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Log-in Information
E-mail: City: State:
Site Information

Organization:

Phone:
Operator's Name: Date of Insertion: / / (MM/DD/YYYY)
Time of Call/Patient Arrival: Operator:
Name of Facility Patient Transported to or Treated at:    
Patient Information
Approximate age of Patient: yrs. Sex of Patient: Height of Patient:
Approximate GCS: Classification: Weight of Patient:
EZ-IO® Information
Number of EZ-IO® 15mm (PD) (less than 40 Kilos) attempts:
Number of EZ-IO® 25mm (AD) (40 Kilos or greater) attempts:
Number of EZ-IO® 45mm (LD) (Excessive Tissue) attempts: 		 

Number of EZ-IO® 15mm (PD) (less than 40 Kilos) insertions:
Number of EZ-IO® 25mm (AD) (40 Kilos or greater) insertions:
Number of EZ-IO® 45mm (LD) (Excessive Tissues) insertions:

 
EZ-IO® Insertion Site:

Other:

EZ-IO® Placed:  
How did you confirm placement? (Check all that apply):
Firmly in place Blood at tip of stylet
Able to Aspirate Marrow Physiologic response to medications
Able to inject fluids and/or drugs X-ray or ultrasound confirmation
More than one EZ-IO® placed in same patient:
Did the Patient complain of pain during insertion? (0=no pain, 10=severe pain):
Time of insertion (seconds) (choose best answer)

Medications/Fluids given: (Check all that apply)

Cardiac Paralytic NS/LR  
Sedative Glucose

Other:

Did the Patient complain of pain with infusion? (0=no pain, 10=severe pain):
Did Lidocaine decrease the pain of infusion?
Did the Patient receive a Syringe Bolus or Flush immdediately following inserion?
If you applied pressure for a continuous infusion please indicate the source
What size drip set did you use?
What was the estimated flow rate in qtts/min? qtt/min
Return of spontaneous circulation (ROSC)?
Describe your experience with the EZ-IO® (1 = easy, 5 = Hard):
Did you feel you had control over the placement of the needle tip:
Did the needle separate easily from the driver:
Was the stylet easy to remove from the needle set:
Complications:
Did the EZ-IO® compromise the Patient or user’s safety?
Do you need to speak with a Vidacare representative immediately? If yes, call 1-800-680-4911.
Comments or suggestions: (We appreciate your comments, good or bad! All reports are taken seriously and the information is used to improve the EZ-IO® and its training. Thank You.)