Quiz 1

It is early on a mild Saturday morning and you are running on the tread mill in your EMS hall and trying not to eat any Christmas chocolates until at least noon. There are two units on today with one BLS unit on first up and the second unit, which is staffed at an ALS level. You are working in a small city of 12,000.

You are dispatched to the home of a well-known businessman and volunteer in your community. He is a 51-year-old male who complains of chest pain and weakness x 1 hour (since he woke up). He is alone at his home, which is well kept and overlooks the lake. He describes chest pressure in the middle of the chest, which is unchanged with a deep breath or pressing on the chest wall; the pain radiates up to his jaw. He is pale and his skin looks gray and he seems apprehensive and restless. You assure him that you are able to help him and begin to package him for the transfer to the nearby hospital.

Your initial assessment reveals:

• Temperature: 36.2° C.
• Respiratory rate: 20 and regular, adequate depth.
• Pulse: 32/minute, weak and thready.
• Sp02: 98% on room air.
• BP: 98/50.
• Blood sugar: 27 mmol/l.
• Cardiac monitor: Shows a profound sinus bradycardia with a first degree AV block.

SAMPLE Hx is as follows:

• Symptoms: Chest pain 7/10 retrosternal x 1 hour. Patient stated that he felt dizzy as well.
• Allergies: None.
• Medications: None.
• Past Hx: None. Had a checkup one year ago and the doctor said he was healthy.
• Last meal, last medications: Pizza at 2100 hours last evening.

Paramedic’s 15-lead: 2 mm ST elevation in aVL, V6, V8, V9, I, II, III, aVF. ST depression in V3, V4. V1, V2, V5, V4R do not show ST elevation or depression.

About the Authors.
Dale Bayliss is an experienced Advanced Care Paramedic and Registered Nurse living in Camrose, Alberta. Dale is an instructor with the University of Alberta, Augustana Faculty’s Paramedic Program. He also works part time as an Emergency Nurse at the University of Alberta Hospital in Edmonton and works casual as a Paramedic with Peace Hills EMS in Wetaskiwin, Alta. and with Beaver EMS in Tofield, Alta.

Ruth Farrow is a 2002 graduate of the University of Alberta, Augustana Faculty’s Paramedic Program and lives in Cold Lake, Alberta. She also has 10 years of experience as a medical laboratory technologist.

Please keep in mind the answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

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.

Please note that questions 1 through 10 are geared to the BLS level, and questions 11 through 20 are geared to the ALS level.

1. The BLS unit should call for advanced life support backup after this initial assessment because:
   A) The patient might have a gastrointestinal bleed.
   B) The patient might be having a stroke.
   C) The patient might have diabetes.
   D) The patient is at risk of shock from a cardiac condition.
2. With a blood glucose of 27 mmol/l and no prior history of diabetes, we are aware that:
   A) The patient has a high amount of adrenaline in his blood stream to compensate for chest pain.
   B) The patient may have eaten a lot of sweets yesterday.
   C) The patient may be dehydrated from excess urination.
   D) The patient has hypoglycemia and needs IV dextrose.
3. The patient should have a normal saline IV started and set to run at:
   A) TKVO.
   B) 100 ml/hour.
   C) 500 ml/hour.
   D) 10 ml/kg bolus.
4. You auscultate the chest and hear fine crackles in the lung bases. As well, the patient begins to cough occasionally. You interpret this to be:
   A) Possibly an early sign of pulmonary edema.
   B) Lung infection.
   C) A sign of dehydration.
   D) All of the above.
5. The Sp02 drops to 94 per cent when the paramedic puts the patient supine for the 15-lead ECG. The GCS is still 15/15 and BP 96/52. The patient is on a nasal cannula. What should you do next?
   A) Place a nasal cannula which will increase the SpO2.
   B) Return the patient to semi-Fowlers after the ECG is done. Change the oxygen supply to a non-rebreather mask at 12 l/minute.
   C) Assess the lungs frequently, as well as the vital signs.
   D) The paramedic should administer narcotics and sedatives and intubate the patient.
   E) b and c and both correct.
6. The electrocardiogram gives the following information:
   A) It can show signs of ischemia and myocardial infarction.
   B) If the heart rate is regular.
   C) How the pacemaker and conduction system are working.
   D) All of the above.
7. It makes sense that this patient felt dizzy when standing, which can be explained by_________ , found on the initial assessment:
   A) Hyperglycemia.
   B) Blockages in the carotid arteries.
   C) Bradycardia/hypotension.
   D) Decreased urine output.
8. You have moved the patient to the unit and the patient has been secured in your controlled environment. You are with a paramedic and another EMT in the back and the transport time is 20 minutes. You are going to reassess the:
   A) ABC and LOC for changes.
   B) Cardiac monitor, Sp02 monitor and vital signs.
   C) IV site.
   D) All of the above.
9. Chest pain (described as “pressure,” “dull,” “squeezing”) is generally considered to be ___________ until blood tests and other investigations prove otherwise.
   A) Angina.
   B) Myocardial infarction.
   C) Pericarditis.
   D) Arrhythmia.
10. Patients with chest pain can develop problems such as:
    A) Cardiogenic shock.
    B) Shortness of breath.
    C) Cardiac arrest.
    D) All of the above.
11. Transport is uneventful and at the hospital the patient is given a fibrinolytic called “TNKase.” The following is NOT a contraindication to TNKase:
    A) Recent stroke.
    B) GI bleed three months ago.
    C) Cervical spinal fusion five years ago.
    D) Hemophilia.
12. The patient has changes in his rhythm after the fibrinolytic is administered. He now has atrial tachycardia of 120 with one out of three P waves resulting in a QRS complex (ventricular rate of 40). His blood pressure is 90/58, SpO2 is 92 per cent, and his GCS is 15. Fine crackles in the lungs, 3/10 chest pain. The patient is nauseated and has been given IV Gravol. What ACLS interventions should be done at this time?
    A) Apply pacing pads to be ready to start transcutaneous pacing. Repeat 12-lead.
    B) Adenosine 6 mg rapid IV push for the tachycardia.
    C) Fluid bolus.
    D) Verapamil 5 mg slow IV push.
13. The repeat ECG doesn’t show any improvement in the ST elevation in II, III, aVF, V8, V9 (posterior) and V6. The patient should receive __________ within the next hour if possible:
    A) Open-heart surgery.
    B) STAT coronary catheterization.
    C) Metoprolol.
    D) Another dose of fibrinolytic.
14. The patient’s difficulty breathing increases and he becomes agitated as his SpO2 drops to 82 per cent. The patient requires intubation and assistance with ventilations as part of the treatment for acute pulmonary edema. Is IV lidocaine indicated as a pre-intubation drug?
    A) No.
    B) Yes.
15. The dosage of succinylcholine is:
    A) 1 mcg/kg.
    B) 1.0 to 1.5 mg/kg.
    C) 5 mcg/kg/min.
    D) 2 to 10 mcg/min.
16. The dosage of rocuronium for an 80 kg man is:
    A) 50 mg.
    B) 80 mg.
    C) 120 mg.
    D) 160 mg.
17. When adjusting the minute volume of the ventilations, the end-tidal pCO2 reading is useful. Which of the following statements is true?
    A) We generally keep the end-tidal pCO2 between about 30 to 45 mmHg.
    B) This patient might have acidosis related to his hyperglycemia and therefore we can allow the pCO2 drop for the short term in order to keep the SpO2 above 80 per cent.
    C) An arterial blood gas for pH would be of value in this patient, which will likely be done at the hospital.
    D) All of the above.
18. The eventual coronary catheterization will show that the left circumflex artery is blocked. The ECG changes show infarction involving what three areas of the heart? (ST elevation in aVL, I, V6, V8, V9, II, III, aVF)
    A) Inferior, lateral, posterior.
    B) Septal, anterior, inferior.
    C) Septal, posterior, right side.
    D) Anterior, inferior, right side.
19. How do we explain the ST depression in V3 and V4 (prior to cardiac catheterization)?
    A) Reciprocal changes (a mirror reflection) of the ST elevation and infarction of the posterior heart (V8,V9).
    B) Ischemia of the anterior left ventricle because the area is near the infarction site.
    C) A sign of pericarditis.
    D) a. or b.—we don’t know for sure at this time.
20. What combinations of PO medications might this patient be on three months from now?
    A) Metformin, Lisinopril, metoprolol, ASA.
    B) Lasix, verapamil, ACE inhibitor, Ventolin.
    C) Insulin, atropine, carbamazepine, cholesterol medication.
    D) ASA, glucagon, warfarin, Epival.