remove the tourniquet. Attach the adaptor and each blood tube in turn, then remove the tour niquet Not taking blood remove the tourniquet. Place the cap on the end of the cannula, secure wit h the adhesive dressing and fl ush with 2 \200\2235ml 0.9% saline through the side port. Da te the dressing and document date and time of insertion in the notes. Dispose of the needle into a sharps bin. Con \201 rmation fl ashback seen, saline fl ush requires minimal pressure and does not for m a proximal subcutaneous \200\230bleb \200\231 or cause pain. Complications early haematoma, tissuing (fl uid/drugs enter subcutaneous tissues), local da mage, air embolism; late thrombophlebitis, cellulitis. OHFP.indb 518 OHFP.indb 518 30/05/2014 16:18 30/05/2014 16:18 519 IV CANNULATION Safety never reinsert the metal needle into the plastic cannula once you have fully removed it as this increases the risk of needle-stick injuries and bits of the plastic cannula may shear off and embolise, steady the patient \200\231s arm on a pillow to reduce movement an d the risk of needle-stick injury, dispose of needles into a sharps bin immediately. Altern atives central venous cannulation (b p534), alternative route of drug administration (PO/IM /SC/PR). Hints and tips \200 See comments under \200\230Taking blood \200\231 \200 Start distal ly in a limb and work your way proximally if you fail to cannulate initially Veins are easier to cannulate at the junction of two veins \200 Try to avoid cannulae ove r a joint as these are uncomfortable and more likely to tissue If you go through the wall of the vein, withdraw a small distance until fl ashback recurs and try to advance the plastic cannula In confused patients and children, always cover the cannula with a cr pe bandage and tape the IV line to their skin to minimize auto-extraction and further cannulation practice. Table 16.2 Intravenous cannulae Color Size Flow rate (ml/min) Use Blue Pink Green White Gray Orange 22G 20G 18G 17G 16G 14G 31 55 90 135 170 265 Small fragile veins IV drugs and fl uids blood Blood, fl uids, drugs Blood, fl uids, drug s Rapid blood, fl uids, drugs Rapid blood, fl uids, drugs Cannula care \200 Inspect cannula daily, looking for infl ammation and replace it every 7 2h \200 If asked to replace it, check cannula is still necessary \200 If blocked, try f l ushing the line gently with 0.9% saline and check the giving set isn \200\231t kinked Remove the cannula if the surrounding skin becomes red, swollen or tender as a result of cannula insertion. _OHFP.indb 519 _OHFP.indb 519 30/05/2014 16:18 30/05/2014 16:18 520 CHAPTER 16 Procedures Taking blood in children Never use a needle and syringe, never use a snapped off broken needle. Diffi culty 3 \200 \2235/5 Consent verbal from parent child Level F1 Indications diagnosis, monitoring physiological state, drug monitoring. Contraindications r elative parental refusal, preserving veins. Planning before you take the blood get all the equipment ready, think about the amount of blood and which bottles you need, work out where the child, parent and staff will go, think about distraction and topical anesthesia (eg EM LA). Choosing a vein the appearance of the vein is more important than the feel in very you ng children (they can be too small to palpate); common sites include hands, feet and forear ms. Antecubital fossa and saphenous veins should only be used if there is no chance of a lo ng line being inserted. (a) (b) (c) Fig. 16.3 (a) Safe area for heel prick. (b) Use of a Tenderfoot for heel prick. (c) A cut -off butterfl y. Heel prick \200 Age range babies <10d; though works on fi ngers at all ages if desperate \200 Samples <1ml of blood, ie 2 bottles, not K+, clotting or blood cultures \200 Analg esia pacifi er dipped in 20% glucose, swaddling \200 Staff can be performed alone in babi es. \200 Advantages easy, usually quick, does not use up a site for cannulation \200 Di sadvantages small quantities, can take a long time, messy. Procedure grip the heel tightly between index fi nger and thumb. Choose a site on the outsi de of the heel (Fig. 16.3a) and wipe with an antiseptic swab then apply a small amount of V aseline . Hold the lancet (Fig. 16.3b) fi rmly against the skin and squeeze the heel as yo u release the lancet. Catch the blood as it drips out; you may need to gently squeeze the f oot. Apply cotton wool. Keeping it \200\230fun \200\231 it is essential to make the experience as pleasant as poss ible \200\223 not least of all to make it easier the next time. Use a special treatment ro om, involve the play therapist, keep their parents with them, smile, off er distraction, an d, most importantly, give out stickers. OHFP.indb 520 OHFP.indb 520 30/05/2014 16:18 30/05/2014 16:18 521 TAKING BLOOD IN CHILDREN Winged needle/cut-off butter \202 y (Fig. 16.3c) \200 Age range <1yr (but works at any a ge) \200 Samples not blood cultures \200 Analgesia pacifi er dipped in 20% glucose, swa ddling, Ametop /EMLA \200 Staff two extra \200\223 one to hold the child, one to act as tourniquet. \200 Advantages relatively easy to hit the vein, can get large quantities \200 Disadvantages very messy, can clot if fl owing slowly. Procedure locate suitable vein (between the knuckles can be surpris- ingly good if no other s are visible). Ask a colleague to act as a tourni- quet. Stretch the skin to fi x the vein ; a baby \200\231s fi st fi ts well between the thumb and index fi nger if their wrist is f l exed. Insert the needle slowly until blood drips out of the needle; catch suffi cient blo od then remove the needle and apply cotton wool. Butter \202 y \200 Age range >1yr \200 Samples not blood cultures \200 Analgesia Ame top /EMLA , cold spray, distraction (play therapist) \200 Staff two extra \200\223 one to hold the child, one as tourniquet and distraction. \200 Advantages clean, can get lar ge quantities \200 Disadvantages hard to hold butterfl y whilst drawing on syringe. Procedure locate suitable vein. Ask a colleague to act as a tourniquet. Stretch the skin to fi x the vein; insert the needle slowly until there is fl ashback. Hold the butterfl y in place whilst gently fi lling the syringe until there is suffi cient blood; remove the butte rfl y and apply cotton wool. Cannula \200 Age range any \200 Samples any including blood cultures \200 Analgesia p acifi er dipped in 20% glucose, swaddling, Ametop / EMLA , cold spray (ethyl chloride), d istraction (play therapist) Staff two extra \200\223 one to hold the child, one as tourniquet and distraction \200 A dvantages sterile, easy to obtain large samples, clean \200 Disadvantages makes future ca nnulation harder, can be diffi cult. Procedure locate suitable vein. Ask a colleague to act as a tourniquet. Stretch the skin to fi x the vein. Hold cannula between thumb and middle fi nger with bevel facing up. Gently insert the cannula until you see fl ash- back then use your index fi nger to gently advance the plastic cannula into the vein. Secure the cannula in place with a couple of steristrip s \204 then completely remove the needle (into a sharps bin at the bedside) and collect bl ood from the cannula by allowing it to drip into the tubes. Remove the tourniquet and secur e the cannula further with an adhesive dressing. Attach the extender to the cannula and fl ush with 2ml 0.9% saline. Wrap the surrounding area and the extender tube in gauze so that only the end of the extender is accessible. _OHFP.indb 521 _OHFP.indb 521 30/05/2014 16:18 30/05/2014 16:18 522 CHAPTER 16 Procedures Arterial blood gas (ABG) Consent verbal Level F1 Diffi culty 3/5 Indications assessment of hypoxia, CO2 retention, acid \200\223base status, acutely ill pat ients, DKA. Contraindications absolute competent patient refusal; radial AV fi stula, poor/absent colla teral circulation, bony fractures; femoral femoral artery graft; relative overlying infecti on, abnormal clotting. Site radial artery (usual), femoral artery, ulnar artery, brachial artery (last resort). Equipment non-sterile gloves, antiseptic swab, heparin-fi lled syringe and cap, needle (blu e for radial, green for femoral), gauze/cotton ball, tape, sharps bin. Checks note the conc entration of O2 the patient is on and their tem- perature. Locate the nearest ABG analysis machine. Radial ABG check ulnar circulation adequacy by squeezing the hand into a fi st, oc cluding the radial and ulnar arteries in the wrist, holding for 10s then opening the hand a nd releasing the pressure on the ulnar artery only; looking for reperfusion of the whole ha nd (modifi ed Allen \200\231s test). Patient position upper limb sit the patient upright, a rm and wrist extended, put a pillow under the wrist to hold the position; femoral ABG lie p atient fl at on their back with their groin exposed. Procedure wash hands and wear non-sterile gloves. Attach needle to syringe and expel excess heparin (if present). Palpate both radial pulses and select the better side. Local anesthe tic can be given intra- dermally or topically prior to this procedure. Roll your fi nger ba ck and forth over the artery to assess its width and course. Do not use a tourniquet. Clean the skin using 2% chlorhexidine. Place a fi nger on the radial pulse, hold the syringe lik e a pen with the bevel facing upwards and proximally (Fig. 16.4). Warn the patient and inse rt the syringe at 30 to the skin, aiming for the center of the artery against the directi on of blood fl ow. Once you hit the artery the blood should pulse into the syringe (best me thod of assessing whether arterial or venous). If not reassess the positions of the pulse a nd needle by feeling for the needle tip as you gently press the syringe upwards. Once you h ave about 1ml of blood apply gentle pressure to the punc- ture site with cotton wool and wi thdraw the needle. Ensure fi rm pres- sure applied to the site for 3 mins \200\223 use an assistant if necessary but not the patient. Remove the needle using a sharps bin and put th e cap on the syringe. Label the syringe at the bedside with the patient \200\231s details, O2 concentration and temp and take it to the ABG machine. OHFP.indb 522 OHFP.indb 522 30/05/2014 16:18 30/05/2014 16:18 523 ARTERIAL BLOOD GAS (ABG) Con \201 rmations during procedure pulsatile, bright-red blood fi lls the syringe automati cally; post-procedure blood O2 saturation (SaO2) is the same as that measured with a sats p robe (SpO2). Complications bleeding, haematoma, arterial damage and peripheral ischaemia, p ain, infection, local tendon/nerve damage. Safety steady the patient \200\231s arm on a pillow to reduce movement and risk of needle-s tick injury, dispose of needles into a sharps container immediately, do not resheath them. Alternatives \200 Femoral blood gas similar to femoral stab (b p516) but aim for the femo ral pulse (usually 2 fi ngers width below the inguinal ligament), with the patient lying fl at on their back. Insert the green (21G) needle at 90 to the skin Brachial artery gas (if unable to get radial or femoral) extend the patient \200\231s arm and insert needle at 45 into the brachial artery (medial to the bic eps tendon, on the inner aspect of the upper forearm) \200 Arterial cannula used for repe ated arterial samples or direct BP measurement (seek senior/specialist advice). Hints and tips \200 Consider applying topical (b p521) or infi ltrated local anesthetic (bleb of 1% lidocaine over the artery using an orange needle) \200 If no blood is seen re position the needle without withdrawing it completely from the skin; ask the patient to dorsifl ex the wrist fully \200 You may miss the artery which lies superfi cially and hit the bone (painful); if this happens gently withdraw the needle to just under the skin, reposition the needle in line with the pulse and try again, taking your time The ED, ICU, HDU, neonatal, and labor wards often have ABG machines; if you cannot process the ABG within a few minutes put it on ice (remove and disp ose of the needle fi rst) Expel air bubbles from the syringe before presenting the sample to the analysis machine. Interpretation see b p584 Fig. 16.4 Obtaining an arterial blood sample from the right radial artery. _OHFP.indb 523 _OHFP.indb 523 30/05/2014 16:18 30/05/2014 16:18 524 CHAPTER 16 Procedures SC/IM injections Consent verbal Level F1 Diffi culty 1/5 Indications preferred route of administration for many drugs; where IV access not possible. Contraindications absolute competent patient refusal, drug allergy; relative abnormal clott ing. Site \200 SC upper arm (tricep/deltoid), anterior abdominal wall, anterior thigh \200 I M shoulder (deltoid), lateral thigh, superior lateral quadrant of the buttocks (to avoid the sciatic nerve; Fig. 16.5). Equipment non-sterile gloves, antiseptic swab, drug, syringe, green (21G) and blue (23G) or orange (25G) needle, cotton wool, sharps bin. Checks patient \200\231s name, hospital number, and DoB (ask patient or check ID band), dos e and strength prescribed, batch number and expiry date, allergies (ask patient, check alle rgy bands and drug chart). Patient position so that target site is exposed and accessible. Procedure wash hands and wear non-sterile gloves. Draw up the medication into a syringe usi ng a fi ltered needle (ie one with foam at the base of the needle that prevents glass enter ing the syringe) and expel any air bubbles: \200 SC attach an orange needle to the syring e and clean the area for injection with a chlorhexidine swab. Raise the skin and subcutaneous tissue between your fi ngers by pinching it and insert the needle at 45 into the skin. Pull the syringe back sl ightly to check you are not in a blood vessel. Inject the medication slowly, watching the p atient as you do so, then withdraw the needle and hold cotton wool over the site \200 IM attach a blue needle to the syringe and clean the area for injection with a chlorhexidine s wab. Insert the needle vertically into the skin and pull back slightly to check you are not in a blood vessel. Inject the medication slowly, watching the patient as you do so, then w ithdraw the needle and hold cotton wool over the site. Depth of needle insertion varies dep ending on depth of patient \200\231s subcutaneous fat layer, but in normal BMI patient inse rt approximately 2 \200\2232.5cm. OHFP.indb 524 OHFP.indb 524 30/05/2014 16:18 30/05/2014 16:18 525 SC/IM INJECTIONS Con \201 rmation drug successfully administered, assess the patient and monitor the HR, BP , and RR to ensure there is no acute reac- tion, remember to write the time given and sign the drug chart. See Table 16.3. Complications anaphylaxis (b p470), drug overdose (b p493), local swelling, pain and bruising, bleeding, accidental IV injection. Safety stay on the ward for at least 5min after giving drugs in case of an acute reaction. Dispose of sharps immediately in a sharps bin at the bedside. Alternatives consider other routes (PO/IV/PR/SL/IN) or other drugs. Hints and tips \200 Use a longer needle for IM injections in obese patients \200 If blo od is aspirated, withdraw and repeat the procedure in a diff erent site with a clean needle For repeated injections, rotate injection sites to limit local reactions \200 Most nurses can give IM/SC injections and are more experienced at it \200 Try to avoid IM injections as much as possible as they are fairly painful. Table 16.3 Drugs commonly given via SC and IM routes Subcutaneous \200 Insulin \200 LMWH \200 Diamorphine \200 Morphine Intramuscular \200 Metoclopramide \200 Cyclizine (very painful) \200 Tramadol/pethidi ne \200 Chlorphenamine \200 Haloperidol Fig. 16.5 Safe area for IM injection in the upper outer quadrant of buttock: avoid the area s marked in red. _OHFP.indb 525 _OHFP.indb 525 30/05/2014 16:18 30/05/2014 16:18 526 CHAPTER 16 Procedures IV injections b p398 b p327 b p380 Morphine injection b p201 b p201 b p209 Blood transfusions Insulin sliding scale IV fl uids Heparin infusion GTN infusion Consent verbal Level F1 Diffi culty 1/5 Indications rapid onset of action needed, to avoid enteral administra- tion, to provide ste ady plasma concentration from infusion, only route of administration available or tolerated . Contraindications absolute competent patient refusal, drug allergy. Site via a cannula (see b p518) or central line (b p534). Equipment IV fl uid/drug/blood, IV cannula in situ, syringe, green needle, giving set (tube connecting the bag to the cannula), 0.9% saline fl ush. Checks patient \200\231s name, hospital number and DoB (ask patient or check ID band), dose and infusion rate prescribed, batch number and expiry date, allergies (ask patient, check allergy bands and drug chart), cannula is sited appropriately and fl ushing, some drugs nee d thera- peutic monitoring. \200 If you are unfamiliar with an IV drug look it up in the BNF before giving \200 Always follow the BNF and manufacturers instructions. Patient pos ition sitting up with the cannula exposed. Procedure fl ush the cannula to make sure it is working then: \200 IV infusion hang the b ag on a drip stand and puncture the port on the bag of fl uids with the sharp plastic end of the giving set. Open the valve and run the fl uid through into a sink (or kidney bowl) to remove air bubbles. Connect the other end o f the giving set to the horizontal cannula porthole (not the colored top). Alter the drip s peed and tape a loop of the tubing to the patient \200\231s arm to limit traction on the ca nnula \200 Drawing up IV drugs if the drug is in powder form reconstitute with solvent as directed (often 0.9% saline/water; Appendix 4 of BNF). Draw solvent into a syringe and inj ect it into the drug vial. Shake well then draw the solution back into the syringe with a f i lter needle. If the drug is already in liquid form in a glass ampoule, use a fi lter need le to draw up the drug to prevent aspiration of tiny shards of glass \200 Giving IV drugs tap the syringe to bring air bubbles to the top then expel any air and remove the needle. Attach the syringe to the side port and slowly administer the medication according to the d rug manufacturer \200\231s instructions or the BNF. Flush with 5ml 0.9% saline. OHFP.indb 526 OHFP.indb 526 30/05/2014 16:18 30/05/2014 16:18 527 IV INJECTIONS Con \201 rmation infusion running/IV drug successfully administered, assess the patient an d monitor the HR, BP and RR to ensure there is no acute reaction, remember to write the tim e given and sign the drug chart. Complications anaphylaxis (b p470), drug overdose (b p493) , local irritation/thrombophlebitis, leakage of drug from tissued cannula, hae- matoma. Safety if multiple infusions are set up check they can be given through the same cannula. I f not, insert a second cannula or give the drugs at diff erent times. Stay on the ward for at least 5min after giving IV drugs in case of an acute adverse reaction. Alternatives consider other routes of administration (PO, IM, SC, PR, SL, IN). As a last re sort fl uids (0.9% saline or glucose saline without KCl) can be given very slowly SC (no fa ster than 1l over 12h). Do not give 5% glucose SC due to infection risk. Blood transfusions (b p398) can only be given IV. You may need a central line (b p534) for some IV infusions/ drugs. Hints and tips \200 Flush the cannula, especially after giving irritant drugs (eg cyclizi ne, amiodarone) If you are unsure of infusion rates, consult the BNF \200 Some medications must be given at a constant rate using a syringe driver (eg heparin, magnesium, GTN, opioids) Keep IV infusions above the level of the patient \200\231s heart to prevent blood entering the giving set Keep syringe drivers below the level of the patient \200\231s heart to prevent drug siphoning (though most modern giving sets contain anti-siphoning valves) Most nurses can administer IV infusions or drugs though some IV injections must be given by a doctor; there is usually good reason for this \200\223 fi nd out what it is before giving the injection. _OHFP.indb 527 _OHFP.indb 527 30/05/2014 16:18 30/05/2014 16:18 528 CHAPTER 16 Procedures ECGs and cardiac monitors Consent verbal Level F1 Diffi culty 1/5 Indications \200 ECG chest/back/abdo pain or suspicion of cardiac ischaemia, unexplained SOB, dGCS, iK+, arrhythmias, pre-op Cardiac monitoring peri- and post-cardiorespiratory arrest, peri- and post-MI, iK+, unstable arrhythmias, cardioversion, administration of certain drugs, adm inistration of anesthesia. Contraindications absolute competent patient refusal; relative patient con- taminated with toxic substance or other risk to operator. Site anterior chest wall and limbs. Equipment ECG/cardiac monitor, adhesive electrodes. Checks suffi cient ECG paper, paper mov ing at 25mm/s. Patient position sitting at 45 for ECG. Procedure \200 ECG apply adhesive electrodes and connect, as described in the box and Fig . 16.6, then turn the ECG machine on. Ask the patient to sit back and stay still. Press \200\230record \200\231 (often an ECG picture or \200\23012 \200\231). The ECG should prin t once the machine has collected enough data Cardiac monitoring apply the leads as follows: red right shoulder; yellow left shoulder and green/black over the apex beat or spleen; see Fig. 16.7. The machine will show the trace o f lead \200\230II \200\231 on a standard 12-lead ECG. Other views can be obtained with 3 l eads. Limb leads red right shoulder; yellow left shoulder; green left foot; black right foot Ches t leads V1 (red) right sternal edge, 4th intercostal space; V2 (yellow) left sternal edge, 4th intercostal space; V3 (green) between V2 and V4; V4 (brown) mid-clavicular line, 5th in tercostal space; V5 (black) anterior-axillary line, horizontal with V4; V6 (purple) mid-axi llary line horizontal with V4 (see Fig. 16.6). Con \201 rmation adequate ECG printout or trace on cardiac monitor. Complications skin rea ction to adhesive electrodes (rare). Safety caution with electricity and wet/bloody environ ments. Alternatives for posterior MIs the ECG is set up with posterior leads; the leads are attached three places further on, ie V1 is connected to V4, V2 to V5, etc. Leads V4 \200 \2236 are attached round the posterior chest at the same horizontal level as V6 to become V 7 \200\2239, see Fig. 16.8. Ensure you document this on the ECG trace. Hints and tips adhes ive electrodes do not stick to hairy skin so you may need to shave a small patch. If the pa tient is sweaty, clean the skin with an alcohol wipe fi rst. In desperation use a pen to ho ld single leads in place. The limb leads can be placed on the ankles and wrists or over the hips and shoulders, however comparing ECGs taken by diff erent methods can be hard. Consid er a chaperone for female patients. OHFP.indb 528 OHFP.indb 528 30/05/2014 16:18 30/05/2014 16:18 529 ECGS AND CARDIAC MONITORS Manubrium Clavicle Mid-clavicular line I II III Mid-axillary line V1 V2 IV V3 V6 V5 V4 V Fig. 16.6 Position of the chest leads for 12-lead ECG. Yellow Red Green Fig. 16.7 Position of the three leads for cardiac monitoring. V9 V8 V7 V6 Fig. 16.8 Position of the posterior chest leads; V7 \200\2239. _OHFP.indb 529 _OHFP.indb 529 30/05/2014 16:18 30/05/2014 16:18 530 CHAPTER 16 Procedures Exercise tolerance test Level F2 Consent verbal/written Diffi culty 4/5 Indications diagnosis of suspected IHD, assess cardiac fi tness, prognosis post-MI, evaluat ion of treatment (eg angioplasty, CABG), assessing exercise- induced arrhythmias. Contraind ications absolute competent patient refusal, unstable angina; relative severe aortic stenos is, recent (<5d) ST elevation MI, uncontrolled arrhythmia, iBP or heart failure, physical i nability (eg severe COPD, stroke, ) arthritis), b-blockade; inability to interpret (paced r hythms, LBBB). ) y ( y Equipment treadmill, ECG, sphygmomanometer, GTN, arrest trolley. Checks exclude contraindic ations, arrest trolley accessible. Patient position record fi rst ECG with patient lying do wn, second with patient standing up and serial ECGs as patient walks on the treadmill. Procedure the technician connects the BP cuff and ECG leads to the patient with a specializ ed harness; a baseline BP is recorded. The test commences with the treadmill moving slowly then gradually speeding up whilst increasing the gradient; this is pre-programmed and most hospitals use the Bruce protocol (OHCM9 b p102). BP is recorded every 3 \200\2235min. Real- time ECGs are often shown on a monitor where changes to the ST segment can be observed. The test is complete once the patient reaches \211 90% of their maximal heart rate (220 \210 \222 age in years) or they complete the protocol (30min). The test is often stopped early ( see below). BP and ECG measurement continues for a further 10 \200\22315min as the patient rests. Con \201 rmation deciding if the test is positive or not is diffi cult, since stopping ear ly (see below) could be either positive or negative depending on the ECG tracing. A senior cardiologist often determines the result. If the test is stopped early consult a senior. Co mplications atrial and ventricular arrhythmias (including VF and VT), syncope, shortness of breath, angina, MI, death. Safety stop the test if: \200 Patient has chest pain or sever e shortness of breath \200 Patient is exhausted, feeling faint, or at risk of falling \200 ST segment depression >2mm in any lead \200 ST elevation \200 Atrial or ventricul ar arrhythmia (occasional ectopics do not count) \200 Systolic BP \211 230mmHg or a fall in systolic BP \211 20mmHg \200 Development of AV block or LBBB. Alternatives the test can be performed on an exercise bicycle, an arm bicycle or induced pharmacologically with a n IV b-agonist. Stress echo- cardiography (OHCM9 b p106) and nuclear cardiography can also be used to assess cardiac disease. Hints and tips most hospitals have specifi c protocols f or exercise testing. The technician is usually much more experienced than the junior doctor and if they suggest stopping a test it is worthwhile doing so. OHFP.indb 530 OHFP.indb 530 30/05/2014 16:18 30/05/2014 16:18 531 CHEMICAL CARDIOVERSION (ADENOSINE) ) Chemical cardioversion (adenosine) Diffi culty 4/5 Consent verbal ( Level F2 Indications regular narrow complex tachycardia, known SVT with bundle branch block. Contrai ndications absolute serious adverse event with adenosine in past; relative cardiovascular i nstability (dGCS, systolic BP <90mmHg, chest pain, heart failure), 2nd- or 3rd-degree heart block, asthma, accessory-pathways (eg WPW), sick-sinus syndrome. Things to try \201 rst vagal maneuvers: 10s of carotid sinus massage (never both sides together); straining down a s if passing a stool; trying to blow the plunger out of a clean 10ml syringe from the narro w end; immersing the ) face in icy cold water (often diffi cult to perform on the ward). y ( Equipment defi brillator with monitoring strip recorder and paper, BP monitoring, pulse oxi metry, large-bore venous access ( \211 green cannula in antecubital fossa), O2 supplementat ion, arrest trolley (equipment and drugs), adenosine, saline fl ushes and drawing-up needle s and syringes. Patient position allow the patient to get themselves into a position where they are comfortable, either laying fl at or at 45 in bed. Patient explanation tell the p atient about the procedure including the common symptoms such as facial fl ushing, lighthea dedness, chest tightness and nausea; most symptoms last <60s after administration. Pre-proc edural checks ensure a 12-lead ECG has been undertaken. Check the patient still has a tachy cardia. Give the patient supplemental O2, ensure O2 sats and BP monitoring are attached to the patient (on the opposite arm to the venous access) and that observations are being note d every few minutes. Attach leads of defi brillator to monitor heart rhythm (select \200 \230leads \200\231 on the defi brillator). Have at least one assistant who is ALS trained. Draw up 6mg of adenosine and a 10ml 0.9% saline fl ush. Check the cannula is patent and fl ushing painlessly. Procedure commence rhythm strip recording/printing on the defi bril- lator (usually press \200\230record \200\231). Warn the patient you are going to give the drug. Inject 6mg adeno sine rapidly, followed immediately by the 10ml fl ush. Observe the rhythm strip and patient . Possible outcomes and further management: \200 No eff ect on HR or rhythm within 60s; rep eat procedure using 12mg of adenosine; if still no response seek senior/specialist advice \200 Transient slowing o f HR, but restoration of original tachycardia; observe underlying rhythm on rhythm strip during slowing; if AF then treat for fast AF (b p 248), otherwise treat according to ALS (b p228) Conversion of tachycardia into sinus rhythm; success \200 Evolution into a more pathologi cal rhythm, eg VF/VT; follow appropriate ALS algorithm (b p228). Complications see patient explanation, above. Safety never perform this procedure for the f i rst time on your own. _OHFP.indb 531 _OHFP.indb 531 30/05/2014 16:18 30/05/2014 16:18 532 CHAPTER 16 Procedures Cardioversion and de \201 brillation Consent verbal/common law in emergency otherwise verb al/written Level F2 Diffi culty 3/5 Indications emergency VF, VT (with or without a pulse), fast AF (new onset or haemodynamica lly unstable), SVT if other treatments have failed (b p248) or patient haemodynamically uns table; elective AF. Contraindications absolute competent patient refusal; relative wet or b loody environment (moisture and electricity don \200\231t mix), if arrhythmia very likely t o persist (eg chronic AF with valvular pathology). Site one electrode to the right of the u pper sternum below the clavicle and the other electrode level with the 5th left intercostal space in the anterior axillary line (see Figs 16.9 and 16.10). In refractory VF/VT con- ) sider shocking in the anterior/posterior position (Fig. 16.11). g ( g Equipment defi brillator with hands-free electrodes (or paddles and gel-pads where still in use), arrest trolley, ECG machine. Checks defi brillator working and battery charged; gel- pads and resuscitation drugs available, at least one assistant, patient \200\231s cardiac r hythm requires cardioversion, nobody touching the patient/bed, O2 removed. In elective case s check the patient is starved and adequately anticoagulated with good IV access. Patient p osition supine. Procedure \200 Emergency follow ALS (b p228)/APLS algorithms. Attach hands- free electrod es. Set defi brillator to required energy, make sure no one is in contact with the patient or bed and the O2 is removed. Give a clear verbal warning to stand clear. Shock. Continue C PR as per ALS/APLS algorithm Elective ensure the anesthetist is available and inform the nursing staff . Attach hands-free electrodes before the patient is anesthetized. Once anaethetised set the defi brillator to \200\230synchronized shock \200\231 and shock in accordance with ALS/APLS algorithms, checking that no one is in contact with the patient/bed and that O2 i s removed. Give a clear verbal warning to stand clear. Shock. Con \201 rmation restoration of sinus rhythm for elective cases or a cardiac output in the emergency situation; perform 12-lead ECG. Complications life-threatening arrhythmias, thro mboembolism, aspiration, local burning to skin, risks to user and bystanders Safety users o f the manual defi brillator must have passed an ALS or ILS course; caution with electricity and wet/bloody environments. Alternatives automated external defi brillators (AEDs) are be coming widespread and require no rhythm recognition by the user. Two hands- free electrodes are applied to the patient and the AED determines if a shock is advisable or not; if a sho ck is advisable the operator just presses the \200\230shock \200\231 button when the AED t ells them to. AEDs should not be used for elective cardioversions. Hints and tips always de fi brillate safely; if in doubt contact your resus- citation offi cer for some extra traini ng. OHFP.indb 532 OHFP.indb 532 30/05/2014 16:18 30/05/2014 16:18 533 CARDIOVERSION AND DEFIBRILLATION Fig. 16.9 Position of manual defi brillator paddles. Make sure gel-pads are placed on the s kin underneath the paddles as these reduce the impedance and limit skin burns. Fig. 16.10 Position of hands-free adhesive defi brillation electrodes. The electrodes for m ost hands-free systems indicate where they should be placed: to the right of the upper ster num and over the 5th left intercostal space in the anterior axillary line. Fig. 16.11 Position of either manual paddles or hands-free electrodes in the AP position. T he anterior site is to the left of the lower sternal border and the posterior position is j ust inferior to the left scapula. _OHFP.indb 533 _OHFP.indb 533 30/05/2014 16:18 30/05/2014 16:18 534 CHAPTER 16 Procedures Central lines Consent verbal/written Level F2+ Diffi culty 3 \200\2235/5 Indications monitoring fl uid balance, temporary pacing wires, drug administration, parente ral feeding, permits blood sampling, pulmonary artery catheterisation (Swann \200\223Ganz c atheters). Contraindications absolute competent patient refusal; relative infection at site , abnormal clotting, shock. Site internal jugular, subclavian or femoral vein. j g Equipment 5ml/10ml syringes, blue (23G) and green (21G) needles, non- absorbable suture, Se ldinger central line kit (introducing needle, 5ml syringe, guidewire, dilator, small blade, central line with 2 \200\2235 lumens and bungs), 1% lidocaine, sterile gown, hat, mask and gloves, dressing pack, sterile drapes, portable ultrasound, continuous ECG monitoring on p atient. Patient position fl at on their back with their head down for internal jugular and subclavian cannulation; fl at on their back with head up for femoral cannulation \200\223 helps fi ll the vein. Procedure using aseptic technique, clean with 2% chlorhexidine and drape the area. Identify landmarks and using ultrasound identify the vein. Anesthetize the skin and deep layers wit h 10ml lidocaine. Whilst the anesthetic takes eff ect, fl ush all lumens of the central lin e with saline and cap all except the green one. Attach 5ml syringe fi lled with saline to t he central line needle and introduce through the skin, directing it towards the vein under ultrasound guidance, visualizing the needle tip at all times, aspi- rating whilst advancing . Once dark red blood is aspirated freely into the syringe, stop advancing. Remove syringe whilst holding the needle fi rmly in place. If blood spurts out in a pulsatile fashion it i s likely to be an arterial cannulation \200\223 STOP (see What to do if the artery is can nulated ). Once venous fl ashback obtained, advance the guidewire through the lumen of the needle (should advance without resistance), checking for ectopic beats on ECG. Once about h alf of the guidewire is inserted, remove the needle, but always holding onto the guidewire. Make a small incision in the skin adjacent to the guidewire with the blade; thread the dil ator over the guidewire and fi rmly advance the dilator through the skin and deep layers, r otating to ease its passage. Stop once half the dilator is through skin and remove it whils t holding on to the guidewire. Pass the central line over the guidewire and advance it thro ugh the skin, holding onto the guidewire at all times. Remove the guidewire once the centra l line is inserted and cap the open lumen. Check blood can be easily aspirated from each lu men and fl ush with saline. Suture the line to the skin, clean the skin and apply clear ste rile dressing. Con \201 rmation blood aspirated from all lumens, blood O2 sats <fi nger O2 sats (SvO2<SpO 2), CXR to locate the catheter tip and exclude pneu- mothorax. Always confi rm guidewire re moved. Complications arterial cannulation, bleeding, pneumothorax (subclavian >internal jug ular), failure to identify vein, air embolism, infection. Safety never perform this procedu re for the fi rst time on your own. Hints and tips make sure you and the patient are both c omfortable before you start. Use suffi cient LA. Ultrasound should be used routinely for in ternal jugular line placement. OHFP.indb 534 OHFP.indb 534 30/05/2014 16:18 30/05/2014 16:18 535 CENTRAL LINES SCM External jugular vein Internal jugular vein Carotid Larynx Clavicular head of SCM Clavicle Sternal head of SCM Subclavian artery Subclavian vein 1st rib Fig. 16.12 Anatomy of the major vessels in the neck. The internal jugular is the most commo n site and has fewer acute complications than subclavian cannulation; subclavian lines have lower rates of infection than internal jugular lines, femoral cannulation has the highest rate of infection. The internal jugular lies deep to sternocleidomastoid muscle (SCM). The needle should puncture the skin midway between the mastoid process and the sternoclavicular joint, lateral to the carotid pulse. The needle should then be directed towards the nipple on the same side to hit the vein. Accidental arterial cannulation Signs of arterial cannulation \200 Bright-red blood, rath er than dark-red \200 Pulsatile blood, rather than constant low fl ow \200 iO2 sats (>9 5%) of blood compared with fi nger O2 sats \200 If the left carotid artery is cannulated the central line will cross the midline on the CXR. What to do if the artery is cannulated \200 Identify arterial cannulation \200 Remove a ll needles, guidewires and lines; press fi rmly over site for 10min \200 Seek senior help . _OHFP.indb 535 _OHFP.indb 535 30/05/2014 16:18 30/05/2014 16:18 536 CHAPTER 16 Procedures Thrombolysisy Consent verbal/written Level F2 Diffi culty 3/5 Indications acute myocardial infarction which meets the following criteria: presentation wi thin 12h of onset of symptoms; typical chest pain lasting >30min; >2mm ST elevation in two or more chest leads (V1 \200\223V6) or >1mm in two or more limb leads (aVR, aVL, aVF, I, II , III) or >2mm ST segment depression in V1 to V3 (suggesting posterior infarct) or new LBBB . Contraindications absolute 3 PCI available within 2h, competent patient refusal, active b leeding, CNS trauma, neoplasms or arteriovenous malfor- mations, previous intracerebral hem orrhage, ischaemic stroke in previous 6mth, major trauma/surgery within previous 3wk, non-c ompressible punc- tures in the last 24 hours (eg liver biopsy, lumbar puncture) relative, T IA in previous 6mth, prolonged CPR, known bleeding disorder or current anti- coagulation th erapy, pregnancy, active dyspepsia or history of GI haemor- rhage, sustained hypertension ( systolic BP >180mmHg), advanced liver disease, infective endocarditis. Age is not a contrai ndication. Site peripheral IV cannulae.