Airway Management Data Collection Form - Paems printable pdf download

PAEMS

Must be faxed to 655-2090 within 48hrs

AIRWAY MANAGEMENT DATA COLLECTION FORM

Please answer ALL of the following questions (circle/check/fill-in) for ANY patient requiring airway management.

1. Ì Trauma Ì Medical Ì Unsure

2. Age: ______ yrs / months (if < 1 y/o)

3. Sex Ì M Ì F

4. Cervical spine immobilized: Ì Yes Ì No

If Yes: Ì Before intubation Ì After intubation

5.. Intubation attempted (blade inserted ): Ì Yes Ì No If No, why? Ì Difficult Airway Ì Other _________________

6. Reason for airway management: Ì GCS < 9 Ì Respiratory distress Ì Arrest Ì Airway trauma Ì Medical problem Ì Other ____________

7. Pre-Oxygenation: Ì Yes Ì No

8. Bag Valve Mask: Ì Yes Ì No

ETT

King Airway

9b. Number of attempts ______

9a. Number of times blade inserted: Ì 1 Ì 2 Ì 3 Ì N/A

10b Size _____

10a. Number of times attempted to pass ETT: Ì 1 Ì 2 Ì 3 Ì N/A

11b OG tube used__________

11a. Laryngoscope Grade (Check): Ì 1 Ì 2 Ì 3 Ì 4

12b Successful ___Yes ____No

12a. Intubation successful: Ì Yes

Ì No

13b If No, Why?

Resistance___

Emesis____

13a. If No, Why? Ì Inadequate relaxation

_______________

Trauma ____

____Other

Explain:__________________

Blood/vomit/secretions in airway

Ì Cords not visualized

Ì Epiglottis not visualized Ì Other / explanation: ________________

14a Inflation ml _________

14a. Method: Ì Orotracheal Ì Reverse Orotracheal (face to face)

15. Airway eventually controlled successfully? Ì Yes

Ì No

16. Tube secured with: Ì Tape Ì Commercial Device

Ì Other: ______________________________

17. Auscultation bilaterally at axilla with good air exchange? Ì Yes Ì No

Air sounds in epigastrium?

Ì Yes Ì No

18. Continuous capnography monitoring device used?

Ì Yes Ì No If not, why not? _______________________

If used: Good wave form Ì Yes Ì No AND ETCO2 reading post intubation: __________mm/Hg;

19. Was ETCO

monitored? Ì Yes How? Ì Colorimetric Ì other _________________

Ì No Why not? ______________________

20. SPO2 pre-intubation: _______% Lowest SPO2 during intubation _______% SPO2 post-intubation: ________% Ì Unavailable Ì Not Used

21. Complications: Ì emesis/aspiration Ì 02 sat fall

Ì Arrest

Ì Arrhythmia Ì Bradycardia (pulse < 60 or decrease by = 20 bpm)

. Verification of ET placement by MD/RN/RT/EMT-P (check one): Ì Good placement Ì Tube misplaced upon transfer of care

Ì Patient not transported or care not transferred - Please explain: ______________________________________________________________

. Name of verifying provider (print): ____________________________

Signature of verifying provider:__________________________

Name of destination hospital: ________________________________

Date:

Time of Day: ___________________

EMS Service Name: _______________________________

Primary Medical Control Hospital Name: __________________________

. Name of EMS Provider (Print): __________________________________________

PLEASE WRITE ADDITIONAL COMMENTS ON THE BACK OF THIS FORM

Airway Management Data Collection Form - Paems

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