Wheezes, rales and rhonchi

It has been a nice summer evening and your sleep is interrupted at 1 a.m. by a pager tone. You are going to a rural address for a man suffering from chest pain and acute SOB. You arrive at a farm house where a 75-year-old male is sitting outside on his scooter awaiting your arrival. He appears to be posturing/tripodding and looks as if he is having trouble catching his breath. On your sixth sense of sick versus not sick says he is sick. He is able to speak in three to four word sentences and he says this has never happened to him before. He apparently awoke from sleep because he couldn't breathe well. He denies any chest pain now but complains more of a pressure sensation to his middle chest area. You notice his skin is pale and diaphoretic.

You are a paramedic student on your practicum and the rest of your crew includes an experienced paramedic (ACP) and an experienced EMT (PCP). You don’t have much for backup in your local area but the police and fire are always an option when all hell breaks loose.

The foundation of prehospital care is basic life support (BLS). You recognize good BLS interventions and skills are essential prior to moving on to advanced life support (ALS) interventions. For this quiz, odd-numbered questions relate to BLS and the even questions relate to ALS.

Quiz 11

1. Possible hazards on this scene include: wild animals or family pets. unseen obstacles due to poor lighting emotional responses from the patient or bystanders. all of the above.

2. Further hazards possibly present on this scene are: infectious airborne pathogens such as influenza or SARS. agricultural chemicals such as organophosphates needle sticks from IV starts, drug administration or the patient’s own needles. all of the above.

3. With three experienced practitioners, this call could be considered a “stay and play” call. There is no reason to be in a hurry to get off-scene. True. False.

4. Although this doesn't appear to be an airway problem, it would be prudent to prepare for the possibility of ET intubation. True. False.

5. You should proceed with this call by first: assessing the patient's mentation. assessing the patient's airway in case he needs an artificial airway. providing supplemental oxygen and assess the respirations. getting an initial set of vitals prior to administration of oxygen.

6. Differential diagnosis for this patient includes all of the following except respiratory infection hypoglycemia. COPD. CHF.

7. While assessing lung sounds you listen to the apices high on the chest in the mid-clavicular line. The bases are auscultated laterally in the mid-axilliary line between the seventh and eighth rib. True. False.

8. Auscultation of lung sounds reveals wheezes at the apices and a grunting or snoring sound in the bases bilaterally. This grunting or snoring sound could be described as: wheezes. rales. rhonchi. grunts.

9. When wheezes can be heard from across the room they are considered to be upper airway sounds and are called: rhonchi. grunts. gurggles. stridor.

10. Auscultation of rhonchi most likely indicates: upper airway obstruction. pneumonia. asthma. pulmonary edema. either b or d.

11. After administration of oxygen and obtaining vitals you could consider administering: Salbutamol 2.5 to 5 mg Neb or 2 to 6 MDI per your local protocol. Atrovent 250 to 500 mg Neb or 2 to 6 MDI per your local protocol. Combivent 2.5 mg/ 250 mg. Ipratropium Bromide 250 to 500 mg.

12. Vital signs for this patient were RR: 32, HR: 98, SPO2: 91%, BP: 210/98, Temp: 36.5 ºC, BGL : 5.0 mmol/l. Other treatments for this patient might include the prehospital administration of: Aminophylline 250 mg rapid IVP. Magnesium Sulphate 4 mg IV. NTG SL prn or start an infusion per your local protocols. sodium bicarbonate 1 mEq/ kg SIVP.

13. After a nebulizer treatment is started the patient says he feels worse and starts trying to take off the mask. “Gurggling crackles” can be heard over the sound of the nebulizer. Auscultation of the chest reveals absent breath sounds at the bases and crackles at the apices. You should: restrain the patient so he doesn't remove the neb. remove the neb and apply a NRB at 12 l/min. place the patient in a seated position with his legs dependant. insert an OPA to “open up the airway.” do b and c only.

14. Appropriate treatment for the patient suffering flash pulmonary edema includes all of the following except: entonox self-administered. NRB at 10-15 l/min. CPAP at 5 cm H2O. ETT with PEEP at 5 cm H2O.

15. When assessing this patient you find that his right leg is smaller than his left and has old scars from multiple surgeries to repair a traumatic injury. The right leg has limited motor function compared to the left and there is no edema in any of the extremities. What has most likely happened to this man? DVT and subsequent PE from multiple surgeries on the right leg. Right-sided heart failure. Left-sided heart failure. Both right and left-sided heart failure.

16. Follow up vitals show that despite treatment the patient's blood pressure is 200/98. Which of these infusions would be appropriate at this time? Nitroglycerine 10-20 mcg/min infusion and increase to a maximum of 200 mcg/min prn. Dopamine 10-20 mcg/kg/min. Epinephrine 2-10 mcg/min. Nitroprusside 0.5-1 mcg/kg/min to a maximum of 8 mcg/kg/min. a and d only.

17. In this situation it is best to reassess vital signs______________. every 30 minutes. every 60 minutes. every 5 to 10 minutes. only when there is a status change. whenever you have a change in LOC.

18. Morphine 5-10 mg IV may also prove beneficial to this patient. True. False.

19. Despite your best efforts the patient loses consciousness. You should: ventilate with BVM. administer bolus IV fluids at 20 ml/kg. apply defibrillator pads. ensure patency of airway.

20. The best action for this unresponsive patient would be to: insert a #8 ETT and ventilate with PEEP. leave the OPA in place and use proper BVM skills to prevent gastric distension. leave the CPAP in place and check the rate and quality of ventilations. insert an LMA classic and ventilate with PEEP.

21. Some possible causes of pulmonary edema include: hypertension. pulmonary embolism. acute myocardial infarction. acute respiratory distress syndrome. all of the above.

22. When treating pulmonary edema with PEEP the following pressures should be used. 5 cm Hg only. 50 mm Hg. 5 cm H2O only. 5-10 cm increments of 2.5 cm H2O.

23. If this patient had been hypotensive instead of hypertensive he should have been treated with a 250-ml bolus of normal saline. True. False.

24. The hypotensive pulmonary edema patient should receive a Dopamine infusion at a rate of: less than 5 mcg/kg/min. 10 mcg/kg/min. 15 mcg/kg/min. 20 mcg/kg/min. any of the above.

25. The percentage of CHF patients who survive longer than five years is: 75%. less than 50%. more than 50%. 85%.