Skill Evaluation Sheets - paramedic.emszone.com 1_Skill... · Skill Evaluation Sheets Skill Drill 11-1: ... Skill Drill 15-14: Suctioning of a Stoma Skill Drill 15-15: Mouth-to-Stoma

Nancy Caroline’s Emergency Care in the Streets, Seventh Edition AAOS

© 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company • www.jblearning.com

Skill Evaluation Sheets

Skill Drill 11-1: Spiking the Bag

Skill Drill 11-2: Obtaining Vascular Access

Skill Drill 11-3: Gaining Intraosseous Access With an EZ-IO Device

Skill Drill 11-4: Administering Medication via a Nasogastric Tube

Skill Drill 11-5: Drawing Medication From an Ampule

Skill Drill 11-6: Drawing Medication From a Vial

Skill Drill 11-7: Administering Medication via the Subcutaneous Route

Skill Drill 11-8: Administering Medication via the Intramuscular Route

Skill Drill 11-9: Administering Medication via the Intravenous Bolus Route

Skill Drill 11-10: Administering Medication via the Intraosseous Route

Skill Drill 11-11: Administering Medication via the Sublingual Route

Skill Drill 11-12: Assisting a Patient With a Metered-Dose Inhaler

Skill Drill 11-13: Administering a Medication via Small-Volume Nebulizer

Skill Drill 11-14: Accessing a Tunneling Device

Skill Drill 11-15: Accessing an Implanted Vascular Access Device

Skill Drill 13-1: Performing a Rapid Exam

Skill Drill 13-2: Performing Percussiong

Skill Drill 13-3: Performing the Full-Body Exam

Skill Drill 13-4: Assessing the Head

Skill Drill 13-5: Examining the Eye

Skill Drill 13-6: Eye Examination With an Ophthalmoscope

Skill Drill 13-7: Examining the Ear With an Otoscope

Skill Drill 13-8: Examining the Neck

Skill Drill 13-9: Examining the Chest

Skill Drill 13-10: Auscultating Heart Sounds

Skill Drill 13-11: Examining the Abdomen



Skill Drill 13-12: Examining the Musculoskeletal System

Skill Drill 13-13: Examining the Peripheral Vascular System

Skill Drill 13-14: Examining the Spine

Skill Drill 13-15: Examining the Nervous System

Skill Drill 13-16: Evaluating Deep Tendon Reflexes

Skill Drill 15-1: Head Tilt–Chin Lift Maneuver

Skill Drill 15-2: Jaw-Thrust Maneuver

Skill Drill 15-3: Tongue-Jaw Lift Maneuver

Skill Drill 15-4: Suctioning a Patient’s Airway

Skill Drill 15-5: Inserting an Oral Airway

Skill Drill 15-6: Inserting an Oral Airway With a 90° Rotation

Skill Drill 15-7: Inserting a Nasal Airway

Skill Drill 15-8: Removal of an Upper Airway Obstruction With Magill Forceps

Skill Drill 15-9: Placing an Oxygen Cylinder Into Service

Skill Drill 15-10: Mouth-to-Mask Ventilation

Skill Drill 15-11: Using CPAP

Skill Drill 15-12: Nasogastric Tube Insertion in a Responsive Patient

Skill Drill 15-13: Orogastric Tube Insertion

Skill Drill 15-14: Suctioning of a Stoma

Skill Drill 15-15: Mouth-to-Stoma Ventilation Using a Resuscitation Mask

Skill Drill 15-16: Bag-Mask Device-to-Stoma Ventilation

Skill Drill 15-17: Replacing a Dislodged Tracheostomy Tube With a Temporary Endotracheal Tube

Skill Drill 15-18: Intubation of the Trachea Using Direct Laryngoscopy

Skill Drill 15-19: Performing Blind Nasotracheal Intubation

Skill Drill 15-20: Performing Digital Intubation

Skill Drill 15-21: Performing Transillumination Intubation

Skill Drill 15-22: Performing Retrograde Intubation



Skill Drill 15-23: Performing Tracheobronchial Suctioning

Skill Drill 15-24: Performing Pediatric Endotracheal Intubation

Skill Drill 15-25: Inserting a Combitube

Skill Drill 15-26: LMA Insertion

Skill Drill 15-27: Inserting a King LT Airway

Skill Drill 15-28: Inserting a Cobra Perilaryngeal Airway (CobraPLA)

Skill Drill 15-29: Performing an Open Cricothyrotomy

Skill Drill 15-30: Performing Needle Cricothyrotomy and Translaryngeal Catheter Ventilation

Skill Drill 17-1: Performing Cardiac Monitoring

Skill Drill 17-2: Acquiring a 12-Lead ECG

Skill Drill 17-3: Performing Manual Defibrillation

Skill Drill 17-4: Performing Defibrillation With an AED

Skill Drill 17-5: Performing Cardioversion

Skill Drill 17-6: Performing Transcutaneous Pacing

Skill Drill 28-1: Restraining a Patient


Candidate: Date:

ID#:

Skill Drill 11-1 Spiking the Bag

Task: Spike an IV bag.

Performance Observations: The candidate shall be able to correctly spike an IV bag.

Candidate Directive: “Properly spike an IV bag.”

No. Task Steps First Test Retest

P F P F

1. Pull on the protective covering on the end of the IV bag to remove it.

2. Move the roller clamp to the off position and slide the spike into the IV bag until it is seated against the bag.

3. Squeeze the drip chamber to fill to the line marking the chamber and then run fluid into the line to flush the air out of the tubing.

4. Twist the protective cover of the opposite end of the IV tubing to allow air to escape. Do not remove this cover yet. Let the fluid flow until air bubbles are removed from the line before turning the roller clamp wheel to stop the flow, or setting the drip rate per the required dose.

5. Check the drip chamber; it should be only half-filled. If the fluid level is too low, squeeze the chamber until it fills; if the chamber is too full, invert the bag and the chamber and squeeze the chamber to empty the fluid back into the bag.

Retest Approved By: Retest Evaluation:

Evaluator Comments: Candidate Comments:

Evaluator Date Candidate Date

Retest Evaluator Date Retest Candidate Date



Candidate: Date:

ID#:

Skill Drill 11-2 Obtaining Vascular Access

Task: Obtain vascular access.

Performance Observations: The candidate shall be able to correctly obtain vascular access.

Candidate Directive: “Properly obtain vascular access.”


P F P F

1. Fill the drip chamber by squeezing it.

2. Flush or “bleed” the tubing to remove any air bubbles by opening the roller clamp.

3. Tear the tape before venipuncture, or have a commercial device available.

4. Apply gloves before making contact with the patient. Palpate a suitable vein.

5. Apply the constricting band above the intended IV site.

6. Clean the area using aseptic technique. Use an alcohol pad to cleanse in a circular motion from the inside out. Use a second alcohol pad to wipe straight down the center.

7. Choose the appropriately sized catheter, and examine it for any imperfections.

8. Insert the catheter at an angle of approximately 45° with the bevel up while applying distal traction with the other hand.

9. Observe for “flashback” as blood enters the catheter. Hold the hub while withdrawing the needle so as not to pull the catheter out of the vein.

10. Immediately dispose of all sharps in the proper container.

11. Attach the prepared IV line. Hold the hub of the catheter while connecting the IV line.

12. Remove the constricting band.

13. Open the IV line to ensure fluid is flowing and the IV is patent. Observe for swelling or infiltration around the IV site.

14. Secure the catheter with tape or a commercial device.

15. Secure the IV tubing and adjust the flow rate while monitoring the patient.






Skill Drill 11-2 Obtaining Vascular Access, continued





Candidate: Date:

ID#:

Skill Drill 11-3 Gaining Intraosseous Access With an EZ-IO Device

Task: Gain intraosseous access with an EZ-IO device.

Performance Observations: The candidate shall be able to correctly gain intraosseous access with an EZ-IO device.

Candidate Directive: “Properly gain intraosseous access with an EZ-IO device.”


P F P F

1. Check selected IV fluid for proper fluid, clarity, and expiration date. Select the appropriate equipment, including an IO needle, syringe, saline, and extension tubing. Select the proper administration set. Connect the administration set to the bag. Prepare the administration set, syringe, and extension tubing.

2. Take standard precautions.

3. Identify the proper anatomic site for IO puncture. Palpate the landmarks and then prepare the site.

4. Cleanse the site appropriately.

5. Attach the needle to the EZ-IO gun and remove the protective cover.

6. Stabilize the tibia, and insert the needle at a 90° angle, advancing it with a twisting motion until a “pop” is felt.

7. Remove the stylet from the catheter.

8. Attach the syringe and extension set to the IO needle. Pull back on the syringe to aspirate blood and particles of bone marrow to ensure proper placement. Slowly inject saline to ensure proper placement of the needle. Watch for extravasation, and stop the infusion immediately if it is noted. Connect the administration set, and adjust the flow rate as appropriate. Secure the needle with tape, and support it with a bulky dressing.







Skill Drill 11-3 Gaining Intraosseous Access With an EZ-IO Device, continued


Candidate: Date:

ID#:

Skill Drill 11-4 Administering Medication via a Nasogastric Tube

Task: Administer medication via a nasogastric tube.

Performance Observations: The candidate shall be able to correctly administer medication via a nasogastric tube.

Candidate Directive: “Properly administer medication via a nasogastric tube.”


P F P F

1. Attach a 60-mL syringe to the proximal end of the gastric tube, and slowly inject air into the tube while auscultating over the epigastrium to confirm proper placement. For further confirmation of correct tube placement, aspirate with the syringe and observe for gastric contents.

2. Inject 30 to 60 mL of normal saline into the gastric tube to irrigate the tube.

3. Inject the appropriate amount of medication into the gastric tube.

4. Flush the gastric tube with 30 to 60 mL of normal saline to ensure dispersal of the drug into the stomach.

5. Clamp off the proximal end of the gastric tube; do not reattach the tube to suction. Monitor the patient for adverse reactions, and repeat the medication dose if indicated.







Candidate: Date:

ID#:

Skill Drill 11-5 Drawing Medication From an Ampule

Task: Draw medication from an ampule.

Performance Observations: The candidate shall be able to correctly draw medication from an ampule.

Candidate Directive: “Properly draw medication from an ampule.”


P F P F

1. Gently tap the stem of the ampule to shake medication into the base.

2. Grip the neck of the ampule using a 4" x 4" gauze pad, and snap the neck off.

3. Without touching the outer sides of the ampule, insert the needle into the medication in the ampule, and draw the solution into the syringe.

4. Holding the syringe with the needle pointing up, gently tap the barrel to loosen air trapped inside.

5. Gently press on the plunger to dispel any air bubbles, and recap the needle using the one-handed method.







Candidate: Date:

ID#:

Skill Drill 11-6 Drawing Medication From a Vial

Task: Draw medication from a vial.

Performance Observations: The candidate shall be able to correctly draw medication from a vial.

Candidate Directive: “Properly draw medication from a vial.”


P F P F

1. Check the medication and its expiration date.

2. Wipe the vial rubber top with an alcohol prep before touching it with the needle. Determine the amount of medication needed, and draw that amount of air into the syringe.

3. Invert the vial, and insert the needle through the rubber stopper. Expel the air in the syringe into the vial, and then withdraw the amount of medication needed.

4. Withdraw the needle, and expel any air in the syringe.

5. Recap the needle using the one-handed method. Label the syringe if the medication is not immediately given to the patient.







Candidate: Date:

ID#:

Skill Drill 11-7 Administering Medication via the Subcutaneous Route

Task: Administer medication via the subcutaneous route.

Performance Observations: The candidate shall be able to correctly administer medication via the subcutaneous route.

Candidate Directive: “Properly administer medication via the subcutaneous route.”


P F P F

1. Check the medication to ensure that it is the correct one, that it is not discolored, and that the expiration date has not passed.

2. Assemble and check the equipment. Draw up the correct dose of medication.

3. Using aseptic technique, cleanse the injection area.

4. Pinch the skin surrounding the area, and insert the needle at a 45° angle. Inject the medication, remove the needle, and hold pressure over the area. Immediately dispose of the needle and syringe in the sharps container.

5. To disperse the medication, rub the area in a circular motion. Monitor the patient’s condition.







Candidate: Date:

ID#:

Skill Drill 11-8 Administering Medication via the Intramuscular Route

Task: Administer medication via the intramuscular route.

Performance Observations: The candidate shall be able to correctly administer medication via the intramuscular route.

Candidate Directive: “Properly administer medication via the intramuscular route.”


P F P F

1. Check the medication to ensure that it is the correct one, that it is not discolored, and that its expiration date has not passed. Assemble and check the equipment. Draw up the correct dose of medication.

2. Using aseptic technique, cleanse the injection area.

3. Stretch the skin over the area, and insert the needle at a 90º angle. Pull back on the plunger to aspirate for blood. If there is no blood, inject the medication and remove the needle.

4. Monitor the patient’s condition.







Candidate: Date:

ID#:

Skill Drill 11-9 Administering Medication via the Intravenous Bolus Route

Task: Administer medication via the intravenous bolus route.

Performance Observations: The candidate shall be able to correctly administer medication via the intravenous bolus route.

Candidate Directive: “Properly administer medication via the intravenous bolus route.”


P F P F

1. Check that the medication is correct, ensure that it is not cloudy or discolored, and check the expiration date. Determine the appropriate dose. Explain the procedure to the patient. Assemble and check the equipment. Cleanse the injection port, or remove the protective cap if using the needleless system.

2. Insert the needle into the port, or attach the needleless syringe to the port. Pinch off the IV tubing proximal to the administration port. Administer the correct dose at the appropriate rate.

3. Unclamp the IV line to flush the medication into the vein, allowing it to run briefly wide open, or flush with a 20-mL bolus of normal saline. Readjust the IV flow rate to the original setting, and monitor the patient’s condition.







Candidate: Date:

ID#:

Skill Drill 11-10 Administering Medication via the Intraosseous Route

Task: Administer medication via the intraosseous route.

Performance Observations: The candidate shall be able to correctly administer medication via the intraosseous route.

Candidate Directive: “Properly administer medication via the intraosseous route.”


P F P F

1. Check the medication to ensure that it is the correct one, that it is not discolored, and that the expiration date has not passed. Assemble the equipment, and draw up the medication. Draw up 20-mL of normal saline for a flush.

2. Cleanse the injection port, or remove the protective cap if using the needleless system.

3. Insert the needle into the port, and pinch off the IV tubing proximal to the administration port. Administer the correct dose at the proper push rate.

4. Unclamp the IV line to flush the medication into the site, allowing it to run briefly wide open, or flush with a 20-mL bolus of normal saline. Readjust the IV flow rate with a pressure infuser to the original setting, and monitor the patient’s condition.







Candidate: Date:

ID#:

Skill Drill 11-11 Administering Medication via the Sublingual Route

Task: Administer medication via the sublingual route.

Performance Observations: The candidate shall be able to correctly administer medication via the sublingual route.

Candidate Directive: “Properly administer medication via the sublingual route.”


P F P F

1. Check the medication for drug type and its expiration date, and determine the appropriate amount for the correct dose. Have the patient rinse his or her mouth with a little water if the mucous membranes are dry.

2. Explain the procedure to the patient, and ask the patient to lift his or her tongue.







Candidate: Date:

ID#:

Skill Drill 11-12 Assisting a Patient With a Metered-Dose Inhaler

Task: Assist a patient with a metered-dose inhaler.

Performance Observations: The candidate shall be able to correctly assist a patient with a metered-dose inhaler.

Candidate Directive: “Properly assist a patient with a metered-dose inhaler.”


P F P F

1. Check to make sure you have the correct medication for the correct patient. Check the expiration date. Ensure the inhaler is at room temperature or warmer.

2. Remove any mask. Hand the inhaler to the patient. Instruct about breathing and lip seal. Use a spacer if the patient has one.

3. Instruct the patient to press the inhaler and inhale one puff. Instruct about breath holding.

4. Reapply oxygen. After a few breaths, have the patient repeat the dose if medical control or local protocol allows.







Candidate: Date:

ID#:

Skill Drill 11-13 Administering a Medication via Small-Volume Nebulizer

Task: Administer a medication via small-volume nebulizer.

Performance Observations: The candidate shall be able to correctly administer a medication via small-volume nebulizer.

Candidate Directive: “Properly administer a medication via small-volume nebulizer.”


P F P F

1. Check the medication and the expiration date.

2. Add premixed medication to the bowl of the nebulizer.

3. Connect the T piece with the mouthpiece to the top of the bowl, connect it to the oxygen tubing, and set the flowmeter at 6 L/min.

4. Instruct the patient to breathe as deeply as possible and hold his or her breath for 3 to 5 seconds before exhaling. Monitor the patient for effects.







Candidate: Date:

ID#:

Skill Drill 11-14 Accessing a Tunneling Device

Task: Access a tunneling device.

Performance Observations: The candidate shall be able to correctly access a tunneling device.

Candidate Directive: “Properly access a tunneling device.”


P F P F

1. Prepare the equipment. Ensure that all lumens are clamped. Use an alcohol prep to prepare the lumen.

2. Attach the empty syringe and withdraw a minimum of 10 mL of blood. Discard it immediately.

3. Attach the 10-mL syringe filled with normal saline and slowly administer it.

4. Attach the prepared IV drip set and set it up for at least 10 mL/h. Administer the medication.







Candidate: Date:

ID#:

Skill Drill 11-15 Accessing an Implanted Vascular Access Device

Task: Access an implanted vascular access device.

Performance Observations: The candidate shall be able to correctly access an implanted vascular access device.

Candidate Directive: “Properly access an implanted vascular access device.”


P F P F

1. Prepare the equipment. Identify and prep the site.

2. Apply pressure around the edges of the port to stretch the skin over the injection site.

3. Insert the needle at a 90° angle.

4. Aspirate for blood.







Candidate: Date:

ID#:

Skill Drill 13-1 Performing a Rapid Exam

Task: Perform a rapid exam.

Performance Observations: The candidate shall be able to correctly perform a rapid exam.

Candidate Directive: “Properly perform a rapid exam.”


P F P F

1. Assess the head. Have your partner maintain in-line stabilization of the head and neck if trauma is suspected.

2. Assess the neck.

3. Apply a properly-sized cervical spinal immobilization device on trauma patients.

4. Palpate both sides of the chest.

5. Assess the abdomen.

6. Assess the pelvis. If there is no pain, gently compress the pelvis downward and inward to look for tenderness and instability.

7. Assess all four extremities. Assess pulse and the motor and sensory function.

8. Assess the back. In trauma patients, roll the patient in one motion.







Candidate: Date:

ID#:

Skill Drill 13-2 Performing Percussion

Task: Perform percussion.

Performance Observations: The candidate shall be able to correctly perform percussion.

Candidate Directive: “Properly perform percussion.”


P F P F

1. Place your hand lightly against the surface to be examined.

2. Hyperextend the middle finger and apply firm pressure.

3. Strike the middle finger with one or two fingertips of the other hand.







Candidate: Date:

ID#:

Skill Drill 13-3 Performing the Full-Body Exam

Task: Perform the full-body exam.

Performance Observations: The candidate shall be able to correctly perform the full-body exam.

Candidate Directive: “Properly perform the full-body exam.”


P F P F

1. Observe the face.

2. Inspect the area around the eyes and eyelids.

3. Examine the eyes for redness and contact lenses. Check pupil function.

4. Look behind the ears for the Battle sign.

5. Check the ears for drainage or blood.

6. Observe and palpate the entire surface of head.

7. Palpate the zygomas.

8. Palpate the maxillae.

9. Check the nose for blood and drainage.

10. Palpate the mandible.

11. Assess the mouth and nose.

12. Check for unusual breath odors.

13. Inspect the neck. Observe for jugular distention and/or tracheal deviation.

14. Palpate the front and back of the neck.

15. Inspect the chest, and observe breathing motion.

16. Gently palpate over the ribs.

17. Listen to anterior breath sounds (midaxillary, midclavicular).

18. Listen to posterior breath sounds (bases, apices). At this point, also inspect the back.

19. Observe and then palpate the abdomen and pelvis.

20. Gently compress the pelvis from the sides.

21. Gently press the iliac crests.

22. Inspect the extremities; assess distal circulation and motor and sensory function.








Skill Drill 13-3 Performing the Full-Body Exam, continued


Candidate: Date:

ID#:

Skill Drill 13-4 Assessing the Head

Task: Assess the head.

Performance Observations: The candidate shall be able to correctly assess the head.

Candidate Directive: “Properly assess the head.”


P F P F

1. Visually inspect the head, looking for any obvious DCAP-BTLS.

2. Palpate the top and back of the head to locate any subtle abnormalities.

3. Part the hair in several places to examine the condition of the scalp.

4. Palpate the structure of the face, noting any DCAP-BTLS.







Candidate: Date:

ID#:

Skill Drill 13-5 Examining the Eye

Task: Examine the eye.

Performance Observations: The candidate shall be able to correctly examine the eye.

Candidate Directive: “Properly examine the eye.”


P F P F

1. Examine the exterior portion of the eye.

2. Measure visual acuity by having the patient count the number of fingers you are holding up at varying distances.

3. Test the pupils for their reaction to light.

4. Test for cranial nerve function by asking the patient to follow your fingers in a “Z” or “H” pattern.

5. Inspect the eyelids, lashes, and tear ducts.







Candidate: Date:

ID#:

Skill Drill 13-6 Eye Examination With an Ophthalmoscope

Task: Examine the eye with an ophthalmoscope.

Performance Observations: The candidate shall be able to correctly examine the eye with an ophthalmoscope.

Candidate Directive: “Properly examine the eye with an ophthalmoscope.”


P F P F

1. Ask the patient to look straight ahead and focus on a distant object.

2. Use your right hand and eye to examine the patient’s right eye; use your left hand and eye to examine the patient’s left eye.

3. Place the scope to your eye and look into the patient’s pupil from 10" to 20" away at a 45° angle to the eye.

4. Inspect for the size, color, and clarity of the disk.







Candidate: Date:

ID#:

Skill Drill 13-7 Examining the Ear With an Otoscope

Task: Examine the ear with an otoscope.

Performance Observations: The candidate shall be able to correctly examine the ear with an otoscope.

Candidate Directive: “Properly examine the ear with an otoscope.”


P F P F

1. Place your hand firmly against the patient’s head and gently grasp the patient’s auricle.

2. Turn on the otoscope and insert the speculum into the ear.

3. Inspect the canal for any lesions or discharge.







Candidate: Date:

ID#:

Skill Drill 13-8 Examining the Neck

Task: Examine the neck.

Performance Observations: The candidate shall be able to correctly examine the neck.

Candidate Directive: “Properly examine the neck.”


P F P F

1. If trauma is suspected, take precautions to protect the cervical spine.

2. Palpate the neck to find any structural abnormalities or subcutaneous air, and to ensure the trachea is midline. Begin at the suprasternal notch and work your way toward the head.

3. Assess the lymph nodes.

4. Assess the jugular veins for distention.







Candidate: Date:

ID#:

Skill Drill 13-9 Examining the Chest

Task: Examine the chest.

Performance Observations: The candidate shall be able to correctly examine the chest.

Candidate Directive: “Properly examine the chest.”


P F P F

1. Inspect the chest for any obvious DCAP-BTLS.

2. Note the shape of the chest and symmetry of movement.

3. Auscultate the lung fields, noting any abnormal lung sounds.

4. Percuss the chest to detect any abnormalities.







Candidate: Date:

ID#:

Skill Drill 13-10 Auscultating Heart Sounds

Task: Auscultate heart sounds.

Performance Observations: The candidate shall be able to correctly auscultate heart sounds.

Candidate Directive: “Properly auscultate heart sounds.”


P F P F

1. Place the patient in a position that will bring the heart closer to the left anterior chest wall, such as sitting up and leaning slightly forward.

2. Place your stethoscope at the fifth intercostal space over the apex of the heart.

3. Ask the patient to breathe normally and hold the breath on inhalation.








Candidate: Date:

ID#:

Skill Drill 13-11 Examining the Abdomen

Task: Examine the abdomen.

Performance Observations: The candidate shall be able to correctly examine the abdomen.

Candidate Directive: “Properly examine the abdomen.”


P F P F

1. Inspect the abdomen for any DCAP-BTLS.

2. Auscultate the abdomen for bowel sounds (if time and quiet environment permit).

3. Palpate the four quadrants of the abdomen in a systematic pattern, beginning with the quadrant farthest from the patient’s complaint.

4. Note any tenderness or rigidity.






Candidate: Date:

ID#:

Skill Drill 13-12 Examining the Musculoskeletal System

Task: Examine the musculoskeletal system.

Performance Observations: The candidate shall be able to correctly examine the musculoskeletal system.

Candidate Directive: “Properly examine the musculoskeletal system.”


P F P F

1. Inspect the skin overlying the muscles, bones, and joints for soft-tissue damage.

2. Check for adequate distal pulse, motor, and sensation to each extremity.

3. Ask the patient to flex and extend the joints of the fingers, hands, and wrist to establish range of motion.

4. Ask the patient to turn the hand from the palm-down position to the palm-up position and back again.

5. Inspect and palpate the shoulders.

6. Inspect and palpate the bony structures. Ask the patient to point and bend the toes to establish range of motion.

7. Ask the patient to rotate the ankle, checking for pain or restricted range of motion.

8. Inspect and palpate the knee joints and patella. Ask the patient to bend and straighten both to establish range of motion.

9. Check for structural integrity of the pelvis by applying gentle pressure to the iliac crests and pushing in and then down.

10. Ask the patient to lift both legs, bending at the hip and then turning the legs inward and outward.








Skill Drill 13-12 Examining the Musculoskeletal System, continued


Candidate: Date:

ID#:

Skill Drill 13-13 Examining the Peripheral Vascular System

Task: Examine the peripheral vascular system.

Performance Observations: The candidate shall be able to correctly examine the peripheral vascular system.

Candidate Directive: “Properly examine the peripheral vascular system.”


P F P F

1. Note any abnormalities in the radial pulse, skin color, or condition.

2. If abnormalities are noted in the distal pulse, work your way proximally, checking these pulse points and noting your findings.

3. Palpate the epitrochlear and brachial nodes of the lymphatic system, noting any swelling or tenderness.

4. Examine the lower extremities, noting any abnormalities in the size and symmetry of the legs.

5. Inspect the skin color and condition, noting any abnormal venous patterns or enlargement.

6. Check distal pulses.

7. Palpate the inguinal nodes for swelling or tenderness.

8. Evaluate for pitting edema in the legs and feet.







Candidate: Date:

ID#:

Skill Drill 13-14 Examining the Spine

Task: Examine the spine.

Performance Observations: The candidate shall be able to correctly examine the spine.

Candidate Directive: “Properly examine the spine.”


P F P F

1. Inspect the cervical, thoracic, and lumbar curves for any abnormalities.

2. Evaluate the heights of the shoulders and the iliac crests.

3. Palpate the posterior portion of the cervical spine, noting any point tenderness or structural abnormalities.

4. In the nontrauma patient, and in the absence of reported pain, ask the patient to move the head forward, backward, and from side to side.

5. Palpate each vertebra with the thumbs.

6. In the absence of pain or trauma, ask the patient to bend at the waist in each direction to establish the range of motion.







Candidate: Date:

ID#:

Skill Drill 13-15 Examining the Nervous System

Task: Examine the nervous system.

Performance Observations: The candidate shall be able to correctly examine the nervous system.

Candidate Directive: “Properly examine the nervous system.”


P F P F

1. Evaluate cranial nerve function.

2. Evaluate the patient’s neuromuscular status by checking muscle strength against resistance.

3. Evaluate the patient’s coordination by performing the finger-to-nose test using alternating hands.

4. If appropriate, test the patient’s gait and balance by having the patient walk heel-to-toe or perform the heel-to-shin stance.

5. Perform the pronator drift test by asking the patient to close his or her eyes and hold both arms out in front of the body.







Candidate: Date:

ID#:

Skill Drill 13-16 Evaluating Deep Tendon Reflexes

Task: Evaluate deep tendon reflexes.

Performance Observations: The candidate shall be able to correctly evaluate deep tendon reflexes.

Candidate Directive: “Properly evaluate deep tendon reflexes.”


P F P F

1. Place the patient in the sitting position.

2. Flex the patient’s arm to 45° at the elbow. Locate the biceps tendon in the antecubital fossa. Place your thumb over the tendon, with your fingers behind the elbow. Strike your thumb with the reflex hammer, noting the flexion of the elbow.

3. With the patient’s arm remaining at a 45° angle, rest the patient’s forearm on your arm with the hand slightly pronated. Strike the patient’s brachioradialis tendon proximal to the wrist, noting the flexion of the elbow.

4. Flex the patient’s arm at the elbow 90° and rest his or her hand against the body. Locate and strike the triceps tendon, noting contraction of the triceps or extension of the elbow.

5. Flex the patient’s knee to 90°, allowing the leg to dangle. Support the upper leg with your hand, and strike the patellar tendon just below the patella.

6. With the patient’s leg in the same position, hold the heel of the patient’s foot in your hand. Strike the Achilles tendon.







Candidate: Date:

ID#:

Skill Drill 15-1 Head Tilt–Chin Lift Maneuver

Task: Perform the head tilt-chin lift maneuver.

Performance Observations: The candidate shall be able to correctly perform a head tilt-chin lift maneuver.

Candidate Directive: “Properly perform a head tilt–chin lift maneuver.”


P F P F

1. Position yourself at the side of the supine patient.

2. Place the hand closest to the patient’s head on the forehead.

3. With your other hand, place two fingers on the underside of the patient’s chin.

4. Simultaneously apply backward and downward pressure to the patient’s forehead and lift the jaw straight up. Do not depress the soft tissue below the chin.







Candidate: Date:

ID#:

Skill Drill 15-2 Jaw-Thrust Maneuver

Task: Perform the jaw-thrust maneuver.

Performance Observations: The candidate shall be able to correctly perform a jaw-thrust maneuver.

Candidate Directive: “Properly perform a jaw-thrust maneuver.”


P F P F

1. Position yourself at the top of the patient’s head.

2. Place the meaty portion of the base of your thumbs on the zygomatic arches, and hook the tips of your index fingers under the angle of the mandible, in the indentation below each ear.

3. While holding the patient’s head still, displace the jaw upward and open the patient’s mouth with your thumb tips.







Candidate: Date:

ID#:

Skill Drill 15-3 Tongue-Jaw Lift Maneuver

Task: Perform the tongue-jaw lift maneuver.

Performance Observations: The candidate shall be able to correctly perform a tongue-jaw lift maneuver.

Candidate Directive: “Properly perform a tongue-jaw lift maneuver.”


P F P F

1. Position yourself at the patient’s side.

2. Place the hand closest to the patient’s head on the forehead.

3. With your other hand, reach into the patient’s mouth and hook your first knuckle under the incisors or gum line. While holding the patient’s head and maintaining the hand on the forehead, lift the jaw straight up.







Candidate: Date:

ID#:

Skill Drill 15-4 Suctioning a Patient’s Airway

Task: Suction a patient’s airway.

Performance Observations: The candidate shall be able to correctly suction a patient’s airway.

Candidate Directive: “Properly suction a patient’s airway.”


P F P F

1. Make sure the suctioning unit is properly assembled, and turn on the suction unit.

2. Measure the catheter from the corner of the mouth to the earlobe.

3. Turn the patient’s head to the side (unless you suspect cervical spine injury), open the mouth using the cross-finger technique if necessary, and insert the catheter to the predetermined depth without suctioning.

4. Apply suction in a circular motion as you withdraw the catheter. Do not suction an adult for more than 15 seconds.







Candidate: Date:

ID#:

Skill Drill 15-5 Inserting an Oral Airway

Task: Insert an oral airway.

Performance Observations: The candidate shall be able to correctly insert an oral airway.

Candidate Directive: “Properly insert an oral airway.”


P F P F

1. Size the airway by measuring the distance from the patient’s earlobe to the corner of the mouth.

2. Open the patient’s mouth with the cross-finger technique or tongue-jaw lift. Hold the airway upside down with your other hand. Insert the airway with the tip facing the roof of the mouth, and slide it in until it touches the roof of the mouth.

3. Rotate the airway 180° after it passes the soft palate. Insert the airway until the flange rests on the patient’s lips and teeth. In this position, the airway will hold the tongue forward.







Candidate: Date:

ID#:

Skill Drill 15-6 Inserting an Oral Airway With a 90° Rotation

Task: Insert an oral airway with a 90° rotation.

Performance Observations: The candidate shall be able to correctly insert an oral airway with a 90° rotation.

Candidate Directive: “Properly insert an oral airway with a 90° rotation.”


P F P F

1. Gently tap the stem of the ampule to shake medication into the base.

2. Grip the neck of the ampule using a 4" x 4" gauze pad, and snap the neck off.

3. Without touching the outer sides of the ampule, insert the needle into the medication in the ampule, and draw the solution into the syringe.







Candidate: Date:

ID#:

Skill Drill 15-7 Inserting a Nasal Airway

Task: Insert a nasal airway.

Performance Observations: The candidate shall be able to correctly insert a nasal airway.

Candidate Directive: “Properly insert a nasal airway.”


P F P F

1. Determine the size of the airway by measuring the distance from the tip of the nos-tril to the patient’s earlobe. Coat the tip with a water-soluble lubricant.

2. Insert the lubricated airway into the larger nostril, with the curvature following the floor of the nose and the bevel facing the septum.

3. Gently advance the airway. If using the left nostril, insert the nasal airway until it meets with resistance, then rotate the airway 180° into position. This rotation is not required if you are using the right nostril.

4. Continue until the flange rests against the nostril. If you feel any resistance or ob-struction, remove the airway and insert it into the other nostril.







Candidate: Date:

ID#:

Skill Drill 15-8 Removal of an Upper Airway Obstruction With Magill Forceps

Task: Remove an upper airway obstruction with Magill forceps.

Performance Observations: The candidate shall be able to correctly remove an upper airway obstruction with Magill forceps.

Candidate Directive: “Properly remove an upper airway obstruction with Magill forceps.”


P F P F

1. With the patient’s head in the sniffing position, open the patient’s mouth and insert the laryngoscope blade.

2. Visualize the obstruction, and retrieve the object with the Magill forceps.

3. Remove the object with the Magill forceps.

4. Attempt to ventilate the patient.







Candidate: Date:

ID#:

Skill Drill 15-9 Placing an Oxygen Cylinder Into Service

Task: Place an oxygen cylinder into service.

Performance Observations: The candidate shall be able to correctly place an oxygen cylinder into service.

Candidate Directive: “Properly place an oxygen cylinder into service.”


P F P F

1. Using an oxygen wrench, turn the valve counterclockwise to “crack” the cylinder.

2. Attach the regulator/flowmeter to the valve stem using the two pin-indexing holes, and make sure that the O-ring is in place over the larger hole.

3. Align the regulator so that the pins fit snugly into the correct holes on the valve stem and hand-tighten the regulator.

4. Attach the oxygen connective tubing to the flowmeter.







Candidate: Date:

ID#:

Skill Drill 15-10 Mouth-to-Mask Ventilation

Task: Perform mouth-to-mask ventilation.

Performance Observations: The candidate shall be able to correctly perform mouth-to-mask ventilation.

Candidate Directive: “Properly perform mouth-to-mask ventilation.”


P F P F

1. Once the patient’s head is properly positioned and an airway adjunct is inserted, place the mask on the patient’s face. Seal the mask to the face using both hands.

2. Exhale slowly into the open port of the one-way valve until you notice visible chest rise.

3. Remove your mouth, and watch the patient’s chest fall during exhalation.







Candidate: Date:

ID#:

Skill Drill 15-11 Using CPAP

Task: Use CPAP.

Performance Observations: The candidate shall be able to correctly use CPAP.

Candidate Directive: “Properly use CPAP.”


P F P F

1. Check your equipment, then connect the circuit to the CPAP device.

2. Connect the face mask to the circuit tubing.

3. Connect the tubing to the oxygen tank.

4. Confirm that the device is on before you apply it to the patient’s face. Place the mask over the patient’s mouth and nose, or allow the patient to hold it to his or her mouth and nose. Allow the patient to get used to the mask.

5. Use the strapping mechanism to secure the CPAP to the patient’s head. Make sure there is a tight seal.

6. Adjust the PEEP valve and the FIO₂ according to the manufacturer’s recommenda-tions to maintain adequate oxygenation and ventilation. Reassess the patient.







Candidate: Date:

ID#:

Skill Drill 15-12 Nasogastric Tube Insertion in a Responsive Patient

Task: Insert a nasogastric tube in a responsive patient.

Performance Observations: The candidate shall be able to correctly insert a nasogastric tube in a responsive patient.

Candidate Directive: “Properly insert a nasogastric tube in a responsive patient.”


P F P F

1. Explain the procedure to the patient, and oxygenate the patient if necessary. Ensure the patient’s head is in a neutral position, and suppress the gag reflex with a topical anesthetic spray.

2. Constrict the blood vessels in the nares with a topical alpha-agonist if available.

3. Measure the tube for the correct depth of insertion (nose to ear to xiphoid process).

4. Lubricate the tube with a water-soluble gel.

5. Advance the tube gently along the nasal floor.

6. Encourage the patient to swallow or drink to facilitate passage of the tube.

7. Advance the tube into the stomach.

8. Confirm placement: Auscultate over the epigastrium while injecting 30 to 50 mL of air, and/or observe for gastric contents in the tube. There should be no reflux around the tube.

9. Apply suction to the tube to aspirate the gastric contents, and secure the tube in place.








Skill Drill 15-12 Nasogastric Tube Insertion in a Responsive Patient, continued


Candidate: Date:

ID#:

Skill Drill 15-13 Orogastric Tube Insertion

Task: Insert an orogastric tube.

Performance Observations: The candidate shall be able to correctly insert an orogastric tube.

Candidate Directive: “Properly insert an orogastric tube.”


P F P F

1. Position the patient’s head in a neutral or slightly flexed position. Measure the tube for the correct depth of insertion (mouth to ear to xiphoid process).

2. Lubricate the tube with a water-soluble gel.

3. Introduce the tube at the midline, and advance it gently into the oropharynx. Advance the tube into the stomach.

4. Auscultate over the epigastrium to confirm correct placement. Afterwards, auscultate over the lung fields to confirm that the endotracheal tube has not been dislodged.

5. Apply suction to the tube to aspirate the stomach contents.

6. Secure the tube in place.







Candidate: Date:

ID#:

Skill Drill 15-14 Suctioning of a Stoma

Task: Suction a stoma.

Performance Observations: The candidate shall be able to correctly suction a stoma.

Candidate Directive: “Properly suction a stoma.”


P F P F

1. Take standard precautions (gloves and face shield).

2. Preoxygenate the patient with a bag-mask device and 100% oxygen.

3. Inject 3 mL of saline through the stoma and into the trachea.

4. Instruct the patient to exhale, and insert the catheter (without providing suction) until resistance is felt (no more than 12 cm).

5. Suction while withdrawing the catheter.

6. Resume oxygenating the patient with a bag-mask device and 100% oxygen.







Candidate: Date:

ID#:

Skill Drill 15-15 Mouth-to-Stoma Ventilation Using a Resuscitation Mask

Task: Perform mouth-to-stoma ventilation using a resuscitation mask.

Performance Observations: The candidate shall be able to correctly perform mouth-to-stoma ventilation using a resuscitation mask.

Candidate Directive: “Properly perform mouth-to-stoma ventilation using a resuscitation mask.”


P F P F

1. Position the patient’s head in a neutral position with the shoulders slightly elevated.

2. Locate and expose the stoma site.

3. Place the resuscitation mask (pediatric mask preferred) over the stoma, and ensure an adequate seal.

4. Maintain the patient’s neutral head position, and ventilate the patient by exhaling directly into the resuscitation mask. Assess the patient for adequate ventilation by observing his or her chest rise and feeling for air leaks around the mask.

5. If air leakage is evident, seal the patient’s mouth and nose and ventilate. For best results use a pediatric mask on the stoma.







Candidate: Date:

ID#:

Skill Drill 15-16 Bag-Mask Device-to-Stoma Ventilation

Task: Perform bag-mask device-to-stoma ventilation.

Performance Observations: The candidate shall be able to correctly perform bag-mask device-to-stoma ventilation.

Candidate Directive: “Properly perform bag-mask device-to-stoma ventilation.”


P F P F

1. With the patient’s head in a neutral position, locate and expose the stoma.

2. Place the bag-mask device over the stoma, and ensure an adequate seal. Ventilate the patient by squeezing the bag-mask device, and assess for adequate ventilation by observing chest rise.

3. Auscultate over the lungs to confirm adequate ventilation.







Candidate: Date:

ID#:

Skill Drill 15-17 Replacing a Dislodged Tracheostomy Tube With a Temporary Endotracheal Tube

Task: Replace a dislodged tracheostomy tube with a temporary endotracheal tube.

Performance Observations: The candidate shall be able to correctly replace a dislodged tracheostomy tube with a temporary endotracheal tube.

Candidate Directive: “Properly replace a dislodged tracheostomy tube with a temporary endotracheal tube.”


P F P F

1. Take standard precautions (gloves and face shield). Assemble the equipment.

2. Lubricate the same-sized tracheostomy tube or an ET tube (at least 5.0 mm).

3. Instruct the patient to exhale, and gently insert the tube approximately 1 to 2 cm beyond the balloon cuff.

4. Inflate the balloon cuff.

5. Ensure that the patient is comfortable, and confirm patency and proper placement of the tube by listening for air movement from the tube and noting the patient’s clinical status. Ensure that a false lumen was not created.

6. Auscultate the lungs to confirm correct tube placement.







Candidate: Date:

ID#:

Skill Drill 15-18 Intubation of the Trachea Using Direct Laryngoscopy

Task: Intubate the trachea using direct laryngoscopy.

Performance Observations: The candidate shall be able to correctly intubate the trachea using direct laryngoscopy.

Candidate Directive: “Properly intubate the trachea using direct laryngoscopy.”


P F P F


2. Measure and inspect an oropharyngeal airway using one of the techniques described in Skill Drills 15-5 and 15-6.

3. Preoxygenate the patient for 2 to 3 minutes with a bag-mask device and 100% oxygen.

4. Check, prepare, and assemble your equipment.

5. Place the patient’s head in the sniffing position.

6. Remove the oropharyngeal airway, then insert the blade into the right side of the patient’s mouth, and displace the tongue to the left.

7. Gently lift the long axis of the laryngoscope handle until you can visualize the glottis opening and the vocal cords.

8. Insert the ET tube through the right corner of the mouth.

9. Visualize its entry between the vocal cords.

10. Remove the laryngoscope from the patient’s mouth.

11. Remove the stylet from the ET tube.

12. Inflate the distal cuff of the ET tube with 5 to 10 mL of air, and detach the syringe from the inflation port.

13. Attach the end-tidal carbon dioxide detector to the ET tube.

14. Attach the detector to the monitor.

15. Attach the bag-mask device and ventilate. Listen over both lungs and over the epigastrium for ventilations.

16. Confirm placement, and then secure the ET tube. Continue to reassess the patient.








Skill Drill 15-18 Intubation of the Trachea Using Direct Laryngoscopy, continued


Candidate: Date:

ID#:

Skill Drill 15-19 Performing Blind Nasotracheal Intubation

Task: Perform blind nasotracheal intubation.

Performance Observations: The candidate shall be able to correctly perform blind nasotracheal intubation.

Candidate Directive: “Properly perform blind nasotracheal intubation.”


P F P F


2. Preoxygenate the patient whenever possible with a bag-mask device and 100% oxygen.

3. Check, prepare and assemble your equipment.

4. Place the patient’s head in a neutral position.

5. Preform the nasotracheal tube by bending it in a circle.

6. Administer a nasal spray to the patient for comfort.

7. Lubricate the tip of the tube with a water-soluble gel.

8. Gently insert the nasotracheal tube into the more compliant nostril, with the bevel facing toward the nasal septum, and advance the tube along the nasal floor.

9. Advance the nasotracheal tube through the vocal cords as the patient inhales. The BAAM device can be helpful in this step.

10. Inflate the distal cuff with 5 to 10 mL of air, and detach the syringe.

11. Attach an end-tidal carbon dioxide detector to the nasotracheal tube.

12. Attach the detector to the monitor.

13. Attach the bagmask device, ventilate, and auscultate over the apices and bases of both lungs and over the epigastrium. Ensure proper tube placement with waveform capnography. Secure the nasotracheal tube.








Skill Drill 15-19 Performing Blind Nasotracheal Intubation, continued


Candidate: Date:

ID#:

Skill Drill 15-20 Performing Digital Intubation

Task: Perform digital intubation.

Performance Observations: The candidate shall be able to correctly perform digital intubation.

Candidate Directive: “Properly perform digital intubation.”


P F P F


2. Insert an airway adjunct if needed.



5. Bend the ET tube by placing a slight curve at its distal end (like a hockey stick).

6. Have a second provider hold the patient’s head in neutral position while one provider continues to preoxygenate the patient. If you did not insert an airway adjunct earlier, at this point, place a bite block in between the patient’s molars to prevent the patient from biting your fingers.

7. Insert the middle and index fingers of one hand into the patient’s mouth and shift the patient’s tongue forward as you advance your fingers toward the larynx. Palpate and lift the epiglottis with your middle finger.

8. Advance the tube with your other hand and guide it between the vocal cords with your index finger.


10. Inflate the distal cuff of the ET tube with 5 to 10 mL of air, and detach the syringe.


12. Attach the bag-mask device and ventilate. Auscultate over the apices and bases of both lungs and over the epigastrium. Ensure proper tube placement with waveform capnography.

13. Secure the ET tube.








Skill Drill 15-20 Performing Digital Intubation, continued


Candidate: Date:

ID#:

Skill Drill 15-21 Performing Transillumination Intubation

Task: Perform transillumination intubation.

Performance Observations: The candidate shall be able to correctly perform transillumination intubation.

Candidate Directive: “Properly perform transillumination intubation.”


P F P F




4. Insert the lighted stylet into the ET tube.

5. Bend the ET tube by placing a slight curve at its distal end (like a hockey stick), and turn on the lighted stylet.

6. Lift the patient’s tongue and mandible anteriorly.

7. Insert the ET tube into the midline of the patient’s mouth and slowly advance toward the larynx, but stop before passing through the vocal cords.

8. Observe for a rightly circumscribed light at the midline of the neck, and advance the ET tube 2 to 4 cm farther.


10. Inflate the distal cuff of the ET tube with 5 to 10 mL of air, and detach the syringe.


12. Attach the bag-mask device, ventilate, and auscultate over the apices and bases of both lungs and over the epigastrium. Ensure proper tube placement with waveform capnography.

13. Secure the ET tube, and recheck breath sounds.








Skill Drill 15-21 Performing Transillumination Intubation, continued


Candidate: Date:

ID#:

Skill Drill 15-22 Performing Retrograde Intubation

Task: Perform retrograde intubation.

Performance Observations: The candidate shall be able to correctly perform retrograde intubation.

Candidate Directive: “Properly perform retrograde intubation.”


P F P F

1. Take standard precautions (gloves and face shield). Place the patient supine. Ventilate the patient while preparing the equipment and the patient. Cleanse the anterior part of the neck from the laryngeal prominence to just below the cricoid ring, and position a fenestrated drape.

2. Numb the area over the cricothyroid membrane using a local anesthetic if the patient is responsive.

3. Puncture the cricothyroid membrane using a large needle aligned with the airway and pointed approximately 30° cephalad, perpendicular at the level of the cricothyroid membrane.

4. Identify the tracheal lumen by aspirating the syringe attached to the needle.

5. Pass the 70-cm guide wire through the catheter until it appears in the oropharynx, mouth, or one of the nares.

6. If the guide wire is in the oropharynx, grasp it with a clamp and pull the wire partially out of the mouth, ensuring that the distal end is still emerging from the neck and the wire is pulled taut.

7. Insert the guide wire emerging from the mouth, through the lumen of the ET tube.

8. Advance the ET tube into the trachea.

9. Auscultate the chest bilaterally and over the epigastrium. Ensure proper tube placement with waveform capnography.

10. Once tube placement is confirmed, remove the guide wire by pulling on the distal end emerging from the neck.

11. If tube placement is incorrect, remove the tube and start over or switch to a different technique.

12. Secure the ET tube in place and ventilate.








Skill Drill 15-22 Performing Retrograde Intubation, continued


Candidate: Date:

ID#:

Skill Drill 15-23 Performing Tracheobronchial Suctioning

Task: Perform tracheobronchial suctioning.

Performance Observations: The candidate shall be able to correctly perform tracheobronchial suctioning.

Candidate Directive: “Properly perform tracheobronchial suctioning.”


P F P F


2. Lubricate the suction catheter.

3. Preoxygenate the patient.

4. Detach the bag-mask device, and inject 3 to 5 mL of sterile water down the ET tube.

5. Gently insert the catheter into the ET tube until resistance is felt.

6. Suction in a rotating motion while withdrawing the catheter. Monitor the patient’s cardiac rhythm and oxygen saturation during the procedure.

7. Reattach the bag-mask device, and resume ventilation and oxygenation.







Candidate: Date:

ID#:

Skill Drill 15-24 Performing Pediatric Endotracheal Intubation

Task: Perform pediatric endotracheal intubation.

Performance Observations: The candidate shall be able to correctly perform pediatric endotracheal intubation.

Candidate Directive: “Properly perform pediatric endotracheal intubation.”


P F P F



3. Measure an adjunct if needed.

4. Manually open the child’s airway and insert an adjunct if needed.

5. Preoxygenate the child with a bag-mask device and 100% oxygen for at least 2 to 3 minutes.

6. Measure the length of the child using a length-based resuscitation tape.

7. Remove the airway adjunct if one was placed. Insert the laryngoscope in the right side of the mouth and sweep the tongue to the left. Lift the tongue with firm, gentle pressure. Avoid using the teeth or gums as a fulcrum.

8. Identify the vocal cords. If the cords are not yet visible, instruct your partner to perform the BURP maneuver, if possible.

9. Introduce the ET tube in the right corner of the child’s mouth.

10. Pass the ET tube through the vocal cords to approximately 2 to 3 cm below the vocal cords. Inflate the cuff if a cuffed tube is used.

11. Attach an ETCO2 detector. Attach the bag-mask device, and auscultate for equal breath sounds over each lateral chest wall high in the axillae. Ensure absence of breath sounds over the epigastrium. Ensure proper tube placement with waveform capnography.

12. Secure the ET tube.








Skill Drill 15-24 Performing Pediatric Endotracheal Intubation, continued


Candidate: Date:

ID#:

Skill Drill 15-25 Inserting a Combitube

Task: Insert a Combitube.

Performance Observations: The candidate shall be able to correctly insert a Combitube.

Candidate Directive: “Properly insert a Combitube.”


P F P F



3. Gather your equipment.

4. Place the patient’s head in a neutral position.

5. Open the patient’s mouth with the tongue-jaw lift maneuver, and insert the Combitube in the midline of the patient’s mouth. Insert the tube until the incisors lie between the two reference marks.

6. Inflate the pharyngeal cuff with 100 mL of air.

7. Inflate the distal cuff with 15 mL of air.

8. Ventilate the patient through the pharyngeal (blue) tube first. Chest rise indicates esophageal placement of the distal tip; continue to ventilate.

9. No chest rise indicates tracheal placement; switch ports and ventilate. Ensure proper tube placement with waveform capnography.







Candidate: Date:

ID#:

Skill Drill 15-26 LMA Insertion

Task: Insert an LMA.

Performance Observations: The candidate shall be able to correctly insert an LMA.

Candidate Directive: “Properly insert an LMA.”


P F P F

1. Take standard precautions. Check the cuff of the LMA by inflating it with 50% more air than is required for the size of airway to be used. Then deflate the cuff completely.

2. Lubricate the outer rim of the device.

3. Preoxygenate the patient before insertion. Ventilation should not be interrupted for more than 30 seconds to accomplish airway placement. Place the patient in the sniffing position.

4. Lift the jaw with one hand, and begin to insert the device with the other hand.

5. Insert the LMA along the roof of the mouth. Use your finger to push the airway against the hard palate.

6. Inflate the cuff with the amount of air indicated for the airway being used.

7. Begin to ventilate the patient. Confirm chest rise and the presence of breath sounds. Ensure proper tube placement with waveform capnography. Continuously and carefully monitor the patient’s condition.







Candidate: Date:

ID#:

Skill Drill 15-27 Inserting a King LT Airway

Task: Insert a King LT airway.

Performance Observations: The candidate shall be able to correctly insert a King LT airway.

Candidate Directive: “Properly insert a King LT airway.”


P F P F



3. Gather your equipment.

4. Place the patient’s head in a neutral position unless contraindicated. Open the patient’s mouth, and insert the King LT airway in the corner of the mouth.

5. Advance the tip behind the base of the tongue while rotating the tube back to midline so the blue line on the device faces the patient’s chin. Gently advance the device until the base of the connector is aligned with the teeth or gums. Do not use excessive force. Inflate the cuffs with the recommended amount of air or enough to just seal the device.

6. Attach the tube to the bag-mask device, and confirm tube placement. Ensure proper tube placement with waveform capnography. Once placement is confirmed, secure the tube and begin ventilating the patient.







Candidate: Date:

ID#:

Skill Drill 15-28 Inserting a Cobra Perilaryngeal Airway (CobraPLA)

Task: Insert a Cobra Perilaryngeal Airway (CobraPLA).

Performance Observations: The candidate shall be able to correctly insert a Cobra Perilaryngeal Airway (CobraPLA).

Candidate Directive: “Properly insert a Cobra Perilaryngeal Airway (CobraPLA).”


P F P F

1. Take standard precautions. Preoxygenate the patient. Gather, inspect, and prepare your equipment. Fully deflate the cuff of the CobraPLA, and fold back against the breathing tube. Apply a water-soluble lubricant liberally to the front and back of the CobraPLA head and to the cuff. Place the patient’s head and neck in the sniffing position. Open the patient’s mouth with a scissor maneuver with your nondominant hand, gently pulling the mandible upward. Direct the distal end of the CobraPLA straight back between the tongue and hard palate while lifting the jaw with your other hand.

2. Continue advancing the CobraPLA until modest resistance is encountered.

3. Inflate the cuff with only enough air to achieve a good seal. Never overinflate the cuff. Ventilate the patient to confirm correct placement and to measure the pressure at which an audible leak occurs. Confirm placement by observing for chest rise and auscultating over the neck, chest, and epigastric region. Ensure proper tube placement with waveform capnography. Secure the tube in place.







Candidate: Date:

ID#:

Skill Drill 15-29 Performing an Open Cricothyrotomy

Task: Perform an open cricothyrotomy.

Performance Observations: The candidate shall be able to correctly perform an open cricothyrotomy.

Candidate Directive: “Properly perform an open cricothyrotomy.”


P F P F


2. Check, assemble, and prepare the equipment.

3. With the patient’s head in a neutral position, palpate for and locate the cricothyroid membrane.

4. Cleanse the area with an iodine-containing solution.

5. Stabilize the larynx, and make a 1- to 2-cm vertical incision over the cricothyroid membrane.

6. Puncture the cricothyroid membrane.

7. Make a horizontal cut 1 cm in each direction from the midline. Spread the incision apart with curved hemostats.

8. Insert the tube into the trachea.

9. Attach an ETCO2 detector between the tube and the bag-mask device.

10. Ensure proper tube placement with waveform capnography. Attach the ETCO2 detector to the monitor.

11. Ventilate the patient.

12. Confirm correct tube placement by auscultating the apices and bases of both lungs and over the epigastrium.

13. Secure the tube with a commercial device or tape. Reconfirm correct tube placement, and resume ventilations at the appropriate rate.








Skill Drill 15-29 Performing an Open Cricothyrotomy, continued


Candidate: Date:

ID#:

Skill Drill 15-30 Performing Needle Cricothyrotomy and Translaryngeal Catheter Ventilation

Task: Perform needle cricothyrotomy and translaryngeal catheter ventilation.

Performance Observations: The candidate shall be able to correctly perform needle cricothyrotomy and translaryn-geal catheter ventilation.

Candidate Directive: “Properly perform needle cricothyrotomy and translaryngeal catheter ventilation.”


P F P F


2. Attach a 14- to 16-guage IV catheter to a 10-mL syringe containing approximately 3 mL of sterile saline or water.

3. With the patient’s head in a neutral position, palpate for and locate the cricothyroid membrane.

4. Cleanse the area with an iodine-containing solution.

5. Stabilize the larynx, and insert the needle into the cricothyroid membrane at a 45° angle.

6. Aspirate with the syringe to determine correct catheter placement.

7. Slide the catheter off of the needle until the hub of the catheter is flush with the patient’s skin.

8. Place the syringe and needle in a puncture-proof container.

9. Connect one end of the oxygen tubing to the catheter and the other end to the jet ventilator. Maintain manual stabilization of the catheter until it has been secured in place to avoid dislodgment with jet ventilation.

10. Open the release valve on the jet ventilator, and adjust the pressure accordingly to provide adequate chest rise.

11. Auscultate the apices and bases of both lungs and over the epigastrium to confirm correct catheter placement.

12. Secure the catheter with a 4" x 4" gauze pad and tape. Continue ventilations while frequently reassessing for adequate ventilations and potential complications.








Skill Drill 15-30 Performing Needle Cricothyrotomy and Translaryngeal Catheter Ventilation, continued


Candidate: Date:

ID#:

Skill Drill 17-1 Performing Cardiac Monitoring

Task: Perform cardiac monitoring.

Performance Observations: The candidate shall be able to correctly perform cardiac monitoring.

Candidate Directive: “Properly perform cardiac monitoring.”


P F P F


2. Explain the procedure to the patient. Prepare the skin for electrode placement.

3. Attach the electrodes to the leads before placing them on the patient.

4. Position the electrodes on the patient.

5. If you plan to obtain a 12-lead tracing as well, place the limb leads.

6. Turn on the monitor and set lead II.

7. Record tracings.

8. Label each strip.







Candidate: Date:

ID#:

Skill Drill 17-2 Acquiring a 12-Lead ECG

Task: Acquire a 12-lead ECG.

Performance Observations: The candidate shall be able to correctly acquire a 12-lead ECG.

Candidate Directive: “Properly acquire a 12-lead ECG.”


P F P F


2. Explain the procedure to the patient. Prepare the skin for electrode placement.

3. Attach the electrodes to the leads before placing them on the patient.

4. Position the electrodes on the patient.

• V1—fourth intercostal space to the right of the sternum

• V2—fourth intercostal space to the left of the sternum

• V3—directly between leads V2 and V4

• V4—fifth intercostal space at left midclavicular line

• V5—level with lead V4 at left anterior axillary line

• V6—level with lead V5 at left midaxillary line

5. Connect the cables to the monitor.

6. Press the 12-lead Analyze button.

7. Record tracings.

8. Review the tracing. Determine whether additional views of the right and posterior walls (15- or 18-lead tracings) are needed. Label the tracing.








Skill Drill 17-2 Acquiring a 12-Lead ECG, continued


Candidate: Date:

ID#:

Skill Drill 17-3 Performing Manual Defibrillation

Task: Perform manual defibrillation.

Performance Observations: The candidate shall be able to correctly perform manual defibrillation.

Candidate Directive: “Properly perform manual defibrillation.”


P F P F

1. Take standard precautions. Prepare the skin. Attach the adhesive defibrillation pads to the patient’s chest as instructed on the package. If using paddles, lubricate them with a conductive gel.

2. Turn on the main power switch. Set the defibrillator to the proper energy setting. Charge the defibrillator. If using paddles, exert firm pressure to make good skin contact. Ensure that no one is touching the patient.

3. Clear the area. Announce, “All clear!” Press the button on the machine if using a hands-free system; if not, discharge the defibrillator by pressing the button on each handle simultaneously. Observe for contraction of the patient’s chest muscles. Resume CPR immediately. Continue CPR for 2 minutes or five cycles, and then pause to check for a pulse and reevaluate the rhythm. If at any point you see an organized rhythm on the monitor, check for a pulse (maximum of 10 seconds).







Candidate: Date:

ID#:

Skill Drill 17-4 Performing Defibrillation With an AED

Task: Perform defibrillation with an AED.

Performance Observations: The candidate shall be able to correctly perform defibrillation with an AED.

Candidate Directive: “Properly perform defibrillation with an AED.”


P F P F

1. Assess compression effectiveness if CPR is already in progress. If the patient is unresponsive and CPR has not been started yet, begin providing chest compressions and rescue breaths at a ratio of 30 compressions to 2 breaths, continuing until an AED arrives and is ready for use.

2. Turn on the AED. Apply the AED pads to the chest and attach the pads to the AED. Stop CPR.

3. Verbally and visually clear the patient. Push the Analyze button, if there is one. Wait for the AED to analyze the cardiac rhythm. If no shock is advised, perform five cycles (2 minutes) of CPR and then reanalyze the cardiac rhythm. If a shock is advised, recheck that all are clear, and push the Shock button. After the shock is delivered, immediately resume CPR beginning with chest compressions.

4. After five cycles (2 minutes) of CPR, reanalyze the cardiac rhythm. Do not interrupt chest compressions for more than 10 seconds. If shock is advised, clear the patient, push the Shock button, and immediately resume CPR compressions.







Candidate: Date:

ID#:

Skill Drill 17-5 Performing Cardioversion

Task: Perform cardioversion.

Performance Observations: The candidate shall be able to correctly perform cardioversion.

Candidate Directive: “Properly perform cardioversion.”


P F P F


2. Prepare the equipment. Place the electrodes in the same position as you would when performing cardiac monitoring or acquiring a 12-lead ECG.

3. Place the multipurpose quick-connect pads in the proper positions. Turn the main power on, and assess the patient’s rhythm.

4. Turn the synchronize switch on the machine to the on position (unlike for defibrillation).

5. Assess the pulse. If a pulse is present, prepare to cardiovert.

6. Connect the pads to the monitor.

7. Check the patient’s blood pressure. Sedate the patient.

8. Confirm the rhythm. Prepare and apply the pads or paddles as described for defibrillation. Set the energy level as ordered by the physician. Charge the pads. Note that the energy level could be set by the physician or by protocol.

9. Clear the area by announcing, “All clear!”

10. Reconfirm the rhythm by looking at the monitor. Depress the shock buttons, and keep them depressed until the defibrillator discharges.

11 Reassess the patient’s condition (ECG rhythm and pulse).








Skill Drill 17-5 Performing Cardioversion, continued


Candidate: Date:

ID#:

Skill Drill 17-6 Performing Transcutaneous Pacing

Task: Perform transcutaneous pacing.

Performance Observations: The candidate shall be able to correctly perform transcutaneous pacing.

Candidate Directive: “Properly perform transcutaneous pacing.”


P F P F


2. Obtain a precapture strip.

3. Explain the need for transcutaneous pacing to the patient and the family. Apply the pacing electrodes.

4. Switch the pacer power on.

5. Set the pacing rate.

6. Start increasing the current.

7. Check for mechanical capture.

8. Once the capture is achieved, briefly lower the current until capture is lost, and then increase it by the smallest amount possible to restore capture. Obtain rhythm strips for documentation.







Candidate: Date:

ID#:

Skill Drill 28-1 Restraining a Patient

Task: Restrain a patient.

Performance Observations: The candidate shall be able to correctly restrain a patient.

Candidate Directive: “Properly restrain a patient.”


P F P F

1. Approach the patient cautiously. If possible, corner the patient in a safe area.

2. Assemble four or five rescuers and have the stretcher or carrying device and soft restraints nearby. Designate a leader. Assign positions to each team member: four extremities and the head.

3. On the direction of the team leader, move together toward the patient. Each team member should grasp the assigned body part and carefully, with the least amount of force, bring the patient to the ground. Carefully place the patient on the stretcher or carrying device in a face-up position.

4. Consider tying the patient with soft restraints at each wrist and ankle as well as the chest and pelvis with sheets.

5. If the patient is spitting, place an oxygen mask or surgical mask on his or her face.






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