Quiz 20

The day has been great with no signs of any more snow in the forecast for at least another week, if you can believe the local weather reports. There are two units on today, with one BLS unit on first-up, and the second unit is staffed at an ALS level. New Year’s Dinner awaits you in just a few more hours. You are working in a rural setting with no other backup units available unless you can wait for at least 45 minutes.

Your pager tones off another call for the BLS unit. They are being dispatched to a fall from a second story apartment down a staircase, possibly an assault. Your patient is semi-conscious at the time of the 911 call. The caller is a neighbor who has called the local police as well. You are also being dispatched to assist the first crew due to the unusual nature of the call.

Your partner is a Primary Care Paramedic (PCP) with five years experience. You are an Advanced Care Paramedic (ACP) with three years experience. Your response time is going to be six minutes today, several minutes after the BLS unit. You apply your PPE as you get closer to the scene.

The call sounds like an assault that has likely been very violent in nature. The initial crew will have to determine the mechanism of injury as they enter the scene, which has been secured by the police. The BLS unit arrives on scene to find a 19-year-old female patient who appears to have been assaulted and is now having a grand mal seizure on a cement pad at the bottom of an open staircase. The patient weighs approximately 55 kg. The BLS unit updates you on the initial primary examination results. You are about 30 seconds away and the golden hour is ticking away with so little time to spare.

Your initial assessment reveals:
• Temperature of 35.9° C
• Respiratory rate of 10 and irregular
• Pulse is 140 minute
• SpO2 is 75 per cent on room air
• BP is 160/114 after the 1st seizure
• Blood sugars are 2.6 mmoL/l
• Cardiac monitor reveals a sinus tachycardia with no PVCs or ectopy noted

SAMPLE Hx is as follows:
• Symptoms: Active seizure, lacerations on the face and head.
• Allergies: Unknown with no medic alert present on your primary examination
• Medications: Unknown.
• Past Hx: Police state the patient has been assaulted in the past by the alleged assailant, who is now in custody.
• Last meal, last medications: Unknown
• Events preceding EMS being called: Police called for an assault in progress where the patient was assaulted and suffered an unwitnessed fall down a flight of stairs during or after the assault. She was found at the bottom of the stairs by the first police officer on scene. To add to the situation a baseball bat was removed from the assailant in the second floor apartment.

You now suspect this patient is suffering from a head injury and may very well have multiple other internal injuries due to the assault and the fall down a flight of stairs.

About The Author.

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. Your BLS unit walks up to the residence with no visible hazards. The police are on scene with one male assailant in custody. They immediately see the patient lying on her back having a grand mal seizure at the bottom of approximately 12 stairs. They would immediately:
   A) Assume C-spine precautions and delegate their partner to take cervical spinal precautions.
   B) Assess the airway for an obstruction.
   C) Suction the airway.
   D) Assess the rate and quality of the respirations.
   E) a and c only.
   F) All of the above.
2. Upon your arrival your partner is obtaining additional history from the BLS crew and the police officers. The patient has multiple lacerations and bruises around her head and face. You witness the patient stop the seizure activity. Your next action would be to:
   A) Attempt to insert an OPA or nasal pharyngeal airway.
   B) Assess the airway and suction the mouth and nares prn.
   C) Assess the respiratory effort and apply oxygen by NRB 10-15 lpm.
   D) Apply oxygen by nasal prongs at 3 lpm.
   E) b and d.
   F) a, b and c.
3. The pulse oxygen saturation monitor is applied and the initial SpO2 is 75 per cent on room air. A possible cause of this fast heart rhythm and low SpO2 would be:
   A) Hypoxia.
   B) Prolonged seizures.
   C) Airway obstruction.
   D) Apnea.
   E) a and c only.
   F) All of the above.
4. You auscultate the chest and hear adventitious sounds—course crackles to the right lung fields. You would expect the crackles to be coming from a (an):
   A) Aspiration of blood or stomach contents.
   B) Asthma.
   C) Croup.
   D) b and c.
   E) All of the above.
5. The SpO2 improves to 90 per cent after you apply oxygen. Your next action would be to:
   A) Assess the respiratory rate and expose the chest to visualize the tidal volume as the patient attempts to breathe.
   B) Assist the respirations with a BVM with high flow oxygen 12 per minute if tolerated.
   C) Monitor the respiratory effort and reassess in 5 minutes.
   D) a and b.
   E) All of the above.
6. 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.
7. What additional past medical information would be helpful in this patient with regards to the current seizure episode?
   A) Past seizure episodes.
   B) Any past medications used for seizures.
   C) Past medication compliance.
   D) Any allergies to medications.
   E) All of the above.
8. The radial pulse is strong and bounding in this patient initially. A strong and bounding pulse can indicate
   A) Hypotension.
   B) A closed head injury.
   C) Increased intracranial pressure (ICP).
   D) Hypovolemia.
   E) b and c.
9. You elect to place the patient on a spine board and transport your patient to the ambulance immediately following a primary exam as the lighting is not the best in the current location. The best position to transport this patient would be in the ___________ position.
   A) Supine.
   B) Prone.
   C) Left lateral.
   D) Feet elevated in a head down position.
10. After you place your patient in the unit you apply your cardiac monitor and SpO2 monitor for transport. You know that persistent hypoxia can be from a (an):
    A) Foreign body obstruction in the right main bronchi.
    B) Upper airway obstruction.
    C) Aspiration pneumonia.
    D) Spontaneous pneumothorax.
    E) All of the above.
11. Your patient has bleeding from the nares and from the right ear. Your patient also has bruising and swelling to both mastoid process regions. You notice the blood also has a positive halo sign. This would indicate:
    A) Spinal trauma.
    B) Minor head injury.
    C) A significant head injury.
    D) Decreased ICP.
12. Prolonged hypoxia to the brain may cause:
    A) Additional seizures.
    B) Prolonged unconsciousness.
    C) Cerebral edema.
    D) Inadequate ventilations and blood pH changes.
    E) All of the above.
13. The patient has a temperature of 35.9° 8Celsius. You know that hypothermic trauma patients should be:
    A) Kept cold due to the possible closed head injury.
    B) Warmed with passive warming.
    C) Maintain a normal body temperature.
    D) Cooled to 32° 8C.
    E) b and c.
14. You have moved the patient to the unit and the patient has been secured in your controlled environment. You would first like to reassess the:
    A) ABC, and LOC for changes.
    B) Cardiac monitor, SpO2 monitor and the vital signs.
    C) Blood sugar and core temperature.
    D) a and b only.
    E) All of the above.
15. The patient weighs approximately 55 kg. The normal tidal volume for this patient should she need to be ventilated with a BVM would be ___________________along with supplemental oxygen.
    A) 2 – 4 ml/kg.
    B) 15 – 20 ml/kg.
    C) 7.5 – 10 ml/kg.
    D) 10 – 15 ml/kg.
16. This patient’s condition requires 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 ampoule.
    D) 2/3 – 1/3 1,000 ml.
    E) a or b.
17. Your patient has a low blood sugar with a suspected head injury. You would be best to administer _________________________ and repeat the blood sugar test in 3 to 5 minutes.
    A) 1/2 amp of D50W Slow IVP.
    B) One amp of D50W IVP.
    C) A bolus of 2,000 ml of ringers lactate.
    D) D5W 1000 ml slowly.
18. You assist your partner in starting a second peripheral IV line for a backup emergency medication route. You note the BP is now 92/40 with a heart rate of 150 bpm. You elect to__________________ and then reassess the vital signs.
    A) Initiate a 250-ml bolus and maintain the IV at 100 ml per hour en route.
    B) Administer a 1,000 ml bolus.
    C) Administer an IV bolus of 20 ml/kg.
    D) All of the above.
19. You elect to intubate this patient as her airway is not protected. Her GCS remains at 3/15. The BP has increased to 120/56 and the heart rate is now 128 bpm. What would be the most appropriate medications prior to intubation in this patient, who has a clenched jaw at this time?
    A) Lidocaine 1 – 1.5 mg/kg.
    B) Versed 2.5 mg repeated x 2 prn.
    C) Fentanyl 1 – 3 mcg/kg slow IVP.
    D) b and c only.
    E) All of the above.
20. Your next medication that can be utilized after you have secured the endotracheal tube would be ____________________ for a patient who starts to buck on the tube.
    A) Anectine 100 mg IVP.
    B) Versed 2.5 mg repeated q 5-10 minutes.
    C) Fentanyl 25 – 50 mcg slow IVP q 5-10 minutes.
    D) b and c.
    E) All of the above.
21. Immediately you recheck the blood sugar to find it at 3.1 mmoL/l. You would next administer:
    A) 1/2 ampoule of D50W slow IVP.
    B) One ampoule of D50W IVP.
    C) 2,000 ml of Ringer’s lactate.
    D) D5W 1,000 ml.
22. You are five minutes from the local emergency unit when your patient begins to have another grand mal seizure. The next therapy for this patient would be to administer:
    A) Ativan 1 – 2 mg IV.
    B) Anectine 100 mg IVP.
    C) Versed 2.5 mg repeated q 3 – 5 minutes.
    D) Valium 2.5 – 5.0 mg IV.
    E) a, b or d.
    F) a, c or d.
    G) All of the above.
23. Your patient continues to seize for the remainder of the transport to emergency unit despite your medication therapy. The patient then would be classified as having:
    A) Status epilepticus.
    B) Partial seizures.
    C) Jacksonian seizures.
    D) Focal seizures.
24. The patient’s SpO2 rapidly deteriorates just after the seizure has ended. 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.
25. Upon arrival the emergency physician orders a loading dose of Dilantin. You know normal loading dose of Dilantin is slow IV in a mini bag over 30 - 60 minutes.
    A) 500 - 1000 mg.
    B) 25 mg.
    C) 10 grams.
    D) 2.5 – 5.0 mg.
    E) All of the above.
26. Pneumothorax induced by trauma will require the use of the following procedures in the prehospital care setting:
    A) Aggressive ventilations with a BVM with the pop-off valve locked in the closed position.
    B) Nasal tracheal intubation as the patient has ineffective respirations with a tension pneumothorax.
    C) Auscultation, percussion and decompressing when dullness is located to the affected side.
    D) Auscultation, percussion and decompressing when hyper-resonance is present on the affected side.
27. You notice the patient’s SpO2 staying around 85 per cent while you assist the ventilations with your BVM. You could now apply________as well as administering ______________to your BVM circuit.
    A) PEEP at 5-10 mmHg.
    B) Sellick manoeuvre.
    C) Ventolin 2.5 – 5.0 mg.
    D) Atrovent 250 – 500 mcg.
    E) A, C, and D only.
    F) All of the above.
28. The seizure stops shortly after arriving in the trauma unit. You give a verbal report to the ER staff present as you roll in the room. Your next action is to reassess the:
    A) ABCs and LOC.
    B) Vital signs, cardiac monitor, SpO2.
    C) Interventions.
    D) a and b only.
    E) All of the above.