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Allegan County Advanced Airway Use Report
This form should be used every time EMS has a use of the following items; Advanced Airway Adjuncts
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* Indicates required question
Reporting Date
*
MM
/
DD
/
YYYY
Airway Use Date
*
MM
/
DD
/
YYYY
Agency Name
*
Your answer
Street Address
*
Your answer
Was the Patient Female or Male
*
Female
Male
Patient Age (Years)
*
Your answer
Approximately how tall was your patient?
*
Less than 2 ft
2-3 Feet
3-4 Feet
4-5 Feet
5-6 Feet
6 Feet and Over
Patient Weight
*
Kg
Your answer
What Device are you reporting on?
*
Choose
i-gel O2
Combitube
King Airway
Endotracheal Tube
What was the clinical reason that required airway intervention?
*
Choose
Cardiac Arrest - Non-Traumatic
Cardiac Arrest - Trauma
Major Trauma - Non-Cardiac Arrest
Respiratory Failure - Asthma
Respiratory Failure - COPD
Respiratory Failure - CHF / Pulmonary Edema
Drug Overdose
Neurological Emergency (non-traumatic) with Decreased LOC
Other Medical Condition, Not Specified
What size airway was used?
*
Your answer
For Endotracheal Tubes, How deep was the airway?
Your answer
For CombiTubes, Which tube did you ventilate through?
Tube #1 (Obturator tube)
Tube #2 (Tracheal tube)
Clear selection
Were there any issues with the performance of the airway?
Your answer
Were any corrective actions needed to improve device performance?
Adjusted the depth
Re-inserted
Abandoned the attempt
No corrective actions were needed
Comments
Your answer
Was the initial airway changed out for any reason
*
IE: unable to place / ventilate, changed out by EMS Physician, etc
Yes
No
PCR / Run Number
*
Your answer
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