Lisbon Fire Department Standard Operating Guidelines and Policies

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	EMT- Intermediate Technician	EMT-Intermediate	EMT-Paramedic
		XX	XX	XX

To obtain a sample of blood for laboratory analysis

Vacutainer tube Vacutainer holder

Vacutainer needle Tourniquet

Alcohol wipe Gauze sponge

Consent to draw blood sample form

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Explain the procedure to the patient and get his/her signature on the consent if appropriate.
   
3. 
   Remove the plastic protective cap from the end of the double needle protected by a rubber sleeve.
   
4. 
   Screw the double needle into the Vacutainer holder.
   
5. 
   Place a venous tourniquet on the patient’s arm.
   
6. 
   Select an appropriate vein in the antecubital fossa.
   
7. 
   Scrub the selected site with an alcohol wipe.
   
8. 
   Select a vacuum tube with the desired color-coded rubber stopper.
   
9. 
   Insert vacuum tube into the sleeve of the Vacutainer holder, do not push needle completely through rubber stopper.
   
10. 
    Remove the protective plastic cap from the exposed end of the double needle.
    
11. 
    Using sterile technique, insert the needle into the vein.
    
12. 
    Maintaining the position of the needle and holder, push the vacuum tube onto the needle inside the Vacutainer holder.
    
13. 
    When the vacuum tube is full, pull it off the needle.
    
14. 
    Remove the venous tourniquet.
    
15. 
    Withdraw the needle from the patient’s arm at the same angle that it was inserted.
    
16. 
    Apply pressure to the puncture site with a gauze sponge.
    
17. 
    Disassemble and dispose of the needle in the appropriate receptacle.
    
18. 
    Label the blood specimen with the date, time, patient’s name and drawer’s initials.
    
19. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

End page 1

Tourniquet

Alcohol wipes and/or Betadine wipes

Gauze square

Tape or Band-aid
Procedure:

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Explain the procedure to the patient and gain his/her consent.
   
3. 
   Assemble syringe and needle.
   
4. 
   Select venipuncture site, typically antecubital.
   
5. 
   Place a venous tourniquet proximal to the venipuncture site.
   
6. 
   Cleanse the venipuncture site with alcohol/Betadine.
   
7. 
   Remove the protective cover from the syringe needle.
   
8. 
   Using sterile technique, insert the needle into the vein.
   
9. 
   Keeping the needle and syringe stable, gently withdraw the plunger of the syringe and fill the syringe with blood.
   
10. 
    Release the tourniquet
    
11. 
    Withdraw the needle from the vein and apply direct pressure with the gauze pad until bleeding has stopped.
    
12. 
    Insert the needle into the Vacutainer tube(s) to be filled. The vacuum in the tube will pull blood from the syringe.
    
13. 
    Dispose of needle and syringe in appropriate receptacle.
    
14. 
    Label Vacutainer tubes with date, time, patient identification and drawer’s initials.
    
15. 
    Cover venipuncture site with band-aid.
    

• 
  Secure a blood sample while the patient is available
  

• 
  Exposure to blood during the procedure
  
• 
  Pain at the needle insertion point
  

• 
  Hematoma formation
  
• 
  Possible infection at the puncture site (poor sterile technique)
  

• 
  Competent patient refuses procedure
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
		XX	XX	XX

To provide a route for administration of fluids and medications into the vascular system via a peripheral vein.

Normal Saline intravenous solution

Administration set of appropriate size for the volume of fluid to be administered

Extension set

Extracatheter of appropriate size for patient and volume of fluid to be administered

Sizes available include 14, 16, 18, 20, 22 and 24 gauge

Tape

Alcohol preps

Armboard

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Assemble IV bag and tubing using sterile technique and fill the drip chamber and line.
   
3. 
   Explain the procedure to the patient and get his/her consent if appropriate.
   
4. 
   Apply a venous constricting tourniquet to the patient’s extremity.
   
5. 
   Select an appropriate vein and cleanse the site with alcohol.
   
6. 
   Stabilize the vein with skin traction.
   
7. 
   Insert the needle with extracatheter, bevel side up, either next to or over the vein.
   
8. 
   Advance the needle and catheter into the vein until a blood return is noted in the extracather
   
9. 
   Holding the needle securely in place, advance the catheter further into the vein.
   
10. 
    Holding the catheter securely in place, withdraw the needle, tamponading the vein to avoid unnecessary exposure to blood leaking from the catheter.
    
11. 
    Release the venous tourniquet.
    
12. 
    Connect the end of the extension set to the hub of the extracatheter.
    
13. 
    Open the flow regulation clamp and observe the site for signs of infiltration.
    
14. 
    If infiltration (pain and swelling at the site) occurs, discontinue the IV line, select an alternate vein and repeat the above steps.
    
15. 
    Tape extracatheter and extension set securely in place.
    
16. 
    Adjust the flow rate to deliver the ordered volume of fluid.
    
17. 
    Support the extremity and administration site with an armboard.
    
18. 
    Continue to monitor flow rate and administration site.
    
19. 
    Dispose of contaminated equipment in an appropriate receptacle.
    
20. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Provides route for administration of fluid for volume replacement.
  
• 
  Provides route for administration of medication
  

• 
  Causes pain during the insertion process
  

• 
  Infiltration of the fluid into the subcutaneous tissue
  
• 
  Extravasation of some medications can cause tissue sloughing
  
• 
  Introduction of bacteria during insertion can cause infection
  

• 
  Unacceptable delay in starting transport of critical patients (trauma, OB)
  
• 
  Infection in the area of the insertion point
  

To provide for a precautionary intravenous access line in patients who do not currently need fluid replacement or intravenous medication administration

Normal saline in syringe of sufficient volume to fill the extension set

Extension set

Extracatheter of appropriate size for patient

Sizes available include 14, 16, 18, 20, 22 and 24 gauge

Tape

Tourniquet

Armboard

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Using sterile technique, fill extension set with normal saline.
   
3. 
   Follow procedure to establish peripheral IV line (above).
   
4. 
   Connect end of extension set to hub of extracatheter.
   
5. 
   Flush line with normal saline, observing for signs of infiltration.
   

7. Document procedure and results, including any unusual circumstances and/or difficulties encountered.

8. Should the need for IV fluids or medication administration arise during transport, the

Note: External jugular and umbilical veins may not be used as sites for a capped IV line.

Tape or band-aid

Sharps container
PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Close the flow clamp on the IV administration line.
   
3. 
   Gently remove tape securing the IV catheter to expose the venipuncture site.
   
4. 
   Cover the site with a gauze square and apply gentle pressure as the catheter is removed.
   
5. 
   Inspect the catheter to insure it is complete, document any abnormalities.
   
6. 
   Maintain direct pressure on the venipuncture site until any bleeding has stopped.
   
7. 
   Apply dressing or band-aid to venipuncture site.
   
8. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
			XX	XX

Administration tubing of a size appropriate for the volume of fluid to be administered

IV extracatheter of an appropriate size for the patient

Sizes available include 14, 16, 18, 20, 22 and 24 gauge

Extension set

Tape

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Prepare equipment using sterile technique, attaching the administration set and extension set to the IV bag, fill the drip chamber and line.
   
3. 
   Explain the procedure to the patient and get his/her consent if appropriate.
   
4. 
   Position the patient supine with the head turned away from the vessel to be cannulated.
   
5. 
   Cleanse the injection site with an alcohol prep.
   
6. 
   Align the needle of the extracather with the bevel side up in the direction of the blood flow with the tip pointing toward the torso.
   
7. 
   Place one finger over the external jugular vein just above the clavicle and press down lightly until the vein is distended.
   
8. 
   Stabilize the vein above the puncture site.
   
9. 
   Perform the venipuncture midway between the angle of the mandible and the clavicle.
   
10. 
    Advance the needle and catheter into the vein until a blood return in noted in the extracather.
    
11. 
    Holding the needle securely in place, advance the catheter further into the vein.
    
12. 
    Holding the catheter securely in place, withdraw the needle, tamponading the vein to avoid leakage of blood from the catheter.
    
13. 
    Connect the end of the extension set to the hub of the extracatheter.
    
14. 
    Open the flow regulator clamp, observing the site for signs of infiltration.
    
15. 
    If infiltration occurs (pain and swelling at the site), discontinue the intravenous line and repeat the attempt in another site.
    

16. 
    Tape the extracatheter and extension set securely in place.
    
17. 
    Adjust the flow to the ordered rate.
    
18. 
    Maintain the patient’s head turned away from the IV site.
    
19. 
    Monitor the flow rate.
    
20. 
    Continue to monitor the site for signs of infiltration. If infiltration occurs, discontinue the intravenous line and repeat the attempt on the other side if the presence of a functioning IV is critical to patient care.
    
21. 
    Dispose of contaminated needle in appropriate receptacle.
    
22. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Provides route for administration of fluid for volume replacement.
  
• 
  Provides route for administration of medication
  

• 
  Causes pain during the insertion process
  

• 
  Infiltration of the fluid into the subcutaneous tissue
  
• 
  Extravasation of some medications can cause tissue sloughing
  
• 
  Introduction of bacteria during insertion can cause infection
  

• 
  Obscured landmarks (trauma, subcutaneous emphysema, etc.)
  
• 
  Presence of cervical collar
  
• 
  Unacceptable delay in starting transport of critical patients (trauma, OB)
  
• 
  Infection in the area of insertion point
  

END

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
			XX	XX

To provide access to the bone marrow canal as an alternative to an intravenous line for administration of fluids and medications

Alcohol preps, Betadine swabs, Chloraprep

Intraosseous needle

Adult - 15 gauge adjustable 3/8  1 7/8 inch

Pediatric 18 gauge adjustable 1/16  1 7/16 inch

Normal Saline IV solution

2% Lidocaine (Preservative free)

Administration set of appropriate size for the volume of fluid to be administered

Extension set

20 cc syringe

Tape

Armboard/splint for the lower extremity

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Obtain physician order as necessary and for all patients who have a pulse.
   
3. 
   Assemble the IV bag, administration set and extension set using sterile technique and fill the drip chamber and line.
   
4. 
   Determine indications and rule out contraindications.
   
5. 
   Identify the intraosseous site -- anteromedial aspect of the proximal tibia 1-2 cm below the tibial tuberosity -- and cleanse with alcohol/Betadine/Chloraprep.
   
6. 
   Consider administering 1 ml of 2% Lidocaine subcutaneously at the insertion site if the patient is conscious.
   
7. 
   Prepare the IO needle by removing the protective caps and adjusting the depth to a length which will transverse skin, subcutaneous tissue and penetrate the bone cortex. Assure that the needle stylette is in place.
   
8. 
   Insert the needle slightly angled (10º from vertical) toward the foot.
   
9. 
   Enter the skin and twist the needle to cut through the bone while applying firm downward pressure.
   
10. 
    When the tip of the needle enters the marrow cavity, remove the stylette.
    

11. 
    Attach a 10 cc syringe and attempt to aspirate marrow. Liquid resembling blood may appear in the syringe.
    
12. 
    Infuse Lidocaine 2% if the patient is conscious
    

Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus.

Try to give it enough time to soak into the marrow

13. 
    Inject 5-10 cc of sterile Normal Saline. If no local infiltration is seen and the fluid infuses easily, stabilize the intraosseous needle in place by taping the intraosseous needle flange securely to the skin.
    
14. 
    Connect the end of the extension set to the hub of the intraosseous needle.
    
15. 
    Open the flow-regulation clamp and observe the site for signs of infiltration.
    
16. 
    If infiltration (pain and swelling at the site) occurs, discontinue the IO line; repeat the procedure on the opposite leg if an intravenous line is critical for the care of the patient.
    
17. 
    Adjust the flow rate to deliver the ordered volume of fluid.
    
18. 
    Support the extremity and administration site with a splint.
    
19. 
    Continue to monitor flow rate and administration site.
    
20. 
    Dispose of contaminated equipment in an appropriate receptacle.
    
21. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.