Preview of the EMCrit Intubation Checklist

This post used to contain a preview of the EMCrit Intubation Checklist. I have since posted the actual episode and the revised checklist. I’m leaving this post here for the 70 excellent comments. Please go to the new post to comment further.

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Comments

  1. The additional space. What about adding a initial vent settings?

    • Not a bad idea

      • Should Vt maybe read 6 cc/kg? I know it seems like a small amount but with the literature out there supporting 6ish seems like the right thing to do. People may use this doc without significant interest or knowledge in VALI. Moreover, it seems like people always round up so 8 will turn into 8.5-9 versus 6.5-7. Just a thought.

  2. Minh Le Cong says:

    great work
    just some quick comments

    propofol 15 mg for hypotensive patient induction?
    why not eliminate it out completely?
    still got etomidate and ketamine there

    Sux still in? are you being sentimental?

    Pretreatment drugs? really?

    And stipulating video laryngoscope for all intubations? caution as they are not all the same!

    brilliant work from smart cookies

    • propfol b/x in some places that is all they have. in some places that is all they use.

      minh, despite our agreement re: rocs superiority, would you really advocate i eliminate sux from the intubation checklist?

      what is your issue with pretreatment drugs?

      As to the video laryngoscope, I was being too insitution specific, we have CMAC so ALL of our intubations are done with it, resident can look at the screen or not as they choose. have to figure out how to word that.

      • Minh Le Cong says:

        thanks Scott

        ok the propofol use is understandable if that is all you have available but not ideal. Personally I would just use fentanyl and a bit of midaz if I did not have ketamine or etomidate in the hypotensive patient.

        About sux, I think you can argue well for a case to remove it. Avoids issues of sux contraindications and bradycardia in kids. You did not mention atropine pretreatment which is traditional for kids RSI with sux.
        Roc you dont need to worry about bradycardia in kids.
        I think the only reason to use Sux is if you are planning to wake the patient up if you fail to secure airway..this does happen but I think if you really decide they need a tube then no point in waking them up.

        as for pretreatment, I dont use lidocaine IV, never used scopolamine but occasionally give some fentanyl for analgesia to help allow a patient to preoxygenate easier and feel more comfortable. RSI strictly should not involve any pretreatment drugs..the whole idea is to secure the airway as quickly as possible. I accept this concept needs to be altered for emergencies and should be made safer with all the ideas in yor checklist.
        George Kovac and colleagues expressed the issues against RSI pretreatment well in this letter to editor
        http://www.cjem-online.ca/v8/n4/p243

        and for video laryngoscopy, yes I think you need to reword that to state what device design you mean. Many will use this checklist to argue to dept managers about getting VL systems..caution about possible conflicts of interest in advocating one device or another.

        • I’m with Minh on the sux (and was surprised to see you include it). Essentially everyone I tube needs the tube, meaning that I’m going to do it, or the person to my left is going to do it (the anaesthesia attending impatiently drumming her fingers), or they’re getting a 10-blade. Good planning (e.g. Your chart) means not needing to wake someone up while you consider what you’re going to do next.

          Eliminate this from your checklist and you eliminate the box about sux contraindications and pediatric pre-treatment (for sux).

        • Gabriel, you will hear my response to Minh’s comments on his show next week. But there are cases in which SUX is absolutely necessary and they certainly aren’t cases where I am going to pretend the patient will wake up before critical hypoxemia. Also, a vast majority of the world is using sux as their muscle relaxant of choice; I am in the minority. Nothing on the sheet is for pediatrics.

        • Sean Marshall says:

          Minh and Scott,
          I have heard the argument for sux if there is a need for a neuro assessment shortly post-intubation or if paralytic is likely to be masking seizures. Do you agree with these indications? Provided that you’re not working somewhere with access to suggamedex.

          • Ding, ding, ding. That is the one. If you are intubating a stat ep patient roc is a horrible idea unless you already have EEG at the bedside. Also you could argue patients with bleeds/strokes though the neurosurg folks will just go by CT even as they yell at you for ruining their exam.

  3. Rob Bryant says:

    Under HOp killers, or in detail section of PLAN on page 2, specify checking, and then matching pre-intubation ETCO2 in setting of severe metabolic acidosis.
    This looks excellent,
    I want my ED’s to start using this immediately.

  4. Our institution only has one wall O2 outlet in most rooms (including trauma bay). As avid devotees to (most of) your advice no one gets intubated without a nasal cannulae in place. As such, I’ve been almost burned a few times by having an empty O2 tank under the bed. I always include this in my intubation checklist.

  5. Awesome work!
    My feedback: Too busy and too inclusive. My take:
    Make it into a 5 x 7 card that can be laminated. One side pure checklist. The reverse, include difficult airway assessment, pre-oxygenation pearls, pre-medications, induction meds, paralytics, sux contraindications.
    Do away with awake intubation, push dose pressor details.

    Big picture: We are in need of an EM Crit Care App with all of this great stuff at our fingertips. Who hasn’t said to themselves “damn, I wish I had Weingart in my pocket”?

    • Chris,

      the bottom of the page and the back are the busy parts and should not be used during the peri-intubation. That is what the dotted line is for. One side will be only checklist and this is easily reduced to an index card.

  6. Hey Scott very nice work. I LIKE IT! One thing though and this may be operator error, but if you print using the directions it prints the first page horizontally and the second page vertically. Just not understanding your intentions. Also, again sorry for not being computer savvy, but is there a way to shrink the images and lettering of the PDF file somewhat so I can make it a pocket guide? Or do I need the ODT file to do that? Then is there a way to make it customizable? Same format, but different details… Also did you get a chance to view my question about BP management in the ischemic stroke PT who is not a candidate for Tpa? Anyways take care and keep up the strong work!

    • That is a problem with your adobe acrobat. On the print screen there should be a rotate to fit paper size checkbox. This allows it to be visualized on screen in a readable manner but still print properly as well.

      I will release index versions after the sheet is finalized.

      Didn’t see your tPA question. Put it up on google community page: http://emcrit.org/plus

  7. Only one comment – some of the abbrevos (Aussie abbreviation for abbreviation – go figure) are not intuitive or standard and may be better to change or write out in full. For example ApOx may be better as ApO2. Also, having a question mark after every point/question just kind of increases the clutter, and given your aim is to reduce cognitive load, perhaps thse could be left out and replaced by a single large question mark on the right hand side of each box. Otherwise, looks like a great tool. Very likely to use this with slight modifications.

    • O2 means oxygen, not oxygenation, hence ApOx it is non-standard everywhere b/c I have been pushing it. Hence: preox, apox, reox all to prevent deox.

      ? marks gone.

      thanks, brother

      • Domhnall says:

        Fair point. I guess to push the concept it makes sense to push the “abbrevos” too!

  8. Len Ulan says:

    Scott, Fantastic…as usual. Can’t wait to see the finished product.
    How about Magill forceps for the occasional food bolus or dental bridge lurking by the cords?

  9. Patrick Burkhardt says:

    Are you sure you want to list ketamine under “sedatives” in the post-intubation protocol? The combination opioid-ketamine doesn´t seem to make much sense to me. Otherwise, a lot of helpful ideas, as usual. Being obsessed with a shipshape workspace, I also like that you´re stressing the point that even such a marginal business as airway management deserves a dedicated table to work from – not the patients´ chest, or whatever space is left on the stretcher.

    • Opioids are the backbone and ketamine has proven synergistic with them.

      • Patrick Burkhardt says:

        Hmm – I still don´t understand. Opioids and ketamine may be synergistic in analgesia, but that doesn´t make any of them an anxiolytic. As there is no ceiling effect in opioids, I don´t see why I would need the synergistic analgetic effect. I occasionally use ketamine with propofol or midazolam primarily in status asthmaticus or COPD, or switch the opioid for ketamine later, if there are issues with constipation/intestinal paralysis and I still need the analgesia. Some elderly patients do fine with either a sedative or an analgesic only. But I don´t see the argument for the opioid/ketamine combination outside of advanced pain therapy.

        • Initial post-intubation strategy is to eliminate all pain with an opioid. Once there ask yourself if the patient needs anything extra for anxiolysis, sedation, and amnesia. Often the answer will be no or if any, just a tiny bit. Ketamine added to the mix after optimization of a synthetic opioid will give partial or full dissociation allowing hemodynamically stable, non-aware patient.

    • Kyle Williams says:

      Working in critical care air transport, I have found Ketamine, and Ketamine-Fentanyl combinations to be invaluable for the hemodynamically unstable patient who are unable to tolerate other sedatives for initial induction and post-intubation sedation. Granted, it may not be the ideal choice past the hyper-critical phase of care, but in the transport environment, it’s a lifesaver. The dissociative and analgesic properties of Ketamine allow us to deal with the main causes of hypotension and avoid the additive hypotensive effects of benzos, higher dose opiods, and Propofol.

      Kyle Williams

  10. Paul Wheeler says:

    U smoke Long time follower!!

  11. UPDATED VERSION POSTED 2013-01-19 13:02 EST

  12. Mat Holland says:

    Nice checklist. One thing that struck me was not that sux was on there (though I am a perennial Ketamine and Roc user for the sickies), but why is etomidate still being used!!
    If we have the choice of something we think is likely to do harm, and others we are fairly sure don’t why use it!

  13. Damon Tedford says:

    I like the document and it looks like it can be readily accessed when loaded onto a smart phone. It will also be a great teaching aid. Thanks!

    I appreciate the arguments for and against sux, and I am at one of those institutions where sux is still the go to for many physicians. Interestingly, I was recently cautioned by anesthesia staff that using Roc instead of Sux in RSI would expose me to medical legal risk if the airway failed. We disagreed.

    Only one suggestion about sux contraindications, and I’m afraid I don’t have the evidence to support it: only a reference. The 4th edition of Manual of Emergency Airway Management states that you can still use Sux up to 5 days post crush or burn injury. I though it would be nice to know if there’s a larger window for the medication’s use in these situations.

    Cheers

    Damon

    • yep, the ranges are all over the map. Sydney HEMS and I both chose to go with the most conservative possibilities out there.

  14. Why is epi the only push dose pressor? I thought that you preferred phenylephrine for this purpose.

  15. Good work. My comments?

    – One size doesnt fit all, as answers above show. Ideally needs to be modifiable for end-users

    – And either as pdf or an iPad/iPhone app would work

    I appreciate that we all “want Weingart in our pocket” (but make sure you dont FOAM in your pants)…meanwhile, some pickings here under ‘theatre checklists’

    http://ki-docs.com/resources

    I’ll be mofifying to incorporate ideas from here, if no objections…

    • So far, from the above comments one size has fit all, but I will figure out a way to make the sheet easily adaptable.

      Will add your checklists to the post; I have a bunch of others as well.

      As always, use anything from EMCrit to help pts.

      Thanks, Tim

    • Kyle Williams says:

      I love my iPhone and I’m not afraid to admit that I am a tech weenie, especially when it comes to medical apps, but as many times I have tried to integrate digital apps into emergency airway management, it just doesn’t seem to work as smoothly for me as a good old fashioned paper checklist. I have pretty much gone digital with everything else that I used to carry in my scubs, so keeping one laminated checklist in my pocket is the way to go for me.

      Admittedly, I will continue the search to integrate it into my digital portfolio.

      Kyle Williams

      • I agree, Kyle. Optimal place for something like this., IMHO, is under plastic on the wall of each resus bay bed and on top of the airway cart.

  16. Sorry, was not clear – we’ve heard comments re use of sux vs roc, etomidate etc – these are the ‘one size not fitting all’ changes to which I refer

    …must be more specific, apologies.

    There was an excellent ‘checklist for checklists’ post recently – am sure everyone’s seen it…

    • The comments were an attempt to make it one-size-fits-all. I like roc so I should not include sux, but the vast majority is using sux. I rarely use etomidate, but I still need it there. I want to make this as universal and evidence-based as possible. Things like the AirQs will have to change though if people stock different LMAs, etc.

  17. This is great and I will definitely push for this to be at all intubations.

    One area I need clarification: Low pH tube
    – the first bullet point has a RR of 0.
    Is that correct?

    Thanks
    Jeff

  18. Minh Le Cong says:

    a smartphone app with a Scott Weingart voice recorded interactive checklist..yes do challenge response RSI checklist with Mr EmCrit every time..that would be gold!

    EmCrit intubation app!

    I dont think you can ever achieve one size fits all..as you point out some folks dont have AirQs, some dont have VL, some dont have ketamine nor roc. But this checklist ticks a lot of useful boxes..lol.
    about the Status epilepticus patient needing sux for RSI..thats debateable and we can discuss that at the podcast.

  19. Rob Bryant says:

    My ED Pharmacist questioned the Vecuronium dosing, ? 0.3mg/kg (20mg in 70kg patient)
    Does higher dose vecuronium give a faster onset of paralysis compared to the usual 0.08-.1mg/kg dose?

    • Minh Le Cong says:

      Rob, the high dose vec is like a poor mans Rocuronium. it works quicker butnot as quick as high dose roc. I have used it before roc became availble

      now just use roc for RSI and maintenance paralysis if needed

  20. Hey Scott,

    Nice work on this. I agree that having some nifty iphone app as a check list to flip through might be the future of this but for now awesome stuff. One thing I might mention under the
    “Patient” section is maybe put “PBW”. For the most part I think we’re pretty good at guessing the weight of the fish, but recently I got caught out in that I had a women I had to do a pretty quick assessment on, get my stuff together and get on with it. In the back of my mind I kind of thought…hmm this chick looks pretty tall. Turns out she was Marfan’s and she was also 6’7″ which didn’t immediately strike me cause she was kinda curled up a bit. But still I thought …she’s a girl and she’s skinny, Maybe 70 – 75 kg? WRONG!! Push the drugs and she didn’t go down or become paralyzed to the extent I usually would expect. Fortunately she was still easy to gently bag because obviously my first try didn’t feel right and I asked the nurse to quickly draw up more drugs. Anyways to make a story short..PBW by ardsnet calc 89kg!

    I think when we get at the extremes of body sizes we should recheck our PBW. It makes a diff with drugs, it makes a diff on your vent.

    Cheers Harold

  21. Hey Scott….working on a local version as I write, but can no longer access your version via yousendit….have you taken it off to adjust, or is it no longer accessible for some other reason? Thanks mate

  22. I want to post this in my ED but I can’t download it. The website says the number of downloads have been exceeded. You can repost the pdf please?

  23. Anand Senthi says:

    Hey Scott:
    Great checklist. Re your post intubation Analgo-sedation, I note morphine is not an option. Why?
    In my city in Oz Hydromorphone is not very available and I’ve never seen it used in ED and I hear it is uncommonly used in Anaesthetics. Which leaves a choice of fentanyl v morphine. My understanding from my anaesthetic buddies is that short acting properties of fentanyl are lost with extended infusions (eg 6hrs+) and both are equally cardiostable as infusions so why is fentanyl superior (which is the implication if morphine not provided as an option)? Also morphine has the benefit of the very easy 50mg + 50mg midaz in 50mls bag for post intubation analgo-sedation which is super common over here in Oz.

    • If fentanyl is available, it is the better infusion med because without giving intermittent bolus doses, any change in the infusion rate will more rapidly be seen in clinical effects. Fentanyl has no histamine release and therefore no intrinisic hypotension induction. You also will see the effects of each dose change much more quickly.

      This si the same reason I choose hydromorphone rather than morphine for bolus dose, but in the latter situation morphine would be fine.

      • Anand Senthi says:

        thanks, fair points though the intrinsic hypotensive histaminic problem of morphine I understand is not much of an issue in real practice when running infusions v’s bolus doses. My only concern with leaving morphine out will be that it will be a less generalisable checklist tool for use in different settings such as in Oz.
        On the other hand, real estate is at a premium on the checklist …

  24. Anand Senthi says:

    also excuse my ignore but what does “HOp Killers-haemodynamics” mean exactly?

    • Hemodynamics, Oxygenation, pH
      pt with soft hemodynamics
      the pt already desaturated or at risk of rapid desat
      pts with severe metabolic acidosis in whom apnea may lead to critical further drops in pH

      listed directly afterwards
      the three physiological killers in the peri-intubation

  25. Anand Senthi says:

    that should read “ignorance”

  26. Kyle Williams says:

    Dr. Weingart,

    Excellent work on the intubation checklist! It’s making its way around both my hospital and air medical program like wildfire. You managed to pull out the most important information in airway management and put it into a concise, well organized, and most importantly user friendly format.

    Thank you,

    Kyle Williams

  27. Agree all the info is there

    But….it doesnt really work for me. Too messy, need to already KNOW the subject matter to make it effective. But i do like the downloadable format and foldable paper

    I reckon a checklist should be usable by the locum,agency nurse and junior team members…at 3am, with no backup

    I reckon they would struggle with this “Hop killers’ WTF?

    Perhaps use the ‘checklist for checklists’ to simplify and make more usable in a crisis

    http://www.projectcheck.org/checklist-for-checklists.html

    Otherwise is preaching to the converted.

    • Kyle Williams says:

      The point of the checklist is not for one person, a locus or junior nurse to use on his / her own, because I believe Scott’s point in creating the checklist is to promote and ensure a team approach during every airway procedure.

  28. Oh, and use challenge-response checkmarks (boxes for ticking)

    Otherwise human factors shows us that users will just skim read the bits they ‘know’…but omit vital stages

    Having a list of checks encourages challenge-response and that people really USE the checklist, not just as a mind map

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