Peripheral venous cannulation, among the most common medical procedures, has revolutionized the practice of medicine. Peripheral intravenous (IV) catheters allow for the safe infusion of medications, hydration fluids, blood products, and nutritional supplements.
Essentials
Vascular access should only be performed when there is an indication for use in the out-of-hospital environment.
The need to obtain vascular access should be balanced against other acute clinical needs of the patient. Conveyance of the patient must not be delayed in favor of establishing vascular access.
Catheter and site selection varies according to the patient's condition and intended use.
General Information
Initiation of peripheral vascular access is contraindicated when appropriate therapy can be provided through a less invasive route (e.g., intramuscularly, intranasally, or orally).
Paramedics must make informed decisions with respect to a patient’s need for vascular access, with consideration given to:
Current clinical status and stability.
Expected out-of-hospital interventions, such as the need to administer medications or fluid en route to hospital.
Anticipated in-hospital clinical course. Note that a general expectation that the patient may require IV access at some point during their hospital stay is not, by itself, grounds to attempt IV cannulation.
In general, paramedics should limit themselves to two attempts per practitioner. After two total failed attempts, consider the clinical requirement for vascular access before making further efforts to obtain IV access. ACPs may, at their discretion, make further attempts if the clinical scenario requires access (intraosseous cannulation remains an option).
Intravenous devices can become dislodged or pulled out during patient movement. Paramedics should consider the timing of patient movements when contemplating IV cannulation.
Intraosseous (IO) administration is available to CCP, ACP and PCP paramedics. See below for further details on license-specific parameters regarding IO initiation and use
Interventions
First Responder (FR) Interventions
Not indicated for this license level
Emergency Medical Responder (EMR) & All License Levels Interventions
Not indicated for this license level
Primary Care Paramedic (PCP) Interventions
Obtain peripheral vascular access
Consider need for fluid or fluid replacement if signs or symptoms of hypotension, hypoperfusion, or hypovolemia are present (including based upon history):
In general, give normal saline in up to 20 mL/kg increments with frequent reassessment for effect (every 500ml)
Target a systolic blood pressure ≥ 90 mmHg
Caution: major trauma, head, and spinal cord trauma have different fluid resuscitation targets; consult appropriate CPGs for guidance
PCPs may not cannulate children < 12 years of age via any method
In children, consider normal saline in increments of 5-10 mL/kg; do not exceed 20 mL/kg.
⚠️ Requires completion of PCP scope expansion education:
Special considerations:
For patients in cardiac arrest with a clear clinical history of hypovolemia as a treatable cause, consider → PR12: Intraosseous Cannulation if intravenous access is unavailable.
Intraosseous cannulation is prohibited in patients with perfusing rhythms or spontaneous respirations except at the direction of an ACP or higher. Children under 12 years of age may not be cannulated by PCPs under any circumstances.
Alberta Health Services. AHS Medical Control Protocols. 2020. [Link]
Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link]
Chopra V. (2019). Central venous access devices and approach to device and site selection in adults. In UpToDate. 2019. [Link]
Frank R. Peripheral venous access in adults. In UpToDate. 2019. [Link]
Heffner A, et al. Overview of central venous access. In UpToDate. 2019. [Link]
Lairet J, et al. A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. 2013. [Link]
Perron C. Intraosseous infusion. In UpToDate. 2019. [Link]
Sabado J, et al. Principles of ultrasound-guided venous access. In UpToDate. 2019. [Link]
Smith, S. Vascular (venous) access for pediatric resuscitation and other pediatric emergencies. In UpToDate. 2019. [Link]
Practice Updates
2023-09-29: added intraosseous cannulation to PCP interventions