EVAC CPR Program BLS Provider Infant CPR Skills Testing Checklist

EVAC CPR Program Infant CPR Skills Testing Checklist

Basic Life Support (BLS)
Student Name*
Date of Test*

MonthDayYear
Date
Hospital Scenario: “You are working in a hospital or clinic when a woman runs through the door, carrying an infant. She shouts, ‘Help me! My baby’s not breathing.’ You have gloves and a pocket mask. You send your coworker to activate the emergency response system and to get the emergency equipment.”

Prehospital Scenario: “You arrive on the scene for an infant who is not breathing. No bystander CPR has been provided. You approach the scene and ensure that it is safe. Demonstrate what you would do next.
Assessment and Activation*

Checks responsivenessChecks breathingShouts for help/Activates emergency response systemChecks pulse
Once student shouts for help, instructor says, “Here’s the barrier device.”
Cycle 1 of CPR (30:2)

*CPR feedback devices are preferred for accuracy
Infant Compressions*

Performs high-quality compressions*:
- Placement of 2 fingers or 2 thumbs in the center of the chest, just below the nipple line
- 30 compressions in no less than 15 and no more than 18 seconds
- Compresses at least one third the depth of the chest, approximately 1½ inches (4 cm)
- Complete recoil after each compression
Infant Breaths*

Gives 2 breaths with a barrier device:
- Each breath given over 1 second
- Visible chest rise with each breath
- Resumes compressions in less than 10 seconds
Cycle 2 of CPR (repeats steps in Cycle 1) - Only check box if step is successfully performed*

CompressionsBreathsResumes compressions in less than 10 seconds
Rescuer 2 arrives with bag-mask device and begins ventilation while Rescuer 1 continues compressions with 2 thumb– encircling hands technique.
Cycle 3 of CPR
Rescuer 1: Infant Compressions*

Performs high-quality compressions*:
- 15 compressions with 2 thumb–encircling hands technique
- 15 compressions in no less than 7 and no more than 9 seconds
- Compresses at least one third the depth of the chest, approximately 1½ inches (4 cm)
- Complete recoil after each compression
Rescuer 2: Infant Breaths
- This rescuer is not evaluated.
Cycle 4 of CPR Rescuer 2: Infant Compressions

This rescuer is not evaluated.
Rescuer 1: Infant Breaths*

Gives 2 breaths with a bag-mask device:
- Each breath given over 1 second
- Visible chest rise with each breath
- Resumes compressions in less than 10 seconds
STOP TEST
Instructor Notes
- Place a check in the box next to each step the student completes successfully.
- If the student does not complete all steps successfully (as indicated by at least 1 blank check box), the student must receive remediation. Make a note here of which skills require remediation (refer to instructor manual for information about remediation
Test Results Check PASS or NR to indicate pass or needs remediation:*

PASSNR
Instructor Name & Number*
Date*

MonthDayYear
Date
Should be Empty:

EVAC CPR Program Infant CPR Skills Testing Checklist

Cycle 1 of CPR (30:2)

Cycle 3 of CPR

Cycle 4 of CPR Rescuer 2: Infant Compressions

STOP TEST