TANGGAL PENYERAHAN :....................................................................................

KODE SEGEL :....................................................................................

DIVISI :....................................................................................
NOMOR KONTAINER :………………………………………………………………………………….

KIT EMERGENCY ANAK

EXPIRED DA
NO NAMA BRAND UKURAN SATUAN JUMLAH TE
A AIRWAY
1/60 mm PCS 1
2/70 mm PCS 1
Oropharengeal Airwa
1 3/80 mm PCS 1
y / Guedel
4/90 mm PCS 1
5/100 mm PCS 1
2,5 non cuff PCS 1
3 cuff PCS 1
3 non cuff PCS 1
3,5 non cuff PCS 1
3,5 cuff PCS 1
Endotracheal Tube (E
2 4 cuff PCS 1
TT)
4,5 cuff PCS 1
5 cuff PCS 1
6 cuff PCS 1
7 cuff PCS 1
7,5 cuff PCS 1
B BREATHING
Bag valve mask bayi
PCS 1
1 (AMBU bag) BAYI
Oxygen Nasal Canul
PCS 2
2 Bayi BAYI
Oxygen Nasal Canul A
PCS 2
3 nak ANAK
Non Rebreathing Ma
PCS 1
4 sk Bayi BAYI
Non Rebreathing Ma
PCS 1
5 sk Anak ANAK
C CIRCULATION
1 Infusion Set Anak - PCS 1
16 PCS 2
18 PCS 2
20 PCS 2
2 Abbocath 22 PCS 2
24 PCS 2

Ringer Laktat 500ML Flabot 1

3
4 Dextrose 10 % 10% (500ML) Flabot 1

5 Dextrose 40% 25 ML 40% (25ML) Flabot 1

6 NaCl 0,9% 0,9% (500ML) Flabot 2
7 KA-EN 3a - Flabot 1
1 ML PCS 1
3 ML PCS 1
5 ML PCS 1
8 Spuit 10 ML PCS 1
20 ML LUBANG
PINGGIR
PCS 1
20 ML LUBANG PCS 1
 TENGAH
50 ML LUBANG
PINGGIR PCS 1
50 ML LUBANG
PINGGIR PCS 1

D DRUG
1 Aminofilin 24MG/ML ampul 1
2 Dexamethason 5MG/ML ampul 2
Diazepam inj 10 mg/
10MG/2ML ampul 1
3 2 ml
4 Epinefrin 50MG/ML ampul 2
5 Atropin Sulfat 0,25MG/ML ampul 2
6 FUROSEMID 10MG/ML ampul 2
7 WFI 25ML ampul 2
8 Lidocain 20MG/ML ampul 2
9 ISDN 5 mg tablet 5
10 Ketorolac 30 mg/ml Suppo 2
11 PHYTOMENADION 2 MG/ML Ampul 1
12 EPHEDRIN HCL 50 MG/ML Ampul 1
E LAIN LAIN
1 Umbilical - PCS 1
2 Maxter No 07 UKURAN 7 PCS 2
10X30 CM PCS 1
3 Hypafix
4 Extention Tube 150 CM PCS 1
NGT NO 8/Stomach
NO 8
5 Tube PCS 1
6 Alkohol Swab - PCS 5
7 Threeway Ekor - PCS 1
8 Dermafix 5x7 cm PCS 1
9 Splak Bayi/Anak - PCS 1
10 Double Spike - PCS 1

PETUGAS YANG MEMBUKA SEG

EL :....................................... PARAF: .......................
TANGGAL BUKA SEGEL :.......................................
JAM BUKA SEGEL :.......................................

JAM KONFIRMASI KE FARMASI :.......................................