Quick cards
Checklists
Tap to check off bedside steps; reset when done
Central line insertion
Before
- Time-out: patient, site, procedure, consent
- Hand hygiene
- Ultrasound ready; avoid femoral if possible
- Chlorhexidine-alcohol skin prep, dried 30 seconds
During
- Cap, mask, sterile gown and gloves for the operator
- Full-body sterile drape
- Assistant masked; observer empowered to stop the procedure
- Guidewire removed and counted
After
- Chlorhexidine dressing, dated
- Tip position confirmed (x-ray or ultrasound) before use
- Document site, depth, ultrasound use
- Daily review of line need
Intubation (RSI)
Prepare
- Two working IVs; BP cuff cycling; monitor and EtCO₂ ready
- Suction working at the head of the bed
- Video laryngoscope and direct blade; tubes two sizes; bougie; stylet
- Supraglottic airway and front-of-neck kit in the room
- Drugs drawn and labeled; push-dose pressor ready
- Plan A, B, C stated out loud
Preoxygenate
- Head up; ear-to-sternal-notch position
- 3 minutes or 8 vital-capacity breaths of 100% O₂ (NIV or HFNC if hypoxemic)
- Apneic oxygenation by nasal cannula 15 L/min
After
- Waveform capnography confirms
- Bilateral breath sounds; tube depth noted
- Post-intubation sedation and analgesia started
- Chest x-ray; OG tube; vent settings documented
Intrahospital transport
- Receiving area ready; the trip is worth the risk
- Monitor with ECG, SpO₂, BP and EtCO₂; batteries charged
- Transport ventilator tested on the patient before leaving; bag-valve mask and PEEP valve
- Oxygen supply for twice the expected time
- Infusions on pumps with enough volume; nonessential drips capped
- Emergency drugs and airway kit
- Lines, tubes and drains secured; chest tubes on water seal unless told otherwise
- Two trained staff (RN plus RT for ventilated patients)
- Chart and consent with the patient
Prone positioning
Before the turn
- Enough staff: one at the airway plus 4–5
- Pre-oxygenate on FiO₂ 1.0; suction the airway
- Secure ETT and lines; note tube depth
- Hold tube feeds; empty stomach
- ECG leads moved to the back; eye care and protection
- Pressure padding ready for face, chest, pelvis, knees
After the turn
- Tube depth and EtCO₂ checked
- Head turned with the face off the tube; arms in swimmer position, alternating every 2 hours
- Pressure points padded; no pressure on eyes
- ABG in 1 hour
- Restart tube feeds: prone position is no reason to stop feeding (ESICM 2017, ESPEN 2023)
- Prone for at least 16 hours
Starting CRRT
- Order: modality, dose (mL/kg/h), fluid removal goal, anticoagulation
- Catheter position confirmed; both lumens draw and flush easily
- Circuit primed; correct fluids hung and labeled
- Baseline BMP, Mg, phosphate, iCa, CBC
- Citrate: post-filter and patient iCa schedule set
- Warmer on
- BP plan for start-up (fluid or pressor ready)
- Drug doses reviewed with pharmacy for CRRT clearance
ECMO shift check
Circuit
- Flow and RPM against the target; chatter?
- Sweep and FdO₂; gas line connected
- Pressures charted (drainage, pre- and post-oxygenator)
- Flashlight check of the circuit and oxygenator for clot and fibrin
- Clamps, hand crank and backup console at the bedside
- Heater on and set
Patient
- Cannula sites, sutures and depth marks
- Distal limb perfusion and NIRS (VA femoral)
- Right-hand SpO₂ for differential hypoxemia (VA femoral)
- Neuro check and pupils
- Anticoagulation labs and bleeding check
- Hemolysis check: urine color, free Hgb
EVD care
- Transducer leveled at the tragus (foramen of Monro)
- Drain height (cm H₂O) matches the order
- Open or clamped as ordered; clamp before moving or repositioning
- CSF output, color and clarity recorded hourly
- ICP waveform present; drain dripping when open
- Dressing dry and intact; no kinks; sterile system closed
- Neuro check and pupils
Brain death: prerequisites
- Known, irreversible catastrophic brain injury on imaging
- Enough time since the injury (at least 24 hours after anoxic injury)
- Core temperature 36 °C or higher
- Adults: SBP 100 or higher and MAP 75 or higher (MAP alone on VA-ECMO)
- No sedative or paralytic effect (levels or half-lives; train-of-four)
- No severe metabolic or endocrine disturbance that could explain coma
- Family informed; organ procurement organization notified per policy
Thoracentesis
Before
- Time-out: patient, side, site and consent; side confirmed on recent imaging
- Coagulation tests only if anticoagulated or known coagulopathy (BTS 2023)
- Elective (BTS 2023): warfarin to INR 1.5 or less, DOAC held 24–48 h; aspirin and prophylactic heparin continue
- Sitting up, leaning on a padded table; if ventilated, supine or rolled as the operator scans
- Ultrasound marks the site in that position; no moving the patient before the needle
- Baseline SpO₂, HR, BP and RR; oxygen, suction and atropine at hand
During
- SpO₂, HR and BP watched; vasovagal slowing, pallor or hypotension called out
- Drained slowly by syringe or gravity; no vacuum bottle or wall suction (BTS 2023)
- Stop at 1.5 L, or sooner for chest tightness, pain, persistent cough or breathlessness
- Samples: protein and LDH (serum sent at the same time), glucose, cell count, culture, cytology
- pH (suspected infection): capped heparinized syringe, no air, run on the blood gas analyzer
After
- Vital signs and SpO₂ soon after, then per policy; site dry; volume and color charted
- First hour: cough, frothy sputum or falling SpO₂ suggests re-expansion edema
- Chest film for symptoms, air aspirated or several passes; not routine after a simple tap (BTS 2023)
- Ventilated: watch peak pressure, SpO₂ and BP for a pneumothorax turning into tension
Paracentesis
Before
- Time-out and consent; bladder emptied (void or catheter)
- No routine plasma or platelets for a high INR or low platelets (AASLD 2021); flag DIC or oozing
- Ultrasound marks a pocket, usually left lower quadrant, lateral to the rectus (inferior epigastric artery)
- Baseline BP, HR, weight and girth; 25% albumin ready for a large-volume tap
- Supine, head slightly up, tilted toward the tap side
During
- BP and HR watched through a large-volume tap; slow or stop for hypotension
- Cell count with differential, albumin, total protein; culture bottles inoculated at the bedside
- Same-day serum albumin for the gradient (SAAG 1.1 g/dL or more: portal hypertension)
- Volume, color and clarity recorded; cloudy or bloody fluid reported
After
- Albumin 6–8 g per liter removed when over 5 L (AASLD 2021): 8 L calls for 48–64 g
- BP, HR and urine output for 2–4 h: hypotension or low output after a big tap is reported
- Site leak: ostomy bag over the site, patient on the opposite side, provider told
- Neutrophils 250/mm³ or more is SBP: antibiotics plus albumin 1.5 g/kg day 1 and 1 g/kg day 3
Lumbar puncture
Before
- Suspected meningitis: cultures, dexamethasone and antibiotics before CT, or before LP if the tap is delayed
- CT first for immunocompromise, CNS lesion, seizure within a week, papilledema, low GCS, focal deficit (IDSA)
- Platelets: transfuse under 20,000 (AABB 2025); UK 2016 defers LP under 40,000 or INR over 1.4
- Anticoagulants held: prophylactic LMWH 12 h, therapeutic 24 h (UK 2016); others per protocol
- Pencil-point (atraumatic) needle on the tray: headache 4% vs 11% (Nath 2018)
- Side-lying at the bed edge, knees to chest, chin down, shoulders and hips stacked vertically
- Sitting forward is easier in obesity, but opening pressure is valid only lying on the side
During
- Opening pressure lying on the side, legs relaxed, once the column settles; normal 10–25 cm H₂O (Whiteley 2006)
- Tubes numbered 1–4 in order; lab map often 1 chemistry, 2 Gram stain and culture, 3 cell count, 4 hold
- SAH question: cell count on tubes 1 and 4; last tube shielded from light for xanthochromia
- Serum glucose drawn now for the CSF-to-serum ratio
- Culture tube to the lab at room temperature, never refrigerated
After
- Site checked for CSF leak or bleeding; neuro checks per policy
- No routine flat bed rest: it does not prevent headache (Cochrane 2016)
- Back pain with leg weakness, numbness or new incontinence: possible spinal hematoma, call now
- Headache within 5 days, worse upright, eased lying flat: analgesia, caffeine; blood patch if severe
Pericardiocentesis
Before
- Echo (or fluoroscopy) guides the needle (ESC 2015); a blind subxiphoid tap is for arrest only
- Large-bore IV; arterial line, coagulation tests and platelets when time allows
- Continuous ECG and SpO₂, defibrillator pads on, resuscitation cart in the room
- Atropine drawn up and fluid ready for a vagal reaction (bradycardia, hypotension)
- Preload and heart rate kept: no diuretics, vasodilators or β-blockers; no sedation or intubation if avoidable
- Head of bed up 30–45° so the fluid pools forward and down
During
- Ectopy or ST change as the needle advances called out (myocardial contact)
- BP, HR and pulsus trended; pressure should rise as fluid comes off
- Specimens: cell count, glucose, protein, Gram stain and culture, cytology, TB tests
- Drain sutured to a closed sterile system; first volume and color recorded
After
- Echo for residual fluid; chest film for pneumothorax and drain position
- Vital signs and drain output every 15 min at first, then hourly; volume and color charted
- Reaccumulation: rising HR or CVP, falling BP or pulse pressure, pulsus over 10 mmHg: echo now
- Drain stops while BP falls or CVP rises: clot, kink or reaccumulation until proven otherwise
- After a large drainage, sudden pulmonary edema or shock may be decompression syndrome (rare)
- Removal usually once output is below about 25–50 mL/day and echo shows no fluid
Bronchoscopy on the ventilator
Before
- Time-out and consent; tube feeds held per policy, OG to suction
- ETT inner diameter at least 2 mm wider than the scope; 8.0 or more for a standard adult scope
- Baseline vent settings, SpO₂ and blood gas noted; FiO₂ 1.0 started before the scope goes in
- Swivel adapter with a sealed scope port on the circuit; suction and bag-valve mask ready
- Sedation and analgesia deepened (often propofol and fentanyl); paralytic only if ordered, after sedation
- Topical lidocaine tallied: total under 8.2 mg/kg (BTS 2013)
During
- Volume control usual; high-pressure limit raised as the team directs (peaks climb with the scope in)
- Exhaled Vt, peak pressure and auto-PEEP watched: the scope narrows the tube and traps gas (AARC 2007)
- PEEP: lowering it limits auto-PEEP but risks derecruitment in ARDS; follow the stated plan
- SpO₂ under 90%, falling Vt, arrhythmia or BP change called out: scope out and ventilate
- Suction bursts kept short: each one pulls volume out of the lung
- Specimens labeled by site and type (wash, BAL, brush, biopsy); lavage in and out recorded
After
- Vent back to baseline: FiO₂ weaned, PEEP restored, alarm limits reset
- Blood gas within 30–60 min, or sooner if SpO₂ fell
- Chest film: pneumothorax (1 h after transbronchial biopsy, AARC 2007), atelectasis, tube position
- Tube depth and cuff pressure rechecked; tube secured
- Watch 24–48 h for bleeding, bronchospasm, fever (common after BAL) and new infiltrates
Arterial line
Before
- Site: radial first (CDC prefers it to femoral for infection); femoral when radial fails or in deep shock
- Allen test optional per policy: it predicts hand ischemia poorly (Brzezinski 2009); check hand perfusion
- No arm with a dialysis fistula or graft, burns, infection or poor perfusion
- Pressure bag at 300 mmHg with saline (heparin only per policy); tubing and transducer purged of air
- Short, stiff tubing with few stopcocks; wrist on an armboard, slightly extended
During
- Cap, mask, sterile gloves and a small sterile drape; full barrier for femoral or axillary (CDC 2011)
- Chlorhexidine-alcohol prep, allowed to dry
- Waveform seen before the catheter is secured; sterile dressing, dated
After
- Stopcock leveled to the phlebostatic axis (4th intercostal space, mid-chest); re-leveled after moves
- Zeroed to air at setup, after disconnection and when numbers do not fit the patient
- Square wave: fast flush shows 1.5–2 oscillations, then baseline; fewer is overdamped, more underdamped
- Waveform: brisk upstroke and dicrotic notch; MAP within about 10 mmHg of the cuff
- Alarms on; line labeled arterial; no drugs through it, no dextrose or nutrition in the flush (CDC 2011)
- Hand color, warmth, capillary refill, sensation and movement checked hourly
- Transducer and tubing changed every 96 h (CDC 2011); line out when no longer needed
- Removal: firm pressure 5 min radial, 10 min femoral, longer if anticoagulated; then site and pulse checks
Patient assessment: trauma
Scene size-up
- PPE put on or stated
- Scene and situation called safe
- Mechanism of injury identified
- Number of patients counted
- More EMS help requested if needed
- Spine stabilization considered
Primary survey and resuscitation
- General impression stated
- Responsiveness and level of consciousness checked
- Chief complaint and obvious life threats found
- Airway opened and assessed; adjunct inserted if indicated
- Breathing assessed and ventilation kept adequate; oxygen started
- Any injury that threatens breathing managed (for example an open chest wound)
- Pulse checked; skin color, temperature or condition assessed
- Major bleeding looked for and controlled
- Shock care started: patient positioned, body heat conserved
- Priority and transport decision made, using the calculated GCS
History
- Baseline vital signs: BP, pulse and respirations at least
- SAMPLE history attempted
Secondary assessment
- Head: scalp and ears inspected and palpated; eyes assessed; mouth, nose and face checked
- Neck: trachea position, jugular veins, cervical spine palpated
- Chest: inspected, palpated and auscultated
- Abdomen inspected and palpated; pelvis assessed; genitalia and perineum checked as needed (stated)
- Each leg: motor, sensory and distal circulation
- Each arm: motor, sensory and distal circulation
- Back: posterior thorax, lumbar area and buttocks
- Secondary injuries and wounds managed
Reassessment
- Shows how and when to reassess the patient
The sheet lets the scalp, ears, mouth, nose, neck, chest, abdomen, pelvis, legs and back be examined during the primary survey. Bleeding that is pouring out is controlled the moment it is seen.
Critical criteria
- No transport started or called for within the 10-minute limit
- PPE not taken or stated
- Scene safety not determined
- Spinal protection not assessed or not given when indicated
- High-concentration oxygen not stated and given
- Ventilation not assessed or not made adequate
- An airway, breathing, bleeding or shock problem missed or mismanaged
- No decision between immediate transport and more care on scene
- Other assessment done before airway, breathing and circulation threats are treated
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Patient assessment: medical
Scene size-up
- PPE put on or stated
- Scene and situation called safe before approaching
- Nature of illness (or mechanism) identified
- Number of patients counted
- More EMS help requested if needed
- Spine stabilization considered
Primary survey and resuscitation
- General impression stated
- Responsiveness and level of consciousness (AVPU)
- Chief complaint and obvious life threats found
- Airway and breathing assessed; ventilation kept adequate; appropriate oxygen started
- Major bleeding checked and controlled; pulse checked; skin color, temperature or condition assessed
- Priority and transport decision made
History of the present illness
- Onset
- Provocation
- Quality
- Radiation
- Severity
- Time
- Clarifying questions about associated signs and symptoms
Past medical history
- Allergies
- Medications
- Past pertinent history
- Last oral intake
- Events leading to the illness
Secondary assessment and vital signs
- Affected body systems examined (cardiovascular, pulmonary, neurologic, musculoskeletal, skin, GI/GU, reproductive, psychological and social)
- Blood pressure
- Pulse
- Respiratory rate
- Respiratory quality
- Field impression stated
- Interventions and treatment stated
Reassessment and handoff
- Shows how and when to reassess for change
- Accurate verbal report given to the arriving EMS unit
Critical criteria
- No transport started or called for within the 15-minute limit
- PPE not taken or stated
- Scene safety not determined before approaching the patient
- Appropriate oxygen therapy not stated and given
- Ventilation not assessed or not made adequate
- An airway, breathing, bleeding or shock problem missed or mismanaged
- No decision between immediate transport and more care on scene
- Secondary exam done before airway, breathing and circulation threats are treated
- No accurate report to the arriving EMS unit
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
BVM ventilation, apneic adult
Assess
- PPE put on or stated
- Responsiveness checked
- More EMS help requested
- Breathing and pulse checked together, 10 seconds or less
Examiner: unresponsive, apneic, weak pulse of 60.
Airway and suction
- Airway opened properly
- Rigid suction catheter prepared
- Suction unit turned on or manual unit ready
- Catheter inserted without suction applied
- Mouth and oropharynx suctioned, briefly
- Airway opened manually again
- Oropharyngeal airway inserted (no gag reflex)
Ventilate
- Ventilations start at once with the BVM not yet attached to oxygen (starting with oxygen and reservoir attached is allowed if the first breath comes within 30 seconds of suctioning)
- Pulse rechecked, 10 seconds or less
- BVM (mask, bag, reservoir) attached to oxygen at 15 L/min
- Each breath makes the chest rise visibly
- Rate 10–12/min: one breath every 5–6 seconds (AHA 2025: every 6 seconds)
- Can explain how to tell each breath is the right size (visible chest rise)
Critical criteria
- Ventilation not started within 30 seconds after suctioning, or stopped for more than 30 seconds at any time
- PPE not taken or stated
- Airway not suctioned before ventilating
- Suctioning excessive or prolonged
- Responsiveness, then breathing and pulse together, not checked within 10 seconds
- High-concentration oxygen (at least 85%) not stated and given
- Rate outside 10–12/min (one breath every 5–6 seconds)
- Inadequate breath volumes (more than 2 errors a minute)
- An airway adjunct inserted or used in a way that endangers the patient
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Oxygen by non-rebreather
Set up
- PPE put on or stated
- Equipment gathered
- Tank valve cracked (opened briefly, then closed)
- Regulator fitted to the tank
- Tank valve opened
- Tank pressure read
- Checked for leaks
Apply
- Mask tubing attached to the correct regulator port
- Oxygen flow on to fill the reservoir bag before the mask goes on
- Flow set to at least 10 L/min
- Mask on the face and adjusted to fit snugly
Critical criteria
- PPE not taken or stated
- Tank and regulator not assembled leak-free
- Reservoir bag not prefilled
- Flow below 10 L/min
- Mask not sealed snugly to the face
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Bleeding control and shock
Bleeding
- PPE put on or stated
- Direct pressure on the wound
- Tourniquet applied when the wound keeps bleeding
Shock
- Patient positioned for shock
- High-concentration oxygen given
- Heat loss prevented (cover the patient)
- Immediate transport called for
The examiner says the wound is still bleeding after direct pressure, then that signs of hypoperfusion have appeared. Local protocol sets when a tourniquet goes on first.
Critical criteria
- PPE not taken or stated
- High-concentration oxygen not given
- Bleeding not controlled correctly and in time
- Need for immediate transport not stated
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Spinal motion restriction
Both: first steps
- PPE put on or stated
- Assistant told to bring and hold the head in neutral, in-line position
- Assistant keeps manual stabilization until the head is secured to the device
- Motor, sensory and circulation checked in each extremity
- Correctly sized extrication collar applied
Seated patient (vest or short board)
- Device placed behind the patient
- Device secured to the torso first
- Torso straps checked and adjusted (snug, chest still rises)
- Space behind the head padded as needed
- Head secured to the device
- Moving the patient to a long board stated
- Motor, sensory and circulation rechecked in each extremity
Supine patient (long board)
- Board positioned for the move
- Patient moved onto the device without twisting the spine (log roll or lift on command)
- Gaps between torso and board padded as needed
- Torso secured to the device
- Space behind the head padded as needed
- Head secured to the device
- Legs secured
- Arms secured
- Motor, sensory and circulation rechecked in each extremity
SMR (ACS-COT, ACEP and NAEMSP 2018) is for altered consciousness or intoxication, midline neck or back pain or tenderness, focal neurologic signs, spinal deformity, or a distracting injury or circumstance. A scoop, vacuum mattress or secured cot also works, and it has no role in penetrating trauma. Local protocol decides the device.
Critical criteria (both)
- Manual stabilization of the head not taken or directed at once
- Manual stabilization released before a correctly sized collar is on
- Manual stabilization released before the head is held by the device
- Patient moved so much the spine could be harmed
- Head secured before the torso is secured
- Seated: device slides up, down or sideways on the torso; supine: patient slides on the board
- Head still moves too much once secured
- Seated: torso straps restrict chest rise
- Head not neutral and in line at the end
- Extremities not rechecked after the patient is secured
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Cardiac arrest with AED
Assess
- PPE put on or stated
- Scene called safe
- Responsiveness checked
- Assistant sent for the AED
- More EMS help requested
- Breathing and pulse checked together, 10 seconds or less
CPR: 2 minutes, one rescuer
- Compressions start at once when no pulse is found
- Depth at least 2 in (5 cm) but not over 2.4 in (6 cm); rate 100–120/min
- Chest recoils fully: no leaning between compressions
- 30 compressions to 2 breaths, each breath over 1 second with visible chest rise
- Interruptions kept to no more than 10 seconds
- About 5 cycles, then the patient is reassessed while a second rescuer takes over compressions
AED
- AED turned on
- Pads attached as the prompts direct
- CPR stopped and everyone clear during analysis
- "All clear" called and checked by looking, then shock delivered
- Rescuer directed to resume compressions right after the shock
Critical criteria
- PPE not taken or stated
- Responsiveness, then breathing and pulse together, not checked within 10 seconds
- Compressions not started as soon as pulselessness is confirmed
- CPR not of acceptable high quality
- CPR interrupted for more than 10 seconds at any point
- AED pads not attached correctly
- AED not operated properly
- Shock not delivered in time
- Everyone not cleared, by voice and by looking, for analysis and for the shock
- Compressions not resumed right after the shock
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
Long-bone and joint immobilization
Both: before splinting
- PPE put on or stated
- Manual stabilization of the injury directed
- Distal motor, sensory and circulation checked in the injured limb
Long bone (e217)
- Splint measured
- Splint applied
- Joint above the injury immobilized
- Joint below the injury immobilized
- Whole injured limb secured
- Hand or foot secured in the position of function
Joint (e216)
- Proper splinting material chosen
- Injury site immobilized
- Bone above the injury immobilized
- Bone below the injury immobilized
- Whole injured limb secured
Both: after splinting
- Distal motor, sensory and circulation rechecked
Critical criteria
- Limb not stabilized by hand at once
- Injured limb moved roughly
- Long bone: joint above and joint below not both immobilized
- Long bone: hand or foot not in the position of function
- Joint: bone above and bone below not both immobilized
- Distal motor, sensory and circulation not checked both before and after splinting
- Not managing the patient as a competent EMT; unacceptable affect with the patient or team
- A dangerous or inappropriate intervention done or ordered
More quick cards
- EMS Field Drugs
- Push and Emergency Meds
- 12-Lead ECG
- Scales and Staging
- Tubes, Lines and Equipment
- Equivalents and Conversions
- IV Fluids
- Empiric Antibiotics
- ICU Bundles
- Renal Dosing
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