BLSBasicLifeSupport

StudentName:_________________________________________TestDate:________________________
Skills Checklist

Checkifdone
Adult/Child/BLS-1and2Responders correctly

Steps SkillsDemo

1-ResponderAdultBLSSkillsEvaluation
Note:EvaluatethefirstrescuersabilitytoinitiateBLSanddeliverhigh-qualityCPRfor5cycles

1 Checkforresponsiveness

2 Callforhelp,activatetheemergencyresponsesystemandsendsforanAED

Checkforbreathingandpulseforatleast5secondsandnomorethan10
3 seconds

4 Beginhigh-qualityCPR

a. CorrectcompressionProperHandPlacement
i. Adult:Lowerhalfofthebreastbone,2hands
ii. Child:Lowerhalfofthebreastbone,1or2hands

b. Rate:Give100to120/minutecompressionsordeliverseachsetof30
Chestcompressionsinnolessthan15secondsandnomorethan18
seconds

c. Depth:Delivercompressionatleast2inchesindepth

d. Minimizeinterruptions:Gives2breathswithpocketmaskinlessthan
10seconds.

SecondRescuerAEDSkillsEvaluationandSWITCH
Note:EvaluatethesecondrescuersabilitytousetheAEDandbothrescuersabilitiestoswitchroles.

5 Instructorprompt:Aftercompleting5cyclesofcompressionsandbreaths,
theAEDarriveswithbagmaskdevice.

6 SecondRescuerpowersonAEDandappliespatcheswhilefirstrescuer
continuesCPR
a. PowerAEDon

b. Applypatches
i. Drypatientifwet
BLSBasicLifeSupport
StudentName:_________________________________________TestDate:________________________
Skills Checklist

ii. DonotuseAEDifpatientonwetsurface
iii. Removeanyvisiblemedicationpatches
iv. DonotapplypatchesoverPacemaker
v. Pediatricpatchesforchild,ifavailable
vi. Donotallowpatchestotouchoroverlap

c. Secondrescuerclearpatient,allowingAEDtoanalyze-Switch
rescuers

d. WhenAEDpromptsshockablerhythm,secondrescuerclearsthe
patientagainanddeliversshock

e. DeliverShock

f. ResumeCPRstartingwithchestcompressions

g. IfAEDstatesNoShockAdvisedresumeCPRstartingwithchest

PASSNeedsRetest

InstructorName:_________________________________________Date:__________________

Checkifdone
Adult/Child/BLS-1and2Responders correctly

Steps SkillsDemo

FirstRescuerBag-MaskVentilation
Note:Evaluatethefirstrescuersabilitytogivebreathswithabagmask.

1 Bothrespondersresumehigh-qualityCPRimmediatelyaftershockdelivery

2 Secondrespondergives30compressionsimmediatelyaftershockdelivery
for2cycles

3 Firstrespondersuccessfullydelivers2breathswithbag-maskfor2cycles

PASSNeedsRetest

InstructorName:_________________________________________Date:__________________

BLSBasicLifeSupport
StudentName:_________________________________________TestDate:________________________
Skills Checklist

Checkifdone
InfantBLS-1and2Responders correctly

Steps SkillsDemo

1RescuerInfantBLSSkillsEvaluation
Note:EvaluatethefirstrescuersabilitytoinitiateBLSanddeliverhigh-qualityCPRfor5cycles

1 Checkforresponsiveness

2 Callforhelp,activatetheemergencyresponsesystemandsendsforAED

Checkbreathingandpulseforatleast5secondsandnomorethan10
3 seconds

4 Deliverhigh-qualityCPR

a. Correctcompression:ProperFingerPlacement

b. b.Rate:100to120/minutecompressions(eachsetof30compressions
innolessthan15secondsandnomorethan18seconds

c. c.Depth:Delivercompressionatleastonethirdofthedepthofthe
chest(approximately1inchesor4cm),atleast23outof30.

d. d.Allowcompletechestrecoil,atleast23outof30.

2RescuerCPRandSWITCH
Evaluatethefirstrespondersabilitytogivebreathwithabag-maskandgivecompressionsby
usingthe2thumb-encirclinghandstechnique.

Evaluatebothrescuersabilitytoswitchroles

Instructorprompt:Aftercompleting5cyclesofcompressionsandbreaths,
1 secondresponderarriveswithbagmaskdevice.

2 a. RespondersSwitchRoles

3 Bothrespondersresumehigh-qualityCPR

a. Secondresponderdelivers15compressionsinnolessthan7seconds
andnomorethan9secondsbyusingthumb-encirclinghands
techniquefor2cycles
BLSBasicLifeSupport Skills Checklist
StudentName:_________________________________________TestDate:________________________

b. Firstrespondersuccessfullygives2breathswithbag-mask
for2cycles

After2Cycles,PromptResponderstoSwitchRoles

4 Bothrespondersresumehigh-qualityCPR

a. Firstresponderdelivers15compressionsinnolessthan7seconds
andnomorethan9secondsbyusingthumb-encirclinghands
techniquefor2cycles

b. Secondrespondersuccessfullygives2breathswithbag-maskfor
2cycles

PASSNeedsRetest

InstructorName:_________________________________________Date:__________________