CARDIAC-CPR

EMS → ED Handoff Communication Tool

Location of Arrest

🏠 Home 🏥 Healthcare Facility 🌳 Outside

CCause (if known)

Suspected or known cause

AAge

Age (years)

RRhythm

DDowntime

Estimated downtime (minutes)

IInterventions

Bystander CPR

Yes No

Defibrillation attempts

Yes No

AAirway Type

ET Tube LMA King Airway Not Intubated

CCirculation

ROSC achieved?

Yes No

Vascular Access

IV IO Other None

CCode Status

Unknown DNR Full Code

PPre-Hospital Medications

Epinephrine (doses)

Calcium (doses)

Bicarbonate (doses)

Amiodarone (mg)

Lidocaine (mg)

Other medication(s)

RReport

Witnessed Arrest?

Yes No

Additional notes

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