Prepare oxygenation, equipment, physiology, RSI medications, and the team before induction.
Critical actions
Oxygenation
Choose a method that treats the patient’s oxygenation and ventilation problem—not merely the oxygen flow rate.
Choose based on the situation
Hypoxemia, obesity, pulmonary edema, or recruitable/shunt physiology: use NIV (BiPAP-style support) when feasible with FiO₂ 1.0, a tight seal, and enough EPAP/PEEP and pressure support to improve oxygenation and ventilation; aim for at least 3 minutes when time permits.
If NIV is not feasible: consider HFNC at approximately 40–60 L/min with FiO₂ 1.0, especially in hypoxemic patients; it can remain in place during laryngoscopy.
Less severe physiology or limited equipment: use a tightly fitted non-rebreather/oxygen mask at maximal flow, often with a standard nasal cannula underneath.
Apnea, hypoventilation, or inadequate saturation despite oxygen: use two-person BVM ventilation with an OPA/NPA and PEEP, using gentle breaths that produce visible chest rise.
Use caution with NIV in active emesis, very high aspiration risk, severe agitation, or inability to tolerate/protect the interface.
Plan to say: Preoxygenation is ___. Our target before induction is ___. If that is not adequate, we escalate to ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Apneic oxygenation may extend safe apnea time, but it does not remove CO₂ and does not replace preoxygenation or positive-pressure rescue ventilation.
Choose based on the situation
Standard nasal cannula: leave in place during laryngoscopy and use up to 15 L/min (or the locally approved maximum) when tolerated.
HFNC: if already available, continue roughly 40–60 L/min with FiO₂ 1.0 during the attempt.
Keep the cannula positioned so it does not break the mask seal, obstruct suction, or interfere with the laryngoscope.
If the patient is apneic, hypoventilating, or desaturating, move to effective BVM or other positive-pressure ventilation rather than relying on nasal oxygen alone.
Plan to say: Apneic oxygenation is ___. If SpO₂ falls or ventilation is inadequate, we will ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Choose and shape the tube-delivery adjunct before the blade enters the mouth.
Choose based on the situation
Macintosh-style direct or video blade: use a malleable stylet or bougie based on the view, operator preference, and local practice.
Hyperangulated GlideScope/LoPro or similar blade: use the manufacturer-compatible rigid stylet shaped to match the blade curve; a standard straight bougie may be difficult to deliver.
Keep the stylet tip recessed within the ETT and confirm it can be removed without excessive force.
Stage a bougie, smaller ETT, and alternative tube-delivery plan for a good view with failed passage.
Plan to say: Blade geometry is ___. Tube-delivery adjunct is ___. Backup adjunct is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Physiology
Identify the shock physiology, start resuscitation, and have an immediately executable vasopressor plan.
Choose based on the situation
Place the patient on continuous monitoring and obtain reliable IV/IO access; have a vasopressor infusion running or ready when risk is high.
Give fluid only when the patient is likely to be preload responsive; avoid a reflexive large bolus in cardiogenic/RV failure or pulmonary edema.
For increased peri-intubation hypotension risk, favor ketamine or etomidate; avoid treating fentanyl, midazolam, or propofol as equivalent induction defaults.
Anticipate the hemodynamic effects of apnea and positive pressure; use the lowest effective PEEP/airway pressure for the physiology while maintaining oxygenation.
State the rescue threshold and who will give the pressor if the pressure falls.
Plan to say: Shock physiology is ___. Pressor is ___. Trigger is ___. Fluid strategy is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Severe metabolic acidosis may depend on a very high minute ventilation. The danger is the loss of compensation during apnea and immediately after intubation.
Choose based on the situation
Treat the cause and support ventilation before induction; consider NIV when it can improve ventilation and is not contraindicated.
Minimize apnea time and avoid unnecessary delays between induction, tube placement, circuit connection, and ventilation.
Have the ventilator programmed before medications; aim to approximate the pre-intubation minute ventilation as safely as possible.
Use sufficient inspiratory flow and expiratory time; watch for auto-PEEP when a high respiratory rate is required.
Reassess pH/PaCO₂ early when the result will change management.
Plan to say: Pre-intubation minute ventilation is approximately ___. Initial ventilator plan is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Verify agent, dose, concentration, label, sequence, and the hemodynamic plan before the syringe reaches the bedside.
Choose based on the situation
Shock/peri-intubation hypotension risk: ketamine or etomidate are the preferred ACEP-supported induction scaffolds.
Bronchospasm or need for dissociation: ketamine may be useful when not otherwise contraindicated.
Propofol or midazolam: reserve for appropriately selected, hemodynamically stable patients and use physiology-adjusted dosing; do not treat them as shock-equivalent choices.
Announce and administer the induction agent before the paralytic.
Use the actual measured/estimated dosing weight and verify the concentration with the medication team.
Plan to say: Induction agent is __ at __ mg. Induction goes before paralytic. If BP falls, we will ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Confirm the drug, dose, contraindications, label, and what analgesia/sedation will cover the entire period of paralysis.
Choose based on the situation
Rocuronium: useful when succinylcholine is contraindicated; anticipate prolonged paralysis and ensure sustained analgesia/sedation.
Succinylcholine: rapid, shorter duration, but avoid when contraindications such as hyperkalemia risk, certain neuromuscular conditions, malignant-hyperthermia susceptibility, or relevant burn/crush/denervation timing are present.
Confirm adequate dosing for RSI and avoid partial paralysis that worsens conditions for laryngoscopy.
Have the post-intubation analgesia and sedation medications prepared before the paralytic is administered.
Plan to say: Paralytic is __ at __ mg. Expected duration is ___. Analgesia/sedation plan is ___.
Dose references mirror the updated checklist. Individualize for physiology and local protocol. In patients at increased risk of peri-intubation hypotension, ACEP 2026 recommends ketamine or etomidate and advises avoiding fentanyl, midazolam, or propofol as induction/coinduction agents. ACEP 2026 policy.
Pearls
Preparation is a coordinated pre-induction pause: oxygenation, equipment, physiology, medication readiness, and team roles should all be visible before the first drug is pushed.
Say aloud: Preoxygenation and apneic oxygenation are planned. Suction is on. The tube, BVM, and stylet are ready. Hypoxia, hypotension, and acidosis have been addressed. Access, labeled induction and paralytic medications, PPE, roles, and the C-spine plan are confirmed. START if ready; STOP if a critical item remains unresolved.
Pitfalls
Suction present but not switched on
Medication syringes unlabeled or sequence unclear
Hypotension or severe acidosis not addressed before induction
C-spine plan, PPE, or team roles left implicit
Treating the listed drug doses as universal defaults rather than physiology- and protocol-dependent references
Proceeding past the START/STOP checkpoint while a critical item remains unresolved
Optional just-in-time support
Checklist guidance
About this resource
Created by: Andrew Pirotte, MD; Kyle Brown, MD; Reba Hodge, MD; Amanda Vanderwerf, PharmD, BCEMP; Morgan Kimball, PharmD, BCEMP; Joshua MohessClinical review: Emergency medicine faculty review completed. Medication content reviewed by Amanda Vanderwerf, PharmD, BCEMP, and Morgan Kimball, PharmD, BCEMP.Last reviewed: 2026-07-23Next scheduled review: 2027-01-23Designed for: EM residents, emergency physicians, EMS clinicians, airway educators, and simulation facultyImportant: Educational resource and cognitive-aid guide only; not a bedside order set or substitute for local protocol, medical direction, or clinical judgment.Website contact:[email protected]
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