INTRODUCTION

According to 2006 statistics, there are 4,800 operating emergency departments (EDs) in the United States, 3,900 of which receive and care for pediatric patients.[1] During that same year, about 6 million patients were triaged into the “immediate category”,which required them to be seen by a physician within one minute of arrival due to the severity of their illness.[2] For patients with such life-threatening conditions presenting to the ED, crash carts have become essential tools for resuscitation. For instance, in cardiac arrest situations,every minute’s delay in resuscitation can lead to a drop in successful outcomes by 7%-10%.[3] Thus, timely access to a defibrillator, resuscitation medications, supplies, and equipment should be fast and easy, and crash carts need to be carefully equipped, organized, and maintained.[4]

近年来，心血管疾病的发病率越来越高，在进行病床和护理人员安排的过程中，坚持平均分配的原则，提高安排的合理性。根据科室的具体情况，对病床进行分组，每组的病床数量具有相同性，然后为每一组病床分配1名护理人员参与床边责任护理。在分配的过程中，需要注意，参与床边责任护理的人员，不应在参与夜班护理工作，一方面，提高护理工作的人性化，另一方面，提高护理工作配合的合理性，提升护理的效果。另外，科室根据自身的实际情况，合理安排床边责任护理人员的数量，提高床边责任制护理工作的质量。

Several references recommend having a consistent approach to the organization of the medication drawers in crash carts in order to reduce the likelihood of medication errors and medication retrieval time,[4,5] and to ensure correct medication labeling in accordance with The Joint Commission (TJC) medication management standard 4.30.[6] Few publications have described crash carts specific to the pediatric population, without being specific to the ED,[7-11] while other publications described “crash cart” or “resuscitation cart” contents in the general and adult populations, without being specific to the ED.[4-6,12-15]

Around the world, EDs rely on “intrinsic experience”and “best practices” for the layout and content of their crash carts. Many ED nurses and physicians seek guidance when putting together a resuscitation cart for their ED. This article aims at performing a systematic review for articles describing comprehensive crash cart contents—both equipment and medications—specifically in the ED for pediatric or adult populations. In addition,the article aims at proposing a set of suggestions specific for the ED crash cart (EDCC) that encompasses adult and pediatric population needs, based on the 2015 American Heart Association (AHA) recommendations for cardiopulmonary resuscitation and emergency cardiovascular care; the 2015 European Resuscitation Council (ERC) guidelines for resuscitation; and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition, in addition to other clinical guidelines.[16-20] Additional suggestions are made regarding an EDCC for use in resource-limited settings.

对照组患者并发症检出率是25.81%,与研究组的3.23%相比高出许多,统计学存在差异(P<0.05),详情如下表2:

METHODS

Figure 1. Search protocol.

Twenty years later, in 1994, a registered nurse in Centerville, Massachusetts, described a crash cart for pediatric resuscitations.[8] The cart had nine drawers that were color coded in coordination with the Broselow®tape, to separate the different pediatric age groups.The drawers were removable to help facilitate running multiple pediatric resuscitations simultaneously. Drugs used in resuscitation were stored in a separate drawer.The cart was checked and replenished after every use,and was checked completely once every 24 hours by a specifically trained nurse.

“MDT是一种初步发展的模式，专病诊疗中心就是更高层次的MDT团队。”孙湛说，“MDT团队成熟以后成立亚专科，亚专科成熟以后成立专病诊疗中心，目前中山医院已经有13个专病诊疗中心了。”

RESULTS

The search yielded a total of 277 results, with 192 unique results and 85 duplicates. After title and abstract review, 185 articles were eliminated because they were not specific to Emergency Departments (EDs) or did not describe crash cart contents. Of the remaining seven articles that underwent full article review, three articles were excluded, because they either did not contain information regarding the contents of the cart, or were not specific to the ED.

Four articles were selected after the final review because they described actual contents of the crash cart,specifically in the ED. However, none of the four articles described comprehensive contents of equipment and medications in both the adult and pediatric populations.Two articles[21,22] listed equipment for both pediatric and adult populations but none of the medications. One article was specific to pediatric crash carts in the ED,[8]and another was specific to toxicological emergencies and described the optimal setup for a “Tox” crash cart.[23] Three articles were written by nurses,[8,22,23] while the remaining article was written by a surgeon.[21]

The first article to mention the EDCC was published in 1972 in Injury and is entitled “A resuscitation trolley for the emergency and accident department”. It narrates that the “trolley” was being used at the Emergency and Accident Department at the Royal Infirmary in Lancashire, England since 1963. The purpose of the“trolley” was cited as follows: “This trolley has been designed to overcome delays which often arise when a seriously ill or injured patient is... and has been found to be indispensable in the initial management of all types of serious conditions.” It describes the “trolley” as follows:“It measures 40×36×18 inch, has a folding for monitoring the central venous pressure. A shelf 18 inch long at one end, and carries a complete plastic drawer unit on the lower shelf holds drugs, set of intubation apparatus,together with an cross-matching bottles, and needles.Disposable appropriate selection of drugs, intravenous syringes, intravenous solutions, and a transfusion fluids,and giving sets.” The article does not specify the name of any medication or the size of any equipment listed but has two large pictures of the “trolley” and its contents without labels.

供试品种：大白菜（高抗王3）；供试肥料：尿素（N2O ≥ 46.6%）；过磷酸钙（P2O5≥ 12%）；硫酸钾（K2O≥50%）。

“纯天然”、“无糖”、“全麦”等，食品包装上经常能看到这些健康的代名词，然而，据美国《健康》杂志报道，一项最新调查显示，59%的消费者都弄不明白食品标签的真正含义，从而“买错”了东西。

In 1974, a nursing officer at the Northwick park Hospital in Harrow, England described a crash cart that is uniquely shaped like a house with a “roof”,[22] which is able to hold a full set of adult airway equipment including bronchoscopy on one side, while the other side holds equipment needed for children and infants. These sides can open up revealing a compartment that can support equipment required for ventilation, oxygenation and suctioning. Below the “roof” are two shelves; the top shelf holds intravenous administration sets and fluids for adult and pediatric patients, while the lower shelf holds syringes of all sizes, bandages and splints. An oxygen tank can be fitted on the side of the cart as well.

On December 20, 2016, the authors performed a systematic review of literature indexed in Pubmed and Embase. Search terms included several crash cart terms (e.g., crash cart, resuscitation cart, code cart); the full search strategy and terms are included in Figure 1.The search was limited to English language only, but not limited by date, clinical setting, or study type. All applicable controlled vocabulary terms were included in the search. Two reviewers independently reviewed all unique titles and selected for abstract review those articles that met the inclusion criteria listed above and whose titles suggested possible emergency department crash cart material. A third reviewer acted as an arbitrator and reviewed any discrepancies to make a final decision.The same 2-step process was performed for the abstract review, and again for the final full article review.

The third row contains mainly antiepileptic agents in addition to a diuretic. Of note, phenytoin can be stored at room temperature, and hence, is included in the EDCC,while fosphenytoin requires refrigeration and needs to be stored in a proxy location. Naloxone is also kept in this drawer.

DISCUSSION

Our systematic review demonstrated a paucity of literature on articles describing the contents of EDCCs; in addition, the articles found were very old and outdated with the most recent being more than twenty years ago. This shows the potential lack of credibility of these resources and the need for future studies regarding this highly important topic. Most of the equipment and medications used in resuscitation algorithms have been updated and modified, however there remain certain medications and equipment that all emergency providers use, that should be readily available and were not clearly outlined in the articles reviewed. After reviewing the articles and latest resuscitation guidelines, the authors would like to put forth suggestions that are meant to augment the ad-hoc and heuristic approach to EDCCs.

Suggestions for the Emergency Department Crash Cart (EDCC)

The EDCC is kept in an easily accessible location in the main ED resuscitation area, where it is most commonly used. The cart is mobile on wheels so that it can be moved to another location in the ED if needed.The suggested design for the EDCC is a tall, five-drawer cart. The top three drawers are relatively small and of equal size, the fourth drawer from the top is larger,and the fifth/bottom drawer is largest. A clearly visible content list with expiration dates is attached to the cart.In addition, a laminated alphabetical list of the contents of each drawer is mounted directly on the front of each drawer.

External contents

On top of the EDCC is a biphasic defibrillator with adult paddles and adult multipurpose (defibrillation/cardioversion/pacing) pads. Infant paddles with cable and infant pads are placed next to the defibrillator in a transparent bag.

陈献章、庄昶在世时，“陈庄体”这一称谓即已出现。与陈献章“以道相契”［1］卷二，40叶b的双槐先生黄瑜在《双槐岁钞》中记道：

The back half will contain the rest of the supplies:Compact surgical airway set (cricothyroidotomy), batteries and light bulbs for the laryngoscope, tape, endotracheal tube holders, CO2 detector, and xylocaine spray.

微电网是能源互联网领域的基础环节,该领域的发展与微电网(以下简称“微网”)技术密不可分[1]。目前,微网仍处于研究和实验室阶段,且其结构趋于复杂,准确把握该研究领域的热点和前沿,对微网的发展具有重要意义。由于微网的研究方向较多[2-3],例如规划设计[4]、运行优化[5]、保护控制[6]、实验仿真[7]等,研究热点相对分散,所以很难把握具体的前沿趋势。行业专家对微网的前沿发展现状研究,大部分是基于定性的点状信息采集和加工分析的方法,主观性较强,未通过具体数据进行量化角度的统计分析。

Internal contents

The top two drawers of the EDCC contain essential resuscitation medications. These drawers are divided into compartments allowing medications to be stored separately and visibly. In addition, each box is labeled with the medication name. The medications in the first two drawers are organized in a systematic way, wherein those with comparable general purpose are grouped in the same rows, and those with more urgency are put in the front rows. In order to reduce medication error,medications with similar names should be marked clearly and separated by at least one other medication. Several of these medications require protection from excessive light exposure.[24]

First drawer (Table 1)

The first row of the first drawer contains all the medications used in a cardiac arrest (epinephrine,amiodarone, sodium bicarbonate, and calcium).Vasopressin has been dropped from the 2015 ACLS guidelines in shockable rhythms due to lack of benefit.[25]

The second row contains Rapid Sequence Induction(RSI) medications needed for intubation, as well as medications for bradycardia. Note that certain medications used in RSI need to be stored in proxy locations (e.g., ketamine in the controlled substances area). Vecuronium is one paralytic that can be placed in the EDCC because it can be stored at room temperature,unlike succinylcholine and rocuronium that require refrigeration. Etomidate is the only sedative suggested for placement in the EDCC for RSI as it has a lower potential for substance abuse compared to other agents.Of note, RSI drugs need not be extensive in areas where intubation is not practiced due to lack of ventilation or subsequent ICU care.

对原始数据采用先中心化再标准化的方式进行量纲统一，即采用z-score标准化，操作较为简单直观，防止边际样本增加、整体分布改变带来的全体分值变动，有利于原样本与新增样本数据的横向对比。在统计年鉴只有总量的情况下，例如“移动电话交换机容量”“局用交换机容量”，根据地区常住人口除以其总量得到人均拥有量，能更直观地展现地区的水平，同时也更符合普通评价和认知标准。具体测算方法如下：

The third row includes medications predominantly used in tachyarrhythmias with a pulse. Some medications can be interchanged with others from the same class with comparable characteristics depending on availability. For instance, Metoprolol might be used as a representative of other beta-blockers.

The fourth row has intravenous medications needed for hypotensive emergencies and for patients with low cardiac output. Hydrocortisone is included for its use in refractory hypotension and suspected adrenal crisis.

Second drawer (Table 2)

The first row in the second drawer is predominantly stocked with medications for hypertensive emergencies,and decreased mental status due to hypoglycemia and opioid overdose.

The second row contains intravenous and inhaled medications for acute exacerbations of respiratory diseases (asthma, chronic obstructive pulmonary disease,and upper airway edema), as well as medications for allergic reactions.

The final article, from 1995, focused on a crash cart designed for toxicological emergencies.[23] This cart is a mobile cart that can be used in the ED or on the ambulance ramp. It is made of two drawers; it has a full set of airway equipment found on the top of the cart, along with gastric lavage supplies, pH paper and various blood tubes and specimen containers. Forty-two antidotes are maintained in the two drawers of the cart.It is checked daily and audited monthly. In addition, it includes quick reference guides, common normograms and numbers for the local poison control centers.

The fourth row contains miscellaneous medications such as thiamine to treat Wernicke-Korsakoff syndrome,and glucagon to treat beta-blocker overdose.

Third drawer

The third drawer is reserved mainly for materials to establish peripheral intravenous (PIV) access, and contains some other miscellaneous items as well. The drawer includes: angiocatheters (14, 16, 18, 20, 22, 24 G)for emergent decompression of tension pneumothorax.For PIV access, contents include needles (16, 18, 21,25 G), alcohol wipes, syringes (1, 3, 5, 10, 20, 30 cc),long spinal needles (Peds: 20, 22 G; Adults: 18 G) for emergency pericardiocentesis, scalpel blades (10, 11,15), sutures (Nylon 2.0, 3.0, 4.0; Prolene 2.0), radial and femoral arterial line catheters (Peds: 22, 24 G;Adults: 20 G), nasal packs and balloons (unilateral and bilateral) for severe nose bleeding, and a magnet to reset malfunctioning pacemakers/defibrillators.

我国国家卫生计生委也提倡建设节约型医院，各医院纷纷响应国家号召，在制定节能计划之前，引进一套有效的能耗监测系统，对医院各科室的水电气能耗进行能耗监测，以掌握全院能耗动向，分析用能分布，制定节能考核指标，以达到节能降耗的目的。有了能耗监控系统，医院管理者对本院的能耗指标的监控和管理更加容易。将系统得到的能耗分项和分析报表进行科学的分析，进而制定相关节能举措。

Fourth drawer (Table 3)

The fourth drawer is designed to store respiratory equipment and supplies for both adults and pediatric patients. The front half of the drawer can be divided into two detachable compartments (pediatric and adult) oneof which can be removed and placed at the head of the bed during resuscitation, depending on the age group of the patient.

Table 1. Medication contents of the 1st drawer of the EDCC

*: representative drug that may be substituted with another from same class; +: stored at room temperature in powder form.

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Table 2. Medication contents of the 2nd drawer of the EDCC

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On the EDCC we suggest placing: on one side, one adult (1,000 mL) Ambu-bag with two facemasks (sizes 3 and 4), and one oxygen tube connector in a transparent bag; in a separate transparent bag, one infant (250 mL)and one child (500 mL) Ambu-bag with two facemasks(sizes 1 and 2), and one oxygen tube connector; on the other side, one compressed oxygen tank; on the back of the cart, a hard cardiopulmonary resuscitation (CPR)backboard and a laminated length-based pediatric resuscitation tape, such as a Broselow®.

Fifth drawer

The 5th drawer is reserved for larger instruments and supplies needed for special procedures. The contents of this drawer will include: Central venous catheters (3-7 F/single and triple lumen); intraosseous kit; cut-down tray;umbilical catheterization set (3.5 & 5 F); chest tubes(sizes 10-42); thoracostomy kit; thoracotomy kit; suture set; delivery set; trauma tourniquets; pericardiocentesis kit; sterile stapler; burr hole manual drill kit.

Safety features, expiration dates, and restocking

It is very important for the EDCC to have breakaway plastic locks for safety and to comply with TJC guidelines.[6] Following each use, the entire crash cart,minus the defibrillator and its external accessories, must be immediately restocked.

Qualified personnel should periodically perform routine inspection of all cart contents. The defibrillator should also be tested on a regular basis. A detailed printed checklist with complete contents and clear expiration dates accompanies the cart. Medication expiration dates should also be checked on a monthly basis by a pharmacy staff member, and replaced accordingly.

Resource-limited settings

Emergency department patient epidemiology in resource-limited settings has not been widely reported,however the most common ED complaints involve infection/sepsis (43.4%) and trauma (28%) in Uganda,and infection (63.7%) in Tanzania.[26,27] A recent ED epidemiology study in India found the most commonchief complaints to be infectious (21.5%), genitourinary(7.3%), and pulmonary (6.9%).[28] There is also a paucity of articles that address caring for patients with sepsis,[29,30]stroke,[31] and respiratory distress[31,32] in resourcelimited settings. Using this limited data, the EDCC may be modified in resource-limited settings to focus on the suggestions from these articles. The authors recommend that drugs and equipment pertinent to the care of patients with sepsis and acute respiratory conditions be prioritized in their presence and location.

Table 3. Contents of the 4th drawer of the EDCC

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Limitations

This study was limited by the fact that there is a paucity of published literature on EDCC contents,for both high-resource and low-resource settings.Additionally, the search was limited to articles in English so it is possible that articles written in other languages may have been missed in our review.

CONCLUSION

In conclusion, our systematic review highlights a striking paucity of literature describing the contents of a comprehensive EDCC that can be applicable to critical scenarios in both the pediatric and adult populations.

We hope that our suggestions for the EDCC contents help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.

As resuscitation guidelines change and technologies advance, the EDCC contents will also require modification. We hope that patient care areas other than the EDs would also benefit from these suggestions, and can customize their crash carts according to their needs.

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: The authors declare that there are no conflicts of interest regarding the publication of this paper.

Contributors: GJ proposed the study, analyzed the data and wrote the first drafts. All authors contributed to the design and interpretation of the study and to further drafts.

疏果是提高枣果品质的重要手段。留果量过大，会削弱树势，影响次年植株生长，使当年果实成熟推迟，果实品质下降。疏果的一般原则是留优去劣、自上而下、自内而外。一般分2次进行，第1次疏掉病果、畸形果、过密果及小果等；第2次去掉弱果与畸形果，使保留的果实大小均匀、果形整齐、分布合理，最后达到壮枣吊三四个果、中枣吊2个果、小枣吊1个果。由于栽培模式不同，水肥投入及产量要求不一样，上市时间不一样，所以疏果应根据实际情况灵活进行。

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