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House Bag/PEDI Bag
House Bag/PEDI Bag
Paul Falavolito

House Bag/PEDI Bag

Revised 10/2/2015

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Free House Bag/PEDI Bag Checklist

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Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

  • Personnel

  • Truck #

  • Select date

House Bag Checklist

Main Compartment

Intubation Roll

  • 1- Stethoscope

  • 1- 60cc Syringe

King LTD (1 each)

  • #2

  • #2.5

  • #3

  • #4

  • #5

ET Tubes

  • (2) 6.0

  • (2) 6.5

  • (2) 7.0

  • (2) 7.5

  • (2) 8.0

  • 8.5

  • 9.0

  • 2- Adult Stylettes

  • 1- Magill Foreceps

  • 5- Surgi Lube

  • 4- Spare Bulbs

  • 1- Roll 1" Tape

  • MAC 3

  • MAC 4

  • MIL 2

  • MIL 3

  • Mil 4

  • 1- Laryngoscope Handle

  • 2- 10cc Syringes

  • 1- ETCO2 Detector

  • 2- Adult Tube Holders

  • 1- Tube (Bulb) Checker

  • 4- Oral Airways

  • 1- Biohazard Bag

  • 2- Spare C Batteries

  • EZ IO Drill w/case<br>1 Adult Needle<br>2 Pediatric Needles

  • Adult Bag Valve Mask

Medication Pouch

  • Old Tag #

6- Epi 1:10,000

  • Epi 1 exp date

  • Epi 2 exp date

  • Epi 3 exp date

  • Epi 4 exp date

  • Epi 5 exp date

  • Epi 6 exp date

2- Atropine

  • Atropine 1 exp date

  • Atropine 2 exp date

  • D50 exp date

  • Narcan 1 exp date

  • Narcan 2 exp date

  • Lidocaine 1 exp date

  • Lidocaine 2 exp date

  • GlucaGen 1 exp date

  • GlucaGen 2 exp date

  • Albuterol 1 exp date

  • Albuterol 2 exp date

  • Ipratropium Bromide 1 exp date

  • Ipratropium Bromide 2 exp date

  • Epi 1:1,000 exp date

  • 1- Solu-medrol Exp Date

  • 1- Zofran exp date

  • 1- Benadryl exp date

  • Adenosine Exp Date

  • Amiodarone Exp Date

  • Amiodarone Exp Date

  • 1- Bottle Baby Aspirin exp date

  • 1- Nitro Spray exp date

  • 1- Oral Glucose exp date

IV Pouch

  • Old Tag #

  • 1- Roll 1" Tape

  • 5- Opsites

  • 2- Extension Sets

  • 2- Flushes

  • 5- Alcohol Wipes

2 Each IV Catheters

  • 14ga

  • 16ga

  • 18ga

  • 20ga

  • 22ga

  • 24ga

  • 2- IV Start Kits

  • 1- Tourniquet

  • 2 Each Syringes

  • (2) 1cc

  • (2) 3cc

  • (2) 5cc

  • (2) 10cc

  • 2 Each Needles

  • (2) 18ga

  • (2) 22ga

  • (2) 25ga

  • 1- MADD Device

Inside Mesh Compartment

  • 10 Small Bandaids<br>10 Large Bandaids<br>2 Kling (1 Large, 1 Small)<br>4 Abdominal Pads<br>5 2x2<br>5 4x4<br>4 Petroleum Dressings<br>2 Ice Packs<br>Pen Light<br>1 Inch Tape

  • Equipment Missing?

Top Mesh Compartment

  • 1 Burn Sheet 2 Trauma Dressings Trauma Sheers Bandage Sheers 1 Commercial Tourniquet with Marker

Left Side Pouch

  • 500 mL bag nSS Exp Date:

  • Macrodrip Set

  • Pressure Infuser

Right Side Pouch

  • 1 Small Sharp Container

  • 1 Large Adult BP Cuff

  • CO Detector (TEST)

Front Pouch

  • 1 Nasal Cannula

  • 1 Non-Rebreather

  • 1 Nebulizer

  • 1 Stethoscope

  • Adult BP Cuff

  • Glucometer with Strips and Lancets

  • Pulse Oximeter

Pedi Bag Checklist

  • 5 Pedi Blades Needed

  • Mac 0

  • Mac 1

  • Mac 2

  • Mil 0

  • Mil 1

  • Mil 2

  • 1- Racemic Epi exp date

  • 1- 10cc syringe

  • Laryngoscope Handle

  • Spare Bulbs (4)

  • Spare AA Batteries (2)

  • Pen Light

  • Surgi Lube(5)

  • Oral Airways (4) Misc

  • Magill Forceps

  • ALL BULBS WORKING?

ET Tubes

  • King LT Size 2

  • King LT Size 2.5

  • 2.5 (2)

  • 3.0 (2)

  • 3.5 (2)

  • 4.0 (2)

  • 4.5 (2)

  • 5.0 (2)

  • 5.5 (2)

  • 6.0 (2)

  • Minimum 2 Pedi Stylettes

  • 1- Large Stylette

  • 2- Pedi Tube Holders

  • 1- Pedi ETCO2 Detector

IV Needles

  • 2-20ga

  • 2-22ga

  • 2-24ga

  • 2- Saline Flushes

  • 1- 20 Drip

  • 1- 60 Drip

  • 500 NSS and exp date

  • Pedi Wheel

  • Broselow Tape

  • Pedi/Infant O2 Sensor (1 ea)

  • 1- Infant Non-Rebreather

  • 2- Pedi Non-Rebreathers

  • 2- Pedi Nasal Cannulas

  • 1- Pedi Trach Mask

  • Meconium Aspirator

  • 1- Pedi B/P Cuff

  • 1- Pedi Stethoscope

  • 2- Pedi BVM's

  • 1- Pedi Quick Combo Pads

  • 12 Pedi Electrodes

  • 5- 4x4's

  • 5- 2x2's

  • 5- Opsites

  • 2- IV Start Kits

  • 10- Alcohol Wipes

  • 2- Extension Sets

  • 1- 1/2" Tape

  • 1- 1" Tape

  • Arm Board

  • NEW TAG(s)#

Trauma Bag Checklist

  • 8- Combine Dressings

  • 1- T-POD pelvic stabilization device

  • 1- Commercial Grade Tourniquet

  • 5- Non-Adhering Dressings

  • 2- Trauma Dressing

  • 1- Burn Sheet

  • 1- 1000 NSS exp date

  • 2- 20 Drip Sets

  • 2- Non-Latex Tourniquets

IV Catheters

  • 2- 14ga

  • 2- 16ga

  • 2- 18ga

  • 1- Pen Light

  • 1- Sharps Container

  • 1- Bottle Sterile Water exp date

  • 5- Large Kling

  • 1- Pair Crash Shears

  • 1- Pair Bandage Shears

  • 10- 2x2's

  • 10- 4x4's

  • 1- Box Band Aids

  • 1- Roll 1"Tape

  • 1- Roll 2"Tape

  • 2- Saline Flushes

  • 1- 10cc Syringe

  • 1- Stethoscope

  • 2- IV Start Kits

  • 5- OpSites

  • 2- Extension Kits

  • 1- Pressure Infuser

  • OLD TRAUMA BAG TAG#'s

  • NEW TRAUMA BAG TAG#'s

Crew Member Signatures

  • Add signature

  • Add signature

  • Add signature

  • Add signature

House Bag/PEDI Bag
Paul Falavolito

House Bag/PEDI Bag

Revised 10/2/2015

Use this Template
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