Acute Care 4: Endotracheal Intubation Flow Sheet
Patient Name:
_____________________________________Date:_________________
Reason:
(Check all that apply) Respiratory Arrest________ Cardiac
Arrest _________
Respiratory Distress _________ Trauma __________ Altered Mental Status
________
Seizure _________ Overdose_______ Increased ICP___________ Shock _______
Safe Transfer___________ Other __________________
Preparation:
Equipment including rescue airways, meds, team, patient.
BP______ Pulse ______ RR_______ SAO2 ________ Time_______
| Preoxengenate: (Circle) 100% by mask 4 tidal volume breaths on 100% | Time______ | |
| Premedicate: (MD calculate dose) | Amt/dose mLs/dose | Time______ |
 Atropine
0.02 mg/kg
(child < 8, minimum 0.1 mg) |
_____mg_____ mL | |
| Lidocaine
1.5 mg/kg (head injury,
asthma) |
_____mg_____ mL | |
| Push sedative: (MD calculate dose) | Time______ | |
| Etomidate
(Amidate) 0.3 mg/kg |
_____mg_____ mL | |
| Ketamine
1 to 2 mg/kg |
_____mg_____ mL | |
| Midazolam
(Versed) 0.1 to
0.3
mg/kg IV |
_____mg_____ mL | |
| Other |
_____mg_____ mL | |
| Paralyze: (MD calculate dose) | Time______ | |
| Succinylcholine:
2 mg/kg IV |
_____mg_____ mL | |
| Vecuronium
0.1 mg/kg IV |
_____mg_____ mL | |
|
Rocuronium (Zemuron) 1 mg/kg IV |
_____mg_____ mL | |
| Position airway:
head/neck, laryngeal manipulation, BURP, cricoid
pressure as needed. Do not ventilate (unless acutely desaturating). |
|||
| Pass the tube: ETT size cuffed uncuffed cm at lips/teeth_____ |
|
||
| Patent airway assessment: EDD BBS ET CO2 CXR | |||
| Post intubation plan: | |||
| Paralysis: Vecuronium 0.1 mg/kg IV | _____mg_____ mL | Time______ | |
| Sedation: Midazolam 0.05 to 0.3 mg/kg | _____mg_____ mL | Time______ | |
| Analgesia: Fentanyl 1 to 2 MICROgrams/kg IV | _____µg_____ mL | Time______ | |
|
Morphine 2 to 4 mg
(titrate
to BP)
Put down oral gastric tube.
|
|||
| Post
Assessment:
BP______Pulse ______ RR_______ SAO2
_____ Time _______ Intubation was: Easy Difficult Reason __________________________________ Used Flex Guide: Yes No Combitube/King: Yes No Other Rescue Airway Yes No Vent Settings: FIO_______ TV_________ RATE________ PEEP_______ Complications: (Circle) None Aspiration - (pre- or post-induction) During intubation: Esophageal
intubation
Bleeding
Dental
trauma
Tube not at proper depth Repositioned at ________ cm_________ Other:___________________________________________________________ |