Critical care, emergency and perioperative nursing
This domain tests prioritisation under time pressure: triage, resuscitation, the first hour of sepsis, the primary survey and safety in the operating suite. Marks are usually lost by choosing a correct action in the wrong order.
Resuscitation
- Compressions 100-120/min, depth 5-6 cm, full recoil, minimise interruptions, change compressor every 2 minutes, ratio 30:2 without an advanced airway.
- Defibrillation as early as possible; biphasic energy per manufacturer, commonly 120-200 J, then resume compressions immediately. Adrenaline 1 mg every 3-5 minutes; amiodarone 300 mg after the third shock in refractory VF or pulseless VT.
Sepsis and trauma
- Sepsis first hour: measure lactate, take blood cultures before antibiotics, give broad-spectrum antibiotics, and 30 mL/kg crystalloid for hypotension or lactate of 4 mmol/L or more.
- Trauma primary survey: catastrophic haemorrhage control, airway with cervical spine protection, breathing, circulation, disability, exposure, then the secondary survey.
Perioperative safety
- WHO surgical safety checklist with sign-in, time-out and sign-out; correct patient, site, side, consent and implants.
- Malignant hyperthermia: rising end-tidal CO2, masseter and generalised rigidity, tachycardia, hyperthermia. Stop volatile agents and succinylcholine, give 100% oxygen with high flow, dantrolene 2.5 mg/kg and repeat, actively cool, treat hyperkalaemia.
Worked example
Thirty minutes into general anaesthesia the end-tidal CO2 rises despite increased ventilation, with tachycardia and rigidity. Reasoning: rising CO2 that does not respond to ventilation suggests a hypermetabolic crisis rather than light anaesthesia. The nurse calls for help and the dantrolene box while the anaesthetist stops the trigger agents.
Traps that cost marks
Interrupting compressions to intubate; delaying antibiotics to finish fluids; mistaking shivering for malignant hyperthermia.