ATLS Instructor Evaluation Form

Skill Station Evaluation

Skill Station A - Airway 1

Skill Performance Airway

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Skill Performance: Pediatric Airway and Surgical and Needle Cricothyrotomy.

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Skill Station B - Breathing

Skill Performance Breathing

FailIncompleteSatisfactoryInstructor Potential
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Skill Station C - Circulation

Skill Performance Circulation

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Skill Station D - Disability

Skill Performance Disability

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Skill Station E - Adjuncts

Skill Performance Adjuncts

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Skill Station F - Secondary Survey

Skill Secondary Survey

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Skill Station G - Initial Assessment and Team Training

Skill Performance: Initial Assessment and Team Training

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Skill Station H - Airway 2

Skill Performance: Airway

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Skill Performance: Pediatric Airway and Surgical and Needle Cricothyrotomy

FailIncompleteSatisfactoryInstructor Potential
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FailIncompleteSatisfactoryInstructor Potential
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Initial Assessment and Management

Patient B - Initial Assessment and Management

YESNO
Adhere to the appropriate priority sequence in management.
Have an organized approach to patient treatment
Perform the assessment and management phases properly and in the correct sequence.
Recognize the patient's airway obstruction as a result of the maxillofacial trauma and quickly perform a cricothyroid-otomy while protecting the patient's cervical spine. This is the only acceptable method to secure a patent airway in this patient.
Recognize that the patient has a potential cervical spine injury, exercise the appropriate precautionary measures.
Recognize and indicate the need for ventilatory assistance and oxygenation.
Recognize the patient's hemorrhagic shock, and initiate appropriate resuscitative therapy, including hemmorrhage control and vigorous, warmed fluid therapy.
Recognize the source of the patient's hemorrhage as being arterial bleeding from the femur and scalp and apply appropriate measures to control the hemorrhage.
Identify the patient's open head injury and take the necessary steps to prevent secondary brain injury.
Identify and manage the conditions requiring critical treatment decisions in the order listed.

Potentials for Adverse Outcome: If the student's performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student's overall performance is unsuccessful.

YESNO
Restricted spinal motion
Performed cricothyroidotomy in timely fashion.
Provided assisted ventilation.
Ordered blood transfusion in timely fashion.
Controlled external hemorrhage early.
Applied a traction splint to control hemorrhage and restore circulation early.
Recognized/immobilized the left wrist fracture.
Did not perform and nasal instrumentation, such as insertion of a nasogastric tube.
Identified a depressed skull fracture and protected the wound from contamination.
Protected the patient from hypothermia.
Considered the need for tetanus prophylaxis.
Recognized the need for transfer.
Did not delay transfer to perform diagnostic tests.
Adequately prepared for contingencies during the transfer process, such as malfunction of the cricothyroidotomy, chest tube malfunction, and deterioration in neurologic status.

Patient C - Initial Assessment and Management

YESNO
Perform the assessment and management phases properly and in the correct sequence.
Before obtaining a chest x-ray, recognize the presence of and indicate the appropriate treatment for the patient's tension pneumothorax.
Protect the patient's cervical spine until a potential injury is definitely excluded.
Appropriately treat the patient's hypoxia.
Appropriately treat the patient's hypotension
Identify the presence of a malpositioned chest tube and take the steps necessary to correct and alleviate the patient's acute respiratory distress.
Identify and manage the conditions requiring critical treatment decisions in the order listed.

Potentials for Adverse Outcome: If the student's performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student's overall performance is unsuccessful.

YESNO
Did not persist with attempts at tracheal intubation.
Did not perform intubation before decompression of tension pneumonothorax.
Did not perform multiple examinations for pelvic instability.
Adequately protected the cervical spine.
Considered pregnancy.
Ordered blood transfusion in timely fashion.
Applied pelvic stabilization device.
Immobilized the tibia/fibula fracture.
Performed neurovascular exam before/after extremity immobilization.
Protected the patient from hypothermia.
Considered the need for tetanus prophylaxis.
Recognized the need for transfer in timely fashion.
Did not delay transfer to perform diagnostic tests.
Adequately prepared for contingencies during the transfer process, such as chest tube malfunction of the cricothyroidotomy, chest tube malfunction, and recurrent tension pneumonothorax, and hemodynamic deterioration.

Patient F - Initial Assessment and Management

YESNO
Perform the assessment and management phases properly and in the correct sequence, recognizing that priorities are the same as for the nonpregnant patient.
Assess and secure a patent airway and relate the potential for a cervical spine injury.
Recognize and treat the patient's initial shock, initiating treatment specific to the pregnant trauma patient.
Relate appreciation for and the significance of the patient's recurrent hypotension, identifying a differential diagnosis for the pregnant trauma patient.
Relate the need for early consultation with a general surgeon and an obstetrician.
Relate that the best treatment for the fetus is the optimal treatment of the mother.
Recognize the need for identifying the Rh status and the possible need for Rh immunization.
Identify and manage the conditions requiring critical treatment decisions in the order listed.

Potentials for Adverse Outcome: If the student's performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student's overall performance is unsuccessful.

YESNO
Did not delay in recognizing pregnancy.
Requested early surgical/obstetrical consultation.
Performed vaginal examination in a timely fashion.
Recognized possible uterine hemorrhage in a timely fashion.
Avoided excessive manipulation of the pelvis.
Monitored the fetus.
Recognized the potential for fetal distress.
Ordered Rh immunoglobulin.
Immobilized the right femur fracture.
Performed a neurovascular examination before and after the immobilization.
Protected the patient from hypothermia.
Considered the need for tetanus prophylaxis.
Did not delay in recognizing the need for transfer.
Did not delay transfer to perform diagnostic tests.
Adequately prepared for contingencies during the transfer process, such as hemodynamic deterioration, fetal distress, and the onset of labor.

Patient G - Initial Assessment and Management

YESNO
Perform the assessment and management phases properly and in the correct sequence.
Recognize the need to establish a definitive airway while restricting cervical spinal motion.
Recognize the presence of hypotension and the need to rapidly administer warmed crystalloid fluids.
Appreciate the potential significance of the bloody otorrhea and Battle's sign, and avoid inserting a nasogastric tube.
Recognize the presence of a widened mediastinum, obtain appropriate radiographic studies to diagnose ruptured aorta, and prepare the patient for transport and/or operation.
Identify and manage the conditions requiring critical treatment decisions in the order listed.

Potentials for Adverse Outcome: If the student's performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student's overall performance is unsuccessful.

YESNO
Did not perform and nasal instrumentation, such as insertion of nasogastric tube.
Recognized basilar skull fracture and cerebrospinal fluid otorrhea.
Performed angiography after checking surgical capabilities to repair the injury.
Restricted spinal motion.
Properly immobilized the left femur fracture.
Performed a neurovascular exam of left leg before and after the immobilization.
Protected the patient from hypothermia.
Considered the need for tetanus prophylaxis.
Did not delay in recognizing the need for transfer.
Did not delay transfer to perform diagnostic tests.
Adequately prepared for contingencies during the transfer process, such as a neurologic deterioration, seizure activity, combative patient, endotracheal tube malposition, and hemodynamic deterioration.