difficult airway / intubation registry - medicalert · difficult airway / intubation registry...
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DIFFICULT AIRWAY / INTUBATION REGISTRYPlease complete this form and give to your patient.
Download this form at www.medicalert.org/difficultairway
1. PATIENT INFORMATION
3. DIFFICULT AIRWAY/INTUBATION EVENT DETAILS
2. PHYSICIAN & HOSPITAL INFORMATION
FIRST NAME LAST NAME
MAILING ADDRESS CITY STATE ZIP
PHONE
EMAIL ADDRESS
DATE OF BIRTH (MM/DD/YYYY) GENDER
FIRST NAME LAST NAME
PROFESSIONAL TITLE AND SPECIALITY
HOSPITAL/FACILITY PHONE
ADDRESS CITY STATE ZIP
PATIENT’S MEDICAL RECORD NUMBER
q Home q Mobile q Work q Home q Mobile q Work
q Male q Female
WHAT WAS THE OPERATIVE PROCEDURE AND DATE?
PROCEDURE MO/DAY/YR
WAS THE OPERATIVE PROCEDURE ELECTIVE OR NON-ELECTIVE?
q Elective q Non-elective
WHERE DID THE DIFFICULT AIRWAY/INTUBATION EVENT OCCUR?q Hospital operating room
q Post-anesthesia care unit/recovery room
q Intensive care unit
q Emergency department
q Nursing unit or ward
q Remote hospital procedure site
q Ambulatory surgery center
q Other ______________________________
PATIENT HEIGHT AND WEIGHT
HEIGHT (IN. OR CM.) WEIGHT (LB. OR KG.)
ASA PHYSICAL STATUSq ASA physical status I (normal healthy
patient)
q ASA physical status II (patient with mild systemic disease)
q ASA physical status III (patient with severe systemic disease)
q ASA physical status IV (patient with severe systemic disease that is constant threat to life)
q ASA physical status V (moribund patient who is not expected to survive without the operation)
q ASA physical status E (emergency procedure)
WHAT TYPE OF MONITORING WAS USED?q Capnography
□ Color-change/colorimetric
□ Digital
□ Waveform
q Oximetry
q None
WAS DIFFICULT AIRWAY/INTUBATION ANTICIPATED?
q Yes q No
IF ANTICIPATED, HOW?
q airway history given by patient
q airway history given by family
q prior anesthesia record
q prior ENT surgery
q prior head and neck radiation
q prior airway pathology
q documentation in patient’s medical record
q diagnostic tests
q consultations
q current physical examination
q radiation changes
q other_______________________________
WHAT TYPE OF DIFFICULTY WAS ENCOUNTERED? SELECT ALL THAT APPLY.q Mask/ventilation
q Supraglattic Airway (SGA)
q Intubation
q Extubation
q Other ______________________________
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4. SUCCESSFUL EQUIPMENT TECHNIQUES
WHAT EQUIPMENT/TECHNIQUES WERE SUCCESSFUL IN THE PATIENT’S AIRWAY MANAGEMENT? SELECT ALL THAT APPLY.q Awake
q Asleep
q Face mask ventilation
q Oral airway
q Nasal airway
q Supraglottic airway (SGA)/extraglottic device (EGD)
□ Intubating supraglottic airway
q Direct laryngoscope
□ Macintosh (Size: □ 1 □ 2 □ 3 □ 4)
□ Miller (Size: □ 1 □ 2 □ 3 □ 4)
□ Other ____________________________
q Video laryngoscope
(Size: □ 1 □ 2 □ 3 □ 4)
q Flexible fiberoptic bronchoscope
□ Oral
□ Nasal
q Endotracheal introducer
□ Aintree exchange catheter
□ Optical stylet ________________________
q Rigid fiberoptic laryngoscope ___________
q Operative laryngoscope/Rigid laryngoscope
□ Holinger
□ Dedo
q Rigid bronchoscope
q Retrograde intubation set
q Cricothyrotomy
q Tracheotomy
q Percutaneous tracheostomy
q Other ______________________________
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WHAT PATIENT CHARACTERISTICS WERE RELATED TO THE DIFFICULT AIRWAY/INTUBATION? SELECT ALL THAT APPLY.
q small mouth opening
q temporomandibular joint
q prognathism
q limited mandibular protrusion
q beard
q large tongue
q dentition/large teeth
q edentulous
q redundant or edematous tissue
q hypertrophied lingual tonsils
q anterior/superior larynx
q limited neck extension
q plastic surg implant in face/neck
q neck circumference
q short thyromental distance
q C-spine instability
q distorted ENT anatomy
q Obesity
q Obstructive sleep apnea
q Infection
q Pediatric syndrome
q Pregnancy
q Other_______________________________
MOUTH OPENINGq 1 fingerbreadth
q 2 fingerbreadths
q 3 fingerbreadths
THYROMENTAL DISTANCEq 1 fingerbreadth
q 2 fingerbreadths
q 3 fingerbreadths
NECK EXTENSION
q Full
q Limited, >35 degrees
q Limited, <35 degrees
MODIFIED MALLAMPATI CLASS
q Modified Mallampati Class I (soft palate, uvula, fauces, pillars, visible)
q Modified Mallampati Class II (soft palate, uvula, fauces visible)
q Modified Mallampati Class III (soft palate, base of uvula visible)
q Modified Mallampati Class IV (only hard palate visible)
KHETERPAL MASK VENTILATION GRADE(IF ATTEMPTED)q Kheterpal mask ventilation grade 1
(ventilated by mask)
□ Spontaneous
q Kheterpal mask ventilation grade 2 (ventilated by mask with oral airway/adjuvant with or without muscle relaxant)
□ Muscle relaxant
q Kheterpal mask ventilation grade 3 (difficult ventilation [inadequate, unstable, or requiring 2 providers] with or without muscle relaxant)
□ Muscle relaxant
q Kheterpal mask ventilation grade 4 (unable to mask ventilate with or without muscle relaxant)
□ Muscle relaxant
MODIFIED CORMACK-LEHANE GRADE
q Grade 1 – most of glottic opening is visible
q Grade 2 - only posterior portion of the glottis or only arytenoid cartilages are visible
q Grade 3 – only the epiglottis is visible
q Grade 4 – neither glottis nor epiglottis is visible
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
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5. UNSUCCESSFUL EQUIPMENT TECHNIQUES
6. PATIENT OUTCOME
7. SIGNIFICANT EVENTS
8. FINAL RECOMMENDATION
WHAT EQUIPMENT/TECHNIQUES WERE UNSUCCESSFUL IN THE PATIENT’S AIRWAY MANAGEMENT? SELECT ALL THAT APPLY.q None
Number of attempts □ 1 □ 2 □ >3
q Awake
q Asleep
q Face mask ventilation
q Oral airway
q Nasal airway
q Supraglottic airway (SGA)/extraglottic device (EGD)
□ Intubating supraglottic airway
q Direct laryngoscope
□ Macintosh (Size: □ 1 □ 2 □ 3 □ 4)
□ Miller (Size: □ 1 □ 2 □ 3 □ 4)
□ Other _____________________________
q Video laryngoscope
(Size: □ 1 □ 2 □ 3 □ 4)
q Flexible fiberoptic bronchoscope
□ Oral
□ Nasal
q Endotracheal introducer
□ Aintree exchange catheter
□ Optical stylet _______________________
q Rigid fiberoptic laryngoscope ___________
q Operative laryngoscope/Rigid laryngoscope
□ Holinger
□ Dedo
q Rigid bronchoscope
q Retrograde intubation set
q Cricothyrotomy
q Tracheotomy
q Percutaneous tracheostomy
q Other ______________________________
ESTIMATED TIME FOR AIRWAY MANAGEMENTq 0-15 minutes
q 15-30 minutes
q 30-60 minutes
q Longer than 60 minutes
WHAT WAS THE PATIENT OUTCOME? SELECT ALL THAT APPLY. FOR RESEARCH PURPOSES ONLY.q Airway secured and procedure completed
q Airway secured but procedure cancelled
q No adverse outcome
q Cancelled procedure
q Desaturation
q Aspiration
q Cardiovascular compromise/arrest
q Cricothyrotomy
q Tracheotomy
q Percutaneous tracheostomy
q Dental trauma
q Soft tissue or nasal trauma
q Esophageal trauma
q Laryngeal trauma
q Vocal cord trauma
q Tracheal trauma
q Barotrauma
q Hemorrhage
q Other ______________________________
PLEASE DESCRIBE THE SIGNIFICANT EVENTS
MedicAlert Foundation is endorsed by the Society for Airway Management.
FINAL COMMENTS/RECOMMENDATIONS FOR COLLEAGUES?
MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2014 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation.PAGE 3
PAGE 4 MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2014 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation.Prices are subject to change without notice.
EMERGENCY CONTACTS
MEDICAL CONDITIONS/DEVICES/MEDICATIONS*
ALLERGIES*
SELECT YOUR MEDICAL ID(S)
PAYMENT
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SEND YOUR COMPLETED REGISTRY TO:
PRIMARY EMERGENCY CONTACT RELATIONSHIP
EMERGENCY CONTACT’S PHONE SECOND PHONE
PRIMARY PHYSICIAN PHYSICIAN PHONE
DIFFICULT AIRWAY/INTUBATION
CLASSIC PINK BRACELET (A658) - $27.99
CLASSIC CONTRAST STRETCH BAND (A704) - $47.99
POLISHED DOG TAG (A601) - $24.99
SWEETHEART NECKLACE(A795) - $34.99
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CREDIT CARD HOLDER’S NAME
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