On this next episode of "useful things that RN Minh taught me", let's go over some neat tricks to effectively using our patient monitors!
Specifically,
How to change the screen layout to display big numbers
Show a 12 lead ECG
Turn on the volume (so one can hear the changes in changing vitals)
Change the alarm ranges
Welcome to one-of-maybe-more series of pearls based off my pet peeves.
Tim’s Pet Peeves Pearls
Magnificent.
Anyways as many of our residents know, central lines placed in the emergency department are frequently changed shortly after transfer to the ICU out of concern that lines were not placed under sterile technique. Not an ideal situation, as repeat catheter placement results in additional risk and discomfort to the patient.
A year ago I asked one of our (now graduated) ICU fellows about this practice, and he mentioned that when he sees an improperly dressed central line (e.g. dressing partially falling off, not completely sealed), he feels obligated to change the line as it seems less clear whether or not that line was placed under sterile technique and has remained sterile.
While lines may still be exchanged regardless once patients have left our care, we should learn how to best dress and maintain sterility on our central lines. Let’s prevent those catheter-related bloodstream infections!
The lesson today was taught to me a couple years ago by our fabulous resus nurse Minh Duong.
Huzzah, you nailed your central line. Fantastic! Sutured down and everything. Now while you still have your sterile gown and mask on, you open your central line dressing kit. Inside you see a dressing, chlorhexidine swabs, barrier film, and extra PPE.
1. Use your chlorhexidine swabs and clean from inside to outside along the length of the catheter. Clean the line itself!
2. Flip the swab and go back and forth over the surrounding skin.
3. Repeat with the remaining swabs (there are multiple swabs in the kit)
4. Allow the site to dry. No need to fan or blow on the site.
5. Take your Sureprep Protective Wipe and draw a rectangle around the catheter site. The dressing will not stick well to the chlorhexidine, but will stick well to the SurePrep barrier film. This is important to make sure the dressing seals properly.
6. Place the dressing over the catheter so that the chlorhexidine-impregnated gel layer overlies the entrance of the catheter into the skin. Important for preventing those catheter infections!
7. Remove the sides of the dressing and press firmly along the sides to ensure that the dressing lies flat along the skin. For IJs, this often requires pulling a small amount of tension along the skin to have the dressing lay flush against the skin along the curves of the neck.
8. Take the next largest piece of the dressing (from the wings of the initial piece) and place it UNDER the catheter but OVER the dressing to create a closed loop around the catheter. Press firmly so the dressing lies flush against the skin.
9. Take the final thin piece of dressing from the remaining wing and apply it overtop the area where the catheter exits the dressing. Label the final piece with the current date.
If applied properly you now have a sealed dressing around a CVC. Do this properly, take a little extra time and your nurses and ICU will love you. Congrats!
https://www.youtube.com/watch?v=BVZq4WgfzQ4
https://www.youtube.com/watch?v=aMxahVmCR2E
https://www.youtube.com/watch?v=DGL8CzKTgVo
I love taking requests!
EMS’s approach to anaphylaxis in NYC is explained across 4 different documents:
The four protocols all include degrees of overlap, which can make them a confusing read, but I’ll try to simplify it for you all as best I can. Fortunately, the upcoming version of the protocols for 2021 has a brand new formatting style that makes the transition from BLS to ALS levels of care easier to understand, but we’ll get to that in the coming weeks.
The reason why I’m including the relevant BLS protocols this week is because this is a rare occurrence where BLS can actually give an injectable medication and thus may need to call OLMC for its approval. Protocol 410 (BLS) provides background information on anaphylaxis for EMTs and instructions for evaluating whether epinephrine is indicated. If it is, EMTs are allowed by Standing Order to administer a single dose of IM epinephrine, either via a patient’s own auto-injector, the crew’s auto-injector, or a “Check and Inject” kit wherein EMTs draw the epi into clearly marked syringes, eliminating the need for dose calculations. Whether a crew carries auto-injectors or “Check and Inject” kits comes down to their service’s formulary. BLS crews can then contact OLMC in order to provide a second dose of epinephrine, if needed, so don’t be caught off guard if an EMT calls you with that request.
Protocol 510 (ALS) also includes Standing Orders for IM epinephrine (allowing paramedics to draw it up themselves) while additionally including obtaining IV access for fluids, diphenhydramine, and steroids (methylprednisolone or dexamethasone), as well as albuterol and advanced airway management if necessary. Medical Control Options for OLMC include repeating any of the previous SOs as well as various pressor options for persistent hypotension (epinephrine drips are not yet an option, although push-dose epinephrine is).
The key distinctions of Protocol 455 (BLS) and Protocol 555 (ALS) is that they include more specific language for pediatric dosing of epinephrine. BLS is also supposed to call OLMC for approval prior to the first dose of epinephrine for a child if there was not previously a prescription for an epinephrine auto-injector, although if the BLS crew is unable to reach OLMC for some reason, they are permitted to give the dose emergently and reattempt contact with OLMC as soon as possible afterwards.
Hope that didn’t overcomplicate things for you all! Keep reaching out with requests, emailing or texting with questions, and paying your respects to www.nycremsco.org and the protocols binder!
Dave
