Silence the room, state the airway plans, and confirm code status, device, operator, positioning, and medications.
Critical actions
Silence - airway lead states
“Video laryngoscopy” is not a complete plan. Name the device geometry, tube-delivery method, operator, position, oxygenation method, and stop point.
Choose based on the situation
Macintosh-style video blade: a useful default when mouth opening is adequate and straightforward tube delivery is expected; allows familiar geometry and a video view.
Hyperangulated GlideScope/LoPro or similar blade: consider for an anterior larynx, limited neck extension, or difficult line-of-sight when the operator is trained; pair it with the matched rigid stylet.
Direct laryngoscopy: reasonable when it is the most familiar/available method or video is unavailable; stage a bougie and rescue video device.
Anticipated difficult airway with stable oxygenation: consider awake/flexible-scope or combined techniques with experienced help rather than converting a controlled problem into a crash airway.
State the ETT size, suction plan, and apneic-oxygenation method.
Plan to say: Plan A is ___ blade/device with ___ adjunct, by ___, in ___ position. Stop threshold is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Confirm
When time and clinical context allow, verify that the airway plan is consistent with documented goals of care and local policy. Do not let an unresolved documentation question silently replace an explicit team discussion.
Choose based on the situation
Confirm the documented code status or advance-care plan when it is available and relevant to the airway decision.
Clarify whether limits apply to CPR, vasopressors, invasive ventilation, escalation, or other interventions rather than assuming that one limit answers every question.
In a time-critical emergency with status unknown, follow applicable emergency-consent and institutional policy while the team continues to seek reliable information.
State any known treatment limits aloud so the airway, medication, and rescue plans are internally consistent.
Plan to say: Code status/goals are ___. Relevant treatment limits are ___. If status remains unknown, we will follow local emergency policy and reassess as information becomes available.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Video laryngoscopy improves first-attempt success in many critically ill adults, but the blade geometry must match the anatomy, tube-delivery plan, and operator skill.
Choose based on the situation
Macintosh-style video blade: familiar geometry, optional direct view, and usually simpler tube delivery; useful for many routine ED intubations.
Hyperangulated GlideScope/LoPro or similar: useful for anterior anatomy, limited neck motion, or poor line-of-sight; requires a matched rigid stylet and deliberate tube delivery.
Low-profile blade: consider when mouth opening is restricted and the device can be inserted safely; operator familiarity matters.
Direct laryngoscope: use when most familiar/available or as a backup; have a bougie and video device ready.
Awake/flexible-scope strategy: consider when difficult laryngoscopy and difficult rescue are anticipated but oxygenation remains controlled.
Plan to say: Device is ___. Blade is ___. Stylet/bougie is ___. Backup device is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
The medication plan must cover induction, paralysis, hemodynamic rescue, and post-intubation comfort.
Choose based on the situation
Verify the dosing weight, concentration, dose, syringe label, and contraindications.
Announce and administer induction before the paralytic.
Use ketamine or etomidate for patients at increased risk of peri-intubation hypotension; avoid treating fentanyl, midazolam, or propofol as equivalent shock defaults.
State the vasopressor/resuscitation plan before induction.
Have analgesia and sedation prepared before paralysis is given.
Plan to say: Induction is ___. Paralytic is ___. Pressor plan is ___. Post-intubation meds are ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Pearls
A timeout is useful only if it changes shared understanding. The room should hear who is doing what, the relevant code-status or goals-of-care limits, which device is being used, and exactly what will happen if the first plan fails.
Say aloud: Silence. Plan A is __. Plan B is __. Rescue Plan C is __. The backup airway/surgical plan is __. Roles are confirmed. Code status/goals are __ when relevant and feasible. Device is __, operator is __, position is __, and medications are __. Induction goes before paralytic. If blood pressure falls, the rescue plan is __.
Pitfalls
Calling for silence but continuing parallel conversation
Naming Plan B without saying what actually changes
No explicit rescue or surgical-airway trigger
Medication sequence not announced
No hemodynamic rescue plan for a shock-risk patient
Code status or relevant treatment limits not clarified when time and context allow
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]
Training video
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