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No.

Ruangan :
No. Urut Absen :

FR-FK-20-06/RO
FACULTY OF MEDICINE UNIVERSITAS TARUMANAGARA
CLINICAL SKILL

STUDENT’S NAME :
PASS / FAIL
STUDENT’S NIM :
STUDENT’S SIGNATURE :

CARDIOPULMONARY RESUSCITATION CLINICAL SKILL


CHECKLIST
Score
No. Checklist Points
0 1 2
Initial Management
1 Evaluates consciousness
2 Activates emergency system and prepares AED
3 Evaluates for probability of cervical trauma and positions the patient in a
supine position in a safe place
4 Positions her/himself against patient ( right side )
Circulation
5* Checks carotid artery pulsation (<10 seconds)
6 • If no pulsation: does chest compressions
• If pulsation palpated, checks airway and breathing. If breathing not
adequate, gives artificial breathing 10-12 breaths/minute (each 5-6
seconds). Evaluates pulse every 2 minutes.
Chest Compression
7 Positions hand and fingers on inferior half of sternum
8 Does compressions firm and fast
• Does compressions with a depth of 5 cm
• Does compressions 100-120 times/minute
• Confirms of chest recoil between each compression
• Does compressions 30 times each cycle
• Does compressions with minimal interruption
Airway
9 Opens airway with head tilt-chin lift technique or jaw thrust on neck trauma and
confirms patency of airway
Breathing
10 Gives artificial breathing within 1 second
11* Blows enough air to elevate chest wall
12 Gives 2 ventilations for each 30 chest compressions (compression : ventilation
= 30 : 2)
Defibrillation
13 • Turns on AED/MD equipment
• Places electrodes (AED) or pads (MD) to evaluate ECG pattern
14* • If rhythm is shockable (ventricular fibrillation/ventricular tachycardia
without pulse):
o On AED: pushes shock button after AED indicates it
o On MD: chooses 360J (monophasic MD) or 200J (biphasic MD), gives
gel on pads, places pads on apex and sternum, gives 12.5 kg pressure on
chest wall and pushes discharge button
o Assess Rhythm, if VT/PEA, assess pulse and continue the procedure.
o Assess Rhythm, if VF/Asystole, act accordingly (shock/continue straight
to CPR), without checking the pulse.
• Makes sure every personnel is not in contact with patient or bed before
discharging (*)
15 Immediately continues with compression-ventilation after defibrillation,
reevaluates after 2 minutes
Pharmacology Intervention
16 Gains IV access
17* Gives 1 mg of Epinephrine every 3 – 5 minutes
18* Gives a bolus of 300 mg Amiodarone IF the patient’s heart rhythm is classified
as shockable (MUST NOT be given at the same time as epinephrine injection,
it MUST be done separately)
Evaluation After Every Cycle ( every 2 minutes )
19* • If ECG Monitor/AED is attached, evaluates the rhythm first
• If there’s no ECG Monitor attached/AED, check pulse, If no carotid
pulsation found: repeats compression ventilation cycle (30:2 ratio)
If shockable, repeats defibrillation
• If pulse is found, no breathing, gives artificial breathing 10-12
breaths/minute for 2 minutes
20 Evaluates after every 5 cycles
21 • If breathing spontaneously and adequately after pulse palpable, positions
patient in recovery position
• Or: stops cardiopulmonary resuscitation as indicated
Successful Recovery
22 Positions the patient in recovery position
23 Evaluates the patient’s vital signs every 2 minutes
TOTAL

Checklist points with * is a must, failure to do so will be considered as a fail


Note:
0 : not done
1 : done imperfectly
2 : done perfectly

SCORE : _______ X 100 =


46

Block Coordinator Examiner

(Alya Dwiana, dr., M.Sc.) (......................................)

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