Health-System Pharmacists: What's in Your Crash Cart?

Certain items are must-haves in any crash cart during a hospital code.

At the 2015 American Society of Health-System Pharmacists (ASHP) Midyear meeting, Andrew North, PharmD, BCPS, of the Ohio State University Wexner Medical Center described what a typical crash cart might look like.

Being familiar with available medications can help pharmacists and other members of the emergency care team streamline procedures during a code, which can help reduce the risk of a medication error in this chaotic time.

“Most institutions will have a similar set of medications within their crash carts, [although] the location of them may differ amongst institutions,” Dr. North explained.

Pharmacists should stock the following medications in crash carts to fully prepare for a hospital code:

Epinephrine

Epinephrine is the cornerstone of emergency treatment during a code. It is considered a vasopressor and used to increase cardiac output by increasing heart rate, heart muscle contractility, and conductivity through the atrioventricular node.

Dr. North explained that epinephrine is used every 3 to 5 minutes during a code, so pharmacists and other members of the emergency care team should make the drug easily accessible on the crash cart.

“It’s pretty much the main medication we use in most cases,” he said.

Amiodarone

Amiodarone is primarily indicated to treat ventricular fibrillation (VF) and ventricular tachycardia (VT) that occurs during cardiac arrest.

Advanced cardiac life support (ACLS) guidelines recommend using amiodarone only after epinephrine and vasopressin have failed to convert VF/VT.

Atropine

Atropine is used to help keep heart rates stable after a heart attack. However, it has been removed from the ACLS guidelines due to a lack of clear benefit.

Calcium

Calcium is important for the strength of contraction of cardiac tissue. It is used to stabilize myocardium and help get a patient out of a lethal rhythm.

Sodium Bicarbonate

Sodium bicarbonate is used when the code response team believes that the patient may be acidotic because the drug helps to increase serum PH, which in turn could prevent further coding.

Vasopressin

Vasopressin is a primary drug used in the pulseless arrest algorithm. Similar to atropine, however, vasopressin has been removed from the ACLS guidelines due to a lack of clear benefit.

Craig Cocchio, PharmD, BCPS, recently wrote in Pharmacy Times that pharmacists “should keep vasopressin in crash carts” despite the ACLS guideline update because evidence has suggested no demonstrable “difference in the rate of survival at discharge between patients who received epinephrine of vasopressin upon arrival to the emergency department.”

Dopamine

Dopamine can be used to treat insufficient cardiac output and for hypotension. During a code situation, it can act as a vasodilator, which brings better circulation to the brain, myocardium, and kidneys.

Naloxone

Dr. North explained that crash carts sometimes contain naloxone or other opioid antidotes in the event that patients are coding due to an overdose—either accidental or stemming from drug abuse.

Beyond medications, Dr. North discussed other items that code team members are likely to find in their crash carts.

“Similar to medications, most institutions will have similar items in their crash carts,” Dr. North explained to Pharmacy Times. “It will depend on the institutions’ specific needs, specific situations, and what might be readily available.”

The non-drug items Dr. North says health care providers can count on include syringes, saline flushes, intravenous placement sets, airway and respiratory equipment, and incubation kits.

Additionally, there are items in the crash cart intended to protect the members of the emergency care team from any safety hazards that may be associated with providing care during a code. These items likely include a sharps container, gloves, gowns, and masks in order to protect against blood-borne illnesses.

Pharmacists and other members of the care team who provide direct patient care should stay alert of serious blood exposures.