Question: Is this patient an infant? A patient less than 12 months old is considered an infant. Please check the box next to the appropriate choice.

Transcription

1 Question: Date of Intubation (Month, Day, Year): Question: Date of Data Entry This should be within 4 weeks to the day of intubation: Question: Is this patient an infant? A patient less than 12 months old is considered an infant. Please check the box next to the Question: Age (months) Please answer if patient is an infant. Question: Age (years) Please answer if patient is not an infant. Question: Estimated weight: (kg) Question: Habitus Please check the box next to the Please disregard if patient is an infant. Very thin Thin rmal Obese Morbidly obese (BMI>40) Question: Sex Male Female Question: Medical Record Number B. Indication for Intubation Question: Why did patient require emergency airway management? Please circle one for either a medical indication OR a traumatic indication but not both. Medical Indication Airway obstruction (not anaphylaxis/angioedema) Cardiac arrest Anaphylaxis Angioedema Asthma Congestive heart failure COPD Gastrointestinal bleed Intracranial hemorrhage Myocardial infarction n-overdose mental status change Overdose Pneumonia Pulmonary embolism Pulmonary hemorrhage Seizure Shock (cardiogenic) Shock (sepsis) Shock (distributive, not sepsis) Shock (pulmonary embolus) Shock (tamponade) Stroke 1

2 Question: Traumatic Indication Abdomen trauma Facial trauma Polytrauma Burn/Inhalation injury Head injury without hemorrhage Shock (hemorrhagic) Chest trauma Head injury with hemorrhage Shock (spinal trauma) Combative/Agitated Neck trauma Traumatic Arrest Question: Primary Mechanism of Trauma Blunt Penetrating Neither (burn only) C. PreIntubation Hemodynamics Question: Please check the below if applicable. If the below checkbox is checked, please disregard the remainder of Section C, and move to Section D. N/A - Patient is coding Question: In the 10 minutes prior to intubation, the patient s blood pressure is best described as (select one): Please select one from the below answer choices only if PATIENT IS AGE 13 OR OLDER. Please check the box next to the Hypertensive (>140) Hypotensive (<100 + intubators gave IV fluids or blood only) rmal ( ) Hypotensive (<100 + intubators gave IV fluids or blood AND pressor medicine) Hypotensive (<100) treatment provided Please select one from the below answer choices only if PATIENT IS AGE 1 THRU 12. Please check the box next to the Hypertensive (>120) Hypotensive (<80 + intubators gave IV fluids or blood only) rmal (80-120) Hypotensive (<80 + intubators gave IV fluids or blood AND pressor medicine) Hypotensive (<80) treatment provided Please select one from the below answer choices only if PATIENT IS 0 THRU 12 MONTHS (younger than 1 year). Please check the box next to the Hypertensive (>100) Hypotensive (<70 + intubators gave IV fluids or blood only) rmal (70-100) Hypotensive (<70 + intubators gave IV fluids or AND pressor medicine) Hypotensive (<70) treatment provided 2

3 Section D: Difficult Airway Characteristics Question: Did your initial impression suggest airway difficulty? Please check the box next to the Question: Did the patient have reduced neck mobility or a cervical collar? Please check the box next to the Question: Mallampati Please check the box next to the Class 1 Class 2 Class 3 Class 4 t assessed Question: Mouth Opening rmal (3 or more fingers) Reduced (1-2 fingers) t assessed Question: Thyromental Distance 1 finger 2 fingers 3 fingers 4 + fingers t assessed Question: Airway Obstruction Present? Please check the box next to the Examples of Airway Obstruction include foreign body, angioedema, anaphylaxis, infection, etc. Question: Facial Trauma Please check the box next to the 3

4 Question: Was blood or vomit in the airway? Please check the box next to the Section E: Preoxygenation Question: Was the need for intubation immediate? (such that the intubator did not have time to pre-oxygenate)? If this question is answered yes, then please skip to Please provide oxygen saturation at start of intubation attempt, if available. If this question is answered, please go on to the next question, Describe patient s ventilatory status. Please check one box next to the Question: Describe patient's ventilatory status Please answer this question only if previous question was answered with. Please check one box next to the appropriate Apneic or hypoventilating requiring bag-valve-mask ventilation Patient breathing spontaneously Question: Please indicate the highest oxygen delivery device used during preoxygenation for patients breathing spontaneously. Please check the box next to the Simple facemask n-rebreather facemask Facemask with venturi device BL-PAP/CPAP BVM without assist Nasal cannula Extraglottic device Question: Was sedation required to facilitate preoxygenation for patients breathing spontaneously? (Delayed Sequence Intubation/DSI) Question: Please select estimated duration of preoxygenation for patients breathing spontaneously. Please check the box next to the <1 min 1-3 minutes >3 minutes Question: Was nasal cannula left in place during intubation attempt for patients breathing spontaneously? Please check the box next to the Question: Oxygen Flow Rate Please only answer this question if patient is breathing spontaneously and answer to Was nasal cannula left in place during intubation attempt is yes. Answer: liters/minute (Acceptable answer choices are 1-20 liters/minute). 4

5 Question: Please provide oxygen saturation (%) at start of intubation attempt, if available. Either the administration of intubation meds (or if no meds were given, at the time of first intubation attempt). Answer: % (Acceptable answer choices are 0-100%) Section F: Intubation Attempt Grid ATTEMPT #1 Question: Pharmacological Method Sedation and Paralysis Sedation Only Paralysis Only Answer Choices: Please select one. Please check the box next to the Topical Anesthesia Topical with Sedation Meds Question: Route Answer Choices: Please select one. Please check the box next to the Nasal Oral Surgical Question: Intubation Position C-spine extension only Answer Choices: Please select one. Please check the box next to the Full sniffing position - C-spine extension plus head elevation Neutral c-spine position Seated upright Question: Device Answer Choices: Please select one. Please check the box next to the Air rifle Air-Q with Intubation Airtraq Bronchoscope flexible fiberoptic Bronchoscope flexible video Clarus video system C-MAC Standard Blade C-MAC D-Blade C-MAC straight blade Direct laryngoscope (MacIntosh) Direct laryngoscope (Miller) Fingers/Digital GlideScope GlideScope cobalt GlideScope teaching blade GlideScope titanium Mac blade I-LMA with intubation (Fastrach) King vision McGrath video laryngoscope Optical semi-rigid stylet Other video laryngoscope Needle cric pediatric Pentax airway scope Percutaneous (MELKER) cric Surgical cric set Question: Was a bougie used? Answer Choices: Please select one. Please check the box next to the 5

6 Question: Pretreatment Med/Dose If "Topical Anesthesia" was selected as the Pharmacological Method, please select "Topical Anesthesia". If "Topical with Sedation" was selected, please select "Topical Anesthesia". Please make any additional selections as necessary. If " Meds" was selected as Pharmacological Method, please skip this question. For all other methods, please complete this field as appropriate. Atropine mg (.25-3) Epinephrine mcg (5-20) Bolus epinephrine for hypotension. Lidocaine mg (50-(10-500)300) Phenylephrine mcg (25-200) Bolus phenylephrine for hypotension. Answer Choices: Please answer for all that apply. Please check the box next to the Dose should be added to the space before the units. Acceptable dose ranges appear next to the units. Fentanyl mcg (50-500) (10-500) repinephrine mcg/min IV infusion(2-12) Topical Anesthesia pretreatment used Question: Primary induction agent: record the drug that was used to put the patient to sleep in prep for intubation: Med/Dose. If Paralysis only or "Topical Anesthesia" was selected as the Pharmacological Method, please select " Induction Used". If " Meds" was selected as the Pharmacological Method, please skip this question. For all other methods, this field is mandatory. Please only consider Dexmedetomidine an option if Topical with sedation or Sedation Only was chosen as the pharmacological method. Etomidate mg (1-100) Ketamine mg ( ) Midazolam mg (1-100) Propofol mg (25-400) Dexmedetomidine mg (10-350) Induction Used Answer Choices: Please select one. Please check the box next to the Dose should be added to the space before the units. Acceptable dose ranges appear next to the units. Question: Paralytic Med/Dose If "Sedation Only", "Topical Anesthesia", or "Topical with Sedation" were selected as the Pharmacological Method, please select " paralytic used". If " Meds" was selected as the Pharmacological Method, please skip this question. For all other methods, this field is mandatory. Rocuronium mg (1-250) Succinylcholine mg (5-400) paralytic used Answer Choices: Please select one. Please check the box next to the Dose should be added in the space before the units. Acceptable dose ranges appear next to the units. Vecuronium mg (.5-200) Question: induction agent was recorded on the first attempt, but a paralytic was used. If incorrect, please enter induction agent used. If correct, please choose reason no induction agent was used. Please answer this question only if NO induction agent was given ( Primary induction agent: record the drug that was used to put the patient to sleep in prep for intubation: Med/Dose was answered with Induction Used ) and paralytic WAS used ( Paralytic Med/Dose was answered with the selection of a medication). Please select one. Shock Crash injury (Glasgow Coma Scale) Previous sedative administered before intubation, no additional sedative thought to be necessary Answer Choices: Please select one. Please check the box next to the appropriate Question: Intubator Specialty Answer Choices: Please select one. Please check the box next to the Emergency Medicine Pediatrics Pediatric Emergency Medicine Anesthesia General Surgery Ear se Throat Internal Medicine Family Medicine Physician Assistant 6

7 Certified Registered Nurse Anesthetist Nurse Practitioner EMT/Paramedic Critical Care Personnel Respiratory Therapist Question: Intubator Level Answer Choices: Please select one. Please check the box next to the appropriate PGY1 PGY2 PGY3 PGY4 PGY>=5 or Fellow Attending Question: Intubator: EM Supervised? Answer Choices: Please check the box next to the appropriate Answer Choices: Please select one. Please check the box next to the Question: Best Glottic View Full View (Grade 1) Partial View (Grade 2) Epiglottis Only (Grade 3) View (Grade 4) Question: Please select one only if C-Mac Standard Blade or Glidescope Teaching Blade was selected under Device. Video View Direct View Answer Choices: Please check the box next to the appropriate Question: Was the larynx manually moved to improve glottic view? (BURP or ELM) Answer Choices: Please check the box next to the Question: Intubation Success? Answer Choices: Please check the box next to the Question: Peri-Intubation Adverse Events? This question is mandatory for this attempt. If yes, you MUST fill out adverse event information in the Adverse Events section (below) before you enter data for additional attempts. After completing the Adverse Events section if needed, if Intubation Success? was answered, please skip to Section G: Intubation Confirmation. If Intubation Success? was answered, please proceed to the following question. Answer Choices: Please check the box next to the Question: Was another attempt started? If yes, please fill out data for additional attempt. Answer Choices: Please check the box next to the 7

8 Question: What happened? Please answer this question only if previous question Was another attempt started? is answered no. Patient died without definitive airway Patient bagged or further attempts aborted until disposition Please select one. Please check the box next to the appropriate Extraglottic device used Question: Extraglottic device used: Select one Please answer this question only if the answer to the question What happened? was answered with Extraglottic Device used. I-LMA without intubation (Fastrach) I-gel King laryngeal tube LMA Answer Choices: Please select one. Please check the box next to the Other Extraglottic Device Question: Was extraglottic device successful? Please answer this question only if the answer to the question What happened? was answered with Extraglottic Device Used. Answer Choices: Please select one. Please check the box next to the Question: Adverse Events Please answer this question if Peri-Intubation Adverse Events? was answered, and if any of the options listed below are applicable. Bradydysrhythmia Cardiac Arrest During/After Intubation Answer Choices: Please select all that apply. Please check the box next to the appropriate Dental trauma Direct airway injury Epistaxis Hypotension <100 mmhg Hypoxia Iatrogenic bleeding Lip laceration >10% drop, or <90% Laryngospasm Main stem intubation Malignant hyperthermia Medication error Pharyngeal laceration Pneumothorax Tachydysrhythmia Tracheal tube cuff failure Vomiting Question: Adverse Events - Esophageal intubation Please answer this question only if Peri-Intubation Adverse Events was answered, and if applicable Esophageal intubation, delayed recognition Answer Choices: If applicable, select one. Please check the box next to the Esophageal intubation, immediate recognition Section G: Intubation Confirmation Question: Confirmed by (Check all that apply): Please check the box next to the Qualitative (colorimetric) ETC02 Quantitative ETC02 Auscultation of lungs Condensation in tube Bedside Ultrasound Bougie (Was a bougie passed through an already placed tube to confirm tracheal location?) Section H: Peri-Intubation Vitals Please disregard this section and move on to Section I if N/A Patient is coding was selected under Section C: Pre-Intubation Hemodynamics. 8

9 Question: Did patient desaturate at any point during intubation? (Drop >10% or Sat <90%). Please check the box next to the Unknown Question: What was the lowest O2 saturation? % Please answer this question only if the answer to the previous question, Did patient desaturate at any point during intubation?, is yes. Answer: % (Acceptable range: 0-90%) Question: At any point in the 15 minutes AFTER intubation or RSI meds, was patient hypotensive (<100mmHg)? Please check the box next to the Question: Lowest systolic blood pressure in mmhg? Please answer this question only if answer to previous question, At any point in the 15 minutes after intubation or RSI meds, was patient hypotensive? was yes. Answer: mmhg (Acceptable range: 0-99) Question: Was treatment required for the low blood pressure that occurred at any point in the 15 minutes AFTER intubation? IV fluid bolus, pressor agent. Please answer this question only if answer to At any point in the 15 minutes after intubation, was patient hypotensive (<100mmHG)? is yes? Please check the box next to the Section I: Disposition Check only one. Please check the box next to the ICU Died in ED - other cause Extubated in ED Died in ED - failed airway Operating Room Transferred Question: Did the patient receive any of the following medications in the 15 minutes after intubation? Check all that apply. Please check the box next to the ne Propofol Midazolam Diazepam Ketamine Fentanyl Long acting paralytic Pressor agent Etomidate Morphine Question: Were any of the following suspected or known prior to intubation? Check all that apply. Please check the box next to the Sepsis Presumed elevated ICP 9