BURN RESOURCE CENTER CHECKLIST

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DEPARTMENT OF HEALTH SERVICES COUNTY OF LOS ANGELES
SUBJECT: BURN RESOURCE CENTER REQUIRED EQUIPMENT/SUPPLIES/PHARMACEUTICALS		REFERENCE NO. 1138.1
FACILITY:

EQUIPMENT	REQUIRED MINIMUM QUANTITY*	ACTUAL QUANTITY	PHARMACEUTICALS	REQUIRED MINIMUM QUANTITY*	ACTUAL QUANTITY
Video equipment for bronchoscope	1 each		Silver Sulfadiazine 1% Any Size	14,400grams
Fluid Infusion Warmer	3 each		Bacitracin (28.4 gm tube)	36 each
IV Pumps (dual channel)	12 each		Cyanide Antidote Kit or CyanoKit	5 kits
Thermal Mylar Blanket	24		Midazolam 5mg/ml	360 vials/ampules
Thermal Blanket Forced Air Warming Blanket	2 each		Naloxone 0.4mg/ml	360 vials/ampules
Video laryngoscope with Pediatric & Adult blades	2 each		Morphine Sulfate 10mg/ml	720 vials/ampules
Cauterizer	1		Lactated Ringers Solution 1 liter bags	250 bags
Cautery Disposable Tips	12		D5 Lactated Ringers Solution 500 cc bags	100 bags
Cautery Grounding Pads	24

BURN WOUND CARE SUPPLIES

SUPPLIES

REQUIRED
MINIMUM QUANTITY*

ACTUAL QUANTITY

Burn Debridement/ Escharotomy Tray

24 trays

Dry Burn Dressing (32X36)

600 each

Gauze Bandage 4" Rolls

400 each

Tubular Elastic Net Bandage (Size #1, 5, 6, 7, 10, 22)

36 each size

*or equivalent

Notes/Comments

Approved by Name:

Received by:

Statement of Verification

I hereby verify that an inventory of all Grant funded items listed above has been completed and all items are up to PAR.

Verified By: Date:
(Printed Name and Signature)

Should any item on the above list fall below PAR levels, notify the EMS Agency immediately.

Notification to EMS Agency by: Date:

EFFECTIVE: 07-01-06
REVISED: 10-01-20
SUPERSEDES: 07-01-19 Express Sending Station: {var MsgSender}

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