September 27, 2024

Welcome back to UH EMS-I’s Pharmacy Phriday. In this installment, we continue our series reviewing various medication routes used by our providers, focusing on the Intravenous (IV) administration route. It is important to understand the benefits, risks, and safety concerns of the IV route, some of which we’ll review today. 

A major advantage of IV administration is that it allows medication directly into the bloodstream, providing a rapid onset of action. An additional benefit is that using the IV route to administer medication does not require repeated needle sticks to administer repetitive doses intramuscularly, if needed. This decreases patient pain and discomfort associated with treatment. It is also a common, familiar, and comfortable method used by the paramedic, and, in some cases, the only accepted route for some medications. 

Though the procedure is a high-frequency skill, there is also a high risk that accompanies IV medication administration. Not considering the obvious risk that goes along with any medication administration, disadvantages, and risks associated with the IV route can include:  

• arterial puncture 

• damage to nerves, tendons, or ligaments, catheter shears  

• extravasation  

• embolisms 

• forming of a precipitate  

• hematomas  

• infection 

• infiltration 

The provider should be mindful of these risks and take steps to prevent such events. Some of these steps may include: following aseptic techniques during the procedure; ensuring IV access is patent before administering any medications, especially those that can irritate or be harmful to surrounding tissues like calcium chloride and glucose; dispelling any air in syringes and tubing to reduce the risk of an air embolism; and check the compatibility of medications and solutions before administration. Mixing incompatible solutions or medications can cause a precipitate to form, causing harm to the patient. An example includes ensuring that calcium chloride is never administered with sodium bicarb.  

In addition to concerns for patient safety, concerns also exist for the provider when using the IV administration route, such as blood-borne pathogen exposures, needle stick injuries, etc. Use appropriate PPE and properly dispose of needles and other equipment used when performing IV cannulation and medication administration.  

IV medications may be administered using a primary IV line running TKO or through a saline lock. Remember that saline locks are an alternative to the traditional IV line and are preferred in some situations. These may include instances when a patient does not require immediate medications or fluids, they only require medication administration and not fluid therapy, and the like. 

Sites for IV cannulation are most frequently located in the upper extremities and may include veins on the hand, forearm, and antecubital. Other peripheral sites can be considered such as on the lower extremities (dorsal veins), or in rare cases, the external jugular (EJ).  

Considerations when choosing a site for an IV might include: 

• The use of the IV and choosing veins appropriately (i.e., fluid boluses, administration of glucose, etc.) 

• Upper extremity sites are preferred over lower extremity sites 

• Lower extremity sites are relatively contraindicated in patients with vascular disease or diabetes 

• In patients that have had a mastectomy, avoid using the arm on the affected side, just like you would avoid that side in obtaining blood pressure 

• Avoid extremities with dialysis fistulas, trauma, or infection 

• The EJ site is only to be used in patients older than 8 years of age, and when an extremity vein is not obtainable. (Use of the IO site is preferred over the EJ, which we’ll cover in the next installment). Only one attempt is permissible in cannulating the EJ!  

• When possible, start distally and work proximally when attempting an IV 

• Involve the patient! They may have experience with having had an IV or blood draw and know sites where other providers have been successful.

In addition to the standard steps of medication administration discussed in previous installments, additional steps to consider in giving medication via the IV route include: 

• Choosing the closest injection port to the patient 

• Cleansing injection ports before use 

• Assure the patency of the line by checking for infiltration (In cases of a saline lock, a flush should be provided before use). 

• Clamp or pinch off the IV tubing proximally to prevent backflow of the medication towards the IV bag and a reduction of the desired dose and effect on the patient 

• Inject the medication into the port (Remember to consider the appropriate rate of the bolus. Most medications administered by the IV route are given slowly to limit adverse reactions or side effects. Check the guidelines provided in your protocol and drug reference guides. Can you recall a medication requiring a rapid push?) 

• Flush the line or open the IV to a wide open flow briefly following the administration of the drug 

• Properly dispose of any needles and equipment used 

In the next installment, we will review the last route covered in this series, the Intraosseous (IO) route. Do you recall the accepted sites? What about the medications that can be given via that route?  

Till then, stay safe! 



Sincerely,

The UH EMS-I Team

University Hospitals