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newSchoolWorks.com › VoTechWorks › Health & Personal Services › EMT / Paramedic › Pharmacology for Emergency Medical Services › Lesson 9
HLT-EMT39-05 · Lesson 9 · 35 clock hours · practice

IV and IO Access and Medication Administration: Psychomotor Skills

Objective. Students will establish peripheral IV access and IO access on task trainers and administer simulated medications via IV push, IV drip, and IO routes, meeting all steps of NREMT paramedic psychomotor skill sheets.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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IV and IO Access and Medication Administration: Psychomotor Skills

Establishing vascular access and delivering medications accurately are core paramedic competencies. Mastery requires correct technique, strict asepsis, and vigilance for complications at every step.

Why Vascular Access Matters

Intravenous (IV) and intraosseous (IO) access give you a direct route to the patient's circulatory system. In emergencies, speed and reliability matter—a secure, patent line can mean the difference between effective drug delivery and treatment failure. The NREMT paramedic psychomotor evaluation tests both routes because each has a distinct clinical role.

Peripheral IV Access: Step-by-Step

Equipment check first. Before touching the patient, confirm you have the correct catheter gauge, IV tubing primed with normal saline (NS), tape or a commercial securement device, and a functioning sharps container within reach.

1. Standard precautions. Don gloves. Eye protection is appropriate when splash risk exists.

2. Select a site. Prefer the antecubital fossa or a large forearm vein for emergencies. Avoid an arm with an arteriovenous fistula, injury, or infection.

3. Apply the tourniquet 3–4 inches proximal to the intended site. Ask the patient to open and close the fist if possible.

4. Prep the site. Cleanse with an alcohol wipe using a circular or back-and-forth motion; allow to dry fully—this is a critical infection-control step.

5. Insert the catheter bevel up at a 10–30-degree angle. Advance until you see a flash of blood in the hub, then lower the angle and advance the catheter off the needle into the vein.

6. Release the tourniquet before removing the needle to prevent excessive bleeding.

7. Remove the needle and immediately place it in the sharps container—never recap.

8. Confirm patency. Connect primed tubing, open the roller clamp briefly, and check for free flow and absence of swelling.

9. Secure the site. Apply tape or a commercial dressing; loop the tubing to reduce tension on the catheter.

10. Set the rate and document time, site, gauge, and patient response.

Intraosseous (IO) Access: Step-by-Step

IO access delivers fluids and medications directly into the bone marrow, which drains into the venous system. It is indicated when IV access cannot be rapidly established in a critically ill or injured patient.

1. Select the site. Common sites include the proximal tibia (2 cm below the tibial tuberosity on the flat medial surface), distal tibia, and proximal humerus, depending on the device used.

2. Standard precautions as above.

3. Prep the site with antiseptic and allow to dry.

4. Insert the IO needle per the device manufacturer's instructions—most EMS systems use a powered driver (e.g., EZ-IO). Apply firm pressure and activate the driver until a decrease in resistance signals entry into the marrow space.

5. Confirm placement. Remove the stylet and confirm with: the needle standing upright without support, ability to aspirate marrow (not always possible), and free flow of flush without significant swelling.

6. Flush with NS (typically 10 mL for adults) to clear the needle and reduce resistance before medication administration. Warn conscious patients that IO flush and medication infusion can be painful; lidocaine IO flush is sometimes used per local protocol.

7. Secure the needle and connect IV tubing or a pressure bag—IO flow depends on gravity and pressure because bone marrow has resistance.

8. Document as with IV access.

Medication Administration Routes

IV push (bolus): Draw up the correct volume, clean the nearest injection port, inject at the rate specified by protocol, then flush the line to ensure the drug reaches the circulation.

IV drip (infusion): Spike the secondary bag, prime secondary tubing, and connect via a Y-site or secondary port. Set the pump or calculate a drip rate manually. Verify the rate is correct before leaving the patient.

IO administration: Use the same principles as IV push or drip. Because flow is slower, use a pressure bag or syringe push to ensure delivery. Follow each medication with a saline flush.

Complication Recognition and Management

| Complication | Signs | Action |

|---|---|---||

| Infiltration | Swelling, pain, slowed flow at site | Stop infusion, remove catheter, apply warm compress, restart at new site |

| Dislodged line | Catheter backed out, no blood return | Stop infusion, reassess; if unsalvageable, remove and restart |

| Rate error | Pump alarm or incorrect volume delivered | Pause pump, recalculate, correct programming, reassess patient |

| IO dislodgement | Needle tilts, swelling in surrounding tissue | Remove, apply pressure, establish new access |

Safety Points

Key terms9

Peripheral IV accessPlacement of a catheter into a peripheral vein (arm, hand, or antecubital) to establish a route for fluids and medications.
Intraosseous (IO) accessInsertion of a specialized needle through the cortex of a bone into the marrow cavity to provide emergency vascular access when IV access is unavailable.
Flash (blood return)The appearance of blood in the catheter hub indicating the needle tip has entered the lumen of the vein.
InfiltrationLeakage of IV fluid or medication into the surrounding tissue instead of the vein, causing localized swelling and pain.
IV push (bolus)Rapid injection of a specific drug volume directly into an injection port of an established IV line to achieve a quick therapeutic effect.
IV drip (infusion)Controlled delivery of a fluid or diluted medication over a set time period, regulated by a pump or calculated drip rate.
Drip rateThe number of drops or milliliters per minute (or hour) needed to deliver a prescribed volume of fluid within a given time frame.
PatencyThe state of an IV or IO line being open, unobstructed, and correctly positioned so that fluid flows freely.
Six Rights of medication administrationA safety checklist: right patient, right drug, right dose, right route, right time, and right documentation, verified before every administration.

Worked examples4

1. A paramedic needs to infuse 500 mL of NS over 2 hours using tubing with a drop factor of 10 gtt/mL. What is the drip rate in drops per minute?
  1. Write the formula: Drip rate (gtt/min) = [Volume (mL) × Drop factor (gtt/mL)] ÷ Time (min).
  2. Convert time to minutes: 2 hours × 60 min/hour = 120 minutes.
  3. Multiply volume by drop factor: 500 mL × 10 gtt/mL = 5,000 gtt.
  4. Divide by time: 5,000 gtt ÷ 120 min = 41.67 gtt/min.
  5. Round to the nearest whole drop: 42 gtt/min.
Answer: 42 drops per minute.
2. A protocol calls for infusing 250 mL of a drug solution over 30 minutes using a pump. What flow rate in mL/hr should you program into the pump?
  1. Convert 30 minutes to a fraction of an hour: 30 min ÷ 60 min/hr = 0.5 hr.
  2. Divide volume by time in hours: 250 mL ÷ 0.5 hr = 500 mL/hr.
  3. Program the pump to deliver 500 mL/hr.
Answer: 500 mL/hr.
3. You are using a 60 gtt/mL (micro-drip) administration set to infuse 100 mL of NS over 1 hour. What is the drip rate in drops per minute?
  1. Apply the formula: Drip rate (gtt/min) = [Volume (mL) × Drop factor (gtt/mL)] ÷ Time (min).
  2. Convert time: 1 hour = 60 minutes.
  3. Multiply: 100 mL × 60 gtt/mL = 6,000 gtt.
  4. Divide: 6,000 gtt ÷ 60 min = 100 gtt/min.
  5. Note: With a 60 gtt/mL set, the numeric drip rate in gtt/min always equals the flow rate in mL/hr—a useful check.
Answer: 100 drops per minute.
4. You must deliver 150 mL over 45 minutes using tubing with a drop factor of 15 gtt/mL. What is the drip rate?
  1. Apply the formula: Drip rate (gtt/min) = [Volume (mL) × Drop factor (gtt/mL)] ÷ Time (min).
  2. Plug in values: 150 mL × 15 gtt/mL = 2,250 gtt.
  3. Divide by time: 2,250 gtt ÷ 45 min = 50 gtt/min.
Answer: 50 drops per minute.

The math in this lesson2

Learners compute drip rate (500 mL x 10 gtt/mL) / 120 min = 41.67, rounded to 42 gtt/min.
6.RP.3A-SSE.1
Brush up in the math halls at newSchoolWorks.com:
In class: Deliberate practice stations: students rotate through IV arm trainers, IO leg trainers, and pump trainers, performing a minimum of five successful IV insertions and two IO insertions each, with instructor observation and verbal feedback at each station. · Timed skill run: each student completes the full sequence—gloves, tourniquet, site prep, insertion, confirmation, securing, fluid administration, documentation—within a time limit consistent with NREMT psychomotor standards, recorded by a peer evaluator using the official skill sheet. · Complication management drill: instructor introduces a simulated complication (infiltration, dislodged line, rate error) mid-scenario; student must identify the problem, stop administration, and implement corrective action before continuing.
Materials: IV arm trainers, IO leg trainers, IV catheters, IO needles (practice), tourniquets, IV tubing, NS bags, IV pumps, tape, alcohol wipes, sharps containers, NREMT psychomotor skill sheets, stopwatches
Check: Formal psychomotor evaluation using NREMT IV/IO skill sheets; student must pass all critical criteria with no critical fails. Students with one or more critical fails repeat the skill with remediation before reassessment.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Airway, Respiration, and Ventilation / Pharmacology
1. During IV insertion, you advance the catheter into the antecubital vein and see a blood flash in the hub. What is the correct next action?
Pharmacology
2. Which finding BEST confirms correct IO needle placement in the proximal tibia?
Pharmacology
3. You are infusing a medication through an IV line when you notice the site is swollen and the patient reports pain at the insertion point. The most likely complication is:
Pharmacology
4. A paramedic must infuse 300 mL of NS over 1 hour using tubing with a drop factor of 10 gtt/mL. What is the correct drip rate?
Pharmacology
5. After IO insertion, you prepare to administer a medication to a conscious patient. Which action is most appropriate before pushing the drug?
Pharmacology
6. Which action is required immediately after removing a used IV needle from the catheter?
Pharmacology
7. During a timed skill run, a student uses a pump to infuse a medication and receives an occlusion alarm mid-infusion. What is the correct sequence of actions?
Pharmacology
8. The Six Rights of medication administration include right patient, right drug, right dose, right route, and right time. What is the sixth right?
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