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Black Bag 5

Emergency Departments

TOP ZIPPER FLAP

Narc Box *

Blunt Needle
Fentanyl Vial
Ketamine
Midazolam
Zofran

Mad Device *

Yes
No

LEFT OUTSIDE POCKET

RIGHT OUTSIDE POCKET

Convenience Bag x3 *

Yes
No

Large Biohazard Bag *

Yes
No

MEDICATION POCKET

Chewable Aspirin 81Mg/Tab *

Yes
No

1 Bottle Minimum of 4

Naloxone Hydrochloride 2mg x2 *

Yes
No

EPINEPHRINE 1:1,000 1MG/ML x2 *

Yes
No

NITRO TABS *

Yes
No

1 Bottle Minimum of 3

DIPHENHYDRAMINE 50MG/ML *

Yes
No

ORAL ONDANSETRON *

Yes
No

STERILE WATER *

Yes
No

GLUCAGONE *

Yes
No

KETOROLAC *

Yes
No

ONDANSETRON *

Yes
No

BLUNT NEEDLE X2 *

Yes
No

GREEN ZIPPER BAG

BVM NEBULIZER KIT *

Yes
No

ALBUTEROL SULFATE 2.5MG/3ML x4 *

Yes
No

IPRATROPIUM BROMIDE 0.02% 0.5MG/2.5ML *

Yes
No

BLUE ZIPPER BAG

GLUCOMITER KIT *

GLUCOMETER
5 LANCETS
5 TEST STRIPS
5 2X2
5 BAND AIDS
5 PREP PADS
2 BATTERIES
1 TUBE OF ORAL GLUECOSE

STETHOSCOPE *

Yes
No

THERMOMETER *

Yes
No

FLASHLIGHT *

Yes
No

PENLIGHT *

Yes
No

PULSE OXIMETER *

Yes
No

YELLOW ZIPPER BAG

TRAUMA SCISSORS *

Yes
No

TRIANGLE BANDAGE x2 *

Yes
No

HYFEN VENT- CHEST SEAL x2 *

Yes
No

TRAUMA WOUND DRESSING 6" *

Yes
No

QUIK CLOT ROLLED GAUZE *

Yes
No

Z-PAK DRESSING *

Yes
No

4x4 DRESSING x2 *

Yes
No

ACE WRAP 3" x2 *

Yes
No

CAT TOURNIQUET *

Yes
No

TRANSPORE TAPE *

Yes
No

1"

DURAPORE TAPE *

Yes
No

2"

RED ZIPPER BAG

SHARPS CONTAINER *

Yes
No

10 ML FLUSH x5 *

Yes
No

3ML SYRINGE x4 *

Yes
No

1.0 ML SYRINGE *

Yes
No

BLUNT NEEDLES x3 *

Yes
No

22 GAUGE NEEDLES x3 *

Yes
No

ALCOHOL PREP PADS x5 *

Yes
No

3 WAY STOPCOCK *

Yes
No

MULTIDOSE VIAL ACCESS SPIKE x2 *

Yes
No

IV KIT

IV NEEDLES *

16g IV CATHETER x2
18g IV CATHETER x2
20g IV CATHETER x2
22g IV CATHETER x2
24g IV CATHETER x2

I.V. START KIT x2 *

Yes
No

10 ML FLUSH x2 *

Yes
No

10 GTT SET *

Yes
No

500ML LR in pressure bag *

Yes
No

MISCELLANEOUS IN BAG

BLOOD PRESSURE KIT with all cuff sizes *

Yes
No

INSIDE LEFT POCKET

INSIDE RIGHT POCKET

D10 *

Yes
No

10GTT SET *

Yes
No

TRIAGE TAGS x10 *

Yes
No

BEHIND LEFT INSIDE ZIPPER POCKET

BEHIND RIGHT ZIPPER POCKET

Trauma Dressing *

Yes
No

SAM SPLINT *

Yes
No

Comments *

Date / Time *

Date

Time

Name *

First

Last

Phone

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