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Train of Four

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Cathy Seymour

on 13 January 2015

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Transcript of Train of Four

Peripheral Nerve Stimulation
Train of Four (ToF): easy and objective tool for routine monitoring
delivered as 4 pulses every 0.5 second
the number of responses/twitches to the ToF stimuli indicates the degree of neuromuscular blockade
in absence of neuromuscular blocking agents, each impulse will produce one contraction
with NMB drugs, the 4th impulse will be lost initially
Train of Four/Peripheral Nerve Stimulation
Depolarizing Agents

Onset of action: 1-2 minutes
Duration of action: 4-6 minutes
Reversal: time
Neuromuscular Blocking Medication (NMB)
Why would you want to medically paralyze a patient?
All patients on NMB agents require ventilator support & cardiac monitoring
(KGH Parenteral Drug Manual)
Types of NMB's
inhibit synthesis/release of acetylcholine
block the acetylcholine receptor
Reasons for using NMB medications
facilitation of endotracheal intubation
to ease mechanical ventilation
poor lung and chest wall compliance
severe ARDS
improve gas exchange
reduce metabolic demands
reduce intracrainal pressure
to control movement with some procedures or tests
Rocuronium, cisatracurium

Onset of action: 2-3 minutes
Duration of action: 20mins to 2 hours
Reversal: anticholinestrerase drugs
(neostigmine, pyridostigmine, edrophonium)
causes muscarinic side effects (bradycardia, increased salivary & bronchial secretions
counteracted by administering anticholinergic drugs (atropine, glycopyrrolate) in conjunction

Neuromuscular blocking drugs have
analgesic, sedative, or amnesic properties
if pt might potentially be conscious or aware, they require sedation
NMB medication administered and continue until NMB medication cleared
should have a sign identifying NMB drug in use
check degree of blockade with a peripheral nerve stimulator
Train of Four Scope of Practice
May be used by authorized physicians and RN's
education, test (80%), and return demonstration
Train of Four Response Interpretation Table
equipment: alcohol swabs, gauze, ECG electrodes (2), and peripheral nerve stimulator
perform hand hygiene
cleanse placement site with alcohol and dry
site: ulnar (preferred), facial nerve (secondary), or sural nerve
Policy: "physician will perform the initial ToF testing....Daily the physician should determine the need for and level of paralysis"
Ulnar Nerve
preferred site
apply electrodes to healthy tissue
place electrodes on writs in line with smallest digit, 3-5 cm apart
negative (black) electrode distal and the positive (red) 3-5cm proximal
Facial Nerve
secondary site
electrodes placed along facial nerve
negative (black) electrode lateral to the eye, positive electrode (red) placed inferior by 3-5cm
response: eye lid twitching
Sural Nerve
place negative (black)electrode proximal to lateral malleous (ankle bone) and positive (red) 3-5cm above
response: planter flexion (curl) of small toe
Turn nerve stimulator on
press TOF to deliver electrical stimuli
if no twitches are seen, increase amplitude and repeat
continue to repeat until maximum amplitude reached
check lead placement
check connections
replace battery
edema of motoring site
thick skin or wrist
electrolyte abnormalities
previous nerve injuries
neuromuscular diseases:
Myasthenia Gravis, Bell's Palsy
Document time, date, response/level of blockade, nerve tested, & name of person doing the procedure
2014/01/15 @ 1335hrs
Objectively monitor degree of neromuscular blockade
Decrease avoidable side effects
Inhibit synthesis or release of acetylcholine
Block the acetylcholine receptor
Do not titrate any of the NMB medications
Full transcript