Rapid Sequence Intubation Checklist
- Oxygen. Pre-oxygenate with NRB/+/- OPA or OPA/BVM or LMA/BVM at 15 lpm x 4 minutes
- Positioning – sniffing position, ideally head up 30 degrees
- Decide on RSI meds below (16, 17, 18) – ask RN to draw up.
- Have RN draw up post intubation vent sedation (Fentanyl or Morphine)
- Have someone get the ventilator, plug in and attach to wall Oxygen.
- Designate someone to watch monitor. Announce if Sats < 93% or MAP < 65 mmHg.
- Have someone (or yourself) draw up Push dose pressor of choice (Epi or Phenylephrine)
- Check for dentures – in for bag mask, out for intubation.
- Attach in line EtCO2 monitor to BVM
- Check neck for potential cricothyrotomy, have cric kit available.
- Have OPA, NPA and LMA available in proper size if not already in use.
- Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie handy.
- +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip
- Choice of laryngoscope. Blade size. Check bulb working. Have spare laryngoscope handy.
- Suction – turn on, place handle under right shoulder of patient or under pillow.
Normotensive, neurologically stable patient:
16. Pretreatment agent? – Fentanyl 3 mcg/kg
17. Induction agents – Ketamine2mg/kg or Propofol1.5 – 3 mg/kg(or Midazolam 0.3 mg/kg TBW)
18. Neuromuscular blocking agents – Succinylcholine2 mg/kgor Rocuronium 1.2 mg/kg
16. Consider Scopolamine 0.4 mg IV
17. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg
18. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kg
Elevated ICP/Traumatic head injury patient
16. Have Labetalol 20-25 mg IV on hand for elevated systolic pressure.
17. Induction agents – Ketamine2 mg/kg
18. Neuromuscular blocking agents – Succinylcholine2 mg/kg
16. If time permits can give Lidocaine1.5 mg/kg 3 minutes prior
17. Induction agents – Ketamine2 mg/kg
18. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg
- Ask the team “anything we have missed, any concerns…?”
- Give Drugs - announce to team "PARALYTICS IN"
- Cricoid Pressure if needed – BURP
- Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon. Secure tube.
- Confirm – listen to chest, check EtCO2 (or colorimetric after 8 breaths)
- Order CXR to confirm ETT depth
- Post intubation medications – Fentanyl or morphine infusion. +/- sedation
- Place NG tube, in line suction
- Head of bed up 30-45 degrees.
- Foley catheter.
- Ventilator settings.
Mode: AC FiO2: 100%
RR 10-14 bpm for Normotensive or Hypotensive.
14 - 18 bpm for ICP
6 - 10 bpm for Asthmatic (or match RR to Pt’s pre intub RR)
Tidal Volume8 cc/kg IBW for all patients (except pneumonia, may be less: 6-8)
PEEP 5 or as needed for all except asthmatics. 0 for asthmatics initially.
Give bronchodilators continuously for asthmatics.
30. ABG within 30 minutes post intubation.
Push Dose Epinephrine Mixing:
Take a 10 cc N/S syringe. Discard 1 cc.
Take a preloaded syringe of Epi 1:10,000 from the cardiac drawer.
Take the bottom stopper off the syringe.
With the 9 cc Saline syringe, draw out 1 cc Epi (1:10,000)
You now have 10 mls of Epinephrine 10 mcg/ml
Dose is 0.5 – 2 ml (5-20 mcg) q 2-5 min
Onset 1 minute, duration 2-5 minutes.
Push Dose Phenylephrine Mixing:
With a 5 ml syringe, draw 1 ml of 10 mg/ml (1 vial) Phenylephrine.
Mix it in 100 cc minibag of normal saline
Draw out 3 – 5 cc of solution.
This is now Phenylephrine of 100 mcg/ml
Put labels on both the minibag and the syringe
Dose is 50 – 100 mcg/min ie give 0.5 – 1 ml q 2-5 minutes.
Action is within 1 minutes and lasts for 10-20 min.
Post Intubation Sedation
Start with 25 mcg bolus and 25 mcg/hr. If still pain then give 25 mcg bolus over 3-5 minutes and increase infusion by 25 mcg/hr.
Maintenance dose is usually in the 25 – 150 mcg/hr
Start with 0.8 mg/hr.
If still pain, may give 2 mg morphine over 4-5 minutes and increase infusion by 2 mg/hr.
Maximum dose is 150 mg/hr.
All of the above intubation protocols must also be viewed in a wider context of the resuscitation. Although much of what you as team leader are doing is getting and checking equipment, there are other actions that need to be done concurrently including:
- If the patient is being actively ventilated by BVM, ensure they are being ventilated at a rate of ~ 10-12 per minute, with appropriate compression of the bag to deliver 6-8 cc.kg IBW. Have they an OPA or NPA?
- Ensure patient is hooked up to monitor (or better yet to Lifepac) with Oxygen saturations, heart rhythm, EtCO2.
- Ensure the other aspects of the resuscitation are occurring, such as IV fluids being administered in appropriate amounts, blood products being ordered if appropriate, maintaining patient ‘normothermia’ (i.e. cover patient with blankets),
- Ask x-ray to be on hand for post intubation CXR.
- Inform lab that ABG’s will be coming.
- Before the actual intubation, if time permits, do a ‘group check’. Ask if anyone thinks something has been omitted, forgotten, needs changes etc.