16.3 Emergency Equipment Operation

16.3 Emergency Equipment Operation

Cardiac catheterization laboratories perform high-risk procedures on critically ill patients, making emergency equipment proficiency a core RCIS competency. Domain D of the RCIS examination explicitly tests the ability to operate defibrillators, locate and deploy code cart resources, manage suction, and support airway interventions. Equipment must be checked at the start of each shift — a defibrillator with a dead battery or an empty oxygen tank is a preventable catastrophe.

Defibrillator Operation

Every cath lab maintains at least one manual biphasic defibrillator with pacing capability and often an integrated 12-lead ECG display. Some labs also stock automated external defibrillators (AEDs) in adjacent corridors, but the cath lab defibrillator is the primary device because it allows manual energy selection, synchronized cardioversion, and external pacing.

Daily Safety Checks

The RCIS verifies at shift start:

• Battery charge: Power-on self-test passes; charge-time test completed per manufacturer schedule.
• Pad/ electrode availability: Adult defibrillator pads within expiration date; spare set accessible.
• Cable connections: Pacing and defibrillation cables connect securely without frayed insulation.
• Paper/recording: ECG paper loaded if the unit prints strips.

Defibrillator Pad Placement

• Anterior-Lateral (Standard): One pad on the upper right chest (below the clavicle, right of the sternum); second pad on the left mid-axillary line at the level of the V6 position (lower lateral chest).
• Anterior-Posterior: Alternative for large breasts, obesity, or when anterior pads cannot make contact — anterior pad over the left precordium, posterior pad between the scapulae.
• Prone Procedures (e.g., some EP cases): Use anterior-posterior placement without flipping the patient mid-code when possible.
• Ensure pads are at least 10 cm apart and not over medication patches, pacemakers, or ICD generators (adjust placement per manufacturer guidance).

Shock Delivery for Cardiac Arrest

For ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) during a cath lab code:

1. Charge the defibrillator while CPR continues (minimize pause in compressions to ≤10 seconds for shock delivery).
2. Biphasic Energy: Deliver 120–200 J for the first shock (follow institutional protocol — many use 200 J maximum for biphasic devices). Escalate energy on subsequent shocks if VF/pVT persists.
3. Clear the Patient: Loudly state "Clear — shock ready — everybody clear" and visually confirm no one is touching the patient or table before pressing the shock button.
4. Resume CPR immediately for 2 minutes before rhythm check (ACLS algorithm).

Synchronized Cardioversion

For unstable tachycardia with a pulse (e.g., monomorphic VT with hypotension, SVT with ischemia):

1. Enable SYNC mode on the defibrillator — the device delivers the shock on the R-wave to avoid the vulnerable T-wave period.
2. Start at 100 J synchronized for unstable SVT or atrial flutter; 150–200 J for unstable monomorphic VT.
3. Sedation/analgesia (e.g., midazolam, fentanyl) when the patient is conscious, per physician order — the RCIS prepares medications and monitors hemodynamics during cardioversion.

External (Transcutaneous) Pacing

When bradyarrhythmia causes hemodynamic compromise (symptomatic heart block, slow junctional rhythm):

1. Attach pacing pads or use the pacing cable with multifunction electrodes.
2. Set rate at 60–80 bpm initially; increase current (mA) from 0 until electrical capture is seen (consistent wide QRS after each pacing spike) and mechanical capture is confirmed (pulse matches paced rate).
3. Typical capture thresholds: 50–100 mA for transcutaneous pacing — expect patient discomfort; sedation may be required if the patient is conscious.

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Code Cart Contents and Organization

The emergency crash cart (code cart) is a mobile unit stocked with ACLS medications, airway tools, IV supplies, and procedural backup equipment. Layout varies by institution, but the RCIS must know their lab's cart without opening drawers during an emergency.

Typical Drawer Organization

• Top/ Airway Drawer: Bag-valve-mask (adult and pediatric sizes), oropharyngeal airways (OPA sizes 3–5), nasopharyngeal airways (NPA sizes 6–8), laryngoscope handle and blades (Macintosh 3–4, Miller 2–3), endotracheal tubes (6.0–8.0 mm), stylet, lubricant, tube holder, King LT or supraglottic airway devices, CO₂ colorimetric detector.
• Medication Drawer: Epinephrine 1:10,000 (1 mg/10 mL), amiodarone 150 mg/3 mL, atropine 1 mg/10 mL, adenosine 6 mg/2 mL, calcium chloride, sodium bicarbonate, dextrose 50%, magnesium sulfate, lidocaine, vasopressin (per local protocol), naloxone, flumazenil.
• IV Access Drawer: Large-bore IV catheters (14–18 gauge), IV tubing, normal saline 500 mL and 1000 mL bags, pressure infusion bags, central line kit (if not in a separate cart).
• Procedure Drawer: Chest tube tray, pericardiocentesis kit, sterile gloves, scalpel, sutures, hemostats, needle decompression kit (angiocath for tension pneumothorax).

RCIS Code Cart Responsibilities

• Verify daily seal or checklist log is signed.
• Restock immediately after any code event — epinephrine and amiodarone are consumed quickly.
• Know the location of pediatric dosing tapes (Broselow) if the lab performs adult congenital cases.
• Bring the cart to the bedside at the first declaration of a code; assign one team member to manage medication preparation while compressions continue.

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Suction Equipment

Effective suction is essential for airway management, vomitus clearance, and bleeding control during oral procedures. Cath labs maintain both central wall suction and portable battery suction units as backup.

Setup and Operation

1. Connect suction tubing to the wall outlet or portable unit; set regulator to 80–120 mmHg (or 12–15 L/min flow) for oropharyngeal suction.
2. Yankauer Suction Tip: Rigid, curved tip for oral pharynx — used during BVM ventilation to clear secretions, blood, or vomitus. Never apply suction to soft tissue for prolonged periods (mucosal damage occurs within seconds).
3. Tonsil Suction Tip (Yankauer alternative / flexible catheter): Flexible French catheter (12–14 Fr) for deeper pharyngeal or tracheal secretions during intubation.
4. Canister Maintenance: Ensure the collection canister is empty and properly seated; a full or disconnected canister eliminates suction instantly.
5. Test Before Each Case: Occlude the tubing briefly — audible suction at the tip confirms function.

During contrast reactions with vomiting or during CPR with gastric insufflation, the RCIS positions suction at the bedside before it is needed — not after the airway is compromised.

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Airway Management Equipment

Most cath lab patients receive moderate sedation; airway emergencies range from partial obstruction (snoring, stertor) to complete apnea requiring intubation. The RCIS supports airway management to the scope of practice — typically BVM ventilation, airway adjunct placement, and intubation equipment preparation for respiratory therapy or anesthesia.

Bag-Valve-Mask (BVM) Ventilation

• Select the correct mask size — the mask should cover the nose and mouth without extending below the chin.
• E-C Clamp Technique (Single Rescuer): One hand forms an "E" over the mask edge and a "C" around the mandible to seal the mask; the other hand squeezes the bag.
• Two-Person Technique: Preferred during codes — one person uses both hands for a two-hand mask seal while the second compresses the bag, delivering 600–800 mL tidal volume over 1 second (avoid excessive volume causing gastric insufflation).
• Connect supplemental oxygen at 15 L/min to the BVM reservoir when available.

Airway Adjuncts

• Oropharyngeal Airway (OPA): Inserted in unconscious patients without a gag reflex. Size by measuring from the corner of the mouth to the angle of the mandible. Too large an OPA can obstruct the larynx; too small fails to maintain patency.
• Nasopharyngeal Airway (NPA): Soft rubber tube through the nares into the posterior pharynx — usable in semi-conscious patients with intact gag reflex. Contraindicated with suspected basilar skull fracture. Lubricate and insert bevel toward the septum.

Intubation Equipment Preparation

When the physician or anesthesia provider prepares for endotracheal intubation, the RCIS assembles:

• Laryngoscope with tested light source and appropriate blade
• ET tube (typically 7.0–8.0 mm for adult men, 7.0–7.5 mm for adult women) with stylet
• 10 mL syringe for cuff inflation
• Tube holder or adhesive tape
• End-tidal CO₂ detector (colorimetric or waveform capnography)
• Functional suction at the head of the bed

Supraglottic Airways

Devices such as the laryngeal mask airway (LMA) or King LT provide a bridge airway when bag-mask ventilation is difficult and intubation is not immediately successful. The RCIS should know the size selection chart and insertion depth markers for the devices stocked in their lab.

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Integration During Cath Lab Codes

Emergency equipment does not operate in isolation — the RCIS integrates defibrillator, cart, suction, and airway tools into the ACLS team dynamic:

• Compressor rotates every 2 minutes to prevent fatigue.
• Airway Manager operates suction and BVM between ventilator placement.
• Medication Nurse/RCIS draws epinephrine 1 mg IV/IO every 3–5 minutes during cardiac arrest.
• Recorder documents rhythm, shocks, medications, and times.
• Operator/Physician leads rhythm interpretation, shock decisions, and procedural causes (tamponade, coronary occlusion, air embolism).

Shift-start equipment checks, spatial familiarity with the code cart, and rehearsed team roles transform emergency equipment from passive inventory into functional life-saving capability. The RCIS who can charge a defibrillator, deliver a shock, clear an airway, and draw epinephrine without hesitation is an indispensable member of every cath lab emergency response.