Quiz 10

The day has been rather cool, with the fall season just around the corner. You and your partner have just finished reviewing the new changes from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Heart and Stroke coming this fall. The changes are considered to be global in all areas of care within the Basic Life Support Course, ACLS, PALS and NALS courses. You see that “harder and faster” chest compressions are back in this round of changes. You have been an Advanced Care Paramedic for four years and a Primary Care Paramedic for two years previously. Your partner has been a Primary Care Paramedic for three years.

Your radio comes to life with the voice of your dispatcher saying “Medic One, ALS Call – Priority Response” to a rural location for a two vehicle accident. Apparently a quad has been hit by a truck at an uncontrolled intersection. Your response time will be approximately 14 minutes to the scene, and 35 minutes to the nearest local hospital. There is no rotary air support available and there are no other units available to assist for this call. Your only backup is the local volunteer fire department, which has several members trained at the EMR level who have been dispatched along with the local police. Your receiving hospital is a level two trauma centre and they will accept you with no delays.

En route, you are advised that there are two patients. The driver of the quad and a passenger are injured. The driver of the truck was uninjured. Apparently the truck was traveling at about 70 – 80 km/hr when it struck the quad broad side. Both occupants of the quad were ejected. The caller states they are both conscious and they both appear to have multiple injuries.

As you and your partner approach the scene and park in a safe zone you see multiple bystanders along with the police controlling the scene. You then see the patients, who are lying a short distance (approximately 12 to 15 metres) away from the crash scene. Bystanders have applied blankets and are comforting the patients until your arrival. You assume care for the first patient, who looks to be a pediatric patient, and your partner heads to the second patient, who appears to be an adult. You note both occupants have helmets on. The police officer on scene is controlling the scene and has asked for additional members to assist him as well who will arrive shortly. The fire department is just arriving as well and will assess the truck and quad for hazards. They will help you with packaging and transport by providing a driver if required if you both are needed to care for patients during transport.

You and your partner perform a primary and rapid survey and work as fast as possible to assess, stabilize and transport this patient to the nearest hospital. You will need to transport both patients in your unit. The initial examination reveals the adult patient likely has significant injuries with the pediatric patient having more minor injuries. Both patients have potentially serious injures but are considerably stable at this time.

You obtain baseline vital signs on patient one. (Sarah, who is a six-year-old female)

Sarah’s primary survey and rapid survey reveal a tender abdomen, an injury to left elbow, with decreased pulses below the injury site. You obtain baseline vital signs on patient two. (Amanda, who is a 21-year-old female)

Amanda’s primary survey and rapid survey reveal a sore left chest with bruising and likely a few rib fractures, left-sided flank pain, left femur compound fracture, left collie’s wrist fracture and weakness to lower extremities with lumbar back pain.

References.

Sanders, M (2001) Mosby’s Paramedic Textbook 2nd Edition Revised, Mosby (A Harcourt Health Sciences Company)

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. You have two patients who both need to be transported. You will need to utilize the equipment resources and personnel present to perform the stabilization and transportation safely and efficiently. What findings at this scene would warrant a load and go on either patient?
   A) Airway compromise.
   B) Ineffective breathing patterns.
   C) Uncontrolled bleeding or internal bleeding within the thoracic, intra-abdominal or intra-peritoneal space.
   D) All of the above.
2. When we review the mechanism of injury (MOI) we recognize the quad ATV and the truck both can cause significant injuries. When you combine the vehicles’ collisions at different speeds you increase the likelihood of increased injures. The truck struck the quad on the left side. What types of injures are common with this type of force when we consider the laws of physics in relationship to mass, speed and the rate of deceleration that can occur in this type of incident?
   A) Fractures of any bone or multiple bones, especially to the patients’ left sides.
   B) Significant facial and intracranial bleeding.
   C) Tension pneumothorax, simple pneumothorax, lacerated liver or spleen, displaced cervical fractures, and intra-abdominal or intra-thoracic trauma.
   D) All of the above.
3. The driver of the quad, Amanda, hit the truck at significantly higher speeds. The passenger, Sarah, was most likely protected from significant injury by Amanda’s body. What is a very good indicator that significant internal or intracranial injury has occurred despite proper protective clothing?
   A) Unconscious immediately after the event, which is commonly witnessed by bystanders or family members.
   B) Significantly low BP on your arrival or within minutes after the incident.
   C) Agitation or restlessness shortly or after the event.
   D) All of the above.
4. How many breaths per minute are considered normal breathing for Sarah, who is the pediatric patient?
   A) 8 to 12.
   B) 12 to 24.
   C) 24 to 40.
   D) 40 to 50.
5. Both patients appear to be in some form of shock. Which of the following is a sign of adequate circulation and oxygenation?
   A) Skin color becomes pink and cap refill is less then 2 seconds.
   B) The chest rises and falls with normal ventilation.
   C) Distal pulses are strong and regular.
   D) All of the above.
6. You apply oxygen and you observe the patients’ ventilations to remain a proper depth and rate. Both patients appear to have some labored breathing. Adequate oxygenation for both patients would be to:
   A) Apply non-rebreather mask (NRB) and ensure the reservoir fills adequately during the end of the inspiration cycle.
   B) Insert a nasal pharyngeal airway (NPA).
   C) Force in an oral airway and then apply the BVM.
   D) A and B.
7. After completing your primary survey you must always consider the organs that can be involved or injured with this type of accident. Which of the following organ(s) show significant early changes in the hypovolemic pediatric or adult patient?
   A) Liver.
   B) Brain.
   C) Stomach.
   D) All of the above.
8. What would be the best method to assess the posterior on both patients prior to loading them into the ambulance?
   A) You log roll the patients carefully with at least three people. One rescuer to establish C-spine control, one rescuer that protects the alignment of the back and abdomen, and one rescuer to hold the legs with manual pressure to keep the fractures from being manipulated. Ideally, four rescuers are optimal.
   B) Using a scoop stretcher device you can lift the patient onto a spine board.
   C) Always transport the patient in the position found.
   D) Log roll the patient into the recovery position.
   E) A and B.
9. While assessing Amanda you suspect a left compound femur fracture as well as a possible hip or knee injury. Select the method to splint the mid-femur fracture on Amanda?
   A) Applying a bilateral Sager splint.
   B) Applying MAST pants after applying gentle inline traction to only 30 pounds pressure.
   C) Padding adequately between the legs and immobilizing them both securely with straps/restraints with a figure 8 bandage to keep the legs together on the spine board. Using the right leg for a splint to the left leg is a great start on the scene to stabilize the fractured femur. A proper traction splint can be applied en route if time permits.
   D) All of the above.
10. The left femur fracture on Amanda appears to be a compound fracture. The best dressing to cover both open fractures is by using:
    A) Dry dressings.
    B) Moist saline soaked dressings with a dry wrap around the legs to hold the initial dressings in place. Ensure blood loss is controlled as well by any means possible.
    C) Apply antibiotic ointment and then an adhesive dressing.
    D) No dressing is required.
11. Sarah does not have any obvious severe or life-threatening injuries but she has guarded respirations and a tender left abdomen. The most important step(s) to perform in treating this pediatric patient is to:
    A) Secure an airway and then provide high concentration of oxygen.
    B) Administer IV fluid with as many boluses to maintain distal pulses.
    C) Stabilize fractures and immobilize the complete spine throughout EMS care.
    D) B and C. only
    E) All of the above.
12. The most common sign of a significant thoracic or abdominal illness or injury is:
    A) Tachycardia with hypotension.
    B) Abdominal distention.
    C) Tachypnea.
    D) All of the above.
13. Amanda is showing signs of:
    A) Hypovolemia
    B) Spinal Shock
    C) Septic Shock
    D) A and B. only.
    E) All of the above.
14. You have two patients on this scene that are both considered “load and go.” The ultimate desired scene time for any load and go would be:
    A) Platinum 10 minutes.
    B) Royal 20 minutes.
    C) Half hour or 30 minutes.
    D) Golden hour or 60 minutes.
15. A parent has arrived on scene and has requested to accompany their daughters in the ambulance. What is the appropriate response at this time with the patient in the present condition?
    A) It would be best if they came with the police who have offered to assist as required.
    B) Allow the patient and parent to travel together as long as the parent is calm and is willing to do what you ask when requested.
    C) Ask the parent to ride up front with the driver as it is not appropriate for the parents to see the procedures and the child in transport.
    D) All of the above.
16. You decide to put Sarah on the portable cot and load her first. Amanda is loaded onto the main cot and then loaded in the unit. After loading the patients into the ambulance you should then:
    A) Reassess the traction or leg splint that is applied to Amanda’s left leg.
    B) Reassess the LOC, pulse and respirations of both patients.
    C) Check and record the Sp02 and the BP on both patients.
    D) All of the above.
17. Both patients could benefit from intravenous therapy and a fluid bolus is also beneficial to normalize intravascular volumes. For pediatric and adult patients who are in hypovolemic shock requiring IV resuscitation, the EMS staff should initially infuse of IV fluid.
    A) 10 ml/kg.
    B) 20 ml/kg.
    C) 2 litre boluses.
    D) 250 ml boluses.
18. During the transport you find Amanda has a BP that has responded to initial fluid bolus. The BP is now 84/42 with a pulse of 110 bpm. Your next actions would to administer:
    A) A second fluid bolus of 20 ml/kg.
    B) Increase the oxygen flow rate to the patient.
    C) Raise the head of the stretcher 8 – 10 degrees.
    D) Raise the feet up 30 degrees and put the patient in the shock position.
    E) A and D.
19. Following the IV bolus on Sarah you find her BP to be 108/66 and the pulse is down to 106 bpm. You would next elect to:
    A) Repeat the IV bolus.
    B) Reassess your interventions.
    C) Perform a secondary examination to assess for changes in the LOC, ABC or continued bleeding.
    D) Maintain the IV at a TKVO rate.
    E) B, C and D.
20. Sarah has a slightly angulated left elbow joint and is unable to straighten her left arm. You would be best to:
    A) Splint the arm in the position found.
    B) Elevate the extremity when it is splinted as much as possible.
    C) Apply an ice pack to the elbow joint area.
    D) All of the above.
21. Amanda has a blood sugar of 3.2 mmol/l You could now provide:
    A) D50W 1/2 ampule bolus
    B) D50W 1 ampule bolus
    C) 1000 ml bolus of D5W
    D) A and B only.
    E) B or C.
22. Essential pain analgesic for fractures and dislocations is provided to pediatric and adult patients by utilizing:
    A) Morphine 0.1 mg/kg (2.5 to 10 mg slowly).
    B) Fentanyl 0.1 mcg/kg (25 to 50 mcg slowly) .
    C) Valium 0.1 mg/kg.
    D) A and B only.
    E) B and C.
23. Essential sedation for significant fractures and dislocations is provided to pediatric and adult patients by utilizing:
    A) Midazolam (Versed) 0.1 mg/kg (2.5 to 5 mg slowly and repeat prn).
    B) Lorazepam (Ativan) 0.05 mg/kg (1 to 2 mg slowly and repeat prn).
    C) Diazepam (Valium) 0.1 mg/kg 0.1 mg/kg (2.5 to 5 mg slowly).
    D) A and B only.
    E) Any one of the above.
24. These patients both appear stable after leaving the scene. The ALS interventions en route could be performed as time permits. Amanda would benefit from a (an):
    A) 12 lead EKG.
    B) Insertion of a Foley catheter to assess renal output.
    C) Second IV site with a help lock or second line TKVO.
    D) All of the above.
25. You elect to administer a low dose of an analgesic/sedative to Amanda en route to the hospital after stabilizing her BP and the injuries are stabilized. What is the main purpose to administer the sedative medications as well?
    A) To enhance the effects of the narcotic.
    B) To provide additional sedation to help alleviate the traumatic memories of the painful transfers and of the whole event.
    C) To help prevent additional unwanted movement of the patient and keep the fracture from causing increased discomfort.
    D) All of the above.
26. In-hospital care for Amanda would include:
    A) Chest X-ray, CTL or cervical, thoracic and lumbar spines), left femur, left arm, pelvis.
    B) CT-scan of the head, chest and abdomen if possible.
    C) Draw and analyze the CBC, PT, INR lytes, blood sugar, creatinine, urea, CK and type and screen as well as a cross match of 4 to 6 units on arrival.
    D) Immediate surgical as well as orthopedic assessment or referral.
    E) All of the above.