EMS Medication Administration - Inhalation Route

EMS Providers need to have a thorough understanding of inhaled medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Respiratory distress due to conditions like asthma, chronic obstructive pulmonary disease (COPD), or anaphylaxis.
• Administration of medications such as bronchodilators (e.g., albuterol), corticosteroids, and emergency medications (e.g., epinephrine via nebulizer for severe allergic reactions).

Contraindications:

• Allergy to the medication.
• Inability of the patient to effectively inhale the medication (e.g., severe respiratory distress, altered mental status).
• Situations where the administration method (e.g., nebulizer, metered-dose inhaler) is not suitable due to specific patient conditions or environmental factors.

2. Types of Inhaled Medications

Metered-Dose Inhalers (MDIs): 

Pressurized canisters that deliver a specific dose of medication in aerosol form.

Dry Powder Inhalers (DPIs): 

• Devices that deliver medication in powder form which the patient inhales.

Nebulizers: 

• Devices that convert liquid medication into a fine mist for inhalation over several minutes.

Breath-Actuated Inhalers: 

• Devices that release medication automatically when the patient inhales.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the inhaler or nebulizer is properly assembled and medication is correctly loaded.

Patient Preparation:

• Ensure the patient is in an upright position to maximize lung expansion and facilitate proper inhalation.
• Instruct the patient on how to use the inhaler or nebulizer correctly.

4. Administration Techniques

MDIs:

• Shake the inhaler well before use.
• Attach a spacer if recommended, which helps in delivering more medication to the lungs.
• Have the patient exhale fully, place the mouthpiece in their mouth, and inhale slowly and deeply while pressing the canister to release the medication.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.
• Wait about a minute between puffs if a second dose is needed.

DPIs:

• Load the dose according to the inhaler’s instructions.
• Have the patient exhale fully away from the inhaler, place the mouthpiece in their mouth, and inhale quickly and deeply.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.

Nebulizers:

• Assemble the nebulizer and add the prescribed medication to the medication cup.
• Attach the mouthpiece or mask to the nebulizer.
• Turn on the nebulizer and have the patient inhale the mist steadily until the medication is finished (usually 5-10 minutes).

5. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on how to use the inhaler or nebulizer, including breathing techniques and the importance of taking slow, deep breaths.

6. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient’s respiratory status, including breath sounds, respiratory rate, and oxygen saturation, to determine the effectiveness of the medication and any need for additional intervention.

7. Complications and Management

Incorrect Usage: 

• Ensure the patient understands and correctly follows the administration technique to avoid ineffective dosing.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, such as tachycardia, tremors, or paradoxical bronchospasm.

Device Malfunction: 

• Recognize and troubleshoot any issues with the inhaler or nebulizer.

8. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering inhaled medications to these populations, such as the use of spacers for children or coordination issues in the elderly.

Environmental Factors: 

• Ensure the environment is suitable for nebulizer use, especially in situations where power sources may be limited or there is a risk of spreading infectious aerosols.

Patient Condition: 

• Be aware of any conditions that might affect inhaled medication administration, such as severe respiratory distress, altered mental status, or inability to follow instructions.

9. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in inhaled medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for inhaled administration.

10. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective inhaled medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Operations - Rural Paramedics Making House Calls

In Terlingua, Texas, a new community paramedicine program is helping reduce emergency room visits by having paramedics regularly check on residents with chronic health issues.

This initiative addresses the lack of nearby hospitals and doctors, providing preventative care and support, especially for elderly and reclusive individuals.

Funded by a USDA grant, the program aims to prove its cost-effectiveness by lowering readmissions, despite current challenges with insurance reimbursements for paramedic house calls.

The goal is to sustain these programs through demonstrated economic and health benefits.

A recent NAEMT report listed more than 150 of these kinds of community paramedicine programs across the country yet economic models are challenging.

For more details, visit the article below.

https://www.marketplace.org/2024/06/28/community-paramedicine-visits-west-texas-ems-paramedics/? 

EMS Medication Administration - Sublingual (SL) Route

EMS Providers must be knowledgeable about sublingual (SL) medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Need for rapid absorption and onset of action.
• Common medications include nitroglycerin (for chest pain) and certain antiemetics or anxiolytics.
• Patients who can follow instructions and keep the medication under their tongue without swallowing.

Contraindications:

• Altered mental status or decreased level of consciousness.
• Difficulty following instructions or maintaining medication placement under the tongue.
• Severe mouth or tongue injuries.
• Allergies to the medication.

2. Mechanism of Action

Rapid Absorption: 

• Medications administered sublingually are absorbed directly into the bloodstream through the rich vascular supply under the tongue, bypassing the gastrointestinal tract and first-pass metabolism in the liver.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the medication is appropriate for sublingual administration.

Patient Preparation:

• Ensure the patient is in a seated or semi-reclined position to facilitate easy administration and reduce the risk of aspiration.
• Instruct the patient to lift their tongue or open their mouth as needed.

Administration:

• Place the medication under the patient’s tongue.
• Instruct the patient to close their mouth and avoid chewing, swallowing, or moving the medication around.
• Ensure the patient understands to let the medication dissolve completely.

4. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on what to do with the medication (e.g., not to swallow or chew it) and how long it might take to dissolve.

5. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient's condition to determine the effectiveness of the medication and any need for additional intervention.

6. Complications and Management

Ineffective Absorption: 

• Ensure the medication remains in place under the tongue to prevent reduced effectiveness.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, including allergic reactions or side effects specific to the medication being administered.

Local Irritation: 

• Monitor for signs of local irritation or discomfort under the tongue.

7. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering sublingual medications to these populations.

Medication Properties: 

• Understand the specific characteristics of the sublingual medication being administered, including onset and duration of action.

Patient Condition: 

• Be aware of any conditions that might affect sublingual administration, such as dry mouth or oral lesions.

8. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in sublingual medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for sublingual administration.

9. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective sublingual medication administration requires EMS Providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medfication Administration - Oral (PO) Route

EMS Providers should be well-informed about oral medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

Situations where the patient can safely swallow and absorb medications.

Management of mild to moderate pain, allergic reactions, nausea, or chronic conditions.

Administration of medications such as aspirin (for chest pain), glucose (for hypoglycemia), or activated charcoal (for certain poisonings).

Contraindications:

Altered mental status or decreased level of consciousness, posing a risk of aspiration.

Difficulty swallowing or a risk of choking.

Severe nausea or vomiting.

Certain medical conditions or contraindicated medications.

2. Types of Oral Medications

Tablets and Capsules: Solid dosage forms that may need to be swallowed whole or chewed.

Liquids: Solutions, suspensions, or syrups.

Orally Disintegrating Tablets (ODTs): Tablets that dissolve quickly in the mouth.

Buccal and Sublingual: Medications placed in the cheek pouch or under the tongue for rapid absorption.

3. Preparation and Technique

Verification:

Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation

Patient Positioning:

Ensure the patient is in an upright position to facilitate swallowing and reduce the risk of aspiration.

Medication Administation:

For tablets/capsules: Provide a full glass of water and instruct the patient to swallow the medication.

For liquids: Measure the correct dose using an appropriate measuring device and ensure the patient drinks it all.

For ODTs, buccal, and sublingual: Place the medication in the patient’s mouth as directed and ensure they do not chew or swallow it prematurely.

4. Patient Communication and Education

Explain the Medication: Inform the patient about the medication’s purpose, expected effects, and any potential side effects.

Instructions: Provide clear instructions on how to take the medication, including any specific considerations (e.g., take with food or on an empty stomach).

5. Monitoring and Follow-Up

Observe for Effects: Monitor the patient for expected therapeutic effects and any adverse reactions.

Reassessment: Regularly reassess the patient's condition to determine the effectiveness of the medication and any need for additional intervention.

6. Complications and Management

Aspiration: Recognize signs of aspiration (e.g., coughing, choking) and know how to manage it (e.g., positioning, suction, airway management).

Allergic Reactions: Be prepared to manage allergic reactions, including anaphylaxis, by monitoring for symptoms and having emergency medications available.

Gastrointestinal Upset: Some oral medications can cause nausea or gastrointestinal discomfort; provide supportive care as needed.

7. Special Considerations

Pediatric and Geriatric Patients: Adjust dosages appropriately and consider additional challenges in administering oral medications to these populations (e.g., difficulty swallowing, altered taste).

Patients with Chronic Conditions: Be aware of any chronic conditions that may affect medication administration or absorption.

Medication Interactions: Understand potential interactions with other medications the patient is taking.

8. Legal and Ethical Considerations

Scope of Practice: Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: Obtain informed consent from the patient or guardian whenever possible.

Documentation: Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective oral medication administration requires EMS providers to combine theoretical knowledge with practical skills.

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS HazMat Emergencies - I Smell A Pool...We Don't Have A Pool...!

The article addresses the dangers of accidentally creating chlorine gas by mixing household bleach and vinegar, a common mistake due to misleading cleaning tips seen on social media. 

Chlorine gas exposure can lead to severe respiratory issues, including tachypnea, cyanosis, wheezing, and potentially fatal pulmonary edema. The Centers for Disease Control (CDC) warns of the risks, highlighting the need for immediate mitigation by removing the victim from the contaminated area and utilizing positive pressure ventilation (PPV) fans for decontamination.

EMS Providers must avoid exposure to chlorine gas without proper protective equipment like SCBA (Self-Contained Breathing Apparatus). They should prioritize ventilating the area and conducting a risk-benefit analysis before attempting rescues. 

The primary treatment for chlorine gas exposure involves removing contaminated clothing, administering oxygen, and using bronchodilators for wheezing. Long-term management may include monitoring for Reactive Airway Dysfunction Syndrome (RADS), a lifelong condition caused by chemical-induced asthma.

Effective communication with medical facilities and poison control is crucial during such incidents. The article emphasizes public education to prevent mixing household chemicals and highlights the historical and industrial uses of chlorine. 

Proper handling and awareness can prevent accidental poisonings and ensure safety in both residential and industrial settings.

Read the full article by accessing the link:

https://www.foamfrat.com/post/i-smell-a-pool-we-don-t-have-a-pool

EMS Medication Administration - Subcutaneous (SC) Route

EMS providers need to be well-versed in subcutaneous (SC) medication administration to ensure effective and safe patient care. Here are the key points they should know:

1. Indications and Contraindications

Indications:

Medications that require slow, sustained absorption such as insulin, heparin, and certain vaccines.

Situations where IV or IM routes are not appropriate or available.

Contraindications:

Allergy to the medication

Presence of infection or injury at the injection site

Conditions causing poor blood flow or perfusion to the skin, such as shock or severe edema.

2. Anatomy and Site Selection

Common SC Injection Sites:

Upper outer arm

Abdomen (avoiding a 2-inch radius around the navel)

Anterior thighs

Upper buttocks or hips

Site Selection Criteria:

Rotating sites to avoid tissue damage

Considering the patient's preference and comfort

Avoiding areas with scars, bruises, or inflammation

3. Preparation and Technique

Medication Preparation:

Verify the medication, dose, and expiration date.

Use aseptic technique to draw up the medication.

Injection Technique:

Clean the injection site with an antiseptic wipe.

Pinch the skin to lift the subcutaneous tissue away from underlying muscle.

Insert the needle at a 45-degree angle (or 90 degrees if using a short needle or for thicker subcutaneous tissue).

Inject the medication slowly and steadily.

Withdraw the needle and apply gentle pressure to the site with a sterile gauze.

4. Needle Selection

Needle Length: Typically 3/8 to 5/8 inches.

Needle Gauge: Usually 25 to 30 gauge, depending on the viscosity of the medication and the patient's subcutaneous tissue.

5. Medication Administration

Dosage and Volume: Adhere to recommended dosage and volume limits (generally up to 1 mL for subcutaneous injections).

Rate of Administration: Inject the medication slowly to reduce discomfort and ensure proper absorption.

6. Complications and Management

Pain and Discomfort: Techniques to minimize pain include using a quick, smooth insertion, and injecting the medication slowly.

Bleeding and Bruising: Applying gentle pressure post-injection can prevent these.

Infection: Use aseptic technique and proper site selection to prevent infection.

Lipodystrophy: Rotate injection sites to avoid lipodystrophy (abnormal distribution of fat tissue).

7. Special Considerations

Patient Age and Size: Adjust needle size and injection site based on the patient’s age, size, and subcutaneous tissue thickness.

Medication Properties: Some medications may cause irritation or require specific injection techniques.

Patient Positioning: Position the patient comfortably to ensure relaxation and reduce the risk of complications.

8. Training and Proficiency

Simulation Training: Regular practice using simulation models to maintain proficiency in SC injection techniques.

Continuing Education: Stay updated on best practices, new medications, and techniques.

9. Legal and Ethical Considerations

Scope of Practice: Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: Obtain informed consent from the patient or guardian whenever possible.

Documentation: Accurate documentation of medication name, dose, route, site of injection, time of administration, and any adverse reactions.

Conclusion

Effective SC medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Operations - Community Paramedicine In Kansas

The article from the Kansas Health Institute discusses the emerging model of community paramedicine in Kansas, which seeks to enhance healthcare delivery through non-traditional roles for paramedics and emergency medical services (EMS) personnel.

Community paramedicine aims to provide more comprehensive care by addressing gaps in the healthcare system, particularly in rural and underserved areas.

This model involves paramedics delivering primary care, conducting follow-up visits, managing chronic diseases, and providing preventive services in patients' homes, thus reducing hospital readmissions and emergency room visits.

Key policy considerations highlighted in the article include:

1. Regulatory and Legislative Framework: Adjustments to state regulations and legislative support are crucial for the successful implementation of community paramedicine programs.
2. This includes defining the scope of practice for paramedics and ensuring appropriate training and certification​.
3. Funding and Reimbursement: Sustainable funding models and reimbursement policies need to be developed to support community paramedicine services.
4. This might involve collaboration with Medicaid, Medicare, and private insurers to recognize and reimburse these services adequately​.
5. Integration with Healthcare Systems: Effective integration with existing healthcare systems and coordination with primary care providers, hospitals, and public health agencies are essential for the program's success.
6. This includes establishing protocols for information sharing and care coordination​.
7. Workforce Development: Ensuring that paramedics receive proper training in areas such as chronic disease management, preventive care, and patient education is vital.
8. This may require changes to current paramedic education programs and ongoing professional development opportunities​.

Conclusion

The community paramedicine model has the potential to improve health outcomes, particularly in areas with limited access to healthcare, by leveraging the skills and availability of paramedics to provide a broader range of services directly in patients' homes.

Further information can be accessed below:

https://www.khi.org/articles/community-paramedicine-in-kansas-policy-considerations-for-an-emerging-model-of-care/ 

EMS Clinical Review - Best Practice For IM Injections

This 2018 article by Andrew Kirk in the Journal of Paramedic Practice emphasizes the importance of adhering to best practices for intramuscular (IM) injection techniques in pre-hospital care. 

It highlights that while these skills are initially taught during training, they often are not revisited, leading to suboptimal practice and potential patient discomfort. 

The article provides an overview of IM injection sites, indications, and complications, promoting an evidence-based approach to ensure the effective administration of medications and to minimize patient pain.

For optimal patient care, understanding the various injection sites and their suitability for different scenarios is crucial. The article identifies five primary sites for IM injections and discusses the differing recommendations in the literature regarding their use. 

Emphasizing evidence-based practice, the article aims to update and refine paramedics' skills to improve patient outcomes.

https://www.paramedicpractice.com/content/features/best-practice-technique-in-intramuscular-injection/The piece underscores the significance of continuous education and skill refinement for paramedics, focusing on practical aspects of IM injections. 

It encourages paramedics to stay informed about best practices to ensure that their techniques remain effective and safe, thereby enhancing the overall quality of patient care in emergency settings. 

For further details, you can read the full article here:

https://www.paramedicpractice.com/content/features/best-practice-technique-in-intramuscular-injection/

EMS Medication Administration - Intramuscular (IM) Route

EMS providers must understand various aspects of intramuscular (IM) medication administration to ensure patient safety and effective treatment.

Here are the key points they should know:

1. Indications and Contraindications

• Indications:
• Rapid medication absorption is needed but IV access is not available or practical.
• Administration of certain vaccines, antibiotics, epinephrine (for anaphylaxis), analgesics, and sedatives.

• Contraindications:
  • Allergy to the medication
  • Presence of infection or injury at the injection site
  • Conditions causing poor blood flow to muscles, such as shock

2. Anatomy and Site Selection

• Common IM Injection Sites:
• Deltoid Muscle: Suitable for small-volume injections (up to 1 mL).
• Vastus Lateralis Muscle: Preferred for larger volumes (up to 5 mL), especially in infants and children.
• Ventrogluteal Muscle: Preferred for larger volumes and irritating medications.
• Dorsogluteal Muscle: Less preferred due to the risk of sciatic nerve injury.

• Site Selection Criteria:
  • Volume of medication
  • Age and size of the patient
  • Muscle mass and presence of adipose tissue

3. Preparation and Technique

• Medication Preparation:
• Check the medication for correct name, dose, and expiration date.
• Use aseptic technique to draw up the medication.

• Injection Technique:
  • Clean the injection site with an antiseptic wipe.
  • Use a quick, dart-like motion to insert the needle at a 90-degree angle.
  • Aspirate slightly to ensure the needle is not in a blood vessel (optional and based on local protocols).
  • Inject the medication slowly and steadily.
  • Withdraw the needle and apply pressure to the site to prevent bleeding.

4. Needle Selection

• Needle Length: Typically ranges from 1 to 1.5 inches for adults and 5/8 to 1 inch for children.

• Needle Gauge: Usually 22 to 25 gauge, depending on the viscosity of the medication and the muscle mass.

5. Medication Administration

• Dosage and Volume:
• Adhere to the recommended dosage and maximum volume for each injection site.
• For adults: Deltoid (up to 1 mL), Vastus Lateralis (up to 5 mL), Ventrogluteal (up to 3 mL).

• Rate of Administration: Inject the medication slowly to reduce discomfort.

6. Complications and Management

• Pain and Discomfort: Techniques to minimize pain include ensuring the muscle is relaxed, using a quick insertion, and administering the medication slowly.

• Bleeding and Hematoma: Applying pressure post-injection can prevent these.

• Infection: Using aseptic technique and proper site selection helps prevent infection.

• Nerve Injury: Correct site selection and needle length are crucial to avoid nerve damage, particularly in the dorsogluteal site.

7. Special Considerations

• Patient Age and Size: Adjust needle size and injection site based on the patient's age, muscle mass, and adipose tissue.

• Medication Properties: Some medications may cause irritation or require specific injection techniques.

• Patient Positioning: Position the patient comfortably to ensure muscle relaxation and reduce the risk of complications.

8. Training and Proficiency

• Simulation Training: Regular practice using simulation models to maintain proficiency in IM injection techniques.

• Continuing Education: Staying updated on best practices, new medications, and techniques.

9. Legal and Ethical Considerations

• Scope of Practice: Adhering to legal scope of practice for their certification level and local regulations.

• Informed Consent: Obtain informed consent from the patient or guardian whenever possible.

• Documentation: Accurate documentation of medication name, dose, route, site of injection, time of administration, and any adverse reactions.

Conclusion

Effective IM medication administration requires EMS providers to combine theoretical knowledge with practical skills.

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medication Administration - Intraosseous (IO) Route

EMS providers should have comprehensive knowledge of intraosseous (IO) medication administration within their scope of practice to ensure patient safety and effective treatment. 

Here are the key points they should know:

1. Indications and Contraindications

• Indications:
• IO access is typically used when IV access is difficult or impossible, especially in emergencies.
• Common scenarios include cardiac arrest, severe shock, trauma, and other situations requiring immediate vascular access.

• Contraindications:
  • Fractures in the targeted bone
  • Previous orthopedic procedures at the insertion site
  • Infection at the insertion site
  • Osteoporosis or other bone abnormalities

2. Anatomy and Site Selection

• Common IO Sites:
• Proximal tibia
• Distal tibia
• Proximal humerus
• Sternum (primarily in adults)

• Site Selection Criteria:
  • Age of the patient
  • Accessibility of the site
  • Absence of contraindications like fractures or infections

3. IO Device Knowledge

• Types of IO Devices: Familiarity with various IO devices such as manual needles, battery-powered devices (e.g., EZ-IO), and spring-loaded devices.

• Device Operation: Understanding the specific operation, insertion technique, and maintenance of the IO device they are using.

4. Insertion Technique

• Preparation:
• Use of aseptic technique to prevent infection
• Selection of appropriate needle size based on patient age and size

• Insertion Steps:
• Properly positioning the patient
• Identifying the correct anatomical landmarks
• Using correct insertion angle and depth

• Confirmation of Placement:
  • Aspiration of bone marrow or blood
  • Easy flushing of saline without resistance
  • Securing the IO needle to prevent dislodgement

5. Medication Administration

• Types of Medications: Most medications that can be given IV can also be administered IO, including fluids, blood products, antibiotics, and emergency medications.

• Dosage and Rate:
• Ensuring correct dosing similar to IV administration
• Awareness of potential variations in absorption and onset of action

• Flush Protocol: Flushing the IO line with saline to ensure patency and proper delivery of medications.

6. Complications and Management

• Extravasation: Recognizing and managing extravasation (leakage of fluid into surrounding tissues).

• Infection: Preventing and identifying signs of infection at the insertion site.

• Compartment Syndrome: Monitoring for and managing compartment syndrome, a serious condition caused by increased pressure in a muscle compartment.

• Fat Embolism: Awareness of the rare risk of fat embolism, particularly in long bone insertion sites.

7. Pain Management

• Local Anesthesia: Use of lidocaine or other local anesthetics to reduce pain during insertion, especially in conscious patients.

• Post-Insertion Pain: Monitoring and managing any pain or discomfort associated with the IO line.

8. Training and Proficiency

• Simulation Training: Regular training and practice using simulation models to maintain proficiency in IO insertion and management.

• Certification: Ensuring certification and adherence to protocols established by the EMS service and medical oversight.

9. Legal and Ethical Considerations

• Scope of Practice: Adhering to the legal scope of practice for their certification level and local regulations.

• Informed Consent: Whenever possible, obtaining informed consent from the patient or their guardian before IO insertion.

• Documentation: Accurate documentation of the indication, insertion site, device used, medications administered, and any complications encountered.

Conclusion

Effective IO medication administration requires EMS providers to combine detailed anatomical knowledge, practical skills, and a strong understanding of the indications, techniques, and potential complications. 

Continuous training and adherence to protocols are essential to ensure the safety and efficacy of this critical intervention. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Philbeck, T. E (2010) Pain Management with the use of IO. Journal of Emergency Medical Services. https://www.jems.com/patient-care/pain-management-use-io/ Accessed June 10, 2024