LIFE EMS 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 *
County *
Initial Scene
Demographics
Street Address *
Was the Patient Female or Male *
Patient Age (Years) *
Approximately how tall was your patient? *
Patient Weight *
Kg
Devices
What Device are you reporting on? *
What was the clinical reason that required airway intervention? *
What size airway was used? *
For Endotracheal Tubes, How deep was the airway?
For CombiTubes, Which tube did you ventilate through?
Clear selection
Were there any issues with the performance of the airway?
Were any corrective actions needed to improve device performance?
Comments
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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