Allegan County Advanced Airway Use Report
This form should be used every time EMS has a use of the following items; Advanced Airway Adjuncts
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 *
Patient Age (Years) *
Your answer
Approximately how tall was your patient? *
Patient Weight *
Kg
Your answer
What Device are you reporting on? *
What was the clinical reason that required airway intervention? *
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?
Were there any issues with the performance of the airway?
Your answer
Were any corrective actions needed to improve device performance?
Comments
Your answer
Was the initial airway changed out for any reason *
IE: unable to place / ventilate, changed out by EMS Physician, etc
PCR / Run Number *
Your answer
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