Quiz 12

It is a mild June evening in the lively nightclub area of Toronto. You are responding to a classy nightclub for a 34-year-old male with chest pain on a Saturday night at 2300 hours. .

Your partner is a primary care paramedic (PCP) with two years experience. You are an advanced care paramedic (ACP) with five years experience. You reach over and hit the siren as your unit leaves the base. .

After a five-minute response time, a bouncer leads you and your partner to a staffroom. Your patient is lying on a couch looking pale and anxious. He is a thin, well-dressed man in the company of a female friend. As you approach, he inquires if the city police have been called as well. .

The patient appears to be alert and orientated with a GCS of 15/15. He complains of retrosternal chest pain which he grades at 9/10. He has fast, pressured speech and muscle twitches. He admits to being high on cocaine. The patient is irritable and impatient, demanding that you give him something for his pain. He also complains of blurred vision and nausea. You call for backup and begin your primary assessment and BLS treatments. .

Your initial vital signs are as follows:
• Temperature of 37.7 C
• Respiratory rate of 32/minute
• Sp02 is 95 per cent on room air
• Pulse is 134/minute
• Blood pressure is 158/110
• Blood sugars 6.4 mmol/l
• Cardiac monitor is sinus tachycardia with no ectopy

SAMPLE Hx is as follows:
• Symptoms: chest pain
• Allergies: penicillin
• Medications: none
• Past Hx: appendectomy 15 years ago
• Last Meal, Last Medications: last meal was at 19:00 hours
• Events preceding EMS being called: habitual cocaine user, snorted cocaine 30 minutes ago

About the Authors.

Dale M. Bayliss is an experienced Paramedic and Registered Nurse living in Camrose, Alta. Dale has been an instructor with the University of Alberta, Augustana Faculty’s Paramedic Program for six years. He has been instructing EMR and EMT-A programs over the last eight years. He also works part time as an Emergency Nurse at the University of Alberta Hospital. In his spare time Dale works as an Advanced Care Paramedic for Peace Hills EMS in Wetaskiwin, Alta., and Beaver EMS in Tofield, Alta. He currently holds an ACLS, PALS and Advanced BTLS Instructor/ Coordinator status. Ruth Farrow is a 2002 graduate of the University of Alberta, Augustana Faculty’s Paramedic Program and lives in Cold Lake, Alta. She also has 10 years of experience as a medical laboratory technologist. Ruth currently is a Board Director for the Alberta College of Paramedics.

1. What dangers are involved with this call?
   A) Unpredictable behavior.
   B) Sharps in pockets of clothing.
   C) Possible blood-borne viruses such as the hepatitis viruses.
   D) All of the above.
2. According to Steve Walton’s excellent handbooks on street drugs called “Get the Dope on Dope,” which of these tactics is not a safety tip for working with drug users?
   A) Speak loudly right off the bat to show the individual that you are clearly the authority and in control of the situation.
   B) Be aware of items in the environment which can become “weapons of opportunity.”
   C) Keep your hands visible to the drug user.
   D) Keep the lighting dim, as long as you can still see clearly.
3. Which of the following is not a street name for cocaine?
   A) Blow.
   B) Coke.
   C) Horse.
   D) White.
4. Which of the following is not a benefit of IV therapy?
   A) Treatment of dehydration
   B) Treatment of hypovolemia.
   C) A route for administering ASA.
   D) Blood transfusion route.
5. What equipment would you immediately take into the establishment?
   A) AED/cardiac monitor and portable oxygen.
   B) Spine board and straps.
   C) Handbook of drug paraphernalia and traction splint.
   D) AED/cardiac monitor and cervical collars.
6. The cardiac monitor is applied and you see a sinus tachycardia at a rate of 134 beats per minute. The most likely cause of this fast rhythm is:
   A) Cocaine.
   B) Anxiety.
   C) Pain.
   D) All of the above.
7. For any overdose or poisoning, what information should we determine by applying the cardiac monitor?
   A) The width of the QRS.
   B) The heart rate and primary pacemaker.
   C) Ectopic beats.
   D) All of the above.
8. Fluid therapy indicated for this patient in the prehospital care setting would be:
   A) Normal saline TKO.
   B) Ringers lactate 200 ml/hour.
   C) 1 ampoule of 50 per cent dextrose.
   D) 1000 ml 2/3–1/3.
9. The normal respiratory rate for this adult patient would be:
   A) 10–14 per minute.
   B) 12–24 per minute.
   C) 16–30 per minute.
   D) 20–32 per minute.
10. The initial SpO2 was 95 per cent. This can be interpreted as:
    A) The blood contains 5 per cent carbon monoxide.
    B) A chronic lung disease such as asthma.
    C) A normal, expected value for an adult.
    D) A sign of a 5 per cent decrease in lung function.
11. The patient rapidly goes unconscious in front of you after you get him in the ambulance. Your next step is to:
    A) Immediately apply the AED.
    B) Check if the patient is breathing and has a pulse.
    C) Start chest compressions.
    D) Charge the AED in case the rhythm is ventricular fibrillation.
12. While using an AED, the paramedics should be:
    A) Assessing the pulse with CPR.
    B) Taking vital signs.
    C) Comforting the bystanders.
    D) Standing clear of the patient.
13. During CPR, this patient’s airway should be managed using:
    A) An oropharyngeal airway and bag valve mask with ventilations at 16 per minute.
    B) A chin lift is adequate because the tongue is blocking the airway.
    C) Mouth-to-mouth rescue breathing at 16 per minute.
    D) Two nasopharyngeal airways and bag valve mask with ventilations at 32 per minute.
14. When performing CPR on an adult, the ratio of ventilations (with a bag valve mask) to chest compressions should be:
    A) 1:5.
    B) Unsynchronized.
    C) 2:15.
    D) 1:2.
15. During a cardiac arrest, the first attempts at intravenous lines could be done at the:
    A) Antecubetal area of the arm.
    B) Saphenous vein of the leg.
    C) Carotid vein in the neck.
    D) All of the above.
16. During a cardiac arrest, the GCS will be:
    A) 1.
    B) 3.
    C) 0.
    D) Depends on pupillary reaction.
17. The following is true of ventricular fibrillation:
    A) The amplitude of the electrical activity as seen on the monitor will decrease as minutes pass, leading to asystole.
    B) The chance of successful defibrillation and restoration of a pulse will decrease as minutes pass.
    C) The patient in ventricular fibrillation will always be pulseless.
    D) All of the above.
18. The second shock results in the return of an organized rhythm on the monitor. Your next step is to:
    A) Assess the airway and carotid pulse.
    B) Give an IV bolus of 20 ml/kg of normal saline if the blood pressure is low.
    C) Stop CPR and put the patient in the recovery position.
    D) All of the above.
19. We know from ACLS current standards that a witnessed cardiac arrest should have the following immediate priority by advanced care providers:
    A) Airway management.
    B) Immediately assess for and treat ventricular fibrillation.
    C) Determine the likely cause.
    D) Determine the past medical history.
20. The patient’s pulse has returned after defibrillation; no drugs have been given and CPR was not performed. The BP returns to 92/68, a pulse of 152, respirations 8 and remains unconscious. Airway management may involve:
    A) An oropharyngeal airway and bag-valve-mask with ventilations at 16 per minute.
    B) Intubation with or without the administration of an RSS drug such as midazolam.
    C) Oral suctioning or deep tracheal suctioning as needed.
    D) All of the above.
21. The first-line drugs to consider in the EMS setting for cocaine-related chest pain are typically:
    A) Valium or Versed, ASA, nitroglycerin, morphine.
    B) Beta blockers.
    C) Clopidogrel (Plavix).
    D) All of the above.
22. When looking at the 12-lead ECG, the locations of myocardial injury are indicated by what changes?
    A) ST segment elevation.
    B) Wide QRS.
    C) PR interval depression.
    D) Prolonged QT interval.
23. The standard 12-lead ECG does not provide much information about the following area of the heart:
    A) Anterior.
    B) Septal.
    C) Right ventricle.
    D) Lateral.
24. The patient describes his chest pain as the following (based on PQRST): Started after cocaine was snorted, feels like squeezing and pressure inside the chest, radiates to his jaw, graded as 9/10 on a pain scale with 10/10 being the worst pain he’s ever experienced, symptoms began 15 minutes ago. The pathophysiology of this event could be:
    A) A normal side-effect of cocaine due to tachycardia.
    B) Coronary artery vasospasm causing a myocardial infarction.
    C) The person is hallucinating; the chest pain is in his mind.
    D) Related to anxiety and is not life threatening.
25. Of the following drugs, which is not an alternative to ASA for its anti-platelet properties?
    A) Clopidogrel.
    B) Ticlopidine.
    C) Streptokinase.
    D) Dipyridamole.