Ambulance Checkout Sheet - ALS - San Diego
| A. Airway Adjuncts | Minimum Requirements |
Part Number |
| Quantitative end tidal CO2 monitor | 1 | Browse |
| Pediatric end tidal CO2 detection device (if capnography not equipped to read EtCO2 in patients weighing ˂15kgs) |
2 | Browse |
| CPAP equipment | 1 | 20051 |
| Endotracheal tubes | ||
| · 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0 (cuffed) | 1 each | Browse |
| Esophageal tracheal double lumen airway (kit) | ||
| · Combitube: Small adult | 1 | N/A |
| OR | ||
| Laryngeal/tracheal airway (King Airway: sizes 3, 4, 5) | 1 each | 50034 |
| ET adapter (nebulizer) | 1 setup | 812-BVMNEBKIT |
| Laryngoscope – handle | 2 | 7862 |
| Laryngoscope – blade | ||
| · Straight sizes 0-4 | 1 each | 6043 |
| · Curved sizes 2-4 | 1 each | 7060 |
| Magill tonsil forceps | 1 Small | 7337 |
| 1 Large | 7338 | |
| Stylet – 6 and 14 french, Adult | 1 each | 4814 |
| Bougie | 1 each | 4583 |
| HEPA/viral filter (for BVM, CPAP, nebulizer) | 6 | 12155 |
| B. Vascular Access/Monitoring Equipment | Minimum Requirements |
Part Number |
| IV administration sets | - | |
| · Macrodrip (2 must be vented) | 4 | 13194 |
| · Microdrip or | 2 | 13196 |
| · Multi-drip chambers | 6 | N/A |
| IV tourniquets | 4 | 3139-250 |
| Needles: | - | |
| · IV cannula – 14 gauge | 8 | 13220 |
| · IV cannula – 16 gauge | 8 | 13221 |
| · IV cannula – 18 gauge | 8 | 13222 |
| · IV cannula – 20 gauge | 6 | 13223 |
| · IV cannula – 22 gauge | 4 | 13224 |
| · IV cannula – 24 gauge | 4 | 13225 |
| · IM – 21 gauge x 1 inch | 6 | 1031791 |
| · Filter needles | 2 | SYR110022FZ |
| · Angiocath for needle decompression- 14 gauge, 3.25 inches | 2 | ZZ-0056 |
| · IO – jamshidi-type (or approved device) needle -18 gauge | 2 | N/A |
| · IO – jamshidi-type (or approved device) needle – 15 gauge | 2 | N/A |
| OR | - | |
| · IO power driver w/appropriate IO needles: | - | |
| o 15 mm (3-39 kg) | 2 | N/A |
| o 25 mm (40 kg and greater) | 2 | N/A |
| Syringes: 1 mL, 3 mL, 10 mL, 20 mL | 3 each | Browse |
| C. Monitoring | Minimum Requirements |
Part Number |
| Capnography cannula | 2 | 4459 |
| 8000-0356 | ||
| Defibrillator pads | 1 adult | 16381 |
| 1 Pediatric | 16380 | |
| Electrodes | 1 box | 8900-0004 |
| 31078135 | ||
| 31439766 | ||
| Electrode cables | 1 set | 12112 |
| 12114 | ||
| Monitor/defibrillator w/12 lead EKG and pacing capability | 1 | N/A |
| Oxygen saturation monitoring device | 1 | |
| · Adult probe | 1 | 1863 |
| · Pediatric/Infant probe | 1 | 13505 |
| D. Other Equipment | Minimum Requirements |
Part Number |
| Length Based Resuscitation Tape (LBRT) | 1 | 50021 |
| Mucosal Atomizer Device (MAD) | 2 | MAD300 |
| Metronome (or equivalent device) | 1 | N/A |
| Nasogastric intubation setup (8, 10 or 12, 18 french) | 1 each | N/A |
| 60mL syringe for nasogastric tube confirmation and placement | 1 | 13096 |
| Thermometer | 1 | 5610 |
| 5614 | ||
| 5122 | ||
| Water soluble lubricant | 1 | 1250 |
| E. Laminated Items | Minimum Requirements |
Part Number |
| Pediatric Drug Chart (Policy P-117 “ALS Pediatric Drug Chart”) | 1 | Link |
| F. Replaceable Medications | Minimum Requirements |
Part Number |
| Acetaminophen IV 1000 mg/100 mL (requires vented tubing) | 2000 mg | N/A |
| Adenosine – 6 mg/2 mL and 12mg/4mL | 30 mg total | N/A |
| Albuterol – 2.5 mg/3 mL or 0.083% | 6 vials | N/A |
| Amiodarone 150 mg/3 mL - With normal saline 100 mL bag |
2 vials |
N/A |
| ASA, chewable – 81 mg each | 6 units | N/A |
| Atropine sulfate – 1 mg/10 mL | 2 | N/A |
| Atropine sulfate – 8 mg/20 mL (0.4 mg/mL) | 1 | N/A |
| Calcium chloride – 1 gm/10 mL | 1 | N/A |
| Charcoal, activated (no sorbitol) – 50gm | 1 | N/A |
| Dextrose, 50% – 25 gm/50 mL | 2 | N/A |
| Dextrose, 10% – 25 gm/250 mL | 2 | N/A |
| Diphenhydramine hydrochloride – 50 mg/1 mL | 2 | N/A |
| Epinephrine 1:1,000 – 1 mg/1 mL ampule | 6 | N/A |
| Epinephrine 1:10,000 – 1 mg/10 mL | 6 | N/A |
| Glucagon – 1 unit (mg)/1 mL | 1 | N/A |
| Ipratropium bromide – 0.5mg/2.5 mL | 2 | N/A |
| Ketamine – 500 mg/10 mL (50 mg/mL) | 1 | N/A |
| Lidocaine hydrochloride (preservative-free) – 100 mg/5 mL (2%) | 4 | N/A |
| Midazolam – 5 mg/1 mL | 20 mg total | N/A |
| Morphine sulfate (injectable) – 10 mg/1 mL | 20 mg total | N/A |
| OR (units may carry morphine or fentanyl, but not both) | N/A | |
| Fentanyl citrate – 100mcg/2mL | 200 mcg total | N/A |
| Naloxone hydrochloride – 2 mg/2 mL | 6 mg total | N/A |
| Nitroglycerin – 0.4 mg | 1 container | N/A |
| Ondansetron (injectable) – 4 mg/2 mL | 2 | N/A |
| Ondansetron (PO/ODT) – 4 mg | 4 | N/A |
| Sodium bicarbonate – 50 mEq/50 mL | 3 | N/A |
| IV Solutions: | ||
| · Normal Saline – 1000 mL bag | 4 | 80005 |
| · Normal Saline – 250 mL bag | 2 | 80007 |
| · Normal Saline – 50 mL bag or 100 mL bag | 2 | N/A |
| G. Optional Items | ||
| Albuterol MDI | N/A | |
| Armboard – long | 61024M | |
| 61036M | ||
| Armboard – short | 61012M | |
| 61018M | ||
| Carboxyhemoglobin monitor | N/A | |
| Chest seals | 10-0037 | |
| Colorimetric carbon dioxide detector (if capnography not equipped to read EtCO2 in patients weighing ˂15kgs) | Adult | 30074 |
| Pediatric | 30075 | |
| Curved laryngoscope blades – size 0, 1 | 7061 | |
| Hemostatic gauze | 1214-47548 | |
| IO power drive needle 45 mm (40kg and greater w/excessive tissue) | N/A | |
| IV extension tubing | 13200 | |
| Lidocaine 2% jelly – 5 mL tube | N/A | |
| Mesh hood (spit sock or similar) – light color only (beige/white) | 19100 | |
| Leave Behind Naloxone kit(s) | N/A | |
| Saline lock | 13200 | |
| Three-way stopcock w/extension tubing | N/A | |
| Video laryngoscope | N/A |