Spreadsheet: 0254af51-6b56-4390-9db8-ad7fda4717a9
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Thomas Jefferson EMS Council | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Revised: May 2007 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25
 |  |  |  |  |  |  | Advanced Airway Management Form
Date: |  |  |  |  | Time: |  |  |  |  | Agency: |  |  |  |  |  |  |  | Provider:
Patient Name: |  |  |  |  |  |  |  |  |  |  |  | Age: |  |  | Cardiac Arrest |  |  |  |  | Live |  |  | RSI used
Breath sounds prior to intubation:
1st Attempt: |  |  |  | Successful |  |  | Y | N |  |  |  |  | 2nd Attempt: |  |  |  | Successful |  |  | Y | N
Endotracheal |  |  |  |  | Size |  | [NAME] |  | Depth |  |  | cm | Endotracheal |  |  |  |  | Size |  | [NAME] |  | Depth |  |  | cm
Combitube |  |  |  |  | Which tube used ? White or Blue |  |  |  |  |  |  |  | Combitube |  |  |  |  | Which tube used ? White or Blue
King LT-D |  |  |  |  | Size |  |  |  | Depth |  |  | cm | King LT-D |  |  |  |  | Size |  |  |  | Depth |  |  | cm
Cricothyrotomy: |  |  |  | Needle |  |  |  | Surgical |  |  |  |  | Cricothyrotomy: |  |  |  | Needle |  |  |  | Surgical
Confirmation methods used: |  |  |  |  |  |  |  |  |  |  |  |  | Confirmation methods used:
 | Direct view of tube passing through cords |  |  |  |  |  |  |  |  |  |  |  |  | Direct view of tube passing through cords
 | Absent sounds in epigastrium |  |  |  |  |  |  |  |  |  |  |  |  | Absent sounds in epigastrium
 | Equal bilateral breath sounds |  |  |  |  |  |  |  |  |  |  |  |  | Equal bilateral breath sounds
 | Equal expansion of chest with ventilation |  |  |  |  |  |  |  |  |  |  |  |  | Equal expansion of chest with ventilation
 | Rise in Sp02 (patient is not in full arrest) |  |  |  |  |  |  |  |  |  |  |  |  | Rise in Sp02 (patient is not in full arrest)
 | Colormetric CO2 detector |  |  |  |  |  |  |  |  |  |  |  |  | Colormetric CO2 detector
 | Esophageal detection device |  |  |  |  |  |  |  |  |  |  |  |  | Esophageal detection device
 | Capnography (attach wave strip) |  |  |  |  |  |  |  |  |  |  |  |  | Capnography (attach wave strip)
Complications: |  |  |  |  |  |  |  |  |  |  |  |  | Complications:
[NAME] |  |  |  |  | Esophageal placement |  |  |  |  |  |  |  | [NAME] |  |  |  |  | Esophageal placement
Blood |  |  |  |  | Tube dislodgement |  |  |  |  |  |  |  | Blood |  |  |  |  | Tube dislodgement
Intact gag reflex |  |  |  |  | Broken teeth |  |  |  |  |  |  |  | Intact gag reflex |  |  |  |  | Broken teeth
Trauma to airway |  |  |  |  | Equipment failure |  |  |  |  |  |  |  | Trauma to airway |  |  |  |  | Equipment failure
Not successful, why? |  |  |  |  |  |  |  |  |  |  |  |  | Not successful, why?
 | Attach copy of capnography strip |  |  |  |  |  |  |  |  |  |  |  |  |  | Attach copy of capnography strip at
 |  | post intubation |  |  |  |  |  |  |  |  |  |  |  |  |  | turn over to hospital or other provider
Tube placement checked by: |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Patient disposition: |  |  |  |  |  |  |  |  | 5/1/07