IV or no IV?

[Milla3P]

I'm personally in favor of starting saline locks on almost everybody.

MOST IVs I've seen started prehospital are started to run NS KVO because someonebody's sick and never have anything more than 15 to 30 cc's of fluid run through them. That's not good justification for a full on 1000 bag/10 set/14ga. But what's wrong with access? The local Level 1 I did my clinicals at drew at least 2 tubes of blood and just left the INT in on almost every pt. Anybody that was even moderately sick usually got bilat lines. (Dear god, how do they take a B/P?!)

Does your local ED accept bloods? If you're saying that you want to make it easier on the nurses why not draw a set of tubes? You might even get a hug out of them.

How long is your T/P time? 7 minutes or less? 45 minutes?

Who hasn't seen a call go from Run-of-the-Mill to Pucker Factor 10? Is that the time to be scrambling to start a line, or do you want to start possible interventions as soon as possible?

And lastly, Is this an argument between younger/newer and more experienced providers? Is there a chance it involves skill level or a level of comfort performing a skill on some stranger?

I typically go with the trusty "Be Prepared" motto, hasn't steered me wrong yet.

99.99% of the time I would say any more fluid than 10cc NS run through a lock is overkill, but IMO, there's nothing wrong with a 20ga INT.

 

[tssemt2010]

I'm personally in favor of starting saline locks on almost everybody.

MOST IVs I've seen started prehospital are started to run NS KVO because someonebody's sick and never have anything more than 15 to 30 cc's of fluid run through them. That's not good justification for a full on 1000 bag/10 set/14ga. But what's wrong with access? The local Level 1 I did my clinicals at drew at least 2 tubes of blood and just left the INT in on almost every pt. Anybody that was even moderately sick usually got bilat lines. (Dear god, how do they take a B/P?!)

Does your local ED accept bloods? If you're saying that you want to make it easier on the nurses why not draw a set of tubes? You might even get a hug out of them.

How long is your T/P time? 7 minutes or less? 45 minutes?

Who hasn't seen a call go from Run-of-the-Mill to Pucker Factor 10? Is that the time to be scrambling to start a line, or do you want to start possible interventions as soon as possible?

And lastly, Is this an argument between younger/newer and more experienced providers? Is there a chance it involves skill level or a level of comfort performing a skill on some stranger?

I typically go with the trusty "Be Prepared" motto, hasn't steered me wrong yet.

99.99% of the time I would say any more fluid than 10cc NS run through a lock is overkill, but IMO, there's nothing wrong with a 20ga INT.

most of the hospitals around here throw away our blood draws from the ambulance so we dont even mess with it anymore, and you can take a bp on an arm with an IV, although it is not preferred it is still possible

 

[Mobey]

I start it,
Of course I practice proactive, not reactive. But I realize that is not for everyone.

 

[Shishkabob]

Do you foresee needing an IV yourself, or see one later on down in their treatment path at the hospital? If so, start one.

If they can justify an ambulance, you can justify an IV.

 

[usalsfyre]

Who hasn't seen a call go from Run-of-the-Mill to Pucker Factor 10? Is that the time to be scrambling to start a line, or do you want to start possible interventions as soon as possible?

Excepting freak circumstance, if this is happening with anything approaching frequency you need to assess your patients more thoroughly.

 

[rhan101277]

If it is warranted I start one. If they have been vomiting and appear dehydrated w/ good vitals I start 1,000 bag and TKO, the hospital usually runs the whole bag in. If it is something I think is non emergent or bologna, I don't start one. If I don't have enough time I don't start one.

If I have to push any meds I will at least hang a 500 bag an run TKO. The people who get the big bags are the ones I think will need fluid boluses for whatever reason after all you aren't hanging these bags to look cool. Is is costing the patient in some way, if it is needed don't do it.

 

[exodus]

most of the hospitals around here throw away our blood draws from the ambulance so we dont even mess with it anymore, and you can take a bp on an arm with an IV, although it is not preferred it is still possible

Hospitals around here love us if we get blood for them. They will even give us extra blood tubes if we're running low so we can get it for them.

 

[RocketMedic]

I start one based on my clinical judgement. For patients who I can't see a need for medication or fluids who have virtually no likelihood of needing those, I don't start a line. Other patients get lines, as appropriate.

 

[Medic2409]

I'm not one to do something to a patient just because I can. If they need it, they get it, if they don't, they don't.

 

[Mobey]

I'm not one to do something to a patient just because I can. If they need it, they get it, if they don't, they don't.

Need is such a subjective word.

Does someone with chestpain "Need" oxygen?
Does a CVA "Need" I.V. access?
Does someone with a broken arm "Need" analgesia?

Does someone going in for a scheduled CT "Need" an IV in the ambulance for the contrast dye thier going to get in hospital?

Again: Proactive vs reactive

 

[the_negro_puppy]

Need is such a subjective word.

Does someone with chestpain "Need" oxygen?
Does a CVA "Need" I.V. access?
Does someone with a broken arm "Need" analgesia?

Does someone going in for a scheduled CT "Need" an IV in the ambulance for the contrast dye thier going to get in hospital?

Again: Proactive vs reactive

I completely agree with proactive vs reactive. However not every patient needs an IV cannula. Sure its a pretty simple procedure with low risk and is of great use but there are risks and complications. Again if you need to give an IV drug or reasonably think you may need to give one / good chance the patients condition may change, then go for it.

For example, a person involved in a medium speed MVA with very mild neck pain, nil deficits and states they don't want analgesia. The pt was encapsulated and needed to be cut out. Most people would start an IV given the mechanism of injury involved, and probability of other injuries becoming apparent, internal injuries, or analgesia due to pain increase.

I guess we have an advantage here, where we have rapid acting analgesia such as methoxyflurane that does not require IV access.


Example a COPD pt with a chest infection c/o increased SOB. Maintaining acceptable (for the pt) Sp02 on titrated oxygen, 15 minute transport time, nil other abnormalities found. I would not be starting an IV unless I suspected the patients condition may deteriorate such that they need IV adrenaline (cardiac arrest) as at our level don't have any IV drugs of use.

 

[mycrofft]

OK, what gauge?

Where I last worked, my co-workers were all big for starting an IV on everyone "just in case", but they would start a 22 ga. in the easiest antecubitus to access. FD and hospitals got fed up because either the pt didn't need it, or the cannula was of inadequate caliber, or the best site for a subsequent IV (like for the anesthetist) had been used.
Point is, if you anticipate a precipitous emergency which requires rapid resuscitation, why start a little bore IV? And since it isn't a little IV, then you will need to go to the antecube for many pt's.

 

[NomadicMedic]

Here's my thoughts:

Most people who require an IV don't need more than a 20ga.

I start a line on people that need it. I don't put 'em in "just in case". It's still and invasive procedure and there's no point in doing it if it's not needed.

If the transport time is short, I'll start a line and draw labs.

(in most cases, If I don't have bloods drawn and a line up, I'll usually get a case of the stinkeye from the RN.)

 

[traumamama]

Our transport time to a rural access hospital is over an hour; depending on where the pt is picked up. The ER nurse, and that is singular because that is who is on shift, always appreciates the IV. If we are doing an ALS rendezvous with a LF they expect an IV. Our closest trauma center is over 150 miles away which equates to 3 hours by ground and will rendezvous with another ground half way. We have a high IV success rate and hardly ever use the AC. We do them on the fly. So, if you are our patient and you are sick or injured you are probably going to get an IV. Our MD says go big or stay at home.

 

[usalsfyre]

...hardly ever use the AC.

Why is this such an issue? I use the A/C regularly. Of course I also only start lines when I feel they're warranted.

The forearm is my favorite, the A/C is next. Generally your patients who need IVs will need lab draws and frequently CT contrast. Neither of these are generally well accomplished through hand veins.

 

[fast65]

Why is this such an issue? I use the A/C regularly. Of course I also only start lines when I feel they're warranted.

The forearm is my favorite, the A/C is next. Generally your patients who need IVs will need lab draws and frequently CT contrast. Neither of these are generally well accomplished through hand veins.

I'm in the same boat as you usalsfyre, if the patient needs vascular access then I'm not going to beat around the bush trying for different veins when they've got a nice AC poking out at me.

It's something that seems to be drilled into the heads of students during clinicals to do avoid the AC at all costs just because it makes things a little more difficult. I can't count the number of nurses who told me to never go for the AC.

Now I'm not saying that I immediately go to the AC, if I see a nice vein elsewhere then I'll go for it. I'm more ashamed to walk into the ER with a missed attempt or two in the forearm or hand than I am to walk in with an AC that I hit on the first try. Different strokes I suppose.

 

[usalsfyre]

I'm in the same boat as you usalsfyre, if the patient needs vascular access then I'm not going to beat around the bush trying for different veins when they've got a nice AC poking out at me.

It's something that seems to be drilled into the heads of students during clinicals to do avoid the AC at all costs just because it makes things a little more difficult. I can't count the number of nurses who told me to never go for the AC.

Now I'm not saying that I immediately go to the AC, if I see a nice vein elsewhere then I'll go for it. I'm more ashamed to walk into the ER with a missed attempt or two in the forearm or hand than I am to walk in with an AC that I hit on the first try. Different strokes I suppose.

People don't like going to the floor with lines in the A/C because it limits mobility when meds are being pumped in. Similarly it's why I prefer a forearm if I can get it. BUT, it's a secondary concern. Anyone who says a missed A/C ruins the arm for further sticks doesn't understand collateral circulation. And hands just suck. Not only do they not flow, they hurt.

 

[fast65]

People don't like going to the floor with lines in the A/C because it limits mobility when meds are being pumped in. Similarly it's why I prefer a forearm if I can get it. BUT, it's a secondary concern. Anyone who says a missed A/C ruins the arm for further sticks doesn't understand collateral circulation. And hands just suck. Not only do they not flow, they hurt.

Yeah, I know about the concern of going to the floor with lines in the AC, and I do take that into consideration, but like you said, it's a secondary concern. I'll look down at the forearm first, then I'll check the AC...I just have a terrible time with hand veins.

 

[NomadicMedic]

And hands just suck. Not only do they not flow, they hurt.

That's your opinion. I find a decent hand vein in at least half of my PTs requiring a line. Some will take an 18 with no issues, and they flow like a champ. And most people say the hand IV hurts no worse than any other stick.

Now obviously, the little old lady with tiny, spidery veins will NOT get a hand stick from me, nor will PTs who need Adenosine, D50 or may need contrast, but if I've got a big ol dorsal vein for a TKO line, I'm on that one first.

 

[usalsfyre]

That's your opinion.

Entirely opinion, and not to say I refuse to stick a hand ever. I just prefer not to. Another disadvantage in my mind is the propensity I've seen out of lines in the hand to get snagged and come out.