What is the proper method for writing intubation notes for a patient in an emergency?

Emergency Intubation Documentation

Document every emergency intubation with a structured note that captures pre-intubation assessment, procedural details, complications, and post-intubation management to guide future airway care and meet medicolegal standards. 1

Essential Components of the Intubation Note

Pre-Intubation Assessment and Indication

• Primary indication for intubation: Document the specific reason (acute respiratory failure, shock, coma, airway protection, cardiac arrest) 1, 2
• Airway assessment findings: Record Mallampati class, mouth opening, neck mobility, thyromental distance, presence of facial trauma or burns, and MACOCHA score if ≥3 (predicts difficult intubation in critically ill) 1
• Physiologic status: Document baseline vital signs, oxygen saturation, hemodynamic stability, presence of shock, degree of hypoxemia, and cardiovascular compromise 1, 2, 3
• Aspiration risk: Note presence of full stomach, vomiting, or decreased level of consciousness 1
• Cricothyroid membrane identification: Document whether the cricothyroid membrane was palpable or required ultrasound identification 1

Team and Preparation

• Personnel present: Record the most experienced operator performing the intubation, team leader, and all team members with their assigned roles 1, 4
• Pre-intubation briefing: Document that a checklist was completed and strategy for Plans A, B/C, and D (primary intubation, rescue ventilation, emergency surgical airway) was shared 1, 4
• Equipment prepared: Note availability of backup equipment including supraglottic airways, cricothyrotomy kit, and vasopressors drawn up 1, 4

Patient Positioning and Preoxygenation

• Position: Document head-up 25-30° when tolerated, sniffing position (lower cervical flexion with upper cervical extension), or ramping for obese patients (external auditory meatus level with sternal notch) 1, 4
• Preoxygenation method: Record technique used (tight-fitting facemask with 10-15 L/min 100% oxygen for 3 minutes, CPAP, NIV, or high-flow nasal oxygen), end-tidal oxygen concentration if measured (goal >85%), and presence of capnograph trace confirming seal 1, 4
• Special considerations: Note if cervical spine precautions with manual-in-line stabilization were used 1

Medications Administered

• Induction agents: Document drug name, dose, and time administered 1, 4
• Neuromuscular blocking agents: Record drug name, dose, and time administered 1, 4
• Hemodynamic support: Note any fluid bolus, vasopressors (epinephrine, norepinephrine), or inotropes given before or during intubation 1, 4

Intubation Procedure Details

• Laryngoscopy technique: Specify whether direct laryngoscopy or videolaryngoscopy was used (videolaryngoscopy increases first-pass success and may prevent esophageal intubation) 1, 4, 5
• Laryngoscopic view: Document Cormack-Lehane grade (I-IV) to guide future airway management 1
• Number of attempts: Record each attempt, operator for each attempt, and technique used (this is critical as multiple attempts increase risk of cardiac arrest from 2% to 12.5% with four or more attempts) 1, 2
• Adjuncts used: Note use of stylet, bougie, or other devices 1, 5
• Endotracheal tube size: Document tube inner diameter (typically 7.0-8.0 mm for adults, though smaller tubes like 6.0 mm may facilitate difficult intubation) 1
• Depth of insertion: Record depth at the teeth or lips in centimeters 1

Confirmation of Tube Placement

• Waveform capnography: Document presence of characteristic CO₂ waveform and end-tidal CO₂ value (this is the most reliable method with 100% sensitivity and specificity) 6, 4, 7
• Clinical examination: Note bilateral breath sounds, absence of epigastric sounds, and chest rise 1, 7
• Chest radiograph: Document if obtained and findings regarding tube position 1

Critical pitfall: Auscultation alone has only 94% sensitivity and 83% specificity for correct tube placement; always use waveform capnography as the primary confirmation method 7

Complications Encountered

• Immediate complications: Document any severe hypoxemia (SpO₂ <80%), hemodynamic collapse (systolic BP <65 mmHg), cardiac arrest, cardiac arrhythmias, esophageal intubation, aspiration, or dental trauma 1, 2
• Difficult intubation: Note if three or more attempts were required or if rescue techniques were needed 1
• Rescue interventions: Record any supraglottic airway placement, facemask ventilation, or front-of-neck airway (FONA) performed 1

Post-Intubation Management

• Immediate post-intubation vital signs: Document oxygen saturation, blood pressure, heart rate, and end-tidal CO₂ after tube secured 1
• Ventilator settings: Record mode, tidal volume, respiratory rate, PEEP, and FiO₂ 1
• Sedation and analgesia: Note medications and doses for ongoing sedation 1
• Tube security: Document method of securing tube (tape, commercial device) 1

Follow-Up Documentation Requirements

Airway Difficulty Communication

• Medical record documentation: Include a detailed description of airway difficulties encountered, distinguishing between difficulties with facemask ventilation, supraglottic airway ventilation, and tracheal intubation 1
• Technique effectiveness: Describe which airway management techniques were beneficial versus detrimental 1
• Patient/family notification: Document that the patient or responsible person was informed of the airway difficulty to guide future care 1
• Ward round handover: Ensure ICU consultant and team are aware of patients with difficult airways, including laryngoscopy grade and patient-specific strategies for re-intubation or extubation 1

Care Plan for Intubated Patient

• Re-intubation strategy: Document specific plan if tube becomes displaced or requires exchange 1
• Extubation strategy: Note considerations for future extubation including risk factors for failure 1
• High-risk patient identification: Use "red flags" to identify patients at risk for tube displacement or blockage 1

Critical pitfall: Over 80% of airway-related critical incidents in ICU occur after initial intubation, most commonly from tube displacement or occlusion; comprehensive documentation prevents these complications 1

Emergency Notification

• Registry enrollment: Instruct the patient to register with an emergency notification service when appropriate and document this instruction 1
• Alert systems: Ensure difficult airway alerts are placed in the electronic medical record 1

Special Circumstances Requiring Additional Documentation

Cervical Spine Injury

• Manual-in-line stabilization: Document that anterior cervical collar was removed and manual-in-line stabilization was maintained throughout intubation 1
• Neurological status: Record neurological examination before and after airway management 1

Burns and Thermal Injury

• Airway examination findings: Note presence of hoarseness, dysphagia, drooling, carbonaceous sputum, soot in airway, or singed facial/nasal hairs 1
• Specialist consultation: Document communication with burns center 1
• Tube selection: Note use of uncut tracheal tube to allow for subsequent facial swelling 1

Obesity

• Positioning: Document use of ramping position and head-up positioning 1
• Rapid desaturation risk: Note speed of desaturation and effectiveness of preoxygenation techniques 1
• FONA considerations: Document cricothyroid membrane identification method (palpation versus ultrasound) given higher FONA risk 1