EMERGENCY PROCEDURES

● CARDIAC MONITOR
● ET TUBE INSERTION
● MECHANICAL VENTILATORS
CARDIAC MONITOR
● It is a device that shows the heart’s electrical
activity wave pattern on a monitor.
● It is a bedside monitor
PURPOSE:
● It shows the cardiac rhythm and sends the
electrocardiogram (ECG) tracing to a main monitor
in the nursing station.
● Mostly commonly used in emergency rooms and
critical care areas, cardiac monitoring allows for
continual observation of several patients.
● It is useful for observation of postoperative
patients, patients with severe electrolyte
imbalances and other unstable patients.
● It allows for prompt identification and initiation of
treatment for cardiac arrhythmias and other
conditions.
DESCRIPTION:
● The monitor provides a visual display of the
patient’s heart rhythm, which is particularly
useful information during heart attacks, when
EQUIPMENT REQUIRED FOR CONTINOUS CARDIAC
patients can develop lethal cardiac arrhythmias.
MONITORING INCLUDES:
● The monitor sounds an alarm if the patient’s
1. MONITOR
heart goes above or below a predetermined
2. MONITOR CABLE
number.
3. LEAD WIRES
● An automatic blood pressure cuff and a pulse
Lead wires attached to the patient are coded:
oximeter, which measures the oxygen saturation in
● RA (Right Arm)
the blood, are also included with some monitors.
● RL (Right Leg)
● LA (Left Arm)
● LL (Left Leg)
● V (Precordial Vector)
4. ELECTRODES
5. DRY WASH CLOTH OR GAUZE PAD
6. ALCOHOL SPONGES
ASSESSMENT:
● Verify the doctor’s order.
● Introduce yourself to the patient.
● Verify the correct patient using two identifiers.
● Perform hand hygiene before patient contact. Don
appropriate protective equipment (PPE) based on
the patient’s need for isolation precautions or the
risk of exposure to bodily fluids.
● Assess the patient’s cardiovascular status.
 ● Review the patient’s history for cardiac
arrhythmia or cardiac problems.
● Explain the procedure to the patient and ensure
that the patient agrees to treatment.
PREPARATION:
● Assist the patient into a supine position.
● Assist the patient with removing clothing that
covers the chest.
● Review the management of clinically appropriate
settings for alarms per the organization’s
practice.
● Check the labels and lead wires for fraying,
broken wires or discoloration. If equipment is
damaged, obtain alternative equipment and notify
the biomedical engineer for repair.
● Check individual alarm signals for accurate
settings, proper operation and detectability.
● Close the curtain or door to ensure the privacy of
the patient.
● Make sure the patient is clean and dry to prevent
electrical shock.
PROCEDURE:
● Turn on the bedside monitor.
● Determine whether the patient is going to be
monitored with a three-lead or five lead system.
● Plug the patient cable into the monitoring system.
● Check that the lead wires are plugged into the
patient cable correctly and securely.
● Manufacturers identify the lead connections by
color, letter or symbol codes.
○ The right arm lead, marked RA, is usually
white.
○ The left arm lead, marked LA, usually
black.
○ The left leg lead, marked LL, is usually
red.
○ The right leg lead, marked RL, is usually
green.
○ The chest lead, marked C or V, is usually
brown.
● Connect the electrodes to the lead wires before
placing the electrodes on the patient.
○ Rationale: Placing electrodes on the chest
and then attaching the lead wires may be
uncomfortable for the patient and may
contribute to the development of air
bubbles in the electrode gel, which may
decrease conduction and distort the ECG
image.
● Identify the sternal angle or angle of Louis.
○ Palpate the upper sternum to identify the
juncture of the clavicle and the sternum,
which is called the suprasternal notch.
○ Slide the fingers down the center of the
sternum to the obvious bony prominence,
the sternal angle.
■ Rationale: The sternal angle
identifies the second rib and
provides a landmark for locating
the fourth intercostal space (ICS)
for accurate placement of
electrodes.
● Wash the patient’s skin with soap and water
(Chlorhexidine) and dry it briskly with gauze pads
or a wash cloth.
○ Rationale: Moist skin is not conducive to
electrode adherence. Wiping the electrode
area with a washcloth or gauze dries and
roughens the skin to enhance conduction.
Some electrodes have a skin abrader on
the back that can be used to roughen the
surface of the skin.
■ Note:Do not use alcohol for skin
preparation because it dries the
skin. To obtain good skin contact
with the electrodes, clip chest
hair with surgical clippers as
necessary.
● Remove the backing from the pre-gelled
electrodes and test the centers of the pads for
moistness.
○ Rationale: Gel may dry out in storage.
Gel should be moist to allow impulse
transmission.
● Place the electrodes on the patient. Apply
electrodes by pressing around their entire edges.
Do not press directly on the gel pads.
○ Rationale: Electrodes must be placed
tightly to prevent external influences
from affecting the ECG. Pressing on the
gel pad may cause the gel to leak onto
the adhesive surfaces and create air
pockets that can interfere with
transmission.
● Place skin electrodes carefully and consistently to
ensure accurate ECG interpretation, which is based
on precise placement of skin electrodes on the
torso. Incorrect placement of skin electrodes can
distort the appearance of the ECG waveform
enough that misdiagnosis and therefore
inappropriate treatment can occur.
● Inaccurate placement of electrodes can affect the
morphology (shape) of the QRS complex and result
in misinterpretation of a rhythm.
● Three-lead system
○ Apply the RA electrode just below the
clavicle and close to the patient’s right
shoulder near the junction of the right
arm and torso.
○ Apply the LA electrode just below the
clavicle close to the patient’s left
shoulder near the junction of the left arm
and torso.
○ Apply the LL electrode on the left side
below pectoral muscles lower edge or left
rib cage
● Reduce tension on the lead wires and cables.
○ Rationale: Reducing tension alleviates
undue stress on wires and cables that
may cause interference or faulty
recordings.
■ Note: For hardwire monitoring,
fasten the lead wire and patient
cable to the patient’s gown.
● Display’s the patient’s ECG tracing in two leads,
if available.
● Obtain an ECG strip and interpret for rhythm and
rate.
● Customize the alarms to meet the patient’s
needs. Adjust the upper and lower limits based on
the patient’s current clinical status and heart
rate.
○ Rationale: Setting alarm limits activates
the bedside or telemetry monitor alarm
system. Monitoring systems allow for
setting and adjusting alarms at the
bedside or at the central monitoring
system. The types of alarms may include
rate (high or low), abnormal rhythms or
complexes, and pacemaker recognition,
depending on the manufacturer.
● Never turn off the monitor alarms.
● Document the procedure in the patient’s record.
ENDOTRACHEAL TUBE INSERTION
● Endotracheal Tube Insertion or Intubation is a
process where a healthcare provider inserts a tube
through a person’s mouth, then down into their
trachea (airway/windpipe).
● The tube keeps the trachea open so that the
 ● air can get through. The tube can connect to a Procedure
machine that delivers air or oxygen. ● Tilt the head back and insert a laryngoscope into
INDICATIONS: the mouth. The tool has a handle, lights and a
● To secure airway dull blade, which help the HCP guide the tracheal
● To supply oxygen tube.
● General Anesthesia ● Move the tool toward the back of the mouth,
● Cardio pulmonary Rescuscitation avoiding the teeth.
● Ventilatory therapy in ICU ● Raise the epiglottis, a flap of tissue that hangs in
EQUIPMENTS: the back of the mouth to protect the larynx.
● Size of Tube ● Advance the tip of the laryngoscope into the
○ 0-1 year old - 2.5 to 3.5 mm (plain) larynx and then into the trachea
○ 1-3 years old - 4 to 5 mm ● Inflate a small balloon around the endotracheal
○ 4-6 years old - 5 to 6 mm tube to make sure
○ 6-10 years old - 6 to 7 mm (cuffed) ● it stays in place in the trachea and all air given
○ Adult female - 7 to 8 mm through the tube reaches the lungs.
○ Adult male - 8 to 9 mm ● Remove the laryngoscope.
● Place tape on the side of the mouth or a strap
around the head to keep the tracheal tube in
place.
● Test to make sure the tube is in the right place.
This can be done by taking an X-ray or by
squeezing air through a bag into the tube and
listening for breath sounds.
(Removal)
● When the healthcare providers decide it is safe to
remove the tube, they will remove it. This is a
simple process called EXTUBATION.
● Laryngoscope
● Magill Forceps
Procedure:
● Stethoscope
● Remove the tape or strap holding the tube in
● Syringe
place.
● Source for ventilation
● Use a suction device to remove any debris in the
● Suction
airway.
● Deflate the balloon inside your trachea.
● Tell the patient to take a deep breath, then cough
Technique of intubation
or exhale while they pull out the tube.
● Raise the head by 5cm with a block or ring pillow
● The throat might be sore for a few days after
extubation, and might have a bit of trouble
speaking.
Care of ET Tube
Procedure:
● Explain the procedure to the patient and position
the patient.
● Flexion of the neck
● Have manual resuscitator and mask at bedside on
at 12-15lpm. Have supplies readily available.
● Suction the endotracheal tube and oral cavity.
● Care for the ET tube. Before changing ET tube
position, oral suctioning should be performed.
Change position of the endotracheal tube with a
 Hollister from one side of mouth to the other by
moving the clip.
● Secure endotracheal tube and airway if block.
Firmly secure in place. Use the upper lip to
anchor the tape.
● Check position of endotracheal tube. Auscultate the
lungs to ensure bilateral breath sounds.
● Ensure comfort of patient. Suction endotracheal
tube if any secretions are obstructing airways.
Check for pressure spots where tapped.
● Document the procedure. Note condition of mouth,
character of secretions, placement of the tube and
how patient tolerated the procedure.
Risk:
● Aspiration
● Endobronchial intubation
● Esophageal Intubation
● Failure to secure airway
● Infection
● Injury
Big valve mask

Tracheostomy

● is a surgical procedure in which an opening is

made into the trachea.
● the indwelling tube inserted into the trachea is
Securing the tube
called a tracheostomy tube.
● it may be permanent or temporary.
● it is used to bypass an upper airway obstruction,
to allow removal of tracheobronchial secretions, to
permit the long-term use of mechanical
ventilation, to prevent aspiration of oral or gastric
secretions in the unconscious or paralyzed patient,
and to replace an endotracheal tube.
● many disease processes and emergency conditions
make a tracheostomy necessary.
Procedure:
● may be done in the OR and ICU.
● opening is made between the second and third
tracheal rings, wherein a cuffed tracheostomy
tube of an appropriate size is inserted.
 ● *** cuff attachment: occlude space between the
tracheal walls and the tube, to permit effective
mechanical ventilation, and to minimize the risk of
aspiration.
● is held in place by tapes fastened around the
patient’s neck.
● Generally, a respiratory therapist (RT) sets
up the ventilator and changes the settings.
● Settings are regulated accdg to the patient’s
assessment, expected outcome, and changes
in ABGs.

Mechanical Ventilation

● is a term used to describe the delivery of life

support to a patient using an invasive airway and
a machine that gives pressurized oxygen.
● MV is done until the patient can breathe
spontaneously and cough on his/her own.
● MV can be based on positive pressure or negative
pressure.
● Negative pressure ventilators (Chest cuirass, iron
lung, or chest ponchos)
Who are at high risk for MV?

Noninvasive Positive-Pressure Ventilators

Definition:
● It is a positive or negative pressure breathing
device that supports ventilation and oxygenation.
● It keeps the airway open, delivers oxygen and
removes carbon dioxide.
TYPES OF MECHANICAL VENTILATION:
INVASIVE MECHANICAL VENTILATION
- this means the tube in the airway connected to a
ventilator. This tube can go through the mouth
(intubation) or neck.
NON-INVASIVE VENTILATION
This uses a face mask connected to a ventilator.
Ventilator Settings
● Ventilator settings are ordered by healthcare
provider.
● is a method of positive-pressure ventilation
that can be given via face masks that cover
the nose and mouth, nasal masks or other oral
or nasal devices such as nasal pillow.
● Candidates for NIPPV: acute or chronic
respiratory failure, acute pulmonary edema,
COPD, chronic heart failure, or a
sleep-related breathing disorder.
● Maybe used at home to improve tissue
oxygenation and to rest the respiratory
muscles while patients sleep at night.
● NIPPV is contraindicated for those who have
experienced respiratory arrests, serious
dysrhythmias, cognitive impairment, or
head/facial trauma.
Types of NIPPV
● Continuous Positive Airway Pressure (CPAP)
● Bilevel Positive Airway Pressure (BiPAP)
 decrease resistance within the tracheal tube
and ventilator tubing.
● Pressure support is reduced gradually as the
patient’s strength increases.
● A SIMV backup rate may be added for extra s
● upport.
● The nurse must closely observe the patient’s
respiratory rate and tidal volume on initiation
Ventilator Modes
of PSV.
● Ventilator modes refer to how breaths are
● It may be necessary to adjust the pressure
delivered to the patient.
support to avoid tachypnea or large tidal
● The most commonly used mode are:
volume.
○ Assist-control (AC)
Low-Pressure Alarms and High Pressure Alarms
○ Synchronized intermittent mandatory
ventilation (SIMV)
○ Pressure support ventilation (PSV)
,and
Assist Control Ventilation
● Provides full ventilatory support by delivering
a preset tidal volume and respiratory rate.
● If the patient initiates a breath between the
machine’s breaths, the ventilator delivers at
the preset volume (assisted breath).
● Therefore, every breath is the preset volume.
Synchronized Intermittent Mandatory Ventilation
● Delivers a preset tidal volume and number of
breaths/minute.
● Between ventilator-delivered breaths, the
patient can breathe spontaneously with no
assistance from the ventilator on those extra
breaths.
● Because the ventilator senses patient
breathing efforts and does not initiate a
breath in opposition to the patient’s efforts,
buckling the ventilator is reduced. As the
patient’s ability to breath spontaneously
increases, the preset number of ventilator
breaths is decreased and the patient does
more of the work of breathing.
● Like IMV, this method can be used to provide
partial or full ventilatory support.
● May be used for weaning.
Pressure Support Ventilation
● PSV applies a pressure plateau to the airway
throughout the patient triggered inspiration to
Nursing Interventions and Rationales for the Patient 2. Adjust the machine to deliver the lowest
During MV concentration of oxygen to maintain normal PaO2
(80-100 mmHg).
3. Record peak inspiratory pressure.
4. Set mode (AC/SIMV) and rate according to
physician order. Set PEEP and pressure support if
ordered.
5. Adjust sensitivity so that the patient can trigger
the ventilator with a minimal effort (usually 2 mmHg
negative inspiratory focal)
6. Record minute volume and obtain ABGs to measure
PaCO2, pH, and PaO2 after 20 minutes of continuous
mechanical ventilation.
7. Adjust setting (FiO2 and rate) according to results
of ABG analysis to provide normal values or those set
by the physician.
8. If the patient suddenly becomes confused or
agitated or begins buckling the ventilator for some
unexplained reason, assess for hypoxia and manually
ventilate on 100% oxygen on resuscitation bag.
Weaning Patient from the Vent
Respiratory Weaning is the process of withdrawing
the patient from dependence on the ventilator, takes
place in three stages:
The patient is GRADUALLY
1. removed from the ventilator
2. removed from the tube
3. removed from oxygen
Commonly Used Respiratory Medications in Critical Weaning Patient from the Vent
Care for the Patient on MV ● Is performed at the earliest possible time
1. Morphine Sulfate consistent with patient safety.
2. Fentanyl (Sublimaze) ● Decisions must be made from a physiologic
3. Diprivan (Propofol) rather than a mechanical viewpoint.
4. Benzodiazepines ● Weaning is started when the patient is
5. Paralytics (Neuromuscular Blocking agents recovering from the acute stage of medical
[NMBAs]) and surgical problems and when the cause of
respiratory failure is sufficiently reversed.
● Successful weaning involves collaboration
among the physician, respiratory therapist,
and nurse.
● Each healthcare provider must understand the
scope and function of other team members in
relation to patient weaning to conserve the
Initial Ventilator Settings
patient’s strength, use resources efficiently,
1. Set the machine to deliver the tidal volume
and maximize successful outcomes.
required. (10 to 15 mL/kg)
Care of the Patient Being Weaned from Mechanical
Ventilation
● * Assess patient for weaning criteria:
1. Vital Capacity: 10 to 15 mL/kg
2. Maximum Inspiratory Pressure
(MIP) at least 20 cm H20
3. Tidal Volume 7 to 9 mL/kg
4. Minute Ventilation: 6L/min
5. Rapid/Shallow breathing index:
below 100 breaths/minute/L; PaO2 >
60mm Hg with FiO2 less than 40%
● * Monitor activity level, assess dietary
intake, and monitor results of laboratory tests
of nutritional status.
● Reestablishing independent spontaneous
ventilation can be physically exhausting. It is
crucial that the patient have energy reserves
to succeed.
● * Assess the patient’s and family’s
understanding of the weaning process and
address any concerns about the process.
● Explain that the patient may feel short of
breath initially and provide encouragement as
needed.
● Reassure the patient that he/she will be
attended closely and that if the weaning
attempt is not successful, it can be tried
again later.
● * Implement the weaning method prescribed:
○ 1. A/C ventilation
○ 2. SIMV
○ 3. PSV
○ 4. CPAP
○ 5. T-piece
● * Monitor vital signs, pulse oximetry, ECG,
and respiratory pattern constantly for the
first 20 to 30 minutes and every 5 minutes
after that until weaning is complete.
● Monitoring the patient closely provides
ongoing indications of success or failure.
● * Maintain a patent airway; monitor arterial
blood gas levels and pulmonary
● function tests. Suction airways as needed.
● * In collaboration with the physician,
terminate the weaning process if adverse
reaction occur. These includes:
1. HR increase of 20 bpm, SBP
increase of 20 mmHg,
2. A decrease in oxygen saturation to
less than 90%
3. Respiratory rate less than 8 or
greater than 20 bpm
4. Ventricular dysrhythmias
5. Fatigue, panic, cyanosis, erratic or
labored breathing
6. Paradoxical chest movement
● * if the weaning process continues, measure
tidal volume and minute ventilation every 20
to 30 minutes;
● Compare with the patient’s desired values,
which have been determined in collaboration
with the physician.
● * Assess for psychological dependence if the
physiologic parameters indicate weaning is
feasible and patient still resists.
● Possible causes of psychological dependence
include fear of dying and depression from
chronic illness.
● It is important to address this issue before
the next weaning attempt.