Primary Indication for Intubation:

Respiratory failure

Shock

Decr. LOC

Cardiac arrest

Procedure

Other 

Location of intubation:

ICU

Emerg

ward  

Other 

Physicians:

Primary Operator:

Supervisor: present?  No Yes

Level:

  medical student PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY 5+ Clinical Associate ICU fellow consultant

  . PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY 5+ Clinical Associate ICU Fellow Consultant Other

Specialty:

  . internal medicine emergency medicine surgery anesthesiology critical care family practice Other

  . internal medicine emergency medicine surgery anesthesiology critical care family practice Other

Airway Exam:

Neck Extension

Not tested

Reduced                         Normal                         Contraindicated

Mallampati

Not tested

1 (entire uvula)     2 (part of uvula)  3 (soft palate) 4 (hard palate only)

Mouth opening (# of fingers)

Not tested

3                         2                         1                         0

Thyromental distance (# of fingers)

Not tested

  4 (or more)    3                         2                         1

No difficulties (good seal with single provider, sats maintained)

Airway (oral or nasotracheal) required to maintain sats

Two hands were required to maintain a mask seal.

Unable to keep sats > 90% with bag mask ventilation.

Not attempted.

Intubation attempts:

Attempt:

Performed by:

Technique(s) employed (check all appropriate)*

1

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

2

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

3

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

4

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

5

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

6

Primary Supervisor

L      B     GS     LW     FOB     LMA     Sx

* L = laryngoscope     B = bougie     GS = glidescope     LW = lightwand

FOB = fibreoptic bronchoscope     LMA = laryngeal mask airwa     Sx = surgical airway

• Total number of intubation attempts:

• Total time from beginning of first attempt until ETT confirmed in trachea (min):

• Cricoid pressure during attempts?     Yes No

• End-tidal CO2 detector used?     Yes No

• Tube size #      

• Evac. tube? Yes No

Medications:

Drug

Dose/unit

1

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

2

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

3

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

4

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

5

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

6

. No drugs used Topical lidocaine Topical benzocaine IV Lidocaine Morphine Midazolam Fentanyl Ketamine Propofol Etomidate Succinylcholine Rocuronium

  . mg mcg

Vasopressors:

Prior to intubation

New or increased following intubation

  mcg phenylephrine total (during and immediately post intubation)

Glottic view:

I (entire vocal cords)     II (part of vocal cords)  III (epiglottis only) IV (non-visualized epiglottis)

Vitals:

Blood pressure

HR

RR

SaO2

FiO2 (0.21-1.00)

Pre-intubation

  mmHg

  bpm

  bpm

  %

5 minutes post intubation

  mmHg

  bpm

  %

Lowest documented during intubation

  mmHg

  bpm

  bpm

  %

 X

Complications:

No complications

Frank aspiration at time of intubation.

New unexpected infiltrate on post intubation CXR.

Endobronchial intubation identified on post intubation CXR.

Pneumothorax

Cardiac arrest at time of intubation

Cardiac arrest within 30 minutes of intubation.

Airway/dental trauma

Death (within 30 minutes)

Other

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