PEMED’s Resus Kit

SNAG-0006

andy-sloasRemember we did an episode with Keith Conover on creating resus resource packs for your body, car, and home? Well, Andrew Sloas of the PEMED podcast took the advice to heart. He created 3 identical kits, for his and his wife’s car and for his house. Crazy or Brilliant? Let us know in the comments section. Here’s Andrew:

PEMED’s Resus Kit

This list is designed to allow you to create a similar emergency resus kit, but saves you the painstaking hours that I spent considering not only how to get all this stuff into a trauma bag, but how to arrange it in the most functional manner.

Click Here for the Full Kit Contents and Where to Buy the Gear

The first column describes the item type and the second column the location of each item. I have also provided you with the merchant i used and a hyperlink to each item’s web-POS page. The price I paid is in the next column, but that will fluctuate. Some of the items must be purchased in bulk, but I try to only have 1-2 in my bag. As you can imagine, the bag is fairly heavy with one of each item. How often are you expecting to get two emergency out of hospital intubations on your family at the same time? Just stick with one item for most things.

Backpack

Compartment-1

Compartment-1-Unpacked

Compartment-1-Unpacked

Compartment 1 – The Main Compartment: This is where all the airway stuff is located (with the exception of the surgical airway kit). When things are really bad (let’s face it they’re really really bad if you ever have to use this kit) and you haven’t looked at the kit in over a year, you wont’ have to relearn where everything is located. Everything you need to intubate is in one space.

Compartment-2

Compartment-2

Compartment 2 – Fluids, Drugs, & Accessories: This section is color coded via the handy multicolor velcro packets that come with the trauma backpack. I labeled each packet with permanent ink to make it easy to find things during a code. Again, the last thing I want to do when I’m thinking about intubating a friend or family member is stop and search for things.

Compartment-3

Compartment-3

Compartment 3 - Central Line, gloves and face shields.

Side-Pockets

Side-Pockets

Side Pockets – For all the non-medical stuff or anything you can’t fit in the main compartments.

 

Kit tips:

  • Some of the items don’t have a merchant listed. Those items were obtained over years of teaching airway. Often your hospital will get rid of items, which would make a great addition to your bag, just because past their expiration date. Make friends with your supply tech.
  • Volume ordered = if I had to buy it in bulk it that is the minimum number you can buy for that price.
  • I keep a central line kit in the bag not because I’m planning on lining-up someone at Arby’s, but because it can be used for so many other things: the scalpel is great for procedures if the other scalpel is in use, the needle is great for thoracostomy, retrograde intubation, or cric.
  • A 10F peds stylet works with a 4.0ET and all adult ETs, so you don’t really need an adult ET stylet.
  • The M6 oxygen tank has a built in wrench, but it’s flimsy and the having an additional oxygen wrench is a necessary backup. Tape the wrench to your oxygen tank or you’ll never find it when you need it.
  • I have a simple CPR resus mask easily accessible in one of the side-pockets because my nanny can’t intubate, but she can use the mask
  • I chose ET sizes 4,5,6, 7 to make sure I have a tube for everyone. I omitted an 8 because I’m not planning on bronching anyone in the field. You could probably get buy with a just a 4, 5, and 6.
  • Super Glue = poor man’s Dermabond. Good for everything from gluing in an IV or chest tube, to repairing small lacerations. This is the item in my bag that I use the most…for lacerations, not chest tubes.
  • I only have an adult EpiPen (no EpiPen Jr in the bag), why no peds dosing, because an overdose of epi doesn’t make your head, heart, or lungs explode. 300-500 mcg ain’t going to hurt anyone (even a child). If they need epi they need epi so just give he adult dose….
  • Cric Kit, just bc I happen to have one and I like contingency plans, but for me I perform surgical airways with a bougie and scalpel.
  • Suction Tubing: Great tubing for Heimlich valve – thoracostomy tube also a good 2nd tourniquet
  • Why an 8F Thoracostomy tube: it has a needle-like trochar stylet, which makes it the most perfect device invented for needling a tension PTX in the field when there are no other options. Put it in the same place you’d put a chest tube; even with the nipple. Once your in, just slip the tube in over the trochar-stylet. I prefer the traditional surgical technique (no trochar) when in a controlled environment like the ED.
  • Write instructions on things you don’t use all the time (ie. “Blue goes toward the chest”on the Heimlich valve package).

 

 

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Comments

  1. Personally, I don’t think this is crazy at all. If you have the capability and ability to perform interventions immediately, why not take advantage of that?

  2. Agree superglue is one of the most useful items, I always carry for simple wound repair on remote kayaking trips, securing lines etc

    With regard to drugs…what are you carrying? And is thermal lability a worry for neuromuscular blockade? Or no paralytic in kit?

    Im a fan of celox haemostatic dressings in austere pack. Thoughts?

  3. Mike Greenway says:

    Two things spring to mind…

    1: Why succinylcholine – it will be out of the fridge and (hopefully) be used infrequently and have a short shelf life so likely wastage – perhaps for such a rare use item something like Vecuronium might be more cost-effective? (DOI: I carry Roc, and Sux but my car is also used for voluntary responding for the ambulance service on a regular basis)

    2: Is the plan to super-glue the wound in the field and let the casualty go home with no further intervention? I would have thought that proper wound toilet would be required or else there is a significant possibility of infection/abscess.

    Great stuff to carry with you, I feel safer with my portable ICU in the boot; my wife is less happy on an unplanned trip to Ikea.

    • That will very, if the wound is obviously clean and just bleeding, say it was a little scrape while riding a bike, I would just have them wash it out with tapwater as I believe that “dilution is the solution to pollution.” You don’t really need to add anything but water under pressure to get the wound clean. Then I’d glue it and send then on their way. If the wound is obviously contaminated but profusely bleeding, I would use the SuperGlue to try and stop the bleeding Then I’d send them on to hospital for definitive managent. The caveat I want everyone to remember is that the kit is really designed to be used on my own family. Not that I wouldn’t use it in an emergency on anyone in extremis, I would, but it was designed to be used in a patient population that I know is not going to sue me (my family). For everyone else, I’m going to trust in the good Samaritan law.

  4. I too carry roc…as well as fentanyl, ketamine, propofol, morphine, adrenaline etc etc

    But interested in the thermal lability of rocuronium. Anyone got data?

    • Mike Greenway says:

      The SPC for Rocuronium states it can be left in temperatures up to 30 degrees Celsius for up to 12 weeks.

      • My understanding is that all paralytics are unstable in heat, but succinylcholine has a longer shelf life than Roc. If vecurronium is the most stable then I should probably reconsider putting that in my kit. Admittedly, I’m taking a chance by having any paralytic in my hot car, but I plan to change it out every six months and would more than likely be giving a big IM/IV dose to increase the chances it would work. Ideally, I guess I should invest in a car fridge.

        • Stefan says:

          I’m not sure about the United States but in Germany, Suxamethonium is available as a powder for reconstitution with saline (brand name: Lysthenon siccum). No issues with temperature and a massive 5 years shelf life. Having to reconstitute is obviously a disadvantage in an emergency but considering frequency of use and not needing a fridge is a pro. We use it in our volunteer ambulance service.

  5. …scope for a research project there.

  6. Hey Scott and Andrew what a great discussion! Scott you asked about comments, so I am going to liberally give mine. I mean all this is the name of good discussion so take it all with a grain of salt, and I hope I articulate my thought in a non-offensive manner. This is my first post on EMCrit, but Scott I have been following you from day 1, and have totally swallowed the cool aid! Thanks for all you do. I believe that if most knew what it takes to put together what you do, they would think you even more amazing… or maybe just simply crazy.

    First an intro, my name is Anthony Baca. I am a flight nurse, paramedic, and regional clinical manager for one of the largest helicopter medical transport programs here in the U.S. I have been involved in prehospital, ER, and ICU care for 21 years first as a paramedic then as an ER, ICU, and Flight Nurse. In our mission profile, we fly with a flight nurse and paramedic team. About 50% of our case mix is scene work including trauma, cardiac, neuro and peds. Additionally, I also have a bit of perspective as a sole medical provider (only medical person on scene). I have been in many sole provider situations as an EMS supervisor as well as while functioning as a police officer, which I have been for about 8 years (in my free time).

    As to the kit, nice work Andrew, looks like you put a ton of time into it. Here are my thoughts on personal aid kits. I’ll take this from the perspective Andrew did, assuming we are building a kit for personal use on people we really care about.

    I’ll start with circulation to make AHA happy (sort of). I can’t under emphasize the need for tourniquets. In the hospital we think of a tourniquet as the end to the “Stop Bleeding Algorithm”. In the prehospital setting with limited resources, they can be life saving as they can buy you time to focus on other stuff. If I am still being shot at, I don’t have a bunch of time to focus on direct pressure right now. Similarly, if my patient has significant bleeding (even significant venous bleeding) from an extremity, but is also drowning in blood, I can’t be two places at once. I can stop extremity bleeding really quickly though with a CAT and then focus on the airway. Once other things are taken care of, or I get more resources, I can round back and deal with the bleeding in a more refined way. Just because I put a tourniquet on for a short period of time does not mean I need to leave it on. Tourniquets = extra hands when extra hands don’t exist.

    Next airway…. As sole provider (i.e. the only medically trained person on the scene), I would forget about intubation totally. We know that RSI and intubation are incredibly complex tasks that are very very easy to do poorly. Intubation must be a team sport and with a team of one there is lots of potential to loose. I would advocate oral and nasal airways with a BVM for good BLS. In my very humble opinion next step would be a supraglottic airway or a cric. For a supraglottic, most EMS services use the king airway, but I think LMAs can work as well. If those don’t work or are contraindicated I would recommend a bougie-aided cric.

    Going back to laryngoscopy for just a second, I want to explain my rationale. First, lets talk simple logistics; you are the only guy on scene who knows any medical stuff and you are in the middle of badness….
    1. If you are outdoors, it is often very, very, difficult to see down someone’s dark throat. Looking from a bright area into a dark one does not typically work well. (Think trying to shoot a photo into a dark room from outside). Even with a bright fiber optic blade, it is not going to help a bunch if you are in the bright outdoors). Unfortunately we are learning that video may not always help here either, many of the VL screens wash out terribly in sunlight and we have to go to plan B.
    2. Everybody here knows that emergency patients are TERRIBLE about fasting before they try and die, so no fast invariably means PUKE (+ or – blood), which means a need for suction. There are a ton of mechanical portable handheld devices that you can buy for less than $100. In my humble experience none of them work well, and you need real suction that is battery powered (which means $500 + dollars and regular battery charges). Without good suction, laryngoscopy may be even harder.
    3. The EM FOAM world has done a really good job lately of acknowledging the role human factors play in the application of medicine during crisis. Going back to our “you are the sole clinical guy on scene” scenario, when you are eyes down in the airway looking for epiglottis, you have NO situational awareness. Additionally, you have no team members to maintain situational awareness for you. Finally, you have no technology to maintain situational awareness (EKG, ETCO2, SPO2, NIBP etc.). Part of that situational awareness is loss of time perception. I feel very comfortable intubating and RSIing. We do it successfully in the uncontrolled pre-hospital environment everyday… as part of team, with technology, and a common well defined game plan. I would not try to RSI by myself with limited technology, while looking in the face of someone I care deeply about. In my mind in this scenario, it is BVM, drop a supraglottic airway, or cric if necessary and move on. There is still a lot to do and it’s just you to do it.

    Breathing- Very nice job on remembering end tidal. Whether using the BVM, the supraglottic, or the cric, the most basic thing to figure out is “are we successfully moving air in and out of the chest?” Often listing to lung sounds is worthless in a loud uncontrolled environment, plus, if it is just you, that is one more thing you probably wont have time to do. If you are busy using both hands to pull the patient’s face into your mask (while holding it thumbs down by the way), the gold of your easy cap can help you at least assure you are moving some alveolar air in and out. Once you place a supraglottic, ETCO2 can also help you to identify dislodgement. Sometimes the supraglotics are a little fidgety when moving people, so continuous tube placement verification is critical. If you end up in a cric, you need to assure it is correctly placed as well, so bougie aided tracheal click, tracheal lock, and end tidal can help assure good placement when lung sounds fail because it is too loud (or because you have audio exclusion from the stress of cricing a loved one in an unfamiliar environment).

    One last note. Little finger pulses oximeters are easily available now and you can even get them at many pharmacies. You might consider getting one for the kit. Of note though, looking at lots of second by second physiologic RSI data, frequent SPO2 findings often include transient loss of pulse ox for a multitude of reasons, including clips falling off fingers, the SPO2 light source being washed out by sunlight, loss of distal perfusion after induction agents and initiation of positive pressure etc.

    As to thoracostomy, in the patient who is remarkably unstable, by myself, I don’t know that would advocate placing a chest tube or even angiocath in the chest at all. If the patient is really unstable and there is a good clinical reason to suspect tension I think it would be very prudent to perform bilateral finger thoracotomies. It the rapidly crashing patient in an uncontrolled environment, by your yourself, with no ultrasound or radiology resources, being able to tell if someone is having a tension is very difficult, telling which side it is on is even harder. So, rather than place an “extra something” in the chest that WILL be unsterile and may potentially poke big holes in a lung that was never injured, I think there is something to be said for sticking a finger in, clearing a tension (or not), and moving on.

    With regard to IV access, we all know central lines can do bad things and we know we should all be putting them in under ultrasound. We also know that triple lumens suck for rapid infusion of fluids. Thinking about this from a human factors perspective, if I am doing a dangerous procedure, in a foreign environment, under far less than ideal circumstances, without technology, and while under the extreme stress of knowing this is my mother, father, spouse, or child… in short it sounds like a really bad plan. I would not want to rely on my regular IV skills either though if I am not putting in lots of IVs regularly. As such, if I could not get a peripheral IV, or don’t have the time to look for one, I believe the “go to” should be an EZ-IO. With a bit a practice you can get really good at them and deploy them fast.

    Often times we arrive to find patients in crisis that need RSI and airway protection and EMS has already tried to get IVs everywhere. We will go straight to an EZ-IO, induce, intubate, get in transport, then look for IV access. It has been my experience that the tibial IO is not the best for fluid resus (but RSI drugs work through it great), humeral IOs work great for both rapidity of induction and administration of fluids, so if you were to get the EZ IO for your kit, get the longer needles. Finally, I definitely would recommend two 1 liter bags of LR (or NS if necessary) and disposable pressure bags to go with them (instead of the 500 ml bags). With crystalloids as your only choice, you may have to give a lot very quickly.

    My last comment is about meds. I would definitely think about the meds you are going to carry and what state regulations (if any) are in place. With regard to paralytics, our helicopters can get hot just like cars do in the summer. We know that paralytics degrade fast in heat. We carry Roc but throw it out every month if it isn’t used. We have seen unsuccessful paralysis with Roc and Sucs, both that were just over a month old in the summer heat. The drug inserts say they can be at room temp (i.e. < 80 degrees) for 90 days, but in the summer the inside of a car or aircraft may be more like 120 + degrees (depending where you live). If I were carrying a paralytic in a vehicle that was not going to be maintained everyday I would carry Vecuronium in powder for reconstitution. It lasts much better in the heat. Of course the trade off would be the delayed paralysis onset time, so while it is not the best for RSI, these are not the best conditions.

    Also there was mention about suppliers for all this stuff. Here are three. I have absolutely no affiliation with any of these three companies so I am not endorsing any of the three, I am just putting these out there because I know they exist.

    http://www.boundtree.com/
    http://www.mooremedical.com
    http://www.vidacare.com/EZ-IO/Index.aspx

    Thanks guys again for a great topic.

    Anthony

  7. Will McMurray says:

    Anthony,
    Im late to the party but just wanted to say great comments.
    In putting together a similar bag for myself, I went the conservative route and stuck with a king airway over an ET setup. My reasons were lack of suction and speed of placement when I am working alone. I have used a King a few times at work as a paramedic and have never had trouble with it.

    The two 1,000mL bags are a good idea, even though they add alot of weight. Ive had a few patients where 1,000mL just wasnt enough to correct their BP.

    The EZ-IO definitely takes a little practice learning to apply enough pressure to drill without bending the needle. I have only used one once for a tibial IO in an arrest, and had to vigorously flush the line and pressure infuse to get a decent flow rate. But it was quick placement and worked well enough. I would feel comfortable going straight to an IO over an IV. Im looking forward to trying the humerus next time and comparing flow rates.

    Great site Scott! Ive been following along for a few years and have enjoyed the great education.

    -Will

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