EquipmentTable

BVM (± PEEP Valve) on OxygenWaveform Capnograph on BVM & Tested

Video LaryngoscopeIntubation Equipment

(Tube, 2xBend Stylet, 2 Syringes, Back-Up Laryngoscope, OPA, Tube-Securing Device)

Failed Airway Equipment at Bedside(At minimum: Bougie, SGA, Scalpel)

Suction x 2

Patient PrepDenitrogenation

Oxygenated (Consider CPAP)Look in Mouth · Dentures

Positioning(Face Parallel, Ears/Notch, 30° Head-Up, Collar Plan)

Monitors (Pulse Ox Visible)Reliable Access

Nasal Prongs for ApOx± Gastric Tube

PlanHOp Killers-Hemodynamics, Ox, pH

RSI · Awake · DSI · RSA · ICP/VascularInduction Agent/Muscle Relaxant

Push-Dose PressorsFailed Airway Plan Verbalized

Cric-Con Evaluation (± Mark/Inject)Post-Intubation Sedation

EMCrit Call/Response Intubation Checklist

TeamRoles Assigned for Each Stage of Failed Airway Plan

Pulse Ox Watcher/Reoxygenation Role AssignedELM/Head Elev. Assistant Briefed

Team is all in PPEby Weingart S, Nickson C, Rabinovich J, Strayer R.version 2013-02-06

Awake Intubationo Glycopyrrolate 0.2 mg IV & Ondansetron 4mg IV (give as early as possible)

o Suction mouth and then pad dry with gauzeo Nebulized Lidocaine 4% 5ml @ 6 lpmo Atomized Lidocaine 4% 3ml sprayed into posterior oropharynxo Viscous Lidocaine lollipop 2%, place on tongue depressoro Preoxygenateo Positiono Restrain armso Switch to nasal cannula at 15 lpmo Sedate with aliquots of Ketamine (10-20 mg) or 1-2 ml Ketamine-

Heavy Ketofol (75 mg Ketamine, 25 mg propofol in the same syringe)o Atomized Lidocaine 4% 3ml sprayed through cordso Intubate awake or place bougie, then sedate/paralyze

Initial Post-Intubation Analgo-Sedation

o Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hror

o Hydromorphone 0.5-1 mg bolus then repeat q 10 minutes until analgesia

and

o Midazolam 0.05 mg/kg bolus then 0.025 mg/kg/hror

o Propofol 0.5 mg/kg bolus then 20 mcg/kg/minor

o Ketamine 1 mg/kg bolus then 0.5 mg/kg/hrTitrate to calm, spontaneously-breathing patient

Push-Dose Epio In a 10 ml syringe, add 9 ml NSo Into this syringe draw up 1 ml of

Cardiac-Arrest (1:10000) Epinephrineo Shake Syringe Hardo Label “Epinephrine 10 mcg/ml”o Dose 0.5-2 ml (5-20 mcg) q 1-5 mino Throw away at end of shift if unusedIntubation Meds

Drug Normotensive DoseNormotensive Dose

(70 kg Pt)Hypotensive Dose

Ketamine 2 mg/kg 140 mg 0.5 mg/kgKetofol (100 mg ketamine,100 mg propofol to make 20 ml) 0.2 ml/kg 14 ml

Etomidate 0.3 mg/kg 20 mg 10 mg

Propofol 1.5-3 mg/kg 150 mg 15 mg

Succinylcholine 1.5-2 mg/kg 140 mg 2 mg/kg

Rocuronium 1.2 mg/kg 80 mg 1.6 mg/kg

Vecuronium 0.3 mg/kg 20 mg

Pretreatment3-5 minutes prior to intubationo Lidocaine 1.5 mg/kg for High-ICP/Vascular with elevated BPo Fentanyl 3 mcg/kg for High-ICP/Vascular with elevated BP

(alternatively Remifentanil 3 mcg/kg)o Scopolamine 0.4 mg for amnesia in hypotensive pt intubation

Sux Contrao Malignant Hyperthermia Historyo Strokes with hemiparesis > 72 hours oldo ICU Stay > 2 weekso Burns/trauma > 72 hours oldo NMJ Diseaseo Myopathies/Muscular Dystrophieso Preexisting Hyperkalemia or Strong

suspicono Guillain-Barre

o Females: 3.5, 7.5 ET Max, inflate 4 ml, 18 cm to tipo Males: 4.5, 8.5 ET Max, inflate 5 ml, 20 cm to tip

Initial Vento Assist Control/Volume Modeo Vt 8 ml/kg IBWo RR 16 (10 in asthma/copd)o IFR 60 l/mino PEEP 5 (0 in asthma/copd)o FiO2 40%

Low pH Tubeo Place on Vent (SIMV-Volume, Vt 550, FiO2

100%, IFR 30 lpm, PS 10, PEEP 5, RR 0)o Place on ETCO2o RSA or Vent as Bag (Change RR to 16)o Change Vent to (IFR 60 lpm, RR 30, VT

8 ml/kg, FiO2 40%)o Confirm same ETCO2 and send ABG

AirQs

Fold and use only this side during Checklist Procedure

Cric-Cono All Airways: Discuss/Feel/See Kit (5)o Diff. but Stable: Mark/Kit to Bedside/US (4)o Diff. & Hypoxemic: Inject / Prep / Open Kit /

Scalpel in Hand (3)

InfoGo to

emcrit.org/airway

This checklist is for informational purposes only. ALL information must be vetted with your clinical judgment, pharmacy, and hospital committees/regulations.

Do

you

have

a ta

ble?

All e

quip

men

t mus

t be

on a

pro

cedu

re ta

ble,

not

on

the

bed

or o

n th

e pa

tient

.

Is th

ere

a BV

M h

ooke

d up

to o

xyge

n se

t to

max

imal

flow

?Is

ther

e a

PEEP

val

ve if

satu

ratio

n on

hig

h-fiO

2is

<95%

?

Is w

avef

orm

cap

nogr

aph

prep

ared

?Te

sted

by

blow

ing

and

hook

itup

to T

he B

VM. Q

ualit

ativ

e Sh

ould

be

with

in e

yesig

ht (L

eave

itin

Its p

acka

ge)

Is th

e vi

deo

lary

ngos

cope

set u

p?Al

l int

ubat

ions

shou

ld b

e pe

rfor

med

with

a v

ideo

dev

ice

if CM

AC(d

ecid

e if

resid

ent w

ants

to lo

ok a

t scr

een)

, oth

erw

ise sh

ould

be

pres

ent a

t bed

side

Is in

tuba

tion

equi

pmen

t pre

pare

d an

d re

ady?

Two

func

tiona

l lar

yngo

scop

es—

sized

and

che

cked

, pro

perly

size

d or

al a

irway

, ETT

tube

with

styl

et b

ent a

t bot

h en

ds in

hoc

key

stic

k co

nfig

urat

ion,

with

syrin

ge

atta

ched

—ba

lloon

che

cked

, 2nd

tube

in p

acka

ge w

ithin

eye

sight

, Ext

ra 1

0 m

l syr

inge

, Tub

e-Se

curin

g De

vice

Is fa

iled

airw

ay e

quip

men

t pre

pare

d an

d re

ady?

All e

quip

men

t nec

essa

ry to

effe

ct th

e fa

iled

airw

aypl

an m

ust b

e at

the

beds

ide.

Usu

ally

this

cons

ists o

f 2 N

PAs,

a b

ougi

e, a

n ap

prop

riate

size

d Ai

rQ IL

A, su

rgilu

be

and

a sc

alpe

l all

still

in th

eir p

acka

ges.

Is th

e su

ctio

n eq

uipm

ent p

repa

red?

2 su

ctio

ns tu

rned

on,

one

at i

ntub

ator

’s ri

ght h

and-

-List

en to

eac

h. P

ull o

n tu

bing

to m

ake

sure

it is

att

ache

d to

the

off-c

ente

red

atta

chm

ent.

Ask

intu

bato

r to

verb

aliz

e th

at if

suct

ion

is ne

eded

, the

y w

ill n

eed

to p

ut th

eir f

inge

r ove

r the

hol

e

Hav

e w

e de

nitr

ogen

ated

?8

brea

ths o

n m

axim

al fl

ow N

RB o

r 3 m

inut

es o

f tid

al v

olum

e br

eath

ing.

Do n

ot re

mov

e th

e N

RB/M

ask

until

pt i

s apn

eic

Hav

e w

e pr

eoxy

gena

ted?

Sat ≥

95%

on

NRB

or s

witc

h to

CPA

P Pr

eox.

Sho

uld

achi

eve

a sa

tura

tion

of ≥

95%

or y

ou m

ax o

ut o

n PE

EP 1

5 cm

/H20

Mon

itors

? Is th

e pa

tient

hoo

ked

upto

BP

set t

o cy

cle

q1 m

inut

e, E

KG, a

nd a

pul

se o

x vi

sible

to re

sus l

eade

r & in

tuba

tor o

r a p

ulse

ox

wat

cher

ass

igne

d?

Is th

e pa

tient

pos

ition

ed a

dequ

atel

y?Ea

r to

ster

nal n

otch

and

face

pla

ne p

aral

lel t

o ce

iling

unl

ess s

pina

l pre

caut

ions

If sp

inal

pre

caut

ions

, hav

e pl

an fo

r col

lar r

emov

al a

nd in

line

stab

iliza

tion

Is th

e he

ad o

f bed

at 3

0° o

r in

Reve

rse-

Tren

dele

nber

g?

Is th

ere

relia

ble

acce

ss?

At le

ast o

ne, p

refe

rabl

y tw

o. If

ther

e is

any

doub

t, pl

ace

IO

Is th

e pa

tient

pre

pare

d fo

r ApO

x (N

oDES

AT)?

Is a

nas

al c

annu

la o

n th

e pa

tient

for a

pnei

c ox

ygen

atio

n?

Is a

pla

n ve

rbal

ized

for w

ho w

ill re

mov

eth

e pa

tient

’s N

RB fr

om O

2po

rt a

nd sw

itch

to N

C@

15 lp

maf

ter m

eds a

re p

ushe

dor

is N

C on

a se

para

te o

xyge

n cy

linde

r?

Wou

ld th

e pa

tient

ben

efit

from

pre

-intu

batio

n N

GT?

RSI o

r Aw

ake?

· DSI

?· R

SA?

· ICP

/Vas

cula

r?Co

nsid

er p

erfo

rmin

g aw

ake

intu

batio

n in

pat

ient

s pre

dict

ed to

be

diffi

cult

airw

ay/r

eoxy

gena

tion

and

will

allo

w 5

-10

min

utes

pre

para

tory

tim

e

Cons

ider

Del

ayed

Seq

uenc

e In

tuba

tion

in p

atie

nts n

ot to

lera

ting

preo

xyge

natio

n/de

nitr

ogen

atio

n/pr

epar

ator

y po

sitio

ning

or p

roce

dure

s

Cons

ider

Rap

id S

eque

nce

Airw

ay (I

nduc

e pa

tient

and

imm

ed. p

lace

SG

A) in

pat

ient

s who

will

nee

d to

be

bagg

ed d

urin

g ap

neic

per

iod

Cons

ider

an

ICP/

Vasc

ular

intu

batio

n in

nor

mot

ensiv

e/hy

pert

ensiv

e pa

tient

s at r

isk fr

om a

n in

crea

se in

sym

path

etic

tone

/MAP

Are

the

peri-

intu

batio

n m

edic

atio

ns re

ady?

Full

poss

ible

dos

eof

indu

ctio

nag

ent w

ith d

ose/

ml l

abel

ing

Full

poss

ible

dos

eof

mus

cle

rela

xant

with

dos

e/m

l lab

elin

g

If pt

has

pot

entia

l for

BP

decr

ease

, pus

h-do

se p

ress

ors s

houl

d be

dra

wn

up a

nd a

t bed

side

in a

syrin

ge m

arke

d w

ith d

ose/

ml l

abel

ing

Wha

t is t

he p

lan

for u

nexp

ecte

d di

ffic

ult o

r fai

led

airw

ay?

The

team

mus

t ver

baliz

e th

e en

tire

prog

ress

ion

of th

e fa

iled

airw

ay p

lan

incl

udin

g w

ho w

ill p

erfo

rm e

ach

step

Wou

ld th

is pa

tient

ben

efit

from

the

pres

ence

of a

2nd

ED A

tten

ding

or a

con

sulta

nt?

Can

the

cric

othy

roid

mem

bran

e be

pal

pate

d?Co

nsid

er m

arki

ng, c

onsid

er u

ltras

ound

-gui

ded

mar

king

, con

sider

pre

-intu

batio

n pr

ep w

ith li

doca

ine

2% w

ith e

pine

phrin

e

Wha

t is

the

plan

for p

ost-

intu

batio

n se

datio

n?A

plan

for a

n an

alge

sic

and

a se

dativ

e sh

ould

be

verb

aliz

ed a

nd p

repa

ratio

n sh

ould

star

t dur

ing

the

intu

batio

n pr

epar

atio

ns if

ther

e ar

e av

aila

ble

pers

onne

l

Eq

uip

men

t

Pati

en

t

Pla

n

Print the next 2 pages on both sides of 1 sheet of paperFold at the dotted line

Use only the above the fold portion in the peri-intubationThe 2nd page includes explanations of the checklist for students, residents, and when training with the checklist

Below the fold are some reference itemsSend me comments and ideas for improvement

Thanks,Scott