Great question asked by Stacey, who is the nurse educator in a northern rural hospital.  As many of our readers, like Stacey, are hours to their closest PCI center, their STEMI protocol is to administer TNKase upon meeting the criteria checklist.

The question I was asked is: "why is the Cardiac Care Network recommending NOT starting the IV in the right wrist or hand?"

I checked the Cardiac Care Network's(CCN) website and found the following two documents for reference:

RECOMMENDATIONS FOR BEST-PRACTICE STEMI CARE IN ONTARIO

ACS MANAGEMENT RECOMMENDATIONS FOR REMOTE COMMUNITIES

I was not able to find a direct CCN policy statement or a TNKase manufacturer’s statement indicating which hand to start the IV in. However, the CCN document did provide examples of various organizations' documentation for CODE STEMI in outlying regions. The example from Thunder Bay Regional Health Centre did indicate to start 2 IVs and to avoid right wrist or hand.

Wanting to know the rationale for this policy, I asked my QRS colleagues who work in the cath-lab or in an organization where PCI is standard practice for their STEMI patients. Their responses were all identical: if the patient requires rescue PCI they generally use the right radial artery. They use the right radial because the left is a really tight angle and very challenging to access the coronary ostia. Another response from one of QRS instructors is, would you even want to put a peripheral IV in the hand or wrist of a STEMI patient who is in any way unstable or has the potential to become unstable? Putting IVs in joint areas is usually problematic because patients move their hands and wrists. You always want to ensure readily available venous access for emergent medication or volume administration should the patient deteriorate.

Thanks to Catherine, Betty Anne, Sevi, and Suzanne for their input. Thanks to Stacey for the question.

References:

http://ccn.on.ca/ccn_public/uploadfiles/files/ACS_management_in_remote_communities_FINAL_Sept_2013.pdf