EMS carries several IV vesicant drugs; it is important to know that they aren't just limited to chemotherapy related medications you may come across in a hospital setting. Vesicant drugs regardless of where they are utilized tend have very high or low pH. Securing a patent IV is paramount in the field because if any of the medications below leaks out of the vein and into the surrounding tissue; it can be very caustic to the surrounding tissue, muscles, tendons, even down to the bone.
Some common vesicants you may carry in your ambulance can include, but aren't limited to the following:
Calcium gluconate [hyperkalemia]
Phenergan [anti-emetic]
Dextrose - especially concentrations over 10% [anti-hypoglycemic]
Dopamine [pressor]
Epinephrine [pressor]
Ativan [benzo]
Sodium Bicarbonate [buffer]
These are all very capable of causing blistering, tissue sloughing, or necrosis if they escape from the vascular pathway into tissues. The phenomena described here is also known as extravasation and it is a big deal!! Some food for thought and a personal anecdote. I had one patient encounter years ago during an interfacility transfer whose right extremity had a bunch of scaring. As I was completing her history and physical exam, I asked about any previous injuries to her arm. She states she had received Phenergan through a blown peripheral IV in another state and she had about 5-6 surgeries in the years after to resolve the issues from that one medication push. I can't recall 100% but she may have sought out monetary damages from that particular health system as a result.
This blog will also serve as a reminder around related terms we may use with IV sticks and their associated complications. While these terms may be related, they are different and may require differing management approaches.
Extravasation - as we stated above - inadvertent leaking of a vesicant
Flare reaction - a local allergic reaction along a vein, caused by irritating drugs
Infiltration - passage or escape of IV administered drugs (non-vesicants)
Irritation - localized inflammatory reaction at the IV site
Vesicant - as we stated above, caustic agents capable of big problems if extravascular
Vesicant extravasation will not have blood return -- the lack of blood return is an ominous sign as helps you, the provider differentiate this from simple venous irritation. In the back of the rig, you may only find generalized pain and redness, but in the coming weeks, the real complications begin to appear. Usually around day 4 the redness and swelling is worse. On days 7-9 blistering begins to surface, along with skin peeling. By the end of the second week - the patient could begin to lose sensation to the affected arm and tissue necrosis begins. Surgical debridement of the necrotic tissue will have to be part of the definitive treatment plans.
If you feel that your peripheral IV is no longer patent and free-flowing, and you find yourself delivering any medication for that matter -- stop the administration immediately.
Disconnect the IV tubing/drip set - leave the IV extension device/angiocatheter attached -only to-
Attempt to aspirate the residual vesicant -then-
Remove the angio from the patient and -finally-
Mark suspected extravasation area with a pen if possible
Document this in your EHR (include estimated volume of medication given) and tell the hospital staff during your verbal handoff
They may be able to give antidotes like hyaluronidase or sodium thiosulfate
November 25, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC