Quiz 18

On a spring day in the late afternoon, you and your partner are dispatched to a lower class neighbourhood in an urban area for a 44-year-old male. The caller states that the man “isn’t talking and is sweating profusely.” You have been a paramedic (ACP) for one year and your partner has been an EMT (PCP) for four years.

On arrival, you find a modest home and a middle-aged couple answers the door. They point you towards the couch where your patient is sitting back with his eyes open, but he has a dysconjugate gaze. When you speak to the patient he responds only with incomprehensible sounds and does not obey commands. The female bystander states that she doesn’t know what is going on; the patient is her brother and he was just dropped off by two males. Apparently they had gone “to get some pills.” The male bystander gives a vague history of multiple pill ingestion from statements the two males gave when they dropped him off; he possibly took Tylenol #3s and muscle relaxants. He hands you an empty pill bottle found in the patient’s pocket with yesterday’s date and the label scratched off where the name of the drug would be. The DIN number is on the bottle, however. The woman states her brother is an alcoholic, but does not know if he has a drug habit. She doesn’t think he has allergies or has been prescribed any medications. He has had seizures in the past. There is no history of depression or psychiatric illness and the patient typically speaks normally.

The light is poor in the living room so you bring the patient over to the front porch area. The patient stands and walks when firmly lead. With difficulty, you manage to get him sitting in a chair and proceed with assessment and vital signs. The patient weighs about 180 pounds or 80 kilograms. He is diaphoretic and his limbs are stiff as if trying to resist you and your partner. Vocal sounds are still pressured and incomprehensible. The airway is clear with shallow, equal breath sounds. The cardiac monitor shows sinus tachycardia with a narrow QRS. The radial pulse is rapid, strong and regular. There are no signs of trauma or needle marks.

Vital Signs
• Temperature is 37.7°C
• Respirations are 18
• Pulse is 128 regular
• Blood pressure is 124/86
• SpO2 is 97% on room air
• Glucose is 5.6 mmol/L
• Pupils are 1 mm, equal and reactive

Basic Life Support Treatment

Oxygen via nasal cannula (or mask), vital signs and glucose checked, patient semi-fowlers on stretcher and loaded in ambulance, IV normal saline en route, cardiac monitor en route.

Advanced Life Support Treatment

Nasogastric tube and emptying of gastric contents, 50 grams of activated charcoal with sorbitol administered via NG tube, naloxone 2 mg IV, 100 mg thiamine IV, 12-lead ECG and haloperidol 5 mg IM.

The pupils dilated to about 2.5 mm after naloxone (Narcan). However, the patient became combative and was therefore restrained to the stretcher in a low fowlers position. About 30 minutes after naloxone administration, the patient still became very agitated when stimulated by activities such as oral suction. Haloperidol 5 mg IM was given en route due to the patient being combative.

Note:

This scenario is based on a real call, and the urine toxicology screen at the hospital showed the presence of cocaine, phencyclidine (PCP), narcotics and benzodiazepines. Furthermore, this patient had presented to the emergency department in a similar state on several previous occasions.

About The Authors.

Dale Bayliss is currently working full time as an Emergency Nurse at the University of Alberta and part time with Muskwachees Ambulance Authority. Dale is also an instructor for the Augustana University College's Paramedic Program in Camrose, Alberta. The Augustana program is a two year distance outreach program relying on the Internet and home study for delivery.

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. What findings at a medical scene would warrant a load-and-go and/or calling ALS backup?
   A) Airway compromise or ineffective breathing patterns.
   B) Hypotension or abnormal heart rhythms.
   C) New onset of confusion, disorientation, inability to speak or combativeness.
   D) All of the above.
2. We must think of the dispatch information en route to start to make a game plan of care required on scene. A 44-year-old male who is diaphoretic and showing signs of decreased mentation may be experiencing:
   A) A cardiac illness.
   B) A toxicological illness.
   C) A severe infection involving the central nervous system.
   D) Any of the above.
3. What is the expected heart rate for an adult patient?
   A) 40 to 60.
   B) 30 to 70.
   C) 60 to 100.
   D) 80 to 120.
4. This patient requires an IV access for emergency medication administration now and may need additional IV fluid in the near future. As we can tell the BP is stable and the HR is slightly tachycardic and this patient does not appear to need a lot of IV fluid initially. The rate of the normal saline IV should be:
   A) To keep the vein open (TKVO).
   B) Wide open.
   C) 500 mI per hour.
   D) A saline lock is ideal.
5. Why should this patient be put on a cardiac monitor?
   A) The portable SpO2 machine will not be accurate.
   B) Besides analyzing the basic rhythm, it is important to know if the QRS has widened in overdose patients.
   C) The patient is presenting with a myocardial infarction.
   D) To show your medical director that you have used all your assessment skills.
6. What are possible reasons that the patient is in sinus tachycardia from what you know so far?
   A) The patient could have taken a stimulant drug.
   B) The patient could be hypervolemic.
   C) The patient is compensating for hypoxemia.
   D) All of the above.
7. What mnemonic is useful to apply due to the decreased level of consciousness?
   A) CHAT.
   B) DOPE.
   C) PQRST.
   D) AEIOU-TIPS.
8. The patient responds to painful stimuli by withdrawing. His rating on the Glasgow Coma Scale is:
   A) 10.
   B) 11.
   C) 12.
   D) 13.
9. Which of the following is NOT true of blood glucose testing?
   A) Most glucose metres must be calibrated to the lot number of the test strips in use.
   B) You can use capillary blood from the side of the fingertip of adults.
   C) You can use capillary blood from the side of a newborn’s heel.
   D) You can use blood that has dripped onto the floor for testing.
10. Which patients should have their blood glucose tested?
    A) Undiagnosed abdomen pain.
    B) Third trimester pregnancy with no prenatal care.
    C) Patients with a decreased level of consciousness.
    D) All of the above.
11. As long as this patient does not need to be restrained or ventilated, he is best transported:
    A) Prone, in case of vomiting.
    B) High fowlers.
    C) Lying on either side with face turned slightly down so that oral secretions drain out of the mouth.
    D) Sitting up with feet dangling over the stretcher.
12. The following symptoms of recent acetaminophen overdose may be seen in prehospital care:
    A) Nausea and vomiting.
    B) Decreased level of consciousness.
    C) Intoxicated state similar to alcohol ingestion.
    D) Hyperventilation.
13. At seven days post-ingestion of a large amount of acetaminophen with a lack of early treatment, the patient may have the following life-threatening condition:
    A) Respiratory failure.
    B) Liver failure.
    C) Kidney failure.
    D) Heart failure.
14. What other relevant history information should be gathered at the scene of a suspected overdose?
    A) Presence of drug paraphernalia.
    B) Empty alcohol bottles.
    C) More information regarding the patient’s lifestyle and recent activities if possible.
    D) All of the above.
15. Infection control precautions such as aseptic techniques are particularly important for invasive procedures in which of the following groups of patients?
    A) Diabetics.
    B) Cancer patients.
    C) Alcoholics and patients with other addictions.
    D) All of the above.
16. Why didn’t the patient show the classic triad of narcotic overdose (respiratory depression, coma, pinpoint pupils)?
    A) Tylenol #3 contains codeine, not heroin.
    B) He was also on stimulants such as cocaine and PCP.
    C) Ingestion of T3s was too recent.
    D) The patient must not have taken narcotics.
17. Would it be acceptable for the paramedic to withhold giving Narcan in prehospital care?
    A) No, brain cells have been saved by giving Narcan.
    B) No, oxygenation was inadequate prior to giving Narcan.
    C) Yes, giving Narcan can cause the patient to become combative and create a dangerous situation.
    D) Yes, the patient had a normal blood pressure.
18. If the patient required dextrose for hypoglycemia, what other drug would be indicated?
    A) Vitamin K.
    B) Glucagon.
    C) Flumazenil.
    D) Thiamine.
19. The most important treatment for toxicological emergencies is:
    A) Charcoal PO or NG.
    B) Managing the airway, breathing and circulation.
    C) Inducing emesis.
    D) Gastric lavage.
20. Which of the following is NOT true of activated charcoal with sorbitol:
    A) “Activated” means that it meets the standard for adsorbents.
    B) Its benefit is questionable when administration of charcoal is over two hours from ingestion of the substance.
    C) Often beneficial in TCA overdose because of the delayed gastric emptying caused by TCAs (anti-cholinergic effect).
    D) The lungs can easily recover from aspiration of charcoal.
21. Which of the following is NOT true of flumazenil?
    A) Commonly used in ground ambulance prehospital care.
    B) Not administered for mixed ingestions.
    C) Not to be administered to habitual benzodiazepine users.
    D) Danger of inducing seizures when the patient has taken both a benzodiazepine and a TCA in excess.
22. Which of the following can help identify the drug when overdose or poisoning is suspected?
    A) The drug index number (DIN) on the prescribed medication can help identify the medication.
    B) Drug paraphernalia on the scene.
    C) Match the patient’s toxidrome symptoms and peripheral nervous system physiology (sympathomimetic effects, cholinergic effects, etc) with drug classes.
    D) All of the above.
23. Why would the hospital team performing a urine drug screen?
    A) To investigate why a patient is in a comatose state.
    B) To find out if the patient has participated in illegal activity for the local police to lay criminal charges.
    C) Because a labeled empty medication bottle was found next to the patient with his name on it.
    D) All of the above.
24. What is the classic triad of Wernicke’s Encephalopathy?
    A) Decreased level of consciousness, hypoglycemia, muscle rigidity.
    B) Facial ticks, ocular palsy, hyperthermia.
    C) Global confusion, nystagmus or dysconjugate gaze, ataxia.
    D) Cardiac arrhythmias, muscle tremors, nystagmus.
25. If the attendant opted to perform a medication-facilitated intubation, the major advantage and disadvantage in this patient would be:
    A) Advantage: decreased risk of aspiration of charcoal. Disadvantage: administering more drugs when the type of ingestion is unknown might be detrimental to the patient.
    B) Advantage: V/Q mismatch. Disadvantage: oxygen toxicity.
    C) Advantage: mechanical ventilation is a more effective and natural ventilation than the patient’s own breathing. Disadvantage: risk of aspiration pneumonia.
    D) Advantage: the patient can be hypoventilated to reverse metabolic acidosis. Disadvantage: patient cannot provide any more history of the ingestion.