RSI Check List Version 4 May 2012

Step Tick or Time

PeopleAnaesthetist: (Unless patient in ED and ED seniors able to manage) Called ____:____ ArrivesED Senior if patient in ED Called ____:____ ArrivesXRay: Call in if not onsite. Called ____:____ Arrives Team leader / drug push _____________ Hands off if possibleList speaker / scribe _____________ Intubator _____________]Prepare air way equipmentIntubator’s assistant _____________]suction, pass tube, hold corner of mouthCricoid / External Laryngeal Manipulation _____________)C-spine stabilisation if required _____________)assist with drug preparationMonitoring, lines, fluids _____________)

_____:__________:__________:_____

Patient assessmentAMPLE Hx – if available

Allergies/sensitivities esp to anaesthetics Medications Past medical, surgical and anaesthetic Hx Last ate or drank Events – what got the patient into this state

Airway assessment. Risk of difficult BVM or intubation Neck size and mobility (including potential c-spine injury) Thyromental distance Beard Mouth opening and jaw protrusion Dentition Tongue size/masses View of oropharynx / modified Mallampati (I: all of uvula; II: part of uvula; III: soft palate; IV:

hard palate only) ______________ If in ED: Call anaesthetist if signs of difficult BVM or intubation

Obs Current Observations. Does technique need to be modified? O2 sat _______% RR _______ HR _______ BP ___/____ GCS E ___/4 V ___/ 5 M ___/6 = ___/15 Best Motor R ________ L ________ Pupils R ______mm Reactive ____ L ______mm Reactive ____ ____:_____

Ponder Is this the right thing to do now with the available resources?Preparation Drugs: Doses calculated, drawn up and labeled

Pressor eg phenylephrine or ephidrine Anaesthetic eg propofol, ketamine, etomidate Muscle relaxant eg suxamethonium or rocuronium Sedative bolus + infusion eg propofol, midazolam, ketamine Analgesic bolus + infusion eg fentanyl

Long acting muscle relaxant if not used for RSI eg rocuronium2 oxygen sources + bag-valve-mask checked. Nasal prongs. Suction on and under pillowETT

Lubed stylet or bougie in ETT: Adult male: 8. Adult female: 7.5. Paeds: age/4 +4 A smaller and larger ETT available

Monitoring x4 Audible oximetry BP set to go every 2 minutes ECG – check the trace to make sure you’re not missing something cardiac/tox Capnography tested and attached to ambubag

Airways: Oral and nasal airways sized but not openedBougieIV line x 2, IV fluid running, take bloods if requiredLaryngoscope x 2 testedLMA of correct size but not openedSurgical airway available but not opened (unless “double set up” deemed necessary)Position patient: ear canal in horizontal line with sternal angle or reverse TrendelenburgPreoxygenate: Ambubag, CPAP or BIPAP, or 15L via reservoir mask > 3 minutes if possible

Check O2 supply and ambubag Consider high flow O2 via nasal cannula

Time preoxygenation startedPut to sleep: Anaesthetic _________________________ Dose ______mg ____:_____Paralyze _________________________ Dose ______mg ____:_____

ProtectionC-spine if neededCricoidPlace tube Type of laryngoscopeIf difficulties: options

External laryngeal manipulation Bougie Different laryngoscope (type) LMA (type) Surgical (type)

Tube type (circle): ETT LMA Surgical Size _______ Depth _________ at Teeth/gums (Adults 24cm, Paeds 3 x ETT) View Grade: __________ (I: complete glottis visible. II: anterior glottis not seenIII: epiglottis seen, but not glottis, 4: epiglottis not seen). Placed by _____________________________ Attempt no: _____Comments:________________________________________________________________________

____:_________:_________:_________:_____

ProofEnd tidal CO2 ___________mmHg ____:_____Fogging of tubeAuscultateO2 sats ______% ____:_____(Also check a BP now: _____/______) ____:_____Secure tubeCXR: Call for XRay now. Take XRay once NG/OG tube in situPost intubation managementDrugs

Sedative o Bolus ________________ Dose ______mg o Infusion ________________ Rate ______mg/hr

Analgesico Bolus ________________ Dose ______mg o Infusion ________________ Rate ______mg/hr

Muscle relaxanto Bolus Rocuronium Dose ______mg o Next dose due: Time ____:_____ (30-45 minutes later depending on initial dose)

____:_________:_____

____:_________:_____

____:_____

Airway Suction ETT Insert NG or OG tube Check tube position

o Auscultate

____:_____

o Tube length at teeth/gums _________cm

o Oximetry ________%

o End tidal CO2 _______mmHg

o XRay Performed: _____:_____ Viewed: _____:_____

Breathing: Put on ventilator eg SIMV, TV 6ml/kg, F = 16, 5cm PEEP, 100% O2 ____:_____Circulation

HR ______ BP ____/_____ ____:_____

Fluids and pressors as required Bloods eg VBG Urinary catheter Consider arterial line if time

D Check patient adequately sedated: Look for HR or BP or tearing Recheck pupils Head up 30º if no spinal injury suspected Consider mannitol if neurosurgery imminent

E: Thermoregulation as appropriate. Keep warm unless post VF arrest. Temp _____˚CF: Inform family + gather history from themG: BSL ______ mmol/LH: Hx eg from old notes, family, GP. Document Hx and events in EDI: Any further investigations needed: Bedside, lab, imagingR: ReferS: Secondary survey if not doneT: Tetanus, clean wounds, antibiotics if time. T: Thank the teamT: Transfer

NB: In ED the intubator is responsible for photocopying this sheet and putting a copy in Dr Cresswell’s pigeon hole.