Quiz 4

The day has been hot with no signs of snow for about a month now. This year has been a strange year with a snow storm near the end of April and several nights with temperatures dropping to around zero, which is very rare for May in your community. There is one BLS unit on today, with one ALS unit on call from home if needed.

Your pager tones off another call for your BLS unit. The call is dispatched as a “medical emergency”. Your patient is conscious at the time of the call. The caller states the patient has awakened with a severe headache and is unable to walk. This is the worst headache of his life. You start to go through the differential diagnosis for a headache complaint. The patient is a 19-year-old male. You know it must be bad if they are calling an ambulance with this complaint.

Your partner is a Primary Care Paramedic (PCP) with five years experience. You are also a PCP with three years experience. Your response time is going to be eight minutes today.

The call sounds like an all so familiar “subarachnoid bleed” or a “subdural hematoma” but it would not be a normal age for these complications. The patient is approximately 100 kg or 220 lbs. The ALS unit can back you up if needed but at this time it sounds like you can handle it with your crew.

Your initial assessment reveals:

• Temperature of 37.7°
• Respiratory rate of 18 with a regular depth and no signs of distress.
• Pulse 82 minute (strong and bounding)
• Sp02 is 98% on room air
• BP is 168/128
• Blood sugars 12.2 mmol/l
• Cardiac monitor is NSR with no PVC or ectopy

SAMPLE Hx is as follows from the parents and the patient:

• Symptoms: The headache started last night. The initial symptoms started like a normal headache and worsened throughout the night and are much worse this a.m. Today he is just clutching his head with both hands to even hold his head up but he is unable to raise his head on his own power to look into your eyes.
• Allergies: NKA
• Medications: Vitamins.
• Past Hx: No significant past medical history.
• Last Meal, Last Medications: last night, no recent medications. His parents state he was studying for a university science honors exam last night when his headache started.
• Events preceding EMS being called: Patient went to bed last night feeling unwell with a headache that keeps worsening all night. Today he is confused and not himself. He will not even follow simple commands given by his parents. They tried to get him to the hospital but he is over six feet tall (72 inches or 182 cm) and over 220 pounds or (100 kg) so that is not an easy task. He is combative towards his parents when they try to get him to walk and while you are initially assessing the history from his parents he appears to be very irritable in his mannerism.

You now suspect this patient is suffering from something other then a normal headache. You elect to dispatch your second unit for ALS interventions and call the local police in case additional assistance is required.

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. The patient appears in a confused state and his parents could not get him out of bed as he has poor motor coordination as well as he is too confused to be cooperative. Your next interventions would be to:
   A) Attempt to introduce yourself and see if you can slowly approach the patient to establish a rapport and see at what level his mental functioning is at currently.
   B) Tell the patient to turn on his back and that he is going to be taken to the local ER whether he likes it or not.
   C) Get the parents to sign a refusal and go back home to your base.
   D) Await your second unit and then an assessment and initiate care.
2. Upon your arrival you find the patient in a fetal position on his bed holding his head still. Your patient is awake and does not notice your approach. He looks uncomfortable and is moaning in pain. Your next assessment would be to:
   A) Assess your patient’s level of consciousness by asking his name, day and events leading up to this event.
   B) Assess the airway.
   C) Assess the rate and quality of the respirations.
   D) b. and c. only.
3. 3. Upon your arrival your SAMPLE history indicates a serious medical complication. What specific problems could cause the confusion, headache, and the hypertensive episode that you currently see on your initial examination?
   A) Intracranial growth or tumor.
   B) Subarachnoid bleeding.
   C) Subdural bleeding.
   D) Cocaine use or abuse.
   E) All of the above.
4. Also on your initial exam you notice the blood sugar slightly elevated. The normal blood sugar range seen in patients would be:
   A) 2 to 4 mmol/l.
   B) 3 to 10 mmol/l.
   C) 4 to 7 mmol/l.
   D) 6 to 12 mmol/l.
5. The patient responds to his name being called. He states his head really hurts but will not rate it on a 1/10 scale. You offer to physically assess him and he states that is okay as he moans. Initially you would like to assess:
   A) The rate of breathing.
   B) The depth of the breathing.
   C) The effort made with the respirations.
   D) All of the above.
6. You next assess the pulse rate at the wrist and note that it’s strong and bounding. That can indicate that the patient is suffering from:
   A) Hypotension.
   B) Anemia.
   C) ICP.
   D) Hypertension.
   E) c. and d. only.
7. The BP remains elevated. What interventions can relieve the hypertension, headache and agitation?
   A) Minimize noise.
   B) Elevate the head of the stretcher eight to ten inches.
   C) Minimize sensory stimulation.
   D) All of the above.
8. What defines hypertension in an adult patient?
   A) Systolic greater then 160 mmHg and a diastolic greater then 110 mmHg consistently.
   B) Systolic greater then 180 mmHg and a diastolic greater then 100 mmHg consistently.
   C) Systolic greater then 140 mmHg and a diastolic greater then 90 mmHg consistently.
   D) Systolic greater then 200 mmHg and a diastolic greater then 100 mmHg consistently.
9. If this patient had a subarachnoid hemorrhage you would expect to see:
   A) A severe headache.
   B) Stiff neck.
   C) Bleeding into the subarachnoid space.
   D) All of the above.
10. If this patient had a subdural bleed you would likely see:
    A) Vomiting and weakness.
    B) Papilledema and hemiplegia on the opposite side of the clot.
    C) A LOC that alters back and forth from unconsciousness to awake followed by a rise in the BP and fall in the pulse rate.
    D) All of the above.
11. Your patient’s intracranial complication can be causing the ICP presentation. Signs of ICP can be defined as a/an:
    A) Widening pulse pressure.
    B) Slowing heart rate.
    C) Increase in either cerebral spinal fluid or blood within the cranium which has a limited space already.
    D) All of the above.
12. You have moved the patient onto your stretcher with assistance after your primary survey. You would next like to reassess the:
    A) ABCs and the LOC.
    B) Vital signs.
    C) cardiac monitor, Sp02 monitor.
    D) Blood sugar and core temperature.
    E) All of the above.
13. The patient has started to vomit. The best thing to do now is to:
    A) Grab the portable suction
    B) Turn the patient onto his side.
    C) Grab his head and turn it to the side as much as he can tolerate.
    D) Make a quick exit from the house as the suction in the unit is much better and more reliable.
14. This patient warrants maintenance 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) D5W TKVO.
    D) 2/3 – 1/3 TKVO.
    E) a and b only.
15. While on scene the patient suddenly decompensates and starts to have a grand-mal seizure. The seizure stops after about two minutes. The patient is not breathing after this event. What would be the most appropriate next action or actions?
    A) Insert an OPA.
    B) Attempt to ventilate with a BVM at 10 to 12 times per minute.
    C) Check for a pulse.
    D) Notify your ALS crew that is arriving of the sudden change.
    E) All of the above.
16. Your ALS crew arrived and prepares to intubate the patient immediately for transport as he still is not breathing and is worsening in his presenting condition. What would be the most appropriate initial medications prior to intubation?
    A) Lidocaine 150 mg IVP.
    B) Versed 1.0 mg slow IVP.
    C) Fentanyl 25 mcg slow IVP.
    D) All of the above.
17. You want your next medications to help assist in the intubation, lower the BP and limit the ICP spike that can occur. To achieve this the paramedic would want to administer:
    A) Fentanyl 200 mcg slow IVP.
    B) Versed 5.0 mg slow IVP.
    C) Anectine 150 mg IVP.
    D) All of the above.
18. Your patient is now sedated and will tolerate the laryngoscope. You advance the tube past the vocal cords. You assess the ET tube and it should be at around ______________ at the teeth.
    A) 19 – 20 cm.
    B) 21 – 22 cm.
    C) 23 – 24 cm.
    D) 24 – 25 cm.
19. Your patient has now become more bradycardic. The heart rate is now at a sinus bradycardia at 44 bpm. The BP is now 210/134. You would now administer:
    A) Atropine 0.5 mg IV.
    B) Mannitol 1.5 to 2 grams/kg IV over 20 to 30 minutes.
    C) Ativan 1 mg IV.
    D) All of the above.
20. The patient begins to clench the tube with his teeth. You know this will cause the tube to obstruct and limit proper ventilations. The easiest way to stop this problem now would be to:
    A) Insert a Thomas Tube lock protector.
    B) Repeat sedation of Versed 2.5 mg IV.
    C) Repeat sedation with Fentanyl 50 mcg IV.
    D) All of the above.
21. Upon arrival to the Emergency Room the physician orders a routine lab test along with a septic protocol, a 12 Lead EKG, a CXR and a CT scan of the head. The priority in this case would be to complete the:
    A) The lab test.
    B) CT scan of the patient’s head on arrival as well as contact the neurosurgeon on call immediately.
    C) CXR.
    D) 12 Lead EKG.
22. The patient continues to deteriorate and he is not responding to the medications as of yet to limit ICP and hypertension. Medications that can assist in this hypertensive emergency would be:
    A) Apresoline 10 to 20 mg IVP prn.
    B) Labetalol 5 mg slow IVP every 10 minutes prn.
    C) Hyperstat 1 to 3 mg/kg slowly with a maximum of 150 mg every 15 minutes.
    D) All of the above are an option.
23. You notice the patient’s end tidal C02 at 49 mmol/l with a good waveform. You can now:
    A) Apply PEEP at 5 to 10 mmHg.
    B) Increase the ventilations to 18 minute.
    C) Slow the ventilations down to 10 per minute.
    D) All of the above.
24. The BP and pulse are now dropping and the heart rate is now 26 per minute. The patient is now:
    A) Deteriorating.
    B) Improving
    C) Coning.
    D) a. and c.
25. The most appropriate next step is to try to:
    A) Encourage the physician and the nurses to allow family involvement in the resuscitation if they wish to be present.
    B) Notify the family members of the deterioration and let them be present.
    C) Notify pastoral care immediately.
    D) Try to get a staff member or pastoral care to sit and explain what is happening to the family in terms they will understand.
    E) All of the above.

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