Step 1: Plan

It’s not just the tube.

This step heavily relies on nursing!

• Identify what each team member’s role will be¹
• Determine why the patient needs to be intubated
• What do you think could go wrong, and what will you do if it does?
• What’s the backup plan if the intubation fails?
• What’s the backup plan for the first backup plan?

Step 2: Prepare

No rushing!

There is no emergency in a pandemic.

• Get your medications for before and after intubation ². 
• Gather PPE.
• Assemble equipment for intubation.
• Provide an opportunity for the patient and family to communicate.

Step 3: Position

Please, no mess.

Ensure your clinical area is organized and clean.

• Position the patient for the procedure².
• Are the team members in the right position?
• De-clutter the room of garbage, chairs, etc.

Step 4: Preoxygenate

This stage should not be rushed.

Take your time.

• Give the patient the most oxygen you can².
• You can use a bag-valve-mask, non-rebreather, anything that can deliver lots of oxygen.

Step 5: Give the Medications

The only rapid part of RSI.

Everything is methodical and systematic.

• COMMUNICATE which medications to give in what order, speed and dose ².
• Push the medications in this order:
  1. Induction
  2. Paralytic
• You can push the medicine over 10 seconds – this is the only rapid part of intubation.

Step 6: Placement with Proof

Wave capnography is supreme.

In the midst of COVID-19, logistics of acquiring a chest x-ray are complicated.

• Once the endotracheal tube is in, confirm its placement with waveform capnography ².
• If you don’t have waveform capnography, you can use a capnograph.
• if you don’t have a capnograph, you can auscultate for air entry.
• A chest x-ray does not confirm tube placement.
• A chest x-ray confirms the depth of the endotracheal tube only.

Step 7: Post-Intubation Care

Nurses stay.

Everyone leaves. This is where nurses are needed the most.

• Confirm what sedation level and pain scores to achieve (see fundamentals of critical care) ².
• Confirm medications to use to sedate the patient.
• Keep the head of bed at 30 degrees unless contraindicated.
• Consider physical wrist restraints.
• Suction the mouth.