difficult airway / intubation registry

DIFFICULT AIRWAY / INTUBATION REGISTRY
Please complete this form and give to your patient.
Download this form at www.medicalert.org/difficultairway
1. PATIENT INFORMATION
2. PHYSICIAN & HOSPITAL INFORMATION
FIRST NAME LAST NAME
MAILING ADDRESS
PHONE
CITY
q Home q Mobile
q Work
FIRST NAME
STATE
ZIP
q Home q Mobile q Work
EMAIL ADDRESS
LAST NAME
PROFESSIONAL TITLE AND SPECIALITY
HOSPITAL/FACILITYPHONE
ADDRESS
CITY
STATE
ZIP
q Male q Female
DATE OF BIRTH (MM/DD/YYYY)
GENDER
PATIENT’S MEDICAL RECORD NUMBER
3. DIFFICULT AIRWAY/INTUBATION EVENT DETAILS
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 STATUS
IF ANTICIPATED, HOW?
q ASA physical status I (normal healthy
patient)
q airway history given by patient
q ASA physical status II (patient with mild
systemic disease)
q prior anesthesia record
q ASA physical status III (patient with severe
systemic disease)
q airway history given by family
q prior ENT surgery
q prior head and neck radiation
q ASA physical status IV (patient with severe
systemic disease that is constant threat to life)
q prior airway pathology
q ASA physical status V (moribund patient
who is not expected to survive without the
operation)
q diagnostic tests
q ASA physical status E (emergency procedure)
q documentation in patient’s medical record
q consultations
q current physical examination
q radiation changes
WHAT TYPE OF MONITORING WAS USED?
q other_______________________________
q Capnography
□ Color-change/colorimetric
□ Digital
WHAT TYPE OF DIFFICULTY WAS
ENCOUNTERED? SELECT ALL THAT APPLY.
□ Waveform
q Mask/ventilation
q Oximetry
q Supraglattic Airway (SGA)
q None
q Intubation
WAS DIFFICULT AIRWAY/INTUBATION
ANTICIPATED?
q Extubation
q Other ______________________________
q Yes q No
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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
THYROMENTAL DISTANCE
KHETERPAL MASK VENTILATION GRADE
(IF ATTEMPTED)
q 1 fingerbreadth
q Kheterpal mask ventilation grade 1
(ventilated by mask)
q 2 fingerbreadths
q 3 fingerbreadths
□ Spontaneous
q Kheterpal mask ventilation grade 2
(ventilated by mask with oral airway/
adjuvant with or without muscle relaxant)
NECK EXTENSION
q Full
□ Muscle relaxant
q Limited, >35 degrees
q Kheterpal mask ventilation grade 3
(difficult ventilation [inadequate, unstable,
or requiring
2 providers]
with or without
2
3
4
1
2
muscle relaxant)
q Limited, <35 degrees
1
MODIFIED MALLAMPATI CLASS
q Kheterpal1mask ventilation
grade 4 (unable
to
2
3
mask ventilate with or without muscle relaxant)
q Modified Mallampati Class
I (soft palate, uvula, fauces,
pillars, visible)
q short thyromental distance
1
2
q C-spine instability
q Obstructive sleep apnea
q Infection
2
3
4
q Grade 1 – most of glottic
opening is visible
3
4
q Grade 2 - only posterior
portion of the glottis or only
arytenoid cartilages are visible
q Modified Mallampati Class
III (soft palate, base of uvula
2
3
visible) 1
4
q Grade 3 – only the epiglottis is visible
q Pediatric syndrome
q Pregnancy
q Other_______________________________
2
MODIFIED CORMACK-LEHANE GRADE
q distorted ENT anatomy
q Obesity
4
□ Muscle
relaxant
3
1
q Modified Mallampati Class
II (soft palate, uvula, fauces
1
visible)
q Modified Mallampati Class IV
(only hard palate visible)
q Grade 4 – neither glottis nor epiglottis is visible
MOUTH OPENING
q 1 fingerbreadth
q 2 fingerbreadths
q 3 fingerbreadths
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
q Rigid fiberoptic laryngoscope ___________
□ Macintosh (Size: □ 1
□ Miller (Size: □ 1
□2
□2
□3
□3
□ 4)
□ 4)
□ Other ____________________________
q Video laryngoscope
(Size: □ 1
□2
□3
q Operative laryngoscope/Rigid laryngoscope
□ Holinger
□ Dedo
q Rigid bronchoscope
□ 4)
q Flexible fiberoptic bronchoscope
q Retrograde intubation set
q Cricothyrotomy
□ Oral
q Tracheotomy
□ Nasal
q Percutaneous tracheostomy
q Endotracheal introducer
q Other ______________________________
□ Aintree exchange catheter
□ Optical stylet ________________________
form continues on next page >
PAGE 2
2
3
□ Muscle relaxant
q plastic surg implant in face/neck
q neck circumference
1
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4
5. UNSUCCESSFUL EQUIPMENT TECHNIQUES
WHAT EQUIPMENT/TECHNIQUES WERE
UNSUCCESSFUL IN THE PATIENT’S AIRWAY
MANAGEMENT? SELECT ALL THAT APPLY.
q None
Number of attempts □ 1
□2
(Size: □ 1
□2
□3
q Percutaneous tracheostomy
□ 4)
q Flexible fiberoptic bronchoscope
□ Oral
□ >3
□ Nasal
q Awake
q Endotracheal introducer
q Asleep
□ Aintree exchange catheter
q Face mask ventilation
□ Optical stylet _______________________
q Oral airway
q Rigid fiberoptic laryngoscope ___________
q Nasal airway
q Other ______________________________
ESTIMATED TIME FOR AIRWAY
MANAGEMENT
q 0-15 minutes
q 15-30 minutes
q 30-60 minutes
q Longer than 60 minutes
q Operative laryngoscope/Rigid laryngoscope
q Supraglottic airway (SGA)/extraglottic
device (EGD)
□ Holinger
□ Dedo
□ Intubating supraglottic airway
q Rigid bronchoscope
q Direct laryngoscope
□ Macintosh (Size: □ 1
□ Miller (Size: □ 1
q Video laryngoscope
□2
□2
□3
□3
□ 4)
□ 4)
□ Other _____________________________
q Retrograde intubation set
q Cricothyrotomy
q Tracheotomy
6. PATIENT OUTCOME
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 Esophageal trauma
q Cardiovascular compromise/arrest
q Laryngeal trauma
q Cricothyrotomy
q Vocal cord trauma
q Tracheotomy
q Tracheal trauma
q Percutaneous tracheostomy
q Barotrauma
q Dental trauma
q Hemorrhage
q Soft tissue or nasal trauma
q Other ______________________________
7. SIGNIFICANT EVENTS
PLEASE DESCRIBE THE SIGNIFICANT EVENTS
8. FINAL RECOMMENDATION
FINAL COMMENTS/RECOMMENDATIONS FOR COLLEAGUES?
MedicAlert Foundation is endorsed by
the Society for Airway Management.
PAGE 3
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EMERGENCY CONTACTS
MEDICALERT MEDICAL IDS
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RELATIONSHIP
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SECOND PHONE
PRIMARY PHYSICIAN
PHYSICIAN PHONE
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DIFFICULT AIRWAY/INTUBATION
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CREDIT CARD NUMBER
EXPIRATION DATE (MM/YY)
CREDIT CARD HOLDER’S NAME
CREDIT CARD HOLDER’S BILLING ADDRESS
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