Roles
INTUBATION CHECKLIST
Adapted from Greater Sydney Area-HEMS checklist v2016-01-30
Monitor Lifeguard or Assistant reads
Intubator checks and responds
Situation briefed
Resuscitation maximized
Roles assigned
Check
Check
Check
P.P.E.
Position optimized
Oxygen sufficient, maximized and preoxygenated
Mask O2 at 15 liters, Nasal O2 at 15 liters
Suction tested
Two I.V.’s working
Monitors visible: Sat Cardiac BP
B.P. cuff cycling, opposite arm
Drugs ready: Induction + Paralytic?
Fluids + or - Pressors?
Post analgesia / sedation?
Monitor lifeguard
Drug pusher
Documenter
Airway assistant
C-spine stabilizer
Intubator
SET-UP
Check
Check
Check
Check
Check
IV/MONITORS/DRUGS
Check
Check
Check
Check
Check
Check
B.V.M., PEEP, End-tidal CO2
O.P.A., N.P.A.
Laryngoscope tested
Endotracheal tube and Syringe
Cuff tested and lubed
Extra tube, Tube tie
Stylet and Bougie
Supraglottic airway and Cric kit
EQUIPMENT
Check
Check
Check
Check
Check
Check
Check
Check
C-spine assistant briefed
Risks discussed
Fail plan briefed
E.L.M. & bougie plan briefed
Desat trigger and plan briefed
TEAM BRIEF
Check
Check
Check
Check
Check
Any other questions and concerns?
CHECKS COMPLETE – ANESTHETIZING AT _ _ : _ _
Yen Chow @TBayEDguy 2016-02-07
Succinylcholine contraindications
Malignant
Organophosphates
NEVERhyperthermia
USE (K+ release+++)
PROLONGED
DURATION
Hyperkalemia
(known or concern), Crush injury
Pseudocholinesterase
def
Malignant hyperthermia
Organophosphate
tox
Myopathies/Muscular
dystrophies
Myasthenia
gravis(?)
Hyperkalemia, Crush injury
Eaton-Lambert Syndrome*
Amyotrophic
Lateral Sclerosis,
Myopathy, Muscular
dystrophyMultiple Sclerosis
Pseudocholinesterase def,
Guillain-Barre,
Botulism,
Tetanus
Amyotrophic Lateral Sclerosis, Multiple Sclerosis
Hypothyroidism
Burns
≥ 2nd degree
over 10%
BSA >5 days until healed
Guillain-Barre,
Botulism,
Tetanus
Stroke
Spinal
6 months
GIVE
MOREpost injury
Burnswith
≥ 2ndhemiparesis,
º >10% BSA >5
dayscord
untilinjury
healed>5 days until
Severe
intra-abdominal
sepsis
>5
days
until
resolution
Myasthenia Gravis** (lasts long tho)
Stroke + hemiparesis, Spinal cord injury >5 days
until 6 months post injury
NO PROBLEM
Severe intra-abdominal sepsis >5 days until
Parkinson’s Disease
resolution
Epilepsy
Acute CVA or spinal cord injury
*Sensitive to BOTH depolarizing and non-depolarizing neuromuscular blockers
**Resistant to succinylcholine; BUT avoid non-depolarizing, response unpredictable, use ½ dose
BRIEFING
Situation
What’s going on
Task
What we need to do
Intent
The reason is
Concerns
Watch out for
Calibrate
Other thoughts/ideas?
Intubation drugs
kg
lbs
40
88
50
110
60
132
70
154
80
176
90
198
100
220
110
242
120
264
130
286
140
308
150 kg
330 lbs
80
160
20
20
40
100
200
25
25
50
120
240
30
30
60
140
280
35
35
70
160
320
40
40
80
180
360
45
45
90
200
400
50
50
100
220
440
55
55
110
240
480
60
60
120
260
520
65
65
130
280
560
70
70
140
300
600
75
75
150
12
6
15
7.5
18
9
21
10.5
24
12
27
13.5
30
15
33
16.5
36
18
39
19.5
42
21
60
6
24
240
75
7.5
30
300
90
9
36
360
105
10.5
42
420
120
12
48
480
135
13.5
54
540
150
15
60
600
165
16.5
66
660
180
18
72
720
195
19.5
78
780
210
21
84
840
225
22.5
90
900
60
160
80
75
200
100
90
240
120
105
280
140
120
320
160
135
360
180
150
400
200
165
440
220
180
480
240
195
520
260
210
560
280
225 mg
600 mg
300 mg
48
64
40
80
40
2
8
1
8
60
80
50
100
50
2.5
10
1.25
10
72
96
60
120
60
3
12
1.5
12
84
112
70
140
70
3.5
14
1.75
14
96
128
80
160
80
4
16
2
16
108
144
90
180
90
4.5
18
2.25
18
120
160
100
200
100
5
20
2.5
20
132
176
110
220
110
5.5
22
2.75
22
144
192
120
240
120
6
24
3
24
156
208
130
260
130
6.5
26
3.25
26
168
224
140
280
140
7
28
3.5
28
180
240
150
300
150
7.5
30
3.75
30
Ketamine (IBW)
IV 2 mg/kg
IM 4 mg/kg
shocky 0.5 mg/kg IV
gtts 0.5 mg/kg/h
to 1.0 mg/kg/h
mg
mg
mg
mg/h
mg/h
Etomidate (TBW)
IV 0.3 mg/kg
shocky 0.15 mg/kg IV
45 mg
22.5 mg
Propofol (LBW vs TBW)
LBW IV 1.5 mg/kg
shocky 0.15 mg/kg IV
TBW gtts 0.6 mg/kg/h
to 6 mg/kg/h
mg
mg
mg/h
mg/h
Succinylcholine (TBW)
IV 1.5 mg/kg
IM 4 mg/kg
shocky 2 mg/kg IV
Rocuronium (IBW)
IV 1.2 mg/kg
shocky 1.6 mg/kg IV
Fentanyl
IV
1 mcg/kg
2 mcg/kg
gtts 1 mcg/kg/h
Midazolam
0 .05 mg/kg
IV/IM 0.2 mg/kg
gtts 0.025 mg/kg/h
to 0.2 mg/kg/h
Yen Chow @TBayEDguy 2016-02-07
mg
mg
mcg
mcg
mcg/h
mg
mg
mg/h
mg/h
POST-INTUBATION
Reassess ABCD vitals
ETT secured
Tube depth, ETCO2 waveform, Cuff pressure
In-line suction ready
Analgesia/Sedation
Supplies (oxygen, drugs, power)
Ventilator settings
Head of Bed raised 30 degrees
Gastric tube & Foley prn
Secure all lines and tubes
Rescue airway equipment nearby
Post debriefing
What was planned?
List objectives and expected actions
What actually happened?
Review any actions not standard operating procedure
Review any safety concerns
Why did it happen?
Reasons for ineffective or unsafe performance
What can we do next time?
Identify effective and ineffecrive performance
Determine how to apply the lessons leared to the next time
Yen Chow @TBayEDguy 2016-02-07
Check
Check
Check
Check
Check
Check
Check
Check
Check
Check
Check
12 (3x4) Step Response to desaturation
BVM
PEEP 15
Mask 15 LPM Nasal 15 LPM
Upright lungs,
Clear FB
OAW
Jaw thrust
position head
fluids
and neck
Coordinated
slow small
Pulse ox lag?
Two person
Mask seal
squeeze
Shock?
underhand
Sex (6) Steps to BVM (adapted from Jason N. Cook @cptjcook “#SexyBagging”)
2 thumbs
2 person
ventilate carefully
OPA/NPA
down jaw
position
BVM
with coordination
thrust
Airways (OPA NPA)
BVM and PEEP
CO2 end-tidal and confirm (stethoscope)
Suction(s)
Laryngoscope and alternates
Oxygen (pre re and apOx)
Positioned
Endotracheal tube cuff lubed tested syringed
Stylet Bougie SGA Surgical airway
Monitors, Meds, IV, BP cuff cycling opp arm
Assistants and roles assigned, tasks briefed
ELM Bougie
Plan, approach, fails, risks
Assistants help add or maintain
•
•
•
•
•
•
•
•
Collar opening, in line stabilization
Cricoid pressure
External Laryngeal Manipulation
Bougie prepass
Head elevation
Extra laryngoscope lift
Jaw thrust
Mouth opening
Yen Chow @TBayEDguy 2016-02-07
Jaw thrust
Airways (oral / nasal)
Work together
Slow small squeeze
from Rich Levitan
@airwaycam
PEEP
Optimize each airway attempt by
Manipulations (head neck larynx device)
Adjuncts
Suction
Change size/type
Oxygenation, O2 flow, PEEP
address Tone
adapted from #Vortex @VortexApproach
Nicholas Chrimes @nicholaschrimes and Peter Fritz @pzfritz
30 second drilled responses to
encountered or anticipated difficulty
1) Release/relax cricoid
2) ELM bimanual laryngoscopy
3) Extra head elevation
4) Extra laryngoscope lift
5) Use Mac as Miller
6) Bougie
Consider
1) More jaw thrust/mouth opening
2) Check position patient/intubator
3) More/better suction
4) Change blade/device size/type Technique (e.g.
right paraglossal straight blade)
5) Change intubator (best experienced)
6) Address patient tone, cooperation, muscle
relaxation
7) Use right corner of mouth/right cheek pull
8) Straight to cuff styletting
9) Left turn at Laryngeal inLet on railroading ETT
over bougie
10) Right turn tube tip hitting tracheal Rings
Each next attempt MUST Address difficulty
encountered and Change something