresSeizures–– Diazepam Diazepam -- ValiumValium–– MidazolamMidazolam -- VersedVersed

•• Other Other –– Calcium ChlorideCalcium Chloride–– NaloxoneNaloxone –– NarcanNarcan–– Sodium bicarbonateSodium bicarbonate

Asthma and COPDAsthma and COPDCaused by inflammation and spasm/constriction of bronchioles.Caused by inflammation and spasm/constriction of bronchioles.

•• You are treating a 26 year old man with a You are treating a 26 year old man with a history of asthma for an acute asthma history of asthma for an acute asthma exacerbation. Where would you find the exacerbation. Where would you find the following and how would you set it up:following and how would you set it up:–– Albuterol sulfate nebulizerAlbuterol sulfate nebulizer–– Atrovent nebulizerAtrovent nebulizer–– SoluSolu--MedrolMedrol injectioninjection

•• THINK before you click to the next slide.THINK before you click to the next slide.

Asthma/COPD DrugsAsthma/COPD DrugsAlbuterol SulfateDose: 2.5 mg in 3 cc bulletAction: Dilates bronchioles when inhaled.Prep: Squirt into assembled nebulizer

as previously described.Cautions: Can cause tachycardia and

palpitations.

Ipatropium bromide (Atrovent)Dose: 2.5 mg in 3 cc bulletAction: Dilates bronchioles byblocking parasympathetics.

Prep: As above. Always with albuterol.

Cautions: As above.

Methylprednisolone (Solu-Medrol)Dose: 125 mg IV (ped 1-2 mg/kg)Action: Decreases inflammation in

the bronchioles, takes severalhours for effect.

Prep: Remove from box, then presstop down as shown. This pushesstopper through and mixes thedrug. Draw up with 10 cc syringe.

Bottom of Box

Middle Drawer

AnginalAnginal Chest PainChest PainCaused by excessive workCaused by excessive work--load of the heart muscle relative to oxygen delivery.load of the heart muscle relative to oxygen delivery.In MI, this is due to a clot forming in a coronary artery.In MI, this is due to a clot forming in a coronary artery.

•• You are treating an 85 year old man with chest You are treating an 85 year old man with chest pain. The medic then asks you to get him the pain. The medic then asks you to get him the following:following:–– Aspirin Aspirin –– 4 tablets chewed4 tablets chewed–– Nitroglycerin Nitroglycerin –– 1 tablet sublingually1 tablet sublingually–– NitropasteNitropaste –– 2” applied to the shoulder2” applied to the shoulder–– Morphine Morphine -- 2 mg for IV use2 mg for IV use–– MetoprololMetoprolol –– 5 mg for IV use5 mg for IV useWhere would you find these medications and what are Where would you find these medications and what are

the basic reasons we give them?the basic reasons we give them?

Middle Drawer

Baby AspirinDose: 4 tablets, chewedAction: binds platelets and

decreases clotting in a potential heart attack.

Sublingual NitroglycerinDose: 1 tablet under the

tongue, repeatedAction: Dilates veins and

arterioles to decrease work on the myocardium.

Cautions: headache, hypotension, tachycardia.

NitroPasteDose: 1-2” transdermal.

One packet equals 1”.Apply to the deltoid area and tape the sides.

Action: same as above.

Morphine SulfateDose: 2 mg IVAction: Binds to opioid receptors

and decreases pain.Prep: Draw up with a 1 cc

syringe. Some medics dilute 1:10 in a 10 cc syringe.

Chest Pain DrugsChest Pain Drugs

Metoprolol TartateDose: 5 mg IV, repeated twice moreAction: Blocks epinephrine at the B-

receptor, and slows down the heart.Prep: Draw up in a 5 cc syringe.Cautions: Do NOT use in asthmatic

patients.

Allergic reactionAllergic reactionCaused by release of histamine and other factors from mast cellsCaused by release of histamine and other factors from mast cells,,which causes flushing and inflammation. A mast cellwhich causes flushing and inflammation. A mast cell--aggravating stimulus (bee aggravating stimulus (bee stings, food) is necessary.stings, food) is necessary.

•• You are called to treat a 3 year old who has You are called to treat a 3 year old who has eaten peanuts and developed hives and eaten peanuts and developed hives and respiratory distress. You want to treat him with:respiratory distress. You want to treat him with:–– Epinephrine SQ (subcutaneously)Epinephrine SQ (subcutaneously)–– Benadryl IM (intramuscular) or IVBenadryl IM (intramuscular) or IV

Where do you find these lifeWhere do you find these life--saving drugs?saving drugs?–– Do you remember how to get them ready?Do you remember how to get them ready?

Allergic reaction drugsAllergic reaction drugsEpinephrine HClDose: 0.3 mg SQ (peds 0.01 mg/kg)Action: Binds to mast cells and inhibits the release of histamine. Also bronchodilates.Prep: Break open ampule and draw up in a 1 cc syringe.

NOTE: These also come packaged as tubex syringes, so be prepared to set up whatever is in the box.

Cautions: Causes tachycardia, anxiety and hypertension.

Diphenhydramine (Benadryl)Dose: 25-50 mg (peds 1 mg/kg)Action: Inhibits the action of released histamine on tissues, such as skin and vessels. Treats hives well.Prep: Draw up into 1 cc syringe.

NOTE: These also come packaged as ampules or tubex syringes.

Cautions: Can be sedating.

Middle Drawer

Cardiac arrestCardiac arrestDifferent from a ‘heart attack,’ this is the absence of anyDifferent from a ‘heart attack,’ this is the absence of anyspontaneous heart beat or respirations. The truest of emergencispontaneous heart beat or respirations. The truest of emergencies.es.

•• Cardiac arrest occurs following any number of insults, Cardiac arrest occurs following any number of insults, but it results in loss of peripheral vessel tone and but it results in loss of peripheral vessel tone and abnormal heart rhythms. It is treated with abnormal heart rhythms. It is treated with vasopressorsvasopressors(vessel squeezers) and (vessel squeezers) and antiarrhythmicsantiarrhythmics (stopping (stopping abnormal rhythms)abnormal rhythms)–– VasopressorsVasopressors

•• VasopressinVasopressin•• EpinephrineEpinephrine

–– AntiarrhythmicsAntiarrhythmics•• AtropineAtropine•• LidocaineLidocaine•• Magnesium SulfateMagnesium Sulfate

•• Would you know where to look for each of these drugs? Would you know where to look for each of these drugs? How do they come packaged? Could you get them How do they come packaged? Could you get them ready?ready?

Cardiac ArrestCardiac Arrest--VasopressorsVasopressorsVasopressin (Pitressin)Dose: 40 Units in 2 cc IV or ET

Action: Increases vascular tone and perfusion of vital organs by shunting blood centrally.Takes the place of epinephrine as a vasopressor in certain rhythms.

Prep: Draw up both vials into a 3 cc syringe.

Epinephrine HClDose: 1 mg every 3-5 minutes

(Peds 0.01 mg/kg)Action: Increases vascular tone. Can

have detrimental effects on brainperfusion if high dosed.

Prep: For regular strength epinephrine(1:10,000), prepare bristojet as shown to the left.

For the high dose (1:1,000), draw up1 cc per dose. Vial shown on right.

Third drawer

Second drawer

Cardiac Arrest Cardiac Arrest -- AntiarrhythmicsAntiarrhythmics

Bottom Drawer

Middle Drawer

Atropine SulfateDose: 1 mg IV (peds 0.02 mg/kg)Action: Blocks a parasympathetic receptor in the heart.

This speeds up the heart rate. It is given for a slow heart rate or for asystole (no heart activity).

Prep: Prepare bristojet as described before.

Lidocaine HydrochlorideDose: 1-1.5 mg/kg IVAction: Blocks sodium channels in the heart muscle and

in nerves, which can get rid of abnormal heart rhythms which are conducted by heart muscle (ventricular tachycardia and fibrillation).

Prep: Prepare bristojet as described before. It can alsobe administered as a drip. To do this, mix the entirebottle in a 250 cc bag with microdrip tubing.

Cautions: Can cause hypotension and lethargy.

Magnesium SulfateDose: 2 g IVAction: Competes with calcium for calcium channels

which is another way to get rid of abnormal heartrhythms. Especially good for a special form of ventricular tachycardia called torsades de pointes.

Prep: Draw up both vials in a 5 cc syringe.Cautions: Can cause hypotension and lethargy.

Sick HeartsSick HeartsThis is a hodgepodge of different medications used to treatThis is a hodgepodge of different medications used to treatpatients with various problems with their heart.patients with various problems with their heart.

•• Case 1 Case 1 –––– You are treating a 25 year old man with a heart rate of 260 c/o You are treating a 25 year old man with a heart rate of 260 c/o

palpitations. Your team decides to treat him with adenosine…palpitations. Your team decides to treat him with adenosine…•• Where do you find this medicine?Where do you find this medicine?•• What size syringe will you use to draw up this medicine?What size syringe will you use to draw up this medicine?•• What else will you need to prepare when giving this medicine?What else will you need to prepare when giving this medicine?

•• Case 2 Case 2 –––– You are treating a 76 year old woman with congestive heart You are treating a 76 year old woman with congestive heart

failure. In addition to nitroglycerin and morphine as describedfailure. In addition to nitroglycerin and morphine as describedbefore, you might treat her with before, you might treat her with lasixlasix or dopamine.or dopamine.•• Where do you find these medicines?Where do you find these medicines?•• What is special about dopamine that you should know?What is special about dopamine that you should know?

Sick Hearts Sick Hearts -- Case 1Case 1Adenosine (Adenocard)Dose: 6 mg, repeated with 12 mg fast

IVAction: Adenosine is a natural hormone

released by the body during periods of cardiac stress. It binds to the adenosine receptor and slows down the heart. It is used for patients with supraventricular tachycardia to slow down the heart.

Prep: The AIC will need lots of help, since these patients are fairly sick. The drug has a half life of 6 seconds once it enters the vein, so you have to follow the bolus with about 30 cc of normal saline (drawn up from the bag into a 30 cc syringe) and pushed into a port in the tubing.-Draw up one vial of medicine in a 3 cc syringe.-Draw up 30 cc of fluid in a 30 cc syringe with a needle)-When the AIC pushes the medicine, push the ‘record’ button on the monitor so the cardiologists can see the rhythm change.

Cautions: The drug causes asystole for usually about 5-10 seconds. This is very scary to the patient, and more so to the person who pushed the medicine. Be ready!

Middle Drawer

Sick Hearts Sick Hearts –– Case 2Case 2Furosemide (Lasix)Dose: 40-120 mg (peds 1 mg/kg) IV/IMAction: Causes increased urine production by decreasing resorption in the loop of Henle. Also briefly dilates vessels.Prep: Draw up one or two vials in a 10 cc syringe. There are 10 mg in each cc you draw up.Cautions: Can cause hypotension and must be administered slowly over a few minutes. Can cause ringing in ears.

Dopamine (Intropin)

Dose: 2-20 µg/kg/min, given as a drip

Action: Depends on dose: 2-5 µg/kg/min leads to dilation of renal arteries; 5-10 µg/kg/min leads to increased rate and force of contraction of the heart; 10-20 µg/kg/min leads to the above and peripheral vasoconstriction. Used anytime there is severe hypotension refractory to fluids and rate control.

Prep: Draw up 200 mg of dopamine (1 vial) into a 5 cc syringe and inject it into a 250 cc D5W bag connected to a minidrip tubing. This will be attached to an injection port in a macrodrip tubing and administered as a drip.

Middle Drawer

Diabetic EmergenciesDiabetic EmergenciesAltered mental status or unresponsiveness can be caused by eitheAltered mental status or unresponsiveness can be caused by either r high or low blood sugar.high or low blood sugar.

•• You are treating a 48 year old diabetic woman You are treating a 48 year old diabetic woman who took her usual dose of insulin today but who took her usual dose of insulin today but forgot to eat breakfast. She was found forgot to eat breakfast. She was found unresponsive by her husband in the house. unresponsive by her husband in the house. Since she is unable to eat, you decide to treat Since she is unable to eat, you decide to treat her with either IV D50% or her with either IV D50% or glucagonglucagon. . –– Dextrose 50% Dextrose 50% --

•• What two things do you need to set up before you get the What two things do you need to set up before you get the D50 ready? D50 ready?

•• Where is the D50% and how do you set it up?Where is the D50% and how do you set it up?–– GlucagonGlucagon

•• Where is the Where is the glucagonglucagon located?located?•• How do you prepare it? How is it administered?How do you prepare it? How is it administered?

Diabetic Emergencies Diabetic Emergencies –– Dextrose 50%Dextrose 50%Dextrose 50% (‘D-50’)

Dose: 25 g (Peds 0.5 mg/kg)

Action: Dextrose is an isomer of glucose. When given into a vein, it raises blood sugar quickly.

Prep: Administration of intravenous sugar consists of three steps:

• Set up a macrodrip IV with saline as the fluid.

• Set up the vacutainer as described before (shown at bottom) to draw a blood sample before administration of the drug. This allows documentation of hypoglycemia.

• Set up the D50 syringe. They come packaged in one of two ways.

• Preassembled syringe (top picture). Just remove the grey cover and attach a 19 g needle. It is now injectable into an IV port.

• Bristo-jet (middle picture). Set up as described before.

• When given to a child, dextrose must be diluted in a 4:1 dilution in 30 cc syringe.

Caution: Always watch the IV for good flow and the site for signs of infiltration, since infiltrated D50 causes death of surrounding tissues.

Top Drawer

Bottom of Box

Diabetic Emergencies Diabetic Emergencies -- GlucagonGlucagonGlucagon

Dose: 1 mg (peds 1 mg) intramuscular

Action: Enters the bloodstream after being absorbed from the muscle. It then enters muscle and liver where it breaks down glycogen into sugar. It usually takes about 5-10 minutes before a patient’s mental status will begin to improve if this is the problem.

Prep: Open the plastic bag and inject the syringe of fluid into the vial with the glucagon powder. Mix up the combination by shaking the vial. Then draw up the homogenous mixture with the syringe. It can be injected IM or IV.

Cautions: None.

Middle Drawer

SeizuresSeizuresCaused by uncontrolled discharges of neurons in the brain.Caused by uncontrolled discharges of neurons in the brain.

•• You are treating a 26 year old alcoholic man You are treating a 26 year old alcoholic man having a tonichaving a tonic--clonic seizure which has been clonic seizure which has been persisting for the past 6 minutes. After treating persisting for the past 6 minutes. After treating with D50, you can treat the seizure with one of with D50, you can treat the seizure with one of two drugs:two drugs:–– Diazepam (Valium) IV or PR (per rectum)Diazepam (Valium) IV or PR (per rectum)–– MidazolamMidazolam (Versed) IV or IM(Versed) IV or IM

•• Where do you find these drugs and how do you Where do you find these drugs and how do you prepare them?prepare them?

•• What is their mechanism?What is their mechanism?

SeizuresSeizuresDiazepam (Valium)

Dose: 2 mg IV, 5 mg PR (peds 0.1 mg/kg)

Action: Goes into the CNS and hyperpolarizes the neurons by opening a chloride channel. This stops seizure activity, which is caused by neuronal depolarization.

Prep: Draw up the entire vial into a 3 cc syringe. It can then be injected IV or PR.

Caution: Causes sedation following cessation of seizure activity. Basically, the patient will appear drunk, since alcohol has much the same effect as this class of drug.

Midazolam (Versed)

Dose: 2 mg IV/IM (peds 0.1 mg/kg)

Action: Same as above. Versed has a quicker onset and is therefore a nice drug to sedate a patient for cardioversion. It can also be given IM to a seizing patient.

Prep: Draw up contents of one vial into a 3 cc syringe.

Cautions: As above.

Middle Drawer

Miscellaneous DrugsMiscellaneous Drugs•• You are treating a 17 year old boy who is unconscious. You are treating a 17 year old boy who is unconscious.

You suspect a narcotic overdose because of his small You suspect a narcotic overdose because of his small pupils. You decide to treat him with pupils. You decide to treat him with naloxonenaloxone..

•• You are treating a 24 year old woman for a You are treating a 24 year old woman for a tricyclictricyclicantidepressant overdose who is in an abnormal heart antidepressant overdose who is in an abnormal heart rhythm due to the drug. The AIC treats her with rhythm due to the drug. The AIC treats her with sodium sodium bicarbonatebicarbonate..

•• Then, the father of the above two patients got Then, the father of the above two patients got depressed and overdosed on his blood pressure depressed and overdosed on his blood pressure medicine called medicine called verapamilverapamil, a calcium channel blocker. , a calcium channel blocker. You decide to treat him with You decide to treat him with calcium chloridecalcium chloride..–– Where are these drugs found and how are they prepared?Where are these drugs found and how are they prepared?

Miscellaneous DrugsMiscellaneous Drugs

Middle Drawer

Base of Box

Bottom Drawer

Naloxone (Narcan)

Dose: 0.8 mg (peds 0.8 mg) IV, IM or ET

Action: Blocks opioid receptors and thus the effect of opiates on the CNS. Reverses narcotic coma.

Prep: Draw up 2 cc in a 3 cc syringe. Give slowly, titrated torespirations. Note – sometimes packaged in a vial.

Sodium BicarbonateDose: 50 mEq (peds 1 mEq/kg) IV

Action: When given IV, it raises the pH of the blood (makes it less acidic). We do this because the heart and brain are significantly impaired in severe acidosis. You will see this given in TCA overdose, cardiac arrest or at an MVA with a trapped extremity (compartment’s syndrome).

Prep: assemble bristo-jet injector.

Calcium Chloride

Dose: 1 gram IV

Action: Raises serum calcium. This helps to overcome calcium channel blockade (CCB) and also causes vasoconstriction. You will see it given in CCB overdose.

Prep: Prepare the syringe by adding a needle to it, as we did before.

Section VI Section VI -- Written TestWritten Test

1.1. To which of the following To which of the following syringes do you need to syringes do you need to add a needle to before add a needle to before using?using?

2.2. Which of the following Which of the following syringes would you use to syringes would you use to draw up the following draw up the following medications?medications?

A. 10 cc B. 5 cc C. 3 ccD. 1 cc

i.i. LasixLasix

ii.ii. BenadrylBenadryl

iii.iii. ValiumValium

iv.iv. MorpineMorpine SulfateSulfate

v.v. MetoprololMetoprolol tartatetartate

vi.vi. MidazolamMidazolam

vii.vii. AdenosineAdenosine

viii.viii. SoluSolu--MedrolMedrol

3.3. In which drawer will you find the In which drawer will you find the following drugs?following drugs?

i.i. Epinephrine 1:1,000Epinephrine 1:1,000ii.ii. AtropineAtropineiii.iii. AdenosineAdenosineiv.iv. AspirinAspirinv.v. NitroNitro--PastePastevi.vi. SyringesSyringesvii.vii. Albuterol nebulizerAlbuterol nebulizerviii.viii. Epinephrine 1:10,000Epinephrine 1:10,000ix.ix. NaloxoneNaloxonex.x. ValiumValiumxi.xi. DextroseDextrosexii.xii. GlucagonGlucagonxiii.xiii. BenadrylBenadryl

A.A. Top DrawerTop DrawerB.B. Middle DrawerMiddle DrawerC.C. Bottom DrawerBottom DrawerD.D. Bottom of BoxBottom of Box

An AIC asks you to set up an IV line. An AIC asks you to set up an IV line. 4.4. What are the different parts of an IV line?What are the different parts of an IV line?5.5. Where in the box are they kept?Where in the box are they kept?6.6. What are your default selections for each part of the line?What are your default selections for each part of the line?7.7. What are the steps of setting up the IV line?What are the steps of setting up the IV line?

An AIC asks you to set up a nebulizer treatment. An AIC asks you to set up a nebulizer treatment. 8.8. Where is the nebulizer located?Where is the nebulizer located?9.9. Where can you find a spare nebulizer setWhere can you find a spare nebulizer set--up?up?10.10. To what do you set the oxygen flow for a nebulizer treatment?To what do you set the oxygen flow for a nebulizer treatment?11.11. The patient is a young child who is moving around too much The patient is a young child who is moving around too much

to hold the nebulizer. What is the best way to deliver his to hold the nebulizer. What is the best way to deliver his medication to him?medication to him?

12.12. What two medications are usually delivered by nebulizer?What two medications are usually delivered by nebulizer?13.13. Where are they found?Where are they found?

14.14. You are asked to give nitroglycerin to a patient. You are asked to give nitroglycerin to a patient. i.i. Where will you give this? Where will you give this? ii.ii. What should you, as part of the medical team, be watching out foWhat should you, as part of the medical team, be watching out for in your r in your

patient?patient?15.15. You are then asked to administer aspirin to a patient. You are then asked to administer aspirin to a patient.

i.i. How do you do this? How do you do this? ii.ii. How many tablets will you give them?How many tablets will you give them?

16.16. You are then asked to prepare 1” of You are then asked to prepare 1” of nitropastenitropaste. . i.i. How do you do this? How do you do this? ii.ii. Where should you place it? Where should you place it? iii.iii. What additional step is necessary to ensure it will not move?What additional step is necessary to ensure it will not move?

17.17. You are treating a hypoglycemic patient. What three things willYou are treating a hypoglycemic patient. What three things will you you need to prepare for the AIC to give D50?need to prepare for the AIC to give D50?

18.18. The above stated AIC was unable to attain the IV line and asks yThe above stated AIC was unable to attain the IV line and asks you to ou to prepare prepare glucagonglucagon. What steps are there in preparing . What steps are there in preparing glucagonglucagon??

19.19. You are treating a patient with tachycardia. The AIC mentions You are treating a patient with tachycardia. The AIC mentions adenosine. What three things will you need to have ready for hiadenosine. What three things will you need to have ready for him?m?

20.20. What color is an 18 g IV catheter package? A 20 g? Which is biWhat color is an 18 g IV catheter package? A 20 g? Which is bigger?gger?

Answer KeyAnswer Key1.1. You will need to add a needle to the 5, 10 and 30 cc syringes. You will need to add a needle to the 5, 10 and 30 cc syringes.

The 1 and 3 cc syringes come attached to a needle.The 1 and 3 cc syringes come attached to a needle.2.2. The following syringes should be used:The following syringes should be used:

i.i. LasixLasix –– 10 cc syringe10 cc syringeii.ii. Benadryl Benadryl –– 1 cc syringe1 cc syringeiii.iii. Valium Valium –– 3 cc syringe3 cc syringeiv.iv. MorpineMorpine Sulfate Sulfate –– 1 cc syringe, though some providers will want a 10 1 cc syringe, though some providers will want a 10

cc syringe to dilute it 1:10.cc syringe to dilute it 1:10.v.v. MetoprololMetoprolol tartatetartate –– 5 cc syringe5 cc syringevi.vi. MidazolamMidazolam –– 3 cc syringe3 cc syringevii.vii. Adenosine Adenosine –– 3 cc syringe3 cc syringeviii.viii. SoluSolu--MedrolMedrol –– 10 cc syringe10 cc syringe

These sizes are shown just to emphasize that the syringe should These sizes are shown just to emphasize that the syringe should be big be big enough to hold the entire dose, but not so big as to be enough to hold the entire dose, but not so big as to be inaccurate in delivering a small volume of concentrated medicineinaccurate in delivering a small volume of concentrated medicine. . You will have a better feel for these as time goes on.You will have a better feel for these as time goes on.

3.3. In which drawer will you find the following drugs?In which drawer will you find the following drugs?i.i. Epinephrine 1:1,000 Epinephrine 1:1,000 –– There are TWO places you will find this There are TWO places you will find this

concentration (1 mg/cc) of concentration (1 mg/cc) of epiepi. The high dose vial for cardiac . The high dose vial for cardiac arrest is in the middle drawer (B), as are the small vials used arrest is in the middle drawer (B), as are the small vials used for treatment of allergic reactions.for treatment of allergic reactions.

ii.ii. Atropine Atropine –– Bottom drawer (C).Bottom drawer (C).iii.iii. Adenosine Adenosine –– Middle drawer (B).Middle drawer (B).iv.iv. Aspirin Aspirin –– Middle drawer (B).Middle drawer (B).v.v. NitroNitro--Paste Paste –– Middle drawer (B).Middle drawer (B).vi.vi. Syringes Syringes –– Top drawer (A).Top drawer (A).vii.vii. Albuterol nebulizer Albuterol nebulizer –– Bottom of box (D).Bottom of box (D).viii.viii. Epinephrine 1:10,000 Epinephrine 1:10,000 –– Bottom drawer (C).Bottom drawer (C).ix.ix. NaloxoneNaloxone –– Middle drawer (B).Middle drawer (B).x.x. Valium Valium –– Middle drawer (B).Middle drawer (B).xi.xi. Dextrose Dextrose –– Bottom of Box (D).Bottom of Box (D).xii.xii. GlucagonGlucagon –– Middle drawer (B).Middle drawer (B).xiii.xiii. Benadryl Benadryl –– Middle drawer (B).Middle drawer (B).

4.4. The components of an IV lineThe components of an IV line–– IV fluidIV fluid–– IV tubingIV tubing–– Extension SetExtension Set–– IV catheterIV catheter–– Extras shown below (top Extras shown below (top

drawer).drawer).

5.5. The remainder of these The remainder of these components can be found in components can be found in the bottom of the drug box.the bottom of the drug box.

6.6. The default fluid is normal The default fluid is normal saline. The default tubing saline. The default tubing should be should be macrodripmacrodrip tubing tubing (10 drips/cc). An extension (10 drips/cc). An extension set should always be used.set should always be used.

7.7. Setting up the IV lineSetting up the IV line

• Begin by opening the IV fluid bag, the IV tubing bag and the extension set.

• Remove the caps and connect the extension set to the IV tubing.

• Squeeze the chamber and insert the tubing into the fluid bag, ensuring there are no bubbles in the line.

• When the catheter is inserted into the vein, assist the AIC with connecting the extension set to the catheter and securing it.

8.8. The nebulizer setThe nebulizer set--up is found in the bottom of the box in a sealed up is found in the bottom of the box in a sealed plastic bag. Either inside the bag or taped to the outside you plastic bag. Either inside the bag or taped to the outside you will find will find the albuterol and atrovent treatments.the albuterol and atrovent treatments.

9.9. If you have to treat two patients with If you have to treat two patients with nebulizersnebulizers, you can find a , you can find a second one in compartment of the ambulance which carries the second one in compartment of the ambulance which carries the NRB’sNRB’s and NC’s.and NC’s.

10.10. Optimal drug delivery occurs at 8Optimal drug delivery occurs at 8--10 LPM of flow. Most providers still 10 LPM of flow. Most providers still set the regulator to 4set the regulator to 4--6 LPM, which is consistent with traditional 6 LPM, which is consistent with traditional teaching.teaching.

11.11. If treating an agitated, active or young patient, the nebulized If treating an agitated, active or young patient, the nebulized oxygen oxygen and medications are best delivered by attaching the nebulizer toand medications are best delivered by attaching the nebulizer to a a NRB mask.NRB mask.

12.12. Albuterol and atrovent are the most common medications to be Albuterol and atrovent are the most common medications to be delivered by nebulizer.delivered by nebulizer.

13.13. As noted above, the bullets can be found in or taped to the bag As noted above, the bullets can be found in or taped to the bag which carries the nebulizer.which carries the nebulizer.

14.14. Nitroglycerin tablets are carried in the middle drawer of the boNitroglycerin tablets are carried in the middle drawer of the box and x and are administered under the lifted tongue. The patient then closare administered under the lifted tongue. The patient then closes the es the mouth, and will often feel a burning under the tongue or a headamouth, and will often feel a burning under the tongue or a headache. che. As part of the team, you will always need to watch out for As part of the team, you will always need to watch out for hypotension caused by the medication. Frequent BP checks are hypotension caused by the medication. Frequent BP checks are necessary and should be done without prompting.necessary and should be done without prompting.

14.14. You are treating a hypoglycemic patient. What three things willYou are treating a hypoglycemic patient. What three things willyou need to prepare for the AIC to give D50?you need to prepare for the AIC to give D50?

15.15. The above stated AIC was unable to attain the IV line and asks The above stated AIC was unable to attain the IV line and asks you to prepare you to prepare glucagonglucagon. What steps are there in preparing . What steps are there in preparing glucagonglucagon??

16.16. You are treating a patient with tachycardia. The AIC mentions You are treating a patient with tachycardia. The AIC mentions adenosine. What three things will you need to have ready for adenosine. What three things will you need to have ready for him?him?

15.15. If asked to give aspirin, give the patient FOUR tablets in his If asked to give aspirin, give the patient FOUR tablets in his mouth to chew. They taste a bit sour.mouth to chew. They taste a bit sour.

16.16. The The nitropastenitropaste is found in is found in premadepremade packets in the middle drawer. packets in the middle drawer. You should apply one packet per inch you are asked to prepare You should apply one packet per inch you are asked to prepare to the white paper supplied with the to the white paper supplied with the nitropastenitropaste. The paper . The paper should then be placed on the shoulder to minimize headache and should then be placed on the shoulder to minimize headache and interference with EKG monitoring. The interference with EKG monitoring. The nitropastenitropaste should always should always be taped on both sides.be taped on both sides.

17.17. GlucagonGlucagon is found in the middle drawer. To mix it, inject the is found in the middle drawer. To mix it, inject the syringe of fluid into the powdered vial, mix it around, and thensyringe of fluid into the powdered vial, mix it around, and thenwithdraw the mixture back into the syringe.withdraw the mixture back into the syringe.

18.18. If you are treating a patient with D50:If you are treating a patient with D50:1.1. You should first begin by setting up a default IV line.You should first begin by setting up a default IV line.2.2. Then you should prepare the Then you should prepare the vacutainervacutainer (top drawer) to (top drawer) to

withdraw a blood sample prior to giving the drug.withdraw a blood sample prior to giving the drug.3.3. Then prepare the D50 syringe (bottom of box) by either Then prepare the D50 syringe (bottom of box) by either

assembling the assembling the bristojetbristojet or attaching a needle.or attaching a needle.19.19. If you are treating a patient with adenosine: If you are treating a patient with adenosine:

1.1. You should first set up an IV with default fluids and tubing. You should first set up an IV with default fluids and tubing. 2.2. Then draw up one vial of adenosine in a 3 cc syringe. Then draw up one vial of adenosine in a 3 cc syringe. 3.3. Then you should draw up 30 cc of saline from the fluid bag Then you should draw up 30 cc of saline from the fluid bag

through the drug port into a 30 cc syringe from the bottom through the drug port into a 30 cc syringe from the bottom drawer. drawer.

4.4. You get many extra points if you remember to press the You get many extra points if you remember to press the ‘record’ button on the monitor when the medicine is pushed to ‘record’ button on the monitor when the medicine is pushed to obtain an EKG strip of the change in rhythm.obtain an EKG strip of the change in rhythm.

20.20. An 18 g catheter package is green, and is bigger than An 18 g catheter package is green, and is bigger than a 20 g catheter, which is packaged in a pink package.a 20 g catheter, which is packaged in a pink package.

Closing notesClosing notesThank you for taking the time to go through this Thank you for taking the time to go through this

presentation. I am well aware that there is a ton of presentation. I am well aware that there is a ton of information here, and it is only intended as an information here, and it is only intended as an introduction. Please do not be discouraged. You will get introduction. Please do not be discouraged. You will get all of this stuff down with practice, which you should do all of this stuff down with practice, which you should do anytime you get the chance. Also, be active in asking anytime you get the chance. Also, be active in asking the questions you have to the members of your the questions you have to the members of your crew…they are there to help you.crew…they are there to help you.–– Thanks also to all the supermodels who let me take pictures of Thanks also to all the supermodels who let me take pictures of

their hands and faces their hands and faces ☺☺–– Thanks to Dayton Thanks to Dayton HaughHaugh for being our great leader and for his for being our great leader and for his

help with this.help with this.–– Please email me (john k) with questions: [email protected] email me (john k) with questions: [email protected]

•• “Wherever you are, be all there.” “Wherever you are, be all there.” --Jim ElliotJim Elliot

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The Basic of ALS Assistance - Albemarle Rescue Squadcarsrescue.org/wp-content/uploads/2012/Downloads/drugbox.pdf · The Basic of ALS Assistance ... – ALWAYS used in trauma and cardiac