Start Time: _______________Stop Time: _______________ Date: ______________________
Candidate’s Name: _______________________________________
Evaluator’s Name: ________________________________________
Points Possible | Points Awarded | |
Takes, or verbalizes, body substance isolation precautions | 1 |
|
Establishes unresponsiveness | 1 |
|
Opens the airway (head tile – chin lift or jaw thrust maneuver) | 1 |
|
Assesses breathing (look, listen and feel) to identify absent or inadequate breathing—taking no more than 10 seconds | 1 |
|
If victim is breathing or resumes effective breathing, place victim in recovery position | 1 |
|
If victim is not breathing, gives 2 slow breaths (without O 2 supplement over 2 seconds each; with O 2 supplement over 1 to 2 seconds) | 1 |
|
If unable to give initial breaths, repositions the head and reattempts ventilation. If still unsuccessful, follows unresponsive FBAO sequence | 1 |
|
Assess for signs of circulation by feeling for a carotid pulse (10 sec max) | 1 |
|
If there are no signs of circulation, begins chest compressions by locating proper hand position; considers AED use if available and appropriate | 1 |
|
Performs 15 chest compressions at a rate of approximately 100 per minute, depressing the chest 1-1/2 to 2 inches with each compression | 1 |
|
Opens the airway and delivers 2 slow rescue breaths (2 seconds each) | 1 |
|
Finds the proper hand position and begins 15 more compressions at a 1 rate of 100 per minute | 1 |
|
Performs 4 complete cycles of 15 compressions and 2 ventilations | 1 |
|
Re-assesses for signs of circulation (10 seconds) | 1 |
|
If there are still no signs of circulation, resumes CPR, beginning with chest compressions, checking for signs of circulation and spontaneous breathing every few minutes | 1 |
|
If signs of circulation are present, checks for breathing | 1 |
|
If breathing is present, places the victim in a recovery position and monitors breathing and circulation | 1 |
|
If breathing is absent but signs of circulation are present, provides rescue breathing at 10 to 12 times per minute (1 breath every 4 to 5 seconds) and monitors for signs of circulation every few minutes | 1 |
|
18 |
|
Total: 18
Critical Criteria
_____ Did not take, or verbalize, body substance isolation precautions
_____ Did not establish unresponsiveness
_____ Did not open the victim’s airway
_____ Did not establish that the victim was not breathing
_____ Did not deliver two adequate rescue breaths
_____ Took longer than 10 seconds to establish the patient was not breathing
_____ Did not assess for a pulse
_____ Took longer than 10 seconds to establish the patient had no pulse
_____ Did not consider AED use
_____ Did not deliver compressions at an appropriate depth, location, or rate
_____ Did not reassess the patient’s circulatory or respiratory status
_____ Did not assess breathing status after the return of a pulse
_____ Did not provide rescue breathing as necessary after the return of a pulse