Quiz 9

The day has been very warm and humid with no rain clouds in sight. There is only one EMS unit on today, but you have the local fire department backup if required. You are an ALS unit. You are based in a small rural hospital today and you and your partner are working in the emergency room providing assistance as they do not have a local physician for the weekend. There are no other backup units available unless you can wait 30 minutes for another BLS ground unit to be available or approximately 25 minutes for them to scramble an air medevac, if it is even available.

Your partner is a Primary Care Paramedic (PCP) with five years experience who also works as an LPN Ortho Tech on her days off. You are an Advanced Care Paramedic (ACP) with three years experience. You are sitting in the trauma room checking the crash cart when a car drives in the emergency bay. A distraught elderly lady comes in stating her grandson will not wake up. She states he lives at her house and his parents live in another province. He is an 18-year-old who is currently working on a science degree at the local university. He was initially awake when placed in the car but some time during the 20-minute drive he became unresponsive and unconscious. You have all the emergency room, laboratory and radiology staff to assist you. You are now expected to be in charge as this is an unknown and unstable patient.

Your initial assessment reveals the following:
• Temperature on arrival of 37.8° C rectal
• Respiratory rate of 6 and irregular
• Pulse is 48/minute, Sp02 is 62 per cen on room air
• BP is 190/134
• Blood sugars are 10.6 mmol/l
• Cardiac monitor is sinus bradycardia with no PVC or ectopy

SAMPLE Hx is as follows:
• Symptoms: Increasing confusion since last night and then collapsed en route.
• Allergies: NKA
• Medications: None
• Past Hx: Was apparently drinking beer yesterday and smoking a few joints of marijuana with some other classmates last evening.
• Last Meal, Last Medications: Last night had supper with the grandparents
• Events preceding EMS being called: Increased headache and confusion since last night

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.

1. Your initial actions are to remove the patient from the car. You would immediately:
   A) Assess the LOC, the respiratory rate and quality of the respirations.
   B) Assume C-spine precaution and delegate your partner to take cervical spinal precautions.
   C) Rapidly extricate the patient from the vehicle utilizing spinal restriction devices.
   D) a and c only.
   E) All of the above.
2. The fastest way to remove this patient would be to:
   A) Apply a KED and then place on a spine board.
   B) Stabilize the cervical spine and place on a long spine board and slide out in a rapid but secure method.
   C) Disregard cervical spine stabilization and remove rapidly.
   D) Call the fire department and they will help extricate the patient from grandma’s car.
3. The pulse oxygen saturation monitor is applied and the initial Sp02 is 62 per cent on room air. Very low oxygen levels can cause bradycardia in pediatric patients and might be contributing to the bradycardia in this 18-year-old. This patient's initial SpO2 of 62 per cent might be caused by:
   A) Inadequate respiratory rate.
   B) Airway obstruction.
   C) Hypoxia.
   D) a and c only.
   E) All of the above.
4. Upon placing the patient on the emergency room stretcher your next actions would be to:
   A) Assess the airway and suction the mouth and oral pharynx prn.
   B) Attempt to insert an OPA or nasal pharyngeal airway (NPA) prior to ventilation attempts.
   C) Apply oxygen by NRB 10 to 15 lpm.
   D) Attempt to ventilate with a BVM at 12 to 20 times per minute.
   E) a, b, and d.
   F) a, b, and c.
5. You auscultate the chest and hear bilateral adventitious sounds. There are fine crackles to the bases bilaterally. You would expect the crackles to be coming from a (an):
   A) Aspiration pneumonia.
   B) Poor ventilations.
   C) Pneumothorax.
   D) a. and b only.
   E) All of the above.
6. The Sp02 improves after you assist ventilations and apply 100 per cent oxygen. Your next action would be to:
   A) Apply your cardiac monitor.
   B) Insert an IV line.
   C) Check the initial blood sugar.
   D) a and b.
   E) All of the above.
7. The normal respiratory rate for this adult patient would be:
   A) 10 to 14 per minute.
   B) 12 to 24 per minute.
   C) 16 to 30 per minute.
   D) 20 to 32 per minute.
8. What additional past medical information would be helpful in this patient with regards to the current state of unconsciousness?
   A) History of hypertension.
   B) Cocaine usage.
   C) Seizure disorder.
   D) Prior head injury.
   E) All of the above.
9. You apply your cardiac monitor and Sp02 monitor in emergency. You know that signs of increased ICP are:
   A) Slow bounding pulse.
   B) Hypertension.
   C) Bradycardia.
   D) Loss of consciousness.
   E) Hypertension.
   F) All of the above.
10. Your patient has a stat CT scan of the head done by the radiology staff. You are told there is a midline shift as well as a large area of bleeding within the subarachnoid tissues. This would indicate:
    A) Epidural hemorrhage.
    B) Subdural hemorrhage.
    C) Subarachnoid hemorrhage.
    D) Increased ICP.
11. Prolonged hypoxia to the brain can cause:
    A) Seizures.
    B) Prolonged unconsciousness.
    C) Cerebral edema.
    D) Hypertension.
    E) All of the above.
12. The patient has a low mild fever of 37.8 Celsius rectally. You know that hyperthermic medical patients should be:
    A) Attempted to be cooled to help decrease cerebral swelling.
    B) Warmed with passive warming.
    C) Maintained at a normal body temperature.
    D) Cooled to 32° C.
    E) a and c.
    F) All of the above.
13. You have moved the patient back to the emergency unit from the CT scanner and the patient is being stabilized for a medevac to an urban trauma centre with a neurosurgeon on call. You would first like to reassess:
    A) ABC, LOC, vital signs.
    B) Cardiac monitor, Sp02.
    C) Blood sugar and core temperature.
    D) a and b only.
    E) All of the above.
14. The patient is approximately 65 kg. The normal tidal volume for this patient should he need to be ventilated with a BVM would be along with supplemental oxygen.
    A) 2 to 4 ml/kg.
    B) 5 to 10 ml/kg.
    C) 7.5 to 10 ml/kg.
    D) 10 to 15 ml/kg.
15. This patient warrants maintenance IV fluid therapy in the prehospital care setting. The IV solution that is indicated for this patient in the prehospital care setting would be:
    A) Normal saline TKVO.
    B) Ringers lactate TKVO.
    C) Dextrose 50 per cent water 1 ampule.
    D) 2/3-1/3 1000 ml.
    E) a and b.
16. Your patient has a higher than normal blood sugar with an internal hemorrhage within the cranium. You would be best to administer and repeat the blood sugar in 15 minutes.
    A) 0.5 amp of D50W slow IVP.
    B) One amp of D50W IVP.
    C) Normal saline TKVO.
    D) Normal saline 1000 ml bolus.
17. You assist your partner in starting a second peripheral IV line for a backup emergency medication route. You note the BP is now 230/145 with a heart rate of 38 bpm. You elect to and then reassess the VS.
    A) Sedate the patient for intubation.
    B) Provide narcotics to help decrease the BP.
    C) Hyperoxygenation of the patient prior to intubation.
    D) Restrict IV fluids.
    E) All of the above.
18. You elect to intubate this patient as his airway is not protected. His GCS remains at 3/15. What would be the most appropriate medications prior to intubation?
    A) Lidocaine 1 to 1.5 mg/kg slow IVP 2 to 3 minutes prior to intubation.
    B) Versed 2.5 to 5 mg IVP prn.
    C) Fentanyl 1 to 3 mcg/kg slow IVP.
    D) b and c only.
    E) All of the above.
19. Your next medication that can be utilized after you have secured the endotracheal tube would be for this patient who continues to be hypertensive.
    A) Anectine 100 mg IVP.
    B) Versed 2.5 mg repeated q 5 to 10 minutes.
    C) Fentanyl 25 to 50 mcg slow IVP q 5 to 10 minutes.
    D) b and c.
    E) All of the above.
20. When you recheck the blood sugar to find it at 4.4 mmol/l You would next administer:
    A) 0.5 ampule of D50W slow IVP.
    B) One ampule of D50W IVP.
    C) 2000 ml of Ringers lactate.
    D) D5W 1000 ml.
    E) None of the above.
21. You have intubated the patient and you are just about ready to do a portable chest X-ray to confirm tube placement. The next therapy for this patient would be to administer:
    A) Insert an oral gastric tube.
    B) Insert a foley catheter.
    C) Perform a 12 lead.
    D) a and c.
    E) All of the above.
22. Your patient’s BP continues to be elevated after intubation and additional sedation at 230/134. Your next medication could be:
    A) Labetalol 5 to 10 mg slow IVP repeated as well as double the dosage every 10 minutes prn to a maximum of 150 to 300 mg in 24 hours.
    B) Midazolam (Versed) 2.5 to 5 mg slow IVP every 15 to 30 minutes.
    C) Fentanyl 25 to 50 mcg slow IVP every 15 to 30 minutes.
    D) Atropine 1 mg slow IVP.
    E) a, b and c only.
    F) All of the above.
23. The patient’s SpO2 rapidly deteriorates just prior to the medevac. You would immediately assess for D.O.P.E., which stands for:
    A) Displacement, Obstruction, Pneumonia and Equipment failure or Extubation.
    B) Displacement, Obstruction, Pneumothorax and Equipment failure or Extubation.
    C) Defibrillation, Obstruction, Partial extubation and Extubation.
    D) Displacement, Operator error, Pneumonia and Equipment failure.
24. The medevac crew initiates a Mannitol 20 per cent drip for transport. You know normal loading dose of Mannitol is slowly infused IV in a mini-bag over 30 minutes with careful monitoring of BP and pulse rates.
    A) 1 to 2 grams/kg.
    B) 10 gram bolus.
    C) 10 grams over 1 hour.
    D) 2.5 to 5.0 mg.
    E) All of the above.
25. On departure the patient’s BP drops to 120/ 94 prior to transport. The heart rate is now 64 bpm. The patient’s chance of survival would be best determined by:
    A) If there was a blown pupil then the chances are dismal.
    B) The patient was not hypoxic for longer then 4 to 6 minutes.
    C) The neurosurgeon and neuroradiologist can find a way to evacuate the blood from the subachachoid spaces to return the brain to its normal location.
    D) The intracranial pressures return to normal and maintain a normal level without inotropes.
    E) All of the above.