EMS Operations

Cardiac Arrest Sheet

Patient Information

Patient Name

Age

Sex

DOB

Chief Complaint

Downtime (approx)

Medical History / Allergies

Presenting Rhythm

Incident Timer

Elapsed Time

00:00

⏸ Paused · EST 23:15:27

Airway Management

ProcedureSizeColorTime
OPA
King Airway
ET Tube

AED / Shocks

Shock #1

Shock #2

Shock #3

Shock #4

Venous Access

TypeSizeLocationTime
IV
IV
IO
IO

⭐ Pediatric Arrest

Weight (lbs)

Weight (kg)

Broslow Color

Key Events

Return of Circulation (ROSC)

Start Hypothermia Protocol

Time of Death

Medication Administration

Epinephrine

Every 4 min

#1

#2

#3

#4

#5

#6

Amiodarone

Max 2 doses · refractory VF/VT only · 1 per pulse check

#1

#2

Lidocaine

Alt to Amio · Max 2 doses · refractory VF/VT only

#1

#2

Sodium Bicarb

1 dose · suspected hyperkalemia only

#1

D10

1 bolus · hypoglycemia only

#1

Narcan

Every 2-5 min · OD suspected only

#1

#2

#3

#4

#5

#6

Calcium

Specific indications only

#1

#2

Magnesium

Not typically given in arrest

#1

Atropine

Post-arrest only · Max 3 doses · Every 3-5 min

#1

#2

#3

Personnel on Scene

Documenter

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Fire Dept on Scene

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EMS Crew on Scene

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EMS Supervisor

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