IV/IO Access and Fluid Therapy - NREMT: AEMT Level

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.

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.

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.

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.

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

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

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.

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.

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.

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.

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.

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

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.

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.

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.

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

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

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

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.

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.

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