Quiz 6

The day has been very cold, with the temperatures below freezing all week. There have only been a few ALS calls this week in your tour and you are ready for almost anything. There is one other BLS unit on day shift today that is sharing the calls evenly. Nothing has occurred that has been very challenging.

Your pager starts to ring as you are walking out to your unit. You are requested to respond Code 3 for a 53-year-old male with an allergic reaction. The caller states that the patient has been sleeping and awakened with his tongue, his face and neck very swollen, with extreme difficulty to even try to swallow his saliva. He is conscious and alert at the time of the 9-1-1 call. Your second unit is dispatched to assist as well due to the severity of the call.

Your partner is a PCP with two years experience. Your response time will be approximately 12 minutes today. You reach over and hit the siren as your unit leaves the hospital grounds. You know this call is a true emergency. You can just hope that on arrival the patient is more stable than the initial call presented to the dispatcher. You also know that there may be a need for you to perform advanced airway procedures and even a small chance for an emergency cricothyrotomy if he deteriorates rapidly. You know this would be the last resort when all else fails. You review the important landmarks in your head and also think about the emergency pharmacology that you might need on this call. You are now about one minute away and you hope you are ready for what is very likely to be your most challenging call of the week in ALS terms.

Upon arrival to your patient, you find that your patient is leaning forward and the saliva is drooling from the corners of his mouth. The patient is alert and orientated looking with a GCS of 15/15. He is barley able to speak at all. He can only state one- or two-word garbled sentences. You notice redness and swelling to his anterior neck region that is new according to his wife. You can see that his tongue is swollen so big that his mouth is almost wide open with minimal ability to move air around the tongue. The patient skin feels warm with slight diaphoresis present. You call your backup unit to keep coming “STAT” while you and your partner quickly obtain a SAMPLE history from the spouse and initiate basic care.

Your initial assessment reveals the following.

Vital signs on arrival:

• Temperature of 37.8
• Respiratory rate of 28 and laboured
• Pulse of 138 minute, Sp02 is 80% on room air
• BP is 174/96
• Blood sugars are 5.7 mmol/l
• Cardiac monitor is sinus tachycardia with occasional PVCs SAMPLE Hx is as follows:
• Symptoms: Went to sleep one hour ago. He awakened with this problem and immediately called his wife for assistance.
• Allergies: Environmental and seasonal allergies.
• Medications: Prednisone 50 mg po daily x 5/7 for a prior allergic reaction from an unknown source. Aspirin two days ago for a mild headache. Claritin for post nasal drip taken three days ago with only one tab used. He also takes a multi-vitamin daily.
• Past Hx: The spouse knows of no recent illnesses. Apparently, he has a history of asthma as a child with two episodes over the last 10 years. None of the recent asthma attacks required hospitalization. He was seen four days ago for an allergic reaction and placed on steroids as well as a referral to the allergist and dermatology in 2/52.
• Last Meal, Last Medications: The patient had a banana and a chocolate bar prior to lying down. You are not sure if it is nut free or not.
• Events preceding EMS being called: Just not feeling 100% today but nothing that was specific or significant.

You now suspect this patient is suffering a severe allergic reaction. You also know epiglottitis is a possibility and that you could also suspect an insect or spider bite, but that is not a certain diagnosis. You are going with an acute allergic reaction for the time being. You also know the local emergency physician will want to know about this patient right away in order to have a resuscitation bed ready as well to prepare an OR room as a backup plan.

About the Authors.

Dale Bayliss is an experienced Advanced Care Paramedic and Registered Nurse living in Camrose, Alberta. Dale is an instructor with the University of Alberta, Augustana Faculty’s Paramedic Program. He also works part time as an Emergency Nurse at the University of Alberta Hospital in Edmonton and works casual as a Paramedic with Peace Hills EMS in Wetaskiwin, Alta. and with Beaver EMS in Tofield, Alta.

Jeremy Rudrud (Primary Care Paramedic) is a ACP Paramedic student with the University of Augustana Paramedic Program. Jeremy is a PCP with Edmonton EMS under the Emergency Response Department (ERD).

Please keep in mind the answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Canadian Emergency News and the authors of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.

1. You walk into a nice looking residence with no visible hazards. You immediately notice a high pitched stridor audible without your stethoscope even. You immediately recognize the stridor sound as a potential:
   A) lower airway obstruction.
   B) upper airway obstruction.
   C) pneumonia.
   D) COPD.
2. Your essential vital signs are being done by your partner as you obtain additional medical history. You see the patient has taken prednisone, aspirin and Decadron recently. You know that two of the three medications can help decrease the effect of an allergic reaction directly. They are:
   A) Prednisone.
   B) Aspirin
   C) Decadron.
   D) Multi-vitamins.
   E) A. and B.
   F) A. and C.
3. The cardiac monitor is applied and you see a sinus tachycardia with a heart rate of 138 bpm. The most likely cause of this rhythm would be from:
   A) hypoxia.
   B) anxiety.
   C) hypothermia
   D) A. and B.
   E) all of the above.
4. You would next auscultate the chest to verify air entry and to validate the extra effort in breathing. On auscultation you hear the stridor over the trachea but not as prominent into the main bronchioles. You then would expect the stridor to be coming from:
   A) the large swollen tongue tissues.
   B) the swollen tissues of the neck putting pressure onto the central airway structures.
   C) the surrounding epiglottis tissues that are likely swollen.
   D) all of the above.
5. The oxygen saturation deteriorates with the exertion of the patient moving onto your stretcher. The best treatment for the falling saturations would be to apply oxygen:
   A) with non re-breather mask at 15 LPM.
   B) by blow-by if a mask is not tolerated.
   C) by nasal prongs at 5 LPM.
   D) all of the above.
6. The patient appears slightly agitated and scared during your secondary assessment. He shakes his head “no” when you tell him you are taking him to the local hospital. The best treatment plan for this patient would be to provide:
   A) reassurance that the oxygen therapy will help him and use calm and precise actions to apply the oxygen device.
   B) reassurance to the patient that his wife can come along with him if she wishes to accompany him to the hospital.
   C) no aggressive or rough manoeuvres. Hypoxia causes increased confusion and he might even think he will be okay at home, but he needs to be packaged and taken to the local hospital emergently.
   D) all of the above.
7. What additional information is pertinent to know in this situation with a patient suffering from an acute allergic reaction?
   A) Past intubations.
   B) Past ICU admissions.
   C) Past asthma admissions.
   D) Current medications therapy.
   E) All of the above.
8. You elect to prepare to transport your patient immediately. The best position to transport this patient would be in the ____________ position.
   A) supine
   B) prone
   C) high fowlers
   D) feet elevated in a head down position
9. Your partner assesses the Sp02 after the oxygen is applied and it is now registering at 100 per cent. You partner suggest you prepare to intubate on scene. Your response at this time would be:
   A) if the patient collapses, then yes, you are right, we need to attempt.
   B) the best chance is in the operating room or in the ER with backup staff ready.
   C) we may only get one chance and if we can get to the hospital and have backup that would be the best solution to this crisis.
   D) all of the above.
10. Your second crew arrives. You ask for their help to get the patient to your unit with limited assessment and interventions on scene. Your rationale for the quick scene time is due to the life threatening airway complication. En route you will need:
    A) three-lead cardiac monitoring, continuous Sp02 monitoring, end tidal CO2 monitoring by nasal prongs.
    B) IV access with a maintenance infusion running TKVO.
    C) pre-draw ALS medications. 12-lead if time permits.
    D) backup staff in your unit to help during the transport to the local ER.
    E) all of the above.
11. You apply your cardiac monitor, Sp02 monitor, and you have already taken a tympanic temperature. You know that the hypoxia can also be from a (an):
    A) foreign body obstruction in the main bronchi.
    B) upper airway obstruction.
    C) systemic infection.
    D) spontaneous pneumothorax.
    E) all of the above.
12. The patient has a low grade fever of 37.8 Celsius. You know the elevated temperature can come from:
    A) infection.
    B) elevated metabolic rate.
    C) tonsillitis.
    D) pneumonia.
    E) all of the above.
13. You have moved the patient to the unit and are ready to leave the scene. You would first like to assess _____________ prior to initiating transport.
    A) ABC, LOC, basic vital signs
    B) 12-lead EKG
    C) blood sugar and core temperature
    D) B. and C. only
    E) all of the above
14. Your next action that would be very beneficial would be to:
    A) patch your local hospital and relay your concerns to the local physician.
    B) ask for additional suggestions and orders that are not or may not be in your normal protocols.
    C) attempt to patch to take to the regional hospital that is 60 minutes away as they have a specialist with allergies on staff.
    D) A and B.
    E) all of the above are appropriate.
15. Fluid therapy indicated for this patient in the prehospital care setting would be _________________ TKO.
    A) normal saline
    B) ringers lactate
    C) dextrose 50 water
    D) 2/3 – 1/3
    E) A and B
16. Anaphylaxis causes the body to go into shock. The normal initial signs of anaphylaxis can be:
    A) hypertension and tachycardia.
    B) hypotension and hypoglycemia.
    C) bradycardia and tachypnea.
    D) all of the above.
17. You elect to have the patient attempt to maintain his airway as his VS are stable and his level of consciousness are okay at this time. What are the main criteria for actively attempting to insert an airway or to perform an emergency surgical airway intervention?
    A) The patient LOC is deteriorating rapidly in front of you.
    B) The patient Sp02 level is dropping rapidly despite high flow oxygen therapy.
    C) The end tidal CO2 is climbing with a decreased respiratory effort.
    D) All of the above.
18. The paramedic would like to initiate medications to prevent additional edema. The best medication for this currently would be:
    A) dexamethasone 4 mg IV.
    B) epinephrine 0.3 – 0.5 mg SC/IM.
    C) lasix 40 mg po.
    D) insulin 10 units of Toronto.
    E) Aspirin 650 mg po.
19. You initiate Ventolin 5 mg and Atrovent 500 mcg Neb running. You have also added Racemic epinephrine with 2 cc of NS neb after the first neb is completed en route as well. Your next medication therapy would likely then be:
    A) Solu-Medrol 125 mg IVP.
    B) Benadryl 25 – 50 mg IVP.
    C) Solu-Cortef 250 mg IVP.
    D) Dexamethasone 4 mg IV.
    E) All of the above.
20. Your next two medication’s that can be used for anaphylaxis therapy would then be:
    A) Solu-Medrol 125 – 250 mg IV in a mini bag over 10 minutes.
    B) Glucagon 1 mg SC.
    C) Dexamethasone 4 mg IV slowly.
    D) A and B.
    E) A and C.
21. You assist your partner in starting a second peripheral IV for an emergency medication route. You note the BP is normal with a slightly tachycardic patient. You may elect to:
    A) initiate a 250 ml bolus and reassess lung sounds after.
    B) administer 1000 ml bolus.
    C) administer an IV bolus of 20 ml/kg.
    D) provide no additional IV fluid.
22. Your arrival to the local ER is in about three minutes now. The allergic reaction does not seem to be stopping with everything you have provided. The best therapy for this patient next would be:
    A) pull over and attempt intubation before it’s too late.
    B) wait until arrival to the local emergency and consult with the local on-call physician about the options—to intubate in the ER or to take the patient to the OR for the on-call anesthesiologist to attempt an intubation with the surgical cricothyrotomy as a second and final step if required.
    C) perform a surgical cricothyrotomy now as intubation will be futile.
    D) lasix 80 mg IVP.
23. You would expect the hospital to attempt to aggressively treat this patient upon your arrival in emergency. You would expect the hospital to:
    A) administer Zantec 50 mg IV.
    B) activate the OR to be on standby for immediate emergency surgery.
    C) provide repeated doses of epinephrine, steroid and repeated Ventolin and Atrovent nebs.
    D) all of the above.
24. Upon arrival to the local ER the nurses and the physician meet you and ask that your patient be taken into the local trauma room. The on-call physician sets up the emergency airway tray. Optional instruments kits that we may see would be:
    A) Combitube.
    B) Rhino scope.
    C) retrograde intubation kit.
    D) Cook critical care cric kit.
    E) B, C and D.
    F) all of the above.
25. The physician sits back and looks at the neck and then listens to your story and report. Additional differential diagnosis that he can be thinking about to rule out would be _________________. The suspected diagnosis can be acute allergic reaction as well as cellulites.
    A) mumps.
    B) angioedema.
    C) tonsillitis.
    D) all of the above.
26. The emergency physician elects to insert the Rhino scope into the nares with the proper topical anesthetic with the patient in the sitting position. After a quick look and additional anesthetic he assists you to take the patient to the OR for intubation and further care with the assistance of the on-call anesthesiologist who has now arrived. En route you administer Ventolin 5 mg and Atrovent 500 mcg by blow-by technique. The anesthesiologist carefully inserts the “Nasal Rae” endotracheal tube past the vocal cords with his fibre optical instruments with local anesthetic spray. Next we need to help:
    A) perform a CXR.
    B) assist to administer sedatives and paralytics to now maintain adequate ventilations.
    C) perform an ABG.
    D) all of the above.

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