Intubation boxes – Emergency Medicine Ireland

Hidden in the depths of the EM Crit site I found this video

[vimeo http://www.vimeo.com/23282023 w=400&h=300]

And it reminded me of something that we had in the ICU and ED where I worked in NZ. I don’t think it was unique to there but it was the first time I’d seen it.

In the fridge of both the ED and the ICU there were what I call “lunch boxes” with all the drugs you might need for an emergency intubation.

These were (in the main) already drawn up and labelled syringes of:

sux 100mg
rocuronium 50mg
propofol 200mg
thio to be reconstituted
midaz 5m
spares in vials of all of the above

So any time there was an RSI to be done, you just grabbed a box broke the seal and you were ready to go.

When I was there, most of what I used it for were arrest calls to the wards and transferring patients to radiology.

I thought they were the best things since sliced bread.

I raised the idea with one of the pharmacists when I got back home and got nowhere… We can’t even get access to paracetamol in our place. The nurses get a fob but we can’t. Sigh.

Anyone else using these or even the kits that Scott describes in the video?

regarding the medication kits that were mentioned, one of the hospitals that I worked at did have these (just an FYI- I am a pharmacist that works primarily in the ED- no longer at the location i will describe). They contained most medications that would be needed for a routine RSI, either in a medical or trauma scenario: etomidate (20 mg vial), sux (200 mg vial), roc (2- 50 mg vials), vec (10 mg vial- and a 10 cc vial of SWFI for reconstitution), propofol (200 mg vial), lidocaine (100 mg bristojet), atropine (1 mg vial), midazolam (10 mg vial), and fentanyl (200 mcg total). Also included was a control sheet that was used to document the administration/wasting of the controlled substances, because after use, the sheets and kits were returned to the pharmacy for reconciliation and legal purposes (documentation- including the locks of each kit). The kits were locked with a numbered plastic tie (similar to the RSI box in the video) and also contained a second lock for securing the used kit when no longer needed until returned to the pharmacy (different color locks- white for filled and ready to be used, red for return to Rx). The syringes or other supplies were available in either the ER resus rooms or on the floor/ICU in the case of emergent intubations. I will also say that at this hospital, a pharmacist would respond 24/7 to all medical codes, rapid responses, and trauma team activations. These kits were kept in the ED in the Pyxis machine in a dedicated drawer, so an RN could obtain even if the pharmacist wasnt there (ex- elective intubations where no code was called). I will say that the creation and use of these kits was positive (RN/MD satisfaction, having everything available without multiple trips to the med stations, etc) but there can also be some difficulties with regards to medication stability/storage (refrig the entire kit or simply label sux/roc with appropriate exp dates and possibly have some med waste?). Also is the chance that an incorrect medication is chosen from the kit (as there were multiple sedatives and neuromuscular blockers available for selection), but most importantly (for the pharmacy director/ ops manager) the security and control of the narcotic medications in the kits and the documentation required. These kits were beneficial in our hospital, but if you can work it out between the ED and Rx departments, having these or similar kits available for RSIs, especially without pharmacist code/trauma response, may improve the speed of care.

2 Replies to “Intubation boxes”

ED_PharmD says:
August 16, 2011 at 4:35 am
regarding the medication kits that were mentioned, one of the hospitals that I worked at did have these (just an FYI- I am a pharmacist that works primarily in the ED- no longer at the location i will describe). They contained most medications that would be needed for a routine RSI, either in a medical or trauma scenario: etomidate (20 mg vial), sux (200 mg vial), roc (2- 50 mg vials), vec (10 mg vial- and a 10 cc vial of SWFI for reconstitution), propofol (200 mg vial), lidocaine (100 mg bristojet), atropine (1 mg vial), midazolam (10 mg vial), and fentanyl (200 mcg total). Also included was a control sheet that was used to document the administration/wasting of the controlled substances, because after use, the sheets and kits were returned to the pharmacy for reconciliation and legal purposes (documentation- including the locks of each kit). The kits were locked with a numbered plastic tie (similar to the RSI box in the video) and also contained a second lock for securing the used kit when no longer needed until returned to the pharmacy (different color locks- white for filled and ready to be used, red for return to Rx). The syringes or other supplies were available in either the ER resus rooms or on the floor/ICU in the case of emergent intubations. I will also say that at this hospital, a pharmacist would respond 24/7 to all medical codes, rapid responses, and trauma team activations. These kits were kept in the ED in the Pyxis machine in a dedicated drawer, so an RN could obtain even if the pharmacist wasnt there (ex- elective intubations where no code was called). I will say that the creation and use of these kits was positive (RN/MD satisfaction, having everything available without multiple trips to the med stations, etc) but there can also be some difficulties with regards to medication stability/storage (refrig the entire kit or simply label sux/roc with appropriate exp dates and possibly have some med waste?). Also is the chance that an incorrect medication is chosen from the kit (as there were multiple sedatives and neuromuscular blockers available for selection), but most importantly (for the pharmacy director/ ops manager) the security and control of the narcotic medications in the kits and the documentation required. These kits were beneficial in our hospital, but if you can work it out between the ED and Rx departments, having these or similar kits available for RSIs, especially without pharmacist code/trauma response, may improve the speed of care.
- Andy Neill says:
  August 16, 2011 at 1:44 pm
  great to hear a pharmacy perspective
  I really like the pyxis machine, though the place where i work most of the time is all cupboards and keys and not that user friendly.
  certainly the narcotics are an issue which is why they weren’t in the boxes in the ED in new zealand where i worked.
  However they did have pre-made syringes of morphine in a sealed bag in the controlled drug cupboard. You still had to get the cupboard open and get them signed out but it saved a lot of time having it pre made especially s you’d be using it 5 or 10 times a shift.
  a pharmacist at a code is a new thing to me! Everything in our ED is done by the nurses or the docs, all the reconstitution all the antibiotics. there are of course problems with that but we do get very good at it!
  Andy Neill http://EmergencyMedicineIreland.com

2 Replies to “Intubation boxes”

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