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Sedation Assisted IntubationSAEMS2026-01-05T14:33:41+00:00

Sedation Assisted Intubation

If you encounter any errors while submitting your encounter, please email Austin Plummer (aplummer@saems.com).

For any information not obtained, please list “N/A” in that field.

Check box if NO usage reported for the quarter.

NO USAGE

Agency Affiliation Number *

Date of Administration

Agency PCR Identifier

Weight of Patient (kg)

Reason for Intubation

Was Medical Command contacted prior to administration?

What Facility Provided Medical Command?

Who was the Medical Command Physician that provided Medical Command?

Medication used

Dose Requested (mg)

Dose Ordered (mg)

Dose Administered (mg)

Total intubation attempts before medication

Total intubation attempts after medication

Was intubation successful?

Was alternative airway used after medication administration?

Was repeat does needed?

Medication Administered?

Repeat Dose (mg)

Two ALS practitioners (Paramedic or above) on scene at time of medication administration?

Was ETT placement confirmed with EtCO2?

Heart Rate pre-intubation (if not recorded, type 'n/a')

Confirmation of airway placement via auscultation.

Complications after medication administration

Suspected Aspiration

Traumatic Intubation

Hypoxia

Myoclonus

Hypotension

Cardiac Arrest

Bradycardia

Esophageal Intubation

None

Destination Facility

Patient Care Report

Additional Comments

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