The Role

of the Anaesthetist

in the

Emergency Service

Published byThe Association of Anaesthetists of Great Britain and Ireland9 Bedford SquareLondon WC1B 3RATel: 0171 631 1650 Fax: 0171 631 4352

Membership of the Working Party

Dr P J F Baskett Chairman, PresidentProfessor P HuttonDr C R D Laird GATProfessor J Norman College of AnaesthetistsMr D SkinnerDr R SleetDr Anne J SutcliffeDr R M Weller

Ex-officio: Office Bearers of the Association ofAnaesthetists

Dr W R MacRae Honorary TreasurerDr J E Charlton Honorary SecretaryDr W L M Baird Immediate Past HonorarySecretaryDr R S Vaughan Assistant Honorary TreasurerDr M Morgan Editor

July 1991

Contents

page

Introduction 1

Section I. Anaesthesia and analgesia in the Accidentand Emergency Department 2

Section II. Resuscitation within the Accident andEmergency 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

Appendix II 21

1

Introduction

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

The contributions include the provision of analgesia, anaesthesiaand resuscitation both inside and outside hospital andinvolvement with major incident plans and responses. Inaddition, anaesthetists have a commitment to traininganaesthetic and other medical staff, nurses, other members of theA & E Department and ambulance personnel.

The Association of Anaesthetists of Great Britain and Ireland setup a multidisciplinary working party to define and report on theservices which should be provided by anaesthetists within theAccident and Emergency Service.

This report provides a framework for the role of the anaesthetistin the emergency service. Local arrangements should be made incollaboration with the consultant in charge of the A & EDepartment.

2

SECTION I

Anaesthesia & Analgesia in the Accident andEmergency Department

The A & E Department of most district general hospitals willrequire anaesthetic services to help with the provision ofanalgesia for many painful conditions, and anaesthesia for minorambulatory surgery such as suturing of lacerations, incision anddrainage of abscesses and manipulation of fractures anddislocations.

Standards of anaesthetic care and safety in the A & EDepartment must be the same as those provided in other theatresuites.

Location and equipment

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

A nominated consultant anaesthetist should be responsible forrecommending the provision of these facilities and ensure theirregular review.

Personnel

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

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

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

A trained anaesthetic nurse or operating department assistant(ODA) should be assigned to assist the anaesthetist at all timeswhen 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 offitness of the American Society of Anesthesiologists. Patients incategories III and IV may present occasionally and may beacceptable for short, relatively minor surgery, provided theirmedical condition is stable and the surgical procedure andanaesthesia will not change this. Pre-anaesthetic assessmentquestionnaires completed by the patient with the aid of admittingstaff can be helpful. Relevant questions should address thepatient’s medical history, including previous and currentmedication. There must be facilities for necessary preoperativeinvestigations. The anaesthetic technique proposed and therecovery arrangements should be explained to the patient by theanaesthetist at a preoperative assessment visit.

The anaesthetist should ensure that adequate enquiries have beenmade with regard to a suitable home environment for the patientto return to, and that the arrangements for transport andpostoperative care at home are satisfactory.

Anaesthesia in the A & E Department is more frequentlyassociated with alcohol and substance abuse, infections such ashepatitis and HIV, and the full stomach than in other locations.

Patients at particular risk of delayed stomach emptying includethose injured shortly after eating, those who have consumedalcohol, those who are in pain or those who are frightened. Thisapplies particularly to children. The optimal period of fastingprior to anaesthesia for trauma has not been established clearly.It is recommended that precautions be taken to preventpulmonary aspiration of gastric contents for 12 hours afterinjury.

4

Children requiring anaesthesia in the A & E Department willrequire special facilities, equipment and expertise and the needs ofparents 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 nerveblocks is safe provided that the local anaesthetic is administeredin non-toxic doses and there are no absolute or relative contra-indications to the use of the technique. Even modest doses oflocal anaesthetic agents can cause problems if administeredwithout due care. If safety measures are adopted, it is acceptablefor one person to administer the local anaesthetic and to performthe operation, provided the operator is trained and experiencedin basic resuscitation.

Intravenous regional analgesia (IVRA) and majorregional analgesic techniques

In addition to the increased danger of using a larger dose of thelocal anaesthetic agent, IVRA and major regional analgesictechniques may be associated with other life threateningcomplications such as hypotension and respiratory depression.IVRA in particular is a source of potential danger because theinherent simplicity of the technique encourages its employmentby people insufficiently trained in its use and the treatment ofcomplications, or in inappropriate circumstances.

It is essential that these techniques are used only when anindividual experienced with their performance and management ispresent. One person should perform the operation while asecond person trained in advanced life support monitors and caresfor the patient. This is essential if the technique is used in apatient who has recently eaten or within twelve hours of injury.Training in IVRA techniques for A & E Department medical staffshould be provided by the Department of Anaesthesia. Theequipment used for IVRA should be maintained regularly andchecked before use.Sedation techniques

5

Sedation should be used only by those with suitable relevanttraining and experience. Overdose is a particular risk, not only inthe frail and elderly who are extremely sensitive to sedativedrugs, but also in young, fit patients when analgesia is inadequateand the patient is restless. As with IVRA, one person shouldperform the operation and another, who is trained inresuscitation, must monitor the patient. Sedated patients canbecome hypoxic easily and the use of supplementary oxygen andpulse oximetry is recommended strongly. Where pulse oximetryis not available, supplementary oxygen should always be given.

Recovery and discharge

Recovery facilities, including patient monitoring, should becomparable to those recommended for day case surgery (KorttilaK. Recovery from day case anaesthesia in ‘Anaesthesia for DayCase Surgery’ Healy T E J (ed) Baillière’s ClinicalAnaesthesiology. 1990; 3: 713-732).

The anaesthetist must ensure that patients have recoveredadequately before handing over care to nursing staff. Designated,suitably trained staff must be available to supervise the recovery ofpatients following general anaesthesia, regional, IVRA and sedationtechniques. They should also administer any postoperativeanalgesic prescribed. Before discharge the patient should be assessedfor ‘street fitness’.

The patient or relative should be given written instructions forpostoperative care including a telephone contact number to callif problems arise after discharge. Specific instructions must begiven concerning the effects of the anaesthetic techniqueemployed, and in relation to driving, operating machines orappliances, and the consumption of alcohol.

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

SECTION II

Resuscitation within the Accident and Emergency

6

Department

Arrangements to provide a satisfactory resuscitation serviceshould be made by the nominated consultant anaesthetist in co-operation with the consultant in charge of the A & EDepartment. The concept of a multidisciplinary resuscitationcommittee being established for each hospital or district iswarmly supported.

Arrangements should ensure that:-

(a) Twenty-four hour cover by skilled anaesthetic personnelis immediately available. Major trauma and other life-threatening emergencies should be dealt with by relativelysenior anaesthetic personnel. Consultant support shouldalways be readily available.

(b) Adequate equipment for resuscitation is available This

equipment will need to cater for a wide range of problems inpatients 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 duringAnaesthesia and Recovery. Association of Anaesthetists ofGreat Britain and Ireland, London, 1988).

(d) There are satisfactory arrangements, including mobileequipment, for intra-and inter-hospital patient transfer afterstabilisation.

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

7

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 thatappropriate 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 nursingstaff and ODAs to be trained in techniques such asintravenous cannulation, endotracheal intubation anddefibrillation;

(iii) accident and emergency and anaesthetic staff should be

trained in advanced trauma life support. It is also desirablethat surgical members of the trauma team receive thistraining.

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

Anaesthetists working in the A & E Department should becompetent in the immediate management of eventscompromising the airway, ventilation and circulation. Thesemay include trauma, burns, poisoning, exposure to hazardoussubstances, 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 & EDepartment. These should be reviewed regularly and used as abasis for teaching and discussion.Audit

Audit of the anaesthetic and resuscitation services in the A & EDepartment is no less important than anaesthetic auditelsewhere. Data collection should be instituted, and departmental

8

protocols may be valuable in improving the standards of care byanaesthetists.

Scoring systems

For some groups of patients, audit may be facilitated by the useof internationally validated scoring systems. Scoring systems canindicate the potential severity of an injury and aid identificationof levels of departmental performance which are above or belowaverage.

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

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SECTION III

Major Incidents

Anaesthetists have vital roles to play in any major incident.These include planning and organising the response to a majorincident, 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 thehospital’s major incident committee. The plans should be madein consultation with the emergency services and voluntary aidsocieties. Special planning is needed for potential local incidentsin industry, at airports, railways, docks, waterways, naturaldisasters, sports events and other occasions where large crowdscan be expected.

Plans should be subject to regular review.

2. Clinical responsibilities

The Department of Anaesthesia provides a number of clinicalservices 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

3. Call out

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

(ii) Action cards (plasticised credit card size) should be prepared

for all personnel likely to be called to respond to majorincidents. These should be issued to all individuals and spareskept in a pre-designated advertised location. Theinstructions 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 permitaccess to the hospital site in the event of a major incident.By prior agreement with the police, identity cards can beused to allow doctors to pass through police check points.

Identity and action cards can be combined back to back on onecard within a single transparent holder (for an example, seeAppendix I).

4. On-site role

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

(i) Mobile teams

The initial mobile team will normally consist of fourpersons; an anaesthetist of sufficient experience andseniority, a surgeon or A & E physician and two nurses orODAs. The most experienced doctor should be designatedteam leader.The team’s initial objectives are to assess the situation andthe need for further assistance, perform triage and, with theambulance service, provide resuscitation and pain relief.

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Rarely, anaesthesia and surgery may be needed to rescue atrapped patient. Such activities should only be undertakenwhen initial objectives have been met.

Normally, mobile teams should be sent to the site from ahospital which is not the major designated receiving hospital.

As soon as possible, a senior doctor, who may be ananaesthetist, should be brought to the site as Medical IncidentOfficer. The role of the Medical Incident Officer is tosupervise on-site medical services, permit the mobile team tocarry out clinical duties and liaise with the receiving hospitaland the emergency services.

(ii) Transport to site

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

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

(iii) Protective clothing

Protective clothing should be worn by all members of themobile team. The clothing should be light, warm andweatherproof and of a distinctive bright colour. Thereshould be identification of the team member’s role on thefront of the jacket and the hospital of origin on the back.

(iv) Portable equipment

Portable first aid and resuscitation equipment should becarried in lightweight weatherproof containers. Equipmentbags and their contents should be compatible with those usedin all local hospitals, so that teams from different sourcescan work together. Re-supply boxes should be kept at thehospital.

12

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

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

(v) Insurance

All members of the mobile team must be covered by adequateinsurance for personal injury, death and third party risk.Insurance cover provided by the Department of Health isoften inadequate and we recommended that additional coverbe arranged from other sources such as hospital trust funds.This cover should include transport of the team by anymeans and should include road, boat, helicopter or fixed wingaircraft.

Suitable insurance cover may be arranged through the BritishMedical Association (BMA House, Tavistock Square,London, WC1H 9JP), or the British Association forImmediate Care (7 Black Horse Lane, Ipswich, IP1 2EF).

It is anticipated that doctors sent out from an NHS hospitalto attend a major accident will be covered for any subsequentmedical negligence claims under the NHS indemnity scheme.

5. Communications

The principle line of communication between the on-site teamand the A & E Department should be a radio link with theambulance service. On-site medical team leaders should be issuedwith a portable radio preferably with a talk-through facility.

Cellular telephones have proved to be of value in the early stagesof a major incident but as time progresses batteries run down andthe cell net becomes saturated.6. Training in disaster medicine

Training for all personnel involved in major incidents includes:

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

Participation in ATLS and ACLS provider courses is stronglyrecommended for anaesthetists. Selected individuals shouldattend instructor courses.

Attendance at disaster medicine meetings and conferences isstrongly commended.

(ii) Clinical practice

Anaesthetists should be familiar with the equipment andtechniques to be employed in the field. Practice within thehospital setting will ensure confidence and expertise. Thisshould include use of protective clothing and radioprocedures.

Clinical practice outside the hospital may be obtained byacting as medical officer at dangerous sporting events or byjoining an immediate care scheme through the BritishAssociation for Immediate Care (BASIC). Anaesthetistshave been valuable members of national and internationaldisaster teams.

Familiarity with hazardous chemicals and HAZCHEM identitycodes is essential. Detailed information can be obtained fromthe Fire Service, and copies should be held in the A & EDepartment. Anaesthetic implications should be highlighted inthese copies.

(iii)Exercises

Regular exercises should be conducted. Small table-topexercises can rehearse separate aspects of the total disasterplan economically. Full scale exercises involving bothhospital and emergency services should be conductedannually. Each major exercise should be carefully plannedand evaluated afterwards. The results should be widelydisseminated and the disaster plan modified accordingly.

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(iv) Post-event audit

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

(v) Counselling

Post-event counselling should be part of the major incidentplan. Any member of staff involved with a major incidentmay become emotionally stressed and such stress can persistfor a long time.

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SECTION IV

Training of Ambulance and Paramedical Staff

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

Curriculum

Extended training of ambulance personnel to paramedic standardis the responsibility of the NHS Training Authority SpecialProjects Group, which has an anaesthetist as a member.Anaesthetists contribute widely to the activities of this Groupwhich include design programmes and conduct of examinations.The curriculum is also reviewed by the Joint Colleges AmbulanceLiaison Committee The College of Anaesthetists is representedon this committee.

Anaesthetists have a particular contribution to make in trainingambulance personnel in the maintenance of airway, ventilationand circulation and in the provision of basic analgesia andsedation. Anaesthetists should be involved with both theoreticaland practical training.

Such training will include the following:- assessment and basiccontrol of the airway using oro and nasopharyngeal and laryngealmask airways, endoctracheal intubation and ventilation usingexpired air, self-inflating bags and automatic resuscitation and theuse 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 drugtherapy. Training in the use of drug therapy will include the useof certain drugs for cardiac and respiratory emergencies,

16

provision of pain relief and sedation using Entonox, parentalopioids and sedative agents e.g. benzodiazepines. Practice trainingwill require manikins and simulators, ECG/defibrillators andexperience with patients.

Consent and responsibility

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

Training of any kind requires patient consent whether it bemedical student nurse, operating department assistant orambulance personnel. The new consent form incorporatesgeneral agreement to trainee involvement, and an opt-out clausefor patients who do not wish to take part.

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

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Section V

Duties, Commitment and Support

Duties of the consultant(s) co-ordinating anaesthetic services inthe 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 withthose in areas such as intensive care, high dependency unitsand 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 inthe A & E Department.

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

Anaesthetists extensively involved with extended training ofambulance personnel should negotiate an appropriate NHDallowance for these duties.

Adequate secretarial and clerical support should be provided topermit audit and assessment tasks to be completed and to assistwith correspondence and administration.

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

REFERENCES

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

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

‘Recommendations for Standards of Monitoring duringAnaesthesia and Recovery’. Association of Anaesthetists ofGreat 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.

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Appendix I

EXAMPLE OF ACTION CARD

BEDFORD SQUARE HOSPITAL

MAJOR INCIDENT ACTION CARD

1st Call for Emergency Anaesthesia

On receiving a major incident alert inform the consultantanaesthetist on duty directly (and 2nd call or senior

registrar). Report to Control Room and carry out initialequipment checks and resuscitation as directed.

EXAMPLE OF IDENTITY CARD

BEDFORD SQUARE HOSPITAL

NAME DR J SNOW

DESIGNATION CONSULTANT

ANAESTHETIST

SIGNATURE J Snow

20

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Appendix IIEQUIPMENT FOR MOBILE TEAMS

Clothing

(Various sizes to supply one of eachitem per team member)

lightweight boiler suits (for hotweather)

Wellington boots (acid resistant)

thermal socks

knee pads

gloves - wool

gloves - chrome leather

salopettes - breather type

fleece shirts

waterproof coats - high visibility withhood

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 inlightweight bags

1. First Aid (1st Responder) bags (oneper team member) to provide basiccontrol of bleeding and the airwayand simple ventilatory support.

2. Medical snatch bags (one perdoctor/paramedic) for:

advanced airway and ventilationcontrol

intravenous fluid replacement

splintage and dressings

drugs - analgesic and resuscitation

3. Back up supply cases for replenishing

Dressings

pad dressings, large medium andsmall, 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

Sutures, chromic catgut, 2/10 10

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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 4uncuffed-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 1014,16 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 FGof 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, ofeach 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 10cannulae, 18 swg, FG10 10

infusion pump bags, large 5

intravenous cut-down setscontaining: 2

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scissors, straight, pointed, small1forceps, mosquito, straight 2forceps, dissecting,toothed, small 1forceps, non-toothed 1aneurysm needle 1needle holder, Kilner 1retractor, single, blunt hook 2scalpel handle, No 4 1scalpel blade, No 10 2scalpel blade, No 11 1dressings

sutures:chromic catgut, round bodied 6chromic catgut ties, 2/0 6silk 2/0, straight needle 6silk 2/0, reverse cutting needle 6silk 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 mlamps 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 mlamps 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 maybe provided by the Ambulance Service)

©This document is published by the Association of Anaesthetistsof Great Britain and Ireland, 9 Bedford Square, London WC1B3RA.