1 Which drugs to stock? Such drugs as flumazenil (Romazicon), naloxone (Narcan), methylene blue (methemoglobinemia from benzocaine sprays), fat emulsion injections (Intralipid) and dantrolene (Dantrium) are high on the needs list, as well as ACLS first-line drugs. At least annually, your medical leadership should review and endorse the code cart medication list. They should also authorize additions and deletions.
2 Make access easy. Use breakable locks and don't lock the cart with a key during business hours. Keep replacement locks with managers, not in the cart. To save time, label the outside of drawers with specific terms ("drugs," "IV solutions" and "laryngoscope").
3 Audit the cart at least monthly. Make different individuals audit the cart each month to underscore the need for all to be familiar with its contents. Set an annual schedule and assign staff for each monthly validation. Frequent mock code drills are also a good idea. Document that you checked medications at least monthly and validated cardiac monitors and defibrillators daily.
4 Prepare for MH. Beyond annual mock code practices with dantrolene, facilities that use "triggers" should stock their cart with an adequate supply (36 vials minimum) of dantrolene, at least 25 x 100ml sterile water for injection, USP, preservative-free and dosage-calculation guidelines. Have your anesthesia staff or pharmacy consultant give an annual malignant hyperthermia in-service. Your cart should have easy-to-retrieve dantrolene dosing guidelines. Also consider adding a breakable-locked MH tote to your code cart, a box that would travel with the transferred patient to the hospital if necessary.
5 Orient new employees. Make the code cart a requirement of new employee orientation. This would include not only nursing personnel, but also anesthesia staff.
6 Stock infusion pumps. If you include certain drugs for which there is a stipulation that an infusion device be used (dopamine, for example), buy such a pump and document that you've been trained to use it.
7 Promptly replace used items. Should you use your code cart or MH cart, you have an inherent responsibility to bring it up to par level and ensure access should the cart be needed for a second event. This is unlikely, I know, but it is possible. Have backup stocks of the included drugs.
8 Keep references handy. We need references on drugs, in particular, to be easily accessible and easy to work with. Check yours and test them for functionality. I suggest ACLS, PALS and products like the Broselow Tape, which offers proper medication dosages for pediatric emergencies.
9 Segregate pediatric emergency drugs. If you serve pediatric patients, you need to have adequate pediatric dosing emergency drugs, such as preloaded emergency drug syringes. Segregate these (you might use a plastic bag) from adult strengths and label the outside of the drawer that houses them.
10 Clearly arrange drugs in the medication drawer. When drugs are intermingled in a common slot, cubby, tray or container, you're likely to have a hard time finding what you need in the event of a code. In addition, label these locations in a large, clear font.
11 Routinely replace expired drugs. Nobody wants to see a note in the code cart that a drug is expired and awaiting replacement (except if that's due to manufacturers' shortages). It's prudent to buy soon-to-expire code cart drugs a month ahead.
12 Properly handle refrigerated drugs. While just a few code cart drugs require refrigeration for example, diltiazem injection (Cardizem) note their location on the inventory sheet ("In Refrigerator").