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 *

YYYY

Airway Use Date *

YYYY

Agency *

County *

Initial Scene

Demographics

Street Address *

Was the Patient Female or Male *

Female

Male

Patient Age (Years) *

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 *

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?

Tube #1 (Obturator tube)

Tube #2 (Tracheal tube)

Clear selection

Were there any issues with the performance of the airway?

Were any corrective actions needed to improve device performance?

Adjusted the depth

Re-inserted

Abandoned the attempt

No corrective actions were needed

Comments

Was the initial airway changed out for any reason *

IE: unable to place / ventilate, changed out by EMS Physician, etc

Yes

PCR / Run Number *

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