Page 281 - 2023 SMOG Digital

FORMS

PATIENT IDENTIFICATION
(Last, First, Middle Initial; SSN/Identification Number; grade; DOB;
treatment facility)
Vasoactive Medications:
[ ] Dopamine ___mg/___mL at____mcg/kg/min IV; titrate to MAP >
______mm Hg
[ ] Norepinephrine 4mg/___mL at____mcg/min IV; titrate to MAP >______
mm Hg
[ ] Phenylephrine 10mg/____mL at____mcg/min IV; titrate to MAP >______
mm Hg
[ ] Epinephrine __mg (1:10,000)/___mL at____mcg/min IV; titrate to MAP
>______ mm Hg [ ] Other________________________________
Sedation and Analgesics:
[ ] Ketamine __mg/kg Q___minutes IVP PRN sedation to Riker Sedation-
Agitation Scale of 1-2 [ ] Midazolam ___mg Q___minutes IVP PRN
sedation to Riker Sedation-Agitation Scale of 1-2 [ ] Haloperidol ___mg
Q___minutes IVP PRN sedation to Riker Sedation-Agitation Scale of 1-2
[ ] Lorazepam ___mg Q___minutes IVP PRN sedation to Riker Sedation-
Agitation Scale of 1-2 [ ] Fentanyl ____mcg Q___minutes IVP PRN pain
[ ] Morphine ___mg Q___minutes IVP PRN pain
[ ] Other__________________________________
Paralytics:
[ ] Rocuronium ______mg IVP
[ ] Vecuronium ______mg IVP
Intracranial Hypertension:
[ ] 3% Hypertonic Saline 250 cc bolus for any signs of herniation
[ ] Mannitol Infusion Rate: _______
Labs:
[ ] ABG 15 minutes prior to departing sending facility
[ ] Other:
Additional critical information:
Physician Signature:

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