Ambulance Checkout Sheet - ALS - Ventura
| Description | Part Number | ALS Unit Minimum Amount | PSV/CCT Minimum Amount |
FR/ALS Minimum Amount |
||
| A. ALL BLS AND ALS RESPONSE AND/OR TRANSPORT UNITS | ||||||
| Bag valve units with appropriate masks Adult (1,000 mL) | 523 211 000 | 1 each | 1 each | 1 each | ||
| Bag valve units with appropriate masks Child (500 mL) | 530 213 000 | 1 each | 1 each | 1 each | ||
| Bag valve units with appropriate masks Adult Infant (240 mL) | 540 212 000 | 1 each | 1 each | 1 each | ||
| Nasal cannula - Adult | 30345 | 3 | 3 | 3 | ||
| Nasopharyngeal airway - 14 French | 2021-14630 | 1 | 1 | 1 | ||
| Nasopharyngeal airway - 18 French | 2021-14640 | 1 | 1 | 1 | ||
| Nasopharyngeal
airway 20 French 22 French 24 French 26 French 28 French 32 French 34 French 36 French |
30335 | 1 each | 1 each | 1 each | ||
| Continuous positive airway pressure / Bi-level Positive Airway Pressure (CPAP/BiPap) device - Child | 2430-57320 | 1 | 1 | 1 | ||
| Continuous positive airway pressure / Bi-level Positive Airway Pressure (CPAP/BiPap) device - Small Adult | 20050 | 1 | 1 | 1 | ||
| Or | ||||||
| 2430-57319 | ||||||
| Continuous positive airway pressure / Bi-level Positive Airway Pressure (CPAP/BiPap) device - Adult | 20051 | 1 | 1 | 1 | ||
| Or | ||||||
| 20030 | ||||||
| Nerve Agent Antidote DuoDote Auto-Injector |
N/A | 3 | 3 | 3 | ||
| Blood glucose determination devices | MPH4540 | 2 | 1 | 1 | ||
| Glucomter Test Strips | MPH4550 | |||||
| Glucometer Calibration Solution | MPH4560 | |||||
| Occlusive Dressing | 3040 | 5 | 5 | 5 | ||
| or | or | |||||
| Chest Seal | 10-0037 | 5 | 5 | 5 | ||
| Oral glucose 15gm unit dose | 20001 | 1 | 1 | 1 | ||
| Oropharyngeal Airways 40 mm (Size 00) 50 mm (Size 0) 60mm (Size 1) 70 mm (Size 2) 80 mm (Size 3) 90 mm (Size 4) 100 mm (Size 5) 110 mm (Size 6) |
Browse | 1 each size | 1 each size | 1 each size | ||
| Or | ||||||
| 30340 | ||||||
| Oxygen with appropriate adjuncts (portability required) | 36391 | 15 L/min for 20min (40min for transport units) |
15 L/min for 20min | 15 L/min for 20min |
||
| Portable suction equipment | 30370 | 1 | 1 | 1 | ||
| Nonrebreather oxygen masks - Adult | 30355 | 3 | 2 | 2 | ||
| Nonrebreather oxygen masks - Child | 30356 | 3 | 2 | 2 | ||
| Nonrebreather oxygen masks - Infant | 30357 | 2 | 2 | 2 | ||
| Bandage scissors | 30325 | 1 | 1 | 1 | ||
| Bandages: 4"x4" sterile compresses | 3354 | 12 | 12 | 12 | ||
| Bandages: 2",3",4" or 6" roller bandages | 3114 | 6 | 2 | 6 | ||
| Bandages: 10"x 30" or larger dressing | 3531 | 2 | 0 | 2 | ||
| Blood pressure cuff: Thigh | 30334 | 1 | 1 | 1 | ||
| Blood pressure cuff: Adult | 30330 | 1 | 1 | 1 | ||
| Blood pressure cuff: Child | 30332 | 1 | 1 | 1 | ||
| Blood pressure cuff: Infant | 30333 | 1 | 1 | 1 | ||
| Emesis Basin | 30318 | 1 | 1 | 1 | ||
| or | or | |||||
| Emesis Bag | 30319 | 1 | 1 | 1 | ||
| Flashlight | 30320 | 1 | 1 | 1 | ||
| Traction splint or equivalent device | 303425 | 1 | 1 | 1 | ||
| Pneumatic or rigid splints (capable of splinting all extremities) | Browse | 4 | 4 | 4 | ||
| Water | 2F7114 | 4 liters | 4 liters | 4 liters | ||
| or | or | |||||
| Saline Solution | 2F7124 | 4 liters | 4 liters | 4 liters | ||
| Cervical collar | 000 281 000 | 2 | 2 | 2 | ||
| Spinal immobilization backboard 60" minimum | 30305 | 1 | N/A | 1 | ||
| Backboard Straps | 303415 | 3 | N/A | 3 | ||
| Sterile obstetrical kit | 1732 | 1 | 1 | 1 | ||
| Tongue depressor | 4314 | 4 | Optional | Optional | ||
| Cold packs | 4512 | 4 | 4 | 4 | ||
| Eye Shield | 81258 | 2 | 2 | 2 | ||
| Tourniquet | 3139 | 2 | 2 | 2 | ||
| 1 mL - syringes with IM needles | 13094 | 4 | 4 | 4 | ||
| 5 mL syringes with IM needles | 6989 | 4 | 4 | 4 | ||
| 10 mL syringes with IM needles | 6990 | 4 | 4 | 4 | ||
| Automated External Defibrillator | ZOLLAED+ | N/A | N/A | N/A | ||
| Manual Defibrillator | N/A | 1 | 1 | 1 | ||
| Defibrillator pads - Adult | 16381 | 2 | 2 | 2 | ||
| Defibrillator pads - Pediatric | 16380 | 2 | 2 | 2 | ||
| Stethoscope | 30312 | 1 | 1 | 1 | ||
| Cellular telephone | N/A | 1 | 1 | 1 | ||
| CO2 monitor Infant (<0.5 mL sidestream or <1 mL mainstream adaptor) Pediatric / Adult ( 6.6 mL sidestream or < 5 mL mainstream adaptor) |
N/A | 2 of each | 2 of each | 2 of each | ||
| CO2 Monitor Adult size EtCO2 sampling nasal cannula Pediatric size EtCO2 sampling nasal cannula |
N/A | 1 of each | 1 of each | 1 of each | ||
| Pediatric length and weight tape | 50021 | 1 | 1 | 1 | ||
| Intranasal mucosal atomization device | MAD300 | 2 | 2 | 2 | ||
| SpO2 Monitor (If not attached to cardiac monitor) | N/A | 1 | 1 | 1 | ||
| SpO2 Adhesive Sensor (Adult, Pediatric, Infant) | Browse | 1 of each | 1 of each | 1 of each | ||
| Thermometer | 5610 | 1 | 1 | 1 | ||
| Thermometer Sheaths | 5614 | 1 | 1 | 1 | ||
| or Disposable Thermometer | 5122NS | |||||
| Rescue Helmet | 64051012 | 2 | 1 | N/A | ||
| EMS Jacket | RAD64056018 | 2 | 1 | N/A | ||
| Goggles | HONS3960HS | 2 | 1 | N/A | ||
| Tyvek Suit | DPPTY127SWH2X00 | 2 L / 2XXL | 1 L / 1XXL | N/A | ||
| Tychem Hooded Suit | DPPQC122BYL2X00 | 2 L / 2XXL | 1 L / 1XXL | N/A | ||
| Nitrile Gloves | Browse | |||||
| Disposable Footwear Covers | 18005 | 1 | 1 | N/A | ||
| Leather Work Gloves | 10975 | 1 | 1 | N/A | ||
| OPTIONAL EQUIPMENT (No minimums apply) | ||||||
| Hemostatic gauze per EMSA guidelines | 1214-47548 | |||||
| B. TRANSPORT UNIT REQUIREMENTS | ||||||
| Ambulance gurney | N/A | 1 | N/A | N/A | ||
| Collapsible stretcher or flat | 30350 | 1 | N/A | N/A | ||
| KED or equivalent (One required for transport units) | 13142 | 1 | N/A | N/A | ||
| Straps to secure the patient to the stretcher or ambulance cot and means of securing the stretcher or ambulance cot in the vehicle. | 303417 | 1 Set | N/A | N/A | ||
| Powered portable suction unit | 88005102 | 1 | N/A | N/A | ||
| Soft ankle and wrist restraints. | 501110 | 1 set of each | N/A | N/A | ||
| Sheets | 30300 | 1 | N/A | N/A | ||
| Pillow Cases | 30301 | 1 | N/A | N/A | ||
| Blankets | 30310 | 1 | N/A | N/A | ||
| Towels | N/A | 1 | N/A | N/A | ||
| Pillows | 30309 | 1 | N/A | N/A | ||
| Bedpan | 30317 | 1 | N/A | N/A | ||
| Urinal | 30316 | 1 | N/A | N/A | ||
| C. ALS UNIT REQUIREMENTS | ||||||
| Supraglottic Airway Devices: I-Gel with passive oxygenation port Sizes 1, 1.5, 2, 2.5, 3, 4, 5 | Browse | 2 of each | 1 of each | 1 of each | ||
| I-Gel Airway Support Straps | Included | 2 | 2 | 2 | ||
| Arm Boards - 9 | N/A | 3 | 0 | 1 | ||
| Arm Boards - 18" | N/A | 3 | 0 | 1 | ||
| Colorimetric CO2 Detector Device | Browse | 1 | 1 | 1 | ||
| EKG Electrodes | 8900-0004-Case | 10 sets | 3 sets | 3 sets | ||
| Endotracheal tubes, sizes 6.0, 6.5, 7.0, 7.5, 8.0 with stylets | 4560-36249 | 1 of each size | 1 of each size | 1 of each size | ||
| EZ-IO intraosseous infusion system | 621515 | 1 Each Size | 1 Each Size | 1 Each Size | ||
| IV admin set - macrodrip | 7030 | 8 | 4 | 4 | ||
| IV catheter, Sizes 14 | 13220 | 6 | 2 | 2 | ||
| IV catheter, Sizes 16 | 13221 | 6 | 2 | 2 | ||
| IV catheter, Sizes 18 | 13222 | 6 | 2 | 2 | ||
| IV catheter, Sizes 20 | 13223 | 6 | 2 | 2 | ||
| IV catheter, Sizes 22 | 13224 | 3 | 2 | 2 | ||
| IV catheter, Sizes 24 | 13225 | 3 | 2 | 2 | ||
| Laryngoscope Curved blade #2, 3, 4 | Browse | 1 | 1 | 1 | ||
| Laryngoscope Straight blade #1, 2, 3 | Browse | 1 | 1 | 1 | ||
| Laryngoscope Handle | Browse | 1 | 1 | 1 | ||
| Magill
forceps Adult Pediatric |
Browse | 1 Each Size | 1 Each Size | 1 Each Size | ||
| Nebulizer | 5604-34120 | 2 | 2 | 2 | ||
| Nebulizer with in-line adapter | 34105 | 1 | 1 | 1 | ||
| Needle Thoracostomy kit | N/A | 2 | 2 | 2 | ||
| Flexible intubation stylet | Browse | 1 | 1 | 1 | ||
| OPTIONAL ALS EQUIPMENT (No minimums apply) | ||||||
| Cyanide Antidote Kit | N/A | |||||
| Needle Thoracostomy Anatomical Landmark Guide | N/A | |||||
| D. ALS MEDICATION, MINIMUM AMOUNT | ||||||
| Adenosine, 6 mg | N/A | |||||
| Albuterol 2.5mg/3ml | N/A | |||||
| Aspirin, 81mg | N/A | |||||
| Amiodarone, 50mg/ml 3ml | N/A | |||||
| Atropine sulfate, 1 mg/10 ml | N/A | |||||
| Diphenhydramine (Benadryl), 50 mg/ml | N/A | |||||
| Calcium chloride, 1000 mg/10 ml | N/A | |||||
| Dextrose 5% 50ml, AND 10% 250 ml |
N/A | |||||
| Epinephrine Epinephrine , 1mg/ml 1 mL ampule / vial, OR Adult auto-injector (0.3 mg), Peds auto-injector (0.15 mg) Epinephrine 0.1mg/ml (1 mg/10ml preparation) |
N/A | |||||
| Fentanyl, 50 mcg/mL | N/A | |||||
| Glucagon, 1 mg/ml | N/A | |||||
| Intravenous
Fluids (in flexible containers) Normal saline solution, 100 ml Normal saline solution, 500 ml Normal saline solution, 1000 ml |
N/A | |||||
| Lidocaine, 100 mg/5ml | N/A | |||||
| Magnesium sulfate, 1 gm per 2 ml | N/A | |||||
| Midazolam Hydrochloride (Versed) | N/A | |||||
| Morphine sulfate, 10 mg/ml (Only required during a Fentanyl shortage) | N/A | |||||
| Naloxone
Hydrochloride (Narcan) IN concentration - 4 mg in 0.1 mL (with atomizer) IM / IV concentration 2 mg in 2 mL preload |
N/A | |||||
| Nitroglycerine preparations, 0.4 mg | N/A | |||||
| Normal saline flush, 5 or 10 ml | N/A | |||||
| Ondansetron
(Zofran) 4 mg IV single use vial 4 mg oral |
N/A | |||||
| Sodium Bicarbonate 8.4%, 1 mEq/mL (50 mL) | N/A | |||||
| Tranexamic Acid (TXA) 1 gm/10 mL | N/A | |||||
| E. BLS MEDICATION, MINIMUM AMOUNT | ||||||
| Epinephrine Epinephrine , 1mg/ml 1 mL ampule / vial (with syringe and needle), OR Adult auto-injector (0.3 mg), AND Peds auto-injector (0.15 mg) |
N/A | N/A | N/A | N/A | ||
| Naloxone
Hydrochloride (Narcan) IN concentration - 4 mg in 0.1 mL (with atomizer) OR IM / IV concentration 2 mg in 2 mL preload |
N/A | N/A | N/A | N/A | ||