CCRN Pediatric Cheat Sheet

Cardiovascular

11% of exam
Age Vital Sign Norms Hypotension SBP Thresholds PALS Arrest Doses Congenital Heart Lesions Hemodynamic Targets Rhythm Response Picker

Respiratory

13% of exam
PARDS Criteria Ventilator Targets Airway Emergencies Airway Sizing Rules Deteriorating Airway Picker

Endocrine, Heme, GI, Renal, Skin

25% of exam
DKA Rules Life-Threatening Electrolytes Sodium and Water Disorders Hematology and Oncology Renal and GI Numbers Sodium and Polyuria Picker

Musculoskeletal, Neuro, Behavioral

15% of exam
ICP and CPP Targets Neuro Assessment Tools Brain Death Rules Behavioral and Musculoskeletal

Multisystem

17% of exam
Sepsis Bundle Numbers Shock States Burns and Toxic Exposure Shock Type Picker

Professional Caring and Ethical Practice

20% of exam
Synergy Patient Characteristics Synergy Nurse Competencies Exam Logistics End-of-Life Practice

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 CA

Duct closing? Start prostaglandin E1
Neonate in shock Keep duct open Watch for apnea Avoid excess oxygen

Cardiogenic vs Hypovolemic Shock CA

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 CA

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 CA

Neonate HR 100-205 awake PALS
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 CA

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 CA

Term neonate Under 60 0-28 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 CA

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 seconds 2025
Arrest DBP goal, infant 25 mm Hg or higher 2025
Arrest DBP goal, child 30 mm Hg or higher 2025
Start CPR when HR under 60, poor perfusion

Congenital Heart Lesions CA

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 CA

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 RE

OI 4 diagnose, OI 16 severe
OSI 5 diagnoses OSI 12 is severe Stratify at 4 hours P/F 300 noninvasive

Croup vs Epiglottitis RE

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 RE

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 RE

Timing Within 7 days of insult PALICC-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 RE

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 RE

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 RE

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 MU

Fluids first, insulin second, dextrose later
Never bolus insulin Potassium in every bag Headache means edema Mannitol or 3% saline

DKA vs HHS MU

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 MU

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 MU

Glucose criterion Over 200 mg/dL ISPAD
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 MU

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 MU

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 MU

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 MU

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 MU

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 MU

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 NE

Head midline, ICP under 20, CPP 40
3% saline 2-5 mL/kg Drain CSF No corticosteroids Normothermia and normoglycemia

ICP and CPP Targets NE

ICP treatment threshold Under 20 mm Hg BTF 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 NE

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 NE

Pediatric examinations Two, by two clinicians 2023
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 NE

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 MU

One hour with shock, three without
10-20 mL/kg boluses Up to 40-60 mL/kg Reassess each bolus Balanced crystalloid

Cold vs Warm Shock MU

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 MU

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 MU

Antibiotics with shock Within 1 hour SSC
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 MU

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 MU

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 PR

Eight patient needs, eight nurse competencies
Patient drives competency Rate level 1, 3, 5 Judgment is the 80% Caring is the 20%

Synergy Patient Characteristics PR

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 PR

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 PR

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 PR

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

AACN CCRN Pediatric Critical Care Nurse

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