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🚨 Emergency Situations — NCLEX & NORCET AIIMS Preparation Guide

Priority Management Using Medical & Nursing Terminology

🔑 UNIVERSAL PRIORITY FRAMEWORK

For ALL emergencies, always apply ABC → D → E first:

A — Airway (establish/maintain patency)
B — Breathing (assess rate, depth, SpO₂)
C — Circulation (HR, BP, skin perfusion, IV access)
D — Disability (GCS, pupils, neurological status)
E — Exposure (full body examination, vital signs)

Then apply SBAR for communication: Situation → Background → Assessment → Recommendation

1. 🫀 CARDIAC ARREST (Cardiopulmonary Arrest)

Step	Action	Terminology
1st	Confirm unresponsiveness; call for help / activate code blue	Code Blue activation
2nd	Check carotid pulse (≤10 sec); if absent → start CPR	Cardiac arrest protocol
3rd	Begin chest compressions: 30:2 ratio, 100–120/min, depth 5–6 cm, hard & fast	High-quality CPR
4th	Attach defibrillator; analyze rhythm — shockable (VF/pulseless VT) → shock 200J biphasic	Defibrillation
5th	Resume CPR immediately post-shock (2 min cycle); establish IV/IO access	Post-resuscitation
6th	Epinephrine 1 mg IV/IO every 3–5 min; amiodarone 300 mg IV for VF/VT	Vasopressor/antiarrhythmic
7th	Identify and treat reversible causes (4H 4T)	H's & T's
8th	Post-ROSC: 12-lead ECG, targeted temperature management (TTM) 32–36°C	Return of Spontaneous Circulation

4H's: Hypoxia, Hypovolemia, Hypo/Hyperkalemia, Hypothermia 4T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (PE/MI)

Nursing Priority: Do NOT delay first compression for IV/airway. Minimize interruptions (<10 sec).

2. 😮‍💨 RESPIRATORY DISTRESS / ARREST

Step	Action
1st	Position: sit upright (high Fowler's/orthopneic position); O₂ via face mask at 10–15 L/min
2nd	Assess SpO₂, RR, breath sounds (auscultation); apply pulse oximetry
3rd	If apneic → jaw thrust/chin lift; bag-valve-mask (BVM) ventilation
4th	Prepare for endotracheal intubation (ETT); RSI (Rapid Sequence Intubation) if needed
5th	Confirm ETT placement: ETCO₂ capnography, bilateral breath sounds, CXR
6th	Mechanical ventilation: set FiO₂, PEEP, tidal volume (6–8 mL/kg IBW)

Bronchospasm (Asthma Attack):

1st: Salbutamol (albuterol) 2.5–5 mg nebulization + ipratropium
2nd: IV/oral corticosteroids (prednisolone/methylprednisolone)
3rd: IV magnesium sulfate 2g over 20 min (severe case)
Monitor: PEFR, SpO₂, accessory muscle use

3. 🩸 SHOCK — Types & Management

A. Hypovolemic Shock (Hemorrhagic/Fluid Loss)

Step	Action
1st	Control active bleeding (direct pressure, tourniquet)
2nd	Two large-bore IVs (16–18G); rapid IV fluid bolus: Lactated Ringer's / NS 1–2L
3rd	Blood typing & cross-matching; transfuse PRBCs if Hgb <7 g/dL or ongoing hemorrhage
4th	Balanced transfusion: pRBCs : FFP : Platelets = 1:1:1 ratio
5th	Monitor: urine output (target >0.5 mL/kg/hr), BP, HR, lactate, base deficit
6th	Treat underlying cause (surgery, endoscopy)

Grading: Class I (<15% blood loss) → Class IV (>40% blood loss, life-threatening)

Key Lab: Serum lactate >4 mmol/L or base deficit < −4 mEq/L = shock marker

B. Septic Shock (Distributive)

Step	Action
1st	Obtain blood cultures × 2 (before antibiotics); lactate level
2nd	Broad-spectrum IV antibiotics within 1 hour (e.g., piperacillin-tazobactam + vancomycin)
3rd	IV fluid resuscitation: crystalloid 30 mL/kg within 3 hours
4th	Vasopressor if MAP <65 mmHg despite fluids: Norepinephrine (1st line)
5th	Hydrocortisone 200 mg/day IV if vasopressor-refractory
6th	Source control: drain abscess, remove infected catheter

Surviving Sepsis Bundle (1-hour bundle): Measure lactate → blood cultures → antibiotics → IV fluids → vasopressors for MAP <65 mmHg

C. Anaphylactic Shock

Step	Action
1st	Epinephrine (Adrenaline) 0.3–0.5 mg IM (anterolateral thigh) — FIRST LINE
2nd	Position: supine with legs elevated (Trendelenburg)
3rd	O₂ high flow; IV access; fluid resuscitation NS bolus
4th	Repeat epinephrine every 5–15 min if needed
5th	Diphenhydramine (antihistamine H1) IV/IM; ranitidine (H2 blocker)
6th	IV corticosteroids: methylprednisolone 125 mg IV
7th	Nebulized salbutamol for bronchospasm; monitor for biphasic reaction (4–12 hrs)

Nursing Key: Epinephrine MUST be given first — not antihistamine!

D. Cardiogenic Shock

Step	Action
1st	O₂, monitor, IV access; 12-lead ECG for MI
2nd	Dobutamine (inotrope) IV; dopamine if severe hypotension
3rd	Cautious IV fluids (avoid fluid overload)
4th	Urgent PCI (percutaneous coronary intervention) if AMI-related
5th	IABP (Intra-Aortic Balloon Pump) / mechanical circulatory support

4. 🧠 STROKE (CVA — Cerebrovascular Accident)

Time is Brain — "FAST": Face drooping, Arm weakness, Speech difficulty, Time to call

Step	Action
1st	Activate stroke team; note exact time of symptom onset
2nd	ABC stabilization; O₂ if SpO₂ <94%; IV access; NPO
3rd	STAT non-contrast CT brain (rule out hemorrhagic stroke)
4th	Blood glucose check (hypoglycemia mimics stroke)
5th	Ischemic stroke within 4.5 hours: IV tPA (alteplase) 0.9 mg/kg (max 90 mg)
6th	Large vessel occlusion within 24 hours: mechanical thrombectomy
7th	BP management: in ischemic stroke, allow permissive hypertension <220/120 mmHg (pre-tPA); keep <180/105 mmHg post-tPA
8th	Aspirin 325 mg (after hemorrhage excluded); statin therapy

Nursing: Position HOB at 30°; monitor for dysphagia (swallow screen before oral intake); neuro checks q1h

Hemorrhagic Stroke:

Reverse anticoagulation if on warfarin (Vitamin K + FFP or PCC)
Neurosurgical consult
BP target: systolic <140 mmHg with IV labetalol/nicardipine

5. 💉 MYOCARDIAL INFARCTION (STEMI/NSTEMI)

MONA (Classic Nursing Mnemonic — now modified):

Step	Drug/Action	Note
1st	12-lead ECG within 10 min of arrival	ST elevation ≥1mm in ≥2 contiguous leads = STEMI
2nd	Aspirin 325 mg (chewed) + P2Y12 inhibitor (clopidogrel/ticagrelor)	Dual antiplatelet
3rd	Nitroglycerin SL 0.4 mg q5min × 3 (if BP >90 systolic, no RV infarct)	Vasodilator
4th	Morphine 2–4 mg IV (only if pain refractory, no longer 1st-line)	Opioid analgesia
5th	O₂ only if SpO₂ <90%	Avoid hyperoxia
6th	IV heparin (unfractionated) or enoxaparin	Anticoagulation
7th	Primary PCI within 90 min (door-to-balloon) — preferred reperfusion	Catheterization lab
8th	If PCI unavailable: IV fibrinolysis (streptokinase/tPA) within 30 min	Thrombolysis

Nursing Priority: Continuous cardiac monitoring; defibrillator ready; restrict activity; NPO for procedure

6. 🫁 PULMONARY EMBOLISM (PE)

Step	Action
1st	O₂ high flow; IV access; monitor SpO₂, BP, HR
2nd	12-lead ECG (classic: S1Q3T3); D-dimer; ABG
3rd	CT pulmonary angiography (CTPA) — gold standard imaging
4th	Anticoagulation: IV unfractionated heparin bolus 80 U/kg, then 18 U/kg/hr
5th	Massive PE (hemodynamic instability): thrombolysis with tPA 100 mg IV over 2 hrs
6th	Surgical embolectomy if thrombolysis contraindicated

Wells Score used to assess pre-test probability

7. 🔋 DIABETIC EMERGENCIES

A. Diabetic Ketoacidosis (DKA)

Step	Action
1st	IV NS 1L/hr for first 1–2 hours (aggressive fluid resuscitation)
2nd	IV regular insulin: 0.1 U/kg/hr (after K⁺ ≥3.5 mEq/L confirmed)
3rd	Potassium replacement: 20–40 mEq/hr if K⁺ <5.5 mEq/L
4th	Monitor glucose hourly; switch to D5 when glucose <200 mg/dL
5th	Monitor ABG (pH, bicarbonate), urine output, electrolytes q2–4h

DKA criteria: Glucose >250 mg/dL + pH <7.3 + bicarbonate <18 mEq/L + ketonemia/ketonuria

B. Hypoglycemia (BGL <70 mg/dL)

Step	Action
1st	Conscious patient: Rule of 15 — 15g fast-acting carbs, recheck in 15 min
2nd	Unconscious/unable to swallow: Dextrose 25–50g (50% dextrose) IV bolus
3rd	If no IV access: Glucagon 1 mg IM/SC
4th	Identify and treat underlying cause; monitor BGL q15–30 min

8. ⚡ STATUS EPILEPTICUS

Step	Action
1st	Protect from injury; lateral position; time the seizure
2nd	O₂ via face mask; suction if secretions (do NOT insert objects in mouth)
3rd	IV access; blood glucose, electrolytes, drug levels
4th	Benzodiazepine (0–5 min): Lorazepam 0.1 mg/kg IV (or diazepam 0.2 mg/kg IV/rectal)
5th	2nd line (5–20 min): Levetiracetam 60 mg/kg IV OR phenytoin/fosphenytoin 20 mg/kg IV
6th	Refractory (>30 min): Propofol/midazolam/barbiturate infusion; ICU admission + EEG monitoring
7th	Check: Thiamine 100 mg IV before glucose (in alcoholic patients — prevents Wernicke's)

Nursing: Seizure precautions: padded side rails, O₂ at bedside, suction ready, NPO

9. 🧊 INCREASED INTRACRANIAL PRESSURE (ICP)

Step	Action
1st	HOB elevated 30° (neutral head position — avoid jugular compression)
2nd	O₂ to maintain SpO₂ >95%; avoid hypercarbia (PaCO₂ 35–40 mmHg)
3rd	Mannitol 0.25–1 g/kg IV (osmotic diuretic — 1st line)
4th	3% hypertonic saline (alternative to mannitol)
5th	Hyperventilation (PCO₂ 30–35 mmHg) — temporary bridge only
6th	Neurosurgical consultation; ICP monitoring; decompressive craniectomy if refractory

Cushing's Triad (late sign of herniation): Hypertension + Bradycardia + Irregular respirations

10. 🔥 BURNS

Step	Action
1st	Stop the burning process; remove clothing/jewelry
2nd	Airway assessment — inhalation injury: hoarseness, singed nasal hairs, stridor → early intubation
3rd	Calculate TBSA (Rule of Nines); calculate fluid requirements
4th	Parkland Formula: 4 mL × weight (kg) × %TBSA (Lactated Ringer's) — ½ in first 8 hrs, ½ in next 16 hrs
5th	Tetanus prophylaxis; wound care; pain management (IV morphine)
6th	Transfer to burn unit for burns >10% TBSA, face, hands, genitalia, circumferential burns

Rule of Nines: Head 9%, each arm 9%, chest 9%, abdomen 9%, each thigh 9%, each leg 9%, perineum 1%

11. 🤰 OBSTETRIC EMERGENCIES

A. Eclampsia

Step	Action
1st	Protect airway; left lateral decubitus (uterine displacement)
2nd	Magnesium sulfate 4–6 g IV loading dose, then 1–2 g/hr maintenance
3rd	Antihypertensive: hydralazine 5–10 mg IV or labetalol 20 mg IV (target BP <160/110)
4th	Fetal monitoring; plan for delivery
5th	Monitor Mg toxicity: check reflexes (lost first), urine output, respiratory rate (keep calcium gluconate at bedside as antidote)

B. Postpartum Hemorrhage (PPH)

Step	Action
1st	Bimanual uterine massage; assess for cause (4T's: Tone, Tissue, Trauma, Thrombin)
2nd	Oxytocin 20–40 units in 1L NS IV — 1st line uterotonic
3rd	Misoprostol 800–1000 mcg rectal/sublingual
4th	Tranexamic acid 1g IV within 3 hours of delivery
5th	Blood transfusion, surgical intervention (B-Lynch suture, hysterectomy)

12. ☠️ POISONING / OVERDOSE

Poison	1st Action	Antidote
Opioid overdose	Airway support	Naloxone (Narcan) 0.4–2 mg IV/IM/IN
Organophosphate	Atropine IV	Atropine + Pralidoxime (2-PAM)
Acetaminophen (paracetamol)	Activated charcoal (if <1hr)	N-Acetylcysteine (NAC) IV/oral
Benzodiazepine	Supportive	Flumazenil 0.2 mg IV
Warfarin	INR, CBC	Vitamin K IV + FFP/PCC
Cyanide	O₂ 100%	Hydroxocobalamin (Cyanokit)
CO poisoning	Remove from exposure	100% O₂ (hyperbaric if severe)
Iron overdose	Supportive	Deferoxamine
Digoxin toxicity	Cardiac monitoring	Digoxin-specific Fab fragments
Beta-blocker overdose	IV fluids, atropine	Glucagon IV
TCA overdose	ABC	Sodium bicarbonate IV

Universal approach: ABCDE → activated charcoal (if <1hr, alert, no caustic) → specific antidote → supportive care

13. 🌡️ HEAT STROKE / HYPOTHERMIA

Heat Stroke (core temp >40°C + CNS dysfunction)

Step	Action
1st	Remove from heat; ABC
2nd	Rapid cooling — target 39°C within 30 min: ice water immersion OR evaporative cooling + fans
3rd	IV cold NS; do NOT give antipyretics (not effective in heat stroke)
4th	Monitor rhabdomyolysis (CK, urine myoglobin), renal function

Hypothermia (core temp <35°C)

Step	Action
1st	Remove wet clothing; prevent further heat loss
2nd	Gentle warming: passive rewarming (mild) → active external (moderate) → active internal/ECMO (severe <30°C)
3rd	Warm IV fluids (39–42°C); warmed humidified O₂
4th	Monitor for J-waves (Osborn waves) on ECG; VF risk
Mantra	"Not dead until warm and dead" — continue resuscitation until core temp >32°C

14. 🩺 HYPERTENSIVE EMERGENCY

(BP >180/120 mmHg with end-organ damage)

Step	Action
1st	IV access; continuous BP monitoring (arterial line preferred)
2nd	Target: reduce MAP by ≤25% in first hour (NOT to normal — risk of ischemia)
3rd	IV antihypertensives: Nicardipine, Labetalol, Clevidipine, or Nitroprusside
4th	Aortic dissection → Esmolol + nitroprusside; target SBP <120 mmHg urgently
5th	Eclampsia → Magnesium sulfate + labetalol/hydralazine

End-organ damage: Hypertensive encephalopathy, stroke, AMI, acute heart failure, renal failure, aortic dissection, retinopathy

15. 🫀 ACUTE PULMONARY EDEMA (Cardiogenic)

Step	Action
1st	Sit upright (high Fowler's 90°); O₂ via NRB mask or BiPAP/CPAP
2nd	IV furosemide 40–80 mg (diuretic — 1st line)
3rd	IV nitroglycerin infusion (vasodilation — reduces preload)
4th	Morphine 2–4 mg IV (reduce anxiety/preload — use cautiously)
5th	Identify cause: STEMI → PCI; HTN → antihypertensives; arrhythmia → cardioversion

LMNOP Mnemonic: Lasix, Morphine, Nitrates, O₂, Position

16. 🌊 DROWNING / NEAR-DROWNING

Step	Action
1st	Safely remove from water; do NOT delay CPR for water drainage
2nd	Begin CPR (5 rescue breaths first if no breathing, then 30:2)
3rd	Remove wet clothes; prevent hypothermia (warm blankets)
4th	O₂ high flow; prepare for intubation (lung injury)
5th	Monitor for secondary drowning (up to 24 hrs); admit for observation

17. ⚡ SPINAL CORD INJURY

Step	Action
1st	Immobilize spine immediately (cervical collar, log-roll technique)
2nd	Airway: jaw thrust ONLY (no head-tilt in cervical injury)
3rd	Neurogenic shock (vasodilation + bradycardia): IV fluids + vasopressors + atropine
4th	MRI spine; neurosurgical consultation
5th	High-dose methylprednisolone (controversial; used within 8 hrs)
6th	Foley catheter (urinary retention); pressure ulcer prevention

18. 🩹 TRAUMA (Polytrauma — Primary Survey)

Using ATLS Protocol:

Survey	Assessment	Priority Actions
A — Airway	Obstruction, stridor, consciousness	Jaw thrust, suction, intubation
B — Breathing	Tension pneumothorax, open chest wound	Needle decompression (2nd ICS MCL), chest seal
C — Circulation	Hemorrhage, BP, HR	Pressure, IV fluids, blood products
D — Disability	GCS, pupils, spinal	C-spine immobilization
E — Exposure	Wounds, fractures	Log roll, prevent hypothermia

Tension Pneumothorax: Absent breath sounds + tracheal deviation + hypotension → immediate needle decompression (2nd intercostal space, midclavicular line) — do NOT wait for X-ray

🏥 NURSING-SPECIFIC PRIORITY RULES (NCLEX/NORCET)

Rule	Principle
Maslow's Hierarchy	Physiological needs first (airway > breathing > circulation)
ABC Priority	Airway always first unless DO NOT RESUSCITATE order
Safety	Seizure precautions, fall precautions, infection control
Assessments First	Assess before intervening (exception: cardiac arrest — act immediately)
Delegation	RN: Assessment, teaching, unstable patients; LPN/LVN: stable, routine care; UAP: bathing, vitals (stable)
When in doubt, prioritize:	Acute over chronic; unstable over stable; life-threatening over comfort

📊 QUICK REFERENCE: KEY ANTIDOTES

Drug/Toxin	Antidote
Heparin	Protamine sulfate
Warfarin/Coumadin	Vitamin K + FFP/PCC
Opioids	Naloxone (Narcan)
Benzodiazepines	Flumazenil
Acetaminophen	N-Acetylcysteine
Digoxin	Digoxin-specific Fab
Organophosphates	Atropine + Pralidoxime
Beta-blockers	Glucagon
Calcium channel blockers	Calcium gluconate + glucagon
Iron	Deferoxamine
Cyanide	Hydroxocobalamin
CO	100% O₂ / Hyperbaric O₂
TCA overdose	Sodium bicarbonate
Methanol/Ethylene glycol	Fomepizole (4-MP)
Magnesium toxicity	Calcium gluconate

📝 EXAM-FOCUSED MNEMONICS

Mnemonic	Meaning
FAST	Face, Arm, Speech, Time (stroke)
MONA	Morphine, O₂, Nitroglycerin, Aspirin (MI — modified)
4H 4T	Reversible causes of cardiac arrest
LMNOP	Lasix, Morphine, Nitrates, O₂, Position (pulmonary edema)
RICE	Rest, Ice, Compression, Elevation (musculoskeletal)
ABCDE	Airway, Breathing, Circulation, Disability, Exposure
SBAR	Situation, Background, Assessment, Recommendation
Rule of Nines	Burns TBSA estimation
Parkland Formula	4 × kg × %TBSA = fluid for burns
SAMPLE	Signs/Symptoms, Allergies, Medications, Past history, Last oral intake, Events (history taking)

🔺 TOP HIGH-YIELD NCLEX/NORCET POINTS

Epinephrine is ALWAYS 1st in anaphylaxis — not antihistamine
tPA contraindicated in hemorrhagic stroke; give only after CT rules out bleed
No aspirin in children <18 (Reye's syndrome risk)
Succinylcholine used for RSI but contraindicated in burn patients >24–48 hrs (hyperkalemia risk)
Position in shock: supine with legs elevated (except cardiogenic/pulmonary edema — sit up)
Potassium must be ≥3.5 before starting insulin in DKA
Thiamine BEFORE glucose in alcoholic patients (prevent Wernicke's encephalopathy)
Never do LP before CT if ICP suspected (herniation risk)
CPR ratio: 30:2 adults; 30:2 one-rescuer child; 15:2 two-rescuer child
Magnesium antidote = Calcium gluconate (keep at bedside during mag infusion)
Urine output target in shock: >0.5 mL/kg/hr; in burns: 0.5–1.0 mL/kg/hr
Primary PCI within 90 minutes (door-to-balloon) for STEMI
Oxygen NOT given in suspected COPD if SpO₂ >88–92% (hypercapnic drive)
Trendelenburg is NOT recommended in most shock (evidence-based update)
Jaw thrust (not head-tilt-chin-lift) in suspected cervical spine injury

Sources: ROSEN's Emergency Medicine (9780323757898), Sabiston Textbook of Surgery, Goldman-Cecil Medicine, Miller's Anesthesia — Medical Library; current ACLS/ATLS/Sepsis Surviving guidelines

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