IV/IO Access and Fluid Therapy - NREMT AEMT Level

1. What is the primary indication for initiating IV access in a prehospital AEMT patient?

   Need for fluid or medication delivery, or anticipated clinical deterioration. IV access is essential in prehospital settings to enable prompt administration of fluids or medications and prepare for potential patient decline.

2. What is the best practice for choosing IV catheter gauge for most adult medication and fluid needs?

   Use the smallest gauge that meets therapy needs (often $18$–$20$). Selecting the minimal size reduces vein trauma while ensuring adequate flow for fluids and medications in adult patients.

3. Which option is the preferred catheter choice for rapid adult fluid resuscitation when possible?

   Large-bore peripheral IV catheter (often $14$–$16$ gauge). Larger bore allows higher flow rates essential for replacing volume quickly in hypovolemic or shock states.

4. Which option best confirms peripheral IV patency immediately after placement?

   Easy saline flush without resistance and no swelling at the site. A smooth flush indicates the catheter is properly positioned in the vein, ensuring no obstruction or extravascular placement.

5. What is the definition of extravasation in IV therapy?

   Leakage of a vesicant medication into surrounding tissue. Extravasation specifically involves harmful vesicants, distinguishing it from general infiltration and highlighting risks of tissue necrosis.

6. What is the tonicity classification of lactated Ringer's solution?

   Isotonic crystalloid. Its osmolality of approximately 273 mOsm/L closely mimics plasma, supporting volume restoration without osmotic imbalances.

7. What is the most important action to reduce catheter-related bloodstream infection during IV starts?

   Strict aseptic technique with skin antisepsis and clean equipment. Aseptic technique prevents microbial contamination, significantly lowering the risk of infections associated with IV catheter insertion.

8. What is the most common pediatric IO insertion site used in prehospital care?

   Proximal tibia. In children, the proximal tibia's thin cortex and large marrow cavity facilitate quick, effective IO access.

9. What is the formula for IV drip rate in gtt/min using a gravity set?

   gtt/min $=\frac{\text{mL} \times \text{drop factor (gtt/mL)}}{\text{time (min)}}$. The formula calculates drops per minute by accounting for volume, administration set calibration, and infusion duration.

10. What is the key contraindication to placing an IV in an extremity with a dialysis fistula or graft?

    Do not use that extremity for IV access. Avoiding the extremity protects the fistula or graft from damage, infection, or thrombosis that could compromise dialysis access.

11. What is the tonicity classification of $0.9\%$ normal saline?

    Isotonic crystalloid. With osmolality near 308 mOsm/L, it maintains fluid balance without shifting water across cell membranes.

12. What is the preferred initial crystalloid for most prehospital volume replacement scenarios?

    Isotonic crystalloid (normal saline or lactated Ringer's). Isotonic solutions match plasma osmolality, effectively expanding intravascular volume without causing cellular shifts in most scenarios.

13. What is the most appropriate immediate action if IV infiltration is suspected during infusion?

    Stop the infusion and remove the catheter. Immediate cessation prevents further fluid leakage into tissues, reducing risks of compartment syndrome or tissue damage.

14. What is the most appropriate immediate action if an IV site shows phlebitis (pain, erythema, warmth)?

    Discontinue the IV and restart at a different site/limb. Discontinuing the IV halts inflammation progression, allowing selection of a new site to maintain therapy without exacerbating vein irritation.

15. Which option is the preferred peripheral IV site selection order when feasible?

    Distal to proximal (hand/forearm before antecubital). Starting distally preserves proximal veins for future access if initial sites fail or require replacement during treatment.

16. What is the key contraindication to placing an IV in an extremity with suspected fracture or severe trauma?

    Avoid the injured extremity if an alternative site is available. Using an alternative site prevents complications like increased pain, compartment syndrome, or interference with fracture management.

17. What is the maximum number of peripheral IV attempts recommended before switching to an alternate plan?

    Two attempts, then escalate (different provider, site, or IO). Limiting attempts minimizes patient discomfort and complications, prompting timely escalation to alternatives for efficient vascular access.

18. What is a key contraindication to IO placement at a specific bone?

    Fracture of that bone or previous IO attempt in that bone. These conditions risk extravasation or compartment syndrome, compromising infusion safety and efficacy at that site.

19. What is the most appropriate fluid strategy for suspected hemorrhagic shock in many EMS protocols?

    Permissive hypotension: titrate to perfusion, avoid over-resuscitation. This approach minimizes risks of coagulopathy and rebleeding by maintaining adequate perfusion without excessive blood pressure elevation.

20. Which option is the preferred vascular access when rapid access is required and IV attempts fail?

    Intraosseous (IO) access. IO access provides rapid vascular entry in emergencies when peripheral IV fails, allowing for quick fluid and medication delivery to the bone marrow.

21. Which option best confirms correct IO placement after insertion and flush?

    Needle stands firmly, flushes easily, and no soft-tissue swelling. These signs verify intraosseous positioning, ensuring stable access and proper marrow infusion without extravascular leakage.

22. What is the most common adult IO insertion site used in prehospital care?

    Proximal tibia. The proximal tibia offers accessible landmarks and reliable marrow access for emergency infusions in adults.

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