Cardiovascular
11%of exam
Respiratory
13%of exam
Endocrine, Heme, GI, Renal, Skin
25%of exam
Musculoskeletal, Neuro, Behavioral
15%of exam
Multisystem
17%of exam
Professional Caring and Ethical Practice
20%of exam
Quick Facts
- Exam
- CCRN (Pediatric)
- Items
- 150 (125 scored)
- Time
- 3 hours
- Pass
- 83 of 125
- Split
- Judgment 80%, caring 20%
- Fee
- $260 member, $375 nonmember
- Delivery
- PSI center or remote
- Renewal
- 3 years, 100 CERPs
- 2025 pass rate
- 68.72% first-time
- Test plan
- Exams from Nov 19, 2025
Ductal-Dependent Rescue
Duct closing? Start prostaglandin E1
Neonate in shockKeep duct openWatch for apneaAvoid excess oxygen
Cardiogenic vs Hypovolemic Shock
Cardiogenic
- Hepatomegaly and gallop
- Rales, distended neck veins
- Small cautious boluses
Hypovolemic
- Dry mucous membranes
- Flat neck veins
- Rapid 20 mL/kg boluses
Wet lungs vs dry
Rhythm Response Picker
- HR under 60, poor perfusion→Start CPR(Oxygenate first)
- Bradycardia after good ventilation→Epinephrine(0.01 mg/kg)
- Vagal or block bradycardia→Atropine(Second line)
- Narrow QRS, variable R-R→Sinus tachycardia(Treat the cause)
- Infant narrow, over 220→SVT(Vagal, then adenosine)
- Child narrow, over 180→SVT(Vagal, then adenosine)
- SVT with poor perfusion→Synchronized cardioversion(0.5-1 J/kg)
- Wide QRS with pulse→Ventricular tachycardia(Expert consult)
- Pulseless VT or VF→Defibrillate(2 J/kg first)
- Shock-refractory VF→Amiodarone or lidocaine(After second shock)
- Asystole or PEA→CPR plus epinephrine(Do not shock)
- Torsades de pointes→Magnesium(25-50 mg/kg)
Age Vital Sign Norms
- Neonate HR
- 100-205 awakePALS
- Infant HR
- 100-180 awake
- Toddler HR
- 98-140 awake
- Preschool HR
- 80-120 awake
- School-age HR
- 75-118 awake
- Adolescent HR
- 60-100 awake
- Infant RR
- 30-53 breaths per minute
- Toddler RR
- 22-37 breaths per minute
- Preschool RR
- 20-28 breaths per minute
- School-age RR
- 18-25 breaths per minute
- Adolescent RR
- 12-20 breaths per minute
- Sleeping heart rate
- Runs lower than awake
Compensated vs Hypotensive Shock
Compensated
- Blood pressure still normal
- Tachycardia, poor perfusion
- Intervene now
Hypotensive
- Systolic pressure below threshold
- Late decompensation
- Arrest is near
Pressure falls last
Hypotension SBP Thresholds
- Term neonate
- Under 600-28 days
- Infant 1-12 months
- Under 70
- Child 1-10 years
- Under 70 + 2x age
- Over 10 years
- Under 90
- Compensated shock
- Normal pressure, poor perfusion
- Hypotensive shock
- Late finding, near arrest
- Sepsis MAP goal
- 5th to 50th percentile
PALS Arrest Doses
- Epinephrine IV or IO
- 0.01 mg/kg, max 1 mg
- Epinephrine interval
- Every 3-5 minutes
- Epinephrine endotracheal
- 0.1 mg/kg if no access
- First defibrillation
- 2 J/kg
- Later defibrillation
- 4 J/kg, max 10
- Synchronized cardioversion
- 0.5-1 J/kg, then 2
- Amiodarone
- 5 mg/kg, may repeat
- Lidocaine
- 1 mg/kg loading dose
- Adenosine first dose
- 0.1 mg/kg, max 6 mg
- Adenosine second dose
- 0.2 mg/kg, max 12 mg
- Magnesium for torsades
- 25-50 mg/kg, max 2 g
- Two-rescuer CPR ratio
- 15:2 without advanced airway
- Compression pauses
- Under 10 seconds2025
- Arrest DBP goal, infant
- 25 mm Hg or higher2025
- Arrest DBP goal, child
- 30 mm Hg or higher2025
- Start CPR when
- HR under 60, poor perfusion
Congenital Heart Lesions
- Tetralogy of Fallot
- VSD, overriding aorta, RVH, PS
- Tet spell response
- Knees to chest, oxygen
- Transposition
- Parallel circulations need mixing
- Hypoplastic left heart
- Single ventricle, ductal dependent
- Ductal-dependent lesion
- Prostaglandin E1 infusion
- Prostaglandin risk
- Apnea, ready to intubate
- Coarctation
- Arm hypertension, weak femorals
- Obstructed TAPVR
- Surgical emergency
- Ventricular septal defect
- Left-to-right shunt, heart failure
- Single ventricle goal
- Qp:Qs near 1:1
- Postoperative JET
- Junctional tachycardia, cool patient
Hemodynamic Targets
- Central venous pressure
- 2-6 mm Hg typical
- ScvO2 goal
- Over 70 percent
- Cardiac index
- 3.3-6.0 L/min/m2
- Lactate concern
- Over 2 mmol/L
- Capillary refill
- Under 2 seconds normal
- Narrow pulse pressure
- Low stroke volume
- Wide pulse pressure
- Vasodilation or diastolic runoff
- NIRS
- Regional tissue oxygenation trend
- Urine output goal
- 1 mL/kg/hr minimum
PARDS Severity Ladder
OI 4 diagnose, OI 16 severe
OSI 5 diagnosesOSI 12 is severeStratify at 4 hoursP/F 300 noninvasive
Croup vs Epiglottitis
Croup
- Viral, gradual onset
- Barky cough, steeple sign
- Dexamethasone and epinephrine
Epiglottitis
- Bacterial, rapid onset
- Drooling, thumbprint sign
- Airway secured in OR
Barky cough vs drooling
Deteriorating Airway Picker
- Barky cough, inspiratory stridor→Croup(Dexamethasone)
- Stridor at rest, retractions→Nebulized epinephrine(Observe for rebound)
- Drooling, tripod, toxic appearance→Suspect epiglottitis(No oral exam)
- Sudden choking, unilateral wheeze→Foreign body(Bronchoscopy)
- Wheeze with poor air movement→Status asthmaticus(Continuous albuterol)
- Silent chest, rising PaCO2→Prepare to intubate(Impending failure)
- Hypoxemia despite high flow→Escalate support(Screen for PARDS)
- OI 16 or higher→Severe PARDS care(Prone, blockade)
- Refractory hypoxemia on ventilator→Consider ECMO(Center dependent)
- Stridor after extubation→Racemic epinephrine(Add steroids)
PARDS Criteria
- Timing
- Within 7 days of insultPALICC-2
- Chest imaging
- New opacities, not atelectasis
- Edema origin
- Not cardiac or overload
- Invasive diagnosis
- OI 4 or higher
- Invasive alternative
- OSI 5 or higher
- Noninvasive diagnosis
- P/F 300 or less
- Noninvasive alternative
- S/F 250 or less
- NIV interface needed
- Full mask, CPAP 5
- Severe on ventilator
- OI 16 or OSI 12
- Severe on NIV
- P/F 100 or less
- Severity timing
- At least 4 hours later
- Possible PARDS
- High-flow nasal cannula
- Cyanotic heart disease
- Acute change beyond cardiac
Ventilator Targets
- Tidal volume, better compliance
- 5-8 mL/kg predicted weight
- Tidal volume, poor compliance
- 3-6 mL/kg predicted weight
- Plateau pressure
- Keep under 28-30
- Driving pressure
- 15 cm H2O or less
- SpO2, mild PARDS
- 92-97 percent
- SpO2, severe PARDS
- 88-92 after PEEP optimization
- Permissive hypercapnia pH
- 7.20-7.30
- Prone positioning
- Consider in severe PARDS
- Neuromuscular blockade
- Severe PARDS, 24-48 hours
- Inhaled nitric oxide
- Pulmonary hypertension, right failure
- ECMO
- Refractory hypoxemia or shock
Airway Emergencies
- Croup organism
- Parainfluenza virus
- Croup steroid
- Dexamethasone 0.6 mg/kg
- Stridor at rest
- Nebulized epinephrine, watch rebound
- Epiglottitis organism
- Haemophilus influenzae type b
- Epiglottitis rule
- No oral exam, call OR
- Status asthmaticus first
- Continuous albuterol plus steroids
- Asthma magnesium
- 25-75 mg/kg, max 2 g
- Silent chest
- Ominous, minimal air movement
- Rising PaCO2 in asthma
- Impending respiratory failure
- Bronchiolitis support
- Suction, oxygen, high-flow
- Post-extubation stridor
- Racemic epinephrine, steroids
Airway Sizing Rules
- Cuffed tube size
- Age/4 plus 3.5
- Uncuffed tube size
- Age/4 plus 4
- Insertion depth
- Tube size times 3
- Suction catheter
- Twice tube internal diameter
- Narrowest infant airway
- Cricoid ring
- Cuff pressure limit
- Under 20-25 cm H2O
- Tube confirmation
- Waveform capnography
- Extubation readiness
- Cuff leak, minimal settings
DKA Order of Operations
Fluids first, insulin second, dextrose later
Never bolus insulinPotassium in every bagHeadache means edemaMannitol or 3% saline
DKA vs HHS
DKA
- Glucose over 200
- pH under 7.3
- Ketones markedly elevated
HHS
- Glucose over 600
- pH above 7.3
- Osmolality over 320
Acidosis vs osmolality
Sodium and Polyuria Picker
- High sodium, dilute urine→Diabetes insipidus(Desmopressin)
- Low sodium, concentrated urine→SIADH(Restrict fluids)
- Low sodium, high urine output→Cerebral salt wasting(Replace sodium)
- Seizure from low sodium→3% saline bolus(3-5 mL/kg)
- Polyuria after head injury→Check sodium and osmolality(DI risk)
- Polyuria with high glucose→Osmotic diuresis(Consider DKA)
DKA Rules
- Glucose criterion
- Over 200 mg/dLISPAD
- Acidosis criterion
- Venous pH under 7.3
- Bicarbonate criterion
- Under 18 mmol/L
- Ketone criterion
- BOHB 3 mmol/L or higher
- Moderate DKA
- pH under 7.2
- Severe DKA
- pH under 7.1
- Shock bolus
- 10-20 mL/kg isotonic fluid
- Insulin infusion rate
- 0.05-0.1 units/kg/hr
- Insulin start
- After fluids, never bolus
- Add dextrose when
- Glucose near 250-300 mg/dL
- Potassium in fluids
- About 40 mmol/L
- Hold insulin when
- Potassium under 3 mmol/L
- Cerebral injury rate
- 0.5-0.9 percent of episodes
- Cerebral edema warning
- Headache, bradycardia, falling consciousness
- Mannitol dose
- 0.5-1 g/kg over 15 minutes
- Hypertonic saline dose
- 3% at 2.5-5 mL/kg
SIADH vs Diabetes Insipidus
SIADH
- Serum sodium low
- Urine concentrated
- Restrict free water
Diabetes insipidus
- Serum sodium high
- Urine dilute
- Give desmopressin
Holds water vs loses
Life-Threatening Electrolytes
- Hyperkalemia first ECG
- Peaked T waves
- Hyperkalemia late ECG
- Wide QRS, sine wave
- Membrane protection
- Calcium gluconate 60-100 mg/kg
- Potassium shifting
- Insulin with glucose, albuterol
- Potassium removal
- Diuretics, binders, dialysis
- Hypokalemia ECG
- Flat T waves, U waves
- Hypocalcemia sign
- Prolonged QT, tetany
- Citrate toxicity
- Massive transfusion lowers calcium
- Hypoglycemia threshold
- Under 70 mg/dL
- Hypoglycemia treatment
- D10 at 5 mL/kg
- Symptomatic hyponatremia
- 3% saline 3-5 mL/kg
- Correction caution
- Avoid rapid sodium swings
- Refractory hypokalemia
- Check and replace magnesium
SIADH vs Cerebral Salt Wasting
SIADH
- Euvolemic or overloaded
- Urine output low
- Fluid restriction
Cerebral salt wasting
- Hypovolemic
- Urine output high
- Replace sodium and volume
Volume status decides treatment
Sodium and Water Disorders
- DI serum sodium
- High and rising
- DI urine
- Dilute, osmolality under 300
- DI urine output
- Over 4 mL/kg/hr
- DI treatment
- Desmopressin plus free water
- SIADH serum sodium
- Low with low osmolality
- SIADH urine
- Concentrated, sodium not low
- SIADH volume status
- Euvolemic or slightly overloaded
- SIADH treatment
- Fluid restriction
- CSW serum sodium
- Low with volume depletion
- CSW urine output
- High, wasting sodium
- CSW treatment
- Replace sodium and volume
- Key discriminator
- Volume status separates them
Hematology and Oncology
- Acute chest syndrome
- New infiltrate plus respiratory symptoms
- Acute chest treatment
- Oxygen, antibiotics, transfusion
- Exchange transfusion goal
- HbS under 30 percent
- Sickle stroke screening
- Transcranial Doppler velocity
- Tumor lysis labs
- High potassium, phosphate, urate
- Tumor lysis calcium
- Low, replace only if symptomatic
- Tumor lysis drugs
- Rasburicase or allopurinol
- TRALI
- Lung injury within 6 hours
- TACO
- Volume overload, hypertension
- DIC labs
- Low fibrinogen, high D-dimer
- Febrile neutropenia
- Antibiotics within 1 hour
- Immune thrombocytopenia
- Isolated low platelet count
Renal and GI Numbers
- Oliguria
- Under 0.5 mL/kg/hr
- AKI staging
- Creatinine rise or oliguria
- CRRT indications
- Overload, electrolytes, uremia, toxins
- HUS triad
- Anemia, thrombocytopenia, kidney injury
- HUS trigger
- Shiga toxin E coli
- Normal pediatric IAP
- 4-10 mm Hg
- Pediatric IAH
- Sustained over 10 mm Hg
- Pediatric ACS
- Over 10 plus organ dysfunction
- IAP measurement
- Bladder, 1 mL/kg instilled
- NEC hallmark
- Pneumatosis intestinalis on film
- NEC management
- NPO, decompression, antibiotics
- Hepatic failure signs
- Encephalopathy plus coagulopathy
- Refeeding syndrome
- Low phosphate, potassium, magnesium
ICP Bundle
Head midline, ICP under 20, CPP 40
3% saline 2-5 mL/kgDrain CSFNo corticosteroidsNormothermia and normoglycemia
ICP and CPP Targets
- ICP treatment threshold
- Under 20 mm HgBTF 2019
- CPP minimum
- 40 mm Hg
- CPP suggested range
- 40-50 mm Hg
- CPP formula
- MAP minus ICP
- Age effect on CPP
- Infants low, adolescents high
- Hypertonic saline bolus
- 3% at 2-5 mL/kg
- Bolus infusion time
- Over 10-20 minutes
- Continuous 3% infusion
- 0.1-1.0 mL/kg/hr
- Refractory hyperosmolar
- 23.4% saline 0.5 mL/kg
- CSF drainage
- External ventricular drain
- Not recommended
- Corticosteroids for raised ICP
- Seizure prophylaxis
- Reduces early post-traumatic seizures
- Early nutrition
- Start within 72 hours
- Hypothermia option
- 32-33 C for ICP
- Cushing triad
- Hypertension, bradycardia, irregular breathing
Neuro Assessment Tools
- Pediatric GCS
- Modified verbal for infants
- Severe brain injury
- GCS 8 or less
- New unequal pupils
- Herniation warning
- Status epilepticus
- Seizure 5 minutes or longer
- First-line anticonvulsant
- Benzodiazepine
- Second-line anticonvulsant
- Levetiracetam, fosphenytoin, valproate
- CAPD delirium cutoff
- Score 9 or higher
- WAT-1 withdrawal cutoff
- Score 3 or higher
- State Behavioral Scale
- Sedation depth in children
- Neuroprotection basics
- Normothermia, normoglycemia, head midline
Brain Death Rules
- Pediatric examinations
- Two, by two clinicians2023
- Interval between exams
- 12 hours at every age
- Apnea tests in children
- Two, one per exam
- Apnea PaCO2 target
- 60 mm Hg or higher
- Apnea rise required
- 20 mm Hg above baseline
- Apnea pH target
- Under 7.30
- Wait under 24 months
- 48 hours after injury
- Hypoxic-ischemic injury
- Wait 24 hours if older
- After rewarming
- Wait 24 hours past 36C
- Donation timing
- Referral before family approach
Behavioral and Musculoskeletal
- Post-intensive care syndrome
- Physical, cognitive, emotional sequelae
- Abuse red flag
- Injury inconsistent with history
- Suicide screening
- Ask directly, secure environment
- Compartment syndrome sign
- Pain on passive stretch
- Compartment pressure concern
- Over 30 mm Hg
- Late compartment finding
- Pulselessness, already ischemic
- Rhabdomyolysis marker
- Very high creatine kinase
- Rhabdomyolysis care
- Fluids, watch potassium
- SCIWORA
- Cord injury, normal radiographs
- Restraint rule
- Least restrictive, frequent reassessment
Sepsis Clock
One hour with shock, three without
10-20 mL/kg bolusesUp to 40-60 mL/kgReassess each bolusBalanced crystalloid
Cold vs Warm Shock
Cold shock
- Cool, mottled extremities
- Delayed capillary refill
- Narrow pulse pressure
Warm shock
- Warm, flushed extremities
- Flash capillary refill
- Wide pulse pressure
Bedside signs alone unreliable
Shock Type Picker
- Vomiting, diarrhea, dry mucosa→Hypovolemic shock(Isotonic boluses)
- Fever plus perfusion change→Septic shock(Antibiotics within hour)
- Hepatomegaly, gallop, rales→Cardiogenic shock(Small 5-10 mL/kg)
- Muffled tones, distended veins→Tamponade(Pericardiocentesis)
- Tracheal shift, absent breath sounds→Tension pneumothorax(Needle decompression)
- Hypotension with bradycardia→Neurogenic shock(Suspect spinal injury)
- Hives, wheeze, facial swelling→Anaphylaxis(Intramuscular epinephrine)
- Neonate collapsing, duct closing→Ductal-dependent lesion(Prostaglandin E1)
- Shock despite fluid and pressors→Add hydrocortisone(Refractory only)
Sepsis Bundle Numbers
- Antibiotics with shock
- Within 1 hourSSC
- Antibiotics without shock
- Within 3 hours
- Blood cultures
- Before antibiotics if possible
- Single bolus size
- 10-20 mL/kg
- First-hour total
- Up to 40-60 mL/kg
- Without intensive care
- Up to 40 mL/kg
- Reassessment
- After every fluid bolus
- Fluid choice
- Balanced crystalloid preferred
- Stop boluses when
- Fluid overload appears
- Lactate use
- Follow trend, not one
- Vasoactive timing
- After 40-60 mL/kg fluid
- Hydrocortisone
- Only if shock refractory
- Glucose target
- Do not target 140
Shock States
- Hypovolemic
- Low preload, fluid loss
- Distributive
- Vasodilation, maldistributed flow
- Cardiogenic
- Pump failure, avoid large boluses
- Obstructive
- Tamponade, tension pneumothorax, embolus
- Neurogenic
- Hypotension with bradycardia
- Anaphylactic
- Intramuscular epinephrine first
- Septic shock definition
- Infection plus cardiovascular dysfunction
- Early pediatric sign
- Tachycardia before low pressure
- MODS
- Two or more organs
Burns and Toxic Exposure
- Parkland formula
- 4 mL/kg per percent TBSA
- First half timing
- Over the first 8 hours
- Pediatric addition
- Add dextrose maintenance fluid
- Infant head share
- About 18 percent TBSA
- Best burn chart
- Lund-Browder, age adjusted
- Inhalation injury clues
- Soot, hoarseness, facial burns
- Carbon monoxide
- Pulse oximetry reads falsely high
- Acetaminophen antidote
- N-acetylcysteine
- Opioid antidote
- Naloxone
- Organophosphate antidote
- Atropine plus pralidoxime
- Submersion priority
- Oxygenation and ventilation first
- Hypothermic submersion
- Rewarm before judging outcome
Synergy Eight and Eight
Eight patient needs, eight nurse competencies
Patient drives competencyRate level 1, 3, 5Judgment is the 80%Caring is the 20%
Synergy Patient Characteristics
- Resiliency
- Ability to return to baseline
- Vulnerability
- Susceptibility to actual stressors
- Stability
- Ability to maintain equilibrium
- Complexity
- Entangled systems and family
- Resource availability
- Personal, social, financial support
- Participation in care
- Family engagement in care
- Participation in decisions
- Family involvement in decisions
- Predictability
- Expected course of illness
- Rating scale
- Level 1, 3, 5
Synergy Nurse Competencies
- Clinical judgment
- Reasoning plus clinical knowledge
- Advocacy and moral agency
- Speak for patient values
- Caring practices
- Compassionate, therapeutic environment
- Collaboration
- Work across the team
- Systems thinking
- Navigate resources across systems
- Response to diversity
- Honor differences in care
- Facilitation of learning
- Teach patient, family, staff
- Clinical inquiry
- Question practice, apply evidence
- Competency scale
- Competent 1 to expert 5
- Tested as caring
- Seven of eight competencies
End-of-Life Practice
- Palliative care timing
- Alongside curative treatment
- Family presence
- Offer during resuscitation
- Assent
- Child agreement alongside parent consent
- Surrogate standard
- Best interest of child
- Moral distress
- Knowing right, blocked from acting
- Ethics consult trigger
- Unresolved goals-of-care conflict
- Organ donation rule
- Trained requestor, not bedside nurse
- Donation after circulatory death
- Planned withdrawal, then donation
Exam Logistics
- Total items
- 150 multiple-choice items
- Scored items
- 125 count toward score
- Pretest items
- 25 unscored and unmarked
- Time limit
- 3 hours
- Cut score
- 83 of 125 scored
- Standard setting
- Modified Angoff, raw number
- Cut score effective
- November 12, 2025
- Test plan applies
- Exams from Nov 19, 2025
- Initial fee
- $260 member, $375 nonmember
- Retest fee
- $185 member, $290 nonmember
- Attempt limit
- 4 per rolling 12 months
- Eligibility option one
- 1,750 hours in 2 years
- Eligibility option two
- 2,000 hours in 5 years
- Recent-year hours
- 875 or 144 respectively
- Certification period
- 3 years, 100 CERPs
- Score report
- On screen, email within 24
Common Traps
Cut score is raw
83 of 125 scored ≠ Not a percentage
Pretest items are hidden
25 items unscored ≠ None are marked
Pediatric weights differ
Cardiovascular is 11% ≠ Adult plan is different
Warm and cold labels
Bedside signs unreliable ≠ Add advanced hemodynamics
PARDS severity simplified
Two severity groups ≠ Severe begins at 16
Insulin timing in DKA
Fluids begin first ≠ Never bolus insulin
Hypotension arrives late
Tachycardia comes first ≠ Pressure falls last
Brain death interval
12 hours at all ages ≠ No longer age-based
Epinephrine concentration
IV route uses 0.1 mg/mL ≠ Endotracheal uses 1 mg/mL
Abdominal pressure thresholds
Children use 10 mm Hg ≠ Adult 12 and 20 differ
Last Minute
- 1.Clinical judgment 80%, professional caring 20%
- 2.Largest clinical block is 25%
- 3.Multisystem 17%, neuro block 15%
- 4.Pass at 83 of 125
- 5.150 items, 125 scored, 3 hours
- 6.Hypotension: under 70 + 2x age
- 7.Start CPR if HR under 60
- 8.Defibrillate 2 J/kg, then 4
- 9.Sepsis antibiotics within 1 hour
- 10.Boluses 10-20 mL/kg, reassess each
- 11.Severe PARDS starts at OI 16
- 12.DKA: fluids first, no insulin bolus
- 13.SIADH restricts; DI needs desmopressin
- 14.ICP under 20, CPP at 40
- 15.Brain death: two exams, 12 hours
- 16.Synergy: eight patient, eight nurse
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