Nurses cut stroke care delays, assist with echoes

Having nurses do injections saves valuable minutes

When a 40-year-old woman came to the University of California-Irvine’s ED for transient ischemic attack of unknown origin, the echocardiogram was done right in the ED — and showed a right-to-left shunt at the atrial level.

She was referred to cardiology for further work-up. "After additional testing, an atrial sepal closure device was inserted in the cath lab, and the patient is now doing well," recalls Margaret Knoll, RDCS, a supervisor at the hospital’s cardiac diagnostic center. Knoll had inserviced the ED nurses on performing injections done for echocardiograms.

ED nurses now assist with agitated saline or bubble echocardiograms for all stroke, cerebral vascular accident (CVA), or transient ischemic attack (TIA) patients. There are two goals: to detect shunting and speed up treatment, reports Marla Gain, RN, ED clinical educator at University of California-Irvine. "This procedure requires only a few moments of the nurse’s time and is done at the patient’s bedside in the ED," she explains.

Agitated saline is used for the following patients:

  • with enlarged right hearts on echo;
  • to evaluate for patent foramen ovale and atrial septal defect;
  • to evaluate for pulmonary artery pressures;
  • with atrial septal aneurysm.

Agitated saline or bubble echoes are required on the ED’s stroke clinical pathway, on all patients being admitted with the diagnosis of CVA or TIA, to rule out shunts at the atrial level, says Knoll. "We have identified patients with previously unknown atrial shunts, both patent foramen ovale and atrial septal defects."

By doing these studies in the ED, they can speed up treatment, diagnosis, and discharge, says Knoll. "That benefits this patient and all other patients in the EDs."

Before the ED nurses were trained, cardiac sonographers would have to wait for the cardiology fellow or nurse practitioner to come to the ED to do the injections of agitated saline, which take fewer than five minutes of the nurse’s time, says Knoll.

Nurses were trained with hands-on inservices held in the ED during change of shifts by the cardiology supervisor and nurse practitioners. "The most difficult challenge for nurses was learning the manual dexterity to agitate the saline," notes Knoll.

Here are the steps that occur:

  • The sonographer brings the cardiac ultrasound system to the patient’s bedside, gathers and prepares the supplies: Two 10-ml luer-lok syringes, a three-way stopcock, three 10-ml normal saline vials, 8-inch extension tubing, an 18-gauge needle, and alcohol prep pads.
  • The ED nurse agitates the saline, injects the saline when instructed to do so by the sonographer, instructs the patient about the procedure, does the second injection if needed, and documents the action in the patient’s medical record.

ED nurses also help the cardiac sonographers to inject a contrast agent that improves the echocardiogram image, says Knoll.

"There are two contraindications to doing this procedure: pregnancy and known ventricular septal defect," adds Gain.


For more information on nurses assisting with echocardiograms in the ED, contact:

  • Marla Gain, RN, MICN, Clinical Educator, Emergency Services, University of California at Irvine Medical Center, 101 The City Drive, Route 14, Orange, CA 92868. Telephone: (714) 456-5675. E-mail:
  • Margaret Knoll, RDCS, FASE Supervisor, Cardiac Diagnostic Center, University of California at Irvine Medical Center, 101 The City Drive, Route 14, Orange, CA 92868. Telephone: (714) 456-7397. E-mail: