Form Center

2. Ketamine Reporting Form

   
   

   The NCCEP requires submission of Ketamine usage. Please refer to the NCCEP Ketamine policy for additional information.

    

   If you have any questions contact the Medical Director

4. EMS System*
   -- Select One --CravenJonesPamlico
5. EMS Agency*
   -- Select One --Bridgeton EMSCarolinaEast EMSCove City EMSHavelock Fire/RescueFort Barnwell RescueMCAS Cherry Point Fire/RescueNew Bern CravenTownship Seven EMSVanceboro RescueJones County EMSPamlico Rescue
7. PCR Number*
8. Date of Call*
   Date of Call
9. Patient Age
10. Patient Sex*

    1. Male
    2. Female
12. Receiving Hospital*
    -- Select One --CarolinaEast Medical CenterVidant Medical CenterUNC LeniorCarteret GeneralOther
13. Primary Protocol Utilized*
    -- Select One --Pain ManagementDAI/SedationBehavioral/Excited DeliriumSeizurePost IntubationOther (please describe in comments)
15. Route (Method given to patient)
    -- Select One --IVIMINIO
16. Dose Administered in mg*
18. Adverse Outcome*
    -- Select One --Cardiac ArrestUnanticipated intubation required after Ketamine AdministrationOther (please describe in coments)None
20. Comments/Action Taken
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field