Quiz 27

It is a warm fall evening. It is 19:30 hrs and the sun is just about ready to set in the distant hills. You are working in rural location with about 17,000 people scattered around the municipality. Your ALS ambulance is staffed with one PCP and one ACP today and an EMR ride along.

You have one BLS backup unit available from the local fire hall if required for assistance or BLS transfers. You are dispatched for a male patient who has collapsed about five minutes away from the EMS base. The 9-1-1 dispatcher states a bystander watched his dad collapse in his residence. He is doing CPR as you are dispatched.

Once you arrive you find the son in the living room with the patient on the floor with CPR in progress. The son states there is no past medical history or past surgical concerns. The rest of the sample history is unremarkable.

His initial vital signs are:

• Heart rate of 0 bpm

• Respiratory rate of 0 bpm

• Blood pressure is 0/0

• SpO2 not registering on arrival

• Blood glucose level is 11.2 mmol/l

• Cardiac monitor: Sinus bradycardia but no pulse detected.

• Temperature is 36.5°C

On your initial exam, you find the patient remains in cardiac arrest. The family member is still performing one man CPR as you walk into the room. He has been doing CPR for around five to 10 minutes now. You know that statistically the odds are against your patient with every passing minute.

1. On arrival you find the family member doing one person CPR. He looks to be performing adequate or the correct CPR sequence. What is the first priority in this situation?
   A) Assess for a pulse while applying the AED.
   B) Assess for breathing for 10 seconds.
   C) Apply the cardiac monitor.
   D) Stop the chest compressions and apply the AED.
2. You establish that there is a pulse with chest compressions and no pulse when chest compressions are paused. You relieve the family member with your staff to perform the chest compressions. You would then:
   A) perform only rescue breathing.
   B) continue with CPR at a 30:2 ratio of chest compressions and ventilations.
   C) apply the AED and push analyze.
   D) perform all of the above.
3. This patient is displaying a pulse on the monitor with no palpable pulse, which is then a PEA arrest. For the BLS rescuer the best therapy in this case would be to:
   A) administer appropriate oxygen therapy.
   B) initiate and administer an IV fluid bolus until 20 ml/kg
   C) assess the blood sugar.
   D) do all of the above.
4. This patient may have any one of the common causes of a PEA arrest which could be from a:
   A) dissecting abdominal aortic aneurism (commonly referred to as a Triple A).
   B) acute GI bleed.
   C) pulmonary embolism.
   D) all of the above.
5. The rate of providing ventilations with a perfusing pulse and with a patient without a pulse are different. If the patient had no pulse the rate of ventilations would be to provide:
   A) one breath every six to eight seconds.
   B) two breaths every six to eight seconds.
   C) two breaths every 30 seconds.
6. During resuscitation you find a spontaneous return of a pulse and the patient is not breathing. Your next actions would be to:
   A) administer IV fluid until the BP is above 90 systolic.
   B) continue with rescue breathing at one every six to eight seconds.
   C) push analyze on the AED.
   D) do all of the above.
7. The rate of chest compressions in an adult should be _______ as well as deep enough and hard enough to actually provide strong pulses with each chest compression.
   A) 60 to 80 per minute
   B) 40 to 60 per minute
   C) 100 times per minute or faster
8. The best success for out of hospital cardiac arrest according to the American Heart Association (AHA) 2006 Guidelines states success is from:
   A) quick intubation and cardiac medications.
   B) quick initiation of chest compression and defibrillation/AED.
   C) repeated defibrillations.
   D) all of the above.
9. The rescuers are to switch every two minutes to ensure that the best chest compressions are performed. The changes or pauses in chest compressions or changes in compressors should be no longer than:
   A) 10 seconds.
   B) five seconds.
   C) 15 seconds.
10. The AHA states that if correct CPR and defibrillation is performed by BLS or ALS providers within three to five minutes, the success rate is increased from:
    A) five per cent to 15 per cent.
    B) 16 per cent to 28 per cent.
    C) 41 per cent to 74 per cent.
    D) 55 per cent to 80 per cent.
11. We know the family member witnessed the cardiac arrest. We also know from retrospective evaluations that witnessed VF arrest with immediate CPR until EMS personnel or health care interventions occur can increase the survival rate by OOOOOO above the normal CPR success rate.
    A) 10 per cent
    B) 25 per cent
    C) 50 per cent
    D) 75 per cent
12. The AHA recommends that an AED is placed in populated areas with more than OOO people in the immediate area for more than 16 hours per day. They also suggest we advocate for the AED to be placed less than a 1.5-minute walk away from the majority of people in the most populated areas.
    A) 100
    B) 250
    C) 500
    D) 1,000
13. The initial treatment for this patient after prehospital CPR and defibrillation has established a return of the pulses at about 90 beats per minute. The next intervention the BLS provider should ensure the:
    A) initiation of respiratory and pulse checks every two minutes. To continue with the BVM at a rate of one ventilation every six to eight seconds until the patient’s respirations are regular and adequate in rate and depth.
    B) initiation of respiratory and pulse checks every two minutes. To continue with the BVM at a rate of two ventilations every 30 seconds until the patient’s respirations are regular and adequate in rate and depth.
    C) initiation of respiratory and pulse checks every two minutes. To continue with the BVM at a rate of one ventilation every three to five seconds until the patient’s respirations are regular and adequate in rate and depth.
14. The best way to ensure the pulse remains present and also adequate would be to:
    A) continue to monitor the Sp02 waveform.
    B) monitor the patient with your cardiac monitor.
    C) repeatedly assess central and peripheral pulses frequently.
    D) do all of the above.
15. The BP is less than 60 systolic at this time with a heart rate between 80 and 100 bpm. The best therapy to assist the BP to increase would be to:
    A) maintain a warm core temperature and decrease environmental cooling as much as possible.
    B) provide an IV bolus of 20 ml/kg and monitor the BP, lung sounds and pulses after every 250 to 500 ml bolus.
    C) keep the patient in a supine position.
    D) do all of the above.
16. As you start to transport the patient you find the pulse is back after you perform a pulse check but the BP is only 56/30 now. The IV bolus has not improved the BP. The pulse is still less then 100 bpm. The next intervention would be to:
    A) initiate a Dopamine infusion at 2.5 mcg/kg/min.
    B) initiate Norepinephrine infusion at 5 mcg/min
    C) initiate Epinephrine infusion at 2 mcg/min.
    D) B and C only.
    E) do all of the above.
17. The HGB was 125 g/dl two weeks ago and it is now 90 g/dl. On examination of the patient you find the abdomen is very distended. The differential diagnoses can indicate many of the following complications. The most likely concern now would be:
    A) gastric distention.
    B) GI bleed.
    C) abdominal aortic aneurism (AAA).
    D) all of the above.
18. The patent has some improvement in his BP after your initial interventions. The BP is now 68/34. You can attempt to assist the BP to stabilize with:
    A) additional repeated IV boluses of 20 ml/kg unless signs of CHF occur.
    B) an increase of the Dopamine infusion by 2.5 to 5.0 mcg/kg/min until you reach 20 mcg/kg/min.
    C) an increase of the Norepinephrine infusion by 2.5 to 5 mcg/min increments until you reach 30 mcg/minute.
    D) an increase of the Epinephrine infusion by 2 to 4 mcg/min from 2 to 10 mcg/min as required.
    E) all of the above.
19. The patient’s pH is now 6.75. (The normal range is 7.35 to 7.45). The best intervention would be to:
    A) administer magnesium sulfate 2 grams IV.
    B) administer sodium bicarbonate 100 mEq slow IVP.
    C) increase the rate of ventilations.
    D) administer 1 amp of dextrose 50 per cent.
20. You have decided to intubate now. What is the most likely complication if you decide to provide sedation or narcotics to a patient who is as unstable as this patient is now?
    A) Cardiac arrest.
    B) Profound hypotension.
    C) Bradycardia.
    D) All of the above.
21. After you have intubated this patient you find that there is decreased air entry to the bases bilaterally. This can be from:
    A) GI distention.
    B) pneumonia.
    C) pulmonary edema.
    D) all of the above.
22. Your next intervention should be to:
    A) insert a GI tube nasally.
    B) insert a GI tube orally.
    C) reevaluate your endotrachial tube placement.
    D) B and C only.
23. Upon arrival to the local ER the patient goes back into a PEA arrest. The best intervention would be to:
    A) repeat epinephrine 1 mg bolus.
    B) perform chest compressions immediately.
    C) continue to ventilate at one every five to six seconds.
    D) do all of the above.
24. What would you do next if you suspected an active hemorrhage as the cause of the return of the PEA arrest in the ER with the local physician?
    A) Initiate rapid infusion of O-negative blood products preferably with a central line that can be inserted in ER by a trained physician.
    B) Repeat the HGB level test by performing a blood gas test if available in the ER.
    C) Perform a fast scan to rule out dissection or active hemorrhage by a trained physician in the Fast U/S methods.
    D) All are appropriate.
25. Your interventions have returned the pulses again. The BP still remains less then 70 systolic now even when the current medications and infusions are maxed out. You are still baffled by the cause of the illness and severity of the patient’s condition. The ER staff physician and the radiology staff are querying Sepsis from an underlying intra-abdominal complication. Your next intervention can be to:
    A) consult the surgical and ICU members to assist in evaluation and interventions until this patient is more stable.
    B) start a Vasopressin infusion at 0.02 to 0.04units/min.
    C) administer Solu-medrol 125 to 250 mg IV.
    D) perform all of the above.