Metronome Other _________________________________ Recorder Signature: ________________________________________ Recorder Printed Name: _____________________________________ Provider Signature: _________________________________________ Provider Printed Name: ______________________________________ () Comments: IO IO IO IO IO or or or or i.e.: Peripheral/Central Line Placement, or () IO, Chest Tube, Vital Signs, IV IV IV IV IV / / / / / Response to Interventions Time Dose Dose Atropine Dose Dose BP Amiodarone Dose Lidocaine Dopamine Epinephrine Vasopressin Epinephrine Norepinephrine Rhythm ETCO2 Joules Spontaneous Assisted Spontaneous Compression
Metronome Other _________________________________ Recorder Signature: ________________________________________ Recorder Printed Name: _____________________________________ Provider Signature: _________________________________________ Provider Printed Name: ______________________________________ Time Spontaneous Assisted () Spontaneous Compression () BP Rhythm ETCO2 Joules Amiodarone Dose / IV or IO Atropine Dose / IV or IO Epinephrine Dose / IV or IO Lidocaine Dose / IV or IO Vasopressin Dose / IV or IO Dopamine Epinephrine Norepinephrine Comments: i.e.: Peripheral/Central Line Placement, IO, Chest Tube, Vital Signs, Response to Interventions