Fig. 1
Photograph of various supplies that may be used for cEEG electrode hookup. Pictured here: reusable pouch, disposable telemetry pouch, large roll of gauze, twist tie, scissors, tub of electrode paste, disposable tongue depressor, alcohol wipes, plastic retractable tape measure, China markers, nonpermanent markers, bottle of collodion, curve-tipped syringes with labels, abrasive prepping gel, electrocardiogram (ECG) snap cables, cotton-tipped applicators, ECG adhesive patches, electrode gel, clear adhesive film, large tightly woven gauze squares, 1 in. paper tape, 2 in. paper tape, small cut loosely woven gauze squares, and roll of loosely woven gauze
Next, the technologist will need supplies to prepare the skin where the electrodes will be applied. Often an abrasive prepping gel is used to clean the scalp and improve the electrical impedances of the electrodes. The technologist may want to use cotton-tipped applicators or gauze to apply the prepping gel. Cotton-tipped applicators have the ability to prep small areas of the skin and may be best for getting through matted hair. Gauze preps a larger skin area and is best used on delicate skin, because the technologist can better assess and control the exact pressure being applied. Select thicker woven gauze to prevent the prepping gel from soaking through the gauze. Alcohol wipes may also be helpful for cleaning or improving electrode impedances. Alcohol has a drying effect on the skin and effectively removes sweat, oils, and greases from the scalp.
The technologist will also need supplies for securing the electrodes to the patient. One method is using a conductive paste and loose woven gauze squares or tape. This is suggested in situations where the patient is not moving around and not sweating, as well as, when other care staff is not moving or working around the head. If there is risk that the electrodes may fall or get knocked off, consider using glue such as collodion or a hardening cream to secure electrodes. Paste can be inserted into the electrodes before being secured, or conductive gel can be squirted into a hole in the top of an electrode cup with a syringe. After assessing which method to use, collect all supplies needed for that particular method of securing electrodes. If gluing with collodion, the technologist will need a device to dry glue such as a medical air regulator or an electric air pump along with tubing, pedal, and stylist (Fig. 2).
Fig. 2
Example of devices that are used to dry glue. (Left) An air regulator, tubing, pedal, and stylist connect to medical air in the room. (Right) An electric air pump with tubing, pedal, and stylist eliminate the need for medical air to be present in the room
Other supplies will be needed to secure the electrode wires, protect the breakout (jack) box, and protect the electrodes on the head. Items for securing the wires could include twist ties, tape, gauze, or a plastic spiral cable covering. The breakout box could be wrapped in gauze, placed in a disposable telemetry pouch, or inserted into a bag provided by the EEG machine manufacturer. Wrapping the head with gauze, making a hat fashioned from tubular dressing retainer, or tying on a bandana protects the electrodes on the head.
Electrodes
Lastly, the technologist will need electrodes. The technologist will need at least enough electrodes for an international 10–20 system or a modified neonatal hookup as well as for any additional locations that should be monitored on the cEEG [2]. It is also a good idea to have a few extra electrodes in case any artifacts need to be monitored or an electrode is defective. It is helpful if the technologist plugs the minimal required number of electrodes into the breakout box before heading to the patient’s room. While doing this, the technologist should inspect the electrodes to ensure that they are in good condition and do not have any breaks along the wires, cup, or hub. In addition to EEG electrodes, the technologist should also select any other types of electrodes or devices to be used such as electrocardiogram (ECG) cables and patches, pneumograph, or respiratory belt.
There are several different types of electrodes that can be used for cEEG monitoring. In the event that several types are available to the technologist, deciding which type to use should be patient dependent. Reusable electrodes seem to remain in place better than disposable electrodes when gluing with collodion or using conductive paste and tape. Reusable electrodes have also been shown to be less conductive to heat, which minimizes the drying of electrode paste or gel and reduces the risk of skin breakdown. On the other hand, in hospitals that need to maintain a large supply of available electrodes to accommodate hookup requests, the use of disposable electrodes is highly effective. These populations are usually more acute and need frequent CT or MRI scans requiring electrode removal and reapplication. Also, technologists do not have to wait for electrodes to be cleaned or sterilized for the reapplication. Time is also saved at removal because electrodes are simply disposed. Some disposable electrodes are compatible with CT and MRI and do not need to be removed for these scans, thus extremely desirable by technologists for eliminating electrode removal and reapplication as well as by physicians for reducing the amount of time EEG is not recorded [2]. Needle electrodes can be very time efficient when used on a comatose patient, because they eliminate the need for prepping the skin before application [3]. However, needle electrodes could increase the risk of infection for the patient and increase risk of a needle stick for the technologist.
EEG Machine
The technologist will also need an EEG machine for the hookup. Many neurointensive care units have EEG equipment mounted in the patient’s room on a wall or boom behind the head of the bed and permanently connected to a network because of the frequent need for cEEG monitoring. However, cEEG monitoring is also ordered on patients admitted to non-neurointensive care units for other medical problems. In this situation, a portable EEG machine will need to be taken to the patient’s room. Whether mounted in the patient’s room or on a portable cart, most EEG machines need the same basic parts for recording: a computer with the EEG acquiring software and storage drives, a computer monitor, a keyboard and mouse, and an amplifier for the electrodes. Most amplifiers or headboxes are connected by a cable to a smaller jack box or breakout box into which the electrodes plug. The breakout box can be easily disconnected if necessary and is small enough to be in the patient’s bed. Most EEG machines used for cEEG monitoring also have a camera for acquiring video of the patient to aid the physicians with interpreting the EEG and distinguishing abnormalities from artifact.
Preparation in the Patient’s Room
Setting Up the EEG Machine
When arriving at the patient’s room, the technologist should let the care nurse know that the patient is about to be hooked up to electrodes for cEEG monitoring, verifying that the patient is still available. The technologist should use at least two patient identifiers such as name, date of birth, and medical record number to confirm that it is the correct patient. The technologist should partner with the care nurse for the best place to set up a portable EEG machine if the room is not hardwired with EEG equipment. Because many other care staff will need access to the patient, the machine should not obstruct the patient. If using a video camera, the technologist should position the machine to view the patient’s whole body including a good image of the patient’s face, if possible [2]. Thus, the best place for the portable machine is at the foot of the bed if the patient’s room allows or on either side of the foot of the bed, being mindful to not obstruct any traffic that needs to get by the machine. If possible, the power cable, network cable, or any other cables should not run along the floor in areas of heavy traffic. This is often achieved by running the cable under the bed to outlets on the wall behind the head of the bed. If a cable must be in a walkway, it is a good idea to secure it to the floor with tape or cover it with a cable organizer or other method to minimize trip hazards (Fig. 3). When plugging the power cable into an outlet, choose one that receives power from a backup generator in case of a power outage. Some EEG machines are also connected to a backup battery that will supply power to maintain the recording even if the machine becomes unplugged or there is a power outage. The cable from the headbox to the breakout box should be kept out of the way of walking traffic. Often patients on cEEG monitoring are on several other monitors and have intravenous lines (IV). Therefore, the breakout box and cable are more likely to remain untangled from any other monitoring cables or IVs if kept near the patient’s head. This location is also best for stress relief on the electrodes to prevent accidental removal from the head or breakout box. Once the machine, cables, and breakout box are in position, the technologist can boot up the machine, enter the patient’s information, and start the acquisition. If available, turning on the electrode impedance check at this point helps keep the technologist from having to come back to the machine before the application is complete.
Fig. 3
Cables are run along a hospital bed out of the walkway. Where the walkway is crossed, the cables are completely covered and taped to the floor
Setting Up the Supplies
Before beginning the hookup, the technologist should ensure that all the needed supplies are available. If brought by the technologist in a basket, supply box, or cart, the needed supplies should be removed with clean hands or gloves so as not contaminate any unused supplies [1]. If using a device to dry glue, it should be plugged in near the head of the bed. Often the technologist has to step over or go under cables to get to the head of the bed to reach the patient’s scalp. Thus, it is helpful if all supplies are set up within reach, and the technologist does not have to come out from behind the bed to obtain anything during the hookup.
Preparing the Patient
The next step is preparing the patient for electrode hookup. With the help of the care nurse, the technologist should position the patient to make the hookup as ergonomic as feasible. Bending and reaching should be avoided whenever possible. This includes partnering with the care nurse to raise the bed or lower the head of the bed, if necessary. Some patients have EVDs that require the patient’s head is not raised or lowered while the EVD is open for draining. The care nurse would need to close the drain before moving or changing the patient’s position. Other medical conditions may affect the ability to position a patient such as recent incision requiring an incline of 30° or breathing issues. Also, any hookup options for obstacles such as EVDs, incisions, bandages, and wounds on the head should be discussed with the care nurse. Removal of bandages or applying electrodes close to any incision or wounds should only be done with the approval and participation of the care nurse. For infection control purposes, it is best to stay at least 1 cm away from the open skin [1].
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