Oxford Handbook of Clinical Examination and Practical Skills (2 edn)
Annotate
Cite
Using this chapter
This chapter describes those practical procedures that the junior doctor or senior nurse may be expected to perform.
Obviously, some of these are more complicated than others—and should only be performed once you have been trained specifically in the correct technique by a more senior colleague.
Rules are made to be broken
Very many procedures and practical skills do not have a ‘correct’ method but have an ‘accepted’ method.
These methods should, therefore, be abided by but deviation from the routine by a competent practitioner, when circumstances demand, is acceptable.
Infiltrating anaesthetic agents
A large number of procedures involve the infiltration of local anaesthetic agents. It is important that you deliver these safely—injection of a large amount of anaesthetic into a vein could lead to potentially fatal cardiac arrhythmias. It is also important, of course, to ensure that you do not damage any vessels.
Advance and pull back
Whenever you inject anything, you should advance the needle and attempt to pull back the plunger at each step—if you do not aspirate blood, you may then go ahead and infiltrate the anaesthetic.
Making a surface bleb
Take the syringe of anaesthetic (e.g. 1% lidocaine = 10mg/ml) and a small needle.
Pinch a portion of skin, insert the needle horizontally into the surface.
Withdraw, as above, and inject a small amount of the anaesthetic—you should see a wheal of fluid rise.
The area of skin will now be sufficiently anaesthetized to allow you to infiltrate deeper.
Other notes on local anaesthetics
The maximum does of lidocaine is 3mg/kg in an adult.
This can be increased to 7mg/kg if mixed with adrenaline (although never to be used in this way at end-arteries).
Lidocaine is a weak base and only works in its non-ionized form. It is, therefore, relatively ineffectual in infected (acidic) tissue.
Lidocaine and other local anaesthetics sting on initial infiltration so warn the patient.
Hand hygiene
When?
The WHO World Alliance for Patient Safety, in 2006, identified ‘five moments’ for hand hygiene. These are:
Before patient contact.
Before an aseptic task.
After body fluid exposure risk.
After patient contact.
After contact with a patient’s surroundings.
Soap or alcohol gel?
Repeated washing with soap and water can cause skin dryness and can be time consuming. For these reasons, alcohol gel has become commonplace in clinical settings. There are no hard and fast rules but:
Alcohol gel should not substitute soap and water if your hands are visibly soiled or if you are undertaking an aseptic procedure.
Remember that alcohol gel is not effective against Clostridium difficile.
Soap and water technique
Adhere to the ‘bare below elbow’ rule.
Wet hands with water.
Apply soap (from a dispenser) to cover all hand surfaces.
Ensure all seven parts of the hands are thoroughly cleaned:
Rub hands palm-to-palm
Rub back of each hand with the palm of the other, fingers interlaced
Rub hands palm-to-palm with fingers interlaced
Lock hands together and rub backs of fingers against opposite palm
Rub thumbs in rotational movement with opposite hand
Rub tips of fingers into opposite palms
Rub each wrist with opposite hand.
Hold hands under running water, rub vigorously to remove all suds.
Turn off taps using elbows.
Dry thoroughly with paper towel.
Dispose of paper towels in appropriate clinical bin (using foot pedal).
DO NOT TOUCH any other objects until task is undertaken and completed.
Alcohol gel technique
Essentially the same technique as above but no need to rinse or dry with a paper towel.
Squirt small amount of gel onto centre of palm.
Ensure all seven parts of the hands are thoroughly cleaned as above.
Allow 20–30 seconds for hands to dry, holding hands up.
Following disinfection, DO NOT TOUCH any other objects prior to commencing procedure.
Consent
Update
Patients under 18 years of age
Overriding decisions: under 18 years
Recent advice from the Care Quality Commission and lawyers indicates that a competent refusal from a young person (aged 16–17) cannot be overridden by an adult with parental responsibility.
See the latest guidance at 
http://www.gmc-uk.org
Introduction
Questions to ask yourself before any procedure:
A = Allergies
B = Bloods
C = Consent
D = Drug history
E = Emergency cover in case of complication or failure of the procedure.
The WHO pre-procedure checklist is a series of questions to ask of the patient and the person performing the procedure
This is usually reserved for complex interventional procedures and surgery
Check your local guidance
Questions cover introductions, patient details, allergies, details of the procedure and any other pre-procedure checks
You should familiarize yourself with the questions and perform these checks yourself before performing any procedure (even if not on a formal WHO checklist form)
For more information, go to 
http://www.who.int
Capacity
The patient must be able to understand what a procedure involves, the possible consequences of a decision or of failure to make a decision. All adults are assumed to have capacity unless demonstrated otherwise.
Assessing capacity
The patient must be able to:
Understand the information including any consequences.
Retain the information.
Weigh the information as part of decision making.
Communicate their decision.
A patient lacking capacity
Your reasons for believing a patient lacks capacity to make a certain decision should be clearly documented.
A patient may become temporarily incapacitated by, for example, acute confusion. Treatment may only be carried out in these circumstances if it cannot reasonably be delayed until incapacity is resolved. If this is the case, treatment must be decided according to the best interests of the patient.
Voluntary consent
Consent is only valid if given voluntarily, without pressure from relatives, friends, or medical professionals.
Information
Patients must be provided with sufficient information to enable them to make an informed decision. Information must include:
What the procedure entails and the rationale for doing it.
Any alternatives available.
Significant risks.
This includes any ‘significant risk which would affect the judgement of a reasonable patient’, not just those risks deemed significant by a responsible body of medical opinion (the Bolam test). Failure to disclose such risks may render you guilty of negligence.
Additional procedures that may be necessary under the same anaesthetic should be discussed during initial consent.
If patients refuse information about a procedure, this should be clearly documented and the patient provided with the opportunity to discuss later.
Consent forms
Written consent is evidence that consent has been sought but does not confirm its validity.
If consent is not voluntary, information is lacking, or the patient lacks capacity, then consent is not valid regardless of the presence of a consent form.
Certain procedures (included in the Mental Health Act and Human Fertilisation and Embryology Act) require written consent.
Consent that is oral or non-verbal may also be valid.
Who should seek consent?
Ideally, the professional providing the treatment or investigation in question, though this is not always possible.
The professional seeking consent should at least have sufficient knowledge to understand and explain the procedure, its indication, and any risks involved.
If you are asked to seek consent for a procedure but lack this knowledge, it is your responsibility to seek advice from colleagues; failure to do so may result in invalid consent.
Refusal to consent
If an adult with capacity refuses to give consent for a procedure, this must be respected (except in specific circumstances outlined in the Mental Health Act), even if refusal will lead to death of the patient or their unborn child.
In these circumstances, rigorous examination of a patient’s competence is necessary.
The same is true if a patient withdraws consent at any time, if they still have capacity.
Advanced refusal
Advance refusal is valid if made at a time when a patient is competent and appropriately informed.
Applicable when patient lacks capacity.
Failure to respect the refusal may result in legal action.
If doubt exists as to validity, the courts must be consulted.
Adults lacking capacity
May be temporary, permanent, or fluctuating.
No-one may give consent on behalf of an incompetent adult, unless a valid Lasting Power of Attorney exists.
Patients must be treated in their best interests (not just medical interests) taking into account psychological, religious/spiritual, and financial well-being.
Those close to the patient should be involved unless the patient has previously made clear that they should not be; independent patient advocacy services exist for consultation when the patient does not have anyone close.
Where there is doubt as to best interests or capacity, the High Court may give a ruling.
Lasting powers of attorney (Mental Capacity Act 2005)
A document created by someone (the ‘donor’) to confer authority to give consent for investigation or treatment (as well as other issues) to a named individual(s) (‘donees’).
Must be registered.
Only valid when the patient lacks capacity.
Must specifically authorize the donee to make decisions regarding welfare or medical treatment.
Unless specifically stated, do not extend to decisions about life-sustaining treatment.
Patients under 18 years of age
16–17 years
If competent, may consent to or refuse an intervention.
If incompetent, an individual with parental responsibility may provide consent.
Under 16: Gillick competence
A child under 16 may consent to treatment if they are able to fully understand what is involved in an intervention.
This may apply to some interventions and not others.
If a child is Gillick competent, parental consent is not required, though it is good practice to encourage a child to inform their parents unless this is not in their best interests.
Overriding decisions: under 18 years
Refusal may be overridden by an individual with parental responsibility or the courts.
Should consider the person’s welfare as a whole. May involve sharing information that the child does not wish divulged; necessary if refusal puts the child at serious risk.
In dire emergency, where a person with parental responsibility is unreachable or refuses consent for life-saving treatment that appears to be in the best interests of the child, it is acceptable to preserve life.
Aseptic technique
You should always consider the sterility of the items to be touched before you begin each procedure. If some or all items need to remain sterile, an aseptic technique should be used.
Aseptic non-touch technique
Insertion, repositioning, or dressing invasive devices such as catheters, drains, and intravenous lines
Dressing wounds healing by primary intention
Suturing
When sterile body areas are to be entered
If there is tracking to deeper areas or the patient is immunocompromised.
Removing sutures, drains, urethral catheters
Endotracheal suction, management of tracheostomy site
Management of enteral feeding lines
Care of stomas
Instillation of eye drops.
If the sterile procedure is interrupted for more than 30 minutes, new sterile packs should be opened and the sterility process started from scratch.
Before
Wash hands with soap and water or alcohol gel.
Put on disposable apron and any other protective items.
Clean trolley/tray with wipes and dry with a paper towel.
Gather equipment and put on the lower shelf of the trolley.
Take trolley/tray to the patient.
During
Wash hands with alcohol gel.
Remove sterile pack outer packaging and slide the contents on to the top shelf of the trolley or onto the tray, taking care not to touch the sterile pack.
Open the dressing pack using only the corners of the paper, taking care not to touch any of the sterile equipment.
Place any other required items on the sterile field ensuring the outer packaging does not come into contact with the sterile field.
Put a pair of non-sterile gloves on to remove any dressings on the patient and ensure that they are positioned appropriately.
Discard gloves and wash hands.
Put sterile gloves on.
After
Dispose of contaminated equipment in the rubbish bag from the dressing pack. Dispose of all packaging.
Dispose of aprons and gloves in the appropriate waste as per local policy.
Wash hands.
Clean the trolley with detergent wipes and dry with a paper towel.
Two-person technique
An assistant can be very helpful in maintaining the position of the patient, opening packs, and decanting solutions for the person performing the procedure.
The ‘clean practitioner’ must wear the sterile gloves and open the first pack to establish a sterile field.
The second (‘dirty’) practitioner can then open all the other equipment and drop onto the sterile field.
Clean technique
This is a modified aseptic technique, aiming to prevent the introduction or spread of micro-organisms and to prevent cross-infection to patients and staff. This is used when true asepsis is not required (e.g. when dealing with contaminated sites or when removing drains and catheters).
Sterile equipment is not always used.
‘Clean technique’ allows the use of tap water, non-sterile gloves, multi-pack dressings, and multi-use containers of creams and ointments.
Subcutaneous and intramuscular injections
Usual sites for subcutaneous injections are upper arms and the abdomen, particularly the periumbilical region.
Intramuscular injections can be administered at any site with adequate muscle mass. Usual sites are deltoids and the gluteal region (upper, outer quadrant of buttock).
Contraindications
Contraindications regarding the drugs being injected will vary dependent upon the drugs being administered.
Infection at the injection site.
Oedema or lymphoedema at the injection site.
Risks
Incorrect drug and/or dosage administered.
Allergy to drug(s).
Haemorrhage, haematoma.
Infection.
Injection into a blood vessel.
Injection into a nerve.
Equipment
Appropriate syringe.
25G (orange) needle (usually).
Prescribed drug.
Prescription chart.
Antiseptic swab.
Plaster.
Before you start
Assess patient for drugs required (i.e. for pain relief, vomiting, etc.).
Refer to prescription chart, double-checking the appropriate drugs and dosage to be given.
Always ensure you are fully aware of any possible side effects of any drugs you are due to administer.
Double-check the prescription chart for date and appropriate route for administration.
Check administration of previous dose—not too soon after last dose?
Ensure that the drug to be given is within its use-by date.
Check patient and chart for any evidence of allergies, or reactions.
Once all above completed as per hospital policy, draw-up required drug and check appropriate needle size.
Complete appropriate documentation.
Once checked by suitably qualified staff, take drug and prescription chart to the patient.
Subcutaneous procedure
Introduce yourself, confirm the patient’s identity, explain the procedure and obtain informed consent.
Check with patient: name and date of birth (if capable).
If incapable, check name band with another healthcare professional.
Select appropriate site, and cleanse with the antiseptic wipe.
Grasp skin firmly between thumb and forefinger of your left hand.
Insert needle at 45° angle into the pinched skin, then release skin from your grip.
Draw syringe plunger back, checking for any blood. If none, inject drug slowly.
If any blood is noted on pulling the plunger back, withdraw and stop procedure—provide reassurance and explanation to the patient.
Once the procedure is completed without complication, withdraw needle and discard into a sharps bin.
Monitor patient for any negative effects of the drug.
Intramuscular procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Check with patient: name and date of birth (if capable).
If incapable, check name band with another healthcare professional
Select appropriate site, and cleanse with the antiseptic wipe.
If injecting into the buttock, mark a spot at the upper, outer quadrant to avoid the sciatic nerve
If using the deltoid muscle, feel the muscle mass and ensure there is enough muscle to take the needle.
Insert needle at 90° angle into the skin.
Draw syringe plunger back, checking for any blood. If none, inject drug slowly.
If any blood is noted on pulling the plunger back, withdraw and stop procedure—provide reassurance and explanation to the patient.
Once the procedure is completed without complication, withdraw needle and discard into a sharps bin.
Monitor patient for any negative effects of the drug.
Documentation
Drugs should always be signed for as per local policy.
Signature and time should be clearly recorded.
Site drug administered.
Reason for drug administration, time given and any impact on the patient should be recorded.
Immediate vital signs should be recorded in notes.
Any causes for concern arising from administration of drugs should be clearly documented in the medical notes.
Signature, printed name, contact details.
Intravenous injections
Intravenous injections can be administered by puncturing the vein with a needle and syringe and injecting directly. The procedure below describes injecting via an intravenous cannula. If no cannula is in place, cannulate first.
Ensure that you comply with the local policy regarding drug administration. In hospital, two healthcare professionals should usually check and administer medication.
Contraindications
Contraindications regarding the drugs being injected will vary dependent upon the drugs being administered.
Infection at the cannula insertion site.
Thrombosis within the vein to be injected.
Risks
Incorrect drug and/or dosage administered.
Allergy to drug(s).
Injection of air embolus.
Equipment
Appropriate syringe (dependent upon quantity of drug to be administered).
Prescribed drug.
Saline flush (10ml syringe with sterile saline).
Prescription chart.
Antiseptic swab.
Before you start
Assess patient for drugs required (i.e. for pain relief, vomiting, etc.).
Refer to prescription chart, double-checking the appropriate drugs and dosage to be given.
Always ensure you are fully aware of any possible side effects of any drugs you are due to administer.
Double-check the prescription chart for date and appropriate route for administration.
Check administration of previous dose—not too soon after last dose?
Ensure that the drug to be given is within its use-by date.
Check patient and chart for any evidence of allergies, or relevant drug reactions.
Always comply with the local hand hygiene practices.
Once all above completed as per hospital policy, draw-up required drug and check appropriate needle size.
Complete appropriate documentation.
Once checked by suitably qualified staff take drug and prescription chart to the patient.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure and obtain informed consent.
Check with patient: name and date of birth (if capable).
If incapable, check name band with another healthcare professional
The patient may need to be assisted to change position, if unable to move themselves, and to enable access to an appropriate site.
Cleanse the cannula port with the antiseptic wipe.
Attach the saline flush to the syringe port and inject a few ml to check patency of the cannula.
Watch for a bleb forming as consequence of extravasation.
If no problems are encountered, swap the flush for the drug-containing syringe and inject drug slowly.
To finish, inject a few more ml of saline into the cannula port and re-attach the bung.
Once the procedure is completed without complication, withdraw needle and discard into a sharps bin.
Monitor patient for any negative effects of the drug.
Documentation
Drugs should always be signed for as per local policy.
Signature and time should be clearly recorded.
Site drug administered.
Reason for drug administration, time given, and any impact on the patient should be recorded in the notes.
Immediate vital signs should be recorded in notes.
Any causes for concern arising from administration of drugs should be clearly documented in the medical notes.
Signature, printed name, contact details.
Venepuncture
Risks
Bleeding, haematoma.
Infection.
Accidental arterial puncture.
Inappropriate sites
Oedematous areas.
Cellulitis.
Haematomas.
Phlebitis or thrombophlebitis.
Scarred areas.
Limb in which there is an infusion.
Upper limb on the side of a previous mastectomy and axillary clearance.
Limbs with arteriovenous (AV) fistulae or vascular grafts.
Equipment
Gloves.
Sterile wipe (e.g. chlorhexidine or isopropyl alcohol).
Cotton wool balls or gauze.
Tape.
Tourniquet.
Needle (try 12G first).
Syringe (size depends on amount of blood required).
Collection bottles.
Procedure: needle and syringe
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain verbal consent.
Position the patient appropriately: sat comfortably with arm placed on a pillow.
Wash hands, put on your gloves and apply the tourniquet proximally.
Identify the vein; the best location is often at the antecubital fossa.
Palpable (not necessarily visible) veins are ideal.
Clean the site with the wipe, beginning centrally and moving outwards in concentric circles/swirls.
Whilst the sterilizing solution dries, remove the needle and syringe from packaging and connect together.
Unsheathe the needle.
Using your non-dominant thumb, pull the skin taut over the vein in order to anchor it.
Warn the patient to expect a ‘sharp scratch’.
Insert the needle, bevel up, at an angle of 30 until a flashback is seen within the hub of the needle.
With experience you will feel a ‘give’ as the vein is entered.
Hold the syringe steady and withdraw the plunger slowly until the required amount of blood is obtained.
Release the tourniquet.
Remove the needle, holding cotton wool or gauze to the puncture site.
Secure the cotton wool or gauze in place or replace with a plaster.
Vacuum collection bottles are filled by puncturing the rubber top with the needle and allowing the blood to enter the tube.
Label the tubes at the patient’s bedside and dispose of the sharps in a sharps bin.
Procedure: vacuum device
The procedure is much the same as with a syringe but:
Vacutainer needles are double-ended, with one end a standard needle, the other covered by a rubber sheath. This end inserts into the holder and is screwed in place.
On penetrating the vein no flashback is seen.
Once the needle is in place, vacuum collection bottles are inserted into the holder over the sheathed needle in turn—the holder must be held firmly in place.
Bottles are self-filling; some require filling to a pre-defined level or tests will be invalidated.
Remove the tourniquet before removing the last bottle, then remove the needle from the skin.
Procedure tips
If no veins are visible or palpable, don’t limit yourself to the upper limb: any peripheral vein will suffice.
If veins are still not visible, try warming the limb.
If several attempts have failed, seek help from a colleague.
If the vacuum collection system is proving difficult, try using needle and syringe:
A ‘flashback’ will be seen on entering the vein
The flow of blood may be controlled
If this also proves unsuccessful, try using a butterfly needle (Box 18.5).
A butterfly is a short needle with flexible ‘wings’ on either side, and a length of flexible tubing to connect to the syringe. It is easy to manoeuvre once the skin is penetrated, and can be easily fixed in place by the wing, pressed down by the non-dominant thumb. It carries a greater risk of needle-stick injury.
Documentation
Detailed documentation of the procedure is usually not required—but you should record that blood was taken and what tests it has been sent for.
Record any adverse incidents during the procedure or if multiple attempts were performed.
If a particularly good vein was found, you may wish to record this for the benefit of the person taking blood next time.
Signature, printed name, contact details.
Sampling from a central venous catheter
Central venous lines should only be used for blood sampling if it is not possible to obtain a sample via the peripheral route. Do not risk catheter sepsis or a clotted line unless there are no alternatives.
The following describes venous blood sampling from a line in the internal jugular vein. The principles are the same for a line at any site.
Risks
Clot or infection in the line.
Air embolus.
Physical damage to the line: burst or torn port.
Equipment
3 x 10ml syringes.
0.9% isotonic or heparinized saline.
Chlorhexidine spray or iodine solution.
Sterile gauze.
Sterile gloves and apron.
Sterile drape.
Procedure
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent.
Stop any infusions (if possible) for at least one minute before sampling.
Place the patient in a supine position.
Ask the patient to turn their head away from the line site during the procedure.
Drape the site and put on a pair of sterile gloves and apron.
Spray the line end with the chlorhexidine solution or wipe with gauze dipped in iodine.
Clamp the line port and remove the cap, if present.
Connect a 10ml syringe to the port and then unclamp.
Withdraw 5–10ml of blood, clamp the line, and remove the syringe.
Discard the blood.
Repeat the procedure with a new syringe, withdrawing 10ml.
Clamp the line, disconnect the syringe.
Keep this sample.
Fill the final syringe with saline and attach it to the port.
Unclamp the port and instil the saline.
Clamp the port again before disconnecting the syringe.
Replace the port cap.
Procedure tips
Always be sure to clamp the port before removing the syringe and unclamp before withdrawing blood or instilling the saline.
Most central lines have several ports: which should I use?
Blood should ideally be sampled from the port with its hole at the tip of the line—this is often the brown port
Check the ports: most will have the gauge printed on them, choose the largest gauge port available.
Be sure to remove any bubbles from the saline before instilling.
Infusions must be stopped: otherwise a significant portion of the sample obtained may be the solution that is entering via the other port giving inaccurate results at analysis!
Arterial blood gas sampling
Contraindications
Negative modified Allen’s test.
Cutaneous or subcutaneous lesion at the puncture site (Box 18.6).
Surgical shunt (e.g. in a dialysis patient) in the limb.
Infection or known peripheral vascular disease at the puncture site.
Coagulopathy.
The radial artery at the level of the radial styloid is the usual site of choice as it is both superficial and easily accessible.
If the vessel is not obviously palpable, it is also possible to sample arterial blood at the brachial artery in the antecubital fossa or femoral artery just distal to the inguinal ligament.
Risks
Bleeding.
Haematoma.
Arteriospasm.
Infection.
False aneurysm formation.
Arterial occlusion.
Equipment
Gloves.
Sterile wipe (e.g. isopropyl alcohol).
Cotton wool balls.
Tape.
Gauze.
Heparinized self-filling syringe and needle.
Procedure: radial artery
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient appropriately: sitting comfortably with arm placed on a pillow, forearm supinated, wrist passively dorsiflexed.
Confirm ulnar arterial supply to the hand before starting (modified Allen’s test):
Compress the radial and ulnar arteries with your thumbs
Ask the patient to make a fist and open it
The hand should appear blanched
Release pressure from the ulnar artery and watch the palm
The palm should flush to its normal colour
If not, there may be inadequate ulnar arterial supply and damage to the radial artery during blood taking may result in critical ischaemia.
Put on your gloves.
Identify the radial artery with index and middle fingers of your non-dominant hand.
Clean the site, beginning centrally and spiralling outwards.
Whilst the sterilizing solution dries, remove the needle and syringe from packaging and attach the needle to the end of the syringe.
Eject excess heparin from the syringe through the needle.
Check local equipment. Some heparinized syringes contain a heparinized sponge and excess heparin/air should not be expelled
Warn the patient to expect a ‘sharp scratch’.
Whilst palpating the artery (but not obliterating the pulsation), insert the needle just distal to your fingertips, bevel facing proximally, at an angle of 45–60° until a flashback is seen within the needle chamber.
Hold the syringe steady and allow it to fill itself with 1–2ml blood.
As you withdraw the needle, apply the gauze swab to the site, maintaining firm manual pressure over for at least 2 minutes
Dispose of the needle and apply a vented cap, expelling any excess air.
(This may not be necessary depending on your equipment.)
Procedure: brachial artery
Position the elbow in extension. Angle the needle 60°.
Procedure: femoral artery
Position the patient with hip extended.
The pulse is felt 2cm below the midpoint between pubic tubercle and anterior superior iliac spine.
Angle the needle at 90° to the skin.
Pressure must be applied for at least 5 minutes.
Procedure tips
Before you start: know where the analyser is and how to use it!
The key is carefully palpating the artery and lining the needle up to puncture it. Take your time!
The majority of the pain comes from puncturing the skin. If no flashback is seen immediately, try repositioning the needle by withdrawing slightly without removing it from the skin.
If there will be some delay in analysing the sample, store the blood-filled syringe on ice.
Errors occur: if there is air in the syringe, if the sample is delayed in reaching the analyser (if this is anticipated, put the sample on ice), or if a venous sample is accidentally obtained.
Documentation
Date, time, indication, consent obtained.
Record how much (if any) supplemental oxygen the patient is on.
Artery punctured.
Modified Allen’s test?
How many passes?
Any immediate complications.
Signature, printed name, contact details.
Peripheral venous cannulation
Contraindications
Cannulae should not be placed unless intravenous access is required.
Caution in patients with a bleeding diathesis.
Risks
Infection, which could be local or systemic.
Before you start
| Gauge | External diameter (mm) | Length (mm) | Approximate maximum flow rate (ml/min) | Colour |
|---|---|---|---|---|
14G | 2.1 | 45 | 290 | Orange |
16G | 1.7 | 45 | 172 | Grey |
18G | 1.3 | 45 | 76 | Green |
20G | 1.0 | 33 | 54 | Pink |
22G | 0.8 | 25 | 25 | Blue |
| Gauge | External diameter (mm) | Length (mm) | Approximate maximum flow rate (ml/min) | Colour |
|---|---|---|---|---|
14G | 2.1 | 45 | 290 | Orange |
16G | 1.7 | 45 | 172 | Grey |
18G | 1.3 | 45 | 76 | Green |
20G | 1.0 | 33 | 54 | Pink |
22G | 0.8 | 25 | 25 | Blue |
Avoid areas of skin damage, erythema, or an arm with an AV fistula
Excessive hair should be cut with scissors before cleaning the skin
It is best to avoid joint areas such as the antecubital fossa
This can cause kinking of the cannula and discomfort
A straight vein, in an area such as the forearm or dorsum of the hand where long bones are available to splint the cannula are usually best.
Wide-bore access requires siting in large veins and often this is only practicable in the antecubital fossa
In practice, especially in patients who have been cannulated many times before, it is often necessary to go wherever you find a vein.
Sizing cannulae
Cannulae are colour-coded according to size. The ‘gauge’ is inversely proportional to the external diameter.
The standard size cannula is ‘green’ or 18G but for most hospital patients, a ‘pink’ or 20G cannula will suffice. Even blue cannulae are adequate in most circumstances unless fast flows of fluid are required.
Equipment
Gloves.
Sterile wipe (e.g. chlorhexidine).
Cannula of appropriate gauge.
Sterile saline for injection (‘flush’) and a 5ml syringe.
Cannula dressing.
Cotton wool balls/gauze.
Tourniquet.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent
Put the gloves on.
Apply the tourniquet proximally on the limb.
Once the veins are distended, select an appropriate vein: it should be straight for the length of the cannula.
Wipe with sterile wipe, beginning where you intend to insert the cannula and moving outwards in circles.
Fill the syringe with saline and eject any air bubbles.
Remove the dressing from its packaging.
Unwrap the cannula and check that all parts disengage easily. Fold the wings down so that they will lie flat on the skin after insertion.
Using your non-dominant hand, pull the skin taut over the vein in order to anchor it in place.
Hold the cannula with index and middle fingers in front of the cannula wings, thumb behind the cap.
Warn the patient to expect a ‘sharp scratch’.
Insert the needle, bevel up, at an angle of 30° to the skin, until a flashback of blood is visible within the chamber of the cannula.
Advance the needle a small amount further, then advance the cannula into the vein over the needle, whilst keeping the needle stationary.
Release the tourniquet.
Place your non-dominant thumb over the tip of the cannula, compressing the vein.
Flush the cannula with a little saline from the end and replace the cap.
Write the date on the cannula dressing and secure in place.
Procedure tips
Local anaesthetic cream may be of benefit if you have time.
Reliable veins are located on the radial aspect of the wrist (cephalic vein), antecubital fossa, and anterior to the medial malleolus (long saphenous).
If you fail initially with a large-bore cannula, try a smaller gauge.
If no veins are visible/palpable at first, try warming the limb in warm water for a couple of minutes.
It may be useful to get assistance to hold the patient’s arm still if they are likely to move it during the procedure.
If you are unable to cannulate after several attempts, try asking someone else. A pair of fresh eyes make a lot of difference!
Femoral venous catheter insertion
Contraindications
Fem-fem bypass surgery, IVC filter, infected site, thrombosed vein.
Risks
Arterial puncture, infection, haematoma, thrombosis, air embolism, arteriovenous fistula, peritoneal puncture.
Equipment
Central line catheter pack.
Containing: central line (16–20cm length, multi-lumen if required), introducer needle, 10ml syringe, guidewire, dilator, blade.
Large dressing pack including a large sterile drape and gauze.
Normal saline.
Local anaesthetic for skin (1% lidocaine).
Sterile preparation solution (2% chlorhexidine).
Securing device or stitch.
Sterile gloves, sterile gown, surgical hat and mask.
Suitable dressing.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain written consent if possible.
Position the patient supine (1 pillow), abduct the leg and place a spill sheet under the patient’s leg.
Identify the entry point: 1–2 cm below the mid-inguinal point and 1cm medial to femoral artery.
Wearing a surgical hat and mask, wash hands using a surgical scrub technique and put on the sterile gown and gloves.
Set up a trolley using an aseptic technique:
Open the dressing pack onto the trolley creating a sterile field
Open the central line catheter pack and place onto the sterile field
Flush all lumens of the catheter with saline and clamp the ends
Ensure the guidewire is ready for insertion
Attach the introducer needle to a 10ml syringe.
Clean the area with sterile solution and surround with a large drape.
Inject local anaesthetic into the skin over the entry point.
Identify the femoral artery with your non-dominant hand.
Pierce the skin through the entry point with the introducer needle.
Direct the needle at a 30–45° angle to the skin and aim for the ipsilateral nipple, aspirating as you advance the needle.
On hitting the vein the syringe will fill with blood.
Keeping the needle still, carefully remove the syringe—blood should ooze (and not pulsate) out through the hub of the needle.
Insert the guidewire part-way through the hub of the needle.
Guidewires are over 50cm in length; do not insert more than 20cm.
Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire.
Thread the dilator over the wire, firmly pushing it through the skin.
This may require a small stab incision in the skin with a blade
Aim to get 2–3cm of dilator into the vein, not its full length.
Check the guidewire has not been kinked by ensuring it moves freely through the dilator.
Remove the dilator and apply pressure over with gauze to stop oozing.
Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!).
Holding the guidewire at its port exit site with one hand, push the catheter through the skin with the other.
Remove the guidewire.
Blood should flow out of the end of the catheter.
Aspirate and flush all ports.
Fix catheter to skin using either a securing device or stitches.
Cover with transparent dressing.
Procedure tips
Placing a sandbag underneath the patient’s buttock may improve positioning (if a sandbag is not available, roll up a towel or wrap a 1-litre bag of fluid in a sheet as an alternative).
Do not force the guidewire. If there is resistance to insertion:
Reduce the angle of the needle, attempt a shallower insertion
Check you are still within the vein by aspirating with a syringe
Rotate the needle: this moves the bevel away from any obstruction.
Losing the guidewire can be disastrous—always have one hand holding either the proximal or distal end of it.
Always consider the possibility of an inadvertent arterial puncture:
Signs include pulsatile blood flow, high-pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
Do not dilate if in any doubt
The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Documentation
Time, date, indication, informed consent obtained.
Site and side of successful insertion.
Site, side, and complications of unsuccessful attempt(s).
Aseptic technique: gloves, gown, hat, mask, sterile solution.
Local anaesthetic: type and amount infiltrated.
Technique used: e.g. landmark, ultrasound guidance.
Catheter used: e.g. triple lumen.
Length of catheter in situ (length at skin).
Signature, printed name, and contact details.
Central venous access: internal jugular vein
This is the ‘landmark’ technique for the internal jugular vein.
Contraindications
Infected insertion site.
Thrombosed vein.
Coagulopathy.
Risks
Pneumothorax.
Arterial puncture.
Haematoma.
Air embolism.
Arrhythmias.
Thrombosis.
Arteriovenous fistula.
Infection.
Malposition.
Equipment
Central line catheter pack:
Central line (16cm length for right side, 20cm for left side), introducer needle and 10ml syringe, guidewire, dilator, blade.
Large dressing pack including a large sterile drape and gauze.
Normal saline.
Local anaesthetic for skin (1% lidocaine) with suitable (22G) needle and syringe.
Sterile preparation solution (2% chlorhexidine).
Sterile gloves, sterile gown, surgical hat and mask.
Trolley and ECG monitoring.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain written consent if possible.
Position the patient supine (1 pillow), tilt the bed head down and place a spill sheet under the patient’s head.
Attach ECG monitoring to the patient.
Turn the patient’s head away from the side of insertion.
Identify triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle.
Identify the entry point at the apex of the triangle.
Wash hands using a surgical scrub technique and put on the sterile gown and gloves.
With assistance, set up a trolley using an aseptic technique:
Open the dressing pack onto the trolley creating a sterile field
Open the central line catheter pack and place onto the sterile field
Flush all lumens of the catheter with saline and clamp the ends
Attach the introducer needle to a 10ml syringe.
Clean the area with sterile preparation solution and place a large drape around it.
Inject local anaesthetic into the skin over the entry point.
Identify the carotid artery with your non-dominant hand. Pierce the skin through the entry point with the introducer needle ensuring the needle is lateral to the artery.
Direct the needle at a 30° angle to the skin and advance using continuous aspiration, aiming for the ipsilateral nipple.
On hitting the vein, the syringe will fill with blood.
Keeping the needle still, carefully remove the syringe.
Blood should ooze (not pulsate) through the hub of the needle.
Insert the guidewire through the needle and watch the ECG.
Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias.
Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire.
Thread the dilator over the wire, firmly pushing it through the skin.
This may require a small stab incision in the skin with a blade
Aim to get 2–3cm of dilator into the vein, not its full length
Check the guidewire has not been kinked by ensuring it moves freely through the dilator.
Remove the dilator over the guidewire and apply pressure over the site with gauze.
Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!).
This may require withdrawing some of the guidewire.
Holding the guidewire at its port exit site with one hand, push the catheter through the skin with the other.
Avoid handling the catheter, in particular its tip.
Insert 16cm for a right-sided line and 20cm for a left-sided line.
Remove the guidewire.
Blood should flow out through the end of the catheter.
Aspirate and flush all ports with normal saline.
Fix catheter to skin with a fixing device or sutures.
Cover with a transparent dressing.
Request a chest radiograph to confirm position.
Documentation
Time, date, indication, and informed consent obtained.
Site and side of successful insertion.
Site, side, and complications of unsuccessful attempt(s).
Aseptic technique: gloves, gown, hat, mask, type of sterile solution.
Local anaesthetic: type and amount infiltrated.
Technique used: e.g. landmark, ultrasound guidance.
Catheter used: length and number of lumens.
Aspirated and flushed.
Length of catheter in situ (length at skin).
Chest radiograph: site of tip, absence/presence of pneumothorax.
Signature, printed name, and contact details.
Procedure tips
The right internal jugular vein is usually favoured due to its relatively straight course and the absence of the thoracic duct on this side (Fig. 18.1).
Tilting the bed head down will minimize the risk of air embolism and help distend the veins of the neck.
Surface anatomy of the internal jugular vein.
Getting started
Asking the patient to sniff or lift their head off the bed will help identify the sternocleidomastoid muscle.
Asking the patient to perform the Valsalva manoeuvre will distend the veins of the neck and help identify the internal jugular vein.
For added safety, you may wish to start by using a 21G (‘green’) hypodermic needle instead of the introducer needle to ‘seek’ out the vessel using the same technique.
Check clotting prior to insertion. Aim for INR <1.5 and platelets >50x109/L.
Minimize spillage.
During the procedure
The internal jugular vein is relatively superficial and should be encountered within 2–3cm. Do not continue advancing the needle if the vein has not been hit by this point.
Do not force the guidewire in. If there is resistance to guidewire insertion:
Try lowering the angle of the needle making it more in line with the long axis of the vessel
Check you are still within the vein by aspirating with a syringe
Try rotating the needle thereby moving the bevel away from any obstruction.
Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it.
The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Always consider the possibility of an inadvertent arterial puncture (Box 18.8):
Signs include pulsatile blood flow, high-pressure blood flow, or blood bright red in colour (in the absence of hypotension or hypoxaemia)
Do not dilate if in any doubt
Consider sending blood for a blood gas to confirm venous placement.
Internal carotid artery
Transverse process of the cervical vertebrae
Sympathetic chain
Phrenic nerve
Dome of pleura
Thoracic duct on left-hand side.
Internal carotid artery
Cranial nerves IX–XII
Common carotid and vagus nerve.
Finishing off
There is an increased incidence of vascular injuries and thrombosis with left-sided catheters mainly because of insufficient catheter depth leading to the tip abutting the lateral wall of the upper SVC. You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC.
On the chest radiograph, confirm catheter position and the absence of a pneumothorax.
The tip of the catheter should lie at the junction of the superior vena cava and right atrium which is approximately at the level of the carina.
Alternative approaches
Anterior approach: midpoint of sternal head of sternocleidomastoid aiming towards ipsilateral nipple.
Posterior approach: posterior border sternocleidomastoid at the crossing of the external jugular vein aiming for the sternal notch.
Central venous access: subclavian vein
This is the ‘landmark’ technique for the right subclavian vein (Fig. 18.2).
Surface anatomy of the right subclavian vein.
Contraindications
Hyperinflated lungs (e.g. COPD patients).
Coagulopathy.
Infected insertion site.
Thrombosed vein.
Risks
Pneumothorax.
Haemorrhage.
Arterial puncture.
Air embolism.
Arrhythmias.
Thrombosis.
Arteriovenous fistula.
Infection.
Malposition.
Equipment
Central line catheter pack:
Central line (16cm length for right side, 20cm for left side), introducer needle and 10ml syringe, guidewire, dilator, blade.
Large dressing pack including a large sterile drape and gauze.
Normal saline.
Local anaesthetic for skin (1% lidocaine) with (22G) needle and syringe.
Sterile preparation solution (2% chlorhexidine).
Sterile gloves, sterile gown, surgical hat and mask.
Trolley and ECG monitoring.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain written consent if possible.
Position the patient supine (1 pillow), place a sandbag between shoulder blades and tilt the bed head down.
Attach ECG leads onto the patient making sure they are not in the surgical field.
Turn the patient’s head away from the side of insertion.
Identify the entry point, just inferior to the midpoint of the clavicle.
Wash hands using a surgical scrub technique and put on the sterile gown and gloves.
With assistance, set up a trolley using an aseptic technique:
Open the dressing pack onto the trolley creating a sterile field
Open the central line catheter pack and place onto the sterile field
Flush all lumens of the catheter with saline and clamp the ends
Ensure the guidewire is ready for insertion
Attach the introducer needle to a 10ml syringe.
Clean the area with sterile preparation solution and place a large drape around it.
Inject local anaesthetic into the skin over the entry point.
Insert the introducer needle under the clavicle at a very shallow angle almost parallel to the floor.
Advance the needle towards the sternal notch, aspirating as you advance.
On hitting the vein the syringe will fill with blood.
Keeping the needle still, carefully remove the syringe.
Blood should ooze (not pulsate) through the hub of the needle.
Insert the guidewire through the needle and watch the ECG.
Guidewires tend to be over 50cm in length but do not introduce more than 20cm as this may lead to arrhythmias.
Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire.
Thread the dilator over the wire, firmly pushing it through the skin.
This may require a small stab incision in the skin with a blade
Aim to get 2–3cm of dilator into the vein, not its full length.
Check the guidewire has not been kinked by ensuring it moves freely through the dilator.
Remove the dilator over the guidewire and apply gauze to the site to mop up any spills.
Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!).
This may require withdrawing some of the guidewire.
Holding the guidewire at its port exit site with one hand, push the catheter through the skin with the other.
Avoid handling the catheter, in particular its tip.
Insert 16cm for a right-sided line and 20cm for a left-sided line
Remove the guidewire.
Blood should flow out through the end of the catheter.
Aspirate and flush all ports with normal saline.
Fix catheter to skin with a fixing device or sutures.
Cover with a transparent dressing.
Request a chest radiograph to confirm catheter position and the absence of a pneumothorax.
Documentation
Time, date, indication, and informed consent obtained.
Site and side of successful insertion.
Site, side, and complications of unsuccessful attempt(s).
Aseptic technique: gloves, gown, hat, mask, type of sterile solution.
Local anaesthetic: type and amount infiltrated.
Technique used: e.g. landmark, ultrasound guidance.
Catheter used: length and number of lumens.
Aspirated and flushed.
Length of catheter in situ (length at skin).
CXR: site of tip, absence/presence of a pneumothorax.
Signature, printed name, and contact details.
Procedure tips
Getting started
Check clotting prior to insertion. Aim for INR <1.5, platelets >50x109/L.
Direct pressure cannot be applied on the subclavian vessels so this route should be avoided in patients with a coagulopathy
There is a greater risk of pneumothorax than with internal jugular cannulation. A subclavian approach should, therefore, be avoided in patients with hyperinflated lungs.
Minimize spillage.
The underside of the clavicle can be reached by first directing the needle onto the clavicle and then carefully walking off it. The angle of the needle should however remain parallel to the floor.
Asking an assistant to pull the ipsilateral arm caudally can improve access.
If a sandbag is not available, roll up a towel or wrap a 1-litre bag of fluid in a spill sheet as an alternative.
During the procedure
The subclavian vein should be encountered within 3–4cm. Do not continue advancing the needle if the vein has not been hit by this point.
Do not force the guidewire in. If there is resistance to guidewire insertion:
Try lowering the angle of the needle making it more in line with the length of the vessel
Check you are still within the vein by aspirating with a syringe
Try rotating the needle thereby moving the bevel away from any obstruction.
Catheter malposition, particularly into the ipsilateral internal jugular vein, is more common using the subclavian vein approach.
Many guidewires have a ‘J’ tip. Directing the ‘J’ tip caudally may help correct placement.
Losing the guidewire can be disastrous. Always have one hand holding either the proximal or distal end of it.
Always consider the possibility of an inadvertent arterial puncture (Box 18.9):
Signs include pulsatile blood flow, high pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
Do not dilate if in any doubt.
The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Clavicle
Subclavius muscle.
Phrenic nerve
Anterior scalene muscle
Subclavian artery.
First rib
Pleura.
Finishing off
The incidence of vascular injuries and thrombosis is increased with left-sided catheters mainly due to insufficient catheter depth leading to the tip abutting the lateral wall of the upper SVC.
You must ensure left-sided lines are long enough so that their tip lies within the lower part of the SVC.
On the chest radiograph, confirm catheter position and the absence of a pneumothorax.
The tip of the catheter should lie at the junction of the superior vena cava and right atrium which is approximately at the level of the carina.
Alternative approaches
Medial approach: junction of medial and middle thirds of the clavicle.
Lateral approach: lateral to the mid-clavicular point. Often used with ultrasound guidance.
Central venous access: ultrasound guidance
Current recommendations in the UK are that ultrasound guidance should be considered when inserting any central venous catheter (NICE guidelines 2002).
Ultrasound basics
‘Ultrasound’ refers to sound waves of such a high frequency as to be inaudible to the human ear (>20 kHz).
Medical ultrasound uses frequencies between 2 and 14 MHz.
The ‘linear’ (straight) transducer is the probe of choice for imaging the vessels and other superficial structures.
The frequency of the probe should be between 7.5–10 MHz for central venous access.
Basic controls
Frequency.
Higher frequency may result in a better resolution but will not penetrate the tissues as deeply.
Gain.
The gain control alters the amplification of the returned signals
This changes the grey scale of the image (can be thought of as increasing the brightness) but may not improve its quality.
Depth.
The depth of the image on screen can be manually adjusted
It is wise to see the structures deep to the vessel to be cannulated.
Focal length.
The focal point is usually displayed as an arrow at the side of the image
At this point, the image will be sharpest but resolution of the deeper structures will suffer
The focal point should be positioned in line with the vein to be cannulated.
Orientation
By convention, the left of the screen should be that part of the patient to your left (i.e. the patient’s right if you are facing the patient, the patient’s left if you are scanning from behind them).
Touch edge of the probe and watch for the movement on screen to be sure you have the transducer the right way round.
Procedure: internal jugular vein catheterization
With the patient positioned, squeeze sterile gel onto the patient’s neck.
Hold the probe cover open like a sock. Ask an assistant to squeeze ultrasound gel into the base and carefully lower the probe in after it. You can then unfurl the probe cover along the length of the wire using aseptic technique.
Place probe over the surface markings of the vein (short axis of vessel).
On the screen, look for two black circles side by side. These represent the vein and the artery.
Identify the vessels by pressing down with the probe.
The vein will be compressible and the artery will not
The artery will be pulsatile. Note that the IJV may also be pulsatile with the patient head down (the JVP)
The artery is often circular in cross-section, the vein may be oval or a more complex ovoid shape.
Follow the course of the vein up the patient’s neck and identify a site where the artery sits relatively medial to the vein. At this point, centre the vein on to the screen holding the probe still with your non-dominant hand.
Don’t press too hard with the probe—you may compress the vein.
Inject local anaesthetic into the skin around the midpoint of the probe using your dominant hand.
Insert the introducer needle through the skin at the midpoint of the probe.
Gently move the needle in and out to help locate the tip and its course on the screen.
The tip of the needle will only be visualized if it is advancing in the same plane as the ultrasound beam.
Advance the needle (with continuous aspiration) towards the vein ensuring the tip is always in view.
On hitting the vein, blood will be aspirated into the syringe. Flatten the needle ensuring blood can still be aspirated. At this point, the probe can be removed and the vein be catheterized using the Seldinger technique (see previous pages).
The ultrasound can be used later in the procedure to ensure that the guidewire lies within the vein, if necessary.
Intravenous infusions
Equipment
Gloves.
An appropriate fluid bag.
Giving set.
Drip stand.
10ml syringe with saline flush.
Procedure
Intravenous infusions require intravenous access.
Check the fluid in the bag and fluid prescription chart.
Ask a colleague to double-check the prescription and the fluid and sign their name on the chart.
Flush the patient’s cannula with a few millilitres of saline to ensure there is no obstruction. If there is evidence of a blockage, swelling at the cannula site, or if the patient experiences pain, you may need to replace the cannula.
Open the fluid bag and giving set, which come in sterile packaging
Unwind the giving set and close the adjustable valve.
Remove the sterile cover from the bag outlet and from the sharp end of the giving set.
Using quite a lot of force, push the giving set end into the bag outlet.
Invert the bag and hang on a suitable drip-stand.
Squeeze the drip chamber to half fill it with fluid.
Partially open the valve to allow the drip to run, and watch fluid run through to the end (it might be best to hold the free end over a sink in case of spills).
If bubbles appear, try tapping or flicking the tube.
Once the giving set is filled with liquid, connect it to the cannula.
Adjust the valve and watch the drips in the chamber.
Adjust the drip rate according to the prescription (Box 18.10).
Most infusions tend to be given with electronic devices which pump the fluid in at the prescribed rate. However, it is still important that healthcare professionals are able to set up a drip at the correct flow rate manually
Using a standard giving set, clear fluids will form drips of about 0.05ml—that is, there will be approximately 20 drips/ml. You can then calculate the number of drips per minute for a given infusion rate as in Table 18.2.
Documentation
Ensure fluid and/or the drug is clearly timed and signed for as per local policy.
Nursing and/or medical notes should be completed to include the reason for the infusion.
Medical notes should be used to record any causes for concern arising from administration of the infusion.
Cannula site (and cannula documentation) should be dated and signed on insertion.
Ensure any fluid-monitoring chart is complete and updated as appropriate.
Ensure that all entries in notes finish with your signature, printed name, and contact details.
| Prescription Number of hours per litre of fluid | Infusion rate (ml/hour) | Infusion rate (ml/minute) | Drip rate (drips/minute) |
|---|---|---|---|
1 | 1000 | 16 | 320 |
2 | 500 | 8 | 160 |
4 | 250 | 4 | 80 |
6 | 166 | 3 | 60 |
8 | 125 | 2 | 40 |
10 | 100 | 1.6 | 32 |
12 | 83 | 1.4 | 28 |
24 | 42 | 0.7 | 14 |
| Prescription Number of hours per litre of fluid | Infusion rate (ml/hour) | Infusion rate (ml/minute) | Drip rate (drips/minute) |
|---|---|---|---|
1 | 1000 | 16 | 320 |
2 | 500 | 8 | 160 |
4 | 250 | 4 | 80 |
6 | 166 | 3 | 60 |
8 | 125 | 2 | 40 |
10 | 100 | 1.6 | 32 |
12 | 83 | 1.4 | 28 |
24 | 42 | 0.7 | 14 |
Arterial line insertion
The following is the procedure for cannulating the radial artery.
Contraindications
Infection at insertion site.
Working arterio-venous fistula in the same limb.
Traumatic injury proximal to the insertion site.
Vascular insufficiency in the distribution of the artery to be cannulated.
Significant clotting abnormalities.
Risks
Non-vascular: superficial bleeding, infection, inadvertent arterial injection.
Vascular: vasospasm, thrombosis, thromboembolism, air embolism, blood vessel injury, distal ischaemia.
Equipment
Arterial catheter set:
Arterial catheter (20G), needle, guidewire
Sterile gloves, sterile gown (+/– surgical hat and mask).
Dressing pack including a sterile drape.
Sterile preparation solution (e.g. 2% chlorhexidine).
Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5ml syringe.
(Optional) A three-way tap with a short extension (flushed with normal saline) connected to a 10ml syringe containing normal saline.
Suture.
Transducer set with pressurized bag of heparinized saline.
Procedure (modified Seldinger technique)
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Choose a site for arterial line insertion.
Position the forearm so that it is supported from underneath and hyperextend the wrist.
Set up a trolley keeping everything sterile:
Open the dressing pack onto the trolley creating a sterile field
Open the arterial catheter set and place onto the sterile field.
Wash hands using a surgical scrub technique and put on the sterile gown and gloves.
Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape.
Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local anaesthetic.
Insert the arterial needle, directing it towards the radial pulsation at a 30–45° angle. (Do not attach to a syringe.)
You can also use a syringe with the plunger removed. This allows identification of the arterial pulsation without excess spillage.
On hitting the artery, blood will spurt out of the hub of the needle.
Keeping the needle still, insert the guidewire through the hub of the needle. Don’t force the guidewire.
Remove the needle leaving the guidewire in place.
Thread the arterial catheter over the guidewire making sure that the guidewire is seen at all times through the distal end of the catheter.
Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other.
Remove the guidewire.
Blood should spill out of the end of the catheter if it is within the artery.
Connect to the short extension of the three-way tap, aspirate and flush with normal saline, and close off the tap.
Alternatively, connect immediately to a pressurized transducer set, aspirate and flush
Do not delay connection to transducer and flush-bag
Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization).
Suture in place.
Label catheter as arterial and inform relevant staff.
Documentation
Time, date, indication, and informed consent obtained.
Site and side of successful insertion.
Site, side, and complications of unsuccessful attempt(s).
Aseptic technique: gloves, gown, hat, mask, sterile solution.
Local anaesthetic: type and amount infiltrated.
Technique used: modified Seldinger, cannula over needle.
Catheter size used: 20G.
Aspirated and flushed.
Signature, printed name, and contact details.
Procedure tips
Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery.
Cover the floor with spill sheets as the procedure can be messy!
The modified Allen’s test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury.
Modified Allen’s test
Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist.
Ask the patient to open the hand.
Release pressure over the ulnar artery.
Watch the palm for return of colour.
Return of colour should normally occur in 5–10 seconds.
Return of colour taking over 15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed.
Fine needle aspiration (FNA)
A method for obtaining a cytological sample of a mass lesion. This procedure should only be performed by, or under strict supervision of, an experienced practitioner.
Fine needle aspiration usually takes place in the radiology department and is performed by an experienced radiologist under ultrasound or CT guidance. The following describes the older, ‘blind’ technique.
Contraindications
Bleeding diathesis.
Overlying infection.
Adjacent vital structures.
Image-guidance should always be used if available.
Risks
Bleeding.
Local infection.
Damage to surrounding structures depending on site e.g. blood vessels, nerves.
Equipment
Local anaesthetic (e.g. 1% lidocaine).
Small-gauge (blue) needle and 10ml syringe.
Sterile pack.
Cleaning solution (e.g. chlorhexidine).
Medium-gauge (green) needle.
10 or 20ml syringe for aspiration.
Sterile gloves.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient according to the biopsy site, allowing easy palpation of the mass.
Expose appropriately.
Wash your hands and put on sterile gloves.
Clean the area with the cleaning solution and apply drapes.
Instil local anaesthetic to the skin and subcutaneous tissues, withdrawing the plunger prior to each injection to avoid intravenous injection and warning the patient to expect a ‘sharp scratch’.
Immobilize the mass with your non-dominant hand.
Using your dominant hand, insert the needle through the skin into the lump, maintaining negative pressure on the plunger as you go.
Once in the lump, the needle may be moved gently back and forth to obtain a greater volume of cells.
It may be necessary to insert the needle several times to obtain a sufficient sample.
Do not expect a large amount of material within the syringe! A tiny sample within the needle will usually suffice.
Remove the needle and send the sample for cytology (you will need to gently expel the sample from the needle into a suitable container).
Apply a sterile dressing to the site.
Alternative method
There are two schools of thought in fine needle aspiration.
Some practitioners use a small (blue) needle without a syringe attached.
This is moved in and out very quickly within the mass whilst also applying rotation
Capillary action deposits a cellular sample within the needle which can then be gently expelled using an empty syringe.
This capillary action technique may result in a larger number of intact cells in the resultant sample as the negative pressure created when using a syringe can disrupt cell membranes.
Documentation
Date and time.
Indication, informed consent obtained.
Type and amount of local anaesthetic used.
Site of puncture.
Aseptic technique used?
How many passes?
Volume and colour of sample obtained.
Any immediate complications.
Tests requested on resultant sample.
Signature, printed name, and contact details.
Procedure tips
Radiological guidance should always be used if available.
Contact the histopathology department in advance to ensure appropriate transport medium is used.
It may be possible to arrange immediate analysis, allowing diagnosis and repeat FNA if insufficient cells are obtained.
Lumbar puncture
Contraindications
Infected skin or subcutis at the site of puncture.
Coagulopathy or thrombocytopenia.
Raised intracranial pressure with a differential pressure between the supra- and infra-tentorial compartments such as seen in space-occupying lesions. If in doubt, image first!
Risks
Post-procedure headache.
Infection.
Haemorrhage (epidural, subdural, subarachnoid).
Dysaesthesia of the lower limbs.
Cerebral herniation (always check local procedures regarding contraindication to LP and whether to perform CT head first).
Equipment
Sterile gloves.
Sterile pack (containing drape, cotton balls, small bowl).
Antiseptic solution (e.g. iodine).
Sterile gauze dressing.
1 x 25G (orange) needle.
1 x 21G (green) needle.
Spinal needle (usually 22G).
Lumbar-puncture manometer.
3-way tap (may be included in a lumbar puncture ‘kit’).
5–10ml 1% lidocaine.
2 x 10ml syringes.
3 x sterile collection tubes and one biochemistry tube for glucose measurement.
Procedure
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent.
Position the patient lying on their left-hand side with the neck, knees, and hips flexed as much as possible.
Ensure that the patient can hold this position comfortably.
Place a pillow between the patient’s knees to prevent the pelvis tilting.
Label the collection tubes ‘1’, ‘2’, and ‘3’.
Identify the iliac crest. The disc space vertically below this (as you are looking) will be ~L3/L4.
Mark the space between the vertebral spines at this point with a pen.
Wash hands and put on the sterile gloves.
Unwrap all equipment and ensure it fits together correctly.
It is usually useful to give the 3-way tap a few twists as it can stick.
Apply the drapes around the area and sterilize with the antiseptic solution and cotton balls in outward-spiral motions.
Inject the lidocaine (using a 10ml syringe and the orange needle) at the marked site to raise a small wheal.
Swap the orange needle for the green one and infiltrate the lidocaine deeper.
Wait for ~1 minute for the anaesthetic to take effect.
Introduce the spinal needle through the marked site at about 90° to the skin, heading slightly toward the umbilicus.
Keep the bevel facing cranially.
Gently advance the needle to ~5 cm depth.
A further slight push of the needle should produce a ‘give’ as the needle enters the subarachnoid space (this takes a little practice to feel).
Withdraw the stilette from the needle. CSF should begin to drip out.
Measure the CSF pressure: connect the manometer to the end of the needle via the 3-way tap (the CSF will rise up the manometer allowing you to read off the number).
Turn the tap such that the CSF within the manometer pours out in a controlled manner and further CSF can drip freely.
Collect about 5 or 6 drops into each collection tube in the order in which they have been labelled.
Collect a few more drops into the biochemistry tube for glucose measurement.
Close the tap so that the manometer will measure the pressure at the end of the collection (‘closing pressure’).
Remove the needle, tap, and manometer in one action.
Apply a sterile dressing.
Send the fluid for analysis.
Cell count (bottles 1 and 3)
Microscopy, culture, and sensitivities (bottles 1 and 3)
Biochemistry: glucose (biochemistry tube), protein (bottle 2).
Advise the patient to lie flat for ~1 hour and ask nursing staff to check CNS observations (see local guidelines).
Documentation
Date, time, indication, and informed consent obtained.
Vertebral level needle inserted.
Number of passes before CSF obtained.
Initial (‘opening’) pressure and final (‘closing’) pressure.
Amount and appearance of CSF.
Tests samples sent for.
Any immediate complications.
Signature, printed name, and contact details.
Procedure tips
Always use the smallest gauge spinal needle available.
In some centres, ‘pencil-point’ needles are used which are associated with a much reduced incidence of post-procedure headache.
If the needle strikes bone and cannot be advanced, withdraw slightly, re-angle, and advance in a stepwise fashion until the gap is found.
Lumbar puncture can be performed with the patient sitting, leaning forwards. This is particularly useful if the patient is obese. However, pressure measurements will be erroneous if taken in this position.
Male urethral catheterization
Contraindications
Urethral/prostatic injury.
Risks
Urinary tract infection.
Septicaemia.
Pain.
Haematuria.
Creation of a ‘false passage’ through prostate.
Urethral trauma.
Beware latex allergy.
Equipment
Foley catheter (male) of appropriate French, usually 12–14 gauge.
10 ml syringe of sterile water.
Syringe of lidocaine gel 1% (e.g. Instilligel®).
Catheter bag.
Sterile gloves.
Catheter pack containing drape, kidney dish, swabs/cotton balls, and a small dish.
Sterile water/chlorhexidine sachet.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient lying supine with the external genitalia uncovered.
Uncover from umbilicus to knees.
Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish.
Wash your hands and put on the sterile gloves.
Tear a hole in the middle of the drape and place it over the genitals so as to allow access to the penis.
Use your non-dominant hand to hold the penis upright.
Withdraw the foreskin and clean around the urethral meatus using the water/chlorhexidine and a swab, moving from the centre outwards.
Instil local anaesthetic via the urethral meatus, with the penis held vertically.
Wait at least one minute for the anaesthetic to act.
Place the kidney bowl between the patient’s thighs.
Remove the tip of the plastic sheath containing the catheter, being careful not to touch the catheter itself.
Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced.
Insert the catheter to the ‘hilt’.
If the catheter will not advance fully, don’t force it. Withdraw a little, extend the penis fully, and carefully try again.
At this point, urine may begin to drain.
Let the hub end of the catheter rest in the kidney bowl to catch the inevitable spills.
Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon’s capacity (written on the cuff of the balloon lumen).
Watch the patient’s face and ask them to warn you if they feel pain.
Once the balloon is inflated, remove the syringe and attach the catheter bag.
Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck.
Replace the foreskin (this is essential to prevent paraphimosis).
Re-dress the patient appropriately.
Documentation
Date and time.
Indication, informed consent obtained.
Size of catheter inserted.
Aseptic technique used?
Volume of water used to inflate the balloon.
Residual volume of urine obtained.
Foreskin replaced?
Any immediate complications.
Signature, printed name, and contact details.
Procedure tips
Difficulty passing an enlarged prostate is a common problem. Tricks to try to ease the catheter past include:
Ensure the catheter is adequately lubricated
Try moving the penis to a horizontal position between the patient’s legs as prostatic resistance is reached
Ask the patient to wiggle his toes
Rotate the catheter back and forth as it advances
If catheter fails to pass, consider using larger bore catheter (e.g. 16F instead of 14F) as this may prevent coiling in the urethra.
If urine fails to drain despite the catheter being fully advanced:
Palpate the bladder: if palpable, the catheter is inappropriately placed
Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
Aspirate with a bladder syringe, or flush with a little sterile saline.
If it is impossible to pass the catheter, ask for help.
If all else fails, it may be necessary to proceed to suprapubic catheterization.
Female urethral catheterization
Contraindications
Urethral injury.
Risks
Urinary tract infection.
Septicaemia.
Pain.
Haematuria.
Urethral trauma.
Beware latex allergy.
Equipment
Foley catheter (female) of appropriate French, usually 12–14 gauge.
10 ml syringe of sterile water.
Syringe of lidocaine gel 1% (e.g. Instilligel®).
Catheter bag.
Sterile gloves.
Catheter pack: drape, kidney dish, swabs/cotton balls, and a small dish.
Sterile water/chlorhexidine sachet.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient with hips externally rotated and knees flexed. Uncover from waist down.
Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish.
Wash your hands and put on the sterile gloves.
Tear a hole in the middle of the drape and place it over the genitals so as to allow access.
Use your non-dominant hand to part the labia.
Clean around the urethral meatus using the water/chlorhexidine and a swab, moving from the centre outwards.
Instil local anaesthetic via urethral meatus.
Wait at least one minute for the anaesthetic to act.
Place the kidney bowl between the patient’s thighs.
Remove the tip of the plastic sheath containing the catheter, being careful not to touch the catheter itself.
Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced.
Insert the catheter to the ‘hilt’.
At this point, urine may begin to drain. Let the end of the catheter rest in the kidney bowl to catch any spills.
Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon’s capacity (written on the cuff of the balloon lumen).
Watch the patient’s face and ask them to warn you if they feel pain.
Once the balloon is inflated, remove the syringe and attach the catheter bag.
Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck.
Re-dress the patient appropriately.
Documentation
Date and time.
Indication, informed consent obtained.
Size of catheter inserted.
Aseptic technique used?
Volume of water used to inflate the balloon.
Residual volume of urine obtained.
Any immediate complications.
Signature, printed name, and contact details.
Procedure tips
Difficulty passing the catheter may be alleviated by slowly rotating the catheter whilst inserting.
Difficulty seeing the urethral meatus may be overcome by asking the patient to ‘bear down’.
If urine fails to drain despite the catheter being fully advanced:
Palpate the bladder: if palpable, the catheter is inappropriately placed
Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
Aspirate with a bladder syringe, or flush with a little sterile saline.
If it is impossible to pass the catheter, ask for help
If all else fails, it may be necessary to proceed to suprapubic catheterization.
Basic airway management
Airway manoeuvres
The following manoeuvres are performed with the patient lying supine and the attender positioned above the head. The aim is to prevent the flaccid tongue from falling back and causing the epiglottis or tongue itself from occluding the airway (Box 18.11 and Fig.18.3). These can be performed with no equipment.
Head tilt and chin lift are usually performed together
Head tilt and chin lift are not suitable if there is any suspicion of cervical spinal injury
Jaw thrust alone should be used in this situation.
Airway manoeuvres. (a) Head tilt. (b) Chin lift. (c) Jaw thrust.
Before you start
Get help!
A patient with an obstructed airway can rarely be adequately treated by one individual, even if appropriate kit is within reach.
Head tilt
Place your hands on the forehead and tilt the head backwards, extending the neck.
Chin lift
Place two fingertips below the mental protuberance of the mandible, with thumb in front.
Draw the mandible anteriorly.
Jaw thrust
Place your fingertips behind the angle of the mandible.
The base of the thenar eminence of each hand should be rested on the cheek bones.
Use your fingers to pull the mandible anteriorly, whilst using your thumbs to open the mouth.
If performed with a mask, the thenar eminence may be used to maintain a good seal.
Procedure tips
After each manoeuvre, check for success.
It is worth-while practising these skills on resuscitation dummies prior to having to do them in real life!
Use the above manoeuvres in conjunction with face masks or bag–valve mask ventilation.
Oropharyngeal (Guedel) airway
A stiff tube with a fixed curvature is inserted through the mouth. A flange limits the depth of insertion.
Use when the patient is semi-conscious.
Indications
Airway compromise in the patient with reduced conscious level.
Contraindications
Active gag reflex.
Conscious patient.
Procedure
Insert the airway initially with the curvature upwards.
Once inside the mouth, rotate 180°.
Continue to insert, following the curvature of the tongue until the flange rests against the teeth or gums.
Ensure there is no gagging, snoring, or vomiting and that air can move in and out freely.
Procedure tips
May be used for suction (size 10, 12, or 14 catheters).
Insertion can be guided with a tongue depressor.
Airway sizes
Oropharyngeal airways come in many sizes and are colour-coded for convenience.
Select the correct size of airway for the patient by measuring it against the side of the patient’s face. The flange should sit at the corner of the patient’s mouth and the tip at the angle of the jaw (Fig. 18.4).
Choose the correct size of oropharyngeal airway by measuring from the corner of the patient’s mouth to the angle of the jaw.
Nasopharyngeal airway
Tolerated better than a Guedel airway in semi-conscious patients.
Consists of a soft plastic tube with flanged end.
The pharyngeal end has a bevel and the body is curved to facilitate insertion.
Some designs have a small flange and a safety pin is often used to ensure the device does not migrate fully into the patient’s nose.
Indications
Patients with reduced conscious level and/or airway compromise who will not tolerate an oropharyngeal airway (intact gag reflex).
Contraindications
Known basal skull fracture (relative contraindication).
Procedure
Lubricate the device.
Insert bevelled end into the wider nostril.
Pass the tube along the floor of the nasal airway.
Aim no higher than the back of the opposite eyeball.
Use size 10 or 12 catheter for suction if required.
Advance until the flange is flush against the nostril.
Procedure tips
If insertion proves difficult, try the opposite nostril.
Airway sizes
Nasopharyngeal airways come in several sizes, the size is usually stamped on the side.
Determine the correct size by comparing those available with the pateint’s little finger and the distance between the nostril and the tragus (Fig. 18.5).
Choose the correct size of nasopharyngeal airway by measuring from the nostril to the tragus.
Laryngeal mask airway (LMA)
A tube with an inflatable cuff (‘mask’) around its base to create a seal around the laryngeal inlet.
This does not prevent aspiration of stomach contents.
Indications
Unconscious patient requiring ventilation.
Contraindications
Conscious patient (absolute).
Maxillofacial trauma.
Risk of aspiration.
>16 weeks’ pregnant.
Procedure
Ensure that the cuff inflates and deflates satisfactorily.
For insertion, the mask should be completely deflated.
Deflate the cuff with a 20ml syringe. Lubricate the outer cuff with aqueous gel.
Gently extend the head and flex the neck (except in possible cervical trauma).
Hold the LMA tubing near the cuff, like a pen.
With the mask facing down, pass along the under-surface of the palate until it reaches the posterior pharynx.
Guide the tube backwards and downwards (using an index finger if necessary) until resistance is felt.
Remove your hand and fill the mask with the required amount of air (usually 20–30ml).
The tube should lift out of the mouth slightly and the larynx is pushed forward if it is in the correct position.
Connect the bag-valve mask and ventilate.
Auscultate in both axillary regions to confirm ventilation.
Insert a bite block/Guedel airway next to the tube in case the patient bites down.
Secure in place with tape/ribbon.
Procedure tips
If inadequately deflated, lubricated, or not pressed against the hard palate on insertion, the LMA may fold back on itself making insertion difficult or preventing appropriate positioning of the mask (Fig. 18.6).
Laryngeal mask airways. (a) Inflated. (b) Deflated.
Oxygen administration
Oxygen is a drug with a correct dosage and side effects which when administered correctly may be life saving.
Oxygen prescribing
The primary responsibility for oxygen prescription at the time of writing lies with the hospital medical staff. It is good practice to record:
Whether delivery is continuous or intermittent.
Flow rate/percentage used.
What SaO2 should be.
Procedure
Explain what is happening to the patient and ask their permission.
Choose an appropriate oxygen delivery device.
Choose an initial dose:
Cardiac or respiratory arrest: 100%
Hypoxaemia with PaCO2 < 5.3kPa: 40–60%
Hypoxaemia with PaCO2 > 5.3kPa: 24% initially.
If possible, try to measure a PaO2 in room air prior to giving supplementary oxygen.
Apply the oxygen and monitor via oximetry (SaO2) and/or repeat ABGs (PaO2) in 30 minutes.
If hypoxaemia continues, the patient may require respiratory support.
Oxygen administration equipment
The method of delivery will depend on the type and severity of respiratory failure, breathing pattern, respiratory rate, risk of CO2 retention, need for humidification, and patient compliance. (Fig.18.7).
Each oxygen delivery device comprises an oxygen supply, flow rate, tubing, interface ± humidification.
(a) Nasal cannulae. (b) Low flow/variable concentration mask. (c) Non-rebreathe mask. (d) Mask with Venturi valve attached. (e) Selection of Venturi valves. (f) Humidification circuit.
Nasal cannulae
These direct oxygen via two short prongs up the nasal passage.
Can be used for long periods of time
Prevent rebreathing
Can be used during eating and talking.
Local irritation, dermatitis, and nose bleeding may occur and rates of above 4L/min should not be used routinely.
Low flow oxygen masks
Deliver oxygen concentrations that vary depending on the patient’s minute volume. At low flow rates there may be some rebreathing of exhaled gases (they are not sufficiently expelled from the mask).
Fixed performance masks
A constant O2 concentration independent of the minute volume.
The masks contain ‘Venturi’ barrels where relatively low rates of oxygen are forced through a narrow orifice producing a greater flow rate which draws in a constant proportion of room air through several gaps.
Partial and non-rebreathe masks
Masks such as this have a ‘reservoir’ bag that is filled with pure oxygen and depend on a system of valves which prevent mixing of exhaled gases with the incoming oxygen.
The concentration of oxygen delivered is set by the oxygen flow rate.
High-flow oxygen
Masks or nasal prongs that generate flows of 50–120L/min using a high flow regulator to entrain air and oxygen at specific concentrations.
It is highly accurate as delivered flow rates will match a high respiratory rate in patients with respiratory distress. It should always be used with humidification.
Peak expiratory flow rate (PEFR) measurement
Background
Normal values vary according to height, age, and gender (Fig.18.8).
The value obtained may be compared against this and/or the patient’s previous best PEFR.
Normal PEFR by age and gender. From BMJ 1989; 298: 1068–70.
Indications
Asthma. Either in an acute attack to assess severity, or during the chronic phase to determine reversibility in response to treatment (>60L/min change defined as reversible).
PEFR may also aid in the diagnosis of asthma by examining the greatest variation over two weeks.
PEFR may also be useful in assessment of COPD, particularly the degree of reversibility in response to inhaled bronchodilator.
Contraindications
Any features of life-threatening asthma or severe respiratory distress.
Equipment
A peak flow meter.
A clean disposable mouthpiece.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain verbal consent.
The patient should be standing or sitting upright.
Ensure that the meter is set to ‘0’.
Ask the patient to take a deep breath in, hold the mouthpiece in the mouth, and seal their lips tightly around it.
Ensure that the patient holds the device at the sides, avoiding obstructing the marker with a finger.
The patient should blow out as hard and as fast as possible.
Patients sometimes have difficulty with this and a quick demonstration or advice to ‘imagine blowing out a candle at the other end of the room’ can help.
Make a note of the reading achieved.
Repeat the procedure and record the best of three efforts.
If the patient is to keep a record, be sure to explain how to record the readings appropriately. (Sometimes a two-week diary is kept by the patient to assess for diurnal variation.)
Procedure tips
If the patient is having difficulty performing correctly, a brief demonstration often proves very useful.
If the highest two values are not within 40L/min, further values should be obtained.
Documentation
Record the highest PEFR in L/min and as a percentage of the patient’s best previous or predicted PEFR.
Make a note of the time and whether the measurement was made before or after therapy.
Inhaler technique
Metered dose inhaler
Requires coordination to use effectively and lacks a dose counter.
May be unsuitable for the very young, elderly, or those with arthritis affecting the hands. (Fig.18.9.)
A metered dose inhaler (MDI). A salbutamol inhaler is pictured.
How to use
Take only one dose at a time.
Remove the cap and shake the inhaler several times.
Sit upright, breathe out completely.
Insert mouthpiece in mouth, sealing with lips.
Take a deep breath in. Just after you begin to breathe in depress the canister whilst continuing to inhale.
The canister should be pressed just after the start of inhalation, not before.
Inhale slowly and deeply.
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
Recover before taking the next dose and repeat above as necessary.
Replace cap.
Autohaler
This is a ‘breath-actuated’ inhaler, releasing a dose automatically as a breath is taken (Fig.18.10).
No hand coordination is required.
The priming lever, however, can prove difficult to use and requires priming before each dose.
A typical Autohaler.
How to use
Remove cap and shake inhaler several times.
Prime by pushing the lever into the vertical position whilst keeping the inhaler upright.
Sit upright, breathe out completely, and insert mouthpiece, sealing with lips.
Inhale slowly and deeply.
Don’t stop when the inhaler clicks.
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
Push lever down and allow time to recover before taking the next dose.
Once doses are taken, replace cap.
Procedure tips
Patients unable to operate the lever by hand may be able to use a hard surface such as the edge of a table for assistance.
Use inhaler only for the number of doses written on the label.
Patients should inhale slowly and steadily rather than hard and fast.
Easi-breathe
Breath-actuated inhaler, as autohaler only primed by opening the cap hence this must be closed and opened again between successive doses (Fig.18.11).
A typical Easi-breathe inhaler.
How to use
Shake the inhaler several times.
Hold upright and prime by opening the cap.
Sit upright, breathe out completely, and insert mouthpiece, sealing with lips.
Make sure that your fingers are not covering the air holes at the top.
Inhale slowly and deeply.
Don’t stop when the inhaler puffs.
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
Close the cap, with the inhaler upright.
Recover before taking the next dose.
Procedure tips
It is essential to close and then open the cap between successive doses. This primes the inhaler.
Advise the patient not to dismantle the inhaler. Patients used to using MDIs may be tempted to take the top off and attempt to depress the canister manually.
Accuhaler
Dry powder device, superseding the Diskhaler and Rotahaler (Fig.18.12).
Has a dose counter.
The several step priming mechanism may be difficult for some to manage.
A typical Accuhaler.
How to use
Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click.
With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed.
Sit upright, breathe out completely, and insert mouthpiece, sealing with lips.
Inhale quickly and deeply.
(In contrast to breath-actuated devices).
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click.
Recover before taking the next dose.
Procedure tips
The Accuhaler must be closed and re-primed between successive doses.
The dose counter indicates how many doses are left.
Turbohaler
Dry-powder device with preloaded tasteless drug (Fig.18.13).
There is no dose counter, but a window that turns red after 20 doses.
The device is empty when there is red at the bottom of the window.
Those with impaired dexterity may find the inhaler difficult to use.
A typical Turbohaler.
How to use
Unscrew and remove the white cover.
Hold the inhaler upright and prime the device by twisting the grip clockwise and anticlockwise as far as it will go (until you hear a click).
Sit upright, breathe out completely, and insert mouthpiece, sealing with lips.
Inhale slowly and deeply.
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
Recover before taking the next dose.
The device must be primed again between successive doses.
Procedure tips
Advise the patient that they will not feel the dose hit the back of their throat.
Patients used to an MDI may find this off-putting.
Clickhaler
Disposable dry-powder inhaler with dose meter which turns red when only 10 doses are left to use.
The inhaler locks when empty so patients can be sure that they have taken a dose.
How to use
Take only one dose at a time.
Remove the cap and shake.
Whilst holding inhaler upright, depress the button firmly and release until you hear a click.
Sit upright, breathe out completely, and insert mouthpiece, sealing with lips.
Inhale deeply.
Remove inhaler and hold your breath for 10 seconds or as long as is comfortable.
Recover before taking the next dose and repeat above as necessary.
Replace cap.
Handihaler
A dry-powder device with an integrated cap.
This requires a lower inspiratory flow rate than other devices.
A dose needs to be inserted via a capsule at each use requiring some dexterity.
Patients may also find the cap rather hard to open as it requires a moderate amount of strength.
How to use
Open cap by pulling upwards exposing mouthpiece.
Open the mouthpiece by pulling upwards exposing the dose chamber.
Take a capsule from the blister-pack and insert it into the chamber.
Replace the mouthpiece (it should click shut).
Press the side button in a few times to pierce the capsule (you can watch through the small window).
Sit upright, hold head up, and breathe out.
Seal lips around mouthpiece.
Breathe in deeply to a full breath.
Remove inhaler and hold breath for as long as is comfortable.
Remove the used capsule and replace the cap.
Non-invasive ventilation
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
CPAP = continuous positive airways pressure.
CPAP traditionally has its own equipment and ‘set-up’
Recently more clinicians are delivering CPAP through the BiPAP Vision®. There is also a ‘low flow’ version used mainly for transport of CPAP dependent patients.
BiPAP = bilevel positive airways pressure.
Contraindications/cautions
Undrained pneumothorax. (Absolute contraindication).
Facial fractures.
Life-threatening epistaxis.
Bullous pulmonary disease.
Proximal lung tumours (air trapping).
Active TB (spread).
Acute head injury.
Low blood pressure.
Uncontrolled cardiac arrhythmias.
Sinus/middle ear infection.
Risks
Abdominal distension (secondary to ‘swallowing’ air).
Decreased cardiac output (drop in BP).
Pressure sores from mask.
Aspiration of vomit.
CO2 retention if patient breathing small tidal volume against high PEEP.
Documentation
Oxygen prescription charts.
Ventilation prescription charts.
Clear record of ABGs with evidence of time, inspired oxygen, and ventilation levels.
Good practice to document the ‘ceiling’ of pressures and FiO2 for the clinical environment.
CPAP equipment
Mask (+/– T-piece), hood.
Head strap (mask), shoulder straps (hood).
Oxygen circuit and humidification.
High flow generator (e.g. Whisper Flow®, Vital Signs®).
PEEP valves (usually 5, 7.5, or 10cmH2O).
‘Blow off’ safety valve (10cmH2O above the PEEP used).
CPAP procedure
Use available templates to assess appropriate sized interface and minimize air leaks (if using the BiPAP Vision®).
Decide on level of PEEP to apply.
Attach PEEP valve to mask (if using traditional set-up, may need T-piece).
Attach oxygen circuit with humidification including ‘blow-off’ valve (for safety).
Set inspired oxygen level.
Set flow rate to ensure the PEEP valve opens a small distance and never closes.
Titrate oxygen and PEEP in response to the patient’s work of breathing, saturations, pH, PaO2, and PaCO2.
If appropriate, set alarms on ventilator (if using BiPAP Vision®).
Write a prescription chart of PEEP or ventilation settings and acceptable saturations, PaO2, and PaCO2, continuous or intermittent.
BiPAP equipment
Interface (face mask, nasal pillows, nasal mask, etc.).
Head straps.
Ventilation circuit (exhalation port unless on mask).
Humidification (if required).
Ventilator (NIPPY 1/2/3/3+, BiPAP Vision®, etc.).
Entrained oxygen (unless with ventilator, e.g. BiPAP Vision®).
BiPAP procedure
Decide on which interface to use.
Use available templates to assess appropriate sized interface and minimize air leaks.
Start with low pressures (EPAP 4cmH2O, IPAP 12cmH2O).
Slowly increase pressures to levels agreed by MDT, for patient comfort and in response to pH, PaO2, and PaCO2
The aim being to reduce RR and work of breathing, normalize ABGs (for the individual) using the minimal pressures possible.
Set inspiratory and expiratory times to those of the patient.
Continually reassess RR as this will change and therefore set times will have to change.
Titrate oxygen and pressures in response to the patient’s saturations, pH, PaO2, and PaCO2.
If appropriate set alarms on ventilator.
Write a prescription chart of ventilation settings and acceptable saturations, PaO2, and PaCO2.
Pleural fluid aspiration
This describes the procedure for aspirating as much pleural fluid as possible. If only a small sample is required for diagnostic purposes, use a green needle and 20ml syringe and follow a similar method to that described under ‘ascitic fluid sampling’. (See Box 18.12 for alternative method.)
An alternative method is to attach a fluid-giving set to one port of the 3-way tap and the 50ml syringe to the other
With this set-up, you can aspirate 50ml into the syringe, turn the tap and empty it down the tubing into a container before turning the tap back to the syringe port
The syringe, therefore, never needs to be disconnected and the risk of pneumothorax or other complication is reduced.
Fluid should be aspirated from a position 1–2 intercostal spaces below the highest level at which dullness is percussed.
Contraindications
Recurrent effusion (chest drain or pleurodesis should be considered).
Empyema (requires intercostal drainage).
Mesothelioma (tumour may spread down needle track).
Bleeding diathesis.
Risks
Pain.
Cough.
Failure to resolve.
Re-expansion pulmonary oedema.
Pneumothorax.
Equipment
Sterile pack.
Sterile gloves.
Cleaning solution (e.g. chlorhexidine).
Large-bore (green) cannula.
3-way tap.
50ml syringe.
5ml 1% lidocaine.
23G (blue) needle.
2 x 10ml syringe.
Dressing/gauze.
Selection of sterile containers and blood bottles.
Heparinized (ABG) syringe.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient leaning forward with arms rested on a table or over the back of a chair.
Percuss the effusion and choose a suitable spot for needle insertion.
Clean the area with chlorhexidine.
Using the blue needle and syringe, infiltrate local anaesthetic down to the pleura.
Insert needle just above a rib to avoid the neurovascular bundle
Be sure to pull back on the syringe each time before injecting to ensure you are not in a blood vessel
Once fluid is withdrawn, you have reached the pleura.
Insert the cannula perpendicular to the chest wall, aspirating with another syringe as you advance until resistance reduces and pleural fluid is aspirated.
Remove the needle and attach the 3-way tap.
You may now aspirate fluid using the 50ml syringe.
Once the syringe is full, close the tap, disconnect the syringe, and empty into a container. Re-attach the syringe, open the tap, and repeat.
The pleural space should never be in continuity with the environment or pneumothorax will occur.
Do not drain more than 2.5L at one time.
Remove the cannula and apply the dressing.
Send samples for:
Microbiology: microscopy, culture, Auramine stain, TB culture
Chemistry: protein, LDH, pH, glucose, amylase
Cytology
Immunology: ANA, rheumatoid factor, complement.
Take simultaneous venous blood for glucose, protein, LDH.
Request chest radiograph to confirm success and look for iatrogenic pneumothorax.
Procedure tips
If unsuccessful, aspiration may be performed under ultrasound guidance: discuss with your radiology or respiratory department, depending on local policy.
Passing a small fluid sample through a blood gas analyser may yield a rapid pH but should be avoided if the sample is purulent.
Documentation
Date, time, indication, informed consent obtained.
Aseptic technique used?
Local anaesthetic used.
Site needle inserted.
Colour, consistency, and volume of fluid aspirated.
Any immediate complications.
Investigations requested.
Signature, printed name, and contact details.
Pneumothorax aspiration
Simple vs secondary pneumothorax
Simple pneumothorax
Aspiration is indicated if the rim of pleural air visible on chest radiograph is larger than 2cm or the patient is breathless.
If initial aspiration is unsuccessful, repeat aspiration may be successful in >30% of cases and may avoid intercostal drain insertion.
The total volume aspirated should not exceed 2.5L.
Secondary pneumothorax
That is, a pneumothorax in the presence of underlying lung disease.
Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50.
Contraindications
Previous failed attempts at aspiration.
Significant secondary pneumothorax.
Traumatic pneumothorax.
Risks
Pain.
Cough.
Failure to resolve/recurrence.
Re-expansion pulmonary oedema may theoretically occur if large volumes (>2.5L) are aspirated.
Equipment
Sterile pack.
Sterile gloves.
Cleaning solution (e.g. chlorhexidine).
Large-bore (green) cannula.
3-way tap.
50ml syringe.
5ml 1% lidocaine.
23G (blue) needle.
2 x 10mL syringe.
Dressing/gauze.
Procedure
Pneumothorax is usually aspirated from either 2nd intercostal space at the midclavicular line or the 4th–6th intercostal spaces at the midaxillary line.
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Position the patient leaning back comfortably at about 45°.
Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination.
Clean the area with the chlorhexidine.
Infiltrate local anaesthetic down to the pleura using the blue needle and a 10ml syringe.
Attach the other 10ml syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces.
Insert the cannula just above a rib to avoid the neurovascular bundle.
Remove the needle and quickly attach the 3-way tap and 50ml syringe.
Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe and eject the air; reattach and open the 3-way tap to continue aspiration.
The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will reaccumulate.
Aspirate until resistance is felt, or up to a maximum of 2.5L.
Remove the cannula and apply the dressing.
Request chest radiograph to re-assess.
Documentation
Date, time, indication, informed consent obtained.
Aseptic technique used?
Local anaesthetic used.
Site needle inserted.
Volume of air aspirated.
Any immediate complications.
Investigations requested.
Signature, printed name, and contact details.
Tension pneumothorax
In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line, without delay and left open to convert the tension pneumothorax to a simple pneumothorax.
Chest drain insertion (Seldinger)
This describes the procedure for a Seldinger-type drain. Other drains are available.
More and more trusts now recommend chest drain insertion under ultrasound guidance. Check your local policy and discuss with your radiology or respiratory departments as appropriate.
Contraindications
The need for an emergency thoracotomy. This should not be delayed for the insertion of a chest drain.
Coagulopathy.
Large bullae.
Thoracic/pleural adhesions.
Skin infection over the insertion site.
Risks
Inadequate placement.
Bleeding (local or haemothorax).
Liver or spleen injury +/– haemoperitoneum.
Organ penetration (lung, liver, spleen, stomach, colon, heart).
Infection.
Iatrogenic pneumothorax.
Equipment
10ml 1% lidocaine.
10ml syringe.
25G (orange) needle.
21G (green) needle.
Sterile gloves.
Sterile pack (containing cotton balls, drape, container).
Seldinger chest drain kit.
Chest drain, introducer, needle, syringe, scalpel, 3-way tap, wire.
Suture (e.g. 1.0 Mersilk).
Cleaning solution (e.g. chlorhexidine or iodine).
Chest drain tubing and drainage bottle.
500ml sterile water.
Suitable dressing (e.g. Hypofix® or drainfix®).
Procedure
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent.
Double-check radiograph and perform clinical examination to be sure of which side needs the drain.
Position the patient sitting on a chair or the edge of their bed, arms raised and resting on bedside table with a pillow.
The usual site for insertion is in the mid-axillary line, within a triangle formed by the diaphragm, the latissimus dorsi, and the pectoralis major (‘triangle of safety’).
Mark your spot (just above a rib to avoid the neurovascular bundle).
Wash hands and put on sterile gloves.
Clean the area with antiseptic solution on cotton wool balls working in a spiral pattern outwards.
Using the 10ml syringe and orange needle, anaesthetize the skin forming a subcutaneous bleb.
With the green needle anaesthetize down to the pleura, withdrawing the plunger before injecting each time.
Use the scalpel to make a small cut in the skin.
Use the drain-kit needle with the curved tip and syringe (in some kits, this has a central stilette which needs to be removed first). With the curved tip facing downwards (upward for a pneumothorax), advance through the anaesthetized area until you aspirate either air or fluid.
Remove the syringe and hold the needle steady.
Thread the guidewire through the needle into the chest.
Once the wire is half in the chest, discard the covering.
Withdraw the needle from the chest but be sure to not remove the guidewire, keeping hold of it at all times, and thread the needle right off the end of the guidewire.
Thread the introducer over the guidewire and into the chest, twisting back and forth as you go to open up a tract for the drain’s passage. Then slide the introducer back off the wire, being careful not to pull the wire out of the chest.
With the central stiffener in place, thread the drain over the wire and into the chest, curving downwards.
Keep hold of the guidewire at all times and do NOT push it into the chest cavity!
Once the drain is in place, remove the wire and stiffener.
Attach the 3-way tap, making sure all the ports are closed.
Stitch the drain in place (unless using a drainfix®).
Apply a drainfix® or other suitable dressing.
Attach the drain to the tubing and the tubing to the collection bottle which you have pre-filled with 500ml of sterile water.
Open the 3-way tap.
You should either see the fluid start to flow or air start to bubble in the collection bottle. Ask the patient to take a few breaths and watch the water level in the tubing to see it rising and falling (‘swinging’).
Request a post-insertion chest radiograph.
Documentation
Date, time, indication, informed consent obtained.
Aseptic technique used?
Local anaesthetic used.
Site drain inserted.
Any immediate complications.
Colour and consistency of fluid obtained.
Investigations requested.
Signature, printed name, and contact details.
Recording a 12-lead ECG
The term ‘12-lead’ relates to the number of directions that the electrical activity is recorded from and is not the number of electrical wires attached to the patient!
Equipment
An ECG machine capable of recording 12 leads.
10 ECG leads (4 limb leads, 6 chest leads).
These should be attached to the machine.
Conducting sticky pads (‘ECG stickers’).
Procedure
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent.
Position the patient so that they are sitting or lying comfortably with their upper body, wrists, and ankles exposed.
Position the stickers on the patient’s body (Fig.18.14).
The chest leads:
V1: 4th intercostal space at the right sternal border
V2: 4th intercostal space at the left sternal border
V3: midway between V2 and V4
V4: 5th intercostal space in the midclavicular line on the left
V5: left anterior axillary line, level with V4
V6: left mid-axillary line, level with V4.
The limb leads are often colour-coded:
Red: Right arm (Red: Right)
Yellow: Left arm (YeLLow: Left)
Green: right leg
Black: left leg.
Attach the leads to the appropriate stickers.
Turn on the ECG machine.
Ask the patient to lie still and not speak for approximately 10 seconds whilst the machine records.
Press the button to record, usually marked ‘analyse’ or ‘record’.
Check the calibration and paper speed:
1mV should cause a vertical deflection of 10mm
Paper speed should be 25mm/s (5 large squares per second).
Ensure the patient’s name, date of birth as well as the date and time of the recording are clearly recorded on the trace.
Remove the leads, discard the sticky electrode pads.
Correct positioning of the chest electrodes for a standard 12-lead ECG.
Procedure tips
Encourage the patient to relax otherwise muscle contraction will cause interference.
If unable to relax, or access to the peripheries is difficult, the ‘arm’ leads can be placed at the shoulders and the ‘leg’ leads at the groins.
Breathing may cause a wandering baseline; breath holding for 6 seconds whilst recording may alleviate this.
Ensure that you cleanse the area gently with an alcohol swab before attaching an electrode to ensure a good connection.
It may be necessary to cut chest hair to allow good contact and adhesion with the chest leads.
The AC mains electricity may cause interference. If this is the case, try turning off nearby fluorescent lights.
Carotid sinus massage
Background
Anatomy and physiology
The carotid sinus is located at the bifurcation of the common carotid artery.
It lies just under the angle of the jaw at the level of the thyroid cartilage.
The carotid sinus contains numerous baroreceptors which coordinate homeostatic mechanisms responsible for maintaining blood pressure.
These baroreceptors are innervated by a branch of the glossopharyngeal nerve (cranial nerve IX), which relays back to the medulla and modulates autonomic control of the heart and blood vessels.
Carotid sinus hypersensitivity
The carotid sinus can be oversensitive to manual stimulation, a condition known as carotid sinus hypersensitivity (also ‘carotid sinus syndrome’ or ‘carotid sinus syncope’).
In this condition, manual stimulation of the carotid sinus provokes significant changes in heart rate and/or blood pressure due to an exaggerated response to carotid sinus baroreceptor stimulation.
This may result in marked bradycardia, vasodilation, and subsequent hypotension.
The patient may complain of episodes of dizziness or syncope related to pressure on the neck (e.g. wearing a tight collar or turning the head quickly).
The underlying mechanism behind this exaggerated response is not fully understood.
Carotid sinus massage
Carotid sinus massage is a diagnostic technique used to confirm carotid sinus hypersensitivity and is sometimes useful for determining the underlying rhythm disturbance in supraventricular tachycardia (SVT).
The procedure acts in a similar way to the Valsalva manoeuvre, increasing vagal tone and, therefore, reducing the heart rate.
Carotid massage is less effective than pharmaceutical management of SVT (verapamil or adenosine) though is still the preferable choice in the young haemodynamically stable patient.
This procedure should be performed with caution in the elderly as it may cause disruption of atheromatous plaque disease in the carotid artery and result in stroke.
Before you start
Explain the procedure in full to the patient and obtain written consent.
If the test is to confirm carotid sinus hypersensitivity, then warn the patient that they may feel like they are going to faint but reassure them it is a controlled procedure
If the test is to determine the underlying rhythm in SVT, explain that they may feel a bit peculiar as the heart rate slows down transiently.
Auscultate over the carotids for any bruits.
If present the procedure will have to be abandoned as the risk of stroke is significant
Document discussion of risks including failure, arrhythmias, stroke, faint, cardiac arrest.
Secure intravenous access.
Ensure that you have ECG monitoring with a recordable rhythm strip.
Ensure access to full resuscitation equipment, including emergency drugs such as atropine and adrenaline.
Procedure
Position the patient supine on a bed with the neck extended and head turned away from the side to be massaged.
Whilst watching the ECG monitor (recording on a rhythm strip) gently massage the carotid sinus for 10 to 15 seconds using circular motions of your hand.
If there is no response, switch to the opposite side.
If successful (or ‘positive’ in the case of sinus hypersensitivity), the heart rate will slow.
This may allow you to determine the underlying rhythm in SVT.
Ensure that the patient feels back to normal afterwards.
Documentation
Date, time, indication, informed consent obtained.
Intravenous access secured.
ECG recording equipment operational.
Emergency drugs on stand-by.
Insert the rhythm strip into the patient’s notes.
Record details of what was seen on massage.
Which carotid was used?
Did the patient feel back to normal afterwards?
Signature, printed name, and contact details.
Vagal manoeuvres
Background
The purpose
Vagal manoeuvres can be used to determine the underlying rhythm or terminate supraventricular tachycardia (SVT) in haemodynamically stable patients.
If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves.
Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia recurs.
Physiology
Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve.
Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way, any supraventricular tachycardia that relies upon the AV node will be modified by an increase in vagal tone.
The Valsalva manoeuvre
This is forced expiration against a closed glottis. Increasing intra-thoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation.
This can be successful in 25–50% of cases.
Procedure
Ask the patient to take a deep breath in and then ‘bear down’ as if they are trying to open their bowels (or for women—as if they are in labour).
Some patients may struggle with this concept and so alternatively:
Give them a 10ml syringe and ask them to blow into the tip, in an attempt to expel the plunger.
The diving reflex
This involves either submerging the face in ice cold water (not very practical) or covering the face with a towel soaked in ice cold water.
Carotid sinus massage
This is described separately (see previously).
Eyeball pressure
This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.
Temporary external pacing
This describes temporary transcutaneous pacing as an emergency.
Before you start
External pacing is usually performed in an emergency resuscitation situation following failure of response to initial management as per the bradycardia algorithm (see bradycardia algorithm from Resuscitation Council at www.resus.org.uk).
A senior doctor should be present and make the decision to proceed with external transcutaneous pacing.
There should be a plan in place for an experienced clinician to insert a temporary pacing wire within the next few hours. External pacing should only be a short-term management of decompensated bradycardia.
There should also be a bed available for the patient on a high-dependency unit or coronary care unit so that they can be closely monitored by experienced nursing staff whilst waiting for a temporary pacing wire. The patient should not be left on a general hospital ward.
Indications
Symptomatic bradycardia unresponsive to treatment (see bradycardia algorithm from Resuscitation Council at end of this topic).
Mobitz type II block.
Complete heart block.
Heart block secondary to myocardial infarction.
Profound bradycardia secondary to drug overdose e.g. beta blockers, digoxin.
Asystole or ventricular standstill.
Overdrive pacing
External pacing can be used to terminate certain tachyarrhythmias that are unresponsive to initial treatment e.g. polymorphic ventricular tachycardia (torsades de pointes) or refractory ventricular tachycardia.
Risks
Failure and progression to temporary pacing wire insertion.
Equipment
Full resuscitation equipment: defibrillator with pacing setting.
Defibrillator pads.
Oxygen.
ECG monitoring.
Emergency drugs (including atropine and adrenaline).
Intravenous fluids.
Sedative drugs (e.g. midazolam or diazepam).
Analgesia (e.g. morphine).
Intubation equipment (in case indicated).
Senior support.
Procedure
The patient should already have:
Large-bore intravenous access
Intravenous fluids running (unless in heart failure)
Oxygen via a non-rebreathe mask at 15L/min
ECG monitor connected and running
Interval BP monitoring.
Place the pacing pads from the defibrillation kit on the patient’s chest: one anteriorly in the V3 position and one posteriorly below the left scapula.
Sedation and analgesia may be required.
Attach the leads from the defibrillator to the pads.
Switch the defibrillator to its pacing mode.
Documentation
Temporary external pacing is usually an emergency procedure so documentation may be delayed until the patient is stable. It should outline the resuscitation and external pacing simultaneously:
Date and time.
Name and grade of persons present.
Events leading up to the need for external pacing.
Any drugs used e.g. atropine or adrenaline, volume/dose, and response.
Indication for external pacing.
If patient was conscious, document consent (usually verbal consent only).
Any sedation used.
When external pacing commenced.
Details of plans for temporary pacing wire insertion.
Sign and bleep/contact details.
DC cardioversion
Indications
Elective cardioversion of atrial fibrillation.
Emergency cardioversion in a peri-arrest situation where a tachyarrhythmia is associated with adverse signs.
Equipment
The ‘crash trolley’ should contain all the equipment required:
Gloves, aprons, defibrillator, pads, leads, ECG electrodes.
Oxygen, reservoir bag and mask with tubing, airways.
Intubation equipment.
Intravenous fluids, giving sets, selection of syringes, needles, intravenous cannulae, and fixation dressings.
Access to emergency drugs (atropine, adrenaline, amiodarone).
Contraindications
Elective: patients unsuitable for general anaesthetic, not anticoagulated or who have not signed a consent form.
Emergency: only performed when a tachyarrhythmia is associated with adverse events in the presence of a pulse (pulseless rhythms require management as per the resuscitation guidelines).
Risks
General anaesthetic risk, if performed electively.
Embolic phenomenon, stroke, myocardial infarction.
Before you start
Elective procedure
Obtain informed consent and save a copy of signed form.
Ensure patient fasted >6hrs.
Check serum potassium (>4.0mmol/L gives greater success).
Confirm patient anticoagulated for previous 4 weeks (INR >2).
Warfarin is continued for 3 months post-procedure if successful.
The procedure should be performed in an anaesthetic room, following short-acting induction by an anaesthetist.
Emergency procedure
Ensure a senior doctor is involved in the decision.
Ensure all other options have been tried or considered.
If possible discuss with the patient or next of kin.
Energy selection
DC cardioversion usually uses biphasic energies. A reasonable guide is:
50 Joules synchronized shock. If fails ...
100 Joules synchronized shock. If fails ...
150 Joules synchronized shock. If fails ...
150 Joules synchronized anteroposterior shock. If fails ...
Abandon procedure if elective, consult seniors if emergency (may need ICU input).
Procedure
Ensure skin is dry, free of excess hair, jewellery is removed.
Attach the ECG electrodes; red under right clavicle, yellow under left clavicle, green at the umbilicus.
Switch on defibrillator and confirm the ECG rhythm.
Place the defibrillator gel pads on the patient’s chest; one under the right clavicle and the other inferolateral to the cardiac apex.
Select the ‘synchronous mode’ on the defibrillator.
Select the Joules required (see 
p.634).
Place the paddles firmly on the chest on the gel pads.
Press the charge button on the paddles to charge the defibrillator and shout ‘Stand clear! Charging!’
Check all persons are standing well clear of the patient and bed (including yourself) and that no-one is touching the patient or bed (including yourself).
Ensure the oxygen has been disconnected and removed.
Check the monitor again to ensure a shockable rhythm.
Shout ‘Stand clear! Shocking!’.
Press both discharge buttons on the paddles to discharge the shock.
Return the paddles to the defibrillator or keep them on the chest if another shock is required.
Documentation
General
Date, time, and place. Name and grade of persons present.
ECG rhythm, intravenous access secured.
Number, volume, dose of any drugs used, and any response noted.
Type of defibrillator machine used.
Method of sedation/anaesthetic.
Asynchronous or synchronous mode. Specify Joules of each shock.
Confirm rhythm at end and 12-lead ECG findings.
Sign and bleep/contact details.
Elective
Indication for DC cardioversion.
Informed consent obtained (retain copy of signed form).
State time fasted from.
Document anticoagulation type and duration.
Serum potassium level.
Any drug allergies.
Name and grade of anaesthetist, type of anaesthetic used.
Emergency
Events leading up to the peri-arrest situation.
HR, BP, GCS on arrival and any deterioration.
Time of decision to shock, name and grade of decision-maker.
Verbal consent obtained? Type of sedation used.
Next of kin have been informed or if they are present or en route?
Pericardiocentesis
Contraindications
Cardiac tamponade secondary to cardiac trauma or aortic dissection (surgical intervention is preferable).
Recurrent pericardial effusions (surgical pericardial window indicated).
Risks
Pneumothorax.
Myocardial perforation.
Cardiac tamponade.
Coronary artery laceration.
Cardiac arrhythmias.
Intra-abdominal trauma (especially to liver).
Haemorrhage.
Infection.
Acute pulmonary oedema.
Failure of procedure.
Death.
Equipment
Echocardiogram machine and sterile probe cover.
Pericardial drain kit (14 gauge needle, syringe, guidewire, pigtail catheter, and drain).
Sterile drape and towels.
Iodine solution.
Sterile gloves and gown.
Local anaesthetic (1% lidocaine).
2 x 10ml syringe.
Orange/blue/green needles.
Sterile gauze.
50ml syringe.
Three-way tap.
Suture, scissors, sticky dressing (e.g. Tegaderm®).
You will also need:
Intravenous access.
ECG monitoring.
Access to ‘crash’ trolley (defibrillator and emergency drugs).
Procedure
Introduce yourself, explain procedure, and obtain informed written consent.
Ensure IV access, ECG monitoring, normal clotting, and access to resuscitation equipment.
(Consider light sedation).
Position patient supine with 20–30° head tilt.
Ensure all equipment is sterile and laid out on sterile trolley.
Wash hands using surgical scrub technique and put on the sterile gown and gloves.
Clean and drape site at the inferior border of the sternum.
Insertion point is below and to the left of the xiphisternum
Confirm location of effusion using echocardiogram machine with sterile probe cover.
Infiltrate overlying skin and subcutaneous tissue with 1% lidocaine. (Always aspirate before each injection).
Attach the 10ml syringe attached to the 14G needle.
Insert the needle between the xiphisternum and left costal margin advancing slowly at 35° to the patient and aiming towards the patient’s left shoulder. Aspirate continuously as the needle advances.
Pericardial fluid is usually aspirated at about 6–8cm depth
Depending on the size of the pericardial effusion and indication for the procedure, you may wish to attach the 50ml syringe and aspirate fluid to send for diagnostic purposes.
A modified Seldinger technique should be used to insert the drain.
Once pericardial fluid is aspirated, hold the needle in position, remove the syringe, and insert the guidewire slowly through the needle into the pericardial space.
Remove the needle, holding the wire in place at all times.
Pass the catheter over the wire into the pericardial space.
Once the catheter position is confirmed on echo, remove the wire and attach the three-way tap and drain bag.
Suture the drain in place and dress to maintain sterility.
Request a chest radiograph to exclude iatrogenic pneumothorax.
Procedure tips
Pericardiocentesis should be performed by a trained doctor (either cardiologist or thoracic surgeon usually) preferably in a sterile environment (theatre or the cardiac catheterization lab) and under echocardiographic guidance, with access to full resuscitation equipment.
The only exception is during cardiopulmonary resuscitation when pericardiocentesis is performed as an emergency to exclude cardiac tamponade as a reversible cause of cardiac arrest.
Always check the patient’s clotting beforehand.
The clinician who performed the procedure should confirm the position of the drain using echo.
Always request a post-procedure chest radiograph to exclude iatrogenic pneumothorax.
Documentation
Date, time, and place.
Name and grade of person who performed the procedure (and anyone who supervised).
Consent obtained (enclose copy of consent form).
Aseptic technique used and volume of anaesthetic used.
Approach taken and anatomy confirmed by echocardiogram.
Any difficulties i.e. ‘first pass’ or ‘second attempt’, etc.
Appearance of pericardial fluid aspirated.
Volume of pericardial fluid aspirated.
Nasogastric tube insertion
Indications
Feeding in patients with poor swallow (e.g. post-cerebrovascular accident).
Lavage of gastric contents in poisoning.
Post-operative for stomach decompression.
Bowel obstruction.
Contraindications
Oesophageal stricture, obstructing tumour.
Tracheo-oesophageal fistula.
Achalasia cardia.
Deviated nasal septum.
Fractured base of skull.
Risks
Malpositioning in a lung.
Trauma to the nasal and/or pharyngeal cavities.
Perforation of oesophagus.
Equipment
Lubricant (e.g. Aquagel®).
pH-testing strips.
50 ml syringe.
Gallipots.
Dressing pack.
Nasogastric tube (12–18 French size).
Hypoallergenic tape.
Sterile gauze.
Gloves.
Disposable bowl.
Procedure
Introduce yourself, confirm the patient’s identity.
Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient.
Make sure that the patient understands the procedure and agree a signal to be made if patient wants you to stop (e.g. raising hand).
To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process.
Position the patient semi-upright.
If unconscious, place the patient on their side.
Check the patency of the nostrils and select a suitable side.
Wash hands and put on gloves.
Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel.
Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity backward and downwards.
As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so.
Using a cup of water and straw often helps here.
If there is any obstruction felt during advancement, withdraw and try in the other nostril.
Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of the above occurs.
Once the tube has reached the measured distance, secure it in place with the tape.
The GOJ is generally 38–42cm from the nostril so advancement of the tube 55–60cm from the nostril usually positions the NG tube tip within the stomach.
Aspirate a sample of fluid using a syringe.
Place the aspirate on a pH-testing strip.
A pH of 5.5 or less suggests that the tube is in the stomach.
If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position.
Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image.
Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose.
It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also.
Procedure tips
Medications such as proton pump inhibitors and acid-suppressing drugs may elevate the pH of the aspirate giving a ‘false-negative’ result. If in doubt, request a chest radiograph before using.
Low-pH fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using.
Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated, or have poor swallow).
The absence of cough reflex does not rule out misplacement of the tube in the airways.
Auscultation for gurgling in the stomach is not a recommended method for confirming position.
Documentation
Date, time, indication, informed consent obtained.
Size of tube inserted.
Length of tube internally (there are markings on the tube).
This is important to allow other staff to assess whether the tube has moved in or out since insertion.
Method by which correct placement was confirmed.
Any immediate complications.
Signature, printed name, and contact details.
Ascitic fluid sampling (ascitic tap)
Indications
Diagnosing nature of new-onset ascites (i.e. exudate or transudate).
Diagnosis of spontaneous bacterial peritonitis (SBP).
Cytology to diagnose malignant ascites.
Contraindications
Acute abdomen that requires surgery.
Pregnancy.
Intestinal obstruction.
Grossly distended urinary bladder.
Superficial infection (cellulitis) at the potential puncture site.
Hernia at the potential puncture site.
Risks
Persistent leak of ascitic fluid.
This is more likely if there is a large amount of fluid under tension
Perforation of hollow viscera (e.g. bowel and bladder). This is very rare.
Peritonitis.
Abdominal wall haematoma.
Bleeding is very rare but may occur if there is injury to inferior epigastric artery (be careful to tap lateral abdominal wall as described).
Equipment
Sterile gloves.
Dressing pack.
Antiseptic solution (e.g. iodine).
1% or 2% lidocaine.
1 x 20ml syringe.
2 x 5ml syringes.
21G (green) and 25G (orange) needles.
Sterile containers.
Culture bottles.
Sterile dressing.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure, and obtain informed consent.
Examine the abdomen and select a site for aspiration, three finger-breadths cranial to the anterior superior iliac spine.
Beware of positioning too medial as this risks hitting the inferior epigastric vessels
Be sure to identify and avoid any organomegaly which might interfere with procedure (in patients with massive splenomegaly, for example, avoid left iliac fossa).
Clean the area with disinfectant and apply sterile drape.
Using the 25 gauge (orange) needle and the 5ml syringe, administer local anaesthetic to the skin and subcutis, raising a wheal.
Using the 21 gauge (green) needle, infiltrate deeper tissues, intermittently applying suction until the peritoneal cavity is reached, confirmed by flow of ascitic fluid into the syringe.
Note the depth needed to enter the peritoneal cavity.
Discard the used needles and attach a clean 21G needle to the 20ml syringe.
With the green needle perpendicular to the skin, insert carefully, aspirating continuously until you feel resistance give way.
Aspirate as much fluid as needed (usually 20ml is plenty).
Withdraw needle and syringe and apply dressing.
Send sample for Gram stain and culture (in blood culture bottles), white cell count/neutrophils, biochemistry, cytology (if malignancy suspected).
White cell count can be calculated in haematology lab; send fluid in EDTA-containing bottle
Total white cell count >500/mm3 or neutrophils >250/mm3 suggests spontaneous bacterial peritonitis—SBP
Neutrophil count is usually a manual procedure via microbiology and may take longer
If malignancy is suspected, a large volume of ascites (e.g. 500ml) should be sent to cytology.
Procedure tips
Check the patient’s clotting and platelet count before the procedure and proceed with caution and senior advice if abnormal (correct if platelets <20x109/L, INR ?2.5).
Inform the laboratory especially during out of hours if cultures needed urgently and if SBP is suspected.
If unable to obtain fluid despite correct technique, do not persist! Stop and seek senior advice.
Documentation
Date, time, indication, informed consent obtained.
Type and amount of local anaesthetic used.
Site aspirated.
Aseptic technique used?
How many passes?
Volume and colour of aspirate obtained.
Tests requested on samples.
Any immediate complications.
Signature, printed name, and contact details.
Abdominal paracentesis (drainage)
The procedure below relates to a ‘RocketMedical’ non-locking drainage kit—the essence is the same for other catheter kits although minor details may differ. You should refer to the kit’s instructions.
Contraindications
Acute abdomen that requires surgery.
Pregnancy.
Intestinal obstruction.
Grossly distended urinary bladder.
Superficial infection (cellulitis) at the potential puncture site.
Hernia at the potential puncture site.
Caution is needed in the presence of omental or peritoneal metastatic disease. In these cases, drainage is often performed under imaging guidance by a radiologist.
Risks
Haemodynamic instability, especially in cirrhotic patients; avoided by albumin replacement. (Usually 100ml 20% human albumin solution IV for every 2.5 litres fluid drained—check local protocols with the gastroenterology department).
Renal dysfunction (in those with abnormal baseline renal function. May need to withhold diuretics and limit drain volume to 5L).
Wound infection.
Bleeding.
Perforation of bowel and bladder.
Abdominal wall haematoma.
Equipment
Rocket abdominal catheter pack (catheter sleeve, puncture needle, and adaptor clamp).
Catheter bag and stand.
1 x 25G (orange) needle.
1 x 21G (green) needle.
3 x 10ml syringes.
5ml 1% lidocaine.
Iodine or antiseptic solution.
Sterile pack (including gloves, cotton wool balls, and bowl).
Suitable adhesive dressing.
Scalpel/blade.
Procedure
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent.
Ensure that the patient has emptied their bladder.
Position the patient lying supine or semi-recumbent.
Percuss the extent of the ascitic dullness.
Mark your spot in the left iliac fossa within the area of dullness.
Double-check clinical examination and imaging, if available. If splenomegaly is present, right-sided drainage is recommended.
Wash hands and put the sterile gloves on.
Clean the area thoroughly with antiseptic.
Infiltrate the skin and subcutaneous tissues with lidocaine via the orange needle and 10ml syringe.
Attach the green needle to another 10ml syringe and insert into the abdomen, perpendicular to the skin. Advance the needle as you aspirate until fluid is withdrawn.
Prepare the catheter kit—straighten the curled catheter using the plastic covering sheath provided.
Take the needle provided in the pack and pass through the sheath such that the needle bevel is directed along inside the curve of the catheter—continue until the needle protrudes from the catheter tip.
Remove the plastic covering sheath.
Attach a 10ml syringe to the end of the catheter.
Make a small incision in the skin using the scalpel.
Grasp the catheter needle ~10cm above the distal end and, with firm but controlled pressure, push the needle through the abdominal wall to ~3.5–4cm deep, aspirating with the syringe.
Disengage needle from the catheter hub and advance catheter until the suture disc is flat against the skin, then withdraw the needle.
Connect adaptor-clamp to the catheter hub and securely attach the rubber portion of the clamp into a standard drainage catheter bag.
Secure the catheter to the abdomen using a suitable adhesive dressing.
Ensure the clamp is open to allow fluid to drain.
Procedure tips
Avoid any scars or engorged veins to minimize complications
Low-grade coagulopathy is common in cirrhotic patients and fresh frozen plasma and platelets is not routinely recommended; seek advice.
Fluid leak can be minimized by the z track technique, moving the skin and subcutaneous tissue during insertion of drain, creating a zigzag path.
If no aspirate is obtained despite multiple attempts, liaise with radiology and request an ultrasound and marking of a suitable site for aspiration. Alternatively, ask the radiology department to insert the drain under ultrasound guidance.
Documentation
Date, time, indication, informed consent obtained.
Type and amount of local anaesthetic used.
Site of drain.
Aseptic technique used?
How many passes?
Volume and colour of fluid obtained.
Any immediate complications.
Document the required albumin replacement (if appropriate) and when the catheter should be clamped.
Signature, printed name, and contact details.
Sengstaken–Blakemore tube insertion
This should be performed only by senior medical staff in close liaison with an anaesthetist and, ideally, with endotracheal intubation especially in agitated patients and those with hepatic encephalopathy.
The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. Perform nasogastric lavage and stomach evacuation prior to procedure.
Indications
Life-threatening variceal bleeding where facilities for endoscopy are not available or pending endoscopic therapy.
Life-threatening variceal bleeding where other modalities to control bleeding have failed.
Contraindications
Variceal bleeding has ceased or significantly slowed.
Recent surgery to the gastro-oesophageal junction.
Known oesophageal stricture(s).
Risks
Mucosal necrosis due to inadvertent traction.
Oesophageal perforation. This may be due to a gastric balloon being inflated within the oesophagus or can occur secondary to over- or prolonged-inflation of the oesophageal balloon.
Aspiration of fluid into the respiratory tract.
Asphyxiation due to superior migration of the tube and balloons. See last ‘procedure tip’ below.
Equipment
Gloves, gown, and goggles.
Saline flush.
2 x 50ml syringe.
Local anaesthetic spray.
Sengstaken–Blakemore tube (usually kept in refrigerator to increase its stiffness).
Lubricant jelly (e.g. Aquagel®).
Basin with sterile water.
Suction equipment.
Sphygmomanometer for pressure monitoring.
Procedure
Introduce yourself, confirm the patient’s identity, explain the procedure to the patient, and obtain informed consent.
Position the patient at 45 degrees.
Administer anaesthetic throat spray to the oropharynx.
Check the balloons in the tube for air leak by inflating them with an air-filled syringe and immersing in a basin of water. Air leak is indicated by air bubbles appearing.
Deflate the balloons.
Apply lubricant over the tip of the tube and advance it through the oral cavity slowly until it crosses the gastro-oesophageal junction.
The GOJ is generally 38–42cm from the nostril so advancement of the tube 55–60cm usually positions the tip within the stomach.
Withdraw if the patient becomes breathless.
Inflate the gastric (not oesophageal) balloon with 50ml air.
At this stage an abdominal radiograph may be performed to confirm the position of the tube in the stomach.
Once position is confirmed, inflate the gastric balloon to a total volume of 250ml air.
Pull gently on the tube until resistance is felt.
Secure with tape near the mouth with gauze pads, maintaining traction and tie the tube to a 500ml bag of saline. A pulley (e.g. a drip stand) is helpful in maintaining traction.
Mark the tube near the mouth which will serve as an indicator to whether the tube has migrated later.
Flush the gastric port with normal saline and aspirate at frequent intervals until it is clear, which indicates that bleeding has ceased.
If bleeding continues, inflate the oesophageal balloon with 40ml air and monitor the pressures using the sphygmomanometer frequently.
After 12 hours’ traction, relax the tension and push the tube into the stomach. If there is evidence of further bleeding, the gastric balloon can be re-inflated and traction re-applied with a view to repeat therapeutic endoscopy.
During extubation (usually after 10–12 hours depending on clinical condition), deflate the gastric balloon first then the oesophageal balloon and withdraw the tube slowly.
Procedure tips
The tube can be used as a measure to control bleeding for about 12–18 hours. It should not be left in place for more than 24 hours.
Frequent aspirations from the gastric port are needed to assess the status of bleeding.
The tube has to remain in traction at the gastric balloon which will decompress the varices. However, direct pressure from the tube can cause mucosal ulceration. Examine frequently to ensure that excessive force is not being exerted.
If the balloons migrate superiorly, airway obstruction may occur. In this instance, as an emergency measure, the tube can be quickly cut with a pair of scissors and removed. Keep a pair of scissors handy.
Documentation
Date, time, indication, informed consent obtained.
Those present, including anaesthetic support.
How many passes?
Volume balloon inflated to and level of tube insertion.
Any immediate complications.
Signature, printed name, and contact details.
Basic interrupted suturing
Many suturing techniques exist. The following is the most commonly used ‘interrupted suture’.
Contraindications
Bites.
Contaminated wounds.
Risks
Infection, bleeding, scar (including keloid scars).
Equipment
Suture (use cutting 3/8 or 1/2 circle needle for skin).
Needle holder.
Forceps.
Toothed for handling skin; non-toothed for other tissues.
Scissors.
Antiseptic solutions, drapes, sterile gloves.
Dressing.
Procedure: placing the suture
Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent.
Position the patient comfortably such that the wound is exposed. Clean and drape the area to be sutured.
Mount the needle in the needle holder approximately 3/4 of the way from the point.
Start suturing in the middle of the wound to ensure skin edges match up.
Grasp the skin edge and support it with the forceps.
Pass the suture through the skin at a 90° vertical angle and approximately 0.5cm from the skin edge.
Rotate your wrist and follow the contour of the needle until the needle point is visible in the wound.
Support the needle tip with the forceps and withdraw it from the wound.
Remount the needle in the needle holder.
Support the other edge of the wound with the forceps.
Pass the needle horizontally into the skin edge. Aim to insert the needle at the same depth from the skin’s surface as the needle emerged on the other side.
Rotate your wrist until the needle is seen at the skin surface. Aim to pass the suture 0.5cm from the wound edge.
Ensure the entry and exit points are directly opposite each other to prevent distortion of the wound when the suture is tied.
Support the needle with the forceps and withdraw it through the skin.
Tie the suture (instructions follow).
Cut suture ends with scissors leaving 0.5cm behind.
This allows it to be grasped when removing.
Repeat the process proximal and distal to the first suture until the wound is closed.
Cover with absorbable dressing.
Give advice on signs of infection, wound care, and when sutures should be removed.
Procedure: tying the suture (instrument tie)
Pull the suture through until a 2–3cm ‘tail’ remains.
Place the needle down at a safe site.
Grasp the exiting suture (attached to the needle) with your non-dominant hand.
Hold the needle holders (closed) in your dominant hand.
Loop the suture twice around the needle holder.
Without letting the loops slip, open the needle holder and use the tip to grasp the end of the suture ‘tail’.
Move your hands in opposite directions such that the loops slip off the jaws and around the suture.
Snug the knot down and tighten it.
Repeat the knot but wrap a single loop around the jaws of the needle holder in the opposite direction to previously.
Tighten the suture.
Pull the suture through the wound so the knot lies to one side of wound.
Repeat until 3 knots are tied.
Documentation
Date, time, indication, informed consent obtained.
Anaesthetic used?
Suture used.
Number of sutures.
Dressing.
Advice given on wound care and follow-up to patient.
Signature, printed name, and contact details.
Cleaning an open wound
The treatment of open wounds depends on:
Depth and area.
Contamination.
Tissue loss (e.g. vascular, tendon, or nerve damage).
Other (open fractures or joints, compartment syndrome).
Contraindications
Major injuries: vascular compromise, tendon rupture, nerve injury, open factures, or joints. These require senior and/or specialist advice.
Risks
Infection, failure to decontaminate wound.
Haemorrhage, scar, further surgery.
Equipment
Anaesthetic (local or general).
Gloves, mask and eye protection.
2 x kidney dish (1 for cleaning solutions, 1 to collect used wash).
50ml syringe.
Swabs.
Forceps, scalpel, scissors.
Normal saline or antiseptic solution.
Sterile drapes.
Procedure
Wound cleaning
Swab for microbiology if visibly contaminated or history suggestive.
Clean wound with copious amounts of normal saline and/or water-based antiseptics using syringe.
Clean wound with swabs from the centre outwards.
Do not use high-pressure irrigation (can push debris deeper).
Inspection and removal of gross contamination
Photograph wound with adjacent ruler to document size.
Look for gross contamination and remove with forceps.
Deep palpation
Methodically check each area visually and with deep palpation to avoid missing contaminants and tissue injuries.
Use forceps and wound retraction to examine all areas.
Look for any damage to blood vessel, nerves, and tendons.
Move the joints above and below the injury whilst looking at the tendon as it moves. Tendon injuries are easily missed if the wound was incurred in a different position to the resting state (e.g. clenched fist).
If deep tracts are palpated, the wound may need to be extended into the skin above it to allow adequate drainage.
Excision of dead tissue
Cut away any dead tissue until healthy tissue is visible.
Maintaining drainage
Any cavity must be adequately drained.
Siting a drain:
Identify the most dependent part of the cavity
Use artery forceps to identify the depth of the tract
With scissors, taper and cut a corrugated drain to fit into the tract
Pass the tip of the forceps from the tract base so they can be seen at the skin surface
Make an incision over the forceps to allow the drain to be sited
Grasp the tip of the drain with the forceps and ease into the wound
To stop the drain dislodging, a loose suture can be placed into the skin and either around the drain or sutured through one of its corrugations. (This depends on the type of drain used.)
Finally, wash the wound with antiseptic solution.
A pack can be used to keep small tracts open and allow drainage.
A loose suture can be placed to keep the pack in place.
Contaminated wounds and bites should not be sutured closed.
Dressing
A non-stick dressing should be placed over the wound and edges, followed by gauze and bandage or tape.
Further wound inspection and debridement is required at 48–96 hrs.
Examine sooner in heavily contaminated wounds.
Procedure tips
Instead of a syringe, a normal saline bag and giving set can be used.
For finger lacerations, a digital nerve block provides good analgesia.
Don’t use adrenaline as this can infarct the digit!
In an ATLS scenario, open wounds should be photographed and covered with an antiseptic-soaked dressing and bandage. The photograph will allow wound inspection by others, without the need to remove bandages and contaminate the wound further.
Always x-ray glass and metal wounds.
Small superficial wounds with no evidence of contamination on inspection can be closed with interrupted non-absorbable sutures.
Patients need to be given information on wound care, signs of infection and when the sutures should be removed.
Superficial face and head wounds can be closed with skin glue.
In some centres, facial wounds are only sutured by maxillo-facial specialists to improve cosmetic results. Check your local policy.
Documentation
Time, date, mechanism of injury.
Vaccination status.
Sensation and pulses.
Analgesia.
Draw diagram of wound site and inspection findings.
How much wash was used?
If sutured, which suture and when should it be taken out?
Printed name, signature, and contact details.
Applying a backslab
Plaster backslabs are used as immediate splints for fractures until definitive treatment is performed and are also used to protect the fracture fixation post-surgery.
Equipment
Stockinette.
Padding (10cm × 1 roll = above or below elbow backslab, 15cm x 2 rolls = below knee backslab).
Plaster of Paris bandages.
Bowl or bucket of water (lukewarm, 25–35°C).
Crêpe bandage.
Scissors.
Risks
Circulatory and nerve impairment, compartment syndrome, pressure sores, joint stiffness.
Procedure tips
Backslab application is a 2-person procedure.
Ensure the plaster fits well. A loosely applied cast will not provide adequate splintage and can rub, causing soreness.
Ensure the plaster does not cause constriction. In the early stages following fractures, the limb may swell, further restricting blood and nervous supply to the limb.
Ensure bony prominences are adequately padded.
Documentation
Date, time, indication, informed consent obtained.
Neurovascular status of limb.
Procedure performed.
Plan of further management.
Patient given instructions to contact staff if develops increasing pain, if extremities change colour (e.g. become blue), or develops ‘pins and needles’ or numbness.
Signature, printed name, and contact details.
Procedure: below knee backslab
Used for fractures/dislocations at the ankle and fractures of the foot.
Use a padded knee rest if available to hold the knee at an angle of 10–15°.
Hold the ankle at 90° with the foot in a neutral position.
Cut a length of the stockinette from just below the knee to the toes and apply onto the patient.
Apply a layer of padding over the stockinette.
The padding should extend from just below the knee to the toes
Start the padding from one end, rolling it around the limb evenly, overlapping half of the previous turn each time.
Measure a slab of 10 layers of 15cm plaster of Paris from just below the back of the knee down to the base of the toes.
Fold the plaster slab and dip it into the water holding the ends.
Remove the plaster from the water, squeeze gently, and straighten it out.
Fan out the upper end of the slab to fit the calf area.
Place from just below the knee along the posterior surface of the lower leg, underneath the heel, and down to the base of the toes.
Mould and smooth the plaster to fit the contours of the leg with the palms of your hands.
Cut two side slabs 10x20cm long (length dependent on size of patient) made from 6 layers of plaster.
Dip these in water and apply either side of the ankle joint.
A U-slab may be used instead of the side slabs. A 10cm wide U-slab (made of 6 layers of plaster) should be applied down one side of the leg under the heel of the foot and up the other side. Great care must be taken not to let the slabs overlap anteriorly.
Finally, turn the stockinette back over the top and bottom edges of the plaster.
Procedure: below elbow backslab
Used for fractures/dislocations at the forearm (including Colles-type injuries) and fractures of the hand.
Cut a length of the stockinette from just below the elbow to the knuckles, cut a small hole for the thumb.
Apply the stockinette to the patient.
Apply a layer of padding over the stockinette.
The padding should extend from the elbow to the knuckles of the back of the hand and showing the palmar crease, allowing flexion of the fingers
The thumb should be completely free
Start the padding from one end, rolling it around the limb evenly and overlapping half of the previous turn each time.
Cut a length of plaster from below the elbow to the knuckles from a plaster of Paris slab dispenser 15 or 20cm wide (dependent on size of patient), or by forming a slab from 15 or 20cm plaster of Paris bandage using 5 layers.
Fold the plaster and dip it into the water holding the ends.
Remove the plaster from the water, squeeze gently, and straighten it out.
Carefully position the slab on the limb over the padding from just below the elbow, down the dorsal surface of the limb to the knuckles.
Mould and smooth the plaster to fit the contours of the forearm with the palms of your hands.
Turn the stockinette back over the edge of the plaster cast at either end.
Finally, apply the roll of crêpe bandage over the plaster and the overturned stockinette to hold the plaster in place as it sets.
Procedure: above elbow backslab
Used for fractures/dislocations at the forearm and elbow, also supracondylar fractures of the humerus.
Place the limb in a position of 90° flexion at the elbow.
Cut a length of the stockinette from the axilla to the knuckles of the hand, cut a small hole for the thumb.
Apply the stockinette to the patient.
Apply a layer of padding over the stockinette.
The padding should extend from the axilla to the knuckles of the back of the hand and showing the palmar crease, allowing finger flexion
The thumb should be completely free
Start the padding from one end, rolling it around the limb evenly and overlapping half of the previous turn each time.
Prepare a 10 or 15cm plaster of Paris slab (dependent on patient size), using 5 layers. The slab should be long enough to extend from the axilla to the knuckles of the hand.
Fold the plaster and dip it into the water holding the ends.
Remove the plaster from the water, squeeze gently, and straighten it out.
Carefully position the slab on the limb over the padding running down the posterior surface of the limb over the back of the elbow.
Mould and smooth the plaster to fit the contours of the forearm with the palms of your hands.
Prepare two 10cm-wide slabs of five layers of 25cm length (adjust length according to size of patient). Place these on each side of the elbow joint to reinforce it.
Turn the stockinette back over the edge of the plaster cast at either end.
Finally, apply the roll of crêpe bandage over the plaster and the overturned stockinette to hold the plaster in place as it sets.
Manual handling
Assisting a patient to stand
Moderate assistance is required from the patient.
Procedure
Before beginning the procedure, ensure the patient has been assessed as able to weight-bear.
Ensure the immediate area is clutter free.
Ensure the patient has full understanding of the manoeuvre, and what is expected of them.
Encourage the patient to move forward in the chair.
Stand at the side of the chair, slightly behind the patient.
Ensure the patient, and any other staff, are aware of which command to respond to, e.g. ‘ready, steady, stand’.
With one hand, place your arm nearest the patient around the patient’s lower back, reaching as long and as low as is comfortable.
Place the other hand at the front of the patient’s shoulder.
On the ‘stand’ command, as the patient rises from the chair, move your position forward such that you are standing next to the patient when upright, to aid their balance.
Get the patient to help as much as possible during the manoeuvre e.g. pushing down on the arms of the chair if available.
If the patient is unsteady and unable to complete the manoeuvre, gently lower the patient back into the chair and re-assess the situation.
Procedure tips
This procedure is only possible with cooperative patients who are able to weight-bear, and are able to understand basic commands.
This can be carried out with 1 or 2 people, dependent on the patient.
Allow sufficient time, so that the patient understands the process.
It is important to encourage the patient’s independence; ask them how they would carry out this manoeuvre at home.
Include the patient in all decision making about the procedure e.g. they may feel comfortable using a Zimmer frame or similar walking aid.
Check bed area for any furniture/equipment that could be moved to allow more space to complete the manoeuvre.
Always check that intravenous fluids, catheters, drains, and other devices are safe and not likely to be pulled out during the procedure.
Check with staff whether the patient has any history of cognitive problems, violence, or aggression or has any health problems which may prevent or impact upon the manoeuvre.
Documentation
All patients should have had a moving/handling assessment completed by a physiotherapist in the first 24 hours after admission.
Any issues raised following the move should be documented in notes.
Full assessment should be completed prior to each move if the patient’s condition has changed.
Assisting a patient to roll whilst lying
Equipment
1 (or 2) members of staff.
Procedure
Ensure the bed/trolley is at waist height and that the brakes are on, to avoid staff injuries.
If the manoeuvre is being carried out with 1 member of staff, always roll the patient towards you.
If 2 members of staff are available, they should stand either side of the bed/trolley.
Ensure adequate explanation is given to the patient.
Ensure the patient’s head is facing the way the patient will be moving.
Place the patient’s distant arm across their chest, and flex their distant hip and knee.
Place an open-palmed hand on the patient’s shoulder, and your other hand on the patient’s hip or knee.
Staff may find it more comfortable to put one of their knees on the bed, to avoid stretching or bending.
On the command ‘ready, steady, roll’, move back slightly, aiding the patient to roll towards you.
Once the patient is on their side, they can be made comfortable with pillows.
It is also important to ensure the patient is secure, by making use of bedrails.
Procedure tips
Before carrying out the procedure ensure the area around the bed/trolley is clear of any obstacles.
Ensure there is adequate space on the bed/trolley for the patient to roll onto.
It is important to have the correct number of staff available to carry out the manoeuvre.
Do not rush and leave enough time to explain the procedure to the patient and other members of staff involved.
It is important to have assessed the patient prior to carrying out this technique, to discover any contraindications to the patient lying on their side (e.g. problems with the patient’s head and neck control, or any potential difficulties such as the patient’s size).
Documentation
All patients should have assessments carried out within 24 hours of admission. Care plan to be maintained/consulted as appropriate.
Any issues or problems with manoeuvre should be documented in the notes.
Assisting a patient to change position in bed (using a glide sheet)
Equipment
Single-patient use multi-directional slide sheet/glide sheet.
Minimum of two staff.
Procedure
Ensure patient is aware of the procedure and has given consent, if able.
Patient should be lying flat in bed.
Discuss desired end position of patient with the other handler(s).
Move the bed to waist height to prevent staff injuries.
Ensure the brakes on bed are secure.
Staff should stand either side of the bed facing each other.
To place glide sheet under patient, roll patient on bed sheet over to one side of the bed. Either:
One staff member leans over patient and pulls the bottom sheet to roll patient onto one side
Or, if possible, encourage the patient to roll themselves onto one side.
The handler nearest the patient should hold sheet (and patient on their side) whilst the glide sheet is inserted by the other handler.
Place the glide sheet between mattress and bottom sheet.
The second handler should hold the glide sheet and push as far as possible under bottom sheet and the patient rolls back onto their back.
Repeat from the other side until glide sheet is fully under the patient.
Once the sheet is in place, agree which handler will give commands.
Both handlers should grip the bed sheet, with both hands, as close to patient as possible. Place both feet firmly on the floor.
On command of ‘ready, steady, move’, both handlers grip bottom sheet and gently move patient to previously agreed position.
Place pillows appropriately for the patient’s revised position.
Reverse patient movement procedure to remove glide sheet.
Procedure tips
Do not rush. Ensure sufficient time available to explain the manoeuvre to the patient and safely complete the manoeuvre.
Check bed area for any furniture/equipment that could be moved to allow more space to complete the manoeuvre.
Always check that intravenous fluids, catheters, drains, and other devices are safe and not likely to be pulled out during procedure.
Check with staff whether the patient has any history of cognitive problems, violence, or aggression or has any health problems which may prevent or impact upon the manoeuvre.
Ensure bedrails are put back into place following procedure.
Documentation
All patients should have assessments carried out within 24 hours of admission and placed in their file.
Any issues or concerns should be documented in the patient’s notes to ensure other ward staff are aware of problems.
Transferring a patient laterally using a transfer board
Use to transfer patients who are unable to move themselves.
Equipment
Patient transfer board or ‘Patslide®’.
Procedure
There should be at least three handlers.
Open transfer board (if folded) and place on bed/trolley you plan to transfer patient to.
Explain the manoeuvre to the patient.
Place destination bed/trolley alongside origin bed/trolley.
Ensure there is only a minimal gap between the bed/trolley.
Check bed is at waist height to prevent staff injuries.
Staff stand either side of bed/trolley facing each other, two people on the ‘destination’ side and one on the other.
Check brakes on bed and trolley secure.
Staff at the patient’s bedside to lean over patient and grip bed sheet as close to the patient’s body as possible in both hands and roll the patient towards them.
Staff at the bed/trolley onto which patient is to be transferred, put transfer board onto patient’s bed/trolley.
Staff at bedside allow patient to roll back onto board (which should be under the bed sheet).
On command of ‘ready, steady, move’....
Handlers push and pull patient gently across on transfer board, dependent upon their position.
Staff should ensure their arms remain straight and they do not lean forward, bending at the waist.
Once patient is transferred, ensure sheets/blankets are replaced.
Bedrails should be put into place as appropriate.
Procedure tips
Ensure time is available to safely complete the manoeuvre.
Check bed area for any furniture/equipment that could be moved.
Always check IV fluids, catheters, drains, etc. are safe and unlikely to be caught or pulled out during procedure.
Move any attachments onto transferring bed/trolley prior to the move.
Check with qualified staff/physiotherapists regarding any changes in the patient’s condition prior to manoeuvre.
Staff should wear suitable footwear and non-restrictive clothing.
Check with ward staff that patient can be laid flat.
If NG-fed, ensure it is switched off to prevent patient aspirating.
Do not climb onto the bed/trolley.
Ensure both surfaces are the same height, making the manoeuvre both easier and more comfortable for the patient.
Documentation
Any issues or problems with equipment or manoeuvre should be conveyed to the nurse in charge, documented in the notes, and an appropriate incident form completed.
Transferring a patient using a hoist
Limited input from patient. Use this technique to transfer patients who are unable to weight-bear, sit patients up in the bed, or use a bedpan.
Equipment
Hoist.
Sling: single patient use (disposable).
Procedure
There should be at least two handlers.
Check care plan regarding patient’s suitability for hoist usage
Before getting equipment, ensure manoeuvre is explained to patient.
Select appropriate sling: small, medium, or large.
Ensure hoist and sling are compatible.
Check hoist is able to take patient’s weight: most are able to take up to 25 stones (170kg).
Check bed is at waist height to prevent staff injuries.
Staff stand either side of bed facing each other.
Check brakes on bed secure.
Patient should be rolled to one side of bed.
Lay the hoist sling on the bed.
Roll the patient to other side of the bed.
Sling should now be in a position from patient’s head to thigh.
Place the loops at shoulder end of sling on arm of hoist.
Pass the thigh-end loops through each other, then place on hoist.
Ensure the loops are correctly positioned before moving.
One handler should now manage the controls of the hoist.
Second handler lowers patient’s bed, then moves behind the patient/hoist, ready to guide them into the chair.
Move patient back with hoist.
Second handler gently guides patient into the chair.
Once patient is in chair, disconnect loops from hoist.
Remove sling from beneath lower legs of patient.
Procedure tips
Ensure sufficient time available to safely complete the manoeuvre.
Check bed area for any furniture/equipment that could be moved.
Always check items such as IV fluids, catheters, and drains are safe and unlikely to be caught in hoist or pulled out during procedure.
Check with qualified staff/physiotherapists regarding any changes in the patient’s condition prior to manoeuvre. Transfer may be inadvisable.
Staff should wear suitable footwear and non-restrictive clothing.
Hoist should only be used to transfer patients short distances.
Ensure hoist is fully charged before commencing manoeuvre.
Ensure the brakes of the hoist are ‘off’. This will allow the hoist to find its own centre of gravity.
Documentation
Any issues with equipment or manoeuvre—advise nurse in charge and document in notes and complete an appropriate incident form.
Transferring a patient using a log roll
Use this technique to transfer patients in whom a cervical spine injury is suspected or confirmed. The following assumes that the patient’s neck is immobilized in a brace or blocks.
Equipment
Minimum five members of staff.
Patient transfer board or ‘Patslide®’.
Procedure
The most senior member of the team should take charge of the patient’s head and neck and initiate commands.
Ensure adequate explanation is given to the patient, and to all members of staff involved.
Place destination bed alongside origin bed at waist height.
One member of staff should position themselves at the head end of the patient, the other three should be spread alongside the patient, at the origin side. The final member of staff should be at the destination.
Check brakes on bed secure.
The person responsible for the patient’s head should have one hand either side of the patient’s head, supporting the patient’s shoulders.
The person responsible for the patient’s upper body should have one hand on the patient’s distant shoulder, and the other on the lateral aspect of the patient’s chest.
The person responsible for the patient’s pelvis should have one hand on the lateral aspect of the pelvis and the other under the thigh.
The person responsible for the patient’s lower legs should have both hands under the calves.
On the command ‘ready, steady, roll’ the three members of staff at the side of the patient will slowly move backwards with straight arms, rolling the patient towards them.
Staff at the bed/trolley onto which patient is to be transferred, put transfer board onto patient’s bed/trolley.
On the command ‘ready, steady, roll’ the four members of staff at the side of the patient roll the patient back flat, keeping the neck straight.
One member of staff should now move around the bed such that there are two on each side and one at the head.
On the command of ‘ready, steady, move’, handlers move the patient gently across keeping the head and neck immobilized.
Procedure tips
Ensure sufficient time available to safely complete the manoeuvre.
Check bed area for any furniture/equipment that could be moved.
Staff should wear suitable footwear and non-restrictive clothing.
It is essential that the patient’s body be kept in alignment, and the manoeuvre is carried out in one smooth and controlled movement.
Documentation
Any issues with equipment or manoeuvre, advise nurse in charge and document in notes and complete an appropriate incident form.
Aiding a falling patient
It is essential that if a patient falls, the member of staff must not try to catch the patient, but must allow them to fall, as there is no safe method for this situation.
Allowing the patient to fall may feel contrary to the staff’s natural instincts to help but trying to catch a patient will only result in injury to staff.
Instead, every attempt must be made to reduce injury to the patient (e.g. moving objects out of the patient’s way if possible).
Falling in a forward direction
If a member of staff is walking with a patient as they fall in a forward direction, the member of staff must allow the patient to fall.
Falling towards a member of staff
If the fall is towards the member of staff, it may be possible to control the patient’s movements safely to minimize injury to them.
The member of staff should move close to the patient, standing directly behind them with their leg closest to the patient flexed. Then they should gently guide the patient’s body down their flexed leg to the floor.
Procedure tips
The risk of falling should be minimized by only performing tasks appropriate to the patient’s ability (e.g. only allow patients to walk if they are fully mobile).
Use equipment to reduce the risk of falls i.e. Zimmer frames or walking sticks.
A patient falling is an unpredictable and sudden event. However, the member of staff should take every care to maintain a good posture at all times, avoiding twisting or stretching.
If present when a patient falls, the member of staff should immediately call for assistance, to ensure an adequate number of staff are present if the situation turns into an emergency.
Documentation
All patients should have assessments carried out within 24 hours of admission and placed in their file.
Any fall or issues should be documented in the patient’s notes to ensure other ward staff are aware of problems.
Aiding a fallen patient
It is important to assess the fallen patient immediately, to establish the cause for the fall and any immediate consequences (e.g. fainting, fractures, or cardiac arrest) so that staff can respond to the situation accordingly.
Equipment
Minimum of two members of staff.
Other equipment dependent on circumstances:
Two chairs, trolley, slide sheets, hoist with appropriate sling.
Procedure: if patient is cooperative
Instructions may be given to help the patient up from the floor. Ask the patient to follow this routine:
Roll onto their side ...
Push up on their hands until they are in a sitting position ...
Bend their knees up and move onto all fours ...
Place their hands onto the seat of a chair for balance ...
Move one leg forward, so they are in a half-kneeling position ...
At this point, the patient should be able to push with their hands to stand up, and sit on a chair placed behind them.
If needed, the patient can now be hoisted onto a trolley for further assessment.
Procedure: if patient is uncooperative
A hoist should be used.
Procedure: if fallen in a confined space
Place a slide sheet under their body.
With a minimum of two members of staff, the patient can then be slid on the floor a short distance to allow better access to assist the patient.
It is essential that the members of staff maintain a good posture at all times during this procedure.
Procedure tips
It is essential to establish the cause of the fall and act accordingly.
It is important that, as the patient is moving up from the floor, their condition is continuously monitored.
If the patient has fainted, they may be at risk of falling again.
It is important to allow the patient time to carry out the manoeuvre, as this will reduce the amount of manual assistance required from staff.
It is extremely important that the patient is NEVER LIFTED.
Lifting a patient is hazardous and may result in staff injury.
