Triage Process
13.3%of exam
Assessment
16.7%of exam
System-Focused Emergencies
37.3%of exam
Special Considerations
16.7%of exam
Multi-System Considerations
8%of exam
Professional Issues
8%of exam
Quick Facts
- Exam
- CPEN
- Board
- BCEN
- Items
- 175 (150 scored)
- Pretest
- 25 unscored
- Time
- 3 hours (180 min)
- Pass
- 110 of 150
- Fee
- $285 ENA / $380
- Retest
- $200, 90-day wait
- Valid
- 4 years
- Delivery
- PSI center or remote
- Blueprint
- August 2023 outline
Appearance: TICLS
Tone, Interactiveness, Consolability, Look, Speech
Tone: muscle activityInteractiveness: alert, engagedConsolability: caregiver soothesLook: fixes and followsSpeech: strong cry
PAT to Impression
- All three normal→Stable(Routine pace)
- Breathing abnormal only→Respiratory distress(Oxygen, position)
- Appearance + breathing→Respiratory failure(Assist ventilation)
- Circulation abnormal only→Compensated shock(Access, fluid bolus)
- Appearance + circulation→Decompensated shock(Boluses, vasoactives)
- Appearance abnormal only→CNS or metabolic(Check glucose first)
- All three abnormal→Cardiopulmonary failure(Prepare for arrest)
Blueprint Item Counts
- Triage Process
- 20 items
- Assessment
- 25 items
- System-Focused Emergencies
- 56 itemsLargest
- Special Considerations
- 25 items
- Multi-System Considerations
- 12 items
- Professional Issues
- 12 items
- Scored total
- 150 items
Pediatric Assessment Triangle
- Appearance
- Tone, interactiveness, consolability
- Work of breathing
- Retractions, flaring, abnormal sounds
- Circulation to skin
- Pallor, mottling, cyanosis
- TICLS
- Appearance memory toolAppearance
- Method
- Visual and auditory only
- Timing
- Done before touching child
- Purpose
- Sick versus not sick
ESI Triage Levels
- ESI 1
- Immediate life-saving intervention
- ESI 2
- High risk; cannot wait
- ESI 3
- Two or more resources
- ESI 4
- One resource
- ESI 5
- No resources
- ESI 2 triggers
- Lethargy, severe pain, distress
- Resource examples
- Labs, imaging, IV fluids
Danger-Zone Vital Signs
- Under 3 months
- HR >180 or RR >50
- 3 months-3 years
- HR >160 or RR >40
- 3-8 years
- HR >140 or RR >30
- Over 8 years
- HR >100 or RR >20
- Oxygen saturation
- Under 92% is abnormal
- Neonatal fever
- 38.0°C rectal, high acuity
Heart Rate by Age
- Neonate 0-28 days
- 100-205 awake
- Infant 1-12 months
- 100-180 awake
- Toddler 1-2 years
- 98-140 awake
- Preschool 3-5 years
- 80-120 awake
- School-age 6-11 years
- 75-118 awake
- Adolescent 12-15 years
- 60-100 awake
- Sleeping rates
- Lower than awake ranges
Respiratory Rate by Age
- Infant under 1 year
- 30-53 breaths per minute
- Toddler 1-2 years
- 22-37 breaths per minute
- Preschool 3-5 years
- 20-28 breaths per minute
- School-age 6-11 years
- 18-25 breaths per minute
- Adolescent 12-15 years
- 12-20 breaths per minute
- Bradypnea
- Ominous; arrest may follow
Primary Survey
Airway, Breathing, Circulation, Disability, Exposure
Airway: open, positionedBreathing: rate, effortCirculation: pulses, perfusionDisability: AVPU, glucoseExposure: undress, keep warm
Hypotension Thresholds
- Term neonate 0-28 days
- Systolic under 60 mmHg
- Infant 1-12 months
- Systolic under 70 mmHg
- Child 1-10 years
- Under 70 + (2 × age)
- Child over 10 years
- Systolic under 90 mmHg
- Hypotension timing
- Late, decompensated finding
- Earliest shock sign
- Tachycardia with poor perfusion
- Capillary refill
- Over 2 seconds abnormal
History CIAMPEDS
Chief complaint, Immunizations, Allergies, Medications
P: past medical historyE: events surrounding illnessD: diet and diapersS: symptoms with progression
Primary + Secondary Survey
- Airway
- Patency, positioning, adjuncts
- Breathing
- Rate, effort, breath sounds
- Circulation
- Pulses, perfusion, bleeding
- Disability
- AVPU, pupils, glucose
- Exposure
- Undress, inspect, keep warm
- Secondary survey
- Full vitals, history, head-to-toe
- Rule
- Treat threats when found
Pediatric GCS + AVPU
- GCS range
- 3 to 15 points
- GCS 8 or less
- Intubate for airway protection
- Infant verbal 5
- Coos and babbles
- Infant motor 6
- Spontaneous purposeful movement
- AVPU
- Alert, Voice, Pain, Unresponsive
- AVPU P or U
- Roughly GCS 8 or less
Pain Scale by Age
- NIPS
- Neonates through 6 weeks
- FLACC
- 2 months to 7 years
- Wong-Baker FACES
- Self-report, age 3+
- Numeric 0-10
- Self-report, age 8+
- COMFORT-B
- Intubated or sedated child
- Reassessment
- After every pain intervention
Post-Intubation DOPE
Dislodgement, Obstruction, Pneumothorax, Equipment failure
Dislodgement: recheck depthObstruction: suction tubePneumothorax: breath soundsEquipment: oxygen, circuit
Croup vs Epiglottitis
Croup
- Barking cough
- Gradual viral onset
- Steeple sign
Epiglottitis
- No cough, drooling
- Abrupt toxic onset
- Thumbprint sign
Cough versus drooling
Airway Adjunct Choice
- Obstructed, gag intact→Nasopharyngeal airway(Nose to tragus)
- Obstructed, no gag→Oropharyngeal airway(Mouth corner to angle)
- Apnea or poor effort→Bag-mask ventilation(Two-person technique)
- Bag-mask failing→Supraglottic airway(Bridge to intubation)
- GCS 8 or less→Endotracheal intubation(Cuffed tube preferred)
- Stridor at rest→Nebulized epinephrine(Plus dexamethasone)
- Tracheostomy obstruction→Suction, then change tube(Same size or smaller)
Airway Equipment Sizing
- Cuffed ETT size
- (age/4) + 3.5 mm
- Uncuffed ETT size
- (age/4) + 4 mm
- ETT depth at lip
- Tube size × 3
- Suction catheter
- Twice the tube size
- Infant, toddler blade
- Straight Miller blade preferred
- Broselow tape
- Length-based weight and doses
- Expected airway edema
- Downsize tube 0.5 mm
- Infant positioning
- Shoulder roll, neutral neck
Dextrose Rule of 50
Concentration × volume per kilogram equals 50
D10 at 5 mL/kgD25 at 2 mL/kgD50 at 1 mL/kgNeonates: D10 only
Respiratory Distress vs Failure
Distress
- Increased work of breathing
- Alert and compensating
- Saturation maintained
Failure
- Decreased effort or apnea
- Altered mentation
- Bradycardia, cyanosis
Quiet child is worse
Stridor Cause Picker
- Barking cough, low fever→Croup(Steeple sign)
- Drooling, tripod, toxic→Epiglottitis(Thumbprint sign)
- Toxic, epinephrine fails→Bacterial tracheitis(Purulent secretions)
- Sudden onset while eating→Foreign body(Unilateral findings)
- Hives after exposure→Anaphylaxis(IM epinephrine now)
- Muffled voice, trismus→Peritonsillar abscess(Hot potato voice)
Resuscitation Drug Doses
- Epinephrine, arrest
- 0.01 mg/kg IV/IOMax 1 mg
- Epinephrine interval
- Repeat every 3-5 minutes
- Epinephrine, anaphylaxis
- 0.01 mg/kg IM thighMax 0.5 mg
- Adenosine, first dose
- 0.1 mg/kg rapid pushMax 6 mg
- Adenosine, second dose
- 0.2 mg/kg rapid pushMax 12 mg
- Amiodarone
- 5 mg/kg IV/IO bolusMax 300 mg
- Atropine
- 0.02 mg/kg IV/IOMin 0.1 mg
- Naloxone
- 0.1 mg/kg under 20 kg
- Lorazepam, seizure
- 0.1 mg/kg IV/IOMax 4 mg
- Midazolam, intranasal
- 0.2 mg/kg intranasalMax 10 mg
- Dexamethasone, croup
- 0.6 mg/kg PO/IMMax 16 mg
- Levetiracetam
- 60 mg/kg second-line
Simple vs Complex Febrile Seizure
Simple
- Generalized, under 15 minutes
- Once in 24 hours
- Age 6 months-5 years
Complex
- Focal features
- 15 minutes or longer
- Recurs within 24 hours
Complex needs further workup
Rhythm Treatment Picker
- Bradycardia, poor perfusion→Oxygenate, then compressions(Rate under 60)
- Bradycardia persists→Epinephrine, then atropine(Atropine for vagal)
- Stable SVT→Vagal, then adenosine(Rapid two-syringe push)
- Unstable SVT→Synchronized cardioversion(0.5-1 J/kg)
- Pulseless VT or VF→Defibrillate 2 J/kg(Resume compressions immediately)
- Asystole or PEA→CPR plus epinephrine(Not shockable)
- Wide complex with pulse→Expert consult, amiodarone(Treat causes)
Electrical Therapy + CPR
- Defibrillation, first
- 2 J/kg unsynchronized
- Defibrillation, second
- 4 J/kg unsynchronized
- Later shocks
- 4 J/kg or higher
- Maximum shock
- 10 J/kg or adult dose
- Cardioversion, first
- 0.5-1 J/kg synchronized
- Cardioversion, repeat
- 2 J/kg synchronized
- Shockable rhythms
- VF and pulseless VT
- Compression rate
- 100-120 per minute
- Compression depth
- One third chest diameter
- Two-rescuer child ratio
- 15 compressions to 2
Sinus Tachycardia vs SVT
Sinus tachycardia
- Infant under 220
- Beat-to-beat variability
- Identifiable cause
SVT
- Infant over 220
- No rate variability
- Abrupt onset and end
Variability means sinus
Upper Airway Emergencies
- Croup
- Barking cough, inspiratory stridor
- Croup imaging
- Steeple sign, subglottic narrowing
- Epiglottitis
- Drooling, dysphagia, distress, tripod
- Epiglottitis imaging
- Thumbprint sign, lateral neck
- Epiglottitis rule
- Never inspect the throat
- Bacterial tracheitis
- Toxic, thick purulent secretions
- Airway foreign body
- Sudden choking, unilateral wheeze
- After racemic epinephrine
- Observe 2-4 hours
Bronchiolitis vs Asthma
Bronchiolitis
- Under 2 years
- First wheezing episode
- Suction and hydrate
Asthma
- Usually over 2 years
- Recurrent reversible wheeze
- Albuterol and steroids
Age and treatment response
Lower Airway Emergencies
- Bronchiolitis
- Under 2 years, RSV
- Bronchiolitis care
- Suction, oxygen, hydration
- Asthma first-line
- Albuterol plus early steroids
- Silent chest
- Impending respiratory arrest
- Magnesium sulfate
- Severe refractory asthma
- Pneumonia clue
- Focal crackles, fever, tachypnea
- Oximetry limit
- Misses ventilation failure
Defibrillation vs Cardioversion
Defibrillation
- Unsynchronized shock
- Pulseless VT, VF
- 2 then 4 J/kg
Cardioversion
- Synchronized shock
- Unstable rhythm with pulse
- 0.5-1 then 2 J/kg
Pulse means synchronize
Cardiac Red Flags
- Infant SVT
- Rate above 220
- Child SVT
- Rate above 180
- SVT on ECG
- Narrow QRS, no variability
- Bradycardia rule
- Under 60 plus poor perfusion
- Ductal-dependent lesion
- Prostaglandin E1 infusion
- Prostaglandin risk
- Apnea; prepare to intubate
- Tet spell
- Knee-to-chest, oxygen, morphine
- Kawasaki disease
- Fever 5 days, coronary risk
- Hyperoxia test
- No rise means cyanotic defect
Intussusception vs Pyloric Stenosis
Intussusception
- Age 3 months-3 years
- Colicky pain, bloody stool
- Enema reduction
Pyloric stenosis
- Age 2-8 weeks
- Projectile, non-bilious vomiting
- Pyloromyotomy
Colic versus projectile vomiting
Neuro Red Flags
- Status epilepticus
- Seizure 5 minutes or longer
- First-line seizure drug
- Benzodiazepine, repeat once
- Second-line agents
- Levetiracetam, fosphenytoin, valproate
- Cushing triad
- Bradycardia, irregular breathing, hypertension
- Cushing timing
- Late herniation warning
- Infant ICP signs
- Bulging fontanelle, sunset eyes
- Hypertonic saline
- 3% saline, 2-5 mL/kg
- Shunt malfunction
- Vomiting, lethargy, headache
- Check first
- Bedside glucose every seizure
GI + GU Emergencies
- Bilious infant emesis
- Malrotation until proven otherwise
- Intussusception age
- 3 months to 3 years
- Intussusception signs
- Colicky pain, currant-jelly stool
- Intussusception treatment
- Air or contrast enema
- Pyloric stenosis age
- 2 to 8 weeks
- Pyloric stenosis labs
- Hypochloremic hypokalemic metabolic alkalosis
- Esophageal button battery
- Emergent endoscopic removal
- Testicular torsion
- Absent cremasteric reflex, sudden pain
- Torsion salvage window
- Within 6 hours
DKA + Hypoglycemia
- DKA glucose
- Above 200 mg/dL
- DKA acidosis
- Venous pH under 7.30
- DKA bicarbonate
- Under 15-18 mEq/L
- DKA insulin
- 0.05-0.1 units/kg/hr infusion
- Insulin bolus
- Contraindicated in pediatric DKA
- Cerebral edema signs
- Headache, bradycardia, falling consciousness
- Cerebral edema treatment
- Mannitol or 3% saline
- Hypoglycemia threshold
- Under 60 mg/dL
- Neonatal dextrose
- D10 only, 2 mL/kg
Cholinergic SLUDGE
Salivation, Lacrimation, Urination, Defecation, Emesis
Killer B's: bradycardia, bronchorrheaCause: organophosphatesAntidote: atropineAdd: pralidoxime
Accidental vs Inflicted Injury
Accidental
- Shins, knees, forehead
- History fits development
- Story stays consistent
Inflicted
- Torso, ears, neck
- History implausible or changing
- Delayed presentation
Pattern plus story
Neonatal Emergencies
- Fever definition
- 38.0°C rectal or higher
- AAP febrile infant bands
- 8-21, 22-28, 29-60 days
- Neonate under 22 days
- Full workup, antibiotics, admit
- Thermoregulation risk
- Large surface area, heat loss
- Hypoglycemia risk
- Limited hepatic glycogen stores
- Pathologic jaundice
- Appears under 24 hours
- Newborn resuscitation
- Warm, dry, stimulate, ventilate
- Newborn compression ratio
- 3 compressions to 1
Bruising TEN-4-FACES-P
Torso, Ear, Neck under 4 years
Any bruise under 4 monthsFrenulum, angle of jawCheek, eyelid, subconjunctivalP: patterned bruising
Maltreatment Red Flags
- TEN-4 bruising
- Torso, ear, neck bruises
- TEN-4 age rule
- Any bruise under 4 months
- FACES-P additions
- Frenulum, jaw, cheek, eyelid
- Sentinel injury
- Bruise in pre-mobile infant
- Suspicious fractures
- Posterior rib, metaphyseal corner
- Abusive head trauma
- Retinal hemorrhage, subdural blood
- Skeletal survey
- Indicated under 2 years
- Nurse duty
- Report suspicion, not proof
Toxidromes + Antidotes
- Anticholinergic
- Hot, red, dry, delirious
- Cholinergic
- SLUDGE, bronchorrhea, bradycardia
- Opioid
- Miosis, apnea, sedation
- Sympathomimetic
- Tachycardia, hypertension, diaphoresis
- Organophosphate antidote
- Atropine plus pralidoxime
- Acetaminophen antidote
- N-acetylcysteine
- Acetaminophen toxic dose
- 150 mg/kg acute ingestion
- Tricyclic antidote
- Sodium bicarbonate, wide QRS
- One pill can kill
- Clonidine, sulfonylurea, opioid, calcium-blocker
- Carbon monoxide
- Falsely normal pulse oximetry
Burns + Environmental
- Infant head TBSA
- 18 percent of surface
- Infant leg TBSA
- 14 percent each
- Parkland formula
- 3-4 mL × kg × TBSA
- Parkland timing
- Half in first 8 hours
- Add maintenance dextrose
- Children under 30 kg
- Urine output goal
- 1 mL/kg/hr, small children
- Burn center transfer
- Partial thickness 10% or more
- Drowning priority
- Ventilation before compressions
- Hypothermia rule
- Rewarm before declaring death
Behavioral Health Triage
- Suicide screening
- Ask directly; screen adolescents
- Environmental safety
- Remove cords, sharps, ligatures
- Observation level
- One-to-one for high risk
- De-escalation order
- Verbal before chemical restraint
- Restraint rule
- Least restrictive, time-limited order
- Trafficking clue
- Controlling companion, inconsistent history
Compensated vs Decompensated Shock
Compensated
- Blood pressure normal
- Tachycardia, delayed refill
- Narrow pulse pressure
Decompensated
- Hypotension present
- Altered mental status
- Bradycardia is preterminal
Blood pressure falls late
Fluid Bolus Picker
- Hypovolemic or septic shock→20 mL/kg isotonic(Over 5-20 minutes)
- Septic shock, ICU available→Up to 60 mL/kg(Within first hour)
- Cardiogenic shock→5-10 mL/kg slowly(Watch for crackles)
- Diabetic ketoacidosis→10 mL/kg over hour(Cerebral edema risk)
- Trauma after crystalloid→10 mL/kg blood(Warm the products)
- Burn resuscitation→Lactated Ringer's, Parkland(Add maintenance if small)
- Mild dehydration, tolerating oral→50 mL/kg oral rehydration(Over 4 hours)
- Neonatal hypovolemia→10 mL/kg isotonic(Smaller aliquots)
Shock Types
- Hypovolemic
- Most common pediatric shock
- Distributive
- Septic, anaphylactic, neurogenic
- Cardiogenic
- Pump failure; cautious boluses
- Obstructive
- Tamponade, tension pneumothorax, embolism
- Compensated sign
- Tachycardia, normal blood pressure
- Decompensated sign
- Hypotension, altered mental status
- Cardiac output driver
- Heart rate, not stroke volume
Sepsis + Anaphylaxis
- Septic shock antibiotics
- Within 1 hour
- Sepsis labs
- Lactate, cultures before antibiotics
- Septic shock fluids
- 10-20 mL/kg repeated boluses
- First vasoactive
- Epinephrine or norepinephrine
- Anaphylaxis first drug
- IM epinephrine, anterolateral thigh
- Anaphylaxis adjuncts
- Antihistamines never replace epinephrine
- Biphasic reaction
- Can recur hours later
Post-Resuscitation + Sedation
- Oxygen target
- Wean to normal saturation
- Avoid after arrest
- Fever, hypotension, hypoglycemia
- Temperature control
- Prevent and treat fever
- Sedation monitoring
- Continuous capnography and oximetry
- Sedation staffing
- Observer separate from proceduralist
- Discharge criteria
- Baseline mentation, stable airway
Legal + Regulatory
- EMTALA
- Screen and stabilize everyone
- HIPAA
- Protects health information privacy
- Implied consent
- Emergency, no guardian reachable
- Emancipated minor
- Consents to own care
- Assent
- Child agreement, not consent
- Forensic evidence
- Paper bags, chain of custody
- Mandatory reporting
- Suspicion triggers the report
Safety + Practice
- Weight unit
- Kilograms only, never pounds
- High-alert medications
- Independent double check required
- Family presence
- Offer during resuscitation
- Just culture
- Report errors without blame
- Delegation limit
- Never delegate nursing assessment
- Compassion fatigue
- Debrief after critical events
- Handoff
- Structured, interruption-free report
Common Traps
Rate versus perfusion
Normal pressure hides shock ≠ Tachycardia signals it earlier
Cough versus drooling
Croup barks and coughs ≠ Epiglottitis drools without cough
Bradycardia meaning
Adults: usually cardiac ≠ Children: hypoxia until disproven
Bolus versus DKA
Shock gets 20 mL/kg ≠ DKA gets slow rehydration
Loud versus silent
Wheezing still moves air ≠ Silent chest is failure
Age versus weight
Never dose by age ≠ Always dose in kilograms
Saturation versus ventilation
Oximetry misses hypercarbia ≠ Capnography shows ventilation failure
Suspicion versus proof
Report reasonable suspicion ≠ Proving abuse is not nursing
Epinephrine versus adjuncts
Anaphylaxis needs IM epinephrine ≠ Antihistamines never come first
Last Minute
- 1.175 items; 150 scored, 25 pretest
- 2.Pass = 110 of 150
- 3.System-Focused Emergencies is largest, 56 items
- 4.PAT = appearance, breathing, skin
- 5.Shock bolus = 20 mL/kg isotonic
- 6.Hypotension 1-10 years: 70 + 2×age
- 7.Arrest epinephrine = 0.01 mg/kg
- 8.Defibrillate 2 J/kg, then 4
- 9.Cardiovert unstable SVT: 0.5-1 J/kg
- 10.Cuffed tube = age/4 + 3.5
- 11.Croup dexamethasone = 0.6 mg/kg
- 12.Bilious infant emesis = surgical emergency
- 13.Bruise before cruising = report suspicion
- 14.Septic shock antibiotics within 1 hour
- 15.CPEN certification lasts 4 years
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