Quiz 24

It is a cool winter day and the days are getting longer every single day. You are working in a mid-sized city of approximately 20,000 people. Your ALS ambulance is staffed with one Primary Care Paramedic (PCP) and one Advanced Care Paramedic (ACP) today. You have one ALS backup unit on day shift as well. You are dispatched for a two-vehicle collision approximately 30 kilometres away. The 9-1-1 dispatcher states a semi tractor trailer has hit a car head on at highway speeds. You are told that the semi has also rolled at least one time and that you have a minimum of two patients trapped.

Your dispatcher automatically dispatches the closest volunteer fire rescue service and the local RCMP to the collision site. Your backup unit is dispatched, and the local air ambulance service calls you a Medevac chopper immediately as well. You also request your local fire department to send additional units to help with extrication. You start responding and it will take you approximately 20 minutes to reach the scene. Upon your arrival, the highway has been closed to all traffic by the fire department and the police. When you arrive on scene you find a bystander who tells you they saw the car lose control and swerve into the path of the semi. The semi tried to avoid the car but clipped the left front of the vehicle and basically ran over the car up to the car driver’s door.

Fire rescue arrives and it takes approximately 20 minutes to extricate the patient. The patient is a 22-year-old male with no passengers in his vehicle. While the firefighters are working on the extrication, you have minimal patient care contact. You have completed a primary exam and part of a secondary exam. You notice his left leg has basically been amputated at about the mid femur region. He has been unresponsive and unconscious throughout the event. You had weak radial pulses initially but only have weak carotid pulses now as the patient has been freed from the car. Others are extricating the driver of the semi tractor but his injures are minor at this time.

Once the patient access is available, you make the decision to perform a rapid extrication. He is removed from the vehicle, placed on a long spine board, and moved to your ambulance on scene. His initial vital signs are:

• HR 140

• RR 7 bpm

• BP 60/26

• SpO2 not registering

• BGL 8.3 mmol/l

• Cardiac monitor — sinus tachycardia

• Temperature of 35.5°deg;C

On your initial exam, you find the casualty is unconscious, has a flail chest and has the injury to the left leg. There is blood oozing to the open leg injury on your arrival with significant bleeding to the open fracture site. You are told the air ambulance is unloading at the local trauma centre and is willing to come now as well and will be on scene in about 25 minutes. You ask them to also bring blood products if possible if it does not delay the priority launch. You inform them your patient is critical and you await their arrival.

You decide to package as quickly as possible as the air ambulance will arrive within minutes and can continue life-threatening interventions in the air as well.

1. Upon assessment of the scene, we understand the driver lost control of the vehicle, then rolled. We look for specific bystander history that would increase our suspicion of possible injuries on our initial primary survey. You will back up your assumptions with a proper complete primary and secondary examination as time permits. What are the immediate life threatening problems that you should interrupt your primary survey for if found? They can include a (an):
   A) airway obstruction.
   B) flail chest or tension pneumothorax.
   C) ineffective breathing pattern or effort.
   D) d. all of the above.
2. Upon your arrival, the patient’s GCS is 3/15. In an acute trauma patient this would most likely be:
   A) airway complication.
   B) breathing complication.
   C) circulatory failure.
   D) all of the above.
3. This patient is displaying profound hypovolemia already. You know the best way to intervene in this complication would be to:
   A) initiate IV therapy.
   B) stop any/all visible bleeding sources now.
   C) rapidly extricate the patient and then initiate any interventions.
   D) A and C only.
4. This patient is unconscious and unresponsive during the primary survey. The most likely cause in a trauma patient would be:
   A) hypovolemic shock.
   B) a closed head injury with or without visible ICP.
   C) hypotension.
   D) all of the above.
5. This patient has a major open laceration to the left mid femur region. What are two ways to stop the bleeding in a patient when limited access is available upon your initial arrival?
   A) Apply a tourniquet.
   B) Apply pressure points.
   C) Put on bulky dressing with a tensor wrap.
   D) A and C.
   E) B and C.
6. This patient’s ineffective breathing can be complicated in this case by the:
   A) flail chest.
   B) abdominal distention.
   C) pelvic injuries.
   D) head injury.
7. The suggested method to supply oxygen to this patient would be from:
   A) NRB at 15 lpm.
   B) BVM at 10 to 12 times per minute.
   C) nasal cannula at 4 to 6 lpm.
   D) a simple face mask at 10 lpm.
8. The initial blood pressure of 60/26 on scene is indicative of significant internal and external injuries. The next step to prevent the BP from deteriorating more would be to:
   A) stop all visible bleeding.
   B) apply oxygen, assist respirations as required.
   C) initiate IV therapy as required.
   D) all of the above.
9. This patient has a visible left chest injury. The best intervention as a BLS provider in this patient would be to:
   A) splint the chest with a gloved hand.
   B) tape a bulky dressing over the affected side tightly.
   C) tape a small IV bag with a bulky dressing over the affected side.
   D) all of the above.
10. What are the most likely causes of the patient to have a slow breathing pattern?
    A) Hypoxia.
    B) Hyperglycemia.
    C) Head injury.
    D) A and C.
    E) All of the above.
11. What is the likely cause of this patient having a rapid heart rate and a very low BP in this case?
    A) Hypovolemic shock.
    B) Pelvic fracture.
    C) Hemothorax.
    D) All of the above.
12. What is the likely cause of the patient to have a low Sp02 or an Sp02 that will not register in this case?
    A) Hypoxia.
    B) Hypothermia.
    C) Hypovolemia.
    D) All of the above.
13. The initial treatment for this patient suggests we provide prehospital care IV fluid resuscitation. The new evidence would recommend that we administer IV fluid to achieve at least _____ systolic BP or a MAP of _____.
    A) 80 and 65
    B) 90 and 70
    C) 70 and 50
    D) 110 and 65
14. If you choose to do a roof rollup on this vehicle and extricate this patient from the top, you can utilize the:
    A) KED or short spine board.
    B) long spine board.
    C) scoop stretcher.
    D) A or B.
    E) all of the above.
15. We know this patient has a flail chest. After reviewing the anatomy of a normal chest we know there are ________ of ribs and ______ of false ribs.
    A) 5 pairs - 7 pairs
    B) 7 pairs - 5 pairs
    C) 10 pairs - 2 pairs
    D) 2 pairs - 10 pairs
16. As you complete your rapid primary assessment of the patient, you find continuous amounts of blood in the airway. Your best treatment option for this patient would be to:
    A) suction the airway.
    B) assist the ventilations until intubation can be achieved safely.
    C) perform a rapid extrication and perform ALS airway interventions when you’re ready and have multiple backup plans ready, such as a boogie, king airway device, a combitube or an LMA at your disposal.
    D) all of the above.
17. On examination of the patient, you see bleeding from both ears and unequal pupils. You see significant frontal and parietal area swelling with raccoon eyes as well as battle signs. You know this patient likely then has a very severe closed head injury. This patient will be transported rapidly in full spinal movement restriction devices to the closest hospital in the following position to help treat the shock and let you keep assessing for complications:
    A) left lateral.
    B) prone.
    C) head elevated 10 to 15 degrees.
    D) A and C only.
18. You have decided start two large bore IVs to the A/C veins in both arms. You want to initiate IV fluid. The best IV solution in this case would be to initiate ____________ in the prehospital care setting.
    A) NS 3 per cent (hypertonic solution).
    B) NS 0.9 per cent (isotonic solution).
    C) Albumin 4 per cent (hypertonic solution).
    D) pentaspam solution.
19. The patent has no improvement in his BP after your initial interventions. You can attempt to assist the BP to stabilize with a (an):
    A) Norepinephrine infusion from 0.5 to 30 mcg/min.
    B) Dopamine infusion from 10 to 20 mcg/kg/min.
    C) Epinephrine infusion at 1 to 20 mcg/min.
    D) all of the above.
20. Is there a role in low volume or delayed IV fluid resuscitation in blunt trauma patients?
    A) Yes.
    B) No.
    C) Undetermined or not scientifically proven with current knowledge.
21. You have decided to intubate this patient immediately. Your BP is now 62/24 after a second IV bolus with a pulse rate of 142 bpm. You would select the following medications to perform an RSS or RSI:
    A) Fentanyl 1 – 3 mcg/kg slow IVP.
    B) Versed 2.5 – 5 mg IVP.
    C) Anectine 1 – 1.5 mg/kg IVP.
    D) No medications are needed at this time.
    E) All of the above.
22. After extrication and intubation, the patient goes into cardiac arrest. This can be from:
    A) decompensated shock.
    B) tension pneumothorax.
    C) hypoxia, hypothermia, hydrogen ion imbalance or hypvolemia.
    D) all of the above.
23. Your next intervention should be to:
    A) initiate CPR.
    B) administer Epinephrine.
    C) stop all infusion and IV fluid infusions.
    D) all of the above.
24. There maybe one more intervention that might improve the patient’s chance of survival. The act of applying pelvic binding or even by applying MAST pants to stabilize the pelvis is a better solution then repeated IV boluses to increase the BP in this case?
    A) Yes.
    B) No.
    C) Undetermined or not scientifically proven with current knowledge.
25. What would you do next if you suspected a tension pneumothorax?
    A) Immediate needle decompression of the affected side and possibly decompress both chest sides as it can be a bilateral tension pneumothorax.
    B) Reassess your patient to see if the life threatening condition reverses or you might need to look for another cause of the arrest.
    C) Reassess your patient with the DOPE pneumonic to ensure there is not another reversible cause.
    D) All are appropriate.