#note/rubric | #on/airway | #on/emergencymedicine | #on/emergencymanual| #on/awakeintubation **Granular Rubric for Observing Awake Intubation** **Scale:** • **1 = Needs Improvement** (Incorrect technique, delays, excessive movement) • **2 = Developing Competency** (Mostly correct but with inefficiencies) • **3 = Mastery** (Efficient, minimal movement, precise execution) **Rubric for Awake Intubation** | **Category** | **1 - Needs Improvement** | **2 - Developing Competency** | **3 - Mastery** | **Score (1-3)** | | --------------------------------------------------------------------------------- | -------------------------------------------------------------------------------- | ------------------------------------------------------------------------------ | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------- | | **1. Recognizing the Indication & Mental Preparation** | Hesitates, delays, or considers other options too long. | Identifies need but lacks confidence or delays in committing. | **Immediately recognizes need, justifies decision with positive self-talk, verbalizes a personal enabling mantra.** Example: _“I have trained for this, and I will keep my patient breathing and safe.”_ | | | **2. Declaring the Emergency** | Does not verbalize or delays clear communication. | States urgency but does not use standardized language. | **Clearly names the emergency: “We need to proceed with awake intubation due to ...” Claims roles, "I'm going to get us organized and I need your help." Aims team" I need you to get the equipment on the patient's right on a table, xxx continuing to try oxygenating from above, xxx to document, xxx on meds, xxx watching the monitor ... what am I missing? ** | | | **3. Equipment Readiness** | Does not organize or retrieve equipment in a timely manner. | Gathers equipment but placement is suboptimal. | **Ensures all required equipment is on the dominant side, within easy reach. Includes flexible or rigid scope, atomizer, gauze, tongue depressor, suction, vasoconstrictor, local anesthetic, intubating airway, ET tube should be at least 29 cm (7-0), syringe, and backup airway. Does not select subglottic suction ETT, choses nasal ETT if nasal route.** | | | **4. Team Coordination & Oxygenation Strategy** | Fails to delegate tasks, leading to confusion or inefficiencies. | Provides some direction but lacks clarity or structured roles. | **Ensures team knows roles: One team member continues passive oxygenation, another prepares suction, and backup airway personnel stand by.** | | | **5. Pre-Treatment (Antisialagogue & Vasoconstrictor if Nasal Approach)** | Does not administer or administers too late. | Administers but timing is not ideal. | **Administers glycopyrrolate (or atropine) 15 minutes before intubation to dry secretions. Nasal route: Applies oxymetazoline or phenylephrine to reduce bleeding.** | | | **6. Airway Drying & Preparation** | Fails to dry or delays application of anesthesia. | Dries airway but with inadequate technique. | **Pads dry the oral cavity with gauze to optimize local anesthetic absorption. Ensures suction is ready.** | | | **7. First Step of Topicalization: Lidocaine Application to Tongue & Oropharynx** | Does not adequately apply topical anesthetic or applies inconsistently. | Applies lidocaine but with inefficiencies or excessive patient discomfort. | **Applies 4% lidocaine cream to the posterior tongue using a tongue depressor and allows time for absorption.** | | | **8. Second Step of Topicalization: Atomization to Oropharynx & Vocal Cords** | Misses key structures or does not allow time for effect. | Applies correctly but with excess movement or patient discomfort. | **Uses MADgic atomizer or equivalent to deliver 4% lidocaine to oropharynx and vocal cords, minimizing patient discomfort.** | | | **9. Ensuring Nasal Patency (If Nasal Approach)** | Does not check patency or selects an inappropriate side. | Inserts nasopharyngeal airway (NPA) but struggles or does not confirm airflow. | **Inserts NPA to confirm nasal patency before proceeding, ensuring smooth passage of the ETT.** | | | **10. Nasal Passage Dilation (If Nasal Approach)** | Does not dilate, causing resistance or trauma. | Dilation performed but not optimally. | **Dilates nare by gently inserting a gloved, lubricated small finger before advancing the ETT.** | | | **11. ETT Placement into Nasopharynx (If Nasal Approach)** | Places ETT with improper angle or incorrect bevel orientation. | Inserts correctly but requires excessive repositioning. | **Advances ETT to ~14 cm, listens for airflow confirming placement in the hypopharynx. If using right nare, bevel faces turbinates (away from septum), then rotates 180° after passing turbinates. ETT tip is slightly angled toward midline for optimal positioning.** | | | **12. Instrument Handling & Scope Insertion** | Rough technique, excessive movement, or poor angulation. | Inserts correctly but with some difficulty or patient distress. | **Best practice: Uses ring and long fingers of the non-dominant hand on the tip of the ETT for stabilization, thumb and index fingers advance the scope. Dominant hand keeps tension on the scope, pivots wrist to rotate.** | | | **13. Glottic Identification & Tube Navigation** | Fails to recognize structures or delays tube advancement. | Locates structures but hesitates or struggles with tube passage. | **Smoothly advances the scope keeping the stripe of the ETT at 12 o'clock while passing through the ETT, clearly identifies the larynx, hugs the epiglottis and directs the tube into the trachea to the carina without excessive repositioning.** | | | **14. Passing the Endotracheal Tube** | Tube placement is too forceful, off-center, or obstructed. | Passes tube but with minor difficulty or excessive maneuvering. | **Directs the patient to breathe in deeply, smoothly advances the ET tube over the endoscope while rotating bevel towards the arytenoids to prevent impingement.** | | | **15. Confirmation of Placement** | Skips confirmation or delays necessary checks. | Confirms but with inefficient timing. | **Quickly confirms placement using capnography, breath sounds, and chest rise. Ensures tube is not too deep before securing.** | | | **16. Post-Intubation Sedation, Analgesia, & Ventilation Strategy** | Forgets to sedate the patient post-intubation or provides excessive ventilation. | Provides sedation but with delays or inconsistent control. | **Administers sedation and analgesia immediately after confirmation. Uses BVM with PEEP valve, avoids over-ventilation.** | | **Total Score: ____ / 48** **Performance Levels** • **43-48 = Mastery**: Minimal movement, optimal efficiency, confident execution. • **35-42 = Competent**: Mostly correct technique but some inefficiencies. • **25-34 = Developing**: Needs refinement in movement efficiency, patient communication, or procedural flow. • **<25 = Needs Improvement**: Major inefficiencies, hesitation, or errors.