KING LT(S)-D
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Minutes
Evaluator
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Student
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Skill Steps
Verbalizes/demonstrates appropriate infection control precautions
Selects appropriate device size
Ventilates and oxygenates (rate of 10 – 12)
Gathers and checks equipment (tests cuff)
Lubricates distal tip of the device [may be verbalized]
Removes adjunct airway
Positions head properly (sniffing)
Performs a tongue-jaw lift
Aligns blue orientation line with corner of the mouth
Advances tube, rotates back to midline
Inserts device until base of connector aligns with teeth
Secures device in patient (inflates cuffs with proper volumes and immediately removes syringe or secures strap)
Ventilates patient
Confirms tube by auscultation and ETCO2
Withdraws tube while bagging until ventilation is easy and free flowing
Secures device
Critical Criteria
Failure to initiate ventilations within 30 seconds after taking BSI
Interrupts ventilations for greater than 30 seconds at any time
Failure to take or verbalize BSI
Failure to provide high flow oxygen
Failure to ventilate the patient at an appropriate rate
Failure to inflate cuffs and immediately remove the syringe
Failure to manage the patient as a competent EMT
Exhibits unacceptable affect with patient or other personnel
Uses or orders a dangerous or inappropriate intervention
Evaluator Comments
Success?
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Pass
Needs Remediation
Signature
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