Nursing Intubation Checklist – Yes, Really.

Do you have a Nursing Intubation Checklist?

Intubation has 4 main Parts

1. The Decision to Intubate
2. Setting Up for Intubation
3. Intubation
4. Post Intubation Care

Some of my thoughts on Intubation

• Communicate with your provider as to what the plan of care is:
  • BP low – do we need push dose pressors or vasopressors before and/or after intubation?
  • Are we anticipating central line or A-line?
• Post Intubation Care is the most critical part of intubation (in my opinion) and it’s VERY NURSING HEAVY.
  • Providers should stick around and watch the patient. Patients like to crash right around this time.
  • If your provider is not your ED Provider, they really need to stick around and not go upstairs.
  • The more you have set up PRIOR to intubation, the SMOOTHER your post intubation care.
  • Soooo Nursing Heavy that there will be a separate episode on Post Intubation Care…stay tuned!

Here’s my Nursing Intubation Checklist

2-3 IV lines

• I prefer 3. Sometimes I even put in 4 or 5. Just depends on what I need or anticipate.
  • Especially if they are very sick and you have a sneaky suspicion that you will need a NE drip for a crashing BP. You may need PDP but if you already have a drip ready to go – even better!
  • Mentally think which medications and how many lines you need. Not all medications are compatible through the same line.
• Pet Peeve Alert! If a provider tells you, don’t worry about the extra IV line, we’ll put in a central line afterwards – don’t listen to them!
  • If your patient is sick enough that the provider is already anticipating the need for a central and/or A line – you betcha you will need those extra IV lines while it takes them 20-30 minutes to put in that central line.
  • Your patient may not have 20-30 minutes to spare if they are that sick because remember, you are doing a lot of medication adjustments for post intubation care.
• Make sure these are actually good lines. If they are not, this is the time to put in an ultrasound guided peripheral IV line or two.
• Traumatic Arrests or Hemorrhagic Shock may require 18 gauge or larger IV lines for massive blood transfusion.
  • Pet Peeve Alert! But my rule of thumb is, if you can DEFINITELY get a 20 gauge in – I’d rather that you get the IV line rather than trying to only go for an 18 gauge or larger and then blowing all of your lines. This is not the time to have your ego in the way of patient care.
    • The larger IV lines, if still required, can be placed after intubation with ultrasound guided peripheral IV placement in this situation.
  • Your provider should also be thinking about inserting a cortis so you can rapidly infuse blood products through that line.
    • If you’re the provider – communicate this thought process to your nurse.

Verbal Orders of Intubation Medications AND Post-intubation sedation.

• Both set of orders PRIOR to intubation – you will have a smoother transition for your patient during post intubation care.
• Draw up your Intubation Medications FIRST and have them labeled. Hand over to provider when ready to intubate.
• I have my post-intubation sedation drips primed and ready to go before we even intubate.
• I’ll even go a step further and have everything on an IV pole.
• At the time of this writing, there is a fentanyl shortage so I’m unable to use a fentanyl drip.
  • The substitute is a hydromorphone drip which doesn’t help with blood pressures – especially if you also have a propofol drip infusing.
  • If BP is a problem, you will have to use a midazalam drip.
  • Problems with midazalam drip in the long run so I personally try to avoid it.

Pumps and Channels

• I like to have extra attached to my IV pole just in case

2 Suction Canisters

• Both turned on to continuous high, one of them should definitely be attached to a yankaur suction
• This is in the provider’s intubation checklist but they generally don’t know how to set it up or where the items are.

BVM attached to oxygen, turned on and ready

• Oxygen should be turned ON. Don’t wait.

CO2 Monitoring ready to go

• Have all of the pieces connected so you only have to do a final attachment to the ETT tube immediately after insertion
• Have the parameter displayed on your telemonitoring

Tube Tamer- and know how to use it.

Items You May Need to Anticipate

• A-Line Set up (optional)
• Push Dose Pressors on the side (optional)
• Vasopressor drip (I like norepinephrine drip) primed (optional)
• 2 point soft restraints (nearby)
• Crash Cart and/or Defibrillator (have nearby)
• ACLS Meds for an arrest (have nearby)

Provider’s Checklist Items that crosses over to Nursing

• Bougie
• Sheets for optimal head placement
  • Consider using the bed to optimize head placement as well (lift up, down, slight reverse trendelenburg, etc.)

• Oral Airway, LMAs 
• OG tube
• 10mL empty syringe to inflate cuffed ETT
• Intubation Box
• Laryngoscope (direct, video, C-MAC direct video)
• Full Intubation Checklist for Providers:
  • Click here for Scott Weingart’s Checklist
  • Click here for Reuben Strayer’s Checklist

Respiratory Therapist (if available yay!)

• If RT is unavailable- you may also have to be RT:
  • Hyperoxgenate your patient- your patient may already be on bipap, if that’s the case bring up the FiO2 to 100% and leave the mask on until ready for intubation.
    • Alternative – Nasal Cannula and NRM at the same time
• Super Basic Initial Vent settings:
  • AC Mode, Rate 12-18, Tidal Volume 420-450mL (remember it’s ideal body weight), P support 3.0, V support 3.0, FiO2 100%, Peep 5.0
  • Do NOT keep an oxygen saturation of 100% – titrate FiO2 down so pt’s oxygen saturation is between 94-99%)
  • May need to work with P support, Peep, and/or respiratory rate but that is a whole other discussion and podcast episode

Documentation

• Note what size ETT tube (cuffed or uncuffed), what centimeter it is at the lip, and on what side of the mouth it is positioned (left, center, right).
  • Ex: 7.5 ETT cuffed, 25cm at the lip, secured at centered of mouth.

Reference:

Reuben Strayer. Emergency Department Intubation Checklist v13. Emergency Medicine Updates. Published on July 8, 2012. Accessed on July 25, 2018. Available at [https://emupdates.com/emergency-department-intubation-checklist-v13/].

Scott Weingart. Podcast 176 – Updated EMCrit Rapid Sequence Intubation Checklist. EMCrit Blog. Published on June 27, 2016. Accessed on July 25th 2018. Available at [https://emcrit.org/emcrit/intubation-checklist-2-0/ ].

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