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Venous Access Extremity

Clinical Indications:
Any patient where intravenous access is indicated (significant trauma or mechanism, emergent or potentially emergent medical condition).

Procedure:
1. Normal Saline IV Lock may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS professional. In addition, a Normal Saline IV Lock will precede all IV set-ups in order to confirm patency prior to IV fluid administration.

2. Inspect the IV solution for vessel/packaging integrity, expiration date, cloudiness, discoloration, leaks, and/or the presence of particles.

3. Using a 10ml syringe filled with Normal Saline (or larger), connect to the Lock set-up (e.g. extension set, "J" loop, etc.), and prime the tubing, flushing all air bubbles from the tubing.

4. Place a tourniquet around the patient's extremity above the expected IV access site to restrict venous flow only. Avoid (if possible) the following:
- Extremities with suspected fracture/trauma.
- Extremities sharing the same side as previous surgical procedures (e.g. lymph node dissection, mastectomy, etc.).
- Extremities with other access types (e.g. dialysis fistula, PICC line, etc.).

5. Select an IV access site and use the largest catheter bore necessary based upon the patient's condition and size of vein. Paramedic should consider as an initial IV access, the right Antecubital (R-AC) site for ALL SUSPECTED STOKE PATIENTS, 18 gauge IV or larger.

6. Prep the skin with an antiseptic solution.

7. Insert the needle with the bevel up into the skin at a 15-30 degree angle in a steady, deliberate motion until the bloody flashback is visualized in the catheter.

8. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle without recapping into an appropriate biohazard container.

9. Draw blood samples when appropriate.

10. Remove the tourniquet and connect the primed Normal Saline IV lock with 10ml prefilled syringe connected.

11. Aspirate the syringe slightly ensuring blood return and venous access patency. Flush the remaining contents of the Normal Saline syringe. Be sure to visualize and/or palpate above the IV access site for infiltration.

12. Cover the site with a sterile dressing and secure Normal Saline IV lock.

13. Disconnect the syringe from the Normal Saline lock and discard.

14. Label the Normal Saline IV lock with date and time, catheter gauge, and name/ID of the person completing the procedure.

15. Document the procedure, time and result (success) on/with the patient care report (PCR).

If IV fluid administration is required, follow steps below:
- Normal Saline IV Lock set-up (10ml prefilled syringe w/ Luer Lock tip) for all initial IV attempts.
- Lactated Ringers or Normal Saline with a macro drip (10 gtt/cc) for trauma or hypovolemia.
- Normal Saline with a macro drip (10 gtt/cc) for medical conditions.
- Normal Saline with a micro drip (60 gtt/cc) for medication infusions.

1. Inspect the IV solution for vessel/packaging integrity, expiration date, cloudiness, discoloration, leaks, and/or the presence of particles.

2. Connect IV tubing per manufacturer/packaging directions to the solution in a sterile manner. Fill the drip chamber of the IV set half full and then flush the tubing, bleeding all air bubbles from the tubing.

3. Prep the Luer lock connection of the Normal Saline IV lock with an antiseptic solution and then connect IV tubing in a sterile manner.

4. Open the IV to insure the free flow of the fluid and then adjust the flow rate as per protocol or clinically indicated.

5. Label the IV with date and time, catheter gauge, and name/ID of the person starting the IV.

6. Document the procedure, time and result (success) on/with the patient care report (PCR).

NOTE: Paramedics may use intraosseous access where threat to life exists, http://www.jointemsprotocols.com/Intraosseous.

DRIP RATES:

Maintenance/Keep Vein Open (KVO)
- Adult: 60 cc/hr (1 gtt/ 6 sec for a macro drip set)
- Pediatric: 30 cc/hr (1 gtt/ 12 sec for a macro drip set)

If shock is present, refer to appropriate protocol
- Adult Medical, http://www.jointemsprotocols.com/hypotension-shock-nontrauma
- Adult Trauma, http://www.jointemsprotocols.com/multiple-trauma
- Pediatric Medical, http://www.jointemsprotocols.com/pediatric-hypotension-shock
- Pediatric Trauma, http://www.jointemsprotocols.com/pediatric-multiple-trauma

Competency Based Skill Requirements:
Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure.

Last Update 08/02/2018

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