DA Form 7595-2-10 "Perform a Surgical Cricothyroidotomy"

What Is DA Form 7595-2-10?

This is a military form that was released by the U.S. Department of the Army (DA) on May 1, 2014. The form, often mistakenly referred to as the DD Form 7595-2-10, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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Download DA Form 7595-2-10 "Perform a Surgical Cricothyroidotomy"

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PERFORM A SURGICAL CRICOTHYROIDOTOMY
For use of this form see TC 8-800; the proponent agency is TRADOC.
II
TABLE:
STP 8-68W13-SM-TG, Task: 081-833-3005, Perform a Surgical Cricothyroidotomy
REFERENCE:
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and Development.
AUTHORITY:
S
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT certification
IAW AR 40-68, AR 220-1 and AR 350-1.
ROUTINE USES:
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of the
Army's compilation of system of records notices may apply to this system.
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error in
DISCLOSURE:
processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
During a night patrol, your infantry squad receives incoming mortar fire. As the squad dives for cover, you notice one of the Soldiers receives a massive
facial wound from flying shrapnel. Once the area has been secured, you move forward to assess the patient. The patient has an altered level of
consciousness and is not breathing. You must perform an emergency surgical cricothyroidotomy to establish an airway and support ventilations.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Took body substance isolation precautions.
b. Identified the cricothyroid membrane between the cricoid and thyroid cartilages.
c. Cleaned the site with alcohol.
d. Stabilized the larynx with nondominant hand.
e. Made a 1 ½ inch vertical incision through the skin over the cricothyroid membrane.
f. Maintained the opening of the skin incision by pulling the skin taut with fingers of the nondominant hand.
g. Inserted the end of the endotracheal tube into the trachea and directed it towards the lungs ¼ inch beyond
the cuff.
h. Inflated the cuff with 10 ml of air.
i. Assessed patient for spontaneous respirations (must count for 10 seconds).
j. Applied pulse oximeter to patient, if available.
k. Auscultated lung fields and watched for rise and fall of the chest, to confirm tube placement.
l. Applied a dressing around the tube.
m. Secured the device to the patient around the patient’s neck.
n. Documented treatment on DD Form 1380 [Tactical Combat Casualty Care (TCCC) Card].
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc.
(NREMT)
, skill sheets ©2011, this form has neither been prepared nor approved by NREMT. Use is
restricted to guidelines contained in the Preface to TC 8-800.
Page 1 of 2
DA FORM 7595-2-10, MAY 2014
Supersedes DA Form 7595-9-R, MAY 2009
APD LC v1.00
PERFORM A SURGICAL CRICOTHYROIDOTOMY
For use of this form see TC 8-800; the proponent agency is TRADOC.
II
TABLE:
STP 8-68W13-SM-TG, Task: 081-833-3005, Perform a Surgical Cricothyroidotomy
REFERENCE:
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and Development.
AUTHORITY:
S
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT certification
IAW AR 40-68, AR 220-1 and AR 350-1.
ROUTINE USES:
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of the
Army's compilation of system of records notices may apply to this system.
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error in
DISCLOSURE:
processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
During a night patrol, your infantry squad receives incoming mortar fire. As the squad dives for cover, you notice one of the Soldiers receives a massive
facial wound from flying shrapnel. Once the area has been secured, you move forward to assess the patient. The patient has an altered level of
consciousness and is not breathing. You must perform an emergency surgical cricothyroidotomy to establish an airway and support ventilations.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Took body substance isolation precautions.
b. Identified the cricothyroid membrane between the cricoid and thyroid cartilages.
c. Cleaned the site with alcohol.
d. Stabilized the larynx with nondominant hand.
e. Made a 1 ½ inch vertical incision through the skin over the cricothyroid membrane.
f. Maintained the opening of the skin incision by pulling the skin taut with fingers of the nondominant hand.
g. Inserted the end of the endotracheal tube into the trachea and directed it towards the lungs ¼ inch beyond
the cuff.
h. Inflated the cuff with 10 ml of air.
i. Assessed patient for spontaneous respirations (must count for 10 seconds).
j. Applied pulse oximeter to patient, if available.
k. Auscultated lung fields and watched for rise and fall of the chest, to confirm tube placement.
l. Applied a dressing around the tube.
m. Secured the device to the patient around the patient’s neck.
n. Documented treatment on DD Form 1380 [Tactical Combat Casualty Care (TCCC) Card].
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc.
(NREMT)
, skill sheets ©2011, this form has neither been prepared nor approved by NREMT. Use is
restricted to guidelines contained in the Preface to TC 8-800.
Page 1 of 2
DA FORM 7595-2-10, MAY 2014
Supersedes DA Form 7595-9-R, MAY 2009
APD LC v1.00
PERFORM A SURGICAL CRICOTHYROIDOTOMY
GRADING SHEET (cont'd)
8. Start Time
9. Stop Time
10. Retest Evaluator
12. Stop Time
13. Final Evaluator
11. Start Time
14. Evaluator's Comments
Page 2 of 2
DA FORM 7595-2-10, MAY 2014
Supersedes DA Form 7595-9-R, MAY 2009
APD LC v1.00
Page of 2