The Role of the Anaesthetist in the Emergency Service

The Role

of the Anaesthetist

in the

Emergency Service

Published by

The Association of Anaesthetists of Great Britain and Ireland

9 Bedford Square

London WC1B 3RA

Membership of the Working Party

Dr P J F Baskett Chairman, President Professor P Hutton

Dr C R D Laird GAT

Professor J Norman College of Anaesthetists Mr D Skinner

Dr R Sleet

Dr Anne J Sutcliffe Dr R M Weller

Ex-officio: Office Bearers of the Association of Anaesthetists

Dr W R MacRae Honorary Treasurer Dr J E Charlton Honorary Secretary Dr W L M Baird Immediate Past Honorary Secretary

Dr R S Vaughan Assistant Honorary Treasurer Dr M Morgan Editor

Contents

page

Introduction 1

Section I. Anaesthesia and analgesia in the Accident and Emergency Department 2 Section II. Resuscitation within the Accident and

Emergency Department 6

Section III. Major incidents 9 Section IV. Training of ambulance and paramedical staff15 Section V. Duties, commitment and support 17

References 18

Appendix I 19

Introduction

Anaesthetists have important roles within the Accident and Emergency (A & E) Department and in the care of patients with major trauma or serious illness before they reach hospital.

The contributions include the provision of analgesia, anaesthesia and resuscitation both inside and outside hospital and involvement with major incident plans and responses. In addition, anaesthetists have a commitment to training anaesthetic and other medical staff, nurses, other members of the A & E Department and ambulance personnel.

The Association of Anaesthetists of Great Britain and Ireland set up a multidisciplinary working party to define and report on the services which should be provided by anaesthetists within the Accident and Emergency Service.

This report provides a framework for the role of the anaesthetist in the emergency service. Local arrangements should be made in collaboration with the consultant in charge of the A & E Department.

SECTION I

Anaesthesia & Analgesia in the Accident and

Emergency Department

The A & E Department of most district general hospitals will require anaesthetic services to help with the provision of analgesia for many painful conditions, and anaesthesia for minor ambulatory surgery such as suturing of lacerations, incision and drainage of abscesses and manipulation of fractures and dislocations.

Standards of anaesthetic care and safety in the A & E Department must be the same as those provided in other theatre suites.

Location and equipment

Appropriate anaesthetic and resuscitation equipment, drugs, and monitoring facilities, and adequate space within the A & E Department should be provided. A suitably equipped and staffed area for recovery is required. If these facilities cannot be provided in the A & E Department then the work should be undertaken within a hospital theatre suite.

A nominated consultant anaesthetist should be responsible for recommending the provision of these facilities and ensure their regular review.

Personnel

All consultant anaesthetists, especially those taking part in the on-call roster, should be familiar with the arrangements in the A & E Department.

The nominated consultant anaesthetist should ensure that trainees administering anaesthesia in the A & E Department are familiar with the equipment available and the techniques required; departmental guidelines may be useful. Trainees must have ready

access to the nominated consultant anaesthetist or the consultant anaesthetist on duty.

A trained anaesthetic nurse or operating department assistant (ODA) should be assigned to assist the anaesthetist at all times when anaesthesia is being conducted in the A & E Department. Patient selection

Most patients will be fit and in categories I and II on the scale of fitness of the American Society of Anesthesiologists. Patients in categories III and IV may present occasionally and may be acceptable for short, relatively minor surgery, provided their medical condition is stable and the surgical procedure and anaesthesia will not change this. Pre-anaesthetic assessment questionnaires completed by the patient with the aid of admitting staff can be helpful. Relevant questions should address the patient’s medical history, including previous and current medication. There must be facilities for necessary preoperative investigations. The anaesthetic technique proposed and the recovery arrangements should be explained to the patient by the anaesthetist at a preoperative assessment visit.

The anaesthetist should ensure that adequate enquiries have been made with regard to a suitable home environment for the patient to return to, and that the arrangements for transport and postoperative care at home are satisfactory.

Anaesthesia in the A & E Department is more frequently associated with alcohol and substance abuse, infections such as hepatitis and HIV, and the full stomach than in other locations. Patients at particular risk of delayed stomach emptying include those injured shortly after eating, those who have consumed alcohol, those who are in pain or those who are frightened. This applies particularly to children. The optimal period of fasting prior to anaesthesia for trauma has not been established clearly. It is recommended that precautions be taken to prevent pulmonary aspiration of gastric contents for 12 hours after injury.

Children requiring anaesthesia in the A & E Department will require special facilities, equipment and expertise and the needs of parents should be considered. (Thornes R. Just for the Day, Caring for Children in the Health Service, 1991).

Local analgesic infiltration and peripheral nerve blocks The use of local analgesic infiltration or isolated peripheral nerve blocks is safe provided that the local anaesthetic is administered in non-toxic doses and there are no absolute or relative contra-indications to the use of the technique. Even modest doses of local anaesthetic agents can cause problems if administered without due care. If safety measures are adopted, it is acceptable for one person to administer the local anaesthetic and to perform the operation, provided the operator is trained and experienced in basic resuscitation.

Intravenous regional analgesia (IVRA) and major regional analgesic techniques

In addition to the increased danger of using a larger dose of the local anaesthetic agent, IVRA and major regional analgesic techniques may be associated with other life threatening complications such as hypotension and respiratory depression. IVRA in particular is a source of potential danger because the inherent simplicity of the technique encourages its employment by people insufficiently trained in its use and the treatment of complications, or in inappropriate circumstances.

It is essential that these techniques are used only when an individual experienced with their performance and management is present. One person should perform the operation while a second person trained in advanced life support monitors and cares for the patient. This is essential if the technique is used in a patient who has recently eaten or within twelve hours of injury. Training in IVRA techniques for A & E Department medical staff should be provided by the Department of Anaesthesia. The equipment used for IVRA should be maintained regularly and checked before use.

Sedation should be used only by those with suitable relevant training and experience. Overdose is a particular risk, not only in the frail and elderly who are extremely sensitive to sedative drugs, but also in young, fit patients when analgesia is inadequate and the patient is restless. As with IVRA, one person should perform the operation and another, who is trained in resuscitation, must monitor the patient. Sedated patients can become hypoxic easily and the use of supplementary oxygen and pulse oximetry is recommended strongly. Where pulse oximetry is not available, supplementary oxygen should always be given. Recovery and discharge

Recovery facilities, including patient monitoring, should be comparable to those recommended for day case surgery (Korttila K. Recovery from day case anaesthesia in ‘Anaesthesia for Day Case Surgery’ Healy T E J (ed) Baillière’s Clinical Anaesthesiology. 1990; 3: 713-732).

The anaesthetist must ensure that patients have recovered adequately before handing over care to nursing staff. Designated, suitably trained staff must be available to supervise the recovery of patients following general anaesthesia, regional, IVRA and sedation techniques. They should also administer any postoperative analgesic prescribed. Before discharge the patient should be assessed for ‘street fitness’.

The patient or relative should be given written instructions for postoperative care including a telephone contact number to call if problems arise after discharge. Specific instructions must be given concerning the effects of the anaesthetic technique employed, and in relation to driving, operating machines or appliances, and the consumption of alcohol.

Customary advice is to avoid these activities for 24 hours, although some authorities have recommended 48 hours. If necessary, the patient should be given appropriate analgesics to take home.

SECTION II

Department

Arrangements to provide a satisfactory resuscitation service should be made by the nominated consultant anaesthetist in co-operation with the consultant in charge of the A & E Department. The concept of a multidisciplinary resuscitation committee being established for each hospital or district is warmly supported.

Arrangements should ensure

that:-(a) Twenty-four hour cover by skilled anaesthetic personnel is immediately available. Major trauma and other life-threatening emergencies should be dealt with by relatively senior anaesthetic personnel. Consultant support should always be readily available.

(b) Adequate equipment for resuscitation is available This equipment will need to cater for a wide range of problems in patients of all ages including:

(i) airway problems

(ii) respiratory failure with or without arrest (iii) pneumothorax, haemothorax or both (iv) hypovolaemia

(v) cardiac failure with or without arrest

(c) Adequate patient monitoring equipment is available. (Recommendations for Standards of Monitoring during Anaesthesia and Recovery. Association of Anaesthetists of Great Britain and Ireland, London, 1988).

(d) There are satisfactory arrangements, including mobile equipment, for intra-and inter-hospital patient transfer after stabilisation.

(e) There should be a regular schedule of maintenance and replacement of all equipment.

Training

In collaboration with the A & E consultant(s), cardiologist(s)., the Resuscitation Training Officer and other interested parties, the nominated consultant anaesthetist should ensure that appropriate training is available as

follows:-(i) all staff should be trained in basic life support;

(ii) all medical staff should be trained in advanced cardiac life support. Local policy should permit appropriate nursing staff and ODAs to be trained in techniques such as intravenous cannulation, endotracheal intubation and defibrillation;

(iii) accident and emergency and anaesthetic staff should be trained in advanced trauma life support. It is also desirable that surgical members of the trauma team receive this training.

Training may be provided locally or by attendance at nationally-organised courses.

Anaesthetists working in the A & E Department should be competent in the immediate management of events compromising the airway, ventilation and circulation. These may include trauma, burns, poisoning, exposure to hazardous substances, near drowning, coma, asthma, epilepsy, epiglottitis, allergic reactions and obstetric and paediatric emergencies.

Information concerning these problems and, where appropriate , local management protocols should be available in the A & E Department. These should be reviewed regularly and used as a basis for teaching and discussion.

Audit

Audit of the anaesthetic and resuscitation services in the A & E Department is no less important than anaesthetic audit elsewhere. Data collection should be instituted, and departmental

protocols may be valuable in improving the standards of care by anaesthetists.

Scoring systems

For some groups of patients, audit may be facilitated by the use of internationally validated scoring systems. Scoring systems can indicate the potential severity of an injury and aid identification of levels of departmental performance which are above or below average.

As an example, the TRISS method is widely used to assess the adequacy of management of trauma patients. The probability of an individual patient’s survival is determined by calculating the Injury Severity Score based on the type of injuries, and the Revised Trauma Score, which gives weighted values to respiratory rate, systolic blood pressure and Glasgow Coma Scale. These scores are plotted on probability charts which are available for different age groups. (Boyd C R, Tolson M A & Copes W S. Evaluating trauma care: the TRISS method. J Trauma. 1987; 27: 370-378).

SECTION III

Major Incidents

Anaesthetists have vital roles to play in any major incident. These include planning and organising the response to a major incident, assessment and clinical management of casualties on-site and in hospital and training anaesthetic and other personnel. 1. Major incident plans

The nominated consultant anaesthetist must be a member of the hospital’s major incident committee. The plans should be made in consultation with the emergency services and voluntary aid societies. Special planning is needed for potential local incidents in industry, at airports, railways, docks, waterways, natural disasters, sports events and other occasions where large crowds can be expected.

Plans should be subject to regular review. 2. Clinical responsibilities

The Department of Anaesthesia provides a number of clinical services in the event of a major incident. These include:

(i) membership of the on-site team (ii) triage and pain relief

(iii) provision of resuscitation in the A & E Department

(iv) co-ordination and provision of an anaesthetic service for patients requiring surgery

(v) co-ordination and provision of intensive and high dependency care

(i) The department of anaesthesia should have a pre-arranged plan for calling out anaesthetists using a ‘telephone cascade’. The system needs to be tested and revised at regular intervals. The plan will identify who is called first and the order and number of subsequent calls will be determined by the level of response required. The call out system can be combined with an action card.

(ii) Action cards (plasticised credit card size) should be prepared for all personnel likely to be called to respond to major incidents. These should be issued to all individuals and spares kept in a pre-designated advertised location. The instructions should be revised at intervals as appropriate. (iii) Identity cards with photographs will identify the holder to

security staff and other health service workers and permit access to the hospital site in the event of a major incident. By prior agreement with the police, identity cards can be used to allow doctors to pass through police check points. Identity and action cards can be combined back to back on one card within a single transparent holder (for an example, see Appendix I).

4. On-site role

Experience at major incidents has shown that anaesthetists have a valuable role to play at the site. Generally triage, resuscitation, relief of severe pain and occasionally anaesthesia at the site of the incident will be required.

(i) Mobile teams

The initial mobile team will normally consist of four persons; an anaesthetist of sufficient experience and seniority, a surgeon or A & E physician and two nurses or ODAs. The most experienced doctor should be designated team leader.

The team’s initial objectives are to assess the situation and the need for further assistance, perform triage and, with the ambulance service, provide resuscitation and pain relief.

Rarely, anaesthesia and surgery may be needed to rescue a trapped patient. Such activities should only be undertaken when initial objectives have been met.

Normally, mobile teams should be sent to the site from a hospital which is not the major designated receiving hospital. As soon as possible, a senior doctor, who may be an anaesthetist, should be brought to the site as Medical Incident Officer. The role of the Medical Incident Officer is to supervise on-site medical services, permit the mobile team to carry out clinical duties and liaise with the receiving hospital and the emergency services.

(ii) Transport to site

Arrangements for transport of the mobile team to the site must be agreed and incorporated in the major incident plan. Options include hospital transport, the ambulance service or the police.

Maritime incidents may involve the life boat service, coastguard, port authority, defence services or other agencies.

(iii) Protective clothing

Protective clothing should be worn by all members of the mobile team. The clothing should be light, warm and weatherproof and of a distinctive bright colour. There should be identification of the team member’s role on the front of the jacket and the hospital of origin on the back.

(iv) Portable equipment

Portable first aid and resuscitation equipment should be carried in lightweight weatherproof containers. Equipment bags and their contents should be compatible with those used in all local hospitals, so that teams from different sources can work together. Re-supply boxes should be kept at the hospital.

Regular drills should be held to acquaint team members with the contents and layout of the bags.

Recommended items of equipment for a mobile team are listed in Appendix II.

(v) Insurance

All members of the mobile team must be covered by adequate insurance for personal injury, death and third party risk. Insurance cover provided by the Department of Health is often inadequate and we recommended that additional cover be arranged from other sources such as hospital trust funds. This cover should include transport of the team by any means and should include road, boat, helicopter or fixed wing aircraft.

Suitable insurance cover may be arranged through the British Medical Association (BMA House, Tavistock Square, London, WC1H 9JP), or the British Association for Immediate Care (7 Black Horse Lane, Ipswich, IP1 2EF). It is anticipated that doctors sent out from an NHS hospital to attend a major accident will be covered for any subsequent medical negligence claims under the NHS indemnity scheme. 5. Communications

The principle line of communication between the on-site team and the A & E Department should be a radio link with the ambulance service. On-site medical team leaders should be issued with a portable radio preferably with a talk-through facility. Cellular telephones have proved to be of value in the early stages of a major incident but as time progresses batteries run down and the cell net becomes saturated.

6. Training in disaster medicine

(i) Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) courses

Participation in ATLS and ACLS provider courses is strongly recommended for anaesthetists. Selected individuals should attend instructor courses.

Attendance at disaster medicine meetings and conferences is strongly commended.

(ii) Clinical practice

Anaesthetists should be familiar with the equipment and techniques to be employed in the field. Practice within the hospital setting will ensure confidence and expertise. This should include use of protective clothing and radio procedures.

Clinical practice outside the hospital may be obtained by acting as medical officer at dangerous sporting events or by joining an immediate care scheme through the British Association for Immediate Care (BASIC). Anaesthetists have been valuable members of national and international disaster teams.

Familiarity with hazardous chemicals and HAZCHEM identity codes is essential. Detailed information can be obtained from the Fire Service, and copies should be held in the A & E Department. Anaesthetic implications should be highlighted in these copies.

(iii)Exercises

Regular exercises should be conducted. Small table-top exercises can rehearse separate aspects of the total disaster plan economically. Full scale exercises involving both hospital and emergency services should be conducted annually. Each major exercise should be carefully planned and evaluated afterwards. The results should be widely disseminated and the disaster plan modified accordingly.

(iv) Post-event audit

All major incidents should be subject to independent post-event audit. Data from patient scoring systems should be evaluated to aid audit and determine the level of departmental performance. Lessons learnt should be widely promulgated at local, national and international levels.

(v) Counselling

Post-event counselling should be part of the major incident plan. Any member of staff involved with a major incident may become emotionally stressed and such stress can persist for a long time.

SECTION IV

Training of Ambulance and Paramedical Staff

It is accepted that expert pre-hospital care is a vital aspect of the management of the suddenly ill and seriously injured. The majority of pre-hospital care can be provided by trained members of the ambulance service. To achieve acceptable standards of pre-hospital care, at least 60% of emergency ambulance crew members should be trained to paramedic standard. The remainder should be trained in life saving first aid, basic life support and the use of automated external defibrillators.

Curriculum

Extended training of ambulance personnel to paramedic standard is the responsibility of the NHS Training Authority Special Projects Group, which has an anaesthetist as a member. Anaesthetists contribute widely to the activities of this Group which include design programmes and conduct of examinations. The curriculum is also reviewed by the Joint Colleges Ambulance Liaison Committee The College of Anaesthetists is represented on this committee.

Anaesthetists have a particular contribution to make in training ambulance personnel in the maintenance of airway, ventilation and circulation and in the provision of basic analgesia and sedation. Anaesthetists should be involved with both theoretical and practical training.

Such training will include the following:- assessment and basic control of the airway using oro and nasopharyngeal and laryngeal mask airways, endoctracheal intubation and ventilation using expired air, self-inflating bags and automatic resuscitation and the use of controlled oxygen therapy and salbutamol inhalations. Training will also cover the assessment and control of blood loss, intravenous access and infusions, external chest compression, ECG recognition, the use of defibrillators and appropriate drug therapy. Training in the use of drug therapy will include the use of certain drugs for cardiac and respiratory emergencies,

provision of pain relief and sedation using Entonox, parental opioids and sedative agents e.g. benzodiazepines. Practice training will require manikins and simulators, ECG/defibrillators and experience with patients.

Consent and responsibility

Anaesthetists must ensure that the employing authority has agreed to honour their vicarious liability in respect of extended training of ambulance personnel, and that trainee ambulance personnel are covered medico-legally by their employer.

Training of any kind requires patient consent whether it be medical student nurse, operating department assistant or ambulance personnel. The new consent form incorporates general agreement to trainee involvement, and an opt-out clause for patients who do not wish to take part.

Anaesthetists training ambulance personnel should participate in local and national audit of training and performance.

Section V

Duties, Commitment and Support

Duties of the consultant(s) co-ordinating anaesthetic services in the A & E Department will

include:-(i) liaison with the A & E consultant and other staff,

(ii) liaison with other members of the department of anaesthesia to ensure that policies and equipment are compatible with those in areas such as intensive care, high dependency units and operating theatres,

(iii) direction of anaesthetic services both inside and outside the hospital,

(iv) involvement with the major incident plans and responses, (v) a commitment to training trainee anaesthetic and other

medical staff, nurses, paramedic ambulancemen and others in the A & E Department.

The job plan of the named consultant(s) co-ordinating anaesthetic services in the A & E Department will require an allowance of one nominal half day (NHD) for up to 25,000 patients per year treated in the A & E Department and pro rata for busier departments.

Anaesthetists extensively involved with extended training of ambulance personnel should negotiate an appropriate NHD allowance for these duties.

Adequate secretarial and clerical support should be provided to permit audit and assessment tasks to be completed and to assist with correspondence and administration.

There should be an adequate budget for purchase of new and replacement equipment, and for training purposes.

Thornes R. Just for the Day, Caring for Children in the Health Service, 1991.

Korttila K. Recovery from day case anaesthesia in ‘Anaesthesia for Day Case Surgery’ (ed) Healy T E J. Baillière’s Clinical Anaesthesiology. 1990; 3: 713-732.

‘Recommendations for Standards of Monitoring during Anaesthesia and Recovery’. Association of Anaesthetists of Great Britain and Ireland, London, 1988.

Boyd C R, Tolson M A & Copes W S. Evaluating trauma care: the TRISS method. J Trauma. 1987; 27: 370-378.

Appendix I

EXAMPLE OF ACTION CARD

BEDFORD SQUARE HOSPITAL

MAJOR INCIDENT ACTION CARD

On receiving a major incident alert inform the consultant anaesthetist on duty directly (and 2nd call or senior registrar). Report to Control Room and carry out initial

equipment checks and resuscitation as directed.

EXAMPLE OF IDENTITY CARD

BEDFORD SQUARE HOSPITAL

NAME

DR J SNOW

DESIGNATION

CONSULTANT

ANAESTHETIST

Appendix II

EQUIPMENT FOR MOBILE TEAMS

Clothing

(Various sizes to supply one of each item per team member)

lightweight boiler suits (for hot weather)

Wellington boots (acid resistant) thermal socks

knee pads gloves - wool

gloves - chrome leather salopettes - breather type fleece shirts

waterproof coats - high visibility with hood

waterproof overtrousers - high visibility tabards - nylon, green high visibility labels for tabards

“Medical Team” “Site Medical Officer” “Hospital Name”

helmets - green

headlight with rechargeable battery heat packs - 2 per team

Bags

Equipment is best packed in lightweight bags

1. First Aid (1st Responder) bags (one per team member) to provide basic control of bleeding and the airway and simple ventilatory support. 2. Medical snatch bags (one per

doctor/paramedic) for:

advanced airway and ventilation control

intravenous fluid replacement splintage and dressings

drugs - analgesic and resuscitation 3. Back up supply cases for replenishing

Dressings

pad dressings, large medium and

small, of each 20

elastoplast, 6.5 x 2.5 cm 20

elastoplast, 6.5 x 5 cm 20

eye pad dressings 10

bandages, triangular, 90 x 127 cm 20 gauze swabs, 7.5 x 7.5 cm, pkts of 5 40 circular, elasticised bandaging,

size C, box 3

circular, elasticised bandaging,

size D, box 3

elastoplast, 7.5 cm, roll 3

tape, clear, adhesive, 2.5 cm, roll 6

crepe bandages, 5 cm, roll 10

safety pins, pkts of 10 10

cetavalon sachets, 25 ml 40

saline sachets, 25 ml 40

surgical drapes, sterile, pkts of 2 20

forceps, Spencer Wells 6

forceps, non-toothed, 12 cm 6

Airway and ventilation

airways, oropharyngeal, disposable,

sizes 3,2, 1 of each 6

facemasks, anaesthetic paediatric,

sizes 2,3 of each 2

adult, sizes 3, 4, 5 of each 4

pocket resuscitation mask 4

manual emergency aspirator 6

portable electric suction units 3

Yankauer sucker ends 10

self-inflating bags 4

automatic resuscitators 3

laryngoscope, handle, Macintosh 6 laryngoscope, blade, adult medium 6

laryngoscope, blade, child 2

batteries, 1.5v 10

bulbs (spare) 10

tracheal tubes, disposable,

cuffed sizes, 9,8,7,6 mm of each 4 uncuffed-sizes, 5,4,3.5 mm of each2 tracheal tube introducer, adult 4 tracheal tube, introducer, child 2

lubricating jelly, 42 g. tube 4

syringes, 10 ml 4

catheter mount and connector 10

ribbon gauze, 2.5 cm, roll 4

forceps, Spencer Wells 6

intubating forceps, adult, Magill 4 tracheal suction catheters:

8,12 swg of each 10

14,16 swg of each 10

scalpel, disposable, No 11 blade 5

cannulae, 12 swg 6

tracheal tube adapters, 3.5 mm 4

stethoscope 4

cricothyrotomy set 4

chest drain set -each containing: chest drains, 16, 20, 24,28 FG

of each 2

scalpel handle 2

scalpel blade, No 11 4

introducing forceps 2

emergency chest drainage bag 4

connectors, tapered, sterile 4

suture, silk 2/0, curved cutting needle 4 Brain laryngeal mask, No 4 & 3, of

each 3

nasal airways, 6.0 mm & 6.5 mm,

of each 3

Intravenous

blood administration sets 40

tourniquet, venous, large 2

swabs, spirit, strips of 5 40

splints, arm, adult 10

splints, arm, child 4

i.v dressings 40

tape, clear, adhesive, 2.5 cm, roll 4

bandages, crepe, 10 cm, rolls 10

cannulae, i.v, 14 swg 40 cannulae, i.v, 16 swg 20 cannulae, i.v, 18 swg 20 cannulae, i.v, 20 swg 20 cannulae, subclavian/jugular: cannulae, 18 swg, FG07 10 cannulae, 18 swg, FG10 10

infusion pump bags, large 5

intravenous cut-down sets

scissors, straight, pointed, small1 forceps, mosquito, straight 2 forceps, dissecting,

toothed, small 1

forceps, non-toothed 1

aneurysm needle 1

needle holder, Kilner 1

retractor, single, blunt hook 2

scalpel handle, No 4 1

scalpel blade, No 10 2

scalpel blade, No 11 1

dressings sutures:

chromic catgut, round bodied 6 chromic catgut ties, 2/0 6 silk 2/0, straight needle 6 silk 2/0, reverse cutting needle 6

silk 0, ties 6 Intravenous fluids Hartmanns, l litre 20 Haemaccel/Gelofusine, 0.5 litre 40 saline 0.9%, l litre 20 Mannitol 20%, 0.5 litre 10 Analgesia kits morphine sulphate, 10 mg/ml, 1 ml 20 nalbup hine, 10 mg/ml, 1 ml 20 naloxone, 400 mcg/ml, 1 ml 10 syringes, 2 ml 40 needles, 23 swg 40 needles, 21 swg 40

swabs, spirit, strips of 5 10

cannulae, i.v, 22 swg 20

cannulae, i.v, 25 swg 20

tape, clear, adhesive, 2.5 cm, roll 6

i.v dressings 40

(Entonox supplied by Ambulance Service)

Resuscitation drugs

(preloaded syringes preferred)

adrenaline, 1 in 10,000, 10 ml amps 10 aminophylline, 25 mg/ml, 10 ml amps 10 atropine, 0.5 mg/ml, 1 ml amps 10 calcium chloride, 100 mg/ml, 10 ml amps 10 dextrose, 50%, 50 ml amps 10 lignocaine, 1%, 10 ml amps 10 ketamine, 50 mg/ml, 10 ml amps 10 midazolam, 2 mg/ml, 5 ml amps 10 suxamethonium, 50 mg/ml, 2 ml amps 10

(kept in fridge until required)

etomidate 10 mg/ml, 10 ml amps 10 sodium bicarbonate 8.4%, 50 ml

amps 5

Other items

sphygmomanometer, aneroid 4

ground sheet, waterproof 6

scissors 10

silverfoil blanket 20

gloves, latex, size medium, pairs 40

sharps, disposal, box 6

Splinting

traction leg splint kits 4

velcro fracture strap set 6

cervical collars 10

full spinal splints 4

arm lock splints 10

pneumatic antishock garment 2

scissors 5 1/2” angled 6

heavy duty sheets

(N.B. Much of the splinting equipment may be provided by the Ambulance Service)

©This document is published by the Association of Anaesthetists of Great Britain and Ireland, 9 Bedford Square, London WC1B 3RA.