When EMS should start an IV
Prehospital intravenous (IV) access is an essential part of the EMS practice. As patient care advocates, EMS providers are charged with applying current science to established practice; establishing vascular access is no different.
As invasive – and potentially harmful to the patient – as it is, intravenous therapy should be performed only when medically necessary, and under stringent guidelines.
Old habits die hard
The 2006 Institute of Medicine (IOM) Safe Practice Report recommends that the practice of using the flow rate terms such as "keep vein open" (KVO,, "to keep open" (TKO), and "wide open" (WO), will be abolished because they do not provide a specific flow rate or volume. These volumes must be specifically documented to improve continuity of care. Despite this recommendation, most major paramedic textbooks on the market continue to embrace this "old thinking".
When should IV access be gained?
Common IV access complications
EMS practitioners may assert that starting prehospital IVs does not increase on-scene times. The data is mixed; some studies have found that starting prehospital IVs are associated with longer EMS on-scene times, while other have not supported this finding.[3,4]
IV access in hypotensive patients
Current fluid resuscitation guidelines call for minimizing fluid infusions to promote clotting and control internal hemorrhage. The harm associated with prehospital IV fluid administration is significant for victims of trauma.[5,6]
Many current texts recommend a 20 ml/kg bolus of NS 0.9 percent or lactated ringers to titrate to a systolic pressure of 80-90 mmHg. However, this volume is not supported by science. Most studies concluded that hypotensive trauma patients did not have improved outcomes with prehospital fluid administration.
In pediatrics, uncontrolled, large volume prehospital fluid replacement in pediatric patient leads to worse clinical outcomes. Recommendations demand that an IV pump be used anytime continuous IV fluids or ongoing IV boluses are indicated for the pediatric patient.
However, some older studies did show improved outcomes in selected patients. A common practice is to infuse smaller boluses and reassess. There are many portable IV pumps and low-tech IV flow rate devices on the market to manage IV volume administration.
If IV fluids are to be given, they should be warmed. The ideal temperature is about 102? F (39?C). There are some inexpensive IV warmers on the market, but even warm packs or a newborn warming blanket will suffice.
Some EMS practitioners will begin IV access in the field so that hospital personnel can begin blood transfusions sooner. One study concluded obtaining a prehospital IV was not associated with more rapid initiation of blood products in the ED.
IV access and medical patients
Other reasons to gain IV access
However, starting a "precautionary IV" as a practice is not supported. Studies show that up to 83 percent of prehospital IVs are not used. In many situations, the use of a saline lock may be a better approach to an intravenous fluid line, such as the renal patient with pulmonary congestion.[12,13,14]
Like any other medical procedure, the decision to initiate IV access must be considered by a risk versus benefit evaluation by the prehospital practitioner. While there are some situations where prehospital IV therapy may be helpful, there are many more where there is either no benefit, or worse, potential harm to the patient.
EMS professionals must be fervent in their adherence to evidence-based practice as they apply their practice to the prehospital patient.
1. Institute of Medicine (IOM). (2006, July 20). Preventing medication errors: Quality chasm series (Rep.). Retrieved November 14, 2014, from Institute of Medicine (IOM) website: http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx
2. Zarate, L., Mandleco, B., Wilshaw, R., & Ravert, P. (2008). Peripheral Intravenous Catheters Started in Prehospital and Emergency Department Settings. Journal of Trauma Nursing, 15(2), 47-52. doi: 10.1097/01.JTN.0000327326.83276.ce
3. Carr, B.G., Brachet, T., David, G., Duseja, R., & Branas, C. (2008). The time cost of prehospital intubation and intravenous access in trauma patients. Prehospital Emergency Care, 12(3), 327-332.
4. Gonzalez, R. P., Cummings, G. R., & Rodning, C. B. (2011). Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time. The American Journal of Surgery, 201(3), 344-347. doi: 10.1016/j.amjsurg.2010.09.021
5. Haut, E. R., Kalish, B. T., Cotton, B. A., Efron, D. T., Haider, A. H., Stevens, K. A., ... Chang, D. C. (2011). Prehospital Intravenous Fluid Administration Is Associated With Higher Mortality in Trauma Patients. Annals of Surgery, 253(2), 371-377. doi: 10.1097/SLA.0b013e318207c24f
6. Seymour, C. W., Cooke, C. R., Hebert, P. L., & Rea, T. D. (2012). Intravenous Access During Out-of-Hospital Emergency Care of Noninjured Patients: A Population-Based Outcome Study. Annals of Emergency Medicine, 59(4), 296-303. doi: 10.1016/j.annemergmed.2011.07.021
7. Werner, S. (2005). Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: A randomized controlled trial. Annals of Emergency Medicine, 45(2), 229-230. doi: 10.1016/j.annemergmed.2004.10.027
8. Smith, C. & Wagner, K. (2008). Principles of fluid and blood warming in trauma. International Trauma Care (ITACCS),71-79.
9. Engels, P. T., Passos, E., Beckett, A. N., Doyle, J. D., & Tien, H. C. (2014). IV access in bleeding trauma patients: A performance review. Injury, 45(1), 77-82. doi: 10.1016/j.injury.2012.12.026
10. Hussmann, B., Lefering, R., Kauther, M., Ruchholtz, S., Moldzio, P., & Lendemans, S. (2012). Influence of prehospital volume replacement on outcome in polytraumatized children. Critical Care, 16(5), R201. doi: 10.1186/cc11809
11. Handly, N. (2009). The Time Cost of Prehospital Intubation and Intravenous Access in Trauma Patients. Yearbook of Emergency Medicine, 2009, 183-184. doi: 10.1016/S0271-7964(08)79106-7
12. Kuzma, K., Sporer, K. A., Michael, G. E., & Youngblood, G. M. (2009). When are Prehospital Intravenous Catheters Used for Treatment? The Journal of Emergency Medicine, 36(4), 357-362. doi: 10.1016/j.jemermed.2007.11.054
13. Martin-Gill, C., Hostler, D., Callaway, C. W., Prunty, H., & Roth, R. N. (2009). Management of Prehospital Seizure Patients by Paramedics. Prehospital Emergency Care, 13(2), 179-184. doi: 10.1080/10903120802706229
14. Ramoska, E. (2013). Intravenous Access During Out-of-Hospital Emergency Care of Noninjured Patients: A Population-Based Outcome Study. Yearbook of Emergency Medicine, 2013, 197-198. doi: 10.1016/j.yemd.2012.07.013Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at firstname.lastname@example.org.
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