When a patient codes, even the most levelheaded person is powerless to help if your crash cart is disorganized. Take a few minutes to make sure this isn't the case at your facility as we review, drawer by drawer, what your crash cart should contain.
The crash cart's top drawer typically contains reversal agents and drugs for blood pressure support and cardiac stimulation. Each vial should be clearly labeled and grouped according to action for quick and easy access. Here's a basic rundown of some key drugs (a complete list of suggested drugs is provided by the American Heart Association in its ACLS protocols).
The group of reversal agents is highlighted by flumazenil, used to reverse the effects of the benzodiazepine midazolam. Diphenhydramine is used on patients experiencing histamine release issues or allergic reactions to blood or plasma. Naloxone reverses the respiratory depressive effects of narcotics. Atropine falls under the cardiac support umbrella of medications. As a pre-anesthetic medication, atropine reduces secretions of the respiratory track and maintains heart rate. In emergency cases, an injection of the drug increases heart rate by blocking the inhibitive actions of the vagus nerve.
Giving any drug intravenously results in the most rapid onset and is the likely form of administration during emergencies. And while the drugs in your crash cart may never be used, it's still a good idea to take measures that simplify the administration process. Buying and storing the medications in pre-mixed doses eliminates the need for further dilution and simplifies the steps for staff who are often unfamiliar with running codes.
Ask your medication sales rep for drugs that expire in three years instead of three months. Hire a pharmacy consultant to ensure your formulary is complete and free of outmoded drugs.
Store equipment for securing the patient's airway together in a common drawer. Essentials include tracheostomy tubes and corresponding scalpels with blades, endotracheal tubes, intubation tray, oral airways, O2 nasal cannula and O2 flow meter. It's also a good idea to include a laryngeal mask airway in the cart to secure ventilation in patients who can't be intubated. Also consider personal protective equipment for the provider.
A bag-valve-mask resuscitator with mask (Ambu bag) forces air into the patient's lungs when attempts at intubation and other forms of ventilation have failed. You can attach these bags to supplemental oxygen. Store cylinders of O2 with the crash cart, even if your facility has oxygen hook-ups in each OR's wall. Emergencies can occur anywhere in your facility and storing O2 tanks with the side of the cart that will respond to the event is convenient. Another time-saver: Pre-attaching O2 flow meters to each cylinder also eliminates another step in the staff's emergency response.
How We Stocked Our Carts
When it comes time to outfit the crash carts in your facility, work with your anesthesia team to ensure the supplies and drugs are those that might actually be used instead of extraneous items more suited for life-saving efforts in acute care facilities. We outfitted our facility, the Reading Hospital Surgicenter at Spring Ridge in Wyomissing, Pa., with emergency intubation supplies and a small transport ventilator so patients in serious trouble can be stabilized and transported to our health system's main hospital. While line equipment is beyond the scope of our facility's monitoring capabilities, we do include a cut down kit to start IVs in patients who code.
Don't forget to store a CO2 detector in the crash cart, especially if you're in a small ASC or an office suite. The presence of CO2 is the standard of care to confirm proper placement of an endotracheal tube. Tools used to start IVs and administer the crash cart's drugs are basic: tubing, extension tubing, alcohol swabs, angiocaths and syringes. Beyond the essentials, consider equipping your cart with a pressure bag, which speeds the flow of IV fluid, a crucial action during emergencies when staff need to quickly get a high volume of drugs into the patient's system.
The cart's bottom drawer, likely its biggest, typically houses equipment used for emergency cardiac and chest procedures, highlighted by a cut down tray and CVP catheter kit. In standard surgical cases, cut down trays help anesthesia providers find difficult-to-spot veins for an IV start. During cardiac emergencies, cut down trays locate veins that have collapsed because of decreased blood circulation. Consider including an internal jugular kit. The jugular is a big vessel and easy to locate, even in patients with decreased blood flow and collapsed veins.
Some of the most crucial pieces of equipment sit atop the crash cart: the defibrillator, defibrillator gel, paddles and suction equipment for removing fluids from the mouth or throat. The user-friendly features of automated defibrillators make the device ideal for the office and ASC settings. But don't ignore the usefulness of the manual defibrillator that's served your facility for several years.
Include the latest Advanced Cardiac Life Support algorithms in your crash cart's setup. I've worked in facilities that have laminated the protocols, slipped each sheet on a ring and hung the documents off the cart's side. Reactions to emergency situations vary. Anesthesia providers are trained for such situations, becoming focused and calm. Staff unaccustomed to code response may panic. The ACLS algorithms are a great reference, offer step-by-step directions for responding to a code and focus the clinical team on the task at hand.