The Tennessee Department of Health, through its Division of Health Licensure and Regulation, Office of Emergency Medical Services, meticulously outlines the essential parameters for ambulance readiness in its PH-3210 form. This comprehensive document serves as a guarantee of medical vehicle integrity, detailing mandatory inspections that assess both the operational and medical equipment facets of ambulances. Ranging from the vehicle's manufacturing details, such as year, make, and identification numbers, to the exhaustive list of medical supplies and equipment—like intravenous therapy tools, resuscitation devices, and emergency pharmaceuticals—the form encapsulates the critical elements required for ambulances to operate under various levels of life support capabilities. Inspections marked by this form culminate in a vehicle receiving one of several statuses like 'Pass', 'Pass with Warning', 'Conditional', or a range of fail statuses suggesting immediate or eventual removal from service. Each category scrutinized, from the vehicle's physical condition to its onboard diagnostic equipment, plays a pivotal role in ensuring that ambulances are not just vehicles, but well-equipped mobile units ready to deliver life-saving care. Revisions and updates to the form, as reflected in its current June 2014 iteration, emphasize the form's evolving nature to align with the latest in emergency medical standards and practices.
| Question | Answer |
|---|---|
| Form Name | Ph 3210 Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | tennessee ambulance requirements, tennessee ambulance inspection forms, O2, state of tennessee ambulance inspection form |
TENNESSEE DEPARTMENT OF HEALTH
DIVISION OF HEALTH LICENSURE AND REGULATION
OFFICE OF EMERGENCY MEDICAL SERVICES
665 MAINSTREAM DRIVE, 2ND FLOOR
NASHVILLE, TN 37243
TELEPHONE:
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AMBULANCE INSPECTION |
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Service |
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Date |
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Permit No. |
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Year of Mfg. |
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Make/Mfg. |
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Unit I.D. No. |
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License Tag |
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V.I.N. |
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Odometer Reading |
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Control # |
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Inspection Rating |
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Vehicle Category |
Type of Unit |
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Pass
Pass with Warning Conditional Failed
Failed/Temporarily Rmv’d from Srvc Failed/Removed from Service
Advanced Life Support
Basic Life Support
Off Line
Type I
Type II
Type III
Current
New Vehicle
Refurbished Vehicle
Service Director Signature |
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Inspector’s Signature |
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(required only if inspection failed) |
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*** NOTE: ESSENTIAL ITEMS ITALICIZED *** |
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DS DRIVING SYSTEMS |
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VE VEHICLE EXTERIOR |
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A U |
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A U |
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1
2
3
4
5
6
7
8
Brake System |
1 |
Engine System |
2 |
Exhaust System |
3 |
Fuel System |
4 |
Steering System |
5 |
Suspension |
6 |
Transmission & Selector |
7 |
Windshield wiper/washer |
8 |
Cleanliness - exterior (check compartments) Body rust free
Damage free
Door latches operable
Rearview mirrors
Tires/Wheels F. R. Window Glazing Windshield Glazing
CC TELECOMMUNICATION |
VS VEHICLE SAFETY EQUIPMENT |
A U NA |
A U |
1
2
3
4
5
6
P.A./Radio Amp. |
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1 |
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Driver console control |
2 |
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Dispatch T |
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R |
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3 |
Patient console control T |
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R |
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VHF High Band |
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UHF Med Channels |
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Cellular telephone |
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Fire Extinguishers (2) (5 lb.)
Reflective warning devices (3)
Flashlight, (4.5 v, 3 cell or lantern type) (2 ea.)
(1)driver compartment
(1)pt. compartment
Page 1 of 4 |
EL ELECTRICAL AND LIGHTING
AU
1 |
Siren amplifier/speakers |
2 |
Horn |
3 |
Spotlight(s) (if present, must be functional) |
4 |
Heating/Air Conditioning |
5 |
Headlights |
6 |
Parking lights |
7 |
Turn Signals |
8 |
Foglights/Accessory lights |
9 |
Marker lights |
10 Side flood lights
11 Brake lights
12 Backup lights/alarm
13 Rear loading lights
14 |
110 volt shoreline |
Pass |
Fail |
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15 |
110 volt outlets |
Pass |
Fail |
NA |
16 |
12 volt outlet |
Pass |
Fail |
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17 Interior domelights - cabin/pt. compartment
18 Front emergency lights
19 Grill emergency lights
20 Rear emergency lights
21 Side emergency lights
ID IMMOBILIZATION DEVICES
A |
U NA |
1 |
Full body immobilizer (2) w/straps |
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Wooden Immobilizers (must be sealed) |
2 |
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3 |
Case or carrier |
4 |
Head immobilizers [CID] (2 sets) |
5Cervical Collars (2 sets each size)
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Large Adult |
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Medium Adult |
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Small Adult |
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Pediatric/Infant |
6 |
Upper extremity splints (2 sets) |
7 |
Lower extremity splints (2 sets) |
8 |
Traction splint w/attachments (2) |
VI VEHICLE INTERIOR |
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A |
U |
1 |
Cleanliness (crew cab & pt. compartment) |
2 |
Floor |
3 |
Headliner |
4 |
Upholstery |
5 |
Equipment Restraint |
6 |
Storage Compartments |
7 |
Safety Hazards (explain in narrative) |
8 |
Watertight |
OS OXYGEN SYSTEMS
AU
1 |
Bag/valve resuscitator (Adult 1600 ml) |
2 |
Bag/valve resuscitator (Child 450 ml) |
3 |
Resuscitation mask, Adult |
4 |
Resuscitation mask, Child |
5 |
Resuscitation mask, Infant |
6 |
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7 |
End tidal Carbon Dioxide (CO2) Detectors |
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Adult |
Pediatric |
8 |
Connecting tubing (min. 2 ea.) |
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9 O2 mask, Adult
10 O2 mask, Pediatric
11 O2 mask, infant medium concentration (2 ea.)
12 Nasal Cannula, Adult (2 ea.)
13 Oropharyngeal airways (5 sizes)
14 Nasopharyngeal airways (5 sizes)
15 |
Installed O2 contents |
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psi |
Cyl |
16 Installed cylinder restraint
17 Regulator & Distribution outlets (2 ea.)
18 |
Installed O2 Flowmeter |
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Pass |
Fail |
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19 |
Portable O2 contents |
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psi |
Cyl |
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20 Full Portable Spare Cylinder
21 Portable cylinder restraints
22 |
Portable Regulator & FlowmeterPass |
Fail |
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23 |
Humidifiers (Single patient use) (optional) |
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SS SUCTION SYSTEMS |
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A |
U |
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1 |
Installed Suction, |
Pass |
Fail |
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(Pump, gauge and control) |
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2 |
Collection bottle (1 liter) |
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3 |
Suction catheters (2 sets ea.) (6, 8,10,14,16 Fr.) |
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4 |
Yankauer tips (2 ea.) |
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5 |
Meconium Aspirator or tubing w/ adapters |
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6 |
Suction tubing (6’ long) (2 sets) |
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Portable suction unit (500 ml) |
Pass |
Fail |
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Collection Bottle (disposable preferred) |
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8 Suction tubing (2’ long) (2 ea.)
DE DIAGNOSTIC EQUIPMENT
AU
1 |
BP Cuff/manometer, Adult |
2 |
BP Cuff/manometer, Child |
3 |
BP Cuff/Large Adult, thigh |
4 Stethoscope (personally assigned equipment if service has posted policy)
5 |
Bandage shears (personally assigned equipment |
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if service has posted policy) |
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6 |
Pulse Oximeter w/sensors |
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Adult probes |
Pediatric probes |
IC INFECTION CONTROL |
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A |
U |
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1 |
Disposable gloves |
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2 |
Gowns |
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3 |
Face masks (2 |
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4 |
Protective eye/face shield |
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5 |
Protective footwear/covers |
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Biohazard trash bags 24”x 30” (2 ea.) |
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Sharps container/locked (installed) |
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Sharps container/sheath style (portable) |
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9 |
Antiseptic hand cleaner |
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10 |
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Page 2 of 4 |
BD BANDAGES AND DRESSINGS
AU
1 |
Adhesive tape (min. 1”) (2 rolls) |
2 |
Roller bandage, gauze 3 in. wide, (6) |
3 |
Triangular bandages, 42 in. base (6) |
4 |
Sterile 4x4 dressings (min. 25) |
5 |
ABD combine dressing (8) |
6 |
Occlusive dressings, 3”x 3” (min. 2) |
7 |
Burn sheets, sterile or clean, separately |
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packaged 60”x 60” (2 ea.) |
8 Saline sol. or sterile water, 2,000 ml Exp.
OB OBSTETRIC SUPPLIES
A |
U |
1 |
Obstetrical kit with |
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drape towel or underpad, gauze pads, |
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cord clamps, sterile gloves, bulb syringe, |
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plastic bag and ties |
2 Receiving blanket with head cover (cloth or
PC PATIENT COMFORT ITEMS
A U
1 |
Bedpan |
2 |
Urinal |
3 |
Emesis basin (2 ea.) |
4 |
Tissues |
5 |
Blankets (2 ea.) |
6 |
Sheets (4 ea.) |
7 Baby blanket with head cover (cloth or
IT |
INTRAVENOUS THERAPY |
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A U |
1 |
Microdrip set |
2 |
Microdrip set [60 gtts] (3 ea.) |
3 |
Antiseptic wipes (12 ea.) |
4 |
Catheters (4 ea.) in sizes 14, 16, 18, 20, 22, 24 |
5 Intraosseus needles (min. of 18 ga.) (Req. on ALS units)
6 |
Venous tourniquet (disposable, |
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7 |
Intravenous Sol. (1 liter) or |
Exp |
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Therapeutic Equiv. |
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8 |
Crystalloid Solution (2 liters) |
Exp |
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Therapeutic Equiv. |
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BU MEDS |
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A U |
NA |
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1 |
Epinephrine 1:1,000 (4 doses) |
Exp |
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2 |
Syringe or anaphylaxis kit |
Exp |
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3 |
Exp |
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Therapeutic Equiv. |
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Exp |
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inhaler |
nebulizer |
Exp |
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Appropriate Admin. Devices |
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4 |
NTG |
spray |
30 tabs |
Exp |
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Therapeutic Equiv. |
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Exp |
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5 |
Aspirin (80 mg.) |
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Exp |
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Therapeutic Equiv. |
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Exp |
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CM CARDIAC MONITOR/ DEFIB
A U NA
1 Automated External Defib. with defib pads (Staffed BLS unit)
2 |
Cardiac Monitor/Defib. (360 watts/sec.) |
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3 |
Adult Electrodes (6) |
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4 |
Pediatric Electrodes (6) |
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Make/Model |
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Biophasic Waveform Min. 10 joule setting |
yes no |
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COMMENTS FOR BASIC LIFE SUPPORT VEHICLES ONLY
Page 3 of 4 |
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ADVANCED LIFE SUPPORT UNITS |
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EI |
ENDOTRACHEAL INTUBATION |
A |
U |
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A U |
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8 |
Bacteriostatic Water |
Exp. |
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1 |
Laryngoscope handle w/batteries |
9 |
Sodium Chloride |
Exp. |
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Adult |
Pediatric |
ANALGESICS |
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Laryngoscope blades: |
A |
U |
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2 |
0, straight |
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10 |
Morphine sulfate |
Exp. |
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3 |
1, straight |
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10 mg/ml (min. 1 amp./syr ) or |
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4 |
2, straight |
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11 |
Meperidine hydrochloride |
Exp. |
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5 |
2, curved |
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12 |
Nalbuphine (Nubain) |
Exp. |
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6 |
3, straight |
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13 |
Butophanol (Stadol) |
Exp. |
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3, curved |
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14 |
Nitrous Oxide |
Exp. |
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7 |
4, straight |
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Therapeutic Equiv. |
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Exp. |
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4, curved |
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15 |
Nitroglycerin 1/150gr. t s |
Exp. |
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Endotracheal Tubes: |
HYPOGLYCEMIC COUNTERMEASURES |
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8 |
Pediatric sizes 2.5 - 6.0 uncuffed (1 ea., total 8 tubes) |
A |
U |
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9 |
Adult sizes 6.5 - 9.5 cuffed (1 ea., total 7 tubes ) |
16 |
Blood Glucose Testing Media |
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10 |
10 cc syringe, luer tip |
17 |
Calibration strips |
Exp. |
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11 |
Sterile lubricant (6 pkgs./ equivalent) |
18 |
Lances |
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12 |
Stylet, adult |
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19 |
Dextrose 50% 25gm/50ml (min.2syr.) |
Exp. |
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13 |
Stylet, pediatric |
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Therapeutic Equiv. |
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Exp. |
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14 |
Esophageal detection device |
20 |
Dextrose 25% 12.5 gm/50ml (2syr) |
Exp. |
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15 |
Magill forceps, adult |
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Therapeutic Equiv. |
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Exp. |
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16 |
Magill forceps, pediatric |
NARCOTIC ANTAGONIST |
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A |
U |
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ALS MEDICATIONS
CARDIOVASCULAR MEDICATIONS
AU
1 |
Adenosine 6 mgm/2 m (total 18mgm) |
Exp. |
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Therapeutic Equiv. |
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Exp. |
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2 |
Atropine sulfate 1.0 mg/ml (4 syr.) |
Exp. |
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Therapeutic Equiv. |
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Exp. |
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BENZODIAZEPINE ANTICONSVULSANT
AU
3 |
Diazepam (Valium) |
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10 mg/2 ml (2 syr./vials) or |
Exp. |
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Therapeutic Equiv. |
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Exp. |
VASOPRESSOR AGENTS
AU
4 |
Epinephrine 1:10,000 (4 syr.) or |
Exp. |
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Therapeutic Equiv. |
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Exp. |
ANTIARRYTHMIC AGENTS
AU
5 |
Lidocaine 100 mg/5 ml (4 syr.) or |
Exp. |
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Amiodarone |
Exp. |
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(amp. of |
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Therapeutic Equiv. |
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Exp. |
6 |
Lidocaine 4 mg/ml premix (min.1) |
Exp. |
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7 |
Magnesium Sulfate |
Exp. |
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(1 gm sufficient to admin. 2 gm doses) |
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21 |
Narcan 1mg/ml (2 amp./syr.) |
Exp. |
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Therapeutic Equiv. |
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Exp. |
ALKALIZING AGENT
AU
22 |
Sodium Bicarb. 50 meq(min 2 syr) |
Exp. |
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Therapeutic Equiv. |
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Exp. |
SYSTEMIC DIURETICS
AU
23 |
Lasix (furosemide) |
Exp. |
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to total 80 mg. (amp/vials/syr) |
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Therapeutic Equiv. |
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Exp. |
ANTINAUSEANT
AU
24 |
Phenergan (promethazine) 25mg/ml |
Exp. |
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Therapeutic Equiv. |
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Exp. |
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ANTIHISTAMINE
AU
25 |
Benedryl (diphenhydramine) (50 mg) Exp. |
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Therapeutic Equiv. |
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Exp. |
26 Syringes: 1cc, 3cc, 10cc (assorted w/needles)
27 Pediatric drug dosage tape (min. 2002 edition) Publication date:
Successor Edition:
COMMENTS FOR ADVANCED LIFE SUPPORT VEHICLES ONLY
Page 4 of 4 |