Endotracheal Intubation Procedure Note

Date/Time: [Date and time of procedure]

Location: [ED / ICU / OR / ward]

Primary Intubator: [Name and credentials]

Assistant(s): [Names and roles (e.g., RT, RN, MD, APP)]

Indication and Urgency

[Procedure performed (e.g., oral endotracheal intubation / nasal intubation / tube exchange)] — [Urgency: emergent / urgent / elective]. [Clinical indication(s): airway protection / failure to oxygenate / failure to ventilate / respiratory failure / severe hypoxemia / severe hypercapnia or acidosis / procedural facilitation / cardiac arrest / other]. [Brief clinical context and rationale].

Consent

[Informed consent obtained from patient (capacity affirmed) / Consent obtained from surrogate ([relationship]) / Implied consent due to emergency]. [Brief explanation of consent discussion or emergency rationale]. (If consent obtained, note that risks, benefits, and alternatives were discussed. If implied consent, document that the patient lacked capacity and delay would risk harm. Default to implied consent for life-threatening emergencies if unclear.)

Pre-Procedure Assessment

• Time-out: [Yes / No / Not feasible due to immediate life threat]
• Airway difficulty factors: [Limited mouth opening / limited neck mobility / obesity / facial trauma / blood or secretions / cervical spine precautions / aspiration risk / none identified] (If assessment was limited by emergent circumstances, state explicitly.)
• Physiologic risk factors: [Hypoxemia / hypotension or shock / acidosis / right heart failure / none identified]
• Preoxygenation: [NRB / BVM / NIV / HFNC / nasal cannula for apneic oxygenation], [flow/FiO2 if known]
• Positioning: [Sniffing / ramped / neutral / reverse Trendelenburg / cervical spine immobilization]
• Pre-intubation vitals: SpO2 [%], BP [systolic/diastolic], HR [bpm]
• Hemodynamic optimization: [Fluid bolus / push-dose vasopressor / vasopressor infusion / none] (Include only if performed.)

Medications

(Include only if medications were administered. Document actual medications given, not orders. If no medications given, state: "No induction or paralytic medications administered due to [reason].")

• Pretreatment/Adjunct: [Agent, dose, route, time]
• Induction/Sedative: [Agent, dose, route, time]
• Paralytic/NMB: [Agent, dose, route, time]

Procedure

[Approach: oral / nasal]. [Method: RSI / awake intubation / intubation without medications]. [Laryngoscopy: direct / video], [blade/device type and size]. [Adjuncts: bougie / stylet / none]. [External laryngeal manipulation / cricoid pressure / none].

Attempts: (Document each laryngoscope insertion as a separate attempt. A single uncomplicated attempt may be documented briefly.)

• Attempt 1: Operator: [name/role]. Device: [blade/device and size]. View: [Cormack-Lehane grade or equivalent]. Outcome: [success / failure with reason]. Physiologic events: [lowest SpO2, hemodynamic changes, or none].
• Attempt 2: (Include only if applicable.) Operator: [name/role]. Device: [blade/device and size]. View: [grade]. Outcome: [success / failure with reason]. Physiologic events: [details].

ETT specifications: [Tube type: standard / cuffed / reinforced], size [ID in mm], depth [cm] at [teeth / lip], cuff [inflated / not inflated], secured with [method].

Confirmation of Placement

• Capnography/ETCO2: [Persistent waveform present / absent], ETCO2 [value if available]. (If absent or low in cardiac arrest or low-perfusion state, note that perfusion may limit interpretation.)
• Additional confirmation methods: [Direct visualization through cords / bilateral chest rise / bilateral breath sounds with absent epigastric sounds / tube condensation / ultrasound confirmation / chest radiograph obtained]

Complications

[None observed / hypoxemia or desaturation / hypotension / bradycardia or arrhythmia / aspiration or vomiting / esophageal intubation (recognized immediately / recognized delayed) / mainstem intubation / dental, lip, or tongue trauma / airway bleeding / laryngospasm or bronchospasm / rescue airway required / surgical airway required]. [If complications occurred, brief description of recognition and management].

Post-Intubation Plan

• Ventilation: [Bag-valve ventilation / mechanical ventilator], [mode and initial settings if applicable]
• Sedation/analgesia: [Agents and doses started], [sedation target if applicable]
• Neuromuscular blockade: [Agent and dosing] (Include only if continued.)
• Monitoring: Continuous waveform capnography
• Imaging: Chest radiograph [ordered / obtained / deferred]. [Depth adjustment if performed].
• Additional actions: [OG/NG tube placement / other immediate interventions] (Include only if applicable.)

Difficult Airway Communication

(Include this section only if a difficult airway was encountered.)

• Difficult features: [Poor laryngeal view / anatomic factors / secretions or blood / multiple attempts required / physiologic instability]
• Successful strategy: [Approach, device, and adjuncts that achieved intubation]
• Communication: [Airway alert placed / difficult airway communicated to receiving team / patient or family notification planned]