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PRACTICE EDUCATOR

Resuscitation trolley contents 2: cardiac arrest equipment to support circulation

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Nurses should know the contents of the cardiac arrest trolley, what each item does and how it should be used, and how often equipment should be checked

Abstract

Cardiac arrest trolleys must be equipped with all the instruments and medication needed to deal with an acute adult cardiac arrest. Nurses must not only be familiar with these contents but also know how to use, check and maintain them. The first part of this two-part series looked at equipment to aid airway and breathing; this second part focuses on circulation. Note that drug doses mentioned here relate to the adult patient and will be different for children.

Citation: Aldridge M, Jevon P (2014) Resuscitation trolley contents 2: cardiac arrest equipment to support circulation. Nursing Times; 110: 31, 17-19.

Authors: Matthew Aldridge is senior lecturer in adult nursing, at the University of Wolverhampton; Phil Jevon is multiprofessional skills manager, medical education at Walsall Healthcare Trust.

Introduction

Cardiac arrest results in the heart being unable to pump oxygenated blood around the body to the vital organs. Delay in the restoration of effective cardiac output can adversely affect the chances of survival and can also result in poor neurological outcomes (Holzer and Behringer, 2005). To maintain some degree of cardiac output, it is imperative cardiopulmonary resuscitation is started as soon as a cardiac arrest is detected, and a defibrillator is obtained without delay.

Defibrillator and pads

Defibrillators (Fig 1) are used to deliver a therapeutic dose of electricity through the chest wall to the myocardium, with the intention of terminating life-threatening arrhythmias such as ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). Designs include fully manual, automated or semi-automated models - the last two being able to ascertain autonomously whether a shock is required.

Some advanced defibrillator models can provide emergency external pacing of the heart for patients with heart block or “p wave” astyole. A defibrillator with pacing capability, if not provided in every area, should be available and accessible in the event of a cardiac arrest. For example, in some hospitals, external pacing units are located only in coronary care units and emergency departments.

Adhesive pads (Fig 2) are the recommended way to deliver shocks. At least two sets should be available on the trolley, including a set that has the capability to allow external pacing to be delivered.

Along with the pads, disposable razors should be provided to remove chest hair that might impede adherence of the pads and conduction of the electricity.

Intravenous cannulas

There should be a range of IV cannula sizes - ideally 14, 16 and 18 gauge - along with chlorhexidine and alcohol preparatory wipes, tourniquets and dressings to secure them.

Intraosseous access device

If IV access is difficult to obtain or delays in obtaining IV access occur during the first two minutes from the point of cardiac arrest, which can often be due to circulatory collapse, intraosseous (IO) access devices (Fig 3) are recommended to establish a route for drug delivery (Resuscitation Council (UK), 2011a). IO involves injecting a needle through the bone into the soft marrow, which allows immediate access to the vascular system. There are two widely available IO devices used in the adult patient:

  • EZ-IO - a hand-held, battery-operated, drill-type device;
  • Bone injection gun, a spring-loaded mechanical device.

The three main insertion sites recommended in adults are the proximal tibia, distal tibia and proximal humerus (Resuscitation Council (UK), 2011a).

IV infusion equipment

The cardiac arrest trolley should contain a range of needles and syringes for drawing up and delivering drugs, along with IV-giving sets, connectors and infusion systems, as per local policy. A pressure bag or pressure infusion system should also be available for the rapid infusion of IV fluids, in case of the need for rapid fluid administration, such as in trauma or haemorrhage.

First-line emergency drugs

Adrenaline

Adrenaline (Fig 4) is the primary drug given in the treatment of cardiac arrest. One in 10,000 (100µg/mL) is recommended in a dose of 1mg (10mL) intravenously or by IO access (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2014). It is given immediately by a competent practitioner to patients who have had a non-shockable (asystole or pulseless electrical activity) cardiac arrest; however, if a patient presents with a shockable rhythm (VF or pulseless VT), adrenaline is given following the third consecutive shock (Resuscitation Council, (UK) 2011b). Once given, it is repeated in the same dose every 3-5 minutes (Resuscitation Council (UK), 2011b).

Adrenaline should be on the cardiac arrest trolley in pre-filled syringes to speed up administration and for ease of preparation. Care should be taken not to confuse 1:10,000 with a 1:1000 dilution - the latter is primarily for intramuscular injection in the treatment of anaphylaxis.

Amiodarone

Amiodarone is an anti-arrhythmic agent, which prolongs the cardiac action potential (BMA and RPSGB, 2014). It is primarily used in the context of cardiac arrest for the treatment of refractory (persistent) VF or pulseless VT and is given along with adrenaline after the third consecutive defibrillatory shock. The emergency dose in cardiac arrest is 300mg (IV/IO) in pre-filled syringes (Resuscitation Council (UK), 2011b) or diluted in 20ml glucose 5% (BMA and RPSGB, 2014).

Other drugs that may be required in peri-arrest and emergency situations but may not be on trolley are listed in Table 1.

Portable ultrasound device

In the hands of a skilled operator, a portable ultrasound device can be used to aid rapid diagnosis of conditions such as cardiac tamponade, pneumothorax and pulmonary embolism (Resuscitation Council (UK), 2011b). If the device is not stored on the trolley, it should be available with minimal delay. However, it is important that other vital elements of resuscitation are not delayed or unnecessarily interrupted while ultrasound is carried out.

Other items that should be on the trolley are outlined in Box 1.

Box 1. Other trolley items

  • Clock or timer for timing resuscitation attempts
  • Central venous access kit
  • Personal protective equipment, for example aprons, gloves, goggles
  • Sharps disposal bin
  • Lubricating jelly to aid insertion of airway devices 
  • Large scissors to remove patients’ clothing in emergency
  • Cardiac arrest recording and audit forms 
  • Laminated cardiac arrest algorithms for reference
  • Oxygen cylinder key (for changing cylinders)
  • Patient handling slide sheets for safe transfer and movement

Checking resuscitation equipment

Pre-use checks

Resuscitation equipment should be checked daily by each ward or department that is responsible for resuscitation (Resuscitation Council (UK), 2013). A system for daily documented checks of the equipment should be in place.

Some cardiac arrest trolleys can be sealed with a numbered seal after being checked, and the number documented by the person who has checked the trolley. The advantage of this system is that an unbroken seal, with the same seal number last recorded, shows that the trolley has not been opened since it was last checked. so the equipment inventory should be complete. A broken seal or an unrecorded seal number suggests the inventory may not be complete, which shows that a complete check is required. The seal can easily be broken if the trolley needs to be opened.

Expiry dates should be checked for items including drugs, fluids, electrocardiogram electrodes and defibrillation pads. Laryngoscopes, including their batteries and bulbs, should also be checked to ensure they are in good working order. Each self-inflating bag should be checked to ensure there are no leaks and the rim of the face mask can be adequately inflated.

The defibrillator should be checked daily, following the manufacturer’s instructions. Most defibrillators need to be plugged into the mains to ensure the battery is fully charged; wall-mounted public access models that incorporate guaranteed fixed term internal batteries do not. It is important to check the defibrillator has been unplugged from the mains before moving the cardiac arrest trolley.

All mechanical equipment, such as defibrillators and suction machines, should be inspected and serviced on a regular basis by the electro-biomedical engineering department, following the manufacturers’ recommendations and local policies.

Post-use checks

Checking resuscitation equipment after use should be a specifically delegated responsibility. As well as the routine checks, used disposable items should be replaced and reusable equipment - such as the stethoscope - should be cleaned in line with local infection-control procedures and manufacturers’ recommendations. Any difficulties with equipment occurring during resuscitation should be documented and reported to the relevant personnel.

Conclusion

This two-part series will assist nurses to perform more effectively during a cardiac arrest and help them with routine checking and maintenance of equipment. 

Key points

  • The contents of the cardiac arrest trolley should be checked every day
  • Each department with a cardiac arrest trolley is responsible for its contents. Practitioners should familiarise themselves with the type and location of emergency equipment in their area
  • Using seals on trolleys shows whether items have been used
  • Equipment should be checked and serviced in line with the manufacturers’ instructions
  • Some items and drugs that do not need to be kept on the trolley may still be useful in peri-arrest and emergency situations
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