Microsoft word - als checklist11012006.doc

Company __________________________ Unit # ___________ Multi-County Ambulance Advanced Life Support Checklist:

Ventilation Equipment:
Patient Assessment Equipment:
__ Chest Decompression: Commercial__ Self Kit__ Monitor/Defibrillator Operational Check: Angiocath: 10g ___ Other: ___________________ Make and Model: ________________________ __ Cricothyrotomy Tray: Commercial__or Self-Kit__ Monitor Serial No. _______________________ ________________________________________ Defibrillator Serial No. ____________________ __ Laryngoscope and Blades, straight and/or curved sizes: Straight: 0, 1, 2, 3, 4, Curved: 0, 1, 2, 3, 4 Uncuffed: __ 2.5 __ 3 __ 3.5 __ 4 __ 4.5 __ 5 __ 5.5 Cuffed: __6 __6.5__ 7__ 7.5__ 8__ 8.5__ 9__ __ End Tidal CO2 detector or alternative device, FDA approved to determine endotracheal tube placemnt Date of last service: _______________________ __ Nasogastric Tube (optional) Size 16 __ Size 18 __ IV Fluids and Equipment:
__ Soluset __________________________________ Medications:
Miscellaneous Equipment:
__ Medical Director selected and approved list (optional) _____________________________ __ Pediatric “length-based” device for sizing drug __ Denver Metro Paramedic Protocols, Section VI dosage calculation and sizing equipment Type:________________date:_____________ Other Comments: _______________________________________________________________________________ ______________________________________________________________________________________________ ‰ Approved ALS
‰ Not Approved. Re-inspection required.
‰ Approved BLS with ALS capabilities
Inspection Expires:
Date of Re-inspection:
Please print Ambulance Service Representative’s Name:
Ambulance Service Representative’s Signature Stanley Howell, Multi-County Ambulance Inspector Denver Metro Paramedic Protocols, Section VI.
DRUG PROTOCOLS
Drug Protocols
Page Number
__ Epinephrine __ 1:1 AMP __ 1:1 MDV __ 1:10 M __ Mark I Nerve Agent Antidote Kit _______________ __ Naloxone Hydrochloride (Narcan) _______________ __ Racemic Epinephrine (Vaponephrine) _______________ Other: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Medical Director: ___________________________________________ Medical Facility: _______________________________________________________________________________ M:/adm/clerical/ambulance/forms/ALS inspection checklist

Source: http://www.dcsheriff.net/emergencymanagement/documents/advancedlifesupportchecklist.pdf