Who Gets a Prehospital IV?

Our regional guidelines require routine ALS on many of our calls. Routine ALS is defined as IV, 02, monitor. Recently the 02 has been modified to only 02 if patient is short of breath or has a SAT >94%. Now we are looking at the IV part. Do all these patients really need prehospital IVs? And should EMS also consider the fact that some hospitals do not use the EMS IVs unless they absolutely have to?

For years, as a rule I put in an IV in a patient if I thought the hospital was going to do it. I did it for three reasons:

1) I might need it to give the patient fluid or medication
2) The more IVs I did, the better at IVs I became
3) It always made the nurses happy.

I put fewer IVs in patients now than I used to, but the real question remains, Is a prehospital IV always in the best interest of the patient?

When the patient says, “Why are you doing an IV?” And the answer is, “They will do one at the hospital in case you may need it, so we are just getting it done for them.” then that is probably not the best reason to do one. Personally, I think the hospitals probably overdue the IVs as well.

A better rule might be, don’t do an IV unless you plan to use it, or think there is a reasonable possibility that you may have to use it.

If we apply that rule to our prehospital patients, who can be excluded?

Anyone who doesn’t meet this criteria:

Any patient who requires IV fluids
Any patient who requires a medication that can only be given by IV
Any patient who is at moderate risk for dropping their blood pressure, and or requiring IV fluid or a medication that can only be given IV.

Under this criteria, these patient would get an IV:

cardiac chest pain, hypotension, allergic reaction/anaphylaxisis, pulmonary edema, severe asthma, sepsis, severe dehydration

These patients might not:

single seizure, hypertension, swollen legs, flu-like symptoms, mild asthma

Trying to come up with a specific list is difficult and raises the perennial EMS qualifier — “It Depends.”

You can never remove judgement from the guidelines.

With the increase of intranasal meds such as fentanyl and narcan, assuming they work, would we remove fractures, muscle injuries, abdominal pain and opiate ODs from the IV list?

And perhaps you could argue that patients with mild vomiting, instead of getting IV fluid and IV zofran, would do just as well with Zofran ODT and a couple bottles of Gatorade.

And with the backup availability of an EZ-IO, do we need to remove even more IV candidates from the list who we are now doing an IV on in case they get worse and we are unable to get IV access.

I don’t really have the answers. I am curious if any systems out there have well-defined guidelines on who gets a prehospital IV.

10 Comments

  • Cameron says:

    I agree that to just do an IV cause its in protocol is perhaps not the greatest reason. As far as I know in the local system where I live there is not a protocol stating a line has to be in place. I will say that from working in an ER, that we appreciate lines on the sick patients for sure! But keep in mind that we almost always have to draw blood for labs, and hospital protocol we cannot draw from an existing line. So your borderline patient who may not need a line will get stabbed more vs just letting the hospital do it. On the sick patients we use your line and will start a second to get labs, and if you bring in with 2 lines we will put a third in, or a butterfly for labs. We have to get the blood no matter what.

    I guess my point is, if you need a line as a provider then no worries, but if its only cause you can, please hold off.

  • Good question, and with rhe national shortage on normal saline, very timely.

    I have essentially the same three reasons you do, but with the saline shortage, #3 has been eliminated from the list.

    Our medical director has urged us to be a little more judicious about #1 and #2, as well.

    • BH says:

      Our DOH finally authorized saline locks for that very reason (a lot of us non-LIV types were doing them anyway, since there was no protocol to say we couldn’t).

  • Va Medic says:

    Our protocol is to start a line and draw labs on ALS calls. The nurses always appreciate this. But we start low and try to leave the AC for the Ed.

  • bee westenra says:

    As a junior medic I admit to inserting plenty of
    IVC to really consolidate that skill. Now I only
    Put one in if I really think I will need to use it or the patient starts to deteriorate.

  • Bob Sullivan says:

    It depend on whether the service draws blood, and if the hospital accepts them. I usually start one to draw blood if the hospital does, but only start lines that I plan to use if they don’t.
    I started more IV’s after my last service added lactate meters, which required venous blood. One was indicated for any patient with SIRS criteria, such as a fever, pulse above 90, RR above 20, and a suspected infection. That covers a lot of patients whom I would not have stuck in the past.

  • BadgerMedic says:

    Certain protocols here do require PIV access; and even some of those are stretching in the actual need for access – I agree in utilizing the provider’s judgement in actually starting that IV. Thankfully, we now have a rational protocol in place to not hang IV fluid unless you intend to actually administer it… NS locks are perfectly acceptable for medication administration only. How many times have you heard, (or accidentally done it yourselves) “Oops – I didn’t mean to give them THAT much fluid.”
    On another note – bigger isn’t always better. It seems the more experienced I become, the less I grab the larger angiocaths.

  • EMS Artifact says:

    You forgot the reason (not yours) that I see a lot when I do QA reviews. Because the service can bill for them and turn a BLS call into an ALS 1 call.

    Which also might be the reason that I see 12 lead ECGs on 24 year old patients from MVAs who complain only of neck pain without LOC.

    The only real reason to start an IV is because the patient needs either fluid or medications IV. There is no reason that a routine Asthma exacerbation patient needs an IV.

    As Ambulance Driver will tell you, I’ve often opined that in EMS it’s often important not to do just something, but to stand there and figure out what needs to be done.

    He’ll also tell you that I have long billed my self as a “stand back, big picture, direct the work of others, non interventional” paramedic.

    Because even something as simple as an IV can cause harm to the patient.

    As paramedics we should be identified by what we know, and that includes knowing not to over treat a patient.

  • Jim Todd says:

    I agree that IV’s should not be just a routine deal or just because they might get one later in the ER. Worse yet, I’ve seen IV’s get started and run wide open on very stable trauma patient’s who are normotensive and and meet no high risk criteria. In addition to the un needed pain, some are determined in their quest for an IV they may be overlooking the need for a more immediate intervention or a more complete exam.

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Peter Canning

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