Start Time: _______________Stop Time: _______________ Date: ______________________
Candidate’s Name: _______________________________________
Evaluator’s Name: ________________________________________
Possible Points | Points Awarded | |
Takes, or verbalizes, body substance isolation precautions | 1 |
|
Establishes unresponsiveness—attempts to stimulate | 1 |
|
Opens the airway (head tilt – 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 (mouth-to-mouth-and nose, with enough volume to make the chest rise, taking 1 – 1-1/2 seconds per breath) | 1 |
|
If unable to give initial breaths, repositions the head and reattempts ventilation. If still unsuccessful, follows unresponsive FBAO sequence | 1 |
|
Assesses for signs of circulation by feeling for a brachial pulse—taking no more than 10 seconds | 1 |
|
If there are no signs of circulation or if the pulse rate is <60 bpm with signs of poor perfusion, begins chest compressions by locating proper hand position | 1 |
|
Performs 5 chest compressions at a rate of approximately 100 per minute at a depth of 1/2 to 1 inch, using the 2 finger technique for 1 rescuer and 2 thumb technique for 2 rescuers | 1 |
|
Opens the airway and delivers 1 slow rescue breath (1 – 1-1/2 seconds, using a bag mask ventilation for 2 rescuers, if readily available) | 1 |
|
Finds the proper hand position and continues with a series of 5 compressions and 1 breath at a rate of 100 per minute | 1 |
|
Performs 10 complete cycles of 5 compressions and 1 ventilation each | 1 |
|
Re-assesses for signs of circulation (taking no more than 10 seconds) | 1 |
|
If there are still no signs of adequate circulation, resumes CPR, beginning with chest compressions at a ratio of 5 compressions to 1 ventilation, checking for signs of circulation and spontaneous breathing every few minutes | 1 |
|
If signs of adequate 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 adequate circulation are present, provides rescue breathing at a rate of 20 per minute (1 breath every 3 seconds) until breathing resumes, and monitors for signs of circulation every few minutes | 1 |
|
18 |
|
Critical Criteria
_____ Did not take, or verbalize, body substance isolation precautions
_____ Did not open the victim’s airway
_____ Did not establish that the victim was not breathing
_____ 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 begin chest compressions with heart rate of 60 bpm or less with signs of poor perfusion
_____ Did not deliver two adequate rescue breaths
_____ 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