Resuscitation and Shock
Domain focus
The Resuscitation and Shock domain tests whether you can run a code, identify shock early, and choose interventions that change outcome. The board favors rhythm-based decisions, drug timing, and the physiology behind blood pressure and lactate.
Core rules
- Start high-quality CPR immediately: rate 100–120/min, depth 5–6 cm in adults, full recoil, interruptions under 10 seconds.
- Defibrillate VF/pVT as soon as possible; biphasic 120–200 J (manufacturer range) or monophasic 360 J. Resume CPR immediately after shock.
- Epinephrine 1 mg IV/IO every 3–5 minutes. For shockable rhythms it follows the second shock; for nonshockable rhythms give it as soon as feasible.
- Amiodarone 300 mg after the third shock, then 150 mg; lidocaine is an alternative.
- Search for Hs and Ts: hypoxia, hypovolemia, hydrogen ion, hypo/hyperkalemia, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis, trauma.
- In shock, treat the type: hemorrhage control and blood products for hemorrhagic, fluids plus vasopressors and antibiotics for septic, immediate decompression for tension pneumothorax.
Worked example
A 58-year-old collapses on the ward. The monitor shows ventricular fibrillation. Start CPR, charge to 200 J, shock, resume compressions for 2 minutes. Rhythm check still shows VF: shock again, resume CPR, give epinephrine 1 mg. After the third shock, give amiodarone 300 mg. The reasoning is rhythm-driven: shock first for VF, CPR minimizes no-flow time, epinephrine and amiodarone follow the algorithm rather than being given before defibrillation.
Traps
Prolonged pulse checks, stopping compressions for intubation, routine bicarbonate, and missing reversible causes cost marks. Do not confuse pulseless electrical activity with a perfusing rhythm; check for output.