Airway Checklist Practicalities and FOAMed PHARM Kit Dump Update

Confessions of a novice PHARM co-author: I am guilty of blogging negligence for not posting this sooner. I had an asynchronous conversation with Scott Weingart on Airway Checklist real world implementation …

This was about 2 weeks ago and he recorded an audio response to me at that time which was gold and thanks to his permission, it has to be shared!

We were discussing how feedback on checklist implementations included lists being too long and how in crash situations some choose to not use a checklist however this is when it might be even more critical to get things right but it cannot take 5 minutes to check things. Scott talks about the <60 second version of the EMCrit checklist.

Since then I have read through Atul Gawande’s “The Checklist Manifesto” twice (a must read).

A few things stick out in my mind:

Checklists protect against “faulty memory and distraction”, however “people can lull themselves into skipping steps [which] … don’t always matter … until one day it [does].”

“Good checklists are remarkably brief, usually just a few lines on a page in big easy to ready type”, “not vague, not too long” and “treat the people using the tools as smart professionals”, “do not spell out every single step … otherwise it turns people’s brains off rather than turn them on”: “checklists cannot fly a plane.”

“Good checklists are precise, efficient … easy to use even in most difficult situations”. They “provide reminders of only the most critical and important steps, ones that even skilled professionals [under duress] could miss”, they “help experts remember how to manage a complex process, can make priorities clearer, prompt people to function better as a team.”

Here is the updated FOAMed PHARM Kit Dump 3.4 (previously tweeted already) with the printed airway checklist in detail (Version 3.3 previously posted).

The brief reminder headings of the Airway Checklist  is printed on the kit dump:

• PreOx
• Resources
• Meds
• Position
• —Pause team briefing—-
• Approach
• Risks (HOp)
• Fail plan
• Roles

The actual Airway Checklist might be on a laminated card with a small picture of the equipment kit dump on the reverse of the card.

• PreOx: O2 by 2 sources 3 ways (reOx deN2ate apOx)
• Resources: other MDs including anesthesia, RNs, RTs
• Meds: induce, paralyze, facilitated, pressors, post intub sed/analg
• Position: ear2notch face|| HoB30 RevTrend BedHeight ELM HeadElev JawThrust
• —Pause team briefing—- situation, task, intent, concerns, calibrate
• Approach: best first attempt
• Risks (HOp): avoid hypotension, hypoxia, hypoventilation, PPE
• Fail plan: no more than 3 attempts if SpO2>92%, change things to address difficulty, reoxygenation plan, surgical airway triggers
• Roles: watch SpO2, waveform, BP, intubation assistant, timer/recorder, lifeguard

The long version below is for training or for the rare/occasional intubator as a quick reminder

20 seconds TASKS CHECKLIST

1) Preoxygenation

• Reoxygenation to >>95%
• Denitrogenation with FiO2 100% for 3 min TV or 8 VC breaths (NRB >>15lpm)
• Apneic oxygenation with nasal cannula at 15LPM with nasopharyngeal patency

2) Resources

• other ED docs
• anesthesia
• intensivist
• RNs
• RTs
• PHARM MD by phone
• receiving MD by phone

3) Meds

• Induction/Paralytic/Facilitation
• Pressor/Fluid bolus
• Preoxygenation
• Premedications (blunt catecholamine surge etc like fentanyl etc.)
• Post intubation sedation/analgesia

4) Position

(a) Patient

• Ear to sternal notch (i.e. ramped in bariatric)
• Face plane parallel to ceiling
• Head of bed 30 degrees
• Reverse trendelenburg in bariatric, 3rd trimester pregnancy, spine immobilized
• Height of bed compared to intubator

(b) Intubation assistant

• External laryngeal manipulation of thyroid held after bimanual laryngoscopy
• Head elevation
• Jaw thrust
• Collar plan
• Bougie assist, post intubation assist/confirmation etc

40 seconds COMMUNICATIONS CHECKLIST – pause for team briefing that includes the situation, task, intent, concerns/questions

• See Search and Rescue Briefings which I heard via a comment by Clint Kalan on the EMCrit Intubation Checklist.

1) What is the planned APPROACH

• Assess airway, look in mouth, dentures, neck mobility, ability to be positioned
• Definitive airway (oral or nasal endotracheal intubation)
• Best optimized first attempt (methodical suction epiglottoscopy, laryngeal exposure and tube delivery)
• Best modality chosen as determined by speed, familiarity, anticipated difficulty in anatomy, pathology, cooperativeness (RSI or facilitated or crash) and physiology

2) Are there any anticipated RISKS (HOpP) and what would be the plan

• Hypotension
• hypOxia
• hypoventilation in low pH severe metabolic acidosis
• PPE

3) What is the FAILURE PLAN in event of airway miss?

• E.g. no more than three attempts at definitive airway if SpO2 >92%
• Each attempt MUST change things to address difficulty of the previous airway misses, consider change intubators
• Reoxygenation goal to >>95% with #1 optimized BMV (2 person, OAW,NPAs, positioned, >>15lpm, PEEP) and #2 supraglottic airway if GCS low enough
• Cricothyroidotomy if oral route fail or improbable for success and failure of reoxygenation

4) Are all present aware of each others names and ROLES? 

• Assign a pulse ox watcher (SpO2 alarm at 92% and waveform quality watch for early perfusion loss)
• Assign a BP watcher (q1-2min BP, alarm if MAP<70)
• Assign a recorder and timer, lifeguard
• Intubation assistant