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Medical CCRN : Critical Care Register Nurse Exam

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Test Number : CCRN
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CCRN test Format | CCRN Course Contents | CCRN Course Outline | CCRN test Syllabus | CCRN test Objectives


A criterion-referenced standard setting process, known as the modified Angoff, is used to establish the passing point/cut score for the exam. Each candidates performance on the test is measured against a predetermined standard.
The passing point/cut score for the test is established using a panel of subject matter experts, an test development committee (EDC), who carefully reviews each test question to determine the basic level of knowledge or skill that is expected. The passing point/cut score is based on the panels established difficulty ratings for each test question.
Under the guidance of a psychometrician, the panel develops and recommends the passing point/cut score, which is reviewed and approved by AACN Certification Corporation. The passing point/cut score for the test is established to identify individuals with an acceptable level of knowledge and skill. All individuals who pass the exam, regardless of their score, have demonstrated an acceptable level of knowledge.

I. CLINICAL JUDGMENT (80%)
A. Cardiovascular (17%)
1. Acute coronary syndrome:
a. NSTEMI
b. STEMI
c. Unstable angina
2. Acute peripheral vascular insufficiency:
a. Arterial/venous occlusion
b. Carotid artery stenosis
c. Endarterectomy
d. Fem-Pop bypass
3. Acute pulmonary edema
4. Aortic aneurysm
5. Aortic dissection
6. Aortic rupture
7. Cardiac surgery:
a. CABG
b. Valve replacement or repair
8. Cardiac tamponade
9. Cardiac trauma
10. Cardiac/vascular catheterization
11. Cardiogenic shock
12. Cardiomyopathies:
a. Dilated
b. Hypertrophic
c. Idiopathic
d. Restrictive
13. Dysrhythmias
14. Heart failure
15. Hypertensive crisis
16. Myocardial conduction system abnormalities
(e.g., prolonged QT interval, Wolff-ParkinsonWhite)
17. Papillary muscle rupture
18. Structural heart defects (acquired and congenital, including valvular disease)
19. TAVR

B. Respiratory (15%)
1. Acute pulmonary embolus
2. ARDS
3. Acute respiratory failure
4. Acute respiratory infection (e.g., pneumonia)
5. Aspiration
6. Chronic conditions (e.g., COPD, asthma, bronchitis, emphysema)
7. Failure to wean from mechanical ventilation
8. Pleural space abnormalities (e.g., pneumothorax, hemothorax, empyema, pleural effusions)
9. Pulmonary fibrosis
10. Pulmonary hypertension
11. Status asthmaticus
12. Thoracic surgery
13. Thoracic trauma (e.g., fractured rib, lung contusion, tracheal perforation)
14. Transfusion-related acute lung injury (TRALI)

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (20%)
1. Endocrine
a. Adrenal insufficiency
b. Diabetes insipidus (DI)
c. Diabetes mellitus, types 1 and 2
d. Diabetic ketoacidosis (DKA)
e. Hyperglycemia
f. Hyperosmolar hyperglycemic state (HHS)
g. Hyperthyroidism
h. Hypoglycemia (acute)
i. Hypothyroidism
j. SIADH
2. Hematology and Immunology
a. Anemia
b. Coagulopathies (e.g., ITP, DIC, HIT)
c. Immune deficiencies
d. Leukopenia
e. Oncologic complications (e.g., tumor lysis syndrome, pericardial effusion)
f. Thrombocytopenia
g. Transfusion reactions
3. Gastrointestinal
a. Abdominal compartment syndrome
b. Acute abdominal trauma
c. Acute GI hemorrhage
d. Bowel infarction, obstruction, perforation (e.g., mesenteric ischemia, adhesions)
e. GI surgeries (e.g., Whipple, esophagectomy, resections)
f. Hepatic failure/coma (e.g., portal hypertension, cirrhosis, esophageal varices, fulminant hepatitis, biliary atresia, drug-induced)
g. Malnutrition and malabsorption
h. Pancreatitis
4. Renal and Genitourinary
a. Acute genitourinary trauma
b. Acute kidney injury (AKI)
c. Chronic kidney disease (CKD)
d. Infections (e.g., kidney, urosepsis)
e. Life-threatening electrolyte imbalances
5. Integumentary
a. Cellulitis
b. IV infiltration
c. Necrotizing fasciitis
d. Pressure injury
e. Wounds:
i. infectious
ii. surgical
iii. trauma
D. Musculoskeletal/Neurological/

Psychosocial (14%)
1. Musculoskeletal
a. Compartment syndrome
b. Fractures (e.g., femur, pelvic)
c. Functional issues (e.g., immobility, falls, gait disorders)
d. Osteomyelitis
e. Rhabdomyolysis
2. Neurological
a. Acute spinal cord injury
b. Brain death
c. Delirium (e.g., hyperactive, hypoactive, mixed)
d. Dementia
e. Encephalopathy
f. Hemorrhage:
i. intracranial (ICH)
ii. intraventricular (IVH)
iii. subarachnoid (traumatic or aneurysmal)
g. Increased intracranial pressure (e.g., hydrocephalus)
h. Neurologic infectious disease (e.g., viral, bacterial, fungal)
i. Neuromuscular disorders (e.g., muscular dystrophy, CP, Guillain-Barr, myasthenia)
j. Neurosurgery (e.g., craniotomy, Burr holes)
k. Seizure disorders
l. Space-occupying lesions (e.g., brain tumors)
m. Stroke:
i. hemorrhagic
ii. ischemic (embolic)
iii. TIA
n. Traumatic brain injury (TBI): epidural, subdural, concussion
3. Behavioral and Psychosocial
a. Abuse/neglect
b. Aggression
c. Agitation
d. Anxiety
e. Suicidal ideation and/or behaviors
f. Depression
g. Medical non-adherence
h. PTSD
i. Risk-taking behavior
j. Substance use disorders (e.g., withdrawal, chronic alcohol or drug dependence)
E. Multisystem (14%)
1. Acid-base imbalance
2. Bariatric complications
3. Comorbidity in patients with transplant history
4. End-of-life care
5. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)
6. Hypotension
7. Infectious diseases:
a. Influenza (e.g., pandemic or epidemic)
b. Multi-drug resistant organisms (e.g., MRSA, VRE, CRE)
8. Life-threatening maternal/fetal complications (e.g., eclampsia, HELLP syndrome, postpartum hemorrhage, amniotic embolism)
9. Multiple organ dysfunction syndrome (MODS)
10. Multisystem trauma
11. Pain: acute, chronic
12. Post-intensive care syndrome (PICS)
13. Sepsis
14. Septic shock
15. Shock states:
a. Distributive (e.g., anaphylactic, neurogenic)
b. Hypovolemic
16. Sleep disruption (including sensory overload)
17. Thermoregulation
18. Toxic ingestion/inhalations (e.g., drug/alcohol overdose)
19. Toxin/drug exposure (including allergies)

II. PROFESSIONAL CARING 7 ETHICAL PRACTICE (20%)
A. Advocacy/Moral Agency
B. Caring Practices
C. Response to Diversity
D. Facilitation of Learning
E. Collaboration
F. Systems Thinking
G. Clinical Inquiry

CLINICAL JUDGMENT
General
Recognize normal and abnormal:
o developmental assessment findings and provide developmentally appropriate care
o physical assessment findings
o psychosocial assessment findings
Recognize signs and symptoms of emergencies, initiate interventions, and seek assistance as needed
Recognize indications for, and manage patients requiring:
o capnography (EtCO2)
o central venous access
o medication reversal agents
o palliative care
o SvO2 monitoring
Manage patients receiving:
o complementary/alternative medicine and/or nonpharmacologic interventions
o medications (e.g., safe administration, monitoring, polypharmacy)
Monitor patients and follow protocols for pre- and postoperative care
Assess pain
Evaluate patients response to interventions
Identify and monitor normal and abnormal diagnostic test results
Manage fluid and electrolyte balance
Manage monitor alarms based on protocols and changes in patient condition Cardiovascular
Apply leads for cardiac monitoring
Identify, interpret and monitor cardiac rhythms
Recognize indications for, and manage patients requiring:
o 12-lead ECG
o arterial catheter
o cardiac catheterization
o cardioversion central venous pressure monitoring
o defibrillation
o IABP
o invasive hemodynamic monitoring
o pacing: epicardial, transcutaneous, transvenous
o pericardiocentesis
o QT interval monitoring
o ST segment monitoring
Manage patients requiring:
o endovascular stenting
o PCI Respiratory
Interpret blood gas results
Recognize indications for, and manage patients requiring:
o modes of mechanical ventilation
o noninvasive positive pressure ventilation (e.g., BiPAP, CPAP, high-flow nasal cannula)
o oxygen therapy delivery devices
o prevention of complications related to mechanical ventilation (ventilator bundle)
o prone positioning
o pulmonary therapeutic interventions related to mechanical ventilation: airway clearance, extubation, intubation, weaning
o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2 )
o thoracentesis
o tracheostomy Hematology and Immunology
Manage patients receiving transfusion of blood products
Monitor patients and follow protocols:
o pre-, intra-, post-intervention (e.g., plasmapheresis, exchange transfusion, leukocyte depletion)
o related to blood conservation Neurological
Recognize indications for, and manage patients requiring neurologic monitoring devices and drains (e.g., ICP, ventricular or lumbar drain)
Use a swallow evaluation tool to assess dysphagia
Manage patients requiring:
o neuroendovascular interventions (e.g., coiling, thrombectomy)
o neurosurgical procedures (e.g., pre-, intra-, post-procedure)
o spinal immobilization Integumentary
Recognize indications for, and manage patients requiring, therapeutic interventions (e.g. wound VACs, pressure reduction surfaces, fecal management devices, IV infiltrate treatment) Gastrointestinal
Monitor patients and follow protocols for procedures pre-, intra-, post-procedure (e.g., EGD, PEG placement)
Intervene to address barriers to nutritional/fluid adequacy (e.g., chewing/swallowing difficulties, alterations in hunger and thirst, inability to self-feed)
Recognize indications for, and manage patients requiring:
o abdominal pressure monitoring
o GI drains
o enteral and parenteral nutrition Renal and Genitourinary
Identify nephrotoxic agents
Monitor patients and follow protocols pre-, intra-, and post-procedure (e.g., renal biopsy, ultrasound)
Recognize indications for, and manage patients requiring, renal therapeutic intervention (e.g., hemodialysis, CRRT, peritoneal dialysis)
Musculoskeletal
Manage patients requiring progressive mobility
Recognize indications for, and manage patients requiring, compartment syndrome monitoring
Multisystem
Manage continuous temperature monitoring
Provide end-of-life and palliative care
Recognize risk factors and manage malignant hyperthermia
Recognize indications for, and manage patients undergoing:
o continuous sedation
o intermittent sedation
o neuromuscular blockade agents
o procedural sedation - minimal
o procedural sedation - moderate
o targeted temperature management (previously known as therapeutic hypothermia)
Behavioral and Psychosocial
Respond to behavioral emergencies (e.g., nonviolent crisis intervention, de-escalation techniques)
Use behavioral assessment tools (e.g., delirium, alcohol withdrawal, cognitive impairment)
Recognize indications for, and manage patients requiring:
o behavioral therapeutic interventions
o medication management for agitation
o physical restraints

I. CLINICAL JUDGMENT (80%)
A. Cardiovascular (14%)
1. Cardiac infection and inflammatory diseases
2. Cardiac malformations
3. Cardiac surgery
4. Cardiogenic shock
5. Cardiomyopathies
6. Cardiovascular catheterization
7. Dysrhythmias
8. Heart failure
9. Hypertensive crisis
10. Myocardial conduction system defects
11. Obstructive shock
12. Vascular occlusion
B. Respiratory (18%)
1. Acute pulmonary edema
2. Acute pulmonary embolus
3. Acute respiratory distress syndrome (ARDS)
4. Acute respiratory failure
5. Acute respiratory infection
6. Air-leak syndromes
7. Apnea of prematurity
8. Aspiration
9. Chronic pulmonary conditions
10. Congenital airway malformations
11. Failure to wean from mechanical ventilation
12. Pulmonary hypertension
13. Status asthmaticus
14. Thoracic and airway trauma
15. Thoracic surgery

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (20%)
1. Endocrine
a. Adrenal insufficiency
b. Diabetes insipidus (DI)
c. Diabetic ketoacidosis (DKA)
d. Diabetes mellitus, types 1 and 2
e. Hyperglycemia
f. Hypoglycemia
g. Inborn errors of metabolism
h. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
2. Hematology and Immunology
a. Anemia
b. Coagulopathies (e.g., ITP, DIC)
c. Immune deficiencies
d. Myelosuppression (e.g., thrombocytopenia, neutropenia)
e. Oncologic complications
f. Sickle cell crisis
g. Transfusion reactions
3. Gastrointestinal
a. Abdominal compartment syndrome
b. Abdominal trauma
c. Bowel infarction, obstruction and perforation
d. Gastroesophageal reflux
e. GI hemorrhage
f. GI surgery
g. Liver disease and failure
h. Malnutrition and malabsorption
i. Necrotizing enterocolitis (NEC)
j. Peritonitis
4. Renal and Genitourinary
a. AKI
b. Chronic kidney disease (CKD)
c. Hemolytic uremic syndrome (HUS)
d. Kidney transplant
e. Life-threatening electrolyte imbalances
f. Renal and genitourinary infections
g. Renal and genitourinary surgery
5. Integumentary
a. IV infiltration
b. Pressure injury
c. Skin failure (e.g., hypoperfusion)
d. Wounds

D. Musculoskeletal/Neurological/Psychosocial (15%)
1. Musculoskeletal
a. Compartment syndrome
b. Musculoskeletal surgery
c. Musculoskeletal trauma
d. Rhabdomyolysis
2. Neurological
a. Acute spinal cord injury
b. Agitation
c. Brain death
d. Congenital neurological abnormalities
e. Delirium
f. Encephalopathy
g. Head trauma
h. Hydrocephalus
i. Intracranial hemorrhage
j. Neurogenic shock
k. Neurologic infectious disease
l. Neuromuscular disorders
m. Neurosurgery
n. Pain: acute, chronic
o. Seizure disorders
p. Space-occupying lesions
q. Spinal fusion
r. Stroke
s. Traumatic brain injury (TBI)
3. Behavioral and Psychosocial
a. Abuse and neglect
b. Post-traumatic stress disorder (PTSD)
c. Post-intensive care syndrome (PICS)
d. Self-harm
e. Suicidal ideation and behavior

E. Multisystem (13%)
1. Acid-base imbalance
2. Anaphylactic shock
3. Death and dying
4. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)
5. Hypovolemic shock
6. Post-transplant complications
7. Sepsis
8. Submersion injuries (i.e. near drowning)
9. Hyperthermia and hypothermia
10. Toxin and drug exposure

II. Professional Caring & Ethical Practice (20%)
A. Advocacy/Moral Agency
B. Caring Practices
C. Response to Diversity
D. Facilitation of Learning
E. Collaboration
F. Systems Thinking
G. Clinical Inquiry

CLINICAL JUDGMENT
General
Manage patients receiving:
o continuous sedation
o extracorporeal membrane oxygenation (ECMO)
o nonpharmacologic interventions
o pharmacologic interventions
o intra-procedural and post-procedural care
o post-operative care
o vascular access
Conduct physical assessment of critically ill or injured patients
Conduct psychosocial assessment of critically ill or injured patients
Evaluate diagnostic test results and laboratory values
Manage patients during intrahospital transport
Manage patients undergoing procedural sedation
Manage patients with temperature monitoring and regulation devices
Provide family-centered care Cardiovascular
Manage patients requiring:
o arterial catheterization (e.g., arterial line)
o cardiac catheterization
o cardioversion
o CVP monitoring
o defibrillation
o epicardial pacing
o near-infrared spectroscopy (NIRS)
o umbilical catheterization (e.g., UVC, UAC)
Manage patients with:
cardiac dysrhythmias
hemodynamic instability Respiratory
Manage patients requiring:
o artificial airways (e.g., endotracheal tubes, tracheotomy)
o assistance with airway clearance chest tubes
o high-frequency oscillatory ventilation (HFOV)
o mechanical ventilation
o noninvasive positive-pressure ventilation (e.g., CPAP, nasal IMV, high-flow nasal cannula)
o prone positioning
o respiratory monitoring devices (e.g., SpO2, SVO2, EtCO2)
o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2)
o thoracentesis
Hematology and Immunology
Manage patients receiving:
o plasmapheresis, exchange transfusion or leukocyte depletion
o transfusion
Neurological
Conduct pain assessment of critically ill or injured patients
Manage patients with seizure activity
Provide end-of-life and palliative care
Manage patients requiring:
o neurologic monitoring devices and drains (e.g., ICP, ventricular drains, grids)
o spinal immobilization Integumentary
Manage patients requiring wound prevention and/or treatment (e.g., wound VACs, pressure reduction surfaces, fecal management devices, IV infiltrate treatment)
Gastrointestinal
Manage patients with inadequate nutrition and fluid intake (e.g., chewing and swallowing difficulties, alterations in hunger and thirst, inability to self-feed)
Manage patients receiving:
o enteral and parenteral nutrition
o GI drains
o intra-abdominal pressure monitoring Renal and Genitourinary
Manage patients requiring:
o electrolyte replacement
o renal replacement therapies (e.g., hemodialysis, CRRT, peritoneal dialysis)
Multisystem
Manage patients requiring progressive mobility
Behavioral and Psychosocial
Conduct behavioral assessment of critically ill or injured patients (e.g., delirium, withdrawal)
Manage patients requiring behavioral and mental health interventions
Respond to behavioral emergencies (e.g., nonviolent crisis intervention, de-escalation techniques)

I. CLINICAL JUDGMENT (80%)
A. Cardiovascular (5%)
1. Acute pulmonary edema
2. Cardiac surgery (e.g., congenital defects, patent ductus arteriosus)
3. Dysrhythmias
4. Heart failure
5. Hypovolemic shock
6. Structural heart defects (acquired and congenital, including valvular disease)

B. Respiratory (21%)
1. Acute respiratory distress syndrome (ARDS)
2. Acute respiratory failure
3. Acute respiratory infection (e.g., pneumonia)
4. Air-leak syndromes
5. Apnea of prematurity
6. Aspiration
7. Chronic conditions (e.g., chronic lung disease/bronchopulmonary dysplasia)
8. Congenital anomalies (e.g., diaphragmatic hernia, tracheoesophageal fistula, choanal atresia, tracheomalacia, tracheal stenosis)
9. Failure to wean from mechanical ventilation
10. Meconium aspiration syndrome
11. Persistent pulmonary hypertension of the newborn (PPHN)
12. Pulmonary hemorrhage
13. Pulmonary hypertension
14. Respiratory distress (RDS)
15. Thoracic surgery
16. Transient tachypnea of the newborn

C. Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (27%)
1. Endocrine
a. Adrenal insufficiency
b. Hyperbilirubinemia
c. Hyperglycemia
d. Hypoglycemia
e. Inborn errors of metabolism
2. Hematology and Immunology
a. Anemia
b. Coagulopathies (e.g., ITP, DIC)
c. Immune deficiencies
d. Leukopenia
e. Polycythemia
f. Rh incompatibilities, ABO incompatibilities, hydrops fetalis
g. Thrombocytopenia
3. Gastrointestinal
a. Bowel infarction/obstruction/perforation (e.g., mesenteric ischemia, adhesions)
b. Feeding intolerance
c. Gastroesophageal reflux
d. GI abnormalities (e.g., omphalocele, gastroschisis, volvulus, imperforate anus, Hirshsprung disease, malrotation, intussusception, hernias)
e. GI surgeries
f. Hepatic failure (e.g., biliary atresia, portal hypertension, esophageal varices)
g. Malnutrition and malabsorption
h. Necrotizing enterocolitis (NEC)
i. Pyloric stenosis
4. Renal and Genitourinary
a. Acute kidney injury (AKI)
b. Chronic kidney disease
c. Congenital genitourinary conditions (e.g., hypospadias, polycystic kidney disease, hydronephrosis, bladder exstrophy)
d. Genitourinary surgery
e. Infections
f. Life-threatening electrolyte imbalances
5. Integumentary
a. Congenital abnormalities (e.g., epidermolysis bullosa, skin tags)
b. IV infiltration
c. Pressure injury/ulcer (e.g., device, incontinence, immobility)
d. Wounds:
i. non-surgical
ii. surgical

D. Musculoskeletal/Neurological/Psychosocial (13%)
1. Musculoskeletal
a. Congenital or acquired musculoskeletal conditions
b. Osteopenia
2. Neurological
a. Agitation
b. Congenital neurological abnormalities (e.g., AV malformation, myelomeningocele, encephalocele)
c. Encephalopathy
d. Head trauma (e.g., forceps and/or vacuum injury)
e. Hemorrhage:
i. intracranial (ICH)
ii. intraventricular (IVH)
f. Hydrocephalus
g. Ischemic insult (e.g., stroke, periventricular leukomalacia)
h. Neurologic infectious disease (e.g., viral, bacterial, fungal)
i. Neuromuscular disorders (e.g., spinal muscular atrophy)
j. Neurosurgery
k. Pain (acute, chronic)
l. Seizure disorders
m. Sensory impairment (e.g., retinopathy of prematurity, hearing impairment, visual impairment)
n. Stress (e.g., noise, overstimulation, sleep disturbances)
o. Traumatic brain injury (e.g., epidural, subdural, concussion, physical abuse)
3. Behavioral and Psychosocial
a. Abuse and neglect
b. Families in crisis (e.g., stress, grief, lack of coping)

E. Multisystem (14%)
1. Birth injuries (e.g., hypoxic-ischemic encephalopathy, brachial plexus injury, lacerations)
2. Developmental delays
3. Failure to thrive
4. Healthcare-associated conditions (e.g., VAE, CAUTI, CLABSI)
5. Hypotension
6. Infectious diseases (e.g., influenza, respiratory syncytial virus, multidrugresistant organisms)
7. Life-threatening maternal/fetal complications (e.g., eclampsia, HELLP syndrome, maternal-fetal transfusion, placental
abruption, placenta previa) 8. Low birth weight/prematurity
9. Sepsis
10. Terminal conditions (e.g., end-of-life, palliative care)
11. Thermoregulation
12. Toxin/drug exposure (e.g., neonatal abstinence syndrome, fetal alcohol syndrome, maternal or iatrogenic).

II. Professional Caring & Ethical Practice (20%)
A. Advocacy/Moral Agency
B. Caring Practices
C. Response to Diversity
D. Facilitation of Learning
E. Collaboration
F. Systems Thinking
G. Clinical Inquiry

CLINICAL JUDGMENT
General
Assess pain considering patients gestational age
Follow protocol for newborn car seat testing, hearing and congenital heart disease screening
Follow protocol for feeding and supplementation
Identify and monitor normal and abnormal diagnostic test results
Implement interventions to keep neonates safe (e.g., transponder use, safe sleep)
Manage monitor alarms based on protocol and change in patient condition
Manage patients receiving complementary alternative medicine and/or nonpharmacologic interventions
Manage patients receiving medications (e.g., safe administration, monitoring, polypharmacy)
Monitor patients and follow protocols for pre- and postoperative care
Recognize indications for, and manage patients requiring, central venous access
Recognize normal and abnormal:
o developmental assessment findings and provide developmentally appropriate care
o family psychosocial assessment findings
o physical assessment findings
Recognize signs and symptoms of emergencies, initiate interventions, and seek assistance as needed
Cardiovascular
Apply leads for cardiac monitoring
Identify, interpret and monitor cardiac rhythms
Monitor hemodynamic status and recognize signs and symptoms of hemodynamic instability
Recognize early signs of decreased cardiac output
Recognize normal fetal circulation and transition to extra-uterine life
Recognize indications for, and manage patients requiring:
o 12-lead ECG
o arterial catheter
o cardioversion
o invasive hemodynamic monitoring Respiratory
Interpret blood gas results
Manage medications and monitor patients requiring rapid sequence intubation (RSI)
Recognize indications for, and manage patients with, tracheostomy
Recognize indications for, and manage patients requiring:
o assisted ventilation
o bronchoscopy
o chest tubes
o endotracheal tubes
o non-invasive positive pressure ventilation (e.g., bilevel positive airway pressure, CPAP, high-flow nasal cannula)
o oxygen therapy delivery device
o prone positioning (lateral rotation therapy)
o rescue airways (e.g., laryngeal mask airway [LMA])
o respiratory monitoring devices (e.g., SpO2, EtCO2) and report values
o therapeutic gases (e.g., oxygen, nitric oxide, heliox, CO2)
o thoracentesis
Hematology and Immunology
Manage patients receiving transfusion of blood products
Monitor and manage patients with bleeding disorders
Monitor patients and follow protocols:
o pre-, intra-, post-intervention (e.g., exchange transfusion)
o related to blood conservation
Neurological
Manage patients with congenital neurological abnormalities



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Medical Care answers

‘no one has very clear answers for them’: docs look for cures for covid-19 long-haulers | CCRN PDF Questions and PDF Dumps

“The disorder, it wears on you — body, intellect and spirit,” Chiluisa, a 51-yr-old clinic employee, stated these days. “You can also be satisfactory all day, after which impulsively your body simply shuts down. No explanation. No reason. It just shuts down.”

however in contrast to some “lengthy-haulers” within the early a part of the pandemic who struggled to influence any one that signs of covid-19 might ultimate for months, Chiluisa is being attended by means of a crew of consultants.

He sees a pulmonologist, a cardiologist, a neurologist, a respiratory therapist and a real therapist, and soon he will see a social employee — a primary step towards getting support for the toll the coronavirus has inflicted on his psyche.

even as they continue to face the every day clinical calls for of the pandemic, caregivers similar to Chiluisa’s are adjusting to the truth that, for a lot of lots of individuals, the lengthy-time period consequences of covid-19 might also ought to be managed for months, and perhaps an awful lot longer.

lengthy-haulers “are in each country, in each language,” observed Igor J. Koralnik, who all started a program for covid-19 neurocognitive issues at Northwestern Memorial medical institution in Chicago, one of numerous post-covid-19 clinics opening within the country. “It’s going to be a large problem. It’s not going to move away.”

Chiluisa’s care is coordinated by using the Winchester Chest health facility at Yale New Haven hospital. The middle for publish-Covid Care operated by using the Mount Sinai health-care gadget in big apple city boasts on its web page that it has medical consultants from 12 disciplines. Penn medicine’s sanatorium in Philadelphia expenses itself as a “post-covid assessment and healing health center.”

while doctors have accrued a long time of adventure within the lengthy-time period management of illnesses reminiscent of diabetes and renal failure, they haven't any such potential in covid-19, which is barely 10 months historical.

“The patients are very scared as a result of nobody has very clear solutions for them,” pointed out Denyse Lutchmansingh, Chiluisa’s pulmonologist. “they're happy to suppose heard. they're satisfied that individuals are trying to aid them. however on the end of the day, [they would] like to learn for certain: ‘here is what goes to turn up to you. here's now not what is going to happen to you.’ And that’s the part that’s problematic for us in drugs, because it’s no longer completely clear.”

Clinicians have learned, for instance, that a large spectrum of sufferers event lengthy-term indicators, from those that have been hospitalized to those who had gentle bouts, from the young to the ancient. Southern Connecticut turned into hit early in the pandemic, when the virus become overwhelming the more advantageous big apple city enviornment and relatively little became widely used in regards to the route of the ailment.

“The indicators that they've span every organ gadget,” observed Jennifer Possick, the Winchester Chest clinic’s scientific director. “It has so many greater faces than i believed it would.”

no person knows how many lengthy-haulers there can be, youngsters a British team lately estimated that as many as 10 percent of the individuals who contract the sickness undergo extended signs. In July, the facilities for ailment control and Prevention mentioned that 35 percent of people who had gentle types of covid-19 had now not lower back to their pre-disorder state of health two to three weeks later.

Many lengthy-haulers have geared up on-line aid agencies, corresponding to Survivor Corps and body Politic, to share tips and focus on symptoms.

Chiluisa’s household moved from Ecuador to Connecticut when he turned into eleven, and he grew up in the enviornment. He labored as an EMT, owned a bakery after which went back to college to turn into a CT scan technician at Yale New Haven clinic.

He became in the health facility’s emergency department in early March when the virus struck the place. uncovered to a positive affected person, he came down with mild symptoms — aches, low-grade fever and a few sweating, he referred to. by the point he might get demonstrated, the influence came back bad. Lutchmansingh said she can certainly not recognize no matter if Chiluisa turned into contaminated then by way of the unconventional coronavirus or another pathogen.

In might also, besides the fact that children, there became no doubt. Chiluisa awoke sweating profusely, with a fever of 103 degrees. This time, he established tremendous for the coronavirus.

He became hospitalized for seven days, five of them in intensive care, the place he directed docs not to put him on a ventilator, in spite of how extreme his ailment grew to become. He feared the penalties of sedation and intubation more than the options, he talked about.

in its place, physicians treated him with a mixture of medication: remdesivir; tocilizumab, a drug used to combat rheumatoid arthritis and other autoimmune disorders; convalescent plasma; a steroid; and even hydroxychloroquine, the drug President Trump erroneously touted as a remedy for the ailment. The drug turned into later removed from Yale’s treatment regimen when research showed it had no price and could damage sufferers.

“The medical professional spoke of: ‘We’re going to offer you a cocktail. If it really works, you reside. If it doesn’t work, you then die,’ ” Chiluisa recalled. “and that i agreed with him, as a result of I didn’t need to be intubated.”

Chiluisa’s 24-yr-old son became contaminated as smartly, but his spouse and two daughters didn't get the ailment.

Chiluisa recovered and changed into launched from the health facility — handiest to be readmitted for a day in June when the oxygen in his blood dropped to dangerously low ranges. He become released once again and has normally Tested negative, but he has not ever felt neatly.

Chiluisa appears to embody a good deal of the worst the virus can do. His coronary heart races. His lungs are inflamed. His chest aches and feels constricted. Even now, he coughs up a thick mucus it really is fitting worse despite numerous treatments. His feel of style, which did not disappear because it has in another covid-19 sufferers, has been altered.

Most ominously, an MRI indicates that the white remember of his mind is affected by tiny lesions that may be the cause of neurological complications, including memory lapses, difficulty concentrating, issue discovering phrases and stuttering. He has insomnia, depression and anxiousness, and different symptoms that resemble put up-traumatic stress disorder.

The mind lesions are greater often present in older americans, or those with uncontrolled metabolic problems comparable to diabetes or chronic high blood drive, stated his neurologist, Arman Fesharaki-Zadeh. Chiluisa has no such underlying situations.

If the mind is a sequence of interconnected highways, each lesion is a piece zone that slows the circulation of counsel, Fesharaki-Zadeh mentioned. They additionally may make Chiluisa vulnerable to dementia at an prior age.

“For a person with out a background of metabolic sickness . . . for his brain to appear the style it did to me changed into quite stunning,” he noted. no person is aware of whether Chiluisa’s dysfunctions are permanent or modern, or whether his mind will discover new paths around the boundaries and restoration his means to are living and work at all times.

Chiluisa’s coronary heart and lung issues present other mysteries. regardless of some lingering bacteria in his lungs that have resisted antibiotic treatments, Chiluisa performs distinctly at all times on assessments of pulmonary and cardiac feature.

however as an alternative of progressing, his situation has fluctuated unpredictably because the months have passed. He turns into winded and exhausted straight away. His blood force rises all of a sudden.

“He has a lot of signs which are ongoing, that are reputedly suggestive of an underlying coronary heart condition, however their testing, for probably the most part, has been standard,” observed Erica Spatz, an affiliate professor of cardiovascular drugs at the Yale faculty of medicine who is Chiluisa’s heart specialist.

It’s feasible, she referred to, that the virus has disrupted Chiluisa’s autonomic nervous device, which controls functions akin to heart and respiratory prices. Or in all probability Chiluisa’s personal immune and inflammatory response to the viral assault did the harm.

The symptoms are likely now not everlasting, Spatz stated, nevertheless it’s now not clear how lengthy they may last.

“This feels very challenging, as a result of they don’t recognize,” she pointed out. “And we’re discovering as they go, and we’re researching from their patients and with their patients about their experiences. And that’s very unsettling as a physician, to now not suppose that you just’re ahead.”

similarly, Lutchmansingh has no conclusive reason for why Chiluisa can turn into so short of breath that he in brief put himself on supplemental oxygen on two fresh events.

“Edison’s standard, run-of-the-mill lung-feature checking out is common,” she said. “however he obviously doesn’t consider neatly. We’ve [examined] the usual already. Now we’re going to the odd.” She noted she is exploring even if the muscle groups that assist the lungs in breathing are working normally.

For Chiluisa and his family, the ailment — together with the be anxious it has led to, together with over fiscal issues — has become exhausting. At one aspect in his convalescence, he observed, he ran via his paid time off and Yale stopped paying him. currently, the state of Connecticut’s medical coverage software is picking up his costs, but he believes Yale will eventually need to pay the tab because he become uncovered in the office. nevertheless, he frets that a economic burden will fall on him and his family.

A spokeswoman for the health center declined to talk about Chiluisa’s employment background.

worried about reinfection, an incredibly unlikely possibility, Chiluisa is additionally uncomfortable working at the clinic, the place he at the moment performs administrative tasks. And considering that he's nonetheless coughing, he also doesn’t like being round other americans. encouraged through his household, he's considering another profession exchange.

“Psychologically, I’m no longer equipped. physically, I’m now not competent,” he said. “The psychological is even worse than the real part. You consider afraid, afraid to move returned to the [emergency department].

“So my intellectual state is ‘I don’t want to die.’ Put it that manner.”


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