COVID-19 Intubation Checklist Form

COVID-19 Intubation Checklist Form
Intubation Goals
1. Minimize Aerosol Exposure
- RSI (Avoid BMV)
- Inflate Cuff Prior to Ventilation
- Clamp ETT Before Circuit Disconnection
2. Minimize Waste
- Rationalize Kit
Equipment
Intubation Bag
Rows Status
ETT 7.5 w/ stylet 1
Syringe & Gel 2
Mcgrath + 4 blade 3
Anchor-fast or Tie 4
ETT Clamp 5
Flex-tube 6
In-line Suction 7
Drugs
Rows Status
Ketamine 200 MG 8
Rocuronium 200 MG 9
Phenylephine X 2
10
Propofol 1% 100 ML 11
Norepinepherine Infusion 12
Crash Bag
Rows Status
Bougie 13
ETT 6.5, 7.0, 8.0 14
X Mcgrath blade 15
LMA 3 & 4 & 5 16
DL Mac 3 & 4 17
Cricothyroidotomy Set 18
ACLS Drugbox & Zoll Defibrillator 19
Anteroom Bag
Rows Status
Plan B Kit (Assembled During Brief from Crash Bag) 20
Outside Room

Rows	Status
Bougie	13
ETT 6.5, 7.0, 8.0	14
X Mcgrath blade	15
LMA 3 & 4 & 5	16
DL Mac 3 & 4	17
Cricothyroidotomy Set	18
ACLS Drugbox & Zoll Defibrillator	19

Rows	Status
Plan B Kit (Assembled During Brief from Crash Bag)	20

Review Intubation Plan & Prepare Kit

Rows	Status
Plan A / B / C	21
RSI Sequence & Drug Dosing Recommend 1.5 mg/kg Rocuronium, 1-2 mg/kg Ketamine	22
Intubation Bag Prepared	23
Drugs Prepared	24
Crash Bag Prepared	25
Anteroom Bag Prepared	26
Trauma Surgeon Notified If Necessary	27
Review Communication Prompts	28

Rows	Status
Collect Intubation Bag & Drugs	36
Collect Anteroom Bag	37
Collect Additional Discussed Equipment + / - CVC, Arterial Line	38
DON PPE	39
Buddy Check	40

Get Ready Intubation Equipment

Rows	Status
McGrath & Blade	41
ETT with Stylet & Syringe	42
Anchor-fast	43
Suction	44
Ventilator + Closed Suction + Capnography	45
Ambu-Bag (No PEEP Valve) + HEPA + Mask + OPA	46
Clamp	47
Ventilator Preset on Stand-by	48

Check Patient
Rows Status
Position 49
Monitors 50
IV Access 51
Prepare Infusions 52
Time Out
Rows Status
Review Intubation Plan 53
Address Concerns 54
Reinforce Key Points to Minimize Exposure 55
Intubation Steps
1. Pre-oxygenate 3-5 min w/ Ambu-Bag
2. RSI
3. Time 60s + Drape
4. Plan A: Fails if Sats < 80%
If Plan A fails, then:
5. Plan B or Plan C
Post-Intubation
Success
Rows Status
Inflate Cuff 56
Attach to Closed Suction + HEPA + Capnography + Ventilator Circuit 57
Confirm ETC02 58
Secure Tube 59
Initiate Sedation Infusion 60
Initiate Ventilation Strategy 61
Insert NGT 62
Before Exit
Rows Status
Ensure Patient Stability 63
Discard Disposables 64
RT Clean McGrath with AHP Wipes (white top) then hand off to Anteroom for Second Clean 65
DOFF PPE with Observer 66
End
Rows Status
Wash Exposed Area 67
Hot Debrief; Critical Points 68
Restock and Clean the Kit 69
Team Roles
Intubator / Room Lead
Drug Administration
Airway Assistant
Anteroom Runner (PPE ON)
Second RN
Second Anesthesiologist
Intensivist
Team Responsible
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Clear
Should be Empty:

Rows	Status
Review Intubation Plan	53
Address Concerns	54
Reinforce Key Points to Minimize Exposure	55

Rows	Status
Inflate Cuff	56
Attach to Closed Suction + HEPA + Capnography + Ventilator Circuit	57
Confirm ETC02	58
Secure Tube	59
Initiate Sedation Infusion	60
Initiate Ventilation Strategy	61
Insert NGT	62

Rows	Status
Ensure Patient Stability	63
Discard Disposables	64
RT Clean McGrath with AHP Wipes (white top) then hand off to Anteroom for Second Clean	65
DOFF PPE with Observer	66

Select theme:

Intubation Goals