Pediatric Intubation Checklist Form
Equipment
Rows
Available
Video laryngoscope (primary)
1
Direct laryngoscope (backup)
2
Cuffed endotracheal tubes
3
Stylet
4
10 mL syringe
5
Lubricant
6
Bagger with PEEP valve and masks
7
HEPA filter for bagger
8
EtCO2 adapter (quantitative)
9
EtCO2 pedi-cap (qualitative)
10
Ventilator and circuit with HME/Filter
11
NG Tube
12
H20 bag for ventilator
13
In-line suction catheter
14
Oro-pharyngeal airway (OPA)
15
Yaunker suction
16
Suction catheters and tubing
17
ETT securement tapes
18
Clamp for ETT
19
Nasal prongs
20
Non-rebreather mask
21
IV Pumps, tubing and catheters
22
Stethoscope
23
Medication
Rows
Available
Atropine (0.02mg/kg/dose)
24
Sedative/analgesic (e.g. Fentanyl, Ketamine, Midazolam)
25
Responsiveness
26
Rocuronium (1mg/kg/dose)
27
Post-intubation sedation
28
Vasoactives (e.g. Epinephrine)
29
IV fluids
30
Saline flushes
31
Screening
Symptoms
Respiratory distress/failure requiring admission to Intensive Care
If screening is positive
Airborne/Contact Precautions (gown, gloves, N-95 mask, eye-protection)
Procedure mask on patient
Airborne isolation room OR single patient room w/ doors closed
Post-Intubation
Rows
Status
Inform parent the remaining risk in the room
32
Document signed of the accepted risk
33
3 of the team members in the room, parents with procedure mask
34
Runner is outside the room
35
Prevent the door opens during procedure
36
Review airway
37
Review backup
38
Review CPR contingency plans
39
Pre-oxygenate with 100% oxygen
40
Turn off CPAP/BiPAP prior to removing mask
41
Rapid sequence intubation (all medications in rapid sequence with flush)
42
Avoid bagging and auscultation (confirmation by EtCO2)
43
Inflate ETT cuff first, then connect directly to ventilator (no bagging)
44
Place the dirty linen cart as nearest as the exit
45
Responsible
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
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