- Normal central venous pressure (CVP)
- 2–6 mmHg — a measure of right-heart preload and volume status.
- Normal pulmonary capillary wedge pressure (PCWP)
- 6–12 mmHg — reflects left atrial pressure and left-ventricular preload.
- Normal cardiac output (CO)
- 4–8 L/min — the volume of blood pumped per minute.
- Normal cardiac index (CI)
- 2.5–4.0 L/min/m² — cardiac output indexed to body surface area.
- Normal systemic vascular resistance (SVR)
- 800–1,200 dynes·sec·cm⁻⁵ — the left-ventricular afterload.
- Normal mean arterial pressure (MAP)
- 70–105 mmHg; the usual resuscitation goal is a MAP ≥ 65.
- MAP formula
- MAP ≈ (systolic + 2 × diastolic) ÷ 3 — diastole is weighted because the heart spends more time in it.
- Normal mixed venous O2 saturation (SvO2)
- 60–80% (central venous ScvO2 ≥ 70%) — low SvO2 means tissues are extracting more oxygen.
- Hemodynamic profile of hypovolemic shock
- Low preload (low CVP/PCWP), low cardiac output, high SVR.
- Hemodynamic profile of cardiogenic shock
- High preload (high PCWP), low cardiac output, high SVR — pump failure.
- Hemodynamic profile of distributive (septic) shock
- Low SVR; cardiac output high early then low late; warm skin early.
- Hemodynamic profile of obstructive shock
- Low cardiac output with a high/variable preload and high SVR; relieve the obstruction.
- Which shock state has a LOW SVR?
- Distributive shock (septic, neurogenic, anaphylactic) — the others compensate with a high SVR.
- Preload definition
- The stretch on the ventricle at end-diastole (its filling); estimated by CVP (right) and PCWP (left).
- Afterload definition
- The resistance the ventricle pumps against; for the left heart it is largely the SVR.
- Three types of acute coronary syndrome
- Unstable angina, NSTEMI, and STEMI.
- STEMI reperfusion goal
- Primary PCI within 90 minutes, or fibrinolysis if timely PCI is unavailable.
- Initial ACS care bundle
- Aspirin, oxygen if hypoxic, nitroglycerin for ischemic pain, and an anticoagulant; get a 12-lead and troponin.
- Why avoid nitroglycerin in inferior/RV MI
- An RV infarct is preload-dependent — nitrates drop preload and can cause severe hypotension; give fluids instead.
- Troponin significance
- A cardiac-specific biomarker that rises with myocardial injury; serial troponins help diagnose MI.
- Cardiogenic shock treatment
- An inotrope (dobutamine or milrinone) to raise contractility/output, careful unloading, and mechanical support (IABP/VAD) — not more fluids.
- Dobutamine mechanism and use
- A β1 inotrope that raises cardiac output and lowers SVR; used in cardiogenic shock and low-output heart failure.
- Milrinone mechanism
- A phosphodiesterase-3 inhibitor (inodilator): raises contractility and vasodilates; renally cleared, can cause hypotension.
- Acute decompensated heart failure signs
- Pulmonary edema, dyspnea, crackles, elevated JVD, and a high filling (wedge) pressure.
- Beck's triad
- Hypotension + jugular venous distension + muffled heart sounds = cardiac tamponade.
- Pulsus paradoxus
- A fall in systolic BP > 10 mmHg on inspiration; a sign of cardiac tamponade.
- Cardiac tamponade treatment
- Pericardiocentesis (or surgical drainage) to relieve the compression.
- Unstable tachycardia WITH a pulse — treatment
- Synchronized cardioversion.
- Pulseless VT or ventricular fibrillation — treatment
- Immediate defibrillation (unsynchronized), CPR, epinephrine, and amiodarone.
- Unstable bradycardia — treatment
- Atropine first; then transcutaneous pacing, dopamine, or epinephrine if it persists.
- Prolonged QT — risk
- Torsades de pointes (polymorphic VT); treat torsades with IV magnesium.
- Wolff-Parkinson-White (WPW)
- An accessory conduction pathway (delta wave) that can cause dangerous tachycardias; avoid AV-nodal blockers in WPW with atrial fibrillation.
- Atrial fibrillation rate vs rhythm control
- Control the rate (beta-blocker or calcium-channel blocker) and anticoagulate per stroke risk; cardiovert if unstable.
- Aortic dissection BP management
- Lower heart rate with a beta-blocker FIRST, then a vasodilator, to reduce aortic wall shear.
- Hypertensive emergency definition
- Severely high BP WITH acute target-organ damage (stroke, MI, dissection, pulmonary edema, encephalopathy).
- Hypertensive emergency BP target
- Lower the MAP by no more than ~25% in the first hour to avoid hypoperfusing the brain, heart, and kidneys.
- Nitroprusside caution
- A balanced vasodilator for hypertensive emergency/dissection; prolonged high doses risk cyanide/thiocyanate toxicity, especially in renal failure.
- Intra-aortic balloon pump (IABP) effect
- Inflates in diastole (improves coronary perfusion) and deflates in systole (reduces afterload) — used in cardiogenic shock.
- Cardiac tamponade on ECG
- Low-voltage QRS with electrical alternans (the heart swinging in fluid).
- Most common cause of cardiogenic shock
- A large myocardial infarction (left-ventricular pump failure).
- Right-sided heart failure signs
- JVD, peripheral edema, hepatomegaly, and ascites (systemic congestion).
- Left-sided heart failure signs
- Pulmonary congestion — crackles, dyspnea, orthopnea, and a high wedge pressure.
- BNP significance
- B-type natriuretic peptide rises with ventricular stretch; a high BNP supports heart failure.
- Cardiac catheterization post-care
- Monitor the access site for bleeding/hematoma, check distal pulses, keep the leg straight (femoral), and assess for contrast nephropathy.
- Pericarditis hallmark
- Pleuritic chest pain relieved by sitting forward, a friction rub, and diffuse ST elevation.
- Endocarditis risk
- Vegetations on valves that can embolize; suspect with fever, a new murmur, and risk factors (IV drug use, prosthetic valves).
- Third-degree (complete) heart block
- No relationship between P waves and QRS; treat unstable patients with pacing.
- Aortic aneurysm rupture
- Sudden severe pain and hemorrhagic shock — a surgical emergency.
- Valvular emergency — acute mitral regurgitation
- Sudden pulmonary edema and a new murmur after MI (papillary muscle rupture); needs urgent surgery.
- Coronary artery bypass (CABG) post-care
- Watch for bleeding/tamponade (sudden drop in chest-tube output with hypotension), dysrhythmias, and hemodynamic instability.
- Dopamine dose-dependent effects
- Low dose dopaminergic, moderate β1 (↑ CO), high α (↑ SVR); arrhythmogenic and used less now.
- Phenylephrine mechanism
- A pure α1 agonist that raises SVR/BP; can cause reflex bradycardia.
- Normal ABG pH
- 7.35–7.45 — below is acidosis, above is alkalosis.
- Normal PaCO2
- 35–45 mmHg — the respiratory (ventilation) component.
- Normal HCO3 (bicarbonate)
- 22–26 mEq/L — the metabolic component.
- Normal PaO2
- 80–100 mmHg on room air.
- ABG step 1
- Read the pH: < 7.35 acidosis, > 7.45 alkalosis.
- ABG step 2 — find the primary driver
- CO2 moves OPPOSITE to pH = respiratory; HCO3 moves the SAME direction as pH = metabolic.
- ROME mnemonic
- Respiratory Opposite, Metabolic Equal — keeps ABG directions straight.
- Respiratory acidosis cause
- Hypoventilation (sedation, COPD, neuromuscular weakness) → ↑ PaCO2, ↓ pH.
- Respiratory alkalosis cause
- Hyperventilation (anxiety, pain, early sepsis) → ↓ PaCO2, ↑ pH.
- Metabolic acidosis cause
- Added acid or lost bicarbonate (DKA, lactic acidosis/shock, renal failure, diarrhea) → ↓ HCO3, ↓ pH.
- Metabolic alkalosis cause
- Vomiting, NG suction, or diuretics → ↑ HCO3, ↑ pH.
- Anion gap formula and normal
- Na − (Cl + HCO3); normal 8–12. A high gap = added acid (MUDPILES).
- MUDPILES
- Causes of high-anion-gap metabolic acidosis: Methanol, Uremia, DKA, Propylene glycol, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates.
- Full vs partial compensation
- Partial: both values abnormal, pH still off. Full: both abnormal, pH back in the normal range.
- Speed of compensation
- Lungs compensate within minutes; kidneys take hours to days.
- ARDS definition
- Acute, non-cardiogenic pulmonary edema with bilateral infiltrates and refractory hypoxemia.
- ARDS P/F ratio grading (Berlin)
- PaO2/FiO2 ≤ 300 mild, ≤ 200 moderate, ≤ 100 severe.
- ARDS vs cardiogenic pulmonary edema
- ARDS has a NORMAL wedge pressure (non-cardiogenic); cardiogenic edema has a HIGH wedge.
- Lung-protective ventilation
- Low tidal volume (~6 mL/kg ideal body weight), plateau pressure < 30 cmH2O, PEEP, and permissive hypercapnia.
- Prone positioning in ARDS
- Improves oxygenation and survival in moderate-to-severe ARDS; named in the CCRN test plan.
- PEEP purpose
- Positive end-expiratory pressure holds alveoli open at end-expiration to improve oxygenation and recruit lung.
- Ventilator HIGH-pressure alarm causes
- Obstruction — kink, secretions, biting, bronchospasm, or a developing pneumothorax.
- Ventilator LOW-pressure alarm causes
- A disconnection or a leak in the circuit.
- DOPE mnemonic (sudden vent desat)
- Displacement of the tube, Obstruction, Pneumothorax, Equipment failure — disconnect and bag while troubleshooting.
- Auto-PEEP (breath stacking)
- Incomplete exhalation in obstructive disease that traps air; can cause hypotension and barotrauma.
- VAP prevention bundle
- HOB 30–45°, daily sedation interruption and spontaneous breathing trials, oral care, and DVT/stress-ulcer prophylaxis.
- Tension pneumothorax signs
- Absent breath sounds, hyperresonance, hypotension, JVD, and late tracheal deviation away from the side.
- Tension pneumothorax treatment
- Immediate needle decompression, then a chest tube.
- Massive pulmonary embolism
- Obstructive shock with acute RV strain — sudden hypoxia and hypotension; treat with anticoagulation ± thrombolysis/embolectomy.
- Status asthmaticus danger sign
- A 'silent chest' and a rising/normalizing PaCO2 (fatigue) signal impending respiratory failure.
- CO poisoning and SpO2
- Carbon monoxide gives a falsely normal SpO2; treat with high-flow 100% oxygen (or hyperbaric).
- Acute respiratory failure types
- Type 1 = hypoxemic (low PaO2); Type 2 = hypercapnic (high PaCO2, ventilation failure).
- Capnography (EtCO2) use
- Confirms ET tube placement and monitors ventilation and CPR quality (a sudden rise can indicate ROSC).
- Chest tube — sudden cessation of tidaling
- Suggests a kink, clot, or re-expanded lung; assess the tube and patient.
- Chest tube — continuous bubbling in the water seal
- Indicates an air leak in the system or patient.
- Hypoxemia vs hypoxia
- Hypoxemia = low oxygen in the blood; hypoxia = inadequate oxygen at the tissues.
- PEEP risk if too high
- Reduced venous return/cardiac output and barotrauma (e.g., pneumothorax).
- ARDS exudative phase
- Early diffuse alveolar damage with protein-rich edema and hyaline membranes → refractory hypoxemia.
- Weaning readiness (SBT)
- A spontaneous breathing trial with adequate oxygenation, stable hemodynamics, and an acceptable rapid-shallow-breathing index.
- Pulmonary hypertension danger
- Right-heart strain and failure; avoid hypoxia and acidosis, which worsen pulmonary vasoconstriction.
- Flail chest
- ≥ 3 adjacent ribs each broken in 2+ places → paradoxical movement and an underlying pulmonary contusion.
- Open pneumothorax treatment
- A three-sided occlusive dressing, then a chest tube.
- Empyema
- Pus in the pleural space, usually from pneumonia; requires drainage and antibiotics.
- NIPPV (BiPAP/CPAP) use
- Non-invasive support for COPD exacerbation and cardiogenic pulmonary edema to avoid intubation.
- Inhaled nitric oxide / prostacyclin
- Selective pulmonary vasodilators used as rescue for refractory hypoxemia/pulmonary hypertension.
- ECMO indication
- Refractory respiratory or cardiac failure not responding to conventional support — a high-acuity CCRN intervention.
- DKA lab criteria
- Glucose > 250, pH < 7.3, ketones present, and a high-anion-gap metabolic acidosis.
- HHS lab criteria
- Glucose often > 600, minimal/no ketosis, very high osmolality, profound dehydration.
- DKA/HHS treatment order
- Fluids FIRST, then an insulin infusion, with close potassium replacement.
- Why monitor potassium in DKA
- Insulin drives K+ into cells, so a normal or low K+ can crash dangerously — replace before/with insulin.
- When to add dextrose in DKA
- When the glucose falls to ~200, add dextrose to fluids to avoid hypoglycemia and cerebral edema.
- SIADH
- Excess ADH → water retention, dilutional hyponatremia, concentrated urine; managed with fluid restriction.
- Diabetes insipidus
- ADH deficiency → large volumes of dilute urine and hypernatremia; the opposite of SIADH.
- Adrenal crisis
- Hypotension refractory to fluids and pressors; treat with stress-dose corticosteroids.
- Thyroid storm
- Severe hyperthyroidism — fever, tachyarrhythmia, agitation; treat with beta-blocker, antithyroid drugs, and supportive care.
- DIC
- Disseminated intravascular coagulation — clotting consumes platelets/factors → simultaneous thrombosis and bleeding; treat the cause.
- HIT
- Heparin-induced thrombocytopenia — immune reaction dropping platelets with paradoxical clotting; STOP all heparin, use a non-heparin anticoagulant.
- TRALI
- Transfusion-related acute lung injury — hypotension + non-cardiogenic edema within ~6 h; does NOT improve with diuresis.
- TACO
- Transfusion-associated circulatory overload — hypertension + volume overload; DOES improve with diuresis.
- TRALI vs TACO blood-pressure clue
- TRALI trends hypotensive (lung injury); TACO trends hypertensive (too much volume).
- Acute hemolytic transfusion reaction
- Fever, flank pain, dark urine, hypotension (often ABO mismatch); STOP the transfusion immediately and support.
- Tumor lysis syndrome
- Massive cell breakdown → high potassium, phosphate, and uric acid, low calcium; treat with hydration, allopurinol/rasburicase.
- Upper GI hemorrhage sources
- Peptic ulcers and esophageal varices; resuscitate with blood, correct coagulopathy, and arrange endoscopy.
- Variceal bleeding treatment
- Blood products, octreotide, endoscopic banding, and balloon tamponade if needed.
- Hepatic encephalopathy treatment
- Lactulose (and rifaximin) to reduce ammonia; the patient may be confused or comatose.
- Acute pancreatitis
- Severe epigastric pain with elevated lipase/amylase; supportive care, fluids, and pain control; watch for SIRS/necrosis.
- Abdominal compartment syndrome
- A tense distended abdomen with rising airway pressures and falling urine output; measure bladder pressure; may need decompression.
- Acute kidney injury causes
- Prerenal (hypoperfusion), intrinsic (ATN, nephrotoxins, sepsis), and postrenal (obstruction).
- CRRT vs intermittent hemodialysis
- CRRT provides slow continuous dialysis tolerated by hemodynamically unstable patients; HD is faster but less tolerated.
- Hyperkalemia — first action
- IV calcium (gluconate/chloride) to stabilize the cardiac membrane — it does NOT lower the K+.
- Hyperkalemia — shift potassium into cells
- Regular insulin with dextrose, plus a nebulized beta-agonist (albuterol).
- Hyperkalemia — remove potassium
- Dialysis, a potassium binder, or a loop diuretic (if making urine).
- Hyperkalemia ECG changes
- Peaked T waves → widening QRS → sine wave → arrest.
- Hypokalemia ECG changes
- Flattened T waves, U waves, and ST depression; risk of arrhythmia.
- Hypocalcemia signs
- Chvostek's and Trousseau's signs, tetany, prolonged QT; common with citrate (massive transfusion).
- Hyponatremia correction caution
- Correct slowly — too-rapid correction risks osmotic demyelination (central pontine myelinolysis).
- Necrotizing fasciitis
- Pain out of proportion, crepitus, rapid systemic toxicity; a surgical emergency.
- Pressure injury prevention
- Repositioning, support surfaces, skin/nutrition care; the critically ill are high-risk from immobility and poor perfusion.
- Extravasation injury
- Leakage of a vesicant (e.g., norepinephrine) into tissue causing necrosis; stop the infusion and follow the antidote protocol.
- Stress-related mucosal disease prophylaxis
- PPIs or H2 blockers reduce GI bleeding risk in high-risk ICU patients.
- SIADH vs DI urine
- SIADH = concentrated urine with hyponatremia; DI = dilute urine with hypernatremia.
- Acute liver failure complications
- Encephalopathy, coagulopathy, cerebral edema, and hypoglycemia.
- Massive transfusion and calcium
- Citrate in stored blood binds calcium → hypocalcemia; replace calcium during massive transfusion.
- Whipple procedure
- Pancreaticoduodenectomy; monitor for bleeding, fistula, and glucose changes post-op.
- Acute tubular necrosis (ATN)
- The most common intrinsic AKI in the ICU — from ischemia or nephrotoxins; often recovers with supportive care.
- Indications for emergent dialysis (AEIOU)
- Acidosis, Electrolytes (refractory hyperkalemia), Intoxication, Overload (fluid), Uremia.
- Thrombocytopenia bleeding risk
- Rising risk as platelets fall; spontaneous bleeding risk is high below ~10–20 ×10⁹/L.
- Neutropenic precautions
- Protect the immunocompromised patient from infection; fever in neutropenia is an emergency (give antibiotics fast).
- Hyperphosphatemia / hypocalcemia link
- High phosphate binds calcium, lowering it — seen in renal failure and tumor lysis.
- Diabetic patient NPO insulin
- Hold short-acting/prandial insulin while NPO but continue basal needs and monitor glucose to avoid DKA.
- Bowel ischemia clue
- Pain out of proportion to the exam plus lactic acidosis — a surgical emergency.
- Normal intracranial pressure (ICP)
- 5–15 mmHg; the goal is to keep it < ~20–22.
- Cerebral perfusion pressure (CPP)
- CPP = MAP − ICP; the net pressure perfusing the brain.
- Rising-ICP nursing measures
- HOB 30° with head midline, normothermia, normocapnia, avoid hypoxia/hypotension, minimize stimulation; hypertonic saline or mannitol for spikes.
- Cushing's triad
- Hypertension with a WIDENING pulse pressure, bradycardia, and irregular respirations — a LATE sign of high ICP.
- Secondary brain injury
- Damage AFTER the initial insult from hypoxia, hypotension, edema, or rising ICP — preventable by nursing care.
- Ischemic stroke treatment
- Thrombolysis within the window after a CT rules out hemorrhage, ± mechanical thrombectomy for a large-vessel occlusion.
- Hemorrhagic stroke management
- Blood-pressure control and reversal of anticoagulation; neurosurgical evaluation.
- Neurogenic shock
- Distributive shock after a high spinal cord injury — hypotension WITH bradycardia and warm, dry skin.
- Neurogenic vs hypovolemic shock heart rate
- Neurogenic shock has BRADYcardia; hypovolemic shock has tachycardia.
- Autonomic dysreflexia
- A hypertensive crisis in cord injuries at/above T6 triggered by a stimulus below the lesion (often a full bladder); sit up and remove the trigger.
- Brain death definition
- Irreversible loss of all brain AND brainstem function; confirmed by coma, absent brainstem reflexes, and a positive apnea test.
- Status epilepticus
- A seizure > 5 min or repeated seizures without recovery; first-line treatment is a benzodiazepine, then an antiepileptic.
- Compartment syndrome 6 P's
- Pain (out of proportion / on passive stretch — earliest), Paresthesia, Pallor, Pulselessness, Paralysis, Poikilothermia.
- Compartment syndrome — earliest sign
- Pain out of proportion and pain on passive stretch; pulselessness and paralysis are LATE.
- Compartment syndrome treatment
- Emergent fasciotomy; do NOT elevate above the heart or apply ice; remove constricting dressings.
- Rhabdomyolysis
- Muscle breakdown releasing myoglobin (elevated CK, dark urine) that threatens the kidneys; treat with aggressive IV fluids.
- Fat embolism syndrome
- Hypoxia, confusion, and a petechial rash 24–72 h after a long-bone/pelvic fracture.
- ICU delirium
- Acute, fluctuating disturbance of attention/awareness — hyperactive, hypoactive (often missed), or mixed.
- Delirium screening tool
- The CAM-ICU (Confusion Assessment Method for the ICU).
- ABCDEF bundle
- Assess/treat pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement.
- Drugs that worsen delirium
- Benzodiazepines (and excessive sedation) — minimize them and treat reversible causes.
- Post-intensive care syndrome (PICS)
- New/worsened physical, cognitive, or mental-health impairment after critical illness; reduced by light sedation and early mobility.
- GCS components and range
- Eye (1–4) + Verbal (1–5) + Motor (1–6); total 3–15; ≤ 8 = secure the airway.
- Lowest possible GCS
- 3 (no eye, verbal, or motor response) — there is no score of 0.
- Spinal shock vs neurogenic shock
- Spinal shock = temporary loss of all reflexes/function below the injury (neurologic); neurogenic shock = hypotension with bradycardia (hemodynamic).
- Guillain-Barré syndrome danger
- Ascending paralysis that can reach the respiratory muscles — monitor vital capacity and prepare for ventilation.
- Myasthenic vs cholinergic crisis
- Both cause weakness; myasthenic improves with edrophonium/anticholinesterase, cholinergic worsens (from excess medication).
- Suicidal ideation precautions
- Ensure safety: remove means, provide one-to-one observation, and consult mental-health/psychiatry.
- Alcohol withdrawal
- Tremor, agitation, autonomic instability, and seizures/DTs; treat with benzodiazepines and monitor with CIWA.
- Agitation management priority
- Identify and treat the cause (hypoxia, pain, delirium); use non-pharmacologic measures first, restraints only as a last resort.
- Mannitol vs hypertonic saline for ICP
- Both lower ICP osmotically; mannitol is a diuretic (watch volume/electrolytes), hypertonic saline raises serum sodium.
- Cerebral salt wasting vs SIADH
- Both cause hyponatremia after brain injury; CSW is volume-depleted (treat with salt/fluids), SIADH is euvolemic (fluid-restrict).
- Decorticate vs decerebrate posturing
- Decorticate = flexion (arms to the core), decerebrate = extension; decerebrate indicates a deeper, worse injury.
- Triple-H therapy (vasospasm)
- Historically hypertension, hypervolemia, hemodilution for cerebral vasospasm after SAH; current practice emphasizes euvolemia and induced hypertension.
- Seizure safety
- Protect the airway, do not restrain or put anything in the mouth, time the seizure, and pad/lower the patient.
- Spinal cord injury — high-cervical risk
- Injuries above C3–C5 can paralyze the diaphragm → respiratory failure needing ventilation.
- Increased ICP and suctioning
- Suction briefly and pre-oxygenate — suctioning and coughing transiently spike ICP.
- Restraint use principles
- Least restrictive, time-limited, with an order and frequent reassessment; a last resort after non-pharmacologic measures.
- Serotonin syndrome
- Agitation, hyperthermia, clonus, and autonomic instability from serotonergic drugs; supportive care ± cyproheptadine.
- Neuroleptic malignant syndrome
- Rigidity, hyperthermia, and altered mental status from antipsychotics; stop the drug and provide supportive care/dantrolene.
- Hypoactive delirium importance
- The quiet, withdrawn form is the most common and most often MISSED — screen routinely with CAM-ICU.
- Sepsis definition
- Life-threatening organ dysfunction from a dysregulated host response to infection.
- Septic shock definition
- Sepsis with persistent hypotension needing vasopressors to keep MAP ≥ 65 PLUS a lactate > 2 despite fluids.
- SIRS
- Systemic inflammatory response syndrome — abnormal temperature, heart rate, respiratory rate, and WBC; may be infectious or not.
- MODS
- Multiple organ dysfunction syndrome — progressive failure of ≥ 2 organ systems; the leading cause of ICU death.
- Surviving Sepsis hour-1 bundle
- Measure lactate, draw cultures BEFORE antibiotics, give broad-spectrum antibiotics, begin 30 mL/kg crystalloid, and start vasopressors to MAP ≥ 65.
- Cultures vs antibiotics order in sepsis
- Draw blood cultures BEFORE giving antibiotics — but do not delay antibiotics beyond the first hour.
- First-line vasopressor in septic shock
- Norepinephrine; add vasopressin when norepinephrine alone is not enough.
- Norepinephrine mechanism
- An α1 ≫ β1 vasopressor that raises SVR and MAP; extravasation causes tissue necrosis.
- Epinephrine uses
- Anaphylaxis (first-line), cardiac arrest, and refractory shock; α and β effects are dose-dependent.
- Vasopressin in shock
- A non-adrenergic V1 vasoconstrictor (fixed ~0.03 units/min) added to norepinephrine in septic shock.
- Lactate significance
- A rising lactate reflects tissue hypoperfusion; clearance is a resuscitation goal in sepsis.
- Four shock states
- Hypovolemic, cardiogenic, distributive (septic/neurogenic/anaphylactic), and obstructive.
- Match the drip to the shock
- Septic → norepinephrine; cardiogenic → dobutamine; anaphylactic → epinephrine; hypertensive emergency → nitroprusside.
- ACLS shockable rhythms
- Ventricular fibrillation and pulseless ventricular tachycardia → defibrillate + epinephrine + amiodarone.
- ACLS non-shockable rhythms
- PEA and asystole → CPR + epinephrine every 3–5 min; NO defibrillation; treat the H's and T's.
- The H's of arrest
- Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia.
- The T's of arrest
- Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary or coronary).
- Epinephrine dose in arrest
- 1 mg IV/IO every 3–5 minutes during CPR.
- Post-ROSC care
- Optimize oxygenation/ventilation and hemodynamics, identify the cause, and provide targeted temperature management.
- Targeted temperature management
- Controlled cooling/temperature control after cardiac arrest to protect the brain.
- Opioid overdose antidote
- Naloxone.
- Acetaminophen overdose antidote
- N-acetylcysteine (NAC).
- Benzodiazepine overdose antidote
- Flumazenil (used cautiously — can precipitate seizures).
- Digoxin toxicity antidote
- Digoxin-specific antibody fragments (DigiFab).
- Tricyclic antidepressant overdose
- Sodium bicarbonate for a widened QRS and arrhythmia.
- Malignant hyperthermia
- A hypermetabolic crisis from anesthetics — rigidity, rising EtCO2, hyperthermia; treat with dantrolene.
- Major burn — first priority
- The airway: intubate early for inhalation injury (facial burns, singed hairs, soot, hoarseness, stridor).
- Burn fluid resuscitation
- Parkland formula: 4 mL lactated Ringer's × kg × %TBSA, half in the first 8 hours; titrate to urine output.
- HELLP syndrome
- Hemolysis, Elevated Liver enzymes, Low Platelets — a severe preeclampsia variant; definitive treatment is delivery.
- Eclampsia treatment
- Magnesium sulfate to prevent/treat seizures, blood-pressure control, and delivery.
- Healthcare-associated infection prevention
- Hand hygiene, CLABSI/CAUTI bundles, the VAP bundle, and appropriate isolation precautions.
- Anaphylaxis first-line treatment
- Intramuscular epinephrine, plus airway support, fluids, antihistamines, and steroids.
- Submersion (drowning) injury concern
- Hypoxia and ARDS; monitor and support oxygenation even if the patient initially looks well.
- qSOFA criteria
- Altered mentation, respiratory rate ≥ 22, and systolic BP ≤ 100 — a quick bedside flag for sepsis risk.
- Lactate clearance goal
- A falling lactate with resuscitation indicates improving perfusion.
- Crystalloid dose in septic shock
- 30 mL/kg of balanced crystalloid for hypotension or a lactate ≥ 4 mmol/L.
- Anaphylaxis epinephrine route/dose
- Intramuscular epinephrine 0.3–0.5 mg in the lateral thigh, repeated as needed.
- Distributive shock subtypes
- Septic, neurogenic, and anaphylactic — all share a LOW SVR.
- Cardiac arrest — high-quality CPR
- Push hard (≥ 2 inches) and fast (100–120/min), allow full recoil, minimize interruptions.
- Amiodarone in arrest
- Given for refractory VF/pulseless VT after defibrillation and epinephrine.
- Carbon monoxide treatment
- High-flow 100% oxygen; hyperbaric oxygen for severe poisoning.
- Cyanide toxicity treatment
- Hydroxocobalamin (and/or the cyanide antidote kit).
- Burn — escharotomy indication
- Circumferential full-thickness burns causing compartment-like compromise of a limb or the chest.
- Heat stroke management
- Rapid cooling and supportive care; differentiate from neuroleptic malignant/serotonin syndrome and malignant hyperthermia.
- Placental abruption signs
- Painful vaginal bleeding, a rigid/tender uterus, and fetal distress — an obstetric emergency.
- Maternal trauma positioning
- After ~20 weeks, left lateral tilt or manual uterine displacement to relieve aortocaval compression.
- AACN Synergy Model core idea
- Patient outcomes are best when the nurse's competencies match the patient's characteristics and needs.
- Eight Synergy nurse competencies
- Clinical judgment, advocacy/moral agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, facilitation of learning.
- CCRN content split
- 80% Clinical Judgment / 20% Professional Caring & Ethical Practice.
- Advocacy / moral agency
- Working on the patient's behalf and acting as a moral agent to identify and resolve ethical and clinical concerns.
- Caring practices
- Activities (vigilance, engagement, responsiveness) that create a compassionate, therapeutic environment to promote comfort and prevent suffering.
- Collaboration
- Working with patients, families, and the interdisciplinary team toward optimal, realistic goals.
- Systems thinking
- Using knowledge and tools to manage environmental and system resources across the care continuum.
- Response to diversity
- Recognizing and incorporating differences (cultural, spiritual, gender, age, values) into patient-centered care.
- Clinical inquiry
- Questioning and evaluating practice and creating change through evidence-based practice and research utilization.
- Facilitation of learning
- Teaching patients, families, staff, and the community, formally and informally.
- Four core ethical principles
- Autonomy, beneficence, non-maleficence, and justice.
- Autonomy
- The patient's right to make their own informed decisions about their care.
- Beneficence vs non-maleficence
- Beneficence = act in the patient's best interest; non-maleficence = do no harm.
- Informed consent elements
- Disclosure, understanding, voluntariness, and competence; the nurse witnesses and verifies, the provider obtains it.
- Advance directive
- A document stating a patient's wishes for care if they cannot decide; honor it and identify the lawful surrogate.
- Surrogate decision-maker priority
- The legally designated surrogate's authority takes precedence over other family members' wishes.
- SBAR
- Situation, Background, Assessment, Recommendation — a structured handoff/communication tool.
- Just culture
- A non-punitive approach to error reporting that focuses on system improvement rather than individual blame.
- Palliative vs hospice care
- Palliative care = comfort/symptom care at any disease stage alongside treatment; hospice = comfort care at end of life.
- Moral distress
- Knowing the right action but being constrained from taking it; recognize and address it to prevent burnout.
- Ethics consultation
- A resource for resolving complex ethical conflicts (e.g., goals-of-care disputes) at the bedside.
- Family-centered care in the ICU
- Including the family in communication, decision-making, and (where appropriate) presence during procedures/resuscitation.
- Organ donation role
- Support the family and follow protocol; the organ procurement organization, not the bedside nurse, approaches the family about donation.
- Patient advocacy example
- Speaking up when planned care conflicts with the patient's documented wishes or is unsafe.
- Evidence-based practice
- Integrating the best research evidence with clinical expertise and patient values to guide care.
- Therapeutic communication
- Active listening, open-ended questions, and empathy that build trust and elicit the patient's concerns.
- Cultural competence example
- Arranging an interpreter and respecting cultural/religious practices in the plan of care.
- Withdrawal of life-sustaining treatment
- A patient/surrogate decision honored with comfort-focused care; the nurse ensures symptom management and family support.
- DNR/DNAR order
- Do-Not-Resuscitate — withholds CPR; it does not mean withholding other care unless specified.
- Brain death vs persistent vegetative state
- Brain death = irreversible loss of all brain function (legally dead); PVS = wakefulness without awareness.
- Interdisciplinary rounds purpose
- Shared, goal-directed planning across the team to align care and prevent errors.
- Chain of command
- Escalating a safety concern up the hierarchy until it is addressed.
- Patient safety — high-alert medications
- Drugs (insulin, heparin, vasoactives, opioids) requiring extra safeguards like independent double-checks.
- Quality improvement (PDSA)
- Plan-Do-Study-Act cycles to test and implement practice changes.
- Healthcare proxy
- A person legally designated to make medical decisions when the patient cannot.
- End-of-life symptom management
- Treat pain, dyspnea, and agitation aggressively for comfort; the goal shifts to quality, not cure.
