8.2 Last-Week Review Map
Key Takeaways
- Clinical Judgment is the largest, integrating domain (~34-38%) and is tested through scenario items across every other domain, so practice deciding-not just recalling-with each medical/cardiac/trauma case.
- Cardiology/Resuscitation and Medical/OB-GYN are the two heaviest content domains; memorize the ACLS doses cold-epinephrine 1 mg IV/IO q3-5 min, amiodarone 300 mg then 150 mg, atropine 1 mg q3-5 min to max 3 mg, adenosine 6 mg then 12 mg.
- Know the 12-lead lead groups (inferior II/III/aVF, septal/anterior V1-V4, lateral I/aVL/V5-V6) and that STEMI = ST-elevation in 2 contiguous leads, with right-sided MI making nitroglycerin dangerous.
- Lock in the high-frequency trauma numbers: needle decompression 2nd ICS midclavicular or 5th ICS anterior axillary line, Rule of Nines, and Parkland 4 mL x kg x %TBSA (half in first 8 hours).
- In the final week, consolidate-drill weak high-weight domains with short mixed sets, refresh dose/algorithm tables daily, and stop adding new resources.
Where the Weight Is
The 2024 exam blueprint integrates pediatrics across every domain (no standalone peds section) and makes Clinical Judgment the largest, cross-cutting domain at roughly 34-38%-it is tested through scenario items embedded in the other domains, so it rewards deciding correctly, not just recalling facts. Among the content domains, Medical/OB-GYN (24-28%) carries the most items, followed by Cardiology/Resuscitation (10-14%), Airway/Respiration/Ventilation (8-12%), EMS Operations (8-12%), and Trauma (6-10%).
Pediatric content is integrated throughout every domain rather than scored as a fixed percentage. Note the psychomotor exam was discontinued nationally July 1, 2024-skills are now program-verified-so all of your final week goes to the cognitive material below.
Spend final-week hours in proportion to weight and weakness: heaviest emphasis on Cardiology and Medical, with daily refresh of the dose and algorithm tables that follow.
The ACLS Drugs and Doses (Memorize Cold)
These are the highest-yield numbers on the exam. Per AHA 2025 ACLS:
| Drug | Indication | Dose |
|---|---|---|
| Epinephrine | Cardiac arrest (all rhythms) | 1 mg IV/IO q3-5 min (give early in non-shockable) |
| Amiodarone | Shock-refractory VF/pVT | 300 mg IV/IO, then 150 mg |
| Lidocaine (alt) | Shock-refractory VF/pVT | 1-1.5 mg/kg, then 0.5-0.75 mg/kg |
| Atropine | Symptomatic bradycardia | 1 mg IV q3-5 min, max 3 mg |
| Adenosine | Stable narrow-complex regular SVT | 6 mg rapid IV, then 12 mg |
| Epinephrine (peri-arrest) | Bradycardia/post-ROSC | infusion 2-10 mcg/min |
| Dopamine | Bradycardia | infusion 5-20 mcg/kg/min |
Defibrillation: biphasic energy per manufacturer, typically 120-200 J (use max if unknown); shock VF/pVT immediately. Synchronized cardioversion for unstable tachycardia with a pulse (e.g., narrow regular ~50-100 J; wide/irregular higher). Resume CPR immediately after every shock-do not pause to check pulse.
The Algorithms in One Pass
- Adult arrest: high-quality CPR 100-120/min, depth 2-2.4 in (5-6 cm), full recoil, 30:2 until advanced airway then 1 breath q6s (10/min) with continuous compressions. Shockable (VF/pVT) -> shock -> CPR -> epi after 2nd shock -> amiodarone. Non-shockable (asystole/PEA) -> CPR -> epi ASAP -> treat H's and T's (Hypoxia, Hypovolemia, Hydrogen ion/acidosis, Hypo-/Hyperkalemia, Hypothermia; Tension pneumothorax, Tamponade, Toxins, Thrombosis-coronary/pulmonary).
- Bradycardia (unstable): atropine -> transcutaneous pacing and/or dopamine or epinephrine infusion.
- Tachycardia: stable narrow regular -> vagal maneuvers -> adenosine; unstable (hypotension, altered mental status, ischemic chest pain, shock) -> synchronized cardioversion.
12-Lead, Airway Numbers, and Trauma Math
12-lead/STEMI: a STEMI is ST-elevation in 2 contiguous leads. Lead groups: Inferior = II, III, aVF; Septal = V1-V2; Anterior = V3-V4; Lateral = I, aVL, V5-V6. Look for reciprocal ST-depression. With an inferior MI, obtain a right-sided 12-lead (V4R)-if right-ventricular infarct, nitroglycerin is contraindicated (preload-dependent; can cause profound hypotension). ACS care chain: aspirin 324 mg chewed, nitro if not contraindicated, oxygen if hypoxic, and rapid transport to a PCI-capable center to meet the door-to-balloon goal.
Airway/capnography: normal ETCO2 35-45 mmHg; a continuous waveform confirms tube placement, sudden loss suggests dislodgement, and an abrupt ETCO2 rise signals ROSC. RSI/DSI = induction sedative (etomidate or ketamine) plus paralytic (rocuronium or succinylcholine). In suspected head injury keep ETCO2 ~35-40 and avoid hypoxia/hypotension.
Trauma high-yield list:
- Tension pneumothorax -> needle decompression: 2nd intercostal space midclavicular line or 5th ICS anterior axillary line.
- Burns: Rule of Nines (adult: head 9%, each arm 9%, each leg 18%, anterior/posterior torso 18% each, perineum 1%). Parkland: 4 mL x kg x %TBSA, give half in the first 8 hours (from time of burn), remainder over 16 hours.
- Hemorrhagic shock classes: Class I <15% loss (minimal), Class II 15-30% (tachycardia, narrowed pulse pressure), Class III 30-40% (hypotension, confusion), Class IV >40% (life-threatening).
- Bleeding control: direct pressure -> tourniquet for extremity hemorrhage; consider TXA within ~3 hours per protocol.
Last-Week Discipline
This week is consolidation, not new learning. Each day: refresh the dose/algorithm tables above, run one short mixed timed set, and re-test your weakest high-weight domain. Stop adding new books or apps once review feels scattered-anxiety, not gaps, is usually the late-stage enemy. Sleep, hydration, and a calm pacing plan beat a midnight new-resource binge.
A sensible final-week map, weighted to the blueprint:
- Days 7-5: Cardiology and Medical/OB-GYN-the heaviest domains. Cardiology means the arrest, bradycardia, and tachycardia algorithms plus 12-lead lead groups and STEMI recognition. Medical means anaphylaxis (epinephrine 0.3 mg IM 1:1,000), hypoglycemia (D10/D50, glucagon 1 mg IM), opioid overdose (naloxone), status epilepticus (benzodiazepines-midazolam 10 mg IM/0.1 mg/kg IV), stroke (last-known-well time, large-vessel-occlusion screen, stroke-center routing), and respiratory emergencies (albuterol/ipratropium, CPAP, magnesium for severe asthma).
- Days 4-3: Trauma and Airway. Hit the needle-decompression sites, the Rule of Nines and Parkland formula, hemorrhagic shock classes, tourniquet/TXA, and capnography (ETCO2 35-45). For airway, rehearse the RSI/DSI drug pairing and head-injury ventilation targets (ETCO2 ~35-40, avoid hypoxia and hypotension).
- Days 2-1: EMS Operations (incident command, START triage, scene safety, mass-casualty) plus a full mixed timed simulation, then taper. The final 24 hours are for light table review and rest.
Why Clinical Judgment Sits On Top of Everything
Clinical Judgment is not a separate body of facts you memorize-it is how the exam asks every other domain. A Clinical Judgment item embeds a Cardiology, Medical, Trauma, or Airway scenario and then tests whether you can recognize the problem, anticipate deterioration, prioritize interventions, and re-evaluate after acting. That is why pure flashcard recall plateaus: you can know that amiodarone is 300 mg then 150 mg and still miss the item if you cannot first decide the rhythm is shock-refractory VF and that a shock and epinephrine precede it.
Drill judgment by working full scenarios end to end:
- Scene size-up and safety-is the scene safe, how many patients, what resources.
- Primary survey-airway, breathing, circulation, disability; treat immediate threats as you find them.
- Working impression-anchor to the worst plausible diagnosis you cannot exclude.
- Intervention in priority order-the most life-threatening, time-critical action first.
- Reassessment-did the intervention work; what changed; what is next.
In the final week, run two or three cases per day this way. It rehearses exactly the integration the exam rewards. Pediatric variants matter here too-doses are weight-based and integrated into every domain, so practice converting an adult algorithm to a child by weight (defibrillation 2 J/kg then 4 J/kg, epinephrine 0.01 mg/kg).
A patient in shock-refractory ventricular fibrillation has received the first dose of epinephrine. The correct first amiodarone dose is:
On a 12-lead ECG, ST-elevation in leads II, III, and aVF indicates injury to which wall, and what additional step is critical?
The two recognized needle decompression sites for a tension pneumothorax are: