IV Sticks - AEMT noob tips and tricks?

[the_negro_puppy]

I am in the same boat. I have performed less than 50 IV attempts and have good days and bad.

Its much harder to start IVs in the field than in supine patient on a hospital bed.


The other week I had my first go on a pt in cardiac arrest I got in the vein successfully but just as I was about to advance the pt's arm moved a bit due to compressions and the needles went straight through

Its all about confidence. Having people standing over you and watching all the time can put the pressure on. The best preceptors are the ones that once they know you have the technique down, go get the stretcher/do other things and let you do it on your own!


try to learn the common anatomical positions where veins are found, especially helpful in children, obese pts etc

Just remember, not everyone needs a large bore cannula in the AC. Different gauges and positions should be used for different reasons. Why put a 16 or 18 gauge in the AC just to give analgesia in an uncomplicated pt?

a 20 gauge (even 22) if need be in the hand, wrist or forearm will suffice! I also find dangling the limb (using gravity) and lightly smacking/tapping veins (releases histamines) works wonders to bring out veins.

If you start distally and blow the vein, you can always move proximal.


Thanks for the tips

 

[alphatrauma]

If you start distally and blow the vein, you can always move proximal.

This!

 

[BeachmedicJB]

What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?[/QUOTE


You can place her feet up and hope that helps, use a flashlight against her skin (this is my personal favorite) or you can place an IO if you REALLY need access. If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway; however the hypotension can be a complication. On the other hand,if she has a pressure of like 90/50 and weighs like 85lbs then she may not be truly hypotensive as the books will teach you. Always treat your patient, (i.e. capillary refill, skin color/conditon/temperature of the extremities) and learn to apply what you learned in class with real world experience.

 

[Shishkabob]

We can't treat dehydration?

 

[NomadicMedic]

If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway.

Really? Cuz I treat that all the time.

(I hate to clue you in, but those big bags of fluid you have on your truck? Ya know, the one's that say "Normal saline" on 'em? Yeah... that's what they're for...)

 

[usalsfyre]

Dangit, I guess I WASN'T really treating the last patient I gave a bolus too...

 

[TomB]

Put down the rail on the gurney and take a knee along side the patient. Place your tourniquet and learn to apply it so that the ends point up toward the patient's head (not your work area). Hold the arm below the level of the patient's heart so the veins become distended. Hold the skin taut. If you do these things you will be well on your way. Don't be afraid to stick the patient. I almost always attempt to obtain a flash with the initial stick. Then give it a little bump to make sure the bevel clears the lumen and look for the secondary flash up the catheter as you advance that lets you know you're in. If you miss (which you will from time to time) keep your cool and don't let the patient see you sweat. It's a rare patient indeed who as ever died for want of a prehospital IV. It's not a big deal so treat it that way and your patient will forgive you. On those rare occasions where you're not sure whether or not you're running fluid into the patient's vein or into the patient's flabby arm you can occlude the vein several inches above the hub of the catheter. If the IV stops flowing you're in the vein. Good luck!

 

[18G]

Put down the rail on the gurney and take a knee along side the patient. Place your tourniquet and learn to apply it so that the ends point up toward the patient's head (not your work area). Hold the arm below the level of the patient's heart so the veins become distended. Hold the skin taut. If you do these things you will be well on your way. Don't be afraid to stick the patient. I almost always attempt to obtain a flash with the initial stick. Then give it a little bump to make sure the bevel clears the lumen and look for the secondary flash up the catheter as you advance that lets you know you're in. If you miss (which you will from time to time) keep your cool and don't let the patient see you sweat. It's a rare patient indeed who as ever died for want of a prehospital IV. It's not a big deal so treat it that way and your patient will forgive you. On those rare occasions where you're not sure whether or not you're running fluid into the patient's vein or into the patient's flabby arm you can occlude the vein several inches above the hub of the catheter. If the IV stops flowing you're in the vein. Good luck!

+1 Some good tips indeed.

 

[18G]

What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?[/QUOTE


You can place her feet up and hope that helps, use a flashlight against her skin (this is my personal favorite) or you can place an IO if you REALLY need access. If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway; however the hypotension can be a complication. On the other hand,if she has a pressure of like 90/50 and weighs like 85lbs then she may not be truly hypotensive as the books will teach you. Always treat your patient, (i.e. capillary refill, skin color/conditon/temperature of the extremities) and learn to apply what you learned in class with real world experience.

I just had an 88 y/o from a nursing home the other day with profound dehydration. Pt. refused to eat for four days, poor skin turgor, membranes dry as a dessert, hypotensive at 77/50, change of mental status.

A line with a bolus of NSS improved pressure to 115/70's and had the patient having a conversation with me enroute to the hospital. DEHYDRATION IS VERY EASILY TREATED IN THE FIELD.

 

[firetender]

It's not half as bad now, while you're learning as it will be when, 2 years down the line and you believe yourself proficient that you get a "run" of calls where you can't start an IV to save your life (or theirs, I guess!)

It happens that way sometimes...

...and never neglect the value of sticking your partner (with consent, of course!).

 

[Akulahawk]

I just had an 88 y/o from a nursing home the other day with profound dehydration. Pt. refused to eat for four days, poor skin turgor, membranes dry as a dessert, hypotensive at 77/50, change of mental status.

A line with a bolus of NSS improved pressure to 115/70's and had the patient having a conversation with me enroute to the hospital. DEHYDRATION IS VERY EASILY TREATED IN THE FIELD.

I had one fairly similar to this one about 10 years ago, only she started off with a BP at about 180/102-ish and by the time I was called to check on her 3 days later, she'd gone to 128/84-ish. A little fluid (about 600 mL) and she was conscious, alert, talking to me. I fully expect that the ED ran more tests and likely switched fluid to something more like D5 1/2NS, however, I was long gone by then...

 

[BeachmedicJB]

Really? Cuz I treat that all the time.

(I hate to clue you in, but those big bags of fluid you have on your truck? Ya know, the one's that say "Normal saline" on 'em? Yeah... that's what they're for...)

We treat hypotension with fluid bolus'. Dehydration is treated over the long term with fluid administration based on labs in the hospital. We can reverse hypotension most of the time but we are not fixing dehydration unless you're giving fluids that are not merely volume increasers such as NaCl and you have a set of labs telling you what the patient's needs are such as K+ etc.

 

[Handsome Robb]

Last time I checked we are treating hypotension which often is secondary to dehydration...so therefore treating the hypotension with fluid boluses we are also treating the dehydration.

I'm pretty sure Na is an electrolyte replaced during infusions of 0.9% NS. Also I'm pretty sure H2O is replaced in that whole solution as well

 

[BeachmedicJB]

Last time I checked we are treating hypotension which often is secondary to dehydration...so therefore treating the hypotension with fluid boluses we are also treating the dehydration.

I'm pretty sure Na is an electrolyte replaced during infusions of 0.9% NS. Also I'm pretty sure H2O is replaced in that whole solution as well

I ll agree with start the treatment of dehydration; however we do not completely replace it. That is all that I meant when I said that. There is truly very little we can do other than treat the symptoms. Would you agree?

 

[usalsfyre]

I personally treat dehydration in the absence of hypotension. You don't need chemistries to treat dehydration. Give a liter, see if they look and feel better.

Treatment of electrolyte disturbance is a whole 'nother kettle of fish.

 

[Handsome Robb]

I do agree.

Most if not all of the things we do are treating the symptoms and starting the ball rolling on treatments not actually definitive treatments.

 

[BlakeFabian]

I like to inflate a BP cuff to the Pt's mean BP and let their arm dangle while I prep my equipment. When I'm ready to stick, those veins are usually huge and obvious.

Or I'll run a flashlight under my Pts hand and search for one.

If worse comes to worse, and you're just not able to get one. Just tell the ER that... 'Unable to initiate IV therapy'

Until you develop confidence in your skills, you WILL miss some IVs. Don't let it get you down. Just keep trying. Always start as distal as you can and work your way up.

 

[Ardmoreff]

I was told by a Paramedic t if you couldn't Laplace a vein you could spray Ntg on it

 

[Handsome Robb]

If you need a line that badly drill an IO or look for an EJ...

 

[Akulahawk]

I was told by a Paramedic t if you couldn't Laplace a vein you could spray Ntg on it

I wouldn't, even if I had NTG spray on hand... and if you would, what if your service doesn't carry NTG spray?

If you need a line that badly drill an IO or look for an EJ...

Agreed.