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Post-intubation checklist for EMS: verify these before you move the patient

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The tube is confirmed, the vent is running, and the next thing that happens is four people pick the patient up: this is exactly the moment a post-intubation checklist exists for. It is not a protocol; it is the printable sequence a crew runs on an intubated adult before that move, and again after it.

A post-intubation checklist is the ordered set of checks a crew runs on an intubated adult after the ventilator settings are on and before the patient moves: the tube, the circuit, the settings, sedation, and the equipment that has to be within reach. It runs again after every move. It applies to adult patients only, and every item is a check to run, not an order to follow; the crew’s own protocol and scope of practice govern which items apply.

It is one piece of the wider post-intubation ventilator management workflow, the sequence that runs from confirming the tube through handoff. This page is the artifact a crew actually runs at one point inside it.

What the checklist covers

The checklist is a sequence, not a list, and the sequence is the point: skipping an item out of order is exactly the failure mode this exists to catch. It runs in two phases. Before you move: verify the tube, the circuit, the settings, and sedation are where they should be. After every move: run a shorter version of the same checks, because a lift or a stretch moves the tube and the circuit right along with the patient.

The depth behind each item lives on the pages built for it. If the crew already worked through the settings that followed RSI, this page picks up right after that: the first settings after RSI, this page’s checks before the move.

What is a post-intubation checklist?

It is the ordered sequence of tube, circuit, settings, and sedation checks a crew runs on an intubated adult, once before the next move and again after every one that follows.

Verify before you move: the checklist

The list below is the checklist itself. Every row is a check, phrased as something you look for, not an order to carry out. Rows with a number carry a named published source; rows with no citable number ship without one, described qualitatively rather than invented.

Before you move: 14 checks

Tick each box as you go, or print the page before ticking for a blank paper copy.

The tube

Checks 1 to 4

  • Waveform capnography should be on before the first breath through the airway (NASEMSO), and it’s how you confirm placement both at the start and for the rest of the transport (NAEMSP 2022). If the trace flattens or disappears, think obstructed device, dislodged tube, poor ventilation, or device failure (StatPearls, Prehospital Mechanical Ventilation).

  • Note the depth at the incisors or gum line (NASEMSO). That number is your reference for every recheck. Don’t trust a depth you remember: reassess often with capnography and a look at the tube.

  • Measure it with a manometer. Squeezing the pilot balloon is documented as inaccurate. Keep it at or below 30 cm H2O, the maximum multiple studies recommend (Tennyson et al., 2016). This is often missed: one study of patients arriving for helicopter transport found 84% already above that limit, averaging 70 cm H2O (Tennyson et al., 2016). The cuff pressure target range has its own page.

  • Once position is confirmed, secure the tube with tape, twill, or a commercial holder. A cervical collar may also reduce the risk of displacement (NASEMSO). An unsecured tube is the one that moves on the next pothole.

The circuit

Checks 5 to 8

  • The ventilator should have had a pre-use check before it went on the patient (NASEMSO; StatPearls, Ventilator Safety). A loose connection is a leak or disconnect waiting for the next bump.

  • Every ventilated patient needs a bag-valve-mask at hand (StatPearls, Ventilator Safety). If the vent needs troubleshooting, or the patient is desaturating or unstable, consider taking them off the vent and bagging (StatPearls, Prehospital Mechanical Ventilation).

  • Secretions can block a tube at any point in the transport, and suction is the fix; every ventilated patient needs suctioning, based on need rather than a schedule (StatPearls, Ventilator Safety). Having it within reach before the move is field practice, not a cited checklist item.

  • Before you move, trace the circuit from vent to tube. A strap or lead pinned across the tubing can kink it without anyone noticing. This is field practice, not a cited standard.

The vent

Checks 9 to 12

  • Confirm that mode, rate, tidal volume, PEEP, FiO2, and sensitivity match what you set (NASEMSO’s documentation list). A mismatch may be an entry error, a setting that drifted, or a ventilator that came back up on its manufacturer defaults when it was powered on (StatPearls, Ventilator Safety).

  • Compare exhaled volume against this patient’s own baseline (NASEMSO). Extreme fluctuation can mean a leak in the circuit or the tube (NASEMSO). An exhaled volume that keeps drifting has its own troubleshooting page.

  • Plateau pressure should stay under 30 cm H2O (NASEMSO; StatPearls, Prehospital Mechanical Ventilation). Compare peak pressure to the same baseline (NASEMSO). If either number is climbing, stop and troubleshoot. The alarm troubleshooting page is linked below the recheck list.

  • Set high pressure, low pressure, minute volume, and apnea alarms appropriately for this patient (NASEMSO; StatPearls, Ventilator Safety). Whatever limits the vent powered on with were not set for this patient. Never silence or ignore an alarm without checking the cause first (StatPearls, Ventilator Safety).

The patient

Checks 13 and 14

  • Write both values down with the settings (NASEMSO’s documentation list). Every later change gets judged against this baseline, not a memory of “normal.”

  • Titrate sedation to a target level using RASS or a similar scale (NASEMSO), and give appropriate analgesia (NAEMSP 2022). A patient who is paralyzed without sedation is a management failure, not something to circle back to.

For the vent rows, the reference card holds the normal vent values each check is judged against, and the settings row 9 checks are laid out in the ventilator settings cheat sheet.

What do you check after intubating a patient?

Fourteen checks, grouped into the tube, the circuit, the vent, and the patient, run once before the next move. The checklist above is the sequence in order.

Sedation, analgesia, and the things that have to be within reach

A paralyzed patient who is not sedated is a management failure, and a vent running without a bag-valve-mask within reach is a vent running without a backup. Both get skipped for the same reason: neither one is announced by an alarm.

Depth is scored, not eyeballed. RASS, or a similar scale, is the tool NASEMSO names for titrating sedation to a target level, and this page prints no goal band: the target depth is protocol-dependent, and NASEMSO’s own wording is “an appropriate target level,” with no number attached. None of that is dosing. Every mg/kg figure, drug name, and route belongs to RSI medication doses on actual body weight, a different page and a different weight basis entirely.

Recheck after every move

Every move moves the tube and the circuit right along with the patient, so the checks above run again, shorter. NASEMSO names the triggers directly: after each patient movement, into and out of the ambulance, and at patient transfer in the ED.

The mechanisms are mechanical, not medical. A tube can shift on a rough stretch of road. A circuit gets pinned under a strap and kinks without anyone noticing. A connector pops loose on the lift into the truck. Not every one of those sets off an alarm, which is why the recheck runs on a trigger, not a hunch.

After every move: 6 rechecks

Into the ambulance, out of it, and at every transfer.

  • Confirmed after each patient movement (NASEMSO)

  • A lift or a stretch can move the tube

  • A connector or a strap is exactly what a lift disturbs

  • Extreme fluctuation may mean a leak in the circuit or the tube (NASEMSO)

  • NASEMSO names into and out of the ambulance as one of the documented moments

  • A lift is exactly the stimulus that can wake a lightly sedated patient

There is a differential built for the move that goes wrong, when the sats drop instead of settling. Whenever the vent itself needs troubleshooting, alarm by alarm, the ventilator alarm causes and first actions is the page built for it.

What should you recheck after moving an intubated patient?

Capnography, tube position, circuit connections, exhaled tidal volume against baseline, EtCO2, and sedation level, run again after every patient movement, not on a clock.

Write down the post-intubation checks before you hand it over

What gets recorded: the confirmation method and the time, the settings and the time they went on, the baseline SpO2 and EtCO2, and every change along with the reason for it. NASEMSO’s own documentation list names both the settings and the patient values, baseline and repeated, as what a crew records, and tube position verified at turnover is one of the profession’s own performance measures.

The app runs the same arithmetic every time it is asked, but it does not remember what changed twenty minutes ago and it does not write any of it down. That part, along with the handoff report itself, stays the clinician’s.

Do post-intubation checklists actually change anything?

The honest answer is not the one the genre usually gives. NASEMSO’s own guideline asserts that checklist use has been shown to improve intubation success and cut peri-intubation complications. The randomized and pooled evidence says otherwise for the outcomes that matter most: a multicenter randomized trial found a preprocedure checklist did not improve the lowest oxygen saturation, the lowest blood pressure, or severe complication rates during intubation of critically ill adults (Janz et al., Chest 2018), and a systematic review and meta-analysis of eleven studies and over 3,200 patients found checklist use was not associated with lower mortality; it was associated with fewer hypoxic events overall, but the studies with a low risk of bias did not show that benefit (Turner et al., JAMA Network Open 2020). An air-medical study did find higher first-pass success after adopting a checklist, but it studied a checklist run before intubation, not after, and its own authors write that the hospital literature has not shown a clinically important benefit (Olvera et al., Air Med J 2024). The only study located of a checklist run after intubation, rather than before it, is an observational study in a single medical ICU, and what it improved was how quickly a blood gas result came back, not a patient outcome (McConnell et al., Respir Care 2016).

So why run one. Because the failure modes the checklist catches, a tube that migrated, a circuit that leaked, sedation nobody scored, are the ones that kill quietly and show up nowhere in a randomized trial’s headline numbers. Nobody has studied whether running this exact sequence, on this exact patient, changes an outcome. Crews run it anyway, and the honest reason is the sequence itself, not a promise the trials do not back up.

Sources

Every cited check above traces to one of the sources below; rows 7 and 8 ship as field practice, with one StatPearls line behind the need for suction in row 7 and no source behind row 8. The evidence section names four studies that disagree with each other and with the genre’s usual pitch; none of them is hidden.

  1. Baez AA, Qasim Z, Wilcox S, Weir WB, Loeffler P, Golden BM, Schwartz D, Levy M. Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care. 2022;26(sup1):88-95. PMID: 35001824. https://pubmed.ncbi.nlm.nih.gov/35001824/
  2. Davis DP, Bosson N, Guyette FX, Wolfe A, Bobrow BJ, Olvera D, Walker RG, Levy M. Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care. 2022;26(sup1):72-79. PMID: 35001819. https://pubmed.ncbi.nlm.nih.gov/35001819/
  3. National Association of State EMS Officials. National Model EMS Clinical Guidelines, Version 3.0. March 2022. Airway Management and Mechanical Ventilation (Invasive) sections. https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines_2022.pdf
  4. Kuhl EA, Perera TB. Prehospital Mechanical Ventilation. In: StatPearls. StatPearls Publishing; updated March 8, 2024. NCBI Bookshelf NBK537072. https://www.ncbi.nlm.nih.gov/books/NBK537072/
  5. Williams LM, Sharma S. Ventilator Safety. In: StatPearls. StatPearls Publishing; updated August 8, 2023. NCBI Bookshelf NBK526044. https://www.ncbi.nlm.nih.gov/books/NBK526044/
  6. Tennyson J, Ford-Webb T, Weisberg S, LeBlanc D. Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport. Western Journal of Emergency Medicine. 2016;17(6):721-725. PMCID: PMC5102598. https://pmc.ncbi.nlm.nih.gov/articles/PMC5102598/
  7. McConnell RA, Kerlin MP, Schweickert WD, Ahmad F, Patel MS, Fuchs BD. Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention. Respiratory Care. 2016;61(7):902-912. PMID: 26932381. https://pubmed.ncbi.nlm.nih.gov/26932381/
  8. Olvera DJ, Lauria M, Norman J, Gothard MD, Gothard AD, Weir WB. Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport. Air Medical Journal. 2024;43(3):241-247. PMID: 38821706. https://pubmed.ncbi.nlm.nih.gov/38821706/
  9. Janz DR, Semler MW, Joffe AM, et al. A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults. Chest. 2018;153(4):816-824. PMID: 28917549. https://pubmed.ncbi.nlm.nih.gov/28917549/
  10. Turner JS, Bucca AW, Propst SL, Ellender TJ, Sarmiento EJ, Menard LM, Hunter BR. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Network Open. 2020;3(7):e209278. PMID: 32614424. https://pubmed.ncbi.nlm.nih.gov/32614424/