Quiz 3

It is a cool fall day with the summer leaving much faster then anyone is ready for in your family. You are on-call today with just five more hours until you are on holidays for a month. The local emergency department has no physician on call today so you are praying there are no serious events in your community as you will need to transport by ground to the regional hospital. Your partners today are Sara, who is an Advanced Care Paramedic who has been working in EMS for three years and Monique, who is a ride-along from the local fire department who happens to be a firefighter/EMR.

You are called to respond to a fall victim who may also be in respiratory arrest after falling at a local construction yard about 16 km south of town. The caller states a 27-year-old male fell from a building down about 12 metres into an open excavation pit. The local RCMP members, fire department and a mutual aid ambulance will be dispatched according to your standing protocols, which you can cancel or call off if they are not required. Your second unit, which is a BLS or ALS unit, will be coming from another community and is about 25 to 30 minutes away.

You know according to the ITLS guidelines a head injury patient with a breathing problem is normally a very serious event. Good airway management along with adequate stabilization and resuscitation are essential to decrease morbidity and lessen permanent end organ damage. There is an ongoing debate about the importance of performing intubations by paramedics in the prehospital care setting. There very likely is a greater need for intubations in a rural remote setting than if you can transport to an urban centre while performing adequate ventilations in an urgent situation. Utilization of good BLS with a BVM and an OPA or NPA initially is sometimes much more lifesaving or mortality reducing then performing an intubation with suboptimal resuscitation efforts. Remember “good BLS” is more important then “adequate or less then adequate ALS.”

Something I learned from a Trauma Course Symposium is a great rule that is applicable to scene time management to help lessen the overall mortality rates and ensure a timely departure from a scene. There was a great trauma speaker and his points made great sense on stabilization and scene times. I do not remember it all but the take home point that I received was simple. The example for the guidelines was initially directed towards the basic skills of IV therapy. If you were less than seven minutes from a hospital then just transport to the hospital. If you were more than seven minutes start one IV and get going, if you were more than 14 minutes start two IVs prior to initiating transportation and if you were more than 21 minutes do everything required for stabilization on scene prior to initiating transport.

If you applied this philosophy towards airway management and you are less than seven minutes from a hospital and you can ventilate adequately, just load and go. If you are more than seven minutes away, perform simple airway interventions or attempt intubation prior to transport if it is deemed straightforward without use of a difficult intubation protocol or medications. If you are more than 14 minutes away, start your IVs and perform the intubation. If you are more than 21 minutes stabilize, perform your interventions such as RSI or RSS, and insert your IVs, NG or OG and anything else that is related to the ABC approach or interventions.

On arrival you find your patient in the drainage ditch by the building under construction in what appears a respiratory arrest. There is easy access to the patient and extraction will not be dangerous or difficult. A co-worker is performing mouth-to-mouth ventilations adequately. The local fire department will assist in packaging and rapid extrication. The patient looks to have fallen without a safety harness or fall protection device. There was no helmet on or present. You initiate your life saving interventions with your team members. There are 37 minutes left in the Golden Hour. You also think “so much for the platinum 10 minutes” to get on scene and 50 minutes to be in the operating room or ICU. Today the operating room or the ICU is not even a consideration until you transport by ground for at least 60 minutes.

Vital Signs
• Temperature—35.3 C
• Respirations—Absent
• Pulse—Weak radial and stronger at the carotid
• SpO2—Not reading
• Glucose—9.3 mmol/l
• Pupils—Unequal. Left is 2 mm and right is about 6 mm

References.
Currents in Emergency Cardiovascular Care. Volume 16 Number 4 Winter 2005 – 2006 American Heart Association.

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.

Jeremy Rudrud (Primary Care Paramedic) is a ACP Paramedic student with the University of Augustana Paramedic Program. Jeremy is a PCP with Edmonton EMS under the Emergency Response Department (ERD).

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.

1. What findings at this scene would stop your resuscitation efforts immediately upon arrival?
   A) Unsafe resuscitation surroundings.
   B) Possibility of poisonous gases in an open excavation.
   C) Bystander CPR for more then 30 minutes.
   D) A and B only.
   E) All of the above.
2. The best extrication tool for this patient in the bottom of a ditch where rapid extrication is required would be:
   A) Scoop.
   B) Ked.
   C) Long spine board.
   D) Vacuum board.
3. This patient does not appear to be breathing upon your arrival. The new standards state if the patient needs rescue breathing from a BLS approach the “two ventilations” can be provided with a pocket mask or a BVM. The rescuer must:
   A) Provide the ventilations over at least one second.
   B) Ensure the chest rises with each separate ventilation.
   C) Allow exhalation between breaths.
   D) All of the above.
4. If the patient is not breathing after the breathing assessment is performed we give:
   A) No ventilations for the first 2 minutes are required.
   B) One slow breath.
   C) Two slow breaths.
   D) Four stacked breaths.
5. On this patient in respiratory arrest we know the rate of ventilation should be:
   A) 10 to 20 per minute.
   B) Directed towards adequately ensuring the chest rises and falls uniformly.
   C) Using about 7 to 10 ml/kg
   D) All of the above.
6. You know that this is a trauma patient who has a significant risk of a spinal cord injury or trauma as well. You ask your ride-along to grab the spine board. You will also get your partner to apply the cervical collar securely. This patient easily may have suffered a:
   A) High spinal cord injury.
   B) Severe head injury.
   C) Hypoxic brain injury.
   D) All of the above.
7. Your patient’s skin is cool and dry on examination. There is a good chance that this patient is suffering a form of shock. It is most likely to be:
   A) Neurogenic shock.
   B) Cardiogenic shock.
   C) Both of the above.
8. The most common rhythm noticed in many neurogenic shock patients is:
   A) PEA.
   B) Ventricular tachycardia with a pulse.
   C) Asystole.
   D) Normal sinus rhythm.
9. We know that since this patient is not breathing or is using diaphragmatic breathing the cervical injury is above or at the:
   A) C 3 – C 5.
   B) L 2.
   C) T 12.
   D) All of the above.
   E) B and C only.
10. You apply the cardiac monitor and see a sinus bradycardia at 52 beats per minute. This can be from:
    A) Hypoxia.
    B) Spinal cord shock.
    C) ICP.
    D) All of the above.
11. This patient needs to have:
    A) Cardiac monitoring.
    B) SpO2 monitoring.
    C) Temperature assessment and reassessment.
    D) All of the above.
12. What is the likely cause of this patient to have a Sp02 that will not register or provide an accurate waveform on our initial arrival?
    A) Shock.
    B) Hypothermia.
    C) Hypovolemia.
    D) All of the above.
13. The initial treatment for this patient would require you to perform certain skills in a rapid manner. Your partner initiates an IV in the right A/C. You would first want to _______________ then ______________ as a BLS provider.
    A) Bolus 20 ml/kg.
    B) Reassess the BP.
    C) A paramedic to initiate pressors and provide no fluid resuscitation.
    D) A and B only
14. Your patient has been ventilated by the bystander for some time and now you have ventilated as well for a short period of time. The patient has no spontaneous respirations. The complications caused from even good BLS ventilations can be:
    A) Spontaneous pneumothorax.
    B) Gastric distension.
    C) Cellular hypoxia.
    D) All of the above
15. The patient’s family have been notified of the incident and will meet you at the receiving emergency department. You know that this presentation of signs and symptoms is likely from:
    A) A reversible or treatable condition with proper medical or surgical interventions.
    B) An acute life threatening event.
    C) Hypoxia and will be reversed with time.
    D) An isolated head injury that can be reversed by neurosurgical interventions.
16. If you look at this patient’s history prior to EMS arrival and currently, he is still unconscious and unresponsive. According to the GCS score this patient’s chance of walking out of the hospital with no deficits would be:
    A) slim to none.
    B) 50/50 odds.
    C) Most likely.
17. The pulse remains weak at the radial with only a 68/28 obtained after the transport is initiated. The heart rate is 54 bpm. The most appropriate therapy would be:
    A) Fluid bolus 20 ml/kg increments to see if the cardiac output improves. Listen and evaluate lungs sounds after every bolus.
    B) Initiate a dopamine infusion at 5 mcg/kg/min and titrate to about 90– 100 systolic after a fluid challenge has been attempted.
    C) Repeat the fluid bolus of 20 ml/kg prn.
    D) All of the above.
18. You have decided to _______________ the rate of ventilations as the end tidal C02 is coming back at 40 mm/hg.
    A) increase.
    B) decrease
    C) leave at the set rate by the BLS provider.
19. This patient has not responded to any stimulation. His GCS is 3/15. What medication can be considered prior to any intubation attempt?
    A) Versed 2.5 – 5 mg slow IV.
    B) Lidocaine 1 – 1.5 mg IVP.
    C) Morphine 2.5 – 5 mg slow IV.
    D) Anectine 1 – 1.5 mg/kg IV.
    E) Anectine 1 – 1.5 mg/kg IV.
20. The patient continues to have hypotension and bradycardia after the intubation. You would next administer:
    A) Lidocaine 1.5 mg/kg.
    B) Atropine 0.5 mg IVP.
    C) Ephedrine 10 mg SIVP.
    D) B and C only.
    E) All of the above.
21. You have intubated the patient and you notice the patient’s Sp02 is not registering above 90. You would expect this complication from:
    A) The endotracheal tube being in the esophagus.
    B) Inadequate ventilation.
    C) Aspiration of foreign material or aspiration pneumonia.
    D) B or C only.
    E) All of the above.
22. You are transporting to the hospital with this patient who continues to display bradycardia and hypotension. If the heart rate stayed low or decreased after you corrected the airway complication or performed airway interventions at the BLS and ALS level you can:
    A) Administer Epinephrine 2–10 mcg/minute infusion.
    B) Administer Atropine at 2 mg IVP.
    C) Apply the pacemaker and initiate pacing.
    D) Apply the pacemaker and initiate pacing.
    E) Administer an ampule of D50W to rule out hypoglycemia.
23. Your patient’s BP remains low. You direct your resuscitation to maintaining a BP over 100 systolic en route or a MAP of 65. The best way to perform this would be to administer:
    A) Atropine 1 mg q 15 minutes.
    B) Dopamine 5–20 mcg/kg/minute.
    C) Epinephrine 0.3 mg q 10 minutes.
    D) All of the above.
24. Upon arrival to the hospital emergency room the physician would likely order a:
    A) CXR.
    B) C-spine X-ray and or CT of the spinal column.
    C) Head CT
    D) All of the above.
25. The emergency room physician calls the neurosurgery specialist after assessing the X-rays and CT scan. The neurosurgeon orders a mannitol infusion immediately. Mannitol will help:
    A) Decrease ICP.
    B) Increase BP.
    C) Decrease renal perfusion.
    D) Increase stroke volume.