| Patient Name: MRN: | Date: |
| Age: M F Weight: kg BMI: | Procedure: |
| Parameter | Finding |
|---|---|
| Mouth Opening | ≥3cm <3cm: cm Trismus |
| Mallampati Class | I II III IV |
| Thyromental Distance | ≥6.5cm (Normal) 6-6.5cm <6cm (Difficult) |
| Neck Mobility | Full Reduced Fixed/C-Spine |
| Upper Lip Bite Test | Class I Class II Class III |
| Neck Anatomy | Normal Short/Bull Neck Thick (>43cm): cm |
| Dentition | Good Poor Edentulous Loose Buck teeth |
| Facial Features | Normal Beard Micrognathia Facial Trauma |
| MOANS Score (Difficult Mask Ventilation) | |
|---|---|
|
M - Mask Seal (Beard/Trauma) O - Obesity/Obstruction A - Age >55 |
N - No Teeth (Edentulous) S - Snores/Stiff Lungs Total Score: / 5 |
| LEMON Score (Difficult Intubation) | |
|---|---|
|
L - Look Externally (Trauma, large tongue) E - Evaluate 3-3-2 Rule Fails M - Mallampati III or IV O - Obstruction (Tumor, abscess) N - Neck Mobility Limited |
|
|
Previous Difficult Airway Head/Neck Radiation Burns/Scarring Ankylosing Spondylitis OSA (STOP-BANG: /8) Morbid Obesity (BMI>40) Airway Tumor/Mass Tracheostomy Present Full Stomach/Aspiration Risk Pregnancy |
|
PLAN A - Primary Approach: Direct Laryngoscopy Video Laryngoscopy Awake Fiberoptic Intubation LMA/i-gel |
|
PLAN B - Backup (If Plan A fails): Video Laryngoscopy Bougie/Stylet Change Blade/Operator Rescue LMA |
|
PLAN C - Cannot Intubate (Oxygenate): Insert LMA/i-gel 2-person Mask Wake Patient Call for Help |
|
PLAN D - CICO (Cannot Intubate, Cannot Oxygenate): EMERGENCY FRONT OF NECK ACCESS (FONA) Scalpel Cricothyroidotomy |
|
Difficult Airway Cart Ready Video Laryngoscope Tested Fiberoptic Scope Available Bougie/Stylet/LMA (3,4,5) |
Cricothyroidotomy Kit 2nd Anesthesiologist ENT Backup Called Difficult Airway Team |
|
Positioning Strategy: Ramped Position (Obese) Sniffing Position (Standard) Head-Up 25-30° (Anti-aspiration) |
Pre-oxygenation Protocol: 100% O₂ x min Target SpO₂ >95% Apneic Oxygenation (NC 15L/min) |
|
Anesthesia Technique: Rapid Sequence Intubation (RSI) Modified RSI (Gentle ventilation) Maintain Spontaneous Ventilation Awake Intubation (Topicalized) Avoid Paralytics until airway secured |
|
|
Cormack-Lehane Grade: Grade I (Full glottis) Grade II (Partial view) Grade III (Epiglottis only) Grade IV (No view) Total Attempts: |
Successful Technique: Complications: None Dental Trauma Bleeding Desaturation (SpO₂ <90%) Airway Edema |
Post-Procedure Actions: Difficult Airway Alert added to chart Patient Informed Patient Letter Given MedicAlert Recommended Database Entry Made Primary Care Physician Notified |
Professional Statement: I have performed a comprehensive airway assessment on this patient. A difficult airway plan has been formulated following ASA guidelines and has been discussed with the anesthesia care team. All necessary equipment has been verified as ready and functional. The patient (or legal surrogate) has been informed of the airway risks, alternative approaches, and the management plan.
| Anesthesiologist Signature | Printed Name & Medical License # | Date & Time |