COVID Intubation Checklist

Last update: March 30, 2020

Hot room

• Intubating provider in aerosol COVID PPE (PAPR if available, otherwise N95 and faceshield), surgical gown, double gloves
• Dedicated RN in aerosol COVID PPE (PAPR if available, otherwise N95 and faceshield), isolation gown, double gloves
• RT in aerosol COVID PPE (PAPR if available, otherwise N95 and faceshield), isolation gown, double gloves
• Primary bag
  • Restraints
  • Viral filter
  • Filtered, inline EtCO2
  • Ensure EtCO2 module attached to monitor
  • ETT holder
  • Glidescope LoPro S4, confirmed functional
  • Regular stylet
  • Defibrillator pads
  • Suction tubing
  • Yankauer
  • 7.5cm ETT, cuff checked
  • Hemostat
  • 10cc syringe
  • Lubricating jelly
• Secondary bag
  • Glidescope LoPro S3 handle
  • LMA (size 4 iGel)
  • 7.0cm ETT
  • 6.0cm ETT
  • Bougie
  • Scalpel
• Other in-room supplies
  • Glidescope tower, confirmed functional
  • Glidescope stylet
  • Ventilator, plugged in and connected
  • Ambu Bag with PEEP valve and mask
  • Intubation drugs – 0.3 mg/kg etomidate, 1.2mg/kg rocuronium pulled by RN unless provider states otherwise
  • 1 box code dose epinephrine, atropine, and sodium bicarbonate
  • Push dose epinephrine/phenylephrine
  • Foley catheter (if not already in place)
  • OG tube (if not already in place)
  • Purple-top (germicidal, 2-minute dry time) wipes
  • Two-way communication to cold room on and confirmed functional

Anteroom / warm room

• Assistant in droplet/contact COVID PPE (surgical, isolation gown, gloves)
• Code cart
• Airway cart
• Biohazard bags for PPE disposal

Cold room

• Assistant with gloves only
• IV pole plugged in with extension tubing through door from hot room to hallway
• Planned post-intubation sedation and analgesia ordered and hanging
• Disposable bronchoscope
• Ultrasound
• Consent signed if not emergent

COVID ICU intubation process

• Don PPE - see PPE/PAPR checklist
• Enter room
• Check IVs
• Position patient for intubation
• Estimate planned ETT depth (ETT size x3, MDCalc)
• Verbalize plan with personnel including drug doses, roles if cardiac arrest occurs
• Pre-oxygenation at the discretion of intubation provider
  • Preferred - Simple NC up to 5L if able
  • Preferred - HFNC between 15-30 LPM with patient’s face covered with surgical mask
  • Discouraged - NIPPV with viral filter (may increase droplet production)
  • Discouraged - BVM with viral filter (may increase droplet production)
• Rapid sequence induction
• Intubate
  • First line video laryngoscopy
• Re-oxygenation
  • Avoid re-oxygenation if at all possible during apneic phase
  • Preferred - LMA for second attempt re-preoxygenation
  • Discouraged - BVM with PEEP valve; two hands to maintain seal
• Outcome
  • No significant desaturation:
    • Immediately connect to vent
    • ETCO2 hooked after filter
    • ETCO2 confirmed - success - move to post-intubation checklist
  • Significant desaturation (at discretion of intubating provider):\
    • Place viral filter
    • ETCO2 hooked after filter
    • BVM with PEEP valve
    • Regained oxygenation - success - move to post-intubation checklist
    • Persistent destuation - failure - move to failed airway checklist

• If cardiac arrest occurs, secure airway and close circuit before proceeding with CPR.
• If more code drugs are needed, hot room staff will request from warm room designee.

Failed airway checklist

• Insert LMA
• Can you ventilate and oxygenate?
  • Yes: consider further options
    • Bronchoscopy through LMA with placement of exchange catheter then exchange of LMA and ETT
    • Re-attempt video laryngoscopy with new positions/equipment
    • Call more advanced airway expert
  • No: declare a "can’t intubate can’t oxygenate (CICO)" scenario
    • Emergency cricothyroidotomy
    • Scalpel, finger, bougie technique

Post-intubation checklist

• Secure ETT
• Clamp ETT
• Transfer filter and ETCO2 to ventilator
• Attach inline suctioning
• Attach ventilator
• Unclamp tube
• Check ventilation: Is there is concern for mainstem intubation?
  • Consider lung ultrasound for bilateral lung sliding
• Avoid breaking ventilator circuit henceforth
  • If circuit must be broken, clamp tube with hemostat prior to disconnection
• Central venous access, arterial access as needed

Room exit checklist

• Physician remove outer gloves and perform hand hygiene
• Five-minute scrub down
  • Anteroom assistant sets and starts timer for 5 minutes
  • Wipe down visibly soiled/highly contaminated surfaces or equipment that need to leave the room with wipe (purple/germicidal vs. orange/bleach) appropriate for the surface or equipment
  • Wait 5 minutes (for one complete negative pressure air cycle)
  • Pass each piece of equipment from hot to warm room one at a time
  • Keep door closed in between equipment passes
• Doffing
  • Communicate order in which team members will leave per room
  • One at a time, each provider doffs gown, then gloves, then PAPR helmet into red trash bin (hand hygiene in between)
  • Anteroom assistant removes and cleans PAPR frame with orange top wipes
  • Used PAPR face shields/hoods are placed into a biohazard bag and sealed for potential cleaning and reuse later
• Post intubation debrief

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.