Quiz 9

1. From your patient presentation you know that whatever he has is bad. You think back to an article on Systemic Inflammatory Response Syndrome (SIRS), which was a new term defined initially by the American College of Chest Physicians and also the Society of Critical Care Medicine in 1992. They were looking for ways to reduce the high mortality rate from sepsis which, when diagnosed, was already too late for many patients. They found if the patients had two or more of the following they should also be SIRS candidates:

a fever greater than 38Ã�Â°C or less than 36Ã�Â°C, an increased heart rate of more than 90 bpm and a respiratory rate more than 20 breaths per minute.
a PaCO2 of less than 32 mm and an abnormal white blood cell count (WBC) count of less than 4,000/uL or greater than 12,000/uL also with greater than 10 per cent bands.
blood pressure of less than 100 systolic and a positive urine culture.
A and B only.
all of the above.

2. This patient does not appear to have suffered from trauma. You know that systemic inflammatory response syndrome (SIRS) can be caused from:

ischemia or infection.
inflammation or trauma.
a combination of several insults.
all of the above.

3. We have been taught that SIRS can be from non-infection sources or from an infection source. They have found a “microbial phenomenon” is characterized by an inflammatory response to the micro-organisms or the:

invasion of normal sterile tissue by those organisms.
increased extracellular fluid levels.
increased blood pressure due to decreased metabolic demands.
increased renal blood flow that causes increased voiding.

4. Three of the most common causes of SIRS are normally from:

pancreatitis, burns or trauma.
renal colic, fractures or psychiatric illnesses.
back strain, anaphylaxis or CHF.
all of the above.

5. This patient has a history of an enlarged heart with CHF, NIDDM type of diabetes and some degree of renal failure from his past medical history. If the patient was on beta blockers or calcium channel blockers, we might not see _________ as well as hypertension from high output shock or SIRS.

Tachycardia
Tachypnea
Bradycardia
All of the above.

6. This patient’s rapid breathing can cause _______________ from ineffective breathing patterns or decreased tidal volume.

Decreased chest compliance
Decreased PaCO2 less than 32 mm
Increased atelectasis
All the above

7. The best oxygen therapy for this patient would be from ____________.

NRB at 12 to 15 lpm
BVM at 8 to 10 breaths per minute with a high sources oxygen reservoir
Nasal prongs at 4 to 6 lpm
A and B

8. On your examination you find the patient is peripherally shut down with weak distal pulses and mottled skin. You know he is unstable or in decompensated shock. You know that with SIRS leading to sepsis then severe sepsis your blood pressure stays stable or does not drop for the first 24 hours of the infection process. True or false?

True
False

9. This patient has multiple system problems. How do you prioritize the care required in this case?

Always perform airway procedures initially.
Assess and apply interventions that will assist the ventilations or breathing secondly.
Assess the circulatory status by evaluating central and peripheral pulses and also work on stabilizing the cardiovascular status.
All of the above in the order as above.

10. The patient’s breathing rate is faster than what you would like to see. The respiratory rate is over 20 bpm and the PaCO2 less than 32 mm. As a BLS provider, can you easily slow or stop the breathing rate from being too fast?

Yes, just bag him with the BVM slow and harder and you will correct the problem.
No, the patients breathing is due to the complication at a cellular level. The ALS provider can work on correcting the complication by aggressive resuscitation and likely intubation and paralytics but that is not an option for the BLS provider.

11. What is likely causing this patient to have a very fast heart rate and a very low BP?

Decompensated shock.
Third spacing of intracellular fluid.
Metabolic demands utilizing more than is available for body functions.
All of the above.

12. What is the likely cause of the patient's low Sp02 or an Sp02 that will not register in this case?

Hypoxia due to poor tidal volume.
Bilateral pneumonia.
Hypovolemia from increased metabolic demands, poor fluid intake and third spacing valuable body fluid from the circulatory system.
All of the above.

13. The initial treatment for this unstable patient suggests we provide prehospital care IV fluid resuscitation. The new evidence would recommend that we administer IV fluid to achieve _____ systolic BP or a MAP of _____ as a minimum.

80 and 65
90 and 70
70 and 50
110 and 65

14. What would be the best position to transport this patient?

Head and chest slightly elevated.
Prone position.
Laying left lateral recumbent.
Supine position.

15. What age group would have a better chance of survival with sepsis? The older or the younger patient?

The older one.
The younger one
Neither.

16. As you complete your rapid primary assessment of the patient you come up with a few different diagnoses that are also likely complications. They are:

acute MI or respiratory failure.
influenza.
meningitis or MODS.
all of the above.

17. On examination of the patient you see a sinus tachycardia with a narrow QRS complex. The best intervention would be to:

apply oxygen at a high flow rate, assist ventilations and intubate when ready or elect to wait until arrival to the local ER.
initiate IV boluses of 20 ml/kg x 2 or 3 to see if the BP will improve and the tachycardia will decrease.
set up a pressor agent and initiate it and titrate prn if the fluid does not help prior to attempting an intubation.
all of the above.

18. You have started two 18-gauge IVs into the A/C veins. You want to initiate IV fluid. With suspected septic shock, the best IV solution in this case would be to use ____________.

NS 3% (hypertonic solution) and infuse 500 ml of fluid initially.
NS 0.9% (isotonic solution) with a 20 ml/kg bolus.
Albumin 4% (hypertonic solution) and administer 100 ml.
Pentaspam solution and administer 500 ml.

19. The patient is showing improvement in his BP after your initial interventions. The BP is now 72/34. You can attempt to assist the BP to stabilize with a (an):

vasopressin infusion at 0.02 to 0.04 units/minute.
norepinephrine infusion from 0.5 to 30 mcg/min.
dopamine infusion from 10 to 20 mcg/kg/min.
all of the above.

20. In the prehospital setting, is there a role for an ephedrine bolus of 5 mg to 25 mg or to initiate as an infusion in unstable patients?

Yes.
No.

21. You have decided to intubate this patient prior to transport but you have a patient that is biting down on the laryngoscope just enough to prevent the tube from going in. The GCS is 4 to 5/15. You would select the following medications to perform an RSS or RSI:

25 to 50 mcg slow IVP Fentanyl or 2.5 mg IVP Versed.
etomidate IV at 0.3 mg/kg.
anectine IVP at 1 1.5 mg/kg.
ensure your pressors agent is initiated prior to any sedatives or mediations that can decrease the sympathetic tone, such as Levophed or Dopamine.
all of the above.

22. After intubation the patient tends to be harder to ventilate than what you would expect. This can be from:

H1N1 virus.
ARDS or bilateral pneumonia.
bacteremia.
A and B.
all of the above.

23. Your online medical control asks you to initiate additional IV boluses based on your patient presentation. What findings can you also look at that will let you know it is an AMI or sepsis en route or on arrival to the local ER?

12 lead.
Blood gases with a lactate.
Chest X-ray.
All of the above.

24. You insert a Foley catheter into the patient. The urine comes out very dark and thick looking. This is a sign of rhabdomyolysis. The treatment for this complication is __________________.

To give IV fluid bolus
To restrict IV fluid now

25. The mortality rate in this patient can be as high as:

3% to 5%.
15% to 21%.
45% to 50%.

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