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26.1 Carotid artery rupture (CAR)

Essential equipment

  • A selection of needles and syringes
  • Non‐sterile gloves
  • Plastic apron
  • Green/blue towels or other dark‐coloured disposable towels
  • Goggles
  • Syringes for cuff inflation on a tracheostomy tube (10 mL non‐Luer lock)

Medicinal products

  • Sedation must be kept in a locked cupboard/room

Pre‐procedure

ActionRationale

  1. 1.
    Ensure that the patient and family are aware of the risk of CAR.
    It may help the patient and family to know that, in the event of a massive carotid rupture, there should be little pain and that death is usually very quick (Cohen and Rad [42], E; Kane [124], E).

Procedure

  1. 2.
    Stay with the patient. Calmly call for assistance from other staff members and press the emergency call bell for assistance to aid with patient and family care and to administer any medication. Avoid panic.
    To minimize the distress, anxiety and fear felt by the patient and family and often the professionals involved (Frawley and Begley [85], E; Grahn et al. [95], E).
  2. 3.
    Talk gently and calmly to the patient and hold their hand. Try to keep them in the same place if possible. Remember that being calm will greatly reassure the relatives.
    To minimize the distress, anxiety and fear felt by the patient and family and often the professionals involved (Frawley and Begley [85], E; Grahn et al. [95], E).
  3. 4.
    Apply towels to the bleeding site and absorb the bleeding if possible.
    Applying pressure to the area will reduce the aggressive nature of the bleed and allow time for sedation to work (Upile et al. [295], E).
  4. 5.
    Apply gentle suctioning to mouth and trachea as necessary.
    To reduce the discomfort to the patient and the family due to the sound the suctioning can make (Schiech [266], E).
  5. 6.
    Prepare and administer sedation (i.e. midazolam) by appropriate route.
    The onset of action for intravenous midazolam is 2–3 minutes, whereas the onset of action for subcutaneous midazolam is 5–10 minutes (Twycross et al. [291], E).
  6. 7.
    If the patient has a cuffed tracheostomy tube in situ, inflate the cuff.
    Cuff inflation prevents soiling of the lower airway with blood (Upile et al. [295], E).
  7. 8.
    Contact the patient's medical team for advice and assistance.
    This can be a chaotic situation and additional support, especially if a clear plan is not in place, will be required (Fawley and Begley 2006, E; Harris and Noble [104], E).
  8. 9.
    Be aware of family presence and needs. Be respectful of the decision by the family whether they wish to stay with the patient. Ensure support is given to family and friends at this time.
    For the patient and family who are unprepared, this will be a horrifying experience and the shock of the death can contribute to complex bereavement issues (Cherny et al. [36], E; Dickenson and Johnson [62], E).

Post‐procedure

  1. 10.
    Relatives and friends should be offered a follow‐up meeting to discuss the event, allowing a chance to debrief. They should also be offered bereavement counselling as appropriate.
    For the patient and family who are unprepared, this will be a horrifying experience and the shock of the death can contribute to complex bereavement issues (Cherny et al. [36], E; Dickenson and Johnson [62], E).
  2. 11.
    All staff should be offered support, not just those immediately involved but all in the vicinity of the incident, i.e. domestic colleagues, ward receptionist, junior nurses and doctors. Other visitors may also be debriefed.
    This can be a traumatic experience for those involved and staff who know the patient (Frawley and Begley [85], E).
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