​Clinical Procedures - Aiding a Fallen Patient
• It is important to assess the fallen patient immediately, to establish the cause for the fall and any immediate consequences (e.g. fainting, fractures, or cardiac arrest) so that staff can respond to the situation accordingly.
Equipment
• Minimum of 2 members of staff
• Other equipment dependent on circumstances:
• 2 chairs, trolley, slide sheets, hoist with appropriate sling.
Procedure
If patient is cooperative
• Instructions may be given to help the patient up from the floor. Ask the patient to follow this routine:
• Roll onto their side.
• Push up on their hands until they are in a sitting position..
• Bend their knees up and move onto all fours...
• Place their hands onto the seat of a chair for balance...
• Move one leg forward, so they are in a half kneeling position..
• At this point, the patient should be able to push with their hands to stand up, and sit on a chair placed behind them
• If needed, the patient can now be hoisted onto a trolley for further assessment.
If patient is uncooperative
• A hoist should be used. 
If fallen in a confined space
• Place a slide sheet under their body
• With a minimum of 2 members of staff, the patient can then be slid on the floor a short distance to allow better access to assist the patient:
• It is essential that the members of staff maintain a good posture at all times during this procedure.

Procedure Tips
It is essential to establish the cause of the fall and act accordingly
• D It is important that, as the patient is moving up from the floor, their condition is continuously monitored:
 If the patient has fainted, they may be at risk of falling again
• It is important to allow the patient time to carry out the manoeuvre, as this will reduce the amount of manual assistance required from staff
• It is extremely important that the patient is NEVER LIFTED
• Lifting a patient is hazardous and may result in staff injury.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any fall should be documented in the patient's notes to ensure other ward staff are aware of any problems.

​Clinical Procedures - Percutaneous Liver Biopsy 
The following describes the technique when using a suction (Menghini) liver biopsy needle.
• Increasingly, 'blind' biopsies are being replaced by ultrasound-guided biopsies performed by the Radiology Department. Check your local guidelines.
Equipment
• Dressing pack (including gauze, bowl, drape)
• Antiseptic solution
• Sterile gloves and gown
• Local anaesthetic (e.g. 1% lidocaine)
• 2 x 10 mL syringes
• 2 × 23G (blue) needles
• Liver biopsy needles/pack
• 10mL sterile saline
• Scalpel/blade
• Tissue/biopsy collection pot.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Review the patient's clotting profile and platelet count:
• If platelets <60 × 10°/L or prothrombin time >3 seconds prolonged, consider transjugular approach or clotting factor support
• D Ensure antiplatelets and anticoagulants are stopped at least 3 days prior to procedure to minimize risk of bleeding
• Ensure the patient has IV access
• Position the patient supine with the right arm abducted
• Examine the patient and percuss the borders of the liver before choosing a biopsy site. This is usually at the 7th or 8th intercostal space in the midaxillary line
• Confirm the site with ultrasonography:
• Confirm the direction the needle will take and a safe depth for the biopsy. Ensure that there are no major vessels within the liver at this point and that no bowel lies between the liver and abdominal wall

• Clean the area with antiseptic solution
• Administer local anaesthetic using both a 23G (blue) and
21G (green) needle down to the depth of the liver capsule
• Make a small incision at the point of insertion with the blade
• Half-fill a syringe with saline and attach to the biopsy needle
• Introduce the biopsy needle just above a rib
• As the needle is advanced, flush small amounts of saline until resistance is encountered (the liver surface)
• Pull back the plunger to apply suction and ask the patient to exhale completely and hold the breath in exhalation
• Whilst maintaining suction on the syringe, push the needle into the liver to the depth and direction estimated previously and then quickly remove the needle
• This should be a quick, fluid movement taking 1 second
• The biopsy now lies either within the needle or the syringe
• Deposit the sample in a suitable collection container:
• Judging an 'adequate' biopsy is controversial, but 2.5 cm is the ideal
• If the sample lies within the syringe, don't try to expel it through the needle, this will damage the tissue. Instead, remove the plunger from the syringe completely and pour the contents into the collection pot
• Apply pressure to the biopsy site for a couple of minutes and then cover with a suitable dressing.
Documentation
• Date, time, indication, informed consent obtained
• How was liver position confirmed?
• Type and volume of local anaesthetic used
• How many passes?
• No more than 2 passes should be made (British
Society of Gastroenterology (BS) guidelines 2004)
• Size and nature of the sample obtained
• Any immediate complications
• Instructions for monitoring and discharge if day-case
• Signature, printed name, and contact details.

Indications
• Staging of chronic hepatitis B and C
• Non-alcoholic liver disease (NAFLD)
• Diagnosis of other chronic liver diseases such as Wilson's, haemochromatosis, primary biliary cirrhosis, and sclerosing cholangitis:
• A 4mm portion can be analysed by some clinical chemistry departments for iron or copper index. The sample should be sent on saline-soaked filter paper in a plain universal tube
• Unexplained altered liver function tests
• Suspected malignant lesion
• To exclude rejection in a previous liver transplant patient.
Contraindications
• Uncooperative patient
• Dilated biliary system (risk of biliary peritonitis)
• Thrombocytopenia or coagulopathy
• Ascites
• Vascular or cystic lesions
• Amyloidosis (risk of haemorrhage increased).
Risks
• Haemo- or pneumothorax, intraperitoneal hemorrhage
• Pain, hypotension, sepsis
•Biliary leak due to gallbladder puncture, injury to other organs.
Procedure Tips
• Check the patient's clotting profile and platelet count. Do not perform if INR >1.3 or platelets <50 x 10°/L
• Ensure blood is group and saved prior to the procedure
• The biopsy sample should have clear clinical information on the request form for the Pathologist.
Post-procedure monitoring
Practice varies and you should consult your local guidelines. Most bleeding complications arise within the first 2 hours post-procedure.
A reasonable strategy (based on guidelines from the BS) is:
• Patient to be monitored for total 6 hours
• Monitor vital signs every 15 minutes for first 2 hours
• Monitor vital signs every 30 minutes for next 2 hours
• Monitor vital signs hourly for remaining time.

​Clinical Procedures - Proctoscopy 

Indications
• Rectal bleeding
• Altered bowel habit
• To assess for perianal fistula
• Assessing patient with proctitis.
Contraindications
• Anal stenosis
• Painful perianal area on digital examination
• Pregnancy (relative).
Risks
• Bleeding
• Pain.
Procedure Tips
• Take care while assessing patients with pain (e.g. anal fissure, ischiorectal abscess, fistula):
• Presence of a fissure might prevent further examination due to pain
• Optimal views are obtained if patient has an enema prior to exam but it might not be feasible in all outpatient settings
• Do not biopsy from anal canal lesions as anus is pain-sensitive.

Equipment
• Gloves and other suitable protection (e.g. apron)
• Water-based lubricant gel
• Dry gauze
• Disposable proctoscope set with bellows
• Light source.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Ensure a chaperone is available during the examination
• Ask the patient to lie on their left side, flexed at the hips and knees (the Sims position) such that their body lies diagonally across the couch or bed and their buttocks are at the edge of the bed towards you
• Ensure the instrument is assembled (connect the bellows tubing, light source, scope, and eyepiece). Ensure that the tip of the obturator (stylet) protrudes slightly from the end of the scope
• Inspect the anus and perform a digital rectal examination:
• If the rectum is faecally-loaded, this should be emptied (with the use of suppository or enema) before continuing
• Apply lubricant to the tip of the scope
• Insert the scope gently, directed towards the umbilicus
• After insertion, remove the obturator and gently inflate the rectum using the bellows
• With direct visualization, advance slowly as much as possible towards the direction of the lumen, insufflating as you advance
• Remove the scope slowly, examining the mucosa as you do so
• Finally, ask the patient to bear down and look for haemorrhoids or mucosal prolapse

• Once the scope is removed, wipe the perianal area and allow the patient to move to a more comfortable position.
Documentation
• Date, time, informed consent taken.
• Chaperone present.
• Indication (s).
• Depth examined.
• Any abnormalities identified and distance from anal verge.
• Any immediate complications.
• Signature, printed name and contact details.

Clinical Procedures - ​Recording a 12-lead ECG
The term '12-lead' relates to the number of directions that the electrical activity is recorded from and is not the number of electrical wires attached to the patient!
Equipment
• An ECG machine capable of recording 12 leads
• 10 ECG leads (4 limb leads, 6 chest leads):
• These should be attached to machine
• Conducting sticky pads ('ECG stickers*).
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Position the patient so that they are sitting or lying comfortably with their upper body, wrists, and ankles exposed
• Position the stickers on the patient's body
• The chest leads:
• V1: 4th intercostal space at the right sternal border
• V2: 4th intercostal space at the left sternal border
• V3: midway between V2 and V4
• V4: 5th intercostal space in the mid-clavicular line on the left
• V5: left anterior axillary line, level with V4
• V6: left mid-axillary line, level with V4
• The limb leads are often colour-coded:
• Red: Right arm. (Red: Right)
• Yellow: Left arm. (YeLLow: Left
• Green: right leg
• Black: left leg
• Attach the leads to the appropriate stickers
• Turn on the ECG machine
• Ask the patient to lie still and not speak for approximately 10 seconds whilst the machine records
• Press the button to record, usually marked 'analyse' or 'record'

Check the calibration and paper speed:
• 1mV should cause a vertical deflection of 10mm
• Paper speed should be 25mm/s (5 large squares per second)
• Ensure the patient's name, date of birth, as well as the date and time of the recording are clearly recorded on the trace
• Remove the leads, discard the sticky electrode pads. Correct positioning of the chest electrodes for a standard 12-lead ECG

Procedure Tips
• Encourage the patient to relax otherwise muscle contraction will cause interference
• If unable to relax, or access to the peripheries is difficult, the 'arm' leads can be placed at the shoulders and the leg leads at the groins
• Breathing may cause a wandering baseline; breath holding for 6 seconds whilst recording may alleviate this
• Ensure that you cleanse the area gently with an alcohol swab before attaching an electrode to ensure a good connection
• It may be necessary to cut chest hair to allow good contact and adhesion with the chest leads
• The AC mains electricity may cause interference. If this is the case, try turning off nearby fluorescent lights.

​Clinical Procedures - Carotid Sinus Massage
Anatomy and physiology
• The carotid sinus is located at the bifurcation of the common carotid artery. It lies just under the angle of the jaw at the level of the thyroid cartilage and contains numerous baroreceptors which coordinate homeostatic mechanisms responsible for maintaining blood pressure
• These baroreceptors are innervated by a branch of the glossopharyngeal nerve (CN IX), which relays back to the medulla and modulates autonomic control of the heart and blood vessels.
Carotid sinus hypersensitivity
• The carotid sinus can be oversensitive to manual stimulation, a condition known as carotid sinus hypersensitivity (also 'carotid sinus syndrome' or 'carotid sinus syncope')
• In this condition, manual stimulation of the carotid sinus provokes significant changes in heart rate and/or blood pressure due to an exaggerated response to carotid sinus baroreceptor stimulation. This may result in marked bradycardia, vasodilation, and subsequent hypotension
• The patient may complain of episodes of dizziness or syncope related to pressure on the neck (e.g. wearing a tight collar or turning the head quickly)
• The underlying mechanism behind this exaggerated response is not fully understood.
Carotid sinus massage
• Carotid sinus massage is a diagnostic technique used to confirm carotid sinus hypersensitivity and is sometimes useful for determining the underlying rhythm disturbance in supraventricular tachycardia (SVT)
• The procedure acts in a similar way to the Valsalva manoeuvre, increasing vagal tone and, therefore, reducing the heart rate

Carotid massage is less effective than pharmaceutical management of SVT (verapamil or adenosine) though is still the preferable choice in the young haemodynamically stable patient
• This procedure should be performed with caution in the elderly as it may cause disruption of atheromatous plaque disease in the carotid artery and result in stroke.
Procedure
• Explain the procedure in full to the patient and obtain written consent
• If the test is to confirm carotid sinus hypersensitivity, then warn the patient that they may feel like they are going to faint but reassure them it is a controlled procedure
• If the test is to determine the underlying rhythm in SVT, explain that they may feel a bit peculiar as the heart rate slows down transiently
• Auscultate over the carotids for any bruits:
•If present, the procedure will have to be abandoned as the risk of stroke is significant
• D Document discussion of risks including failure, arrhythmias, stroke, faint, cardiac arrest
• • Secure intravenous access
• Ensure that you have ECG monitoring with a recordable rhythm strip
• I Ensure access to full resuscitation equipment, including emergency drugs such as atropine and adrenaline
• Position the patient supine on a bed with the neck extended and head turned away from the side to be massaged
• Whilst watching the ECG monitor (recording on a rhythm strip) gently massage the carotid sinus for 10-15 seconds using circular motions of your hand
• If there is no response, switch to the opposite side
• I Never massage both carotid sinuses simultaneously
• If successful (or 'positive' in the case of sinus hypersensitivity), the heart rate will slow:
• This may allow you to determine the underlying rhythm in SVT
• Ensure that the patient feels back to normal afterwards.

Clinical Procedures - Vagal Maneouvres
Background
The Purpose
• Vagal manoeuvres can be used to determine the underlying rhythm or terminate SVT in haemodynamically stable patients. If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves
• Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia reoccurs.
Physiology
• Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve
• Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way any SVT that relies upon the AV node will be modified by an increase in vagal tone.

​​Clinical Procedures - The Valsalva manoeuvre
• This is forced expiration against a closed glottis. Increasing intrathoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation
• This can be successful in 25-50% of cases.
Procedure
• Ask the patient to take a deep breath in and then 'bear down' as if they are trying to open their bowels (or for women, as if they are in labour)
Some patients may struggle with this concept and so alternatively:
• Give them a 10mL syringe and ask them to blow into the tip, in an attempt to expel the plunger.
Showing off
The technique is named after Antonio Maria Valsalva a 17th-century physician from Bologna, who was mainly interested in the workings of the ear. He first described the manoeuvre with regard to testing the patency of the Eustachian tubes.
The Diving Reflex
• This involves either submerging the face in ice cold water (not very practical or covering the face with a towel soaked in ice cold water.
Carotid Sinus Massage
• This is described separately (see topic).
Eyeball Pressure
•This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.

​Clinical Procedures – Defibrillation 
Indications
• Elective cardioversion of atrial fibrillation
• Emergency cardioversion in a peri-arrest situation where a tachyarrhythmia is associated with adverse signs
• (See tachyarrhythmia algorithm by Resuscitation Council UK).
Equipment
The 'crash trolley' should contain all the equipment required:
• Gloves, aprons
• Defibrillator, pads, leads, ECG electrodes
• Oxygen, reservoir bag and mask with tubing, airways
• Intubation equipment
• IV fluids, giving sets, selection of syringes, needles, IV cannulas and fixation dressings
• Access to emergency drugs (e.g. atropine, adrenaline, amiodarone, magnesium sulphate).
Before You Start
The procedure is essentially the same whether it is performed electively or as an emergency. However, consider:
Elective procedure
• Obtain informed consent and save a copy of signed form
• Ensure patient fasted >6 hours
• Check serum potassium (>4.0mmol/L is associated with greater success)
• Confirm patient has been successfully anticoagulated for previous 4 weeks (INR >2):
• Warfarin is continued for 3 months post-procedure if successful
• The procedure should be performed in an anaesthetic room, following short-acting induction by an anaesthetist.
Emergency procedure
• Ensure a senior doctor is involved in the decision
• Ensure all other options have been tried or considered
• If possible, discuss with the patient or next of kin.

Procedure
• Ensure skin is dry, free of excess hair, jewellery is removed
• Attach the ECG electrodes; red under right clavicle, yellow under left clavicle, green at the umbilicus
• Switch on defibrillator
• Confirm the ECG rhythm
• Place the defibrillator gel pads on the patient's chest; one under the right clavicle and the other inferolateral to the cardiac ape
• Select the 'synchronous mode' on the defibrillator
• D Select the joules (J) required (see below)
• Place the paddles firmly on the chest on the gel pads
• Press the charge button on the paddles to charge the defibrillator and shout 'Stand clear! Charging!'
• Check all persons are standing well clear of the patient and bed (including yourself and that no one is touching the patient or bed (including yourself)
• Ensure the oxygen has been disconnected and removed
• I Check the monitor again to ensure a shockable rhythm
• Shout 'Stand clear! Shocking!'
• Press both discharge buttons on the paddles simultaneously to discharge the shock
• Return the paddles to the defibrillator or keep them on the chest if another shock is required.
Energy Selection
DC Cardioversion usually uses biphasic energies. A reasonable general guide is:
• 50] synchronized shock. If fails..
• 100] synchronized shock. If fails...
• 150] synchronized shock. If fails..
• 150J synchronized anteroposterior shock. If fails...
• Abandon procedure if elective, consult seniors if emergency (may need ICU input).

Contraindications
• Elective: patients unsuitable for general anesthetic, not anticoagulated or who have not signed a consent form
• Emergency: only performed when a tachyarrhythmia is associated with adverse events in the presence of a pulse (pulseless rhythms require management as per the resuscitation guidelines).


Risks 
• General anaesthetic risk, if performed electively
• Embolic phenomenon, stroke, myocardial infarction.
Documentation
General
• Date, time and place. Name and grade of persons present
• ECG rhythm
• IV access secured
• Number, volume, dose of any drugs used, and any response noted
• Type of defibrillator machine used
• Method of sedation/anaesthetic
• Asynchronous or synchronous mode. Specify joules of each shock
• Confirm rhythm at end and 12-lead ECG findings
• Sign and bleep/contact details.
Elective
• Indication for DC cardioversion
• Informed consent obtained (retain copy of signed form)
• State time fasted from
• Document anticoagulation type and duration
• Serum potassium level
• Any drug allergies
• Name and grade of anaesthetist
• Type of anaesthetic used.
Emergency
• Events leading up to the peri-arrest situation
• HR, BP, Glasgow coma score on arrival and any deterioration
• Time of decision to shock, name and grade of decision-maker
• Verbal consent obtained?
• Type of sedation used
• Next of kin have been informed or if they are present or on route?

​Clinical Procedures – Temporary External Pacing 
This describes temporary transcutaneous pacing as an emergency.
Before You Start
•  External pacing is usually performed in an emergency resuscitation situation following failure of response to initial management, as per the bradycardia algorithm from the Resuscitation Council (UK) at the end of this topic
•  A senior doctor should be present and make the decision to proceed with external transcutaneous pacing
• There should be a plan in place for an experienced clinician to insert a temporary pacing wire within the next few hours. External pacing should only be a short-term management of decompensated bradycardia
• There should also be a bed available for the patient on a high-dependency unit or coronary care unit so that they can be closely monitored by experienced nursing staff whilst waiting for a temporary pacing wire. The patient should not be left on a general hospital ward.
Indications
• Symptomatic bradycardia unresponsive to treatment (see bradycardia algorithm)
• Mobitz type II block
• Complete heart block
• Heart block secondary to myocardial infarction
• Profound bradycardia secondary to drug overdose, e.g. beta blockers, digoxin
• systole or ventricular standstill
• External pacing can be used as overdrive pacing to terminate certain tachyarrhythmias that are unresponsive to initial treatment, e.g. polymorphic ventricular tachycardia (torsades de pointes) or refractory ventricular tachycardia.

Equipment
• Full resuscitation equipment: defibrillator with pacing setting
• Defibrillator pads
• Oxygen
• ECG monitoring
• Emergency drugs (including atropine and adrenaline)
• IV fluids
• Sedative drugs (e.g. midazolam or diazepam)
• Analgesia (e.g. morphine)
• Intubation equipment (in case indicated)
• Senior support.
Procedure
• The patient should already have:
• Large-bore IV access
• IV fluids running (unless in heart failure)
• Oxygen via a non-rebreathe mask at 15L/min
• ECG monitor connected and running
• Interval BP monitoring
• Place the pacing pads from the defibrillation kit on the patient's chest: one anteriorly in the V3 position and one posteriorly below the left scapula
• Sedation and analgesia may be required
• Attach the leads from the defibrillator to the pads
• Switch the defibrillator to its pacing mode.
Risks
• Failure and progression to temporary pacing wire insertion.

Documentation
Temporary external pacing is usually an emergency procedure so documentation may be delayed until the patient is stable. It should outline the resuscitation and external pacing simultaneously:
• Date and time
• Name and grade of persons present
•Events leading up to the need for external pacing
• Any drugs used, e.g. atropine or adrenaline, volume/ dose, and response
• Indication for external pacing
• If patient was conscious, document consent (usually verbal consent only)
• Any sedation used
• When external pacing commenced
• Details of plans for temporary pacing wire insertion
• Sign and bleep/contact details.

​Clinical Procedures - Turbohaler
Dry powder device with preloaded tasteless drug. There is no dose counter, but a window that turns red after 20 doses.
The device is empty when there is red at the bottom of the window. Those with impaired dexterity may find the inhaler difficult to use.
How to use
• Unscrew and remove the white cover
• Hold the inhaler upright and prime the device by twisting the grip clockwise and anticlockwise as far as it will go (until you hear a click)
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• Inhale slowly and deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose
• The device must be primed again between successive doses.
Procedure Tip
• Advise the patient that they will not feel the dose hit the back of their throat. Patients used to an MDI may find this off-putting.