Note: Approach below dated from 1990's

PURPOSE

1. Precautionary measures if the carotid artery is endangered.

EQUIPMENT

1. To be placed at the bedside (OR cart available on unit):
   1. Standard precaution supplies (gloves, goggles, masks, gowns)
   2. Bath towels or abdominal pads x 3
   3. Cuffed Shiley tracheostomy tubes (sizes 4, 6, and 8)
   4. 10 cc syringe
   5. Supplies to establish IV site (large bore)
   6. Standard IV tubing
   7. Stopcock with extension tubing
   8. IV solution (normal saline 1000 cc)
   9. IV blood administration set
   10. Type and cross match supplies
   11. Magill forceps
   12. Kelley clamps x 3
   13. Large vascular clamps (Cooley vascular clamps) x 2
   14. Venisection tray (cut down tray)
   15. Hemorrhage tray:
       1. Long curved Allis clamps x 2
       2. Tonsil forceps
       3. Pillar retractor
       4. Medicine glasses x 2
       5. Tonsil sponge carriers (ring forceps) x 2
       6. Weder tongue depressor
       7. Bayonet forceps
       8. Vienna nasal speculum
       9. 5 cc plastic syringe
       10. Needles (18 G, 25 G, and 27 G)
       11. Curved tonsil needle
       12. Laryngeal mirrors (sizes 0, 2, and 4)
       13. Frazier suction tip (1 large and 1 small)
       14. Metzenbaum scissors
       15. Mayo scissors (long)
       16. Small curved mosquito hemostats x 2
       17. Towel clips
       18. Large needle holder
       19. 4 x 4 gauze sponges x 2
       20. 24 inch drape
       21. Tongue blades
       22. Tonsil sponges x 2
   16. Tracheostomy Tray
   17. Vaginal packing
   18. Vaseline packing (6 in x 36 in)
   19. Suction
   20. Cart for transport

PROCEDURE

1. Place patient under close observation and assign to a room near nurses' station.
2. Note on patient care plan that Carotid Artery Rupture Precautions are to be observed.
3. Consult with physician to determine if patient should be typed and screened or kept typed and crossmatched.
4. First indication of potential carotid artery rupture may be slight ooze 24 to 48 hours before actual hemorrhage (herald bleed). Notify physician if this occurs.
5. If hemorrhage occurs, summon help immediately.
6. Observe standard precautions (ie, gloves, gown, masks, goggles) as appropriate.
7. Inflate tracheostomy cuff immediately. If patient is a laryngectomy or has uncuffed tracheostomy tube in place, insert Shiley tracheostomy tube and inflate cuff. Suction as necessary to maintain patent airway.
8. If external rupture occurs:
   1. Apply pressure over site immediately with towel or abdominal pad.
   2. Continue pressure until otherwise directed by physician.
9. If internal rupture occurs:
   1. The physician may attempt to pack area intraorally using Magill forceps, Vaseline gauze, or vaginal packing. Note: A registered nurse may do this only if patient has a tracheostomy or laryngectomy.
   2. If it is not possible to control bleeding with pressure:
      1. Position the patient to facilitate drainage.
      2. Suction the patient orally or via tracheostomy tube.
10. Instruct second person to notify physician immediately.
11. Notify operating room/anesthesia/medical staff as directed.
12. Assist physician as directed (ie, assemble IV equipment, blood administration equipment, obtain operating room cart).
13. Direct other nursing staff (ie, monitor vital signs, observation and care of other patients).
14. Transport patient to operating room.
15. Document activities.

PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS

1. Ascertain from physician where patient may potentially bleed and where to apply pressure in the event of hemorrhage. Document pertinent information in the care plan.
2. The patient may bleed intraorally or externally with either an internal or external carotid artery rupture.
3. The patient's blood pressure should increase if pressure is applied effectively.
4. Vascular clamp application is restricted to physician use only.
5. If the patient is on Carotid Artery Rupture Precautions and the neck wound requires dressing changes, only a registered nurse is permitted to do the change using sterile technique. Avoid the use of a hemostat or forceps while packing wound.