SOP for Opthalmic Eye Clinics
It is recommended that a crash cart be maintained in every ophthalmic clinic where fluorescein angiograms are performed.
Emergency Crash Cart (Code Cart) Content Checklist
An emergency crash cart is a wheeled chest of drawers that stores lifesaving equipment, drugs, or anything that will be required in the event of a medical emergency. This HealthHearty write-up provides an emergency crash cart content checklist.
Doctors and Nurses need to be Trained:
• The doctors and nurses involved in such cases have to be familiar with the contents of the cart so that the emergency is handled properly. They have to be trained in life support protocols such as Advanced Cardiac Life Support/Advance Life Support (ACLS/ALS) and Pediatric Advanced life Support (PALS).
• The number of drawers present in a cart can vary from 3 to 7.
Contents of the Emergency Crash Carts
➠ Placed on top of the crash cart is the defibrillator, which administers an electric shock of a certain voltage to the heart so as to restore the normal rhythm of the heart in the event of a cardiac arrest. Other items that are placed on the shelf, containers, and the left side include defibrillator pads, latex gloves, stethoscope, BVM masks, sharps container, oxygen, inventory checklist/Code Blue sheets, etc. A cardiac board is often placed on the rear.
➠ The first drawer contains emergency or ACLS first-line, rapid sequence drugs such as epinephrine, atropine, amiodarone, lidocaine, nitroglycerin, diazepam, naloxone, sodium bicarbonate, dopamine, and vasopressin.
➠ Pediatric medication and IV solutions might be placed in the second drawer.
➠ The adult intubation supplies are mostly placed in the third drawer. These include endotracheal tubes, tracheostomy tube, ambu bag, oral airways, pressure cuffs, carbon dioxide detector, suction catheters, nasal cannulas, laryngoscope, forceps, guidewire, bulbs, blades, batteries, straight and curved blade, syringe, lubricant, adhesive tape, exam gloves, IV cannulas, disposable syringes, etc.
➠The infant and pediatric intubation supplies are placed in the fourth drawer. Pediatric doses of emergency drugs, and small-sized endotracheal tubes, blood pressure cuffs, oxygen masks, cannulas, etc., can be found in this drawer.
➠ The fifth drawer contains IV supplies (cannulas, drip sets, fluids) and blood draw supplies. It usually contains catheters, tourniquets, syringes, tubes, and tape.
➠ Intravenous solutions, tubing, and different types of surgical kits are usually placed in the last drawer.
Crash Cart Checklist
Click on the checklist to obtain a print.
Top, Side, and Rear of the Cart
• ◻ Defibrillator/Cardiac Monitor
• ◻ Defibrillator pads
• ◻ Latex gloves
• ◻ Eye protection
• ◻ Adult and pediatric multi-function electrodes
• ◻ 5 in 1 connector and 02 tubing
• ◻ Adult and pediatric BVM with masks
• ◻ Surgical cone masks
• ◻ Oxygen tank and gauge
• ◻ Cart inventory list
• ◻ Defibrillator gel
• ◻ Sharps container
• ◻ Code blue forms
• ◻ Procedures sheet
First Drawer (Medications)
• ◻ Adenosine 6mg/2ml vial
• ◻ Amiodarone 150 mg/3ml vial
• ◻ Atropine 1mg/10 ml syringe
• ◻ Calcium chloride 1g/10 ml syringe
• ◻ Dopamine 400 mg/250 ml IV bag
• ◻ Epinephrine 1 mg/10 ml (1:10,000) syringe
• ◻ Flumazenil
• ◻ Lidocaine 100 mg 5ml syringes
• ◻ Lidocaine 2 g/250 ml IV bag
• ◻ Dextrose 50% 0.5 mg/ml 50 ml syringe
• ◻ Diphenhydramine 50mg/ml vial
• ◻ Sodium bicarbonate 50mEq/50 ml syringe
• ◻ Sodium chloride 0.9% 10 ml vial
• ◻ Sterile water Injection 20 ml vial
• ◻ Vasopressin 20 units/ml 1 ml vial
Second Drawer (Pediatric Medications and IV Solutions)
• ◻ Atropine 0.5 mg/ 5 ml syringe
• ◻ Sodium bicarbonate 10 mEq/10 ml (8.4%) syringe
• ◻ Saline flush syringes
• ◻ Sodium chloride 0.9% 10 ml flush syringe
• ◻ Sodium chloride 0.9% 100 ml IV bag
• ◻ Dextrose 5% 250 ml IV bag
• ◻ Sodium chloride 0.9% 1000 ml IV bag
Third Drawer (Adult Intubation Supplies)
• ◻ Endotracheal tubes of different sizes
• ◻ Nasopharyngeal airway
• ◻ Intubation tray
• ◻ Suction catheters
• ◻ Batteries: size C and D
• ◻ Tongue depressor
• ◻ Kelly clamp with rubber tip
• ◻ Carbon dioxide indicator
• ◻ Flashlight
• ◻ Forceps and syringes
• ◻ Laryngoscope blades
• ◻ Laryngoscope handle
Fourth Drawer (Pediatric Intubation Supplies)
• ◻ Endotracheal tubes of different sizes
• ◻ Pediatric/Neonatal stylet
• ◻ Laryngoscope blades
• ◻ Batteries: size AA
• ◻ Laryngoscope handle
• ◻ Forceps
• ◻ Airways of different sizes
• ◻ Huggable ECG electrode
• ◻ BP cuff with sphygmomanometer and BP Bulb
• ◻ Nasopharyngeal airway
• ◻ Armboards
• ◻ Spinal needle
• ◻ Insyte autoguard
• ◻ Swabsticks
• ◻ Infant feeding tube
• ◻ Umbilical vessel catheter
• ◻ Bone marrow needle (15 G, 18G)
• ◻ Suction catheter kits
Fifth Drawer (Circulation)
• ◻ IV start kit
• ◻ Normal saline and Ringer’s lactate, and Dextrose5% Water
• ◻ Angiocath
• ◻ 3-way stopcocks
• ◻ Heparinized aspirators
• ◻ Blood tubes
• ◻ Syringes and non-coring Huber needles
• ◻ Luer lock syringes
• ◻ Tourniquet tubing
• ◻ Insyte autoguard of different sizes
• ◻ Spinal needle and other needles
• ◻ Tape
• ◻ Vacutainers
• ◻ Arterial blood sampling kit
• ◻ Macrodrip, microdrip, and extension tubing
• ◻ Armboard
Sixth Drawer (Procedure Trays)
• ◻ ECG electrodes
• ◻ Surgeon’s gloves
• ◻ Sutures
• ◻ Disp. needle holder
• ◻ Yankauer suction
• ◻ Sterile field
• ◻ Salem sump
• ◻ Syringe (10 or 12 cc)
• ◻ Sponges
• ◻ Adult/Pediatric cut down pack
• ◻ Cricothyroidotomy pack
It must be noted that the arrangement of the equipment and the drugs in a crash cart could vary, depending on the policy of the hospital. In fact, for pediatric population, the drawers of the cart are color-coded, based on the Broselow Pediatric Emergency Tape. The drawers are organized as per the patient’s length and weight range. The drawer contains the drugs in the pediatric doses and the equipment and supplies for resuscitation are appropriately sized for the child in that specific weight range.
Instructions Related to Crash Cart Use
Carts are of three types. These include adult crash carts, pediatric crash carts, and newborn intensive care crash carts. The guidelines for crash cart use that need to be followed by the hospitals and clinics include:
➠ The crash carts have to be conveniently placed near the emergency rooms, treatment rooms for anaphylaxis, etc.
➠ There has to be an inventory of medications, equipment, and IV fluids listed by the contents of each drawer in the carts.
➠ The inventory of the crash cart items, such as the drugs and the IV fluids, should contain the name, strength, and amount of the drug along with its expiration date.
➠ The inventory of the crash cart contents has to be checked on a monthly basis to check for the IV fluids and drugs and their expiration date.
➠ The drugs need to be replaced before the expiration date.
➠ In case of a battery-assisted equipment, batteries need to be checked.
➠ Defibrillator load checks must be performed once daily, with the defibrillator plugged in, as well as unplugged.
➠ The defibrillator should be checked on a daily basis, and it has to be documented.
➠ If changes are made to the cart’s contents, the drug and equipment inventory list needs to be updated.
➠ The crash cart must be locked or should have an integrity seal.
➠ If the seal of the cart is broken, the reason for the same needs to be documented, with the necessary details such as the date, time, individual’s initials, and the new lock or seal number.
➠ The oxygen tanks must be secured to the side of the cart.
➠ If the oxygen tank is empty, oxygen cylinders need to be replaced.
➠ Drawers of the crash cart need to be clearly labeled.
On a concluding note, it is extremely essential that carts are well-stocked with all the necessary drugs and equipment to ensure that the doctors are able to confidently handle emergencies. A licensed official is designated for the purpose of checking the defibrillator, oxygen cylinder levels, and the other contents of the crash cart. He/She is also responsible for rechecking and restocking the cart following its use. He is also responsible for documenting compliance on crash cart checklist. In fact, code drills are often conducted to check the response of the staff during such situations.
Reference: https://healthhearty.com/emergency-crash-cart-content-checklist
OCT -A ANGIOGRAPHY
https://journalretinavitreous.biomedcentral.com/articles/10.1186/s40942-015-0005-8
https://www.zeiss.com/meditec/int/products/ophthalmology-optometry/glaucoma/diagnostics/oct/oct-optical-coherence-tomography/cirrus-oct-with-angioplex.html
The newest advances in angiography is OCT-A. There is far less risk to the patient because there is no need for dye to be injected, which eliminates the possibility of an allergic reaction. The photographer can concentrate on the quality of the captured images since there is no need to hurry to take the photographs before the dye is absorbed. For the same reason, this imaging is easier to reproduce than fluorescein angiography.
Please note that, “FA imaging of the radial peripapillary network, deep retinal capillary plexus and choroidal vasculature is poor.3 FA image interpretation is based on dynamic properties of dye leakage, staining and blockage.” http://www.retina-specialist.com/article/will-oct-angiography-replace-fa
The FA technique can be limited by its more expensive technical requirements, time constraints, invasive nature and risk of allergic reaction to the fluorescein dye, ranging from nausea to, rarely, death from anaphylactic shock.
Anaphylaxis is a severe allergic reaction that needs to be treated right away. If you have an anaphylactic reaction, you need an epinephrine (adrenaline) shot as soon as possible, and someone should call 911 for emergency medical help. Left untreated, it can be deadly.
Epinephrine can reverse the symptoms within minutes. If this doesn’t happen, you may need a second shot within half an hour.
http://www.retina-specialist.com/article/will-oct-angiography-replace-fa
Central Serous Retinopathy
An association has also been made between CSC and patients with emotional distress and/or “type A” personalities. It is possible that the body produces natural corticosteroids in times of stress that may trigger CSC in an individual prone to this condition.
Patients with high blood pressure or heart disease, and those with a current or recent pregnancy have been shown to have a higher risk of developing CSC.
Reference:
Treatment and prognosis
Central Serous Retinopathy, CSC is typically a self-limiting disease, and visual recovery usually occurs within a few weeks to months without treatment.
Several therapies have been used to treat chronic CSC, including thermal laser treatments, oral medications, and eye injections. A “cold laser,” called photodynamic therapy, is also effective and often used to focally treat the source of fluid leakage under the retina in chronic CSC.
https://www.asrs.org/patients/retinal-diseases/21/central-serous-chorioretinopathy
