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