Critical Care and Emergency Nursing
Critical Care and Emergency Nursing tests rapid recognition, structured resuscitation and ongoing monitoring of the deteriorating patient. Items reward the correct sequence under pressure and punish actions that delay oxygenation, circulation or defibrillation.
Primary survey: ABCDE
Airway with cervical spine protection; Breathing with oxygen and capnography; Circulation with IV access, bloods and fluid; Disability with Glasgow Coma Scale and pupils; Exposure with temperature and full examination. Reassess after every intervention.
Sepsis and shock
Use the sepsis bundle: measure lactate, obtain blood cultures before antibiotics, give broad-spectrum antibiotics within one hour, give 30 mL/kg crystalloid for hypotension or lactate of 4 mmol/L or more, and start vasopressors (noradrenaline first line) to keep mean arterial pressure at 65 mmHg or above. Distinguish shock types: hypovolaemic (low filling, cold), cardiogenic (crackles, raised JVP, cold), distributive or septic (warm then cold, low systemic vascular resistance) and obstructive (pulmonary embolism, tamponade).
ACLS essentials
- Unresponsive and not breathing normally: start CPR at 30:2, depth 5–6 cm, rate 100–120/min, full recoil, minimal interruptions.
- Shockable rhythms (VF or pulseless VT): defibrillate immediately, then adrenaline 1 mg IV every 3–5 minutes after the second shock, and amiodarone after the third.
- Non-shockable rhythms (asystole, PEA): adrenaline 1 mg every 3–5 minutes and treat reversible causes (the 4 Hs and 4 Ts).
- After return of spontaneous circulation: target oxygen saturation 94–98% and avoid hyperoxia and hypotension.
ABG interpretation in four steps
- pH: acidosis below 7.35, alkalosis above 7.45. 2. PaCO2: the respiratory component. 3. HCO3: the metabolic component. 4. Compensation and oxygenation (PaO2/FiO2 ratio). Example: pH 7.28, PaCO2 30 mmHg, HCO3 14 mmol/L - metabolic acidosis with respiratory compensation; calculate the anion gap and check lactate or ketones.
Worked example
A postoperative patient has fever 39 °C, pulse 124/min, BP 84/50 mmHg, respiratory rate 26/min and lactate 4.2 mmol/L. What are your first actions? Reasoning: this is septic shock. Call for help, give high-flow oxygen, secure two IV lines, draw cultures and lactate, start 30 mL/kg crystalloid, and give antibiotics within the hour. Vasopressors follow if mean arterial pressure stays below 65 mmHg after fluids. Waiting for a repeat BP before acting is a classic wrong answer.
Traps that cost marks
- Large fluid boluses in cardiogenic shock or heart failure.
- Delaying defibrillation in order to give drugs.
- Rushing intubation before basic airway manoeuvres and suction.
- Ignoring rising lactate or falling urine output.