What equipment and medications should be included on an intubation trolley?

Essential Equipment and Medications for an Intubation Trolley

An intubation trolley must contain standardized airway equipment organized by difficulty algorithm steps, capnography for tube confirmation, and rapid sequence intubation medications including induction agents and neuromuscular blockers, with all equipment immediately accessible and checked daily. 1, 2

Airway Equipment Organization

The difficult airway trolley should be organized to correspond with sequential progression through airway management algorithms 1, 3:

Primary Intubation Equipment (First-Line)

• Laryngoscopes: Standard and short handles with metallic blades (sizes 0-4 straight Miller; sizes 2-4 curved MacIntosh) 1
• Video laryngoscope with disposable blades - should be used either initially or after first failure of direct laryngoscopy 1, 2
• Endotracheal tubes:
  • Uncuffed: 2.5,3.0,3.5,4.0,4.5.0,5.5 mm 1, 2
  • Cuffed: 5.0,5.5,6.0,6.5,7.0,7.5,8.0 mm 1, 2
• Malleable stylets for shaping endotracheal tubes - recommended by default for anticipated or unexpected difficult intubation 1, 2
• Extra laryngoscope batteries and bulbs 1

Backup Airway Devices (Second-Line)

• Supraglottic airway devices (laryngeal mask airways in multiple sizes) 1, 2
• Oropharyngeal airways (sizes 0-5) 1, 2
• Nasopharyngeal airways (#26, #30 or 12F-30F) 1, 2
• Magill forceps (adult and pediatric) 1

Emergency Surgical Airway Equipment (Third-Line)

• Cricothyroidotomy kit with scalpel and blade 1, 2
• Needle cricothyroidotomy kit 1

Advanced Airway Equipment

• Bronchoscope (conventional reusable or single-use disposable) - must be immediately available in ICU proximity 1
• Long guides for tracheal tubes (Cook, Frova) - useful for difficult intubation 1

Monitoring Equipment (Critical Safety Items)

• Capnography device - mandatory to confirm correct endotracheal tube placement 1, 2
• Pulse oximeter with sensors appropriate for all patient sizes 1, 2
• Cardiorespiratory monitor with ECG electrodes (infant, pediatric, adult) 1, 2
• Blood pressure cuffs (neonatal, infant, child, adult small and large) 1

Ventilation and Oxygenation Equipment

• Bag-valve-mask systems with oxygen reservoir (adult and pediatric) 1, 2
• Masks for bag-valve system in multiple sizes 1
• High-flow nasal oxygen device for preoxygenation 2
• Non-invasive positive pressure ventilation equipment for preoxygenation, especially for anticipated difficult laryngoscopy 2
• Oxygen tubing and nasal cannulas (adult and pediatric) 1
• PEEP valve (adjustable) 1
• Nebulizer for aerosol medication delivery 1

Suction Equipment

• Suction apparatus with Yankauer and flexible suction catheters 1, 2
• Suction catheters in multiple sizes (#5, #8, #10, #14, tonsil) 1

Vascular Access and Medication Administration

• IV catheters (14-24 gauge) 1
• Intraosseous needles or devices appropriate for children and adults 1
• Syringes of various sizes including tuberculin 1, 2
• Hypodermic needles in assorted sizes 1
• IV administration tubing (microdrip and macrodrip) 1
• Three-way stopcocks and extension tubing 1

Medications for Rapid Sequence Intubation

Induction Agents

• Etomidate (0.3 mg/kg) - recommended for hemodynamically unstable patients 2
• Ketamine (1-2 mg/kg) - alternative induction agent for hemodynamically unstable patients 2
• Midazolam - for sedation/anxiolysis, but requires immediate availability of oxygen, resuscitative drugs, and equipment for bag/valve/mask ventilation and intubation 4

Neuromuscular Blocking Agents

• Succinylcholine (1-1.5 mg/kg) - first-line when no contraindications exist 2
• Rocuronium (0.6-1.2 mg/kg) - alternative neuromuscular blocker 2
• Sugammadex - must be immediately available for "cannot intubate/cannot oxygenate" scenarios when using rocuronium 2

Additional Medications

• Cardiovascular medications: 1:10,000 epinephrine, atropine, adenosine, amiodarone 1
• Vasopressors for infusion 1
• Naloxone hydrochloride - reversal agent 1
• Flumazenil - specific reversal agent for midazolam, immediate availability highly recommended 4
• Crystalloid solutions: Normal saline (1000 mL bags), Ringer's lactate 1
• 50% dextrose solution with sterile diluent 1

Positioning and Preparation Equipment

• Equipment to facilitate semi-Fowler position (wedge or pillows) 2
• Water-soluble lubricant 1
• Adhesive tape for tube securing 1
• Antiseptic solution (alcohol wipes and povidone-iodine wipes) 1

Additional Essential Supplies

• Nasogastric tubes in assorted sizes 1
• 10-mL non-Luerlock syringes 1
• Surgical dressings (sponges, Kling, Kerlix) 1
• Trauma scissors 1
• Stethoscope 1

Critical Organizational Requirements

Daily equipment checks must be performed with documented records to ensure all equipment is present and functional 1. The trolley should be organized in a standardized manner corresponding to the four-step difficult airway algorithm: A = intubation, B = supraglottic airway, C = facemask ventilation, D = emergency invasive airway 3.

Common Pitfalls to Avoid

• Never proceed without capnography - absence of waveform indicates failed intubation unless proven otherwise 1, 2
• Avoid rapid IV administration of midazolam - must be titrated slowly over at least 2 minutes, especially in neonates where rapid injection can cause severe hypotension and seizures 4
• Do not use plastic disposable laryngoscope blades for anticipated difficult intubation - metal blades are mandatory 1
• Ensure immediate availability of reversal agents when using sedatives - flumazenil for midazolam must be immediately accessible 4
• Limit laryngoscopy attempts to maximum of three to prevent airway trauma and progression to cannot-intubate-cannot-oxygenate scenarios 2