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______
_____mg_____ mL
Atropine 0.02 mg/kg (child < 8, minimum 0.1
mg)
_____mg_____ mL
Lidocaine 1.5 mg/kg (head injury, asthma)
Push sedative: (MD calculate dose) Time______
_____mg_____ mL
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
Paralyze: (MD calculate dose) Time______
_____mg_____ mL
Succinylcholine: 2 mg/kg IV
_____mg_____ mL
Vecuronium 0.1 mg/kg IV
_____mg_____ mL
Rocuronium (Zemuron) 1 mg/kg IV
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 Time______
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:___________________________________________________________