The Role of ALS Infusions in Prehospital Care
Advanced Life Support (ALS) infusions allow paramedics to deliver critical medications in a controlled, sustained manner during high-stakes calls. Unlike one-time bolus injections, these intravenous drips require precision, continuous monitoring, and a strong grasp of pharmacologic endpoints. In the fast-paced world of EMS, paramedics must adjust to changing patient vitals while ensuring that fluid volumes, drip rates, and medication concentrations stay within safe therapeutic windows.
Paramedics working 911 and interfacility calls routinely encounter vasoactive agents, antiarrhythmics, sedation infusions, and glucose control therapies. Each has its own titration rules and delivery setup. This guide walks through everything from pump programming to gravity-flow backups, giving you the skills to manage ALS drips with safety, clarity, and efficiency in the field.
Preparing and Mixing Infusions in the Field
Double-Check Concentrations and Compatibility
Most ALS systems supply premixed bags for common drips, but field mixing still occurs, especially for less frequently used medications. Before drawing up anything, paramedics must verify drug concentration, fluid compatibility, and dilution ratios. Lidocaine, dopamine, and amiodarone all have specific mixing protocols and carrier fluid requirements.
Using laminated drug cards or app-based calculators helps reduce math errors. Syringe concentration, final bag volume, and mg/mL ratios must match department-approved standards. Whenever possible, paramedics should mix and label infusions before patient contact to avoid distractions during critical care handoffs.
Labeling the Bag and Tubing System
Proper labeling improves both patient safety and handoff clarity. Use waterproof markers or pre-printed adhesive labels to record:
- Drug name and total concentration (e.g., “Lidocaine 2g in 250mL D5W = 8mg/mL”)
- Date and time mixed
- Your initials
- Dosing parameters (e.g., “1–4 mg/min”)
Secure the label directly to the IV bag and repeat the medication name on the pump module or roller clamp if using gravity.
Setting Up the Infusion Pump: Programming Without Guesswork
Reviewing Common Pump Interfaces
Most modern ambulance services use compact infusion pumps with quick-load cassette ports and digital programming screens. While brands vary, all follow the same basic setup: input volume, concentration, and desired rate in mL/hr.
Before attaching the line to the patient, paramedics should:
- Program the full concentration and dosing range into the device
- Lock the keypad or enable “field mode” to prevent accidental input changes
- Prime the tubing to ensure no air remains in the line
Many systems allow rapid switching between medications using saved presets or color-coded channels. Carrying a brief pump guide laminated in your bag can save time during high-pressure scenarios.
Responding to Pump Alarms and Failures
If the pump fails mid-transport, paramedics must pivot quickly. Always bring microdrip tubing and a spare carrier fluid bag as a fallback. If reprogramming proves unsuccessful in the field, calculate an equivalent drip rate and switch to gravity delivery until you reach definitive care.
Gravity Drip Backups: Calculating When Technology Fails
Mastering Macro- and Microdrip Conversions
Gravity infusions rely on simple math and reliable eyes. For emergency field backups, you must know your tubing’s drop factor (gtt/mL) and use this formula:
(Volume × Drop Factor) / Time (in minutes) = Drops per minute
A dopamine drip at 10mcg/kg/min for a 220 lb adult may require 36 gtt/min using macrodrip tubing. Always cross-check with your partner and use a metronome app or stopwatch to stay consistent.
Avoiding Runaway or Underdosed Drips
When managing vasoactive drugs by gravity, tape your target gtt/min directly to the drip chamber. Keep the IV bag at a stable height and re-check rate every few minutes, especially during transport turbulence. These analog methods remain essential when batteries fail or pumps misbehave.
Titration Techniques for Field-Use Medications
Understanding Safe Ranges and Endpoint Goals
Titration refers to the process of slowly adjusting medication delivery to achieve a desired physiologic effect. Paramedics commonly titrate:
- Dopamine or norepinephrine for blood pressure support
- Amiodarone or lidocaine for rhythm stabilization
- Midazolam or ketamine for sedation or seizure control
Each drug has a narrow therapeutic window. Paramedics must observe trends, not just snapshots, when titrating doses. Blood pressure, heart rate, consciousness, and respiratory effort must guide your next adjustment.
Common Titration Errors and How to Avoid Them
The most frequent mistake in the field is overcorrection. If a patient stabilizes, avoid increasing the dose out of habit. Another common error involves titrating without documenting the endpoint goal. Before making changes, state your reason aloud and document your logic clearly in the ePCR system.
Documenting ALS Drips and Dose Adjustments
What to Include in Your Narrative
Every drip should be backed by clear documentation. Include:
- Time started and total volume administered
- Initial vital signs and titration goals
- All dose changes with times and justifications
- Patient response to each dose range
If you titrate dopamine from 5 to 8 mcg/kg/min due to low MAP, record the rationale, not just the new rate.
QA/CQI and the Role of Infusion Logs
Some agencies require infusion-specific logs or barcode scans for ALS-level medications. Include pump serial numbers, drug expiration dates, and dosing ranges to meet audit criteria. These records help validate both patient care and controlled substance management.
Field-Based Scenarios: When Things Don’t Go to Plan
Case: Transport with Multiple Drips
Imagine a post-ROSC patient on norepinephrine and amiodarone during a 20-minute transfer. One pump battery dies mid-run. Switching norepi to gravity while keeping amiodarone on the other pump allows uninterrupted care. Titration continues with close BP monitoring and reassessment.
Case: Conflicting Orders and Drug Interactions
A sending facility orders three overlapping drips, including magnesium sulfate and a sedative bolus. Paramedics must assess potential interactions and clarify priority medications before departing. Always clarify goals with the sending physician and document field decisions with precision.
Safety Pearls and Best Practices
- Always trace all lines from bag to port before administering any infusion.
- Confirm medications with a second provider whenever possible.
- Reassess drips after each patient movement or stretcher tilt.
- Use portable whiteboards or tape to list all active drips in multi-line patients.
- Ensure every infusion site is visible during transport for infiltration checks.
Common ALS Infusions and Titration Guidelines
| Medication | Typical Concentration | Titration Range | Monitoring Parameters |
|---|---|---|---|
| Dopamine | 400 mg in 250 mL D5W | 2–20 mcg/kg/min | MAP, urine output, HR |
| Norepinephrine | 4 mg in 250 mL D5W/NS | 2–30 mcg/min | MAP, skin perfusion |
| Amiodarone | 150 mg in 100 mL D5W | 1 mg/min (post-bolus) | Rhythm, QT interval |
| Midazolam | 5 mg in 50 mL NS | 1–5 mg/hr (continuous) | Sedation scale, RR, BP |
| Lidocaine | 2 g in 250 mL D5W | 1–4 mg/min | Rhythm, mental status |
Getting Cleared for ALS Drip Use During Clinicals
Most paramedic programs require documented ALS infusion setup and titration experience during clinical rotations. This includes pump setup, drip calculation, and live titration under preceptor supervision. Students unable to complete required logs often must remediate during field internship.
To prepare in advance, review the EMS Ricky Application Process page for a breakdown of uniform, gear, and compliance items required before participating in ALS-level clinicals.
Final Takeaways for Field Success
Paramedic-level infusion management goes far beyond math and pump buttons. Safe administration demands real-time decision-making, constant reassessment, and careful documentation. Grasping the nuances of titration and knowing how to pivot when technology fails makes the difference between good and exceptional care in the field.
As ALS roles continue to evolve, mastery of infusions will remain one of the most essential clinical tools in a paramedic’s arsenal.
FAQ
What’s the difference between a titratable drip and a fixed-rate infusion?
A titratable drip adjusts based on patient response, like dopamine for blood pressure. A fixed-rate infusion delivers a steady dose without modification, such as amiodarone post-bolus. Titration requires frequent monitoring and clear endpoint goals.
Can I mix and administer ALS drips as a paramedic student?
Only under direct supervision. Most programs allow students to mix and run drips during clinicals, but a licensed preceptor must oversee every step and sign off on logs.
How often should I reassess a patient on a vasoactive drip?
Vital signs and perfusion indicators should be reassessed every 2–5 minutes during titration. Once stabilized, reassessment intervals may extend, but should still occur every 10–15 minutes or with any patient change.
What’s the safest way to transport a patient on multiple drips?
Label all lines clearly, use programmable pumps if available, and document each infusion separately. Communicate with your partner constantly and reevaluate every time the stretcher moves or the patient is repositioned.