EMS Cardiac Arrest/Resuscitation Record

Date: [Date (YYYY-MM-DD)]   Incident/ePCR Number: [Incident/ePCR Number]   Agency/Unit: [Agency name / Unit ID]   Service Level: [BLS / ALS]   Patient Identifiers: [Per local policy]   Scene Location Type: [home / public / workplace / other]

Response Times: (Use absolute 24-hour times with seconds when available. If documented elsewhere in the ePCR, write "See eTimes section" and omit the list below.)
Dispatch [HH:MM:SS]; En route [HH:MM:SS]; Scene arrival [HH:MM:SS]; Patient contact [HH:MM:SS]; Scene departure [HH:MM:SS]; Destination arrival [HH:MM:SS]; Transfer of care [HH:MM:SS]

Arrest Context

(Capture Utstein elements concisely. For any unknown element, enter "Unknown" rather than leaving blank.)

• Arrest relative to EMS arrival: [before EMS arrival / after EMS arrival / unknown]
• Presumed etiology: [cardiac / trauma / overdose / drowning / asphyxia / other / unknown] (If other: [etiology details])
• Witness status: [unwitnessed / bystander-witnessed / EMS-witnessed / unknown]
• Estimated arrest time: [HH:MM:SS or time range] (Source: [bystander report / first responder report / device summary / unknown])
• Bystander CPR prior to EMS: [yes / no / unknown] (If yes: [continuous / interrupted / unknown quality])
• AED applied prior to EMS: [yes / no / unknown] (Shocks delivered: [number / unknown])
• Modifying factors: [pregnancy / hypothermia / submersion / suspected toxin / none / unknown] (List all that apply)
• Advance directive/DNR/POLST: [present / absent / unknown] (Verification: [document reviewed / bracelet / family report / facility record / online medical control])

Initial Assessment

(Brief objective findings at resuscitation start; include only elements that inform diagnosis or reversible causes.)

• Responsiveness: [unresponsive / responsive]
• Breathing: [apneic / agonal respirations / normal]
• Pulse check: [no pulse / pulse present / uncertain] (Site: [carotid / femoral / other])
• Initial monitored rhythm: [VF / pVT / asystole / PEA / organized / unknown]
• CPR status on arrival: [ongoing by bystander / ongoing by first responder / not ongoing—initiated by EMS at HH:MM:SS]
• Initial ETCO₂: [value mmHg / not available]
• Immediate reversible-cause findings: [Relevant H's and T's findings or "None identified"] (Include only if observed: trauma signs, overdose indicators, airway obstruction, etc.)

Event Timeline

(This timeline is authoritative. Use absolute 24-hour times with seconds when available. Format: Time — Event Type — Details. For estimated times, prefix with "~" and specify source.)

Time Source: [device auto-log / manual entry / mixed]   Device clocks synchronized: [yes / no / unknown] (Offset if known: [details])

• [HH:MM:SS] — CPR — [initiated / continued / paused (reason) / provider change / mechanical CPR started / discontinued] (Quality metrics if available: rate, depth, fraction, ETCO₂)
• [HH:MM:SS] — Rhythm/Pulse Check — Rhythm: [VF / pVT / asystole / PEA / organized]; Pulse: [present / absent]
• [HH:MM:SS] — Defibrillation — Shock #[number]; Energy [J]; Pre-shock rhythm [VF / pVT]; CPR resumed immediately: [yes / no]
• [HH:MM:SS] — Airway — [BVM / SGA / ETT]; Attempt #[number]; Device/size [details]; [successful / unsuccessful]; Confirmation: [waveform capnography / colorimetric / auscultation]; Tube depth [cm]; ETCO₂ [value]
• [HH:MM:SS] — Vascular Access — [IV / IO]; Site [location]; Gauge [size]; Attempt #[number]; [successful / unsuccessful]
• [HH:MM:SS] — Medication — [Drug name]; Dose [amount + units]; Route [IV / IO / IM / IN]; Flush [volume]
• [HH:MM:SS] — ROSC — Evidence: [palpable pulse at (site), BP (value), ETCO₂ rise to (value), patient movement]; Rhythm [description] (Do not document ROSC without perfusion evidence)
• [HH:MM:SS] — Re-arrest — Rhythm: [VF / pVT / asystole / PEA]
• [HH:MM:SS] — Other — [Procedure or critical event: needle decompression, glucose check, temperature, notable complications]
• [HH:MM:SS] — Transport — Departed scene to [destination]; Status: [ongoing CPR / sustained ROSC / recurrent arrests]
• [HH:MM:SS] — Termination — Resuscitation discontinued; Pronouncement: [HH:MM:SS if separate]

Post-ROSC Care

(Include only if ROSC achieved. Document each ROSC/re-arrest cycle separately if multiple occurred. Omit entire section if no ROSC.)

• ROSC time and evidence: [HH:MM:SS]; [Perfusion evidence: pulse site, BP, ETCO₂ rise, movement]
• Airway status: [BVM / SGA / ETT]; Confirmation: [waveform capnography / other]; Tube depth [cm]; ETCO₂ [value]
• Immediate vitals: HR [value], BP [value] or MAP [value], SpO₂ [value] (waveform: [good / poor]), ETCO₂ [value], Glucose [value if checked]
• Oxygenation/ventilation: FiO₂ [%], Ventilation rate [breaths/min], Target SpO₂ [range], Target ETCO₂ [range]
• Hemodynamic support: [Fluids (type/volume) / Vasopressors (drug/dose/rate) / None required]
• 12-lead ECG: Time [HH:MM:SS]; Interpretation: [STEMI suspected / no STEMI / nondiagnostic]; Activations: [cath lab / destination alert / none]
• Sedation: [Drug, dose, route, time] (If applicable)

Termination of Resuscitation

(Include only if resuscitation terminated in field. Omit if patient transported.)

• Resuscitation discontinued: [HH:MM:SS]
• Pronouncement time: [HH:MM:SS / same as above]
• Decision authority: [protocol-driven / online medical control] (Identifier if required: [details])
• Criteria met: (Document as factual observations)
  • Witness status: [as documented above]
  • Shocks delivered: [total number including pre-EMS]
  • ROSC during resuscitation: [yes / no]
  • Total resuscitation duration: [minutes] (Estimated: [yes / no])
  • Rhythm at termination: [asystole / PEA / other]
  • DNR/POLST basis: [documented and verified / not applicable]
  • Obvious death signs: [present—specify / absent / not applicable]
• Persons present and notifications: [Per agency policy, non-editorial]

Transport and Handoff

(Include only if patient transported. Omit if terminated in field.)

• Destination: [Facility name]; Rationale: [closest appropriate / cardiac arrest center / cath lab activation / other]
• Status during transport: [sustained ROSC / ongoing CPR / recurrent arrests]
• Interventions during transport: [Key airway, medication, shock, or procedure events]
• Arrival condition: Rhythm [description]; Clinical status [description]
• Handoff: Time [HH:MM:SS]; Receiving: [role]; Data transferred: [code summary / ECG / 12-lead / capnography]

(For post-ROSC transports, documentation must support medical necessity for ambulance transport.)

Code Summary Totals

(Totals must reconcile with Event Timeline. Prioritize device log data; note discrepancies.)

• Total CPR duration: [minutes] (Estimated: [yes / no])
• Total shocks: [number] (Pre-EMS AED shocks: [number / unknown])
• Medication totals: [Drug — total dose, route] (List each drug)
• Final airway: [BVM / SGA / ETT]; Confirmation: [waveform capnography / other]
• Disposition: [ROSC in field / expired in field / ongoing resuscitation at ED arrival]
• Reconciliation notes: [Discrepancies between timeline and device logs, if any]

Attachments

• Defibrillator code summary: [attached / not available]
• ECG strips/12-lead: [attached / not available]
• Capnography waveform: [attached / not available]
• Mechanical CPR report: [attached / not available]

(If not available: [device malfunction / not exported / other reason])

Documentation Integrity

• Author: [Name], [Credentials]
• Signature timestamp: [YYYY-MM-DD HH:MM:SS]
• Entry timing: [real-time / retrospective] (If retrospective, source: [device log / written notes / witness report])
• Amendments: [Per agency policy if applicable]

(Omit sections that do not apply. Do not infer witness status, arrest time, rhythm, ROSC, or termination rationale—document what is known or state Unknown/Estimated with source. The Event Timeline is authoritative and must not be contradicted by other sections.)