Copyright EMAP Publishing 2023
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Clinical Practice
Practical procedures
Critical care
Adult emergency trolley 2:
equipment to support circulation
Authors Sarah Cocker is senior lecturer
advanced practice, Lorraine Whatley
is senior lecturer simulation and
immersive learning technology; both
at Oxford Brookes University.
Abstract This article – the second of
two on emergency equipment to
support resuscitation of adults during
cardiopulmonary arrest in acute
hospitals – focuses on equipment and
supplies to support circulation. It
explores overarching quality standards
and checking procedures, before
describing circulation equipment, and
its function and use during an
emergency. The need to maintain the
equipment and locate it quickly is
emphasised, along with the importance
of practitioners operating within their
own scope of practice and level of
competence, while adhering to local
trust policy.
Citation Cocker S, Whatley L (2023)
Adult emergency trolley 2: equipment
to support circulation. Nursing Times
[online]; 119: 9.
Fig 1. Chain of survival
Source: Resuscitation Council UK (2021)
Nursing Times [online] September 2023 / Vol 119 Issue 9
T
he annual incidence of in-hospital
cardiac arrest (IHCA) in the UK is
1.0 to 1.5 per 1,000 hospital admis-
sions (Perkins et al, 2021). Patients
will often display clinical signs of deterio-
ration in the hours preceding the event,
which is why the Resuscitation Council UK
(RCUK) advocates early recognition and
calling for help as one of the first links in
the chain of survival (RCUK, 2021) (Fig 1).
Early warning score (EWS) systems –
such as National Early Warning Score 2
(NEWS2) developed by the Royal College of
Physicians – are often used to help nursing
staff identify and escalate the deterio-
rating patient, allowing for interventions
to help prevent cardiac arrest. Importantly,
nurses will often use clinical judgement
and experience to identify factors outside
of EWS systems, such as breathing pat-
terns and skin colour, as vital cues in the
decision to escalate (Ede et al, 2019).
Should the patient go on to have a car-
diac arrest, interventions that can con-
tribute to a successful outcome are:
● Early cardiopulmonary resuscitation
(CPR) – immediate chest compressions
and ventilation of the patient’s lungs
will slow down deterioration of the
brain and heart;
● Early defibrillation – in a hospital
setting, if there is an appropriate
presenting rhythm, defibrillation
should be attempted within three
minutes;
● Post-resuscitation care – if return of
spontaneous circulation (ROSC) is
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Keywords Emergency trolley/Cardiac
arrest/Resuscitation/Circulation
This article has been
double-blind peer reviewed
reached, the aim is to restore the patient
to a state of ‘normal’ (RCUK, 2021).
Reasons for cardiac arrest are often
complex but, sometimes, a reversible
cause can be identified, and early recogni-
tion and escalation for management
increases the chances of a positive out-
come for the patient. Nurses should recog-
nise the need to seek help early from spe-
cialist resuscitation teams, who can
provide advanced life support to patients
in cardiac arrest.
Alongside early recognition and escala-
tion, ensuring the availability, and staff
knowledge of, key resuscitation equip-
ment to support circulation is essential to
providing timely and effective life sup-
port. Nurses should familiarise themselves
with resuscitation equipment in their clin-
ical environment as this may save time
during an emergency.
Resuscitation education and training is a
statutory mandatory requirement for
health staff, to give them the necessary
knowledge and skills to provide appro-
priate life support to their patients (Nursing
and Midwifery Council, 2018). Nurses
should ensure they maintain competence
in resuscitation, which is appropriate to
their role, by undertaking regular updates
in line with professional regulations,
national guidance and local trust policy.
They must also be aware of the importance
of ensuring their own personal safety (as
well as that of other staff and patients)
during a cardiac arrest, and adhering to
national and local guidance on infection
control procedures and personal protective
equipment (PPE) during their practice.
This article is a guide to the emergency
equipment and supplies needed to support
resuscitation of adults during cardiopul-
monary arrest in acute hospitals, with a
focus on circulation. It includes items that
should be on the emergency trolley or easily
accessible in your clinical area, along with
information on their function and use.
Cardiac equipment
Defibrillator
Defibrillation means applying an electrical
current across the chest wall that passes
through the myocardium. It is achieved
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Clinical Practice
Practical procedures

Fig 2. Automated external defibrillator using a defibrillator device (Benson-

Clarke, 2022). After cardiac arrest, early
defibrillation for ventricular fibrillation
and pulseless ventricular tachycardia,
complemented by immediate uninter-
rupted early bystander CPR, will help
improve survival (RCUK, 2021). A defibril-
lator should be immediately available in
acute care settings (RCUK, 2023) and will
often reside on the top of the resuscitation
trolley. The type of defibrillator available
will depend on a local risk assessment and
be one of the following:
● An automated external defibrillator
(AED) (Fig 2);
● A manual defibrillator/multifunction
device that may have an AED function
and, depending on location, pacing
functions (Fig 3).

Fig 3. Manual defibrillator with pacing function Automated external defibrillator

Defibrillators with automated rhythm rec-
ognition, commonly known as AEDs, are
often placed in clinical and non-clinical
areas where staff do not have rhythm
interpretation skills. Public-access devices
are also now commonly found in the com-
munity, such as in supermarkets, sports
centres, train stations and village halls, so
lay rescuers can use them quickly in an
emergency. AEDs will often use both visual
and voice prompts to help health profes-
sionals and lay rescuers attempt defibrilla-
tion safely when a person is in cardiac
arrest (RCUK, 2021).
The AED must be turned on and used
with compatible defibrillator pads/elec-
trodes. The device will provide verbal
instructions to the responder and assess
whether defibrillation is appropriate for
Courtesy ZOLL Medical Corporation the patient. Training and orientation in
the AED in your clinical area will be via
your mandatory resuscitation training.
Fig 4. Defibrillator pads
Manual defibrillator/multifunction device
In certain areas, patients may have a higher
risk of cardiac arrest requiring the availa-
bility of a manual defibrillator with or
without a pacing function. A manual defi-
brillator differs from an AED in that it is
the operator who interprets the rhythm
and identifies whether a shock is needed –
this is a skill that requires additional
training. Local policy may determine who
can deliver manual defibrillation in this
way, but it is often a skill possessed by
members of the resuscitation team.
The manual defibrillator optimises the
provision of chest compressions by ena-
bling the defibrillator to be charged while
chest compressions are being delivered
(RCUK, 2021).

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Clinical Practice
Practical procedures
Fig 5. Anterior-lateral defibrillator pad position
Fig 6. Anterior-posterior defibrillator pad position
Front
Manual defibrillators are also some-
times known as multifunction devices, as
they can often do many other things as
well as manual defibrillation. Most models
can also be used in AED mode to enable
first responders without rhythm interpre-
tation skills to deliver a shock safely during
the first few minutes of a cardiac arrest.
Some devices also have the capability to
monitor vital signs – such as blood pres-
sure, oxygen saturations, electrocardio-
gram (ECG) and carbon dioxide waveform
capnography – allowing close monitoring
of peri-arrest or post-arrest patients. Cer-
JENNIFER N.R. SMITH
tain machines can also provide external
pacing and cardioversion if required. This
may be appropriate in certain areas, such
as cardiac units, emergency departments
Nursing Times [online] September 2023 / Vol 119 Issue 9
Back
and intensive care units (RCUK, 2023).
External pacing and cardioversion are
advanced skills that require individuals to
have additional education and training if
they are to be competent to deliver them.
Defibrillator pads
Defibrillator pads (Fig 4) are applied to the
patient’s bare chest and transmit the elec-
trical energy from the defibrillator via con-
nector cables through the chest and across
the heart. They are usually available in two
sizes: child and adult. Pad size in children
depends on the child’s weight (Hucker and
Lawson-Wood, 2023) with larger children
sometimes requiring adult pads, so it is
important that staff in paediatric or dual
areas know which pads to use.
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Defibrillation pad application
The pads should be applied to clean, dry
and hairless skin. This may mean pre-
paring the chest first to ensure good con-
tact. Excess chest hair will give poor con-
tact that results in poor energy transfer, so
can be clipped or shaved off. However, it is
better to try to avoid shaving to minimise
infection risk should the skin be grazed
(Carvalho et al, 2020). The better the pad
application, the better the energy transfer
so, provided chest compressions are occur-
ring simultaneously, practitioners should
take time when applying the pads to make
sure contact is optimised. It is worth
noting that the pads are extremely sticky.
There must be no jewellery under the
pad placement as this will deviate the path
of the electrical energy. Necklaces should be
moved away from the chest but, as upper-
body piercings can be difficult to remove
quickly, practitioners should instead place
the pad away from the piercing and not
directly over it. Acute wounds, burns and
dressings should be avoided when placing
the pads as they will also impede contact.
Pacemakers and implanted cardioverter
devices will also deviate the path of elec-
tricity. If you are aware of their existence or
can view one of these devices in the chest,
place the pad at least 8cm (about a pad’s
width) away from it (RCUK, 2021) or use an
alternate pad position, such as the ante-
rior-posterior position described below.
Defibrillator pad electrodes cannot be
cut and need to be placed at least one pad’s
width away from each other. If your
patient has a very small chest, again you
may need to consider alternative pad
placement, such as the anterior-posterior
position described below.
The most common pad placement in
adults is the anterior-lateral position, in
which one pad is applied just below the
right clavicle and the other is placed to the
lower-left rib cage in the midaxillary line
(Fig 5). This ensures the heart is sandwiched
between the two pads and directly in the
path of transferring energy. Most pads will
have images on them to reflect this.
The alternative is the anterior-posterior
position. Here, one pad is placed at the
front of the chest over the left precordium,
then the patient is rolled and the other pad
is applied posteriorly in a similar position
inferiorly to the left scapula, again sand-
wiching the heart (Fig 6).
ECG electrodes
The manual defibrillator pads, as well as
delivering a shock, will read and display a
cardiac rhythm. However, it is also good

Clinical Practice
Practical procedures
practice to apply the three cardiac leads
(red, yellow, green) (Fig 7) in a timely
fashion as they can provide alternative
views of the electrical activity. They are
also important in monitoring peri- and
post-arrest patients.
Vascular access and fluids
Cannulation equipment and adhesive
tape
A cannula is required for the administra-
tion of drugs, fluids and, possibly, blood
during resuscitation. A variety of can-
nulas, tourniquets, adhesive tape and can-
nula dressings (Fig 8) should be readily
available on the resuscitation trolley. If the
patient is already cannulated, a second
cannula is often useful.
Intravenous (IV) extension set
Syringes will need to be repeatedly con-
nected/disconnected and products are
administered often throughout the resus-
citation process, so an IV extension set
(Fig 8) will help to protect the cannula
from movement, irritation and contami-
nation at its site of entry.
IV fluids
The selection of IV fluids (Fig 8) should
include:
● 1L 0.9% sodium chloride (saline)
– hypovolaemia is a common cause of
patient deterioration/arrest so fluid
replacement is often required;
● Glucose for infusion – a patient’s
collapse is often preceded, or
accompanied, by hypoglycaemia; if
this can be readily reversed, further
deterioration may be avoided.
Needles and syringes
Needles and syringes in various sizes (Fig 8)
are needed to administer fluids and drugs.
Pressure bag for infusion
A pressure bag for infusion (Fig 8) is key to
making sure fluids can be administered
quickly if urgent prescribed volumes are
needed.
Blood–gas syringe
A blood–gas syringe is useful when moni-
toring causes of collapse, as well as
response to treatment. Responders should
also be aware of the location of the nearest
blood–gas analysing machine.
Blood-sampling tubes (various)
These tubes are needed for investigations
into the cause of collapse and to monitor
the response to resuscitation.
Nursing Times [online] September 2023 / Vol 119 Issue 9
Fig 7. Three-lead
electrocardiogram placement
RA LA
LL
Red: electrode placed under right clavicle
near right shoulder within the rib cage frame
Yellow: electrode placed under left clavicle
near left shoulder within the rib cage frame
Green: electrode placed on the left side below
pectoral muscles lower edge of left rib cage
Intraosseous (IO) access device
It can be difficult to cannulate a patient
who is critically unwell or in cardiac arrest
as their circulation is often very poor and
veins can be hard to locate. However, drugs,
fluids and medications are often needed
urgently. When vascular access cannot be
obtained rapidly, an IO access device may
be used. The IO needle is inserted through
the cortex of a bone (humerus, femur, tibia)
into the medulla, which is a well-vascular-
ised area of bone marrow. The needle can be
inserted using a handheld drill version of
the IO access device (Fig 8) or a spring-
loaded IO device. Device operation and
insertion of an IO needle is an advanced
skill that should be performed:
● Only by staff who have received the
appropriate training;
● Following local policy guidance.
IO devices may not be located on every
trolley, but responders should be able to
identify how to readily access them.
Additional items for the
emergency trolley
Razor/clippers
Clippers or a razor (Fig 8) are needed to
remove any excessive chest hair that will
impede pad application. These should be
used with care as any trauma (bleeding
from wounds) will also impede pad contact.
Clock/timer
There is often a clock or timer located in
the defibrillator, but this will only start
when the defibrillator is switched on.
Therefore, a timer or clearly visible clock is
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useful for noting timings for drug admin-
istration, measuring two-minute cycles
and documenting events.
PPE, including eye protection
Consult your local policy guidance for the
most recent requirements about PPE in
your clinical area.
Sharps bin
This should be readily available and either
on, or attached to, the emergency trolley to
ensure safety and correct sharps disposal.
Large scissors
Commonly, large scissors (Fig 8) or trauma
shears that can can cut through clothing,
belts and jewellery in an emergency are
provided on the trolley; these are also
useful for bandages and dressings. They
are blunt tipped, so safer for the patient
when used in a hurry.
Drugs labels
Drugs labels are vital to support the safe
identification and administration of medi-
cations in a rapidly changing situation
that involves many staff members, and
where multiple drugs, products and fluids
are administered quickly and often.
Paperwork: audit, patient and do-not-
attempt-resuscitation (DNAR) forms
These forms may be centrally accessible
and available electronically in many clin-
ical areas; contact your resuscitation ser-
vice for local details and requirements.
Hospitals are encouraged to participate
in the national audit into cardiac arrest,
jointly run by RCUK and the Intensive Care
National Audit and Research Centre. Com-
pletion of a DNAR form by a doctor or, in
some trusts, a senior nurse may also be an
appropriate outcome in some clinical
emergency situations.
Algorithms and emergency drug doses
Although information on these may be
available on local electronic systems,
access to paper copies of guidelines, emer-
gency protocols and drug doses can be
helpful in the high-pressure environment
of a resuscitation attempt. All are evidence
based so will support safe care delivery.
Further cardiovascular
resuscitation Items
Central venous access device
A central venous access device (Fig 9) is
extremely useful in the care of the critically
unwell patient, both for monitoring and
administering therapies. It may be difficult
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Clinical Practice
Practical procedures

Fig 8. Circulatory equipment

a
b

e f
d

l
k

a. Cannula (various sizes) f. Intravenous fluids: saline and glucose j. Intraosseous access device (drill
b. Adhesive tape solution version) and needles
c. Pressure bag for infusion g. Intravenous extension set k. Large scissors
d. Tourniquet h. Syringes (various sizes) l. Razor
e. Cannula dressing i. Needles (various sizes)

and unsafe to obtain central venous access
during an acute emergency but, once the
patient is more stable and the setting more
controlled, this may be achieved.
Ultrasound/echocardiography device
Both ultrasound and echocardiography
devices are commonly used for bedside
investigations, and may be used in an
emergency to identify or rule out causes of
deterioration and arrest. The ultrasound
device may also be used to help with both
central and peripheral vascular access
insertion. Such devices can only be oper-
ated by staff who are trained and compe-
tent in their use and interpretation, but
staff in clinical areas may need to facilitate
access to these devices.
First-line cardiac arrest drugs
Adrenaline
Adrenaline/epinephrine 1mg at a concen-
tration of 1 in 10,000 (100µg/mL) is recom-
mended via IV injection, repeated every

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Clinical Practice
Practical procedures
Fig 9. Central venous access device
three to five minutes (RCUK, 2021). Adren-
aline is a vasopressor, causing vasocon-
striction and optimising perfusion to the
coronary tissue and other major organs. It
also increases heart rate and contractility.
Adrenaline is delivered in shockable
and non-shockable arrests. Commonly, it
may be available in pre-filled syringes for
IV administration in adults. It is important
to note that 1:1,000 adrenaline is also avail-
able (commonly used for anaphylaxis via
intramuscular injection).
Health staff involved in preparing and
administering adrenaline in an emergency
need to ensure they are:
● Accessing the appropriate
concentration;
● Competent in IV therapy
administration.
Amiodarone
Amiodarone 300mg may be given in a ven-
tricular fibrillation or pulseless ventric-
ular tachycardia arrest, so is only given in a
shockable arrest. It is administered for
refractory rhythms (failure to respond to
initial defibrillation) so may be adminis-
tered after the third shock; a subsequent
dose of 150mg may also be administered
after the fifth shock.
As amiodarone is an antiarrhythmic
drug, it may improve a patient’s response
Nursing Times [online] September 2023 / Vol 119 Issue 9
to defibrillation. This is often available for
cardiac arrest in a pre-filled syringe.
Other recommended drugs
RCUK (2023) outlines a list of additional
drugs that are recommended for use in
emergency incidents. These may be too
numerous to be included in the resuscita-
tion trolley and are not always needed.
However, these additional drugs may be
located:
● In the clinical area (see your local
policy);
● Centrally in the acute hospital setting.
Responders should know how to access
these additional drugs.
Conclusion
Recognising the deteriorating patient and
escalating care accordingly can allow for
interventions to prevent cardiac arrest.
However, if cardiac arrest does occur,
following the chain of survival and having
immediate access to familiar emergency
equipment that is well maintained
supports the delivery of high-quality resus-
citation care for patients.
This article has explored the equipment
and supplies that should be available to
support circulation in an adult who is
acutely ill. It concludes our two-part series
on the contents of the adult emergency
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trolley, and how nurses can use them to
support the best resuscitation outcomes. NT
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Professional responsibilities
This procedure should be
undertaken only after approved
training, supervised practice and
competency assessment, and carried
out in accordance with local policies
and protocols.