BCEN CPEN Cheat Sheet

Triage Process

13.3% of exam
Pediatric Assessment Triangle ESI Triage Levels Danger-Zone Vital Signs Heart Rate by Age PAT to Impression

Assessment

16.7% of exam
Hypotension Thresholds Primary + Secondary Survey Pediatric GCS + AVPU Pain Scale by Age

System-Focused Emergencies

37.3% of exam
Resuscitation Drug Doses Airway Equipment Sizing Upper Airway Emergencies Cardiac Red Flags DKA + Hypoglycemia Rhythm Treatment Picker

Special Considerations

16.7% of exam
Neonatal Emergencies Maltreatment Red Flags Toxidromes + Antidotes Burns + Environmental

Multi-System Considerations

8% of exam
Shock Types Sepsis + Anaphylaxis Fluid Bolus Picker Post-Resuscitation + Sedation

Professional Issues

8% of exam
Legal + Regulatory Safety + Practice EMTALA + HIPAA Mandatory Reporting

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 TR

Tone, Interactiveness, Consolability, Look, Speech
Tone: muscle activity Interactiveness: alert, engaged Consolability: caregiver soothes Look: fixes and follows Speech: strong cry

PAT to Impression TR

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 TR

Triage Process 20 items
Assessment 25 items
System-Focused Emergencies 56 items Largest
Special Considerations 25 items
Multi-System Considerations 12 items
Professional Issues 12 items
Scored total 150 items

Pediatric Assessment Triangle TR

Appearance Tone, interactiveness, consolability
Work of breathing Retractions, flaring, abnormal sounds
Circulation to skin Pallor, mottling, cyanosis
TICLS Appearance memory tool Appearance
Method Visual and auditory only
Timing Done before touching child
Purpose Sick versus not sick

ESI Triage Levels TR

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 TR

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 TR

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 TR

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 AS

Airway, Breathing, Circulation, Disability, Exposure
Airway: open, positioned Breathing: rate, effort Circulation: pulses, perfusion Disability: AVPU, glucose Exposure: undress, keep warm

Hypotension Thresholds AS

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 AS

Chief complaint, Immunizations, Allergies, Medications
P: past medical history E: events surrounding illness D: diet and diapers S: symptoms with progression

Primary + Secondary Survey AS

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 AS

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 AS

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 SY

Dislodgement, Obstruction, Pneumothorax, Equipment failure
Dislodgement: recheck depth Obstruction: suction tube Pneumothorax: breath sounds Equipment: oxygen, circuit

Croup vs Epiglottitis SY

Croup

Barking cough
Gradual viral onset
Steeple sign

Epiglottitis

No cough, drooling
Abrupt toxic onset
Thumbprint sign
Cough versus drooling

Airway Adjunct Choice SY

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 SY

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 SY

Concentration × volume per kilogram equals 50
D10 at 5 mL/kg D25 at 2 mL/kg D50 at 1 mL/kg Neonates: D10 only

Respiratory Distress vs Failure SY

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 SY

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 SY

Epinephrine, arrest 0.01 mg/kg IV/IO Max 1 mg
Epinephrine interval Repeat every 3-5 minutes
Epinephrine, anaphylaxis 0.01 mg/kg IM thigh Max 0.5 mg
Adenosine, first dose 0.1 mg/kg rapid push Max 6 mg
Adenosine, second dose 0.2 mg/kg rapid push Max 12 mg
Amiodarone 5 mg/kg IV/IO bolus Max 300 mg
Atropine 0.02 mg/kg IV/IO Min 0.1 mg
Naloxone 0.1 mg/kg under 20 kg
Lorazepam, seizure 0.1 mg/kg IV/IO Max 4 mg
Midazolam, intranasal 0.2 mg/kg intranasal Max 10 mg
Dexamethasone, croup 0.6 mg/kg PO/IM Max 16 mg
Levetiracetam 60 mg/kg second-line

Simple vs Complex Febrile Seizure SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SY

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 SP

Salivation, Lacrimation, Urination, Defecation, Emesis
Killer B's: bradycardia, bronchorrhea Cause: organophosphates Antidote: atropine Add: pralidoxime

Accidental vs Inflicted Injury SP

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 SP

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 SP

Torso, Ear, Neck under 4 years
Any bruise under 4 months Frenulum, angle of jaw Cheek, eyelid, subconjunctival P: patterned bruising

Maltreatment Red Flags SP

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 SP

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 SP

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 SP

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 MU

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 MU

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 MU

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 MU

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 MU

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 PR

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 PR

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

BCEN CPEN Certified Pediatric Emergency Nurse

Practice Questions 400 questions Study Guide 36 topics Cheat Sheet 222 facts Flashcards 50 cards Blogs 1 blog Free CE Podcast