Before administering any medication, the EMT should know the 5 rights of drug safety:
Right patient: Is the medication indicated for this patient's condition (i.e. why are you using it and what are your expected positive effects and adverse/side effects?) ; are there any contraindications (why or when would you NOT use this medication?) ; and have you confirmed that the patient has no known allergies to this or similar medications?
Right drug: Have you examined the container and positively identified the medication being used, verifying the correct name (trade name vs. generic name) and noted it is in the correct concentration and that it is appropriate for the patient in the current context?
Right Dose: Have you checked that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions.
Right Route: Have you checked that the route of administration is appropriate for the patient's current condition (see below for common administration routes)
Right Date/time: Is the medication expired? Has it been long enough since the last dose?
Many add a 6th "Right" which is the "Right documentation" Correct documentation of medications administered and/or IV/IO placement will include:
- Time of medication administration including IV/IO placement
- Route of administration
- Size of catheter (for IV/IO administrations)
- Site location for IV/IO and SQ, IM medication (include unsuccessful IV/IO attempt locations)
- Dose or volume infused
- Time of infusion if infused (e.g., rapid IVP, infused over 10 minutes, etc.)
- Name of EMT/Paramedic responsible
- Any complications and steps made to correct
- Patient's response to treatment
Use of a medication simply because it is in the protocol is not an acceptable standard of medical care. When there are questions about medication administration, consult medical control.
Routes of Administration[edit | edit source]
Oral Administration - Oral medications are swallowed by the patient and absorbed through the gastrointestinal tract. The most common EMS medication given by this route is aspirin. To administer an oral (PO) medication ensure that the patient has an intact gag reflex and place the patient in a seated or semi-seated position. Place the medication in the patient's hand or mouth and ask them to swallow. If the patient needs a drink of water, it may be given to them if available.
Sublingual Administration - To administer a sublingual (SL) medication, place the pill or direct the spray between the underside of the tongue and the floor of the oral cavity. The medication is rapidly absorbed through the mucous membranes of the mouth and blood vessels of the tongue. The most common drug given by this route is nitroglycerin. To administer a buccal medication place the medication between the patient's cheek and gum. The drug is rapidly absorbed through the mucous membranes of the cheek. An example of a buccal medication is oral glucose.
Inhalation – Concentrated oxygen is the most common drug administered by direct inhalation (see Oxygen Administration). To administer oxygen, place the appropriate oxygen delivery device and set the flow accordingly. Appropriate flow rates for common EMS devices are: Nasal Cannula 1-6 liters/min resulting in 24-44% oxygen delivery, a Simple face mask 6-10 liters/min 30-60%, or a Non-Rebreather Mask 10-15liters/min 60-95%
Metered-Dose Inhaler (MDI) – MDIs are common self administered medications for direct airway effect that patients with respiratory conditions may have with them. The route of absorption is through the cell walls of the linings of the airways. To assist the patient with self administration, place the inhaler in the patient's mouth and press down on the inhaler if they are unable to. For the medication to be fully absorbed, have the patient breathe in slowly after the inhaler has been depressed. A spacer device may be used to increase the amount of medication to reach the bronchioles. Albuterol is a common medication delivered by MDI.
Nebulizer – To administer an aerosol medication with a nebulizer, place the medication in the assembled nebulizer. The drug is then administered with oxygen and absorbed in the alveoli and capillaries.
Intranasal Administration (IN) - For self-contained, pre-measured IN devices like Narcan, simply insert 1.5 cm into the nostril and squeeze to deliver the entire dose of medication into a single nostril (see Naloxone Administration). The medication is then delivered as a fine mist that is absorbed through the nasal mucosa. For IN delivery of other medications, draw up desired medication in a syringe, attach a mucosal atomization device (MAD) to the syringe and insert the device into the nostril, and depress the plunger to deliver. Medication dose can be divided between nares with a maximum dose of 1 ml per nares. The onset of action for this route is rapid. Medications that can be delivered via the intranasal route are naloxone and midazolam.
Intramuscular (IM) Injection - For self-contained auto injectors, see Epinephrine Auto-injectors. For IM delivery of other medications, draw up the desired medication in a syringe no larger than 5 ml. The appropriate needle size for an adult is 19-23 gauge and 1-2 inches long and 25 gauge ½-3/8" for children. Length of needle may vary based on the patient's size. The injection should be given at a 90° angle in one of the following locations: vastus lateralis, ventrogluteal, dorsogluteal, or deltoid. The ideal volume for a deltoid injection is 1 ml (2 ml max) and 3 ml (5ml max) for other sites. Avoid giving injections to patient exhibiting signs / symptoms of shock or edema / burns at injection site. Aspiration for blood should be performed with an IM injection to avoid giving the medication intravenously. In the event that blood is aspirated, dispose of needle and syringe and attempt again. Examples of IM medications include: epinephrine 1:1000, glucagon, diphenhydramine, haloperidol.
Subcutaneous (SQ) Injection – For Subcutaneous injection, draw up the desired medication in a syringe no larger than 3 ml. The appropriate needle size for adult is 25-28 gauge and ½ - 5/8" and 25 gauge ½ - 3/8" for children. Length of the needle may vary based on the patient's subcutaneous tissue. The injection should be given at a 45-90° angle in one of the following locations: lateral aspect of the upper arm, the abdomen from the costal margins to the iliac crests, and the anterior thighs. Avoid giving injections to patient exhibiting signs / symptoms of shock or edema / burns at injection site. The maximum volume for SQ injection is 1 ml. Epinephrine 1:1000 is a common medication given by the SQ route.
Intravenous (IV) Access - Peripheral Intravenous (IV) access IVs may be started on patients of any age providing there are adequate veins and patient's condition warrants an IV. Generally, no more than two attempts or more than 5 minutes should be spent attempting IV access. IV placement must NOT delay transport of any critical patient. The initial attempt should be the dorsum of the hand. Further attempts should proceed to the forearm. Do NOT use the antecubital fossa unless the patient is unstable AND the IV is a life-saving procedure. External jugular veins are an option for critical adult patients. Veins in the feet and lower legs are an option, particularly for infants and young children; do not use these veins in patients with peripheral vascular disease due to risk of phlebitis. Do NOT use an arm used for hemodialysis. Avoid side of previous mastectomy. Gauge Use Approximate Flow Rate 14 (large bore) Trauma, surgery, blood administration, administration of thick (viscous) medication in adolescents and adults 315 ml/min 16 (large bore) Trauma, surgery, blood administration, administration of thick (viscous) medication in adolescents and adults 210 ml/min 18 Trauma, surgery, blood administration in adolescents and adults 110 ml/min 20 Suitable for most IV infusions in older children, adolescents and adults 65 ml/min 22 Children and elderly patients 38 ml/min 24 Neonates, infants, children and adults with fragile veins 24 ml/min
Intraosseous (IO) Access - When IV access is unsuccessful or taking too long in a critically ill / injured patient, intraosseous access is an alternative method of gaining vascular access. Any medication or fluid that can be administered IV can be administered IO. Manual or mechanical insertion of an IO is appropriate if vascular collapse is present and rapid access is essential. The preferred IO site is the medial aspect of the proximal tibia. Alternative sites: distal femur, distal medial tibia, proximal humerus. IO access should not be performed in an extremity with fractures proximal to the insertion site, orthopedic surgery, possible infection or other medical condition. For Pediatric patients, if the tibial tuberosity CAN be palpated the insertion site is one finger-width below the tuberosity and then medial along the flat aspect of the tibia, however, it is often difficult to palpate the tibial tuberosity on very young patients. If the tibial tuberosity CANNOT be palpated the insertion site is two fingerwidths below the patella and then medial along the flat aspect of the tibia.