Adult emergency trolley 2: equipment to support circulation

Equipment to support circulation during cardiopulmonary respiratory arrest is described in the second of two articles on emergency trolley checks to support adult resuscitation in acute hospitals

This article – the second of two on emergency equipment to support resuscitation of adults during cardiopulmonary arrest in acute hospitals – focuses on equipment and supplies to support circulation. It explores overarching quality standards and checking procedures, before describing circulation equipment, and its function and use during an emergency. The need to maintain the equipment and locate it quickly is emphasised, along with the importance of practitioners operating within their own scope of practice and level of competence, while adhering to local trust policy.

Citation: Cocker S, Whatley L (2023) Adult emergency trolley 2: equipment to support circulation. Nursing Times [online]; 119: 9.

Authors: Sarah Cocker is senior lecturer advanced practice, Lorraine Whatley is senior lecturer simulation and immersive learning technology; both at Oxford Brookes University.

The annual incidence of in-hospital cardiac arrest (IHCA) in the UK is 1.0 to 1.5 per 1,000 hospital admissions (Perkins et al, 2021). Patients will often display clinical signs of deterioration in the hours preceding the event, which is why the Resuscitation Council UK (RCUK) advocates early recognition and calling for help as one of the first links in the chain of survival (RCUK, 2021) (Fig 1).

Early warning score (EWS) systems – such as National Early Warning Score 2 (NEWS2) developed by the Royal College of Physicians – are often used to help nursing staff identify and escalate the deteriorating patient, allowing for interventions to help prevent cardiac arrest. Importantly, nurses will often use clinical judgement and experience to identify factors outside of EWS systems, such as breathing patterns and skin colour, as vital cues in the decision to escalate (Ede et al, 2019).

Should the patient go on to have a cardiac arrest, interventions that can contribute to a successful outcome are:

Reasons for cardiac arrest are often complex but, sometimes, a reversible cause can be identified, and early recognition and escalation for management increases the chances of a positive outcome for the patient. Nurses should recognise the need to seek help early from specialist resuscitation teams, who can provide advanced life support to patients in cardiac arrest.

Alongside early recognition and escalation, ensuring the availability, and staff knowledge of, key resuscitation equipment to support circulation is essential to providing timely and effective life support. Nurses should familiarise themselves with resuscitation equipment in their clinical environment as this may save time during an emergency.

Resuscitation education and training is a statutory mandatory requirement for health staff, to give them the necessary knowledge and skills to provide appropriate life support to their patients (Nursing and Midwifery Council, 2018). Nurses should ensure they maintain competence in resuscitation, which is appropriate to their role, by undertaking regular updates in line with professional regulations, national guidance and local trust policy. They must also be aware of the importance of ensuring their own personal safety (as well as that of other staff and patients) during a cardiac arrest, and adhering to national and local guidance on infection control procedures and personal protective equipment (PPE) during their practice.

This article is a guide to the emergency equipment and supplies needed to support resuscitation of adults during cardiopulmonary arrest in acute hospitals, with a focus on circulation. It includes items that should be on the emergency trolley or easily accessible in your clinical area, along with information on their function and use.

Defibrillation means applying an electrical current across the chest wall that passes through the myocardium. It is achieved using a defibrillator device (Benson-Clarke, 2022). After cardiac arrest, early defibrillation for ventricular fibrillation and pulseless ventricular tachycardia, complemented by immediate uninterrupted early bystander CPR, will help improve survival (RCUK, 2021). A defibrillator should be immediately available in acute care settings (RCUK, 2023) and will often reside on the top of the resuscitation trolley. The type of defibrillator available will depend on a local risk assessment and be one of the following:

Automated external defibrillatorDefibrillators with automated rhythm recognition, commonly known as AEDs, are often placed in clinical and non-clinical areas where staff do not have rhythm interpretation skills. Public-access devices are also now commonly found in the community, such as in supermarkets, sports centres, train stations and village halls, so lay rescuers can use them quickly in an emergency. AEDs will often use both visual and voice prompts to help health professionals and lay rescuers attempt defibrillation safely when a person is in cardiac arrest (RCUK, 2021).

The AED must be turned on and used with compatible defibrillator pads/electrodes. The device will provide verbal instructions to the responder and assess whether defibrillation is appropriate for the patient. Training and orientation in the AED in your clinical area will be via your mandatory resuscitation training.

Manual defibrillator/multifunction deviceIn certain areas, patients may have a higher risk of cardiac arrest requiring the availability of a manual defibrillator with or without a pacing function. A manual defibrillator differs from an AED in that it is the operator who interprets the rhythm and identifies whether a shock is needed – this is a skill that requires additional training. Local policy may determine who can deliver manual defibrillation in this way, but it is often a skill possessed by members of the resuscitation team.

The manual defibrillator optimises the provision of chest compressions by enabling the defibrillator to be charged while chest compressions are being delivered (RCUK, 2021).

Manual defibrillators are also sometimes known as multifunction devices, as they can often do many other things as well as manual defibrillation. Most models can also be used in AED mode to enable first responders without rhythm interpretation skills to deliver a shock safely during the first few minutes of a cardiac arrest.

Some devices also have the capability to monitor vital signs – such as blood pressure, oxygen saturations, electrocardiogram (ECG) and carbon dioxide waveform capnography – allowing close monitoring of peri-arrest or post-arrest patients. Certain machines can also provide external pacing and cardioversion if required. This may be appropriate in certain areas, such as cardiac units, emergency departments and intensive care units (RCUK, 2023). External pacing and cardioversion are advanced skills that require individuals to have additional education and training if they are to be competent to deliver them.

Defibrillator pads (Fig 4) are applied to the patient’s bare chest and transmit the electrical energy from the defibrillator via connector cables through the chest and across the heart. They are usually available in two sizes: child and adult. Pad size in children depends on the child’s weight (Hucker and Lawson-Wood, 2023) with larger children sometimes requiring adult pads, so it is important that staff in paediatric or dual areas know which pads to use.

Defibrillation pad applicationThe pads should be applied to clean, dry and hairless skin. This may mean preparing the chest first to ensure good contact. Excess chest hair will give poor contact that results in poor energy transfer, so can be clipped or shaved off. However, it is better to try to avoid shaving to minimise infection risk should the skin be grazed (Carvalho et al, 2020). The better the pad application, the better the energy transfer so, provided chest compressions are occurring simultaneously, practitioners should take time when applying the pads to make sure contact is optimised. It is worth noting that the pads are extremely sticky.

There must be no jewellery under the pad placement as this will deviate the path of the electrical energy. Necklaces should be moved away from the chest but, as upper-body piercings can be difficult to remove quickly, practitioners should instead place the pad away from the piercing and not directly over it. Acute wounds, burns and dressings should be avoided when placing the pads as they will also impede contact.

Pacemakers and implanted cardioverter devices will also deviate the path of electricity. If you are aware of their existence or can view one of these devices in the chest, place the pad at least 8cm (about a pad’s width) away from it (RCUK, 2021) or use an alternate pad position, such as the anterior-posterior position described below.

Defibrillator pad electrodes cannot be cut and need to be placed at least one pad’s width away from each other. If your patient has a very small chest, again you may need to consider alternative pad placement, such as the anterior-posterior position described below.

The most common pad placement in adults is the anterior-lateral position, in which one pad is applied just below the right clavicle and the other is placed to the lower-left rib cage in the midaxillary line (Fig 5). This ensures the heart is sandwiched between the two pads and directly in the path of transferring energy. Most pads will have images on them to reflect this.

The alternative is the anterior-posterior position. Here, one pad is placed at the front of the chest over the left precordium, then the patient is rolled and the other pad is applied posteriorly in a similar position inferiorly to the left scapula, again sandwiching the heart (Fig 6).

The manual defibrillator pads, as well as delivering a shock, will read and display a cardiac rhythm. However, it is also good practice to apply the three cardiac leads (red, yellow, green) (Fig 7) in a timely fashion as they can provide alternative views of the electrical activity. They are also important in monitoring peri- and post-arrest patients.

A cannula is required for the administration of drugs, fluids and, possibly, blood during resuscitation. A variety of cannulas, tourniquets, adhesive tape and cannula dressings (Fig 8) should be readily available on the resuscitation trolley. If the patient is already cannulated, a second cannula is often useful.

Syringes will need to be repeatedly connected/disconnected and products are administered often throughout the resuscitation process, so an IV extension set (Fig 8) will help to protect the cannula from movement, irritation and contamination at its site of entry.

The selection of IV fluids (Fig 8) should include:

Needles and syringes in various sizes (Fig 8) are needed to administer fluids and drugs.

A pressure bag for infusion (Fig 8) is key to making sure fluids can be administered quickly if urgent prescribed volumes are needed.

A blood–gas syringe is useful when monitoring causes of collapse, as well as response to treatment. Responders should also be aware of the location of the nearest blood–gas analysing machine.

These tubes are needed for investigations into the cause of collapse and to monitor the response to resuscitation.

It can be difficult to cannulate a patient who is critically unwell or in cardiac arrest as their circulation is often very poor and veins can be hard to locate. However, drugs, fluids and medications are often needed urgently. When vascular access cannot be obtained rapidly, an IO access device may be used. The IO needle is inserted through the cortex of a bone (humerus, femur, tibia) into the medulla, which is a well-vascularised area of bone marrow. The needle can be inserted using a handheld drill version of the IO access device (Fig 8) or a spring-loaded IO device. Device operation and insertion of an IO needle is an advanced skill that should be performed:

IO devices may not be located on every trolley, but responders should be able to identify how to readily access them.

Clippers or a razor (Fig 8) are needed to remove any excessive chest hair that will impede pad application. These should be used with care as any trauma (bleeding from wounds) will also impede pad contact.

There is often a clock or timer located in the defibrillator, but this will only start when the defibrillator is switched on. Therefore, a timer or clearly visible clock is useful for noting timings for drug administration, measuring two-minute cycles and documenting events.

Consult your local policy guidance for the most recent requirements about PPE in your clinical area.

This should be readily available and either on, or attached to, the emergency trolley to ensure safety and correct sharps disposal.

Commonly, large scissors (Fig 8) or trauma shears that can can cut through clothing, belts and jewellery in an emergency are provided on the trolley; these are also useful for bandages and dressings. They are blunt tipped, so safer for the patient when used in a hurry.

Drugs labels are vital to support the safe identification and administration of medications in a rapidly changing situation that involves many staff members, and where multiple drugs, products and fluids are administered quickly and often.

These forms may be centrally accessible and available electronically in many clinical areas; contact your resuscitation service for local details and requirements.

Hospitals are encouraged to participate in the national audit into cardiac arrest, jointly run by RCUK and the Intensive Care National Audit and Research Centre. Completion of a DNAR form by a doctor or, in some trusts, a senior nurse may also be an appropriate outcome in some clinical emergency situations.

Although information on these may be available on local electronic systems, access to paper copies of guidelines, emergency protocols and drug doses can be helpful in the high-pressure environment of a resuscitation attempt. All are evidence based so will support safe care delivery.

A central venous access device (Fig 9) is extremely useful in the care of the critically unwell patient, both for monitoring and administering therapies. It may be difficult and unsafe to obtain central venous access during an acute emergency but, once the patient is more stable and the setting more controlled, this may be achieved.

Both ultrasound and echocardiography devices are commonly used for bedside investigations, and may be used in an emergency to identify or rule out causes of deterioration and arrest. The ultrasound device may also be used to help with both central and peripheral vascular access insertion. Such devices can only be operated by staff who are trained and competent in their use and interpretation, but staff in clinical areas may need to facilitate access to these devices.

AdrenalineAdrenaline/epinephrine 1mg at a concentration of 1 in 10,000 (100µg/mL) is recommended via IV injection, repeated every three to five minutes (RCUK, 2021). Adrenaline is a vasopressor, causing vasoconstriction and optimising perfusion to the coronary tissue and other major organs. It also increases heart rate and contractility.

Adrenaline is delivered in shockable and non-shockable arrests. Commonly, it may be available in pre-filled syringes for IV administration in adults. It is important to note that 1:1,000 adrenaline is also available (commonly used for anaphylaxis via intramuscular injection).

Health staff involved in preparing and administering adrenaline in an emergency need to ensure they are:

AmiodaroneAmiodarone 300mg may be given in a ventricular fibrillation or pulseless ventricular tachycardia arrest, so is only given in a shockable arrest. It is administered for refractory rhythms (failure to respond to initial defibrillation) so may be administered after the third shock; a subsequent dose of 150mg may also be administered after the fifth shock.

As amiodarone is an antiarrhythmic drug, it may improve a patient’s response to defibrillation. This is often available for cardiac arrest in a pre-filled syringe.

RCUK (2023) outlines a list of additional drugs that are recommended for use in emergency incidents. These may be too numerous to be included in the resuscitation trolley and are not always needed. However, these additional drugs may be located:

Responders should know how to access these additional drugs.

Recognising the deteriorating patient and escalating care accordingly can allow for interventions to prevent cardiac arrest. However, if cardiac arrest does occur, following the chain of survival and having immediate access to familiar emergency equipment that is well maintained supports the delivery of high-quality resuscitation care for patients.

This article has explored the equipment and supplies that should be available to support circulation in an adult who is acutely ill. It concludes our two-part series on the contents of the adult emergency trolley, and how nurses can use them to support the best resuscitation outcomes.

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

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