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before anything else, first thing to do when BP crashing is to--TURN OFF DIPRIVAN. right now the pt gagging on the ET tube isnt your priority--the BP is. you're turning up the propofol and turning up the pressors--youre see-sawing the pt. 1. this was an emergency yes? if so it must be treated like one. i dont think there is time to insert an IABP while the pt is crashing. your thinking and thus the flow of interventions should follow this train of thought. if the pressure was in the 40s this is a code (at least i would have treated it as one) especially in that you were doing everything and nothing was working and the trend is going down real fast. 2. secondly, time wasted on calling people back and forth--again, in a code, cant do this. need to get the crash cart, call for help, get your charge nurse/supervisor, and get ACLS protocol. it is better to call a code and be wrong and get embarrassed by looking stupid than to try to do things all by yourself and kill a pt (not insinuating you did, just making a point). 3. first thing i would have done was give fluid bolus. one of the basic things to treat a crashing bp. get NS and open it all the way or if on a pump set rate at 999. 4. next thing was of course titrate his pressors. highest levo for us here in SICU is around 80 (some have gone up to 100). we would also have hung neo (as high as 180). 5. the priority at this point would have been to save the pt and thus, treat his emergency sx--crashing bp. all the other stuff--fluid overload, low urine output, etc...are secondary and should have been attended to AFTER THE PT CRASHING RESOLVES. 6. if youre going to call a code, then you can get some EPI in and see how that works. also, NaHCO3 sometimes help--i have seen a doctor order 3 amps for crashing bp. next thing would be calcium chloride--1amp--which helps with the myocardial membrane ionization. 7. last stuff to check--what are the H/H? he probably needs blood, or he was probably bleeding somewhere. what are the electrolytes? at the end of the day, pat yourself on the back because you did what you were able to do and tried to save the pt. you cared for the patient and that's worth more than any accolade. like others have said, you need to learn to let go. you need to learn to leave work at work. you cannot save everyone but you have the right mentality to TRY TO save everyone. you did a good job. learn from it and get better. all you can really do.

like i said in the other thread--you DONT NEED TO BUY ANYTHING ELSE. 1. pass CCRN! question CD - available on ebay cheap. harder than the actual CCRN exam, will make your brain explode. 2. Laura Gasparis Vonfrolio CCRN Exam Cram DVDs - worth every penny. these will make you LEARN the stuff. review them repeatedly then sharpen with the question CD. the CCRN exam is peanuts compared to the passCCRN! cd; there are some psychosocial and family-issues questions that make the CCRN easy. those questions should "pad" you but do not rely on them. know your material. Cardiac is 50 questions (30%)--CONCENTRATE on this. the questions are FREAKING HARD--most of them are hemodynamics/drugs to give. know your cardiac medications (i never knew milrinone would turn up!). make sure you know and can analyze multiple drugs and their multiple effects (one will lower afterload, one will lower preload, one will increase cardiac output, one will slow diastole for coronary filling, etc...). a question will have multiple drugs for each letter answer and you need to analyze what will happen with all of them running. after the cardiac part the rest of the exam is easy as pie (if you've trained with gasparis and the passCCRN cd).

hey, im not about to go preaching and debating with you on the rights and wrongs and all that--im just helping those who want to pass, straight and simple. now, with the gasparis DVDs and questionCD--that's not only going to make you pass, but make you LEARN as well--i mean, you dont just go through all that material and questioning without absorbing something. in fact, its going to make you LEARN enough to pass--which is the point--the point is to be familiar enough and knowledgeable enough to prove to an accrediting body that you know your critical care stuff; and you wear that badge with a CCRN title. but to add on to what you said--and i agree with this--you need to review before you take the test. i thought i knew DKA and HNNK in and out before taking the test and then suddenly when an osmolality question came up, i bombed that question--i totally forgot what i learned. so yeah, review all your material, and make sure you know ALL of it, not just "most" of it because the more you know, the more chances you have of passing. the test is so damn hard you do not want to give it any chance of failing you.

not to sound cocky or anything but the ccrn wasnt as hard as i thought it was. its DAMN HARD, but if you use the proper resources and review well, you shouldnt have a problem. 1. pass ccrn! cd questionnaire - harder than the actual ccrn exam, will blow your brains out. 2. laura gasparis vonfrolio ccrn exam cram dvds - worth every penny. will make you understand the material without having to ever read the aacn ccrn book. you dont need anything else. no aacn book. no book--any book, period. just the dvds and practice cd. you need 88pts to pass (out of 125). i reviewed for one week straight cram and got 97 and im a one year (new grad) nurse. not the best way to do it because you dont retain a lot of information but if you want to pass then this is the way.

no one at work has them. oh and, its probably just me, but i have always thought of us nurses as trustworthy people for the most part. especially in a community like this, i would trust someone knowing i would have their address/number/license apart from the fact that the road we nurses take to succeed isnt an easy one, and that for the most part weeds out the not so trustworthy ones. sure, there's a bad apple in every bunch, but in general, compared to MOST professions, many surveys have us at the top of trust ratings. i also offered to buy it at a reduced price.

anybody selling used review material? i am planning to take ccrn but cant shell out the dough for the laura gasparis vonfrolio ones. they're not available on ebay nor amazon as well. perhaps i can borrow and return? any help would be kindly appreciated. https://www.greatnurses.com/exp/index.php/products/item/ccrn_review/ thanks.

anybody selling used ones? i am planning to take ccrn but cant shell out the dough for the laura gasparis vonfrolio ones. they're not available on ebay nor amazon as well. perhaps i can borrow and return? any help would be kindly appreciated. https://www.greatnurses.com/exp/index.php/products/item/ccrn_review/ thanks.

im a new grad in SICU as well. i think it depends on YOU--not the facility for the most part. you have to impress your interviewer and let them know you are serious about working there. 1. you have to have your med-surg skills all straightened out. i was always strong clinically as a student, i was far better than a lot of my classmates when it came to bedside skills--passing meds, knowing what they're for, critical thinking, communication skills with family/nurses/doctors, etc...you should have your basic skills down already (NGT insertion, IV insertion, IV pumps/piggybacks, pharmacology calculations, rates, etc...). it will be difficult and i wouldnt recommend going straight to ANY ICU, much less SICU (the most difficult ICU environment) if you dont have excellent clinical skills as a student. 2. you have to be serious, persistent, and willing to do anything to succeed. study your critical care concepts, know your diseases and pathophysiology like it was the back of your hand, know the meds given there and the equipment--swan ganz, a-lines, cvp monitoring, ventriculostomies, chest tubes, CO/CI, EKG, etc... 3. probably the most important thing you need is CRITICAL THINKING and a very, very, strong pathophysiology body of knowledge. things can go really bad really fast and you should be able to detect sudden changes and be able to react accordingly. im not going to lie to you or sugarcoat anything--IT IS FREAKING HARD. and it will take A LOT of dedication. i have had patients go bad on me--AAA on one and a ICH on another that both died (though no fault of my own :wink2:) and it is fast-paced, nervewrecking, and crazy when that happens. you need to keep your cool, be able to think FAST and act FAST, and be able to calm the family down with the other hand while talking to the doctor on your left ear. it is not for the faint of heart; but i have done it (7 months into it and will take CCRN) and so have many others. A HUGE responsibility--and thus, a HUGE LIABILITY rests on your shoulders should you proceed. a lot of the tele nurses who float to our unit as scared crapless and many of them decline and rather go home than float to us. a lot of the ICU and CCU nurses dread our unit. the big question is, WHY? why should you put unnecessary burden on yourself? why should you want to go through the eye of a needle just to succeed in that unit? why do you brave the raised eyebrows of the 10-, 20-, 30- year veterans who ALL had to go through med-surg/telemetry before going to SICU? why should you suffer the ridicule and spit of the doctors who would rather deal and talk to the "real ICU nurse" than you fresh grad meat? for me? BECAUSE I CAN.

thanks for the reply, some follow-up questions... where do you get your picc kits? can i buy them too or can i just buy them from you? what is the bard/cook/angiodynamics? i have seen many types of piccs--what are the differences of each (like powerpicc)?

okay, for a couple of months now i have heard of various success rates with picc-certified nurses who have broken off with their hospital and independently formed a group that goes to hospitals in their area to insert PICCs. 1. how many of you are doing this and what is the success rate like? one picc a day demand? more than one a day? 2. what is the demand with the hospitals? i know that our hospital trains the supervisors to insert piccs so they "save" on FTE. 3. what is the pay rate like? i heard that its something like 300$ per insertion here in los angeles. i hope to go into this because it seems like a huge revenue stream that not many are going into (partly because its expensive to train--500$ theory package for MST/US plus additional clinical/actual insertion training--and that not many want to train others). there is another way that i heard to do this--and that is to partner with an MD who almost always needs a picc for his patients (oncology/chemotherapy, neurosurgeon/neurointerventionalist, intensivist/ICU) and then insert piccs for his demand. the pay i hear is lower--200$ per insertion but then you get the advantage of referral and guaranteed business by way of the MD (of course the MD gets a cut). 4. how many of you are doing this route? 5. what is the success rate like? how is the experience and can you partner with multiple MDs (for more business)? i also know that medicare reimburses 600$ for picc placement and an additional 80$ if it is with ultrasound--so this is a good business to go into. i am really studying how to get into this business as i feel i am more a "technical"/"skill"-nurse than a bedside nurse. i have 6 months experience in the SICU fresh from school and i could say i am pretty competent compared to others. lastly, 6. where do you get the picc materials (actual picc) to train with? i can buy the dvd and books online, but none offer the actual insertion kit. 7. who certifies us as a picc-certified nurse? various companies online are offering classes, but is there an actual, formal, CERTIFICATION given by a goverened body like BRN? companies often just quote position papers by INS/AVA. is this legal? 8. what is the longest time it would take for a picc insertion? i have watched a few and they always never go beyond an hour. 300$ for one hour's work looks sweet, imagine five of them in a day--that's my two weeks' pay! let me know your thoughts and thanks to those who take the time to read and answer, your help is immensely appreciated and valued. p.s.--yes, i know there are a bunch of RNs out there who will hurl the traditional "you need years of experience first!", "you're fresh out of school and youre doing this already, take one step at a time", "you should never have gone into nursing if $$$ is all you think of", "stop having delusions of grandeur and earn your time the way we did". please. do us all a favor and just answer the questions and help out. i highly respect those that paid their dues and got to where they are through difficult means. please find merit in just answering factually the questions aired.