RSI Check List Version 4 May 2012Step Tick or TimePeopleAnaesthetist: (Unless patient in ED and ED seniors able to manage) Called ____:____ Arrives _____:_____ED Senior if patient in ED Called ____:____ Arrives _____:_____XRay: 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 stateAirway 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 intubationObs • 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?PreparationDrugs: 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 availableMonitoring 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 ambubagAirways: 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 tubeType of laryngoscopeIf difficulties: options ____:_____ • External laryngeal manipulation ____:_____ • Bougie ____:_____ • Different laryngoscope (type) ____:_____ • LMA (type) • Surgical (type)Tube type (circle): ETT LMA SurgicalSize _______ 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 ____:_____ • Analgesic o Bolus ________________ Dose ______mg ____:_____ o Infusion ________________ Rate ______mg/hr ____:_____ • Muscle relaxant ____:_____ o 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 timeD • 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 imminentE: 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 team
T: Transfer NB: In ED the intubator is responsible for photocopying this sheet and putting a copy in Dr Cresswell’s pigeon hole.