PM TEST 2 id 363355 Nieznany

Test 2

1. The mother of an 11-year-old tells you that her daughter cannot breathe.

Assessment reveals her to be complaining of a headache and malaise. Her mother
states that she has been sick for two days and does not seem to be getting any
better. Her vital signs are pulse 88 beats per minute, respirations 20 per minute,
blood pressure 102/70 mmHg, and Sp

99% on room air. Her temperature is

100.6F and she has a considerable amount of greenish-yellow mucous discharging
from her nose. Palpation to the sinuses under both cheekbones reveals tenderness.
Why would medical command order you to administer acetaminophen to this
patient?

2. You have been dispatched to a physician’s office for an 18-year-old male who is

short of breath. On arrival, the physician states that the patient has a confirmed
spontaneous pneumothorax to the right lower lung and requires transport to the
hospital. The patient is complaining of some shortness of breath associated with
slight pain to the right lower chest when he takes a deep breath. His pulse is 80
beats per minute, respirations 16 per minute, blood pressure 110/70 mmHg, and
Sp

97% on room air. There is no tracheal deviation or JVD; however, breath

sounds are slightly decreased to the right lower lung. Based on the presentation and
physician’s diagnosis, the underlying cause of the patient’s shortness of breath is
best described as:

Decrease inflammation

Liquefy the mucous

Decrease the fever

Dry up secretions

Rationale

Treatment of an upper respiratory tract infection, including sinusitis, is mainly supportive
and not geared towards acute intervention, unless a life threatening condition exists.
Acetaminophen is an antipyretic and helps to reduce the fever associated with the
infection as well as provide analgesia to any associated pain or discomfort.
Acetaminophen does not dry up secretions, as would an antihistamine, nor does it
decrease inflammation as would aspirin. Mucolytics and fluid are used to liquefy and
loosen mucoid secretions, not acetaminophen.

(Dot Objective 5-1.1)

air trapping in the alveoli located in the right lower lung.

air accumulation in the right intrapleural space.

blood and air collection in the right lower lobe.

infection and accumulation of pus in the right lobe.

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3. You have been dispatched to a physician’s office for an 18-year-old male who is

97% on room air. There is no tracheal deviation or JVD; however, breath

sounds are slightly decreased to the right lower lung. The appropriate management
of this patient would include:

4. You have been dispatched to the scene for a patient who is actively seizing. Upon

your arrival at the scene, you find a 24-year old male who appears to be in a
postictal state. As you approach the patient you note that he has sonorous
respirations and is breathing at 14 breaths per minute and shallow. The victim’s
sister stated that she called 911 after she walked in the house and found her brother
lying on the ground seizing. Your initial approach to this patient should include:

Rationale

A pneumothorax describes a condition in which air has entered and accumulated in the
intrapleural space, compressing the alveolar compartments and the small airway passages
in the lower airway. The compressed alveoli and airways are useless in the transfer of
oxygen and carbon dioxide into and out of the bloodstream respectively. The
pathophysiology underlying a spontaneous pneumothorax does not involve air trapping or
blood collection within the lung tissue itself. The accumulation of pus in the lung is more
descriptive of consolidation secondary to pneumonia or empyema.

(Dot Objective 5-1.1)

nebulized beta2 bronchodilator.

needle decompression.

orotracheal intubation.

oxygen

Rationale

Despite the stable clinical presentation of the patient, the most appropriate treatment
listed would still be oxygen. The paramedic may also elect to apply the cardiac monitor
and establish IV access. There is no indication for orotracheal intubation given the
stability of the patient. Since the pneumothorax has not become a tension pneumothorax
(hemodynamic instability), needle decompression is not appropriate and could create
more of a problem (most likely necessitating a chest tube in the hospital). The patient s
underlying problem deals with air in the intrapleural space, not bronchiole constriction.
Therefore, nebulized beta2 bronchodilators are not indicated.

(Dot Objective 5-1.1)

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5. You respond for an unresponsive patient at a local festival. Upon your arrival,

bystanders indicate that they think he has been drinking heavily. As you assess the
patient, you note alcohol odor on the breath, the patient is responsive to painful
stimuli, has gurgling respirations, and is breathing shallow at 14 times per minute.
What are the initial management priorities for this patient?

performing orotracheal intubation with bag-valve assisted ventilations at a rate of 10 to
12 per minute.

opening the airway using the modified jaw-thrust maneuver followed by the
administration of high-flow oxygen through a nonrebreather mask.

opening the airway using the modified jaw-thrust maneuver followed by bag-valve
assisted ventilations.

performing nasotracheal intubation with bag-valve assisted ventilations at a rate of 10-
12 per minute.

Rationale

Opening the airway using the modified jaw thrust maneuver is imperative because it is
unknown as to whether the patient had fallen or had already been lying down when he
began to have his seizure. It is necessary to assist this patient s respirations since he has
inadequate tidal volume and will therefore not be effectively exchanging gases at the
alveolar level. The vast majority of post ictal patients do not require long-term airway
maintenance; rather, they require simple airway maintenance until they can completely
regain consciousness and assume control of their own airway.

(Dot Objective 2-1.2)

Open the airway, insert an oral airway, and place the patient on a non-rebreather mask
device

Open the airway, suction the airway, and place the patient on a nonrebreather mask
device

Open the airway, insert an oral airway, and ventilate the patient with a bag-valve-mask
device

Open the airway, suction the airway, and ventilate the patient with a bag-valve-mask
device

Rationale

The most appropriate intervention for this patient is to open the airway and immediately
begin suctioning. The patient has gurgling respirations, which indicates that he has fluid in
his upper airway. Opening the airway alone will not alleviate the gurgling respirations.
Bag-valve ventilation would be necessary in this patient because the shallow respirations
represent an inadequate tidal volume.

(Dot Objective 2-1.32)

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6. You have an unresponsive patient who has snoring respirations. One advantage of

the nasopharyngeal airway over the oropharyngeal airway is that it:

7. Suppose that you are working in a rural area with an average transport time of 25

minutes to the closest hospital. Which of the following patients would you consider
an appropriate candidate for the use of an automatic transport ventilator (ATV)?

8. You have responded for an unresponsive infant. Upon your arrival, first responders

indicate that the baby had been the unrestrained passenger in a rollover MVC. As
you assess the patient, you note the infant to be unresponsive with gurgling
respirations, and shallow respirations at 10 breaths per minute. What are the initial
management priorities for this patient?

may be used in the presence of a gag reflex.

does a better job displacing the tongue.

isolates the trachea from the esophagus.

reduces the possibility of hypoxia.

Rationale

When used in a conscious patient, the nasopharyngeal airway can be inserted along the
posterior pharynx, behind the tongue but anterior and superior to the epiglottis.
Stimulation of the vagus nerve and gag reflex is avoided with this insertion device.

(Dot Objective 2-1.42)

A 36-year-old status asthmaticus patient

A 600 pound, 19-year-old patient with a hemopneumothorax

A 4-year-old respiratory failure patient

A 44-year-old post cardiac arrest patient

Rationale

Automatic transport ventilators can be beneficial in many scenarios. They are not to be
used in the cases of airway obstruction, or in excessively small or large patients. They
should also be used with caution in patients who have the susceptibility for pressure
related complications.

(Dot Objective 2-1.46)

Open the airway, suction the airway, and ventilate the patient with a bag-valve-mask
device.

Open the airway, suction the airway, and place the patient on a non-rebreather mask

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9. In the management of a pediatric airway, the anatomic differences of the pediatric

epiglottis suggest that the paramedic utilize which of the following laryngoscope
blades to intubate the patient?

10. What drug would you administer to block the vagus nerve in response to intubation

with children?

device.

Open the airway, suction the airway, and nasally intubate the patient.

Open the airway, suction the airway, and orally intubate the patient.

Rationale

The most appropriate intervention for this patient is to open the airway and immediately
begin suctioning. The patient has gurgling respirations, which indicates that he has fluid in
his upper airway; opening the airway alone will not alleviate the gurgling respirations.
Bag-valve ventilation would be necessary in this patient because the shallow respirations
represent an inadequate tidal volume. Additionally, although intubating this patient is
appropriate, it is not appropriate to delay transport to intubate the patient on the scene.

(Dot Objective 2-1.56)

Fiberoptic blade

Miller blade

Macintosh blade

Wisconsin blade

Rationale

The Miller or straight blade is preferred over the other blades because it directly lifts the
oblong, u-shaped, epiglottis up and out of the way, for better visualization of the vocal
cords.

(Dot Objective 2-1.76)

Atropine

Succinylcholine

Lidocaine

Fentanyl

Rationale

When the vagus nerve is stimulated, as can occur with hypoxia and laryngoscopy, it
excites the parasympathetic nervous system. Atropine is a parasympatholytic, which
means that it blocks the parasympathetic nervous system and can help prevent the drop

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11. What is the purpose of oxygen in the blood?

12. To adequately ventilate an adult male with a pulse, what respiratory rate and tidal

volume is required?

13. Hyperventilation lowers CO

levels and can be the result of:

in heart rate with pediatric intubation.

(Dot Objective 6-1.21)

It is essential in the Krebs cycle for the metabolism of proteins and fatty acids.

Cells require oxygen in the production of important biological enzymes.

Oxygen serves as the final electron acceptor in the electron transport chain.

It serves in the production of adenosine triphosphate (ATP) in glycolysis.

Rationale

Oxygen is the final electron acceptor in the electron transport chain during the production
of ATP during fat and sugar catabolism. Without oxygen present, anaerobic respiration
would occur producing far less energy than aerobic respiration. The difference is about 2
ATP molecules per glucose (pyruvate) molecule to 36 ATP molecules per glucose
(pyruvate) in the presence of oxygen in the electron transport chain.

(Dot Objective 2-1.9)

1 breath every 3 seconds with enough volume to cause the chest to rise

1 breath every 4-5 seconds with enough volume to cause the chest to rise

1 breath every 3 seconds with a volume of 1200cc per breath

1 breath every 5 seconds with a volume of 1200cc per breath

Rationale

One breath every 4-5 seconds will provide about 12 breaths per minute, which is within
the normal respiratory range of the average adult with a pulse. The normal tidal volume
of an adult is between 500-800cc per breath. By achieving adequate chest rise with
ventilations, you will achieve an adequate tidal volume.

(Dot Objective 2-1.19)

decreased minute volume.

shallow respirations.

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14. Which of the following is the most appropriate method for relieving a persistent

foreign body airway obstruction in an unresponsive infant after manual techniques
have failed?

15. During your history and physical exam of a patient with a suspected stroke, you note

that the patient seems extremely attentive to your treatment interventions, but
keeps asking the same question repeatedly, “Where are we going?" Upon calculation
of the Glasgow Coma Scale, you would document the verbal response section as a:

an increased respiratory rate.

a decrease in normal serum blood pH.

Rationale

Carbon dioxide is essential in the production of bicarbonate. Several factors influence
carbon dioxide’s concentration in the blood, including increased CO

production and/or

decreased CO

elimination.

(Dot Objective 2-1.19)

Direct laryngoscopy and McGill forceps

Continued abdominal thrusts

Providing Cardiopulmonary resuscitation

Providing additonal sets of 5 back blows

Rationale

For a persistent airway obstruction, you should attempt direct laryngoscopy and use
McGill forceps to remove an obstruction. Abdominal thrusts are not recommended for
infants. CPR is not required until after the airway is cleared and the patient is pulseless
and apneic.

(Dot Objective 2-1.53)

Rationale

The Glasgow Coma Scale (GCS) is a widely used scoring system used in quantifying level
of consciousness following brain injury. It is used primarily because it is simple, has a
relatively high degree of reliability, and because it correlates well with outcome following
severe brain injury. The best response of eye opening, motor response, and verbal

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16. Which of the following will reduce gastric distention during artificial ventilations on an

adult victim?

17. If your patient has a partial laryngectomy and stoma, what must you do to provide

adequate mask-to-stoma ventilations?

18. What is a possible complication associated exclusively with digital tracheal

response is used to compute the score, which ranges between 3 and 15. In this patient,
the patient would be awarded 4 points for their verbal response, which means they are
disoriented, but can converse.

(Dot Objective 3-2.3)

Rapidly squeezing the bag-valve-mask during ventilations

Positioning the patient at a 15 degree angle during ventilations

Providing ventilations over approximately 1 second

Pressing on the stomach periodically during ventilations

Rationale

Providing slow ventilations (over one second) will allow for more air to enter into the
glottic opening and lungs. A tidal volume that is only enough to provide chest rise will also
reduce the amount of air that enters the stomach. Providing fast sharp respirations will
force air into the esophagus and increase distention. Pressing on the stomach could cause
vomiting and therefore it is not recommended.

(Dot Objective 2-1.39)

Pinch the nose and close the mouth

Suction the stoma with a soft-tip suction catheter first

Use a special bag-valve-mask that is designed to ventilate a stoma

Use less pressure to produce adequate chest rise

Rationale

When providing mask to stoma ventilations with a bag valve mask to a patient with a
partial laryngectomy, you must close the nose and mouth or air will be able to escape and
reduce the amount of positive pressure that you are providing. You only need to suction if
the patient is difficult to ventilate. Approximately the same amount of pressure will be
required to generate chest rise.

(Dot Objective 2-1.29)

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intubation?

19. Which of the following correctly describes what will occur with an esophageal

detection device (EDD) after it is applied to the endotracheal tube that is properly
positioned in the trachea?

20. Which of the following is the preferred method by which you should insert an

oropharyngeal airway (OPA) into an infant patient?

Increasing the patient’s intracranial pressure

Stimulating a vagal response

Damage to the intubator’s hand

Damage to the soft tissues of the oropharynx

Rationale

Digital intubation is often considered a dangerous technique. If the patient is still
conscious or semiconscious, the risk of clamping is possible resulting in damage to the
intubator’s hand. Other forms of intubation can also stimulate a vagal response, increase
ICP and damage the oropharynx so they are not exclusive limitations or concerns of
digital intubation.

(Dot Objective 2-1.63)

It will quickly inflate due to the lack of air in the trachea

It will quickly inflate due to the residual air in the trachea

It will stay deflated due to the lack of air in the trachea

It will stay deflated due to the residual air in the trachea

Rationale

The EDD will inflate due to the nature of the trachea. By applying negative pressure with
the EDD the trachea will remain open and air will enter the EDD. If the tube is in the
flaccid esophagus, air will not enter the EDD and it will remain deflated. If the tube is
positioned incorrectly in the right mainstem bronchi, however, it will still reinflate. As
such, although it confirms tracheal placement, it does not confirm proper tracheal
placement (i.e. proximal to the carina).

(Dot Objective 2-1.73)

Use a tongue depressor and insert in normal anatomical position.

Airway adjuncts should be avoided in all infants if possible.

Use upside-down and then rotate 180 degrees into position.

Use sideways and then rotate 90 degrees into position.

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21. Which of the following patients most likely suffers from chronic bronchitis?

22. A home health nurse has contacted 911 and asked that EMS be dispatched to a

residence for a patient with altered mental status. On scene, you find the 53-year-
old male in bed with the nurse by his side. The nurse states that the patient was
released from the hospital one week ago after being treated for acute renal failure
secondary to an exacerbation of lupus. However, a blood work-up has shown that he
is back in severe acute failure and not producing any urine, despite adequate fluid
and dietary intake. Assessment reveals the patient to be responsive to pain
accompanied by labored breathing. The radial pulse is difficult to locate. His skin is
cool and diaphoretic and lung sounds reveal bilateral rales. There is no jugular
venous distention or edema noted. Vital signs are pulse 40 beats per minute,
respiration 14 and labored, blood pressure 70/50 mmHg, and temperature 98.6 F.
Aside from lupus, the patient has no other medical history. Oxygen has been applied
and an IV established. The cardiac monitor shows the following rhythm: Given the
history and presentation of the patient, which of the following is most likely
responsible for the patient s ECG tracing?

Rationale

The risk of damaging the soft tissues of the oropharynx is increased in infants, so
inserting an OPA and then rotating it should be avoided. The correct means to insert an
OPA is with the aid of a tongue depressor and then insert it in the manner in which it is to
stay (normal anatomical position).

(Dot Objective 3-2.6)

A 56-year-old female who has been a heavy cigarette smoker for the past 40 years
with a productive cough

A 44-year-old male patient who is overweight and is frequently cyanotic

A 20-year-old female who has a genetic disorder causing her lungs to trap and hold
infectious particles

A 75-year-old male patient who is very thin and often has productive cough

Rationale

Chronic Bronchitis is characterized by frequent outbreaks of bronchitis over several years.
The patient is classically overweight and cyanotic becomes dyspneic with very little
movement. The other patients are at risk of emphysema, and the youngest patient
probably has cystic fibrosis.

(Dot Objective 5-1.10c)

Bacterial infection

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23. A home health nurse has contacted 911 and asked that EMS be dispatched to a

residence for a patient with altered mental status. On scene, you find the 53-year-
old male in bed with the nurse by his side. The nurse states that the patient was
released from the hospital one week ago after being treated for acute renal failure
secondary to an exacerbation of lupus. However, a blood work-up has shown that he
is back in severe acute failure and not producing any urine, despite adequate fluid
and dietary intake. Assessment reveals the patient to be responsive to pain
accompanied by labored breathing; the radial pulse is difficult to locate. His skin is
cool and diaphoretic and lung sounds reveal bilateral rales. There is no jugular
venous distention or edema noted. Vital signs are pulse 40 beats per minute,
respiration 14 and labored, blood pressure 70/50 mmHg, and temperature 98.6 F.
Aside from lupus, the patient has no other medical history. High flow oxygen has
been applied and an IV established. The cardiac monitor shows the following rhythm:
The initial intervention for this patient would be:

Hyperglycemia

Electrolyte imbalance

Dehydration

Rationale

The kidneys are responsible for regulating electrolytes. Failure of the kidneys results in
elevated electrolyte levels since they cannot be properly excreted. A critical electrolyte
that becomes elevated in renal failure is potassium, which is described as hyperkalemia.
Hyperkalemia typically manifests itself with cardiac abnormalities, the most common
being an ECG showing flattened “P” waves, widened QRS complexes, and peaked “T”
waves. Heart blocks, including the third degree block shown, are also common. There is
no mention made of diabetes or a blood glucose evaluation, therein eliminating
hyperglycemia as a cause. With a normal body temperature, it is unlikely that a bacterial
infection is at play. Since the kidneys cannot excrete urine, fluid overload, not
dehydration, would be the concern.

(Dot Objective 5-2.37)

transcutaneous pacing.

dopamine infusion (5 to 10 mcg/kg/min.).

fluid bolus of 0.9% normal saline.

furosemide (Lasix).

Rationale

The most appropriate initial treatment would be geared towards increasing the patient’s
heart rate. As such, transcutaneous pacing (TCP) would be the intervention of choice.
Transcutaneous pacing is an effective and quick means of increasing the heart rate and
cardiac output of a patient with hemodynamically significant bradycardia. (The American
Heart Association also states that TCP is a class I intervention for third degree heart block
with cardiovascular compromise.) An increase in heart rate and cardiac output will
increase blood flow to the vital organs, thereby minimizing the opportunity or severity of
damage from hypoperfusion. Diuresis via Lasix is not indicated given the hypotensive

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24. You are providing transcutaneous pacing to an adult patient with hemodynamically

significant bradycardia. The rate is set at 70 per minute and milliamps 60. The ECG
shows the following tracing: At this time, your immediate action would be to:

25. You have been dispatched to an apartment of a 73-year-old male who has

summoned you for shortness of breath. The patient is confused and trying to sit
upright in his bed as he talks to you. Assessment reveals the patient to have labored
breathing, a rapid radial pulse, and to be cool and diaphoretic. Lung sounds indicate
scattered rales bilaterally, with greater pronouncement in the bases. While his neck
displays distention of the jugular veins, there is no edema noted elsewhere on the
body. Vital signs are pulse 132 beats per minute, respirations 20 per minute, blood
pressure 156/98 mmHg, and Sp

91%. The cardiac monitor shows the rhythm

below: Based on these assessment findings, the paramedic should recognize:

status of the patient and history of acute renal failure. A fluid bolus to increase blood
pressure is questionable since the patient is in renal failure and may be intolerant of
additional body fluid. Although dopamine may be beneficial in simultaneously increasing
the heart rate and blood pressure, transcutaneous pacing should be attempted first due to
its ease in implementation and proven effectiveness.

(Dot Objective 5-2.16)

decrease the rate setting.

adjust the milliamps to 70.

continue to monitor the patient.

synchronize cardiovert.

Rationale

The ECG indicates that the pacer is not “capturing” the heart’s electrical system. The most
common cause of non-capture is not having the milliamps at a high enough setting.
Therefore, given the situation, the paramedic should gradually increase the milliamps until
electrical and mechanical capture occurs. Since synchronized cardioversion is reserved for
tachydysrhythmias, there is no indication for this intervention. A rate of 70 to 80 per
minute is standard for the adult patient and is generally not adjusted unless extenuating
circumstances exist. Monitoring the patient is incorrect because the pacemaker has yet to
capture the heart’s electrical system, thus proving no benefit. Monitoring would be
appropriate once both electrical and mechanical capture have been achieved.

(Dot Objective 5-2.57)

heart failure.

cardiogenic shock.

asthma.

hypertensive emergency.

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26. You have been dispatched to an apartment of a 73-year-old male who has

91%. The cardiac monitor shows the rhythm

below: Which of the following scene clues would best support your selection of the
above field impression?

27. You have been dispatched to an apartment of a 73-year-old male who has

summoned you for shortness of breath. The patient is confused and trying to sit

Rationale

The assessment findings, particularly the pulmonary edema, jugular venous distention,
low pulse oximeter reading, and hypertension, along with the complaint of shortness of
breath, should led the paramedic to a field impression of heart failure. Although the
patient is hypertensive, a hypertensive emergency is generally not seen until the diastolic
blood pressure reaches 130 mmHg. Aside from the complaint of shortness of breath,
there are no clinical findings indicative of an acute asthmatic episode. Cardiogenic shock
would present similarly, but the blood pressure would indicate hypotension, not
hypertension.

(Dot Objective 5-2.17)

Albuterol inhaler on the nightstand

Stacked pillows on the bed

Cold temperature in the bedroom

Vomit on the bed sheet

Rationale

Patients with heart failure frequently experience orthopnea, or difficulty breathing, when
lying in bed. When the body is supine, the return of blood to the heart is greater than if
seated or standing. Consequently, the weak heart cannot pump all of the blood and the
plasma portion escapes into the interstitial and alveolar compartments of the lung,
making it difficult to breathe. By sleeping with several pillows under the head, neck, and
chest, the body assumes more of an upright position, decreasing the return of blood to
the heart and resultant dyspnea. A cold temperature in the bedroom would not be
indicative or exacerbate heart failure. Vomitus on the bed sheet is nonspecific and could
indicate any of a variety of conditions. An albuterol inhaler suggests asthma or CPOD, not
heart failure.

(Dot Objective 5-2.87)

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upright in his bed as he talks to you. Assessment reveals the patient to have labored
breathing, a rapid radial pulse, and to be cool and diaphoretic. Lung sounds indicate
scattered rales bilaterally, with greater pronouncement in the bases. While his neck
displays distention of the jugular veins, there is no edema noted elsewhere on the
body. Vital signs are pulse 132 beats per minute, respirations 20 per minute, blood
pressure 156/98 mmHg, and Sp

91%. The cardiac monitor shows the rhythm

below: Given the patient’s presentation, what medication would you expect to find
this patient taking?

28. You are in a long-term care facility assessing a patient with altered mental status

and a history of pericarditis. The staff physician is also present and informs you that
the patient has developed pericardial tamponade secondary to the infection and
requires emergency medical treatment and transport to the emergency department.
The patient is responsive to verbal stimuli and confused when questioned. An
assessment has been completed, oxygen applied, and an IV established. The cardiac
monitor displays the following rhythm: Given the physician’s description of the
patient’s underlying problem, the paramedic would understand that:

Diuretic

Antihistamine

Antibiotic

Bronchodilator

Rationale

Patients with heart failure are prescribed diuretics for use at home. Diuretics such as
Lasix, Bumex, or Spironolactone are useful in excreting excess fluid from the body,
decreasing the chance of backup in the lung tissue. Bronchodilators are not typically
prescribed in the home setting for patients with heart failure. Rather, bronchodilators are
found with patients with reactive or chronic airway diseases (e.g., asthma, bronchiectasis,
chronic bronchitis, and emphysema). Antibiotics would hold no benefit to the patient with
heart failure. The same is true of an antihistamine like Benadryl.

(Dot Objective 5-2.95)

blood is accumulating in the pleural space.

pus is leaking from the pericardial sac into the lung tissue.

a coronary artery has ruptured and is spilling blood into the ventricles.

fluid is accumulating between the heart and pericardial sac.

Rationale

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29. You are in a long-term care facility assessing a patient with altered mental status

and a history of pericarditis. The staff physician is also present and informs you that
the patient has developed pericardial tamponade secondary to the infection and
requires emergency medical treatment and transport to the emergency department.
The patient is responsive to verbal stimuli and confused when questioned. An
assessment has been completed, oxygen applied, and an IV established. The cardiac
monitor displays the following rhythm: Which of the following assessment findings
would indicate that the pericardial tamponade is severe?

30. You are in a long-term care facility assessing a patient with altered mental status

(Dot Objective 5-2.97)

Hypotension

Abdominal pain

Flat jugular veins

Loud heart sounds

Rationale

Pericardial tamponade describes a condition in which fluid, blood, or pus (depending on
the casual condition) accumulates between the heart and pericardial sac. Since the
pericardial sac is very fibrous and has difficulty expanding, the heart is compressed and
cardiac output falls. This results in hypotension and is an ominous sign in a critical
patient. Flat jugular veins are indicative of hypovolemia, not pericardial tamponade. In
severe cases, jugular venous distention is seen in conjunction with tamponade since the
heart is so compressed by fluid that it cannot accept returning blood. The blood then
backs up into the jugular veins. Heart tones in tamponade are muffled and difficult to
hear secondary to the increased volume of fluid between the pericardial sac and
myocardium. There is no direct correlation between abdominal pain and pericardial
tamponade. Additionally, abdominal pain is nonspecific and could indicate any of a
number of conditions.

(Dot Objective 5-2.17)

third degree heart block.

pulsus paradoxus.

electrical alternans.

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31. Which of the following statements would be most concerning coming from a patient

with chronic heart failure?

32. During which cardiac phase are the coronary vessels filled?

Wolff-Parkinson-White syndrome.

Rationale

The ECG as shown is best described as electrical alternans. In electrical alternans, the
shape and size of the “P” wave, QRS complex, and “T” wave changes with every other
beat. This is caused when contraction of the myocardium causes the heart to move within
the accumulation of fluid in the pericardium and then shifts back to its original position.
Electrical alternans is a highly specific sign for pericardial tamponade. Pulsus paradoxus
describes a drop in systolic blood pressure of 10 mmHg or more with each inspiration and
may be observed in pericardial tamponade. A third degree heart block would be indicated
by dissociation between the “P” waves (atrial activity) and QRS complexes (ventricular
activity). Wolff-Parkinson-White syndrome describes an accessory pathway between the
atrial and ventricles and is apparent by a “delta” wave immediately preceding the QRS
complex.

(Dot Objective 5-2.1)

“I have not been able to urinate.”

"I have gained 4 pounds in two days.”

“I have a constant headache.”

“I am hungry all of the time.”

Rationale

Rapid weight gain is associated with fluid retention in the patient suffering from heart
failure. The additional fluid is deposited into body tissues and can be outwardly observed
through signs like pulmonary rales and/or jugular venous distention and edema to the
legs and arms. Furthermore, the already weak heart must work harder to pump an
expanded blood volume, predisposing it to cardiac dysrhythmias and/or infarction. A
chronic headache or hunger is not specific to heart failure. Difficulty in urinating suggests
a problem with the renal system, not the cardiovascular system.

(Dot Objective 5-2.88)

Consistently throughout the cardiac function

Ventricular diastole

Ventricular systole

They fill independent of the cardiac cycle

Rationale

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33. Based on Frank Starling’s Law, when a failing heart is subjected to increases in

preload and afterload, its ability to compensate is directly proportional to what
mechanism?

34. While assessing a 56-year-old male patient with complaints of shortness of breath,

you note that the patient has some mild wheezing and bi-basilar crackles.
Additionally, you note that the patient has an audible S3 cardiac sound. Vital signs
include a heart rate of 98, respirations of 22, and a Blood pressure of 172/96 mm
Hg. What is the most likely cause of the S3 cardiac sound in this patient?

The coronary blood vessels are perfused during ventricular diastole. When the ventricles
are resting, the residual blood left in the aorta after the ventricle has pumped blood
through to systemic circulation will drop into the coronary vessels.

(Dot Objective 5-2.8)

Rate of cardiac contraction

Strength of contraction

Vasoconstriction

Vasodilation

Rationale

Frank Starling’s law states that “When the venous return of blood to the heart increases
the heart beats more forcefully and puts out more blood”

(Dot Objective 5-2.18)

Congestive heart failure

Physiologic murmur

Cardiogenic shock

Mitral valve disease

Rationale

This patient is most likely experiencing acute CHF. An S3 cardiac sound is indicative of
elevated left ventricular filling pressures and to a lesser degree, left ventricular function.
When a patient over 40 has an S3 sound, it should be considered abnormal. The most
common clinical presentation of a patient with an S3 is either Acute Coronary Syndrome
or Congestive Heart Failure.

(Dot Objective 5-2.28)

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35. What is considered to be a normal P-R interval?

36. A 44-year-old male is brought by his wife to your station with the complaint of

intermittent chest pain for three days but he states that it never completely went
away. Vital signs include a heart rate of 116, respirations of 26, and a blood pressure
of 76/palpation. Lung sounds have rales and are decreased throughout, his jugular
veins are distended, and he has 4 plus pitting edema to his lower extremities. What
is your initial field diagnosis of this patient?

37. You are evaluating a 47-year-old female who has the complaint of chest pain, for two

days that has been intermittent, but never completely resolved. The patient is
waning in and out of consciousness, her vital signs include a heart rate of 116,
respirations of 32, and a Blood pressure of 76/palpation. Lung sounds have rales and
are decreased throughout, her jugular veins are distended, and she has 4 plus
pitting edema to her lower extremities. What drug treatment would you recommend
for this patient?

.08-.12 msec

.04-.12 msec

.12-.20 msec

.20-.24 msec

Rationale

The normal PR interval in a physiologic rhythm is between .12 and .20 milliseconds.

(Dot Objective 5-2.38)

Isolated left heart failure

Cardiogenic shock

Isolated right heart failure

Massive pulmonary embolus

Rationale

The patient is exhibiting signs of both right and left heart failure with hypotension. The
patient has most likely infracted some time in the last three days and the infarct has
affected the patient’s cardiac output to the point that it is no longer adequate to perfuse
the body or the myocardium. This patient is in cardiogenic shock until proven otherwise.

(Dot Objective 5-2.88)

Nitroglycerin infusion at 20 mcg/kg/min

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38. You have responded to a local residence for a 77-year-old male who is complaining

of leg weakness and lower back pain. Your assessment of the patient reveals him to
be alert and oriented with strong radial pulses and weak popliteal and pedal pulses.
The patient s heart rate is 124, respirations are 18 and his blood pressure is 178/88
mmHg. The patient tells you that he was diagnosed with an aneurysm about 2 years
ago. What type of aneurysm do you suspect in this patient?

39. You have responded to a local residence for a 64-year-old male who is complaining

of severe chest pain and shortness of breath. As you are assessing the patient, he
becomes unresponsive. The patient’s heart rate is 46, respirations are 18 and his
blood pressure is 72/40 mmHg. What is the most appropriate treatment for this
patient?

Retavase infusion of 10 mg

Lasix 40-80 mg IVP

Dopamine 5-10 mcg/kg/min

Rationale

The patient is exhibiting signs of both right and left heart failure with hypotension. The
patient has most likely infarcted some time in the last two days and the infarct has
affected the patients cardiac output to the point that it is no longer adequate to perfuse
the body or the myocardium. This patient is in cardiogenic shock and requires pressure
support. Dopamine is the only drug in this list that will support the patient’s pressure
emergently.

(Dot Objective 5-2.118)

Cerebral aneurysm

Aortic arch aneurysm

Descending aortic aneurysm

Subclavian aneurysm

Rationale

The decrease in blood flow to the lower extremities in light of strong radial pulses is
concerning and suggests that flow to the lower extremities is inhibited. This places the
location of the vascular irregularity in the decending abdominal aorta.

(Dot Objective 5-2.148)

Immediate transcutaneous pacing

Dopamine infusion

20cc/kg fluid bolus

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40. You have responded to a local residence for a 50-year-old male who is complaining

of shortness of breath. The patient’s heart rate is 104, respirations are 26 and his
blood pressure is 176/92 mmHg. Auscultation of his heart sounds suggest that the
patient may be in the early stages of heart failure. What cardiac sounds would you
expect to hear in this patient?

41. A cardiac arrest patient received 150 mg of Lidocaine IVP for his ventricular

dysrhythmia. Since he has not converted, what would the next dose of Lidocaine be?

Atropine 0.5mg IVP

Rationale

Since this patient is hemodynamically unstable, and in a bradycardic rhythm, he requires
transcutaneous pacing. Drugs may not work quick enough in a patient with decreased
perfusion. Atropine may also be considered, but pacing is an intervention that can be
readily implemented with excellent results.

(Dot Objective 5-2.158)

Rationale

The presence of an S3 heart sound is suggestive of ventricular dysfunction, most
commonly as the result of too much pressure in the left ventricle. Although an S4 may be
suggestive of left ventricular dysfunction, it is most commonly associated with ischemia
and left ventricular dysfunction simultaneously.

(Dot Objective 5-2.168)

Lidocaine 75 mg IVP

Lidocaine 150 mg IVP

Lidocaine 100 mg IVP

Another antidysrhythmic should be attempted

Rationale

Pharmacologic management of the cardiac arrest victim includes a patient specific
appropriate dose of Lidocaine, followed by a repeat dose if the cardiac rhythm did not
convert following the first dose. Remember however, that the doses of lidocaine should
occur in conjunction with onging defibrillation attempts, ventilations, oxygenation, and

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42. Which of the following conditions has the least effect on neurovascular ischemia or

death that occurs in a patient from an accidental poisoning?

43. Which of the following treatment modalities is the most correct for the treatment of a

patient suffering from pulmonary edema?

44. A 24-year-old female patient gave birth to a healthy baby boy four days ago. She

called 911 from her home with complaints of sudden onset of shortness of breath
and very sharp chest pain that began about 10 minutes ago. You note that she is
talking in broken sentences, her lips and nail beds are cyanotic, and she is very
diaphoretic. The following is your patient s initial EKG: What is the most likely cause

chest compressions.

(Dot Objective 5-2.178)

Collateral circulation

Oxygen level in the blood stream

Blood pressure

Cerebral drug level

Rationale

The amount of drug that a patient has ingested should have no bearing on the extent of
neurovascular damage that the patient will suffer. Whereas the level of oxygen, perfusion
pressure, and cerebral collateral circulation will have a direct impact.

(Dot Objective 5-3.4)

Oxygen, intravenous line at 30 cc/hour, sublingual nitroglycerin, and 40 mg Lasix IV

Oxygen and Lasix PO

Oxygen, saline lock, and 2 mg of IV morphine sulfate

Oxygen, intramuscular morphine sulfate, intravenous line at 30 cc/hour, and 40mg
Lasix IV

Rationale

The correct order of treatment for a patient suffering acute pulmonary edema is as
follows: Oxygen, IV at TKO or lock, 0.4 mg of SL nitroglycerin, IV Lasix, and IV morphine.
Generally, the paramedic does not administer medications through the oral route (PO).

(Dot Objective 5-1.6)

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of your patient s shortness of breath?

45. A 24-year-old female patient gave birth to a healthy baby boy four days ago. She

46. Which of the following is a common result of right-sided heart failure?

Pulmonary embolism

Pneumonia

Postpartum emphysema

Myocardial infarction

Rationale

A patient is at greatest risk of developing a pulmonary embolism several days after OB
delivery, trauma, or surgery. Although an MI and pneumonia may cause respiratory
distress the clinical picture does not fit either of those field impressions.

(Dot Objective 5-1.10g)

Positive pressure ventilations and 100% oxygen

Intravenous line of normal saline and 6 mg of Adenosine

Synchronized cardioversion at 100J

Direct laryngoscopy and intubation with a 7.0 tube

Rationale

The initial treatment that should be rendered is high flow oxygen and positive pressure
ventilations. After PPV, the patient may still require better airway maintenance with
intubation and continuation of positive pressure ventilations. The patient does not require
synchronized cardioversion or Adenosine since the problem is not pure cardiac in nature.
The problem is not a pump or rate problem, it is a respiratory problem.

(Dot Objective 5-1.6)

Mitral valve prolapse

Pulmonary edema

Pedal edema

Pericardial tamponade

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47. You respond to the scene of a 62-year-old female patient complaining of syncope

and shortness of breath that began about 20 minutes prior to your arrival. She has a
history of emphysema and angina pectoris. You find the patient lying supine on the
floor. Her skin is cool, pale, and diaphoretic. Her EKG is as follows: What is the
patient s dysrhythmia that is producing her signs and symptoms?

48. You respond to the scene of a 62-year-old female patient complaining of syncope

Rationale

Pedal edema often times results when the patient s body is not able to adequately
circulate the blood from the body back to the heart. Blood tends to back up into the
jugular veins and other parts of the periphery such as the feet. Left sided heart failure will
often result in blood being forced back into the lungs resulting in pulmonary edema. Mital
valve damage is not associated with right ventricular failure as the mitral valve prevents
backflow of blood between the left ventricle and left atria. A pericardial tamponade results
from blood force trauma to the chest.

(Dot Objective 5-2.91)

Second degree block type II

Second degree block type I

Ventricular escape

Third degree block

Rationale

The patient is in a third degree or complete heart block. Note that the atrial rhythm is
regular and the ventricular rhythm is regular, but the two do not coincide. It is as if there
are two separate EKGs superimposed on one another. Note the common findings of shock
and syncope associated with the third degree block. It is true that the P wave to P wave
distance will remain constant and the QRS to QRS distance will also remain the same, but
they do not correlate with each other.

(Dot Objective 5-2.35)

Transcutaneous pacing at a rate of 80 and starting at 80mA

Intravenous line of normal saline and 1mg of epinephrine 1:10000

Direct laryngoscopy and intubation with a 7.5 tube

Intravenous line of normal saline and 0.5 mg of Atropine

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49. You respond to the scene of a 62-year-old female patient complaining of syncope

and shortness of breath that began about 20 minutes prior to your arrival. She has a
history of emphysema and angina pectoris. You find the patient lying supine on the
floor. Her skin is cool, pale, and diaphoretic. Her EKG is as follows: If you discovered
that your patient had a heart transplant 4 years ago, how would you change your
initial treatment?

50. You are treating a male patient who complains of chest pain while he was performing

heavy lifting at work. His pain subsided when the patient stopped what he was
doing. From the given information, what is the most likely cause of his pain? His EKG
is as follows:

Rationale

TCP is indicated in a patient that is hemodynamically unstable with a high degree AV
block. TCP is indicated in the case of any unstable bradycardia. This patient is unstable
due to her condition and obvious signs of shock. TCP should be continued until a
transvenous pacer can be inserted at the hospital. Atropine is usually avoided in third
degree (or infranodal) blocks.

(Dot Objective 5-2.55)

It would not change since the patient is unstable.

10mg/min epinephrine drip would be administered to stimulate the sympathetic
nervous system.

10mg/min epinephrine infusion would be administered since the heart has been
separated from the parasympathetic nervous system.

1 mg Atropine would be administered to inhibit the parasympathetic nervous system.

Rationale

Although it is correct that the patient s heart has been denervated and separated from the
parasympathetic nervous system, the patient is still unstable and needs immediate
transcutaneous pacing. If the patient were stable, dopamine or epi infusions would be
indicated since the vagus nerve has been separated from the heart.

(Dot Objective 5-2.55)

Stable angina pectoris

Myocardial infarction

Pericardial tamponade

Unstable angina pectoris

Rationale

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51. Left-sided heart failure as the result of a myocardial infarction will often result in

which of the following?

52. You are called to a scene where a patient is entrapped in a vehicle. This patient has

an obvious humeral fracture. In the management of this patient, which of the
following pharmacological interventions are most appropriate for treating the
patient’s pain? Your assessment of his lower extremities has not yet been completed
because the lower body remains trapped.

Stable angina pectoris is chest pain that usually dissipates with rest. The onset of chest
pain associated with angina is usually the result of physical activity or stress, but unstable
angina can develop without any known cause and may not subside with rest. Unstable
angina and myocardial infarction may be difficult to differentiate between.

(Dot Objective 5-2.75)

Jugular venous distention

Pulmonary edema

Pedal edema

Hypertension

Rationale

Left sided heart failure causes the back up of blood into the lungs(pulmonary edema), and
right-sided heart failure often causes the back up of blood to the jugular veins and
periphery (peripheral edema).

(Dot Objective 5-2.91)

Demerol 50-100mg IV

Fentanyl 100mcg IVP

Morphine sulfate 10-20mg IVP

Versed 5-10mg IV

Rationale

Fentanyl is the most appropriate choice of the drugs listed because (1) it is the correct
dose and (2) it is very short acting when given IVP and will not prevent you from
discovering any additional injuries that the patient may have sustained to his lower
extremities.

(Dot Objective 8-3.38)

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53. A 24-year-old male patient was an unrestrained driver of a car and was involved in a

car versus tree motor vehicle accident. He was traveling at 55 miles per hour upon
impact with the tree. The car suffered major front-end damage. This model vehicle
was produced before airbags were mandatory in vehicles. What injury pattern should
be suspected for this type of trauma?

54. A 24-year-old male patient was an unrestrained driver of a car and was involved in a

car versus tree motor vehicle accident. He was traveling at 55 miles per hour upon
impact with the tree. The car suffered major front-end damage. This model vehicle
was produced before airbags were mandatory in vehicles. What would be your first
step in the treatment of this patient?

55. Which of the following is the result of cavitation?

Pelvis, leg, and feet injuries

Abdominal, head, and chest injuries

Head, neck, and chest injuries

Abdominal, back, and neck injuries

Rationale

In a frontal impact motor vehicle accident, two major injury patterns are expected. For an
unrestrained patient, head, neck, and chest injuries are expected as the patient goes up
and over the steering wheel. For a restrained patient, pelvis, abdominal, and leg fractures
are expected as the patient goes down and under the steering wheel. Since this patient
was unrestrained, he would be expected to go up and over the steering wheel through the
windshield.

(Dot Objective 4-1)

Manual cervical spine control.

Remove the patient from the vehicle.

Oxygen via nonrebreather mask.

Perform a 360 degree walk around the vehicle.

Rationale

When approaching a motor vehicle collision, you should perform a 360 degree walk
around to insure that the vehicle is safe to approach. This walk around is to look for
hazards such as fuel leaks and downed power lines. After the walk around, manual
cervical spine control and oxygen should be administered.

(Dot Objective 4-1.1)

Depressed skull wound from a direct blow to the head

Rupture of hollow organs from an explosion

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56. Which of the following groups of symptoms are associated with compensated shock?

57. Which of the following is an early physiological response to shock that a human body

will suffer?

Larger exit wound than entrance wound from a bullet

Injuries to the back of the brain from a frontal blow

Rationale

Cavitation is the process by which a projectile causes a larger cavity in a body than the
projectile itself. This is related to the speed of the projectile and the shockwave
associated with the projectile. According to the formula for kinetic energy, the greater the
velocity of a projectile, the greater the kinetic energy and the energy available to cause
injury such as cavitation.

(Dot Objective 4-1.1)

Increased heart rate, hypotension, and anxiety

Hypotension, decreased heart rate, and apnea

Pallor, thirst, and increased heart rate

Sense of impending doom and cyanosis

Rationale

Compensated shock is often associated with early shock. The patient will develop pallor,
thirst, anxiety, and increased heart rate. Often times hypotension and dropping heart rate
are associated with decompensated shock. Once the patient has begun to decompensate,
death is quickly approaching.

(Dot Objective 4-1.27)

Decreased heart rate

Vasodilatation

Decreased urine output

Cessation of peristaltic motion

Rationale

As perfusion decreases one of the first signs of shock is decreased urinary output. The
average adult should create about 30 cc per hour of urine. A Foley catheter should quickly
be inserted in the patient to judge their distal perfusion status. If the patient is producing
adequate urine output, his distal circulation is adequate. Vasodilation, decreased heart
rate, and enhanced peristaltic activity are not correlated with hypoperfusion syndromes.

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58. You respond to the scene of a 24-year-old male patient that was working on the

59. You respond to the scene of a 24-year-old male patient that was working on the

engine of his car when his radiator exploded, spewing hot water on his face and
chest. You note that the patient has red and white mottled skin on his chest and
blisters on his face. The patient is conscious and in obvious pain. The patient has red
and white-spotted skin and intense pain on his chest. This is a sign of a partial
thickness burn (aka second degree burn). A partial thickness burn includes burns to
the patient’s outer two skin layers, the epidermis and dermis. Note that blister
formation is characteristic of partial- thickness burns, but blisters do not always have
to be present. Red and white mottled skin is also associated with partial-thickness
burns. What percent BSA is involved in this injury?

(Dot Objective 4-1.17)

Epidermis, dermis, adipose, and muscle

Epidermis, dermis, and adipose

Epidermis and dermis

Epidermis

Rationale

The patient has red and white spotted skin and intense pain on his chest. This is a sign of
a partial thickness burn (aka second degree burn). A partial thickness burn includes burns
to the patient s outer two skin layers, the epidermis and dermis. Note that blister
formation is characteristic of partial thickness burns, but blisters do not always have to be
present. Red and white mottled skin is also associated with partial thickness burns.

(Dot Objective 4-3.2)

16%

21%

25%

Rationale

Using the rule of nines, the patient s entire chest and abdomen accounts for 18% and his
head accounts for 9%. Since the patient s chest and face were the only location of burns,
16% is the closest possible answer.

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60. You respond to the scene of a 24-year-old male patient that was working on the

61. A head injury patient is seizing upon your arrival to his side. What is the most

appropriate treatment in the care of this patient?

(Dot Objective 4-4.52)

Oxygen at 15 liters per minute via a nonrebreather mask

Covering the burns with a clean sheet

Establishing an intravenous line of normal saline and administering 2 mg morphine
sulfate

Wetting the burned area with tepid water

Rationale

When caring for a patient that has suffered burns, you should treat the airway and
breathing first. After the airway has been controlled and oxygen has been administered,
you should then begin to care for the patient s burns. The most appropriate care for the
patient s burns is wetting the area with tepid water since the BSA is less than 25% of his
body surface and then cover the burns with sterile dressings.

(Dot Objective 4-3.34)

Direct laryngoscopy and intubation with a 7.5 endotracheal tube

Nasal intubation with a 6.5 endotracheal tube

Intravascular line of normal saline and 5.0 mg of diazepam

Rectal administration of 5.0 mg of diazepam

Rationale

The patient s cervical spine requires control, but it is also difficult to control the cervical
spine and airway of a seizing patient. Often times, the patient has clenched teeth and
direct laryngoscopy is impossible. Nasal intubation should be avoided in a patient with a
head injury. An IV and 5 mg of diazepam should be administered to control the seizures,
then the patient s cervical spine is easier to maintain.

(Dot Objective 4-5.36)

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62. Which of the following injuries is most often associated with primary blast injuries?

63. When managing an open fracture, you should do which of the following?

64. What is the appropriate manner in which you should splint a dislocated knee?

Ruptured frontal sinuses

Injured globes

Spleen ruptures

Liver lacerations

Rationale

Primary blast injuries are often referred to as “shock wave” injuries. These shock wave
injuries often result in rupture to hollow organs and cavities. Eardrums, sinuses, and
hollow organs, such as the lungs, are at greatest risk of injury.

(Dot Objective 4-4.12)

Cover the exposed bone ends with a moist sterile dressing.

Provide mild manual traction to restore distal circulation.

Apply a pressure dressing to prevent blood loss.

Leave the wound exposed if there is no massive bleeding from the area.

Rationale

When bone is exposed, care must be taken to prevent further injury and infection. A good
rule of thumb for the use of moist, sterile dressings is as follow: If the protruding part is
normally on the inside of the body, cover it with a moist sterile dressing. Do not attempt
to reinsert or reduce the exposed bone back into the body.

(Dot Objective 4-3.4)

It should be splinted in a position of function as to insure maintenance of a distal pulse.

It should be splinted in its normal anatomical position.

No splinting is required for a dislocated knee.

It should be splinted in the position in which it was discovered.

Rationale

When splinting a joint, you should always splint the joint in the position in which it was
discovered, as long as distal circulation is adequate. Routine manipulation of an injured
joint could further injure the extremity and decrease distal circulation. The only time you
manipulate a joint injury is when there is no distal perfusion upon initial assessment.

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65. Which of the following is appropriate on scene care of a person with bilateral femur

fractures who is experiencing severe hypovolemic shock?

66. What is the most common spinal injury associated with improper lifting techniques?

67. You respond to the scene of a residential natural gas explosion to find a 36-year-old

male patient complaining of a diminished ability to hear, moderate dyspnea, and
acute abdominal pain. These symptoms are likely due to what mechanism?

(Dot Objective 4-3.4)

Starting an intravenous line and 10mg of intravenous diazepam

Splinting the extremities prior to transport with improvised splints

Applying traction splints

Administering oxygen and maintaining of an adequate body temperature

Rationale

You should control the patient s airway, breathing, and circulation prior to applying any
form of splint to the patient s legs. The patient will also need assistance in maintaining a
normal body temperature due to the effects of shock. Do not delay transport for on scene
splinting of critical patients. The application of traction splints is not recommended for on
scene application of an unstable patient.

(Dot Objective 4-3.35)

Lumbar

Sacral

Cervical

Thoracic

Rationale

The most common spinal injury is injury to the cervical spine, but improper lifting
techniques result in lumbar injuries. Common lumbar injures are buldging and/or
compressed vertebra. You must remember to lift with your legs and knees and not your
back.

(Dot Objective 1-2.9)

Toxic inhalation of natural gas

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68. You are called to the scene of an accident to find a 52-year-old male patient lying on

the roadway. Bystanders report that the patient was riding a bike that was struck by
a car and thrown to the street approximately 10 minutes prior to your arrival. The
patient was not wearing a helmet, and was initially conscious and ambulatory. Your
assessment reveals that the patient is now unresponsive, the right pupil is dilated
and non-reactive, respirations are deep and rapid at a rate of 32, blood pressure is
184/88 mmHg and the radial pulse is 56 beats per minute. Upon painful stimuli the
patient exhibits decerebrate posturing. What would be your next immediate action?

69. You are called to the scene of an accident to find a 52-year-old male patient lying on

Primary blast injury

Secondary blast injury

Tertiary blast injury

Rationale

Primary Blast Injuries are caused by the compression of air filled organs by an
overpressure wave, typically affecting the tympanic membranes, lungs, stomach,
intestines, and sinuses. Toxic Exposure to Natural Gas may cause nausea, diarrhea,
dizziness, headache, and labored breathing, but would not explain diminished hearing or
acute abdominal pain. Secondary Blast Injury refers to trauma caused by flying shrapnel
or debris, while Tertiary Blast Injury refers to trauma caused when a patient is thrown
from the blast area and strikes an object or the ground.

(Dot Objective 4-3.14)

Insert a nasopharyngeal airway and hyperventilate at a rate of 24 per minute.

Insert an oropharyngeal airway and ventilate at a rate of 12 per minute.

Manually stabilize his spine.

Administer mannitol 1 mg/kg intravenously.

Rationale

Although airway management and ventilatory support are certainly necessary in this
patient, the simple act of ensuring manual immobilization of the head and cervical spine
must occur prior to any manipulation of the airway. The airway techniques mentioned are
appropriate after the head is first held manually inline.

(Dot Objective 4-6.2)

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184/88 mmHg and the radial pulse is 56 beats per minute. Based on the patient’s
presentation, what condition is he most likely suffering from?

70. While assessing the anterior and lateral aspects of the neck in your trauma victim,

you note that there is no jugular venous distention present. This finding most likely
represents?

71. While assessing the carotid and radial pulse in your unresponsive patient, you

determine that the carotid pulse is weak and rapid, and the peripheral pulses are
absent. What other clinical assessment finding would you expect to be present?

Subdural hematoma

Intracerebral hemmorhage

Subarachnoid hemmorhage

Epidural hematoma

Rationale

The speed of signs and symptom onset coupled with the mechanism of injury makes an
epidural hematoma the most likely cause of this patient’s symptoms. Epidural hematoma
usually involves arterial vessels, causing symptoms to develop very rapidly. Subarachnoid
Hemorrhage usually develops more slowly and does not cause herniation and compression
of brain tissue. Intercerebral Hemorrhage typically presents much like a stroke due to
blood’s direct irritation of the brain tissue. Subdural hematoma typically involves veins
that hemorrhage at a lower pressure and are therefore associated with a slower onset.

(Dot Objective 4-5.64)

Excessive increase in intrathoracic pressure

Increased venous pressure from left ventricular heart failure

Traumatic asphyxia

Potential volume depletion

Rationale

Jugular venous distension is a common finding in a patient with normal blood volume in a
supine position (as a trauma victim would be positioned). If the patient is found to be
devoid of jugular venous distension while in a supine position, one concern could be
volume depletion in the trauma patient. Traumatic asphyxia, left heart failure, and
increased intrathoracic pressure will all promote jugular venous distension as the blood
flow from the brain and skull becomes impaired.

(Dot Objective 3-2.2)

An irregular rhythm of the pulse

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72. What assessment finding would best indicate a traumatic spinal cord injury?

73. Following a fight at a bar, a patient sustained a deep knife wound to his medial left

thigh. Which of the following would be an immediate life threat associated with the
injury?

Cool and pale skin

An increase in arterial pressure

A decrease in the respiratory rate

Rationale

Checking the central and peripheral pulses in the unresponsive patient will give the
paramedic a rough estimate of peripheral perfusion. In this instance, where there is no
peripheral pulse and a weak central pulse, the inference can be made that there is poor
peripheral perfusion. Another expected finding in this patient then would be cool and pale
skin from the diminished peripheral blood flow.

(Dot Objective 3-2.33)

Ability to stand up and bear weight on the legs

Loss of sensory perception in the legs

Palpable crepitation to the vertebrae

Patient complains that his back hurts

Rationale

A loss in nerve transmission in the acute spinal cord injury patient will result in a
disturbance in motor and/or sensory findings distal to the injury location. In this situation,
a loss of perception in the legs would be consistent with a spinal cord injury. The
musculoskeletal findings (pain and crepitation) reflect potential vertebrae injury, but not
injury to the spinal cord specifically. Finally, a cord injury would probably result in the
inability to ambulate.

(Dot Objective 3-2.53)

Increased capillary permeability

Uncontrolled hemorrhage

Femoral nerve damage

Introduction of infection leading to cellulites

Rationale

Soft tissue trauma from almost any cause can disrupt skin integrity allowing for infection
(or even cellulites), nerve damage, or scarring after the wound heals. Uncontrolled
hemorrhage, however, is the most immediate concern that could result in the patient
rapidly deteriorating into cardiac arrest.

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74. What is the most important difference between a puncture wound and a stellate-

shaped laceration to the thorax?

75. You arrive on the scene of a one-car motor vehicle crash in which the unrestrained

driver was thrown from the car as it rolled over, coming to a rest on its roof with the
patient pinned beneath it. Upon extrication, the patient presents as unresponsive,
hypotensive, tachypneic, and cyanotic. Upon inspection of the patient, you note
redness and abrasions to the anterior abdomen and pelvic region. What type of
injury is most likely responsible for the patient’s presenting conditions?

(Dot Objective 4-3.11)

The mechanism associated with the puncture wound may also result in unseen
intrathoracic organ damage.

The laceration typically results in increased pain.

The puncture wound takes longer to heal than the laceration.

The laceration has a higher incidence of infection than the puncture wound.

Rationale

A stellate shaped laceration is one that has irregular shapes, or edges. Although they are
harder to control bleeding in, they usually are not as deep as puncture injuries can be.
Puncture injuries, on the other hand, can pose a greater life threat because the
mechanism associated with the puncture wound may also result in unseen intrathoracic
organ damage.

(Dot Objective 4-3.12)

Probable brain herniation

Flail segment to the anterior chest wall

Airway occlusion from mandibular muscle hypotonia

Suspected pelvic fracture

Rationale

Crush injuries can be problematic because the patient may present initially conscious, but
when the weight is lifted from the body, the vascular and skeletal damage done may
result in significant bleeding (that can lead to arrest). In this situation, the crushing
mechanism and physical findings indicate severe blood loss into the abdomen and/or
pelvic cavity from abdominal injuries and/or a fractured pelvis.

(Dot Objective 4-3.25)

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76. A patient presents with a deep laceration to the medial aspect of the left proximal

forearm. Currently, the first responders on scene are applying direct pressure,
elevation, and have attempted the use of an appropriate pressure point to manage
the hemorrhage. Despite this, it continues to bleed. What would be your next step in
the management of this injury?

77. If an adult patient has sustained a deep laceration with arterial hemorrhage that is

difficult to control, at what time should the application of a tourniquet be considered?

78. Which of the following criteria would indicate that a burn is classified as a critical

burn?

Removing all dressings and applying digital pressure to the damaged area.

Adding additional dressings and maintaining the pressure.

Applying a cold compress and pressure dressing.

Applying a tourniquet just above the laceration site.

Rationale

The next step in the emergency care for this patient with continued bleeding is the
removal of the dressings and application of digital pressure to the damaged blood vessel if
it can be identified. Beyond this, employ elevation and cold compress application as is
possible. Following digital pressure on the appropriate pressure point, the only other
option is application of a tourniquet, which should only be done in the most severe
situations of an uncontrolled bleed.

(Dot Objective 4-3.31)

After diffuse direct pressure to the wound has failed

After application of direct digital pressure at the wound’s site of hemorrhage

After wound elevation and application of a cold compress has failed

After the application of pressure to the proximal pulse site has failed

Rationale

The application of a tourniquet should only be preformed after all other attempts to stop
the bleeding have failed. This is because the tourniquet will stop all distal blood flow to
the limb, and can potentially result in greater tissue damage. The application of a
tourniquet follows the failed attempt to control the bleed by digital pressure point
compression at a more proximal pulse site.

(Dot Objective 4-3.35)

A burn that is leathery, white, or charred

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79. A thermal burn that is described as painful with reddened skin, large, thin-walled

blisters, and skin that is moist is a:

80. The patient has been brought to you by the fire department. After your initial

assessment, you find the patient is unresponsive, she has stridorous respirations,
she is hypotensive, tachycardic, and has full- thickness burns over 40% of her body.
What life-threatening condition would you most likely suspect that could prove fatal
for the patient?

The age of the patient

A burn that results in loss of body function

A history of myocardial infarction

Rationale

Any burn that has the potential to result in the loss of some important bodily function
should immediately be considered a critical burn. While the other findings (age, medical
history, and burn appearance) help describe how severe the burn might be, any loss of
function is considered critical regardless of the other three findings. Loss of function may
be described as airway burns, burns to the hands/feet/major joints/genitalia, or
circumferential burns of the chest.

(Dot Objective 4-4.7)

superficial full-thickness burn.

superficial burn.

partial-thickness burn.

full-thickness burn.

Rationale

Because of the deeper capillary damage seen with a partial thickness burn that increases
local capillary permeability, fluid seeps to the surface of the skin and forms blisters. These
blisters in concert with reddened skin that is moist and painful, is a typical description of a
partial thickness burn.

(Dot Objective 4-4.17)

Inhalation injury

Full-thickness burns

Hypotension from burn shock

Head injury

Rationale

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81. The patient has been brought to you by the fire department. After your initial

assessment, you find the patient is unresponsive, she has stridorous respirations,
she is hypotensive, tachycardic, and has full- thickness burns over 40% of her body.
What is the most likely cause of her unresponsiveness?

82. The priority prehospital management for this patient with major burns and airway

trauma should include:

In a situation like this where a patient was exposed to flames and smoke in a confined
area for a period of time, the primary concern should be for inhalation injuries due to
airway burns. The presence of a head injury from a potential fall, full thickness burns, or
hypotension may result in the patient’s demise, but the first injury likely to cause their
death will be the airway burns.

(Dot Objective 4-4.17)

Tachypnea

Hypotension

Hypoxemia

Tachycardia

Rationale

The presence of stridorous respirations alone indicates that she has suffered a significant
airway burn and has considerable glottic swelling. The disturbance in the airway will lead
to poor oxygenation and carbon dioxide retention, and will be compounded by the fact
that she was subject to smoke inhalation while still entrapped in the confined space.

(Dot Objective 4-4.17)

Initiation of an intravenous line

Complete spinal immobilization

Immediate tracheal intubation

Administration of oxygen via a nonrebreather at 15 lpm

Rationale

Tracheal intubation is the priority management for this patient in order to secure a patent
airway before the glottic edema becomes so severe, her airway becomes occluded.
Complete spinal immobilization, oxygen administration, and intravenous access are also
important, but do not precede airway establishment in the upper airway burn.

(Dot Objective 4-4.17)

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83. The trauma surgeon indicates that the patient you previously brought into the

emergency department suffered a severe blunt crush injury to the pelvis. Which of
the following structures was also most likely injured?

84. What is the most likely cause of respiratory distress in a pateint with low cervical

vertebrae damage?

85. What would cause this patient with a low cervical injury to present with quadriplegia?

The sacrum

The tragus

The hyoid bone

The greater trochanter

Rationale

The sacrum comprises an inferior aspect of the vertebral column, and also constitutes the
posterior aspect of the pelvis. Since the pelvis typically fractures in more than one place
with blunt compressive trauma, the sacrum has a higher likelihood of injury too. The
greater trochanter is the most proximal bony process of the femur. The tragus is the
cartilaginous triangular structure anterior to the external ear canal. The hyoid bone is
embedded in the neck and supports the epiglottis and swallowing.

(Dot Objective 4-6.2)

Unilateral hemothorax

Herniating brainstem injury

Poor pulmonary perfusion due to hypotension

Spinal injury

Rationale

The patient’s injury pattern is most suggestive of a spinal cord injury. With this injury,
affective nerve impulses cannot reach the intercostal muscles to aid in the work of
breathing (they become paralyzed), so the diaphragm has to accommodate for the lost
intercostal muscles. The diaphragm is still innervated because the nerve impulse for this
originates from the cervical spine ganglia.

(Dot Objective 4-6.6)

Spinal cord transaction in the lumbar region

Cauda equina syndrome

Significant musculoskeletal trauma

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86. This patient's hypotension and poor peripheral perfusion are most likely due to:

87. What is the most common cause of intracerebral hemorrhage?

Cervical spinal cord damage

Rationale

If the injury to the spinal cord is high enough (like in this patient), there will also be an
inability of the motor impulses from the brain to reach voluntary muscle. This then
presents as a patient with upper and lower paralysis, which is called quadriplegia.

(Dot Objective 4-6.13)

loss of parasympathetic innervation.

blood loss.

left ventricular failure.

loss of sympathetic innervation.

Rationale

The sympathetic nervous system, which helps to regulate vascular constriction and
cardiac output, has spinal nerves that exit out through the thoracic and lumbar vertebrae,
which is why the sympathetic nervous system is also occasionally called the
“thoracolumbar nervous system”. In this high cord injury, sympathetic tone is also lost,
which causes the diminishment in heart rate, warm dry skin from vasodilation, and
eventual hypovolemia.

(Dot Objective 5-6.13)

Cerebral emboli

Trauma

Hypertension

Cerebral thrombus

Rationale

Persistent, high blood pressure promotes vessel weakening and hardening. As vessels
continue to harden and weaken further, an acute increase in blood pressure will cause
rupture of the cerebral vessels.

(Dot Objective 5-3.44)

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88. Which of these processes would not be a cause for a TIA?

89. You have responded to a local residence for a 67-year-old male who is complaining

of a sudden onset of weakness, a facial droop, and slurred speech. The patient s
heart rate is 126, respirations are 18, and his blood pressure is 224/112 mmHg and
his glucose level is 100. As you continue with your evaluation of this patient, he
becomes unconscious and starts to seize. What is the initial anticonvulsant drug that
should be administered for this patient?

90. Why does a diabetic patient with an elevated blood glucose level still metabolize fat?

aneurysm

arteriosclerosis

vasospasm

hypotension

Rationale

A cerebral bleed would cause a stroke, not a transient brain attack. The key with a TIA is
that it is a temporary loss of function. If there were a cerebral bleed, it would most likely
cause permanent brain damage.

(Dot Objective 5-3.54)

Adenosine

Valium

Magnesium sulfate

Dextrose

Rationale

Since the patient is actively seizing, he needs to be given Valium (a benzodiazepine) to
stop any of his seizure activity. Adenosine is used to control SVT rhythms, Magnesium
sulfate is for ventricular dysrhythmias primarily, and dextrose is administered to the
hypoglycemic patient.

(Dot Objective 5-3.74)

The glucose is outside of the cell and cannot be broken down.

The glucose is in the cell and cannot be broken down.

The insulin is outside of the cell and cannot break down the glucose.

There is no insulin available to transport glucose into the cell.

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91. The physiological function of insulin is to promote utilization of glucose by the cells.

What would happen to a patient with a low level of insulin?

92. An anaphylactic patient exhibits wheezing, urticaria, and a low pulse oximeter

reading. What would you expect her blood pressure and heart rate to be?

Rationale

Metabolism of fat occurs because glucose is outside of the cells and there is not enough
insulin available to get the glucose into the cell. If glucose cannot get into the cell, it
cannot be broken down. In response to this, the body tries to convert non-carbohydrate
substances into glucose, thinking that will fix the energy shortage problem in the cells.
This does not fix the problem unfortunately, and it actually drives the blood sugar levels
up to potentially dangerous levels.

(Dot Objective 5-4.9)

The level of insulin outside of the cell would be insufficient and would not break down
the glucose.

Glucose would remain in the cell and would not be functional.

The level of insulin inside the cell would be insufficient and would not break down the
glucose.

Glucose would remain on the outside of the cell and would not be broken down.

Rationale

Insulin is a hormone that is responsible for transporting glucose into the cell where it can
be metabolized and made into energy. With a low level of insulin, very little sugar can be
metabolized; the result is that the cells' ability to function is drastically reduced.

(Dot Objective 5-4.19)

hypotensive, bradycardic

hypertensive, bradycardic

hypertensive, tachycardic

hypotensive, tachycardic

Rationale

Anaphylaxis is characterized by respiratory and/or hemodynamic compromise. The patient
experiencing an anaphylactic reaction would present with wheezing, urticaria (hives),
hypotension, and tachycardia. Eventually the mental status would change due to poor
cerebral perfusion and hypoxemia.

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93. Your patient is complaining of abdominal cramping and has a history of peptic ulcer

disease. Your assessment reveals abdominal distention, and cool skin and pallor. The
patient s heart rate is 136, respirations are 22, and his blood pressure is 104/68
mmHg. The patient tells you that he has had bright red stools. What type of bleeding
is this patient experiencing?

94. What is the most common cause of esophageal varices?

95. You are called to a childrens' home for a 14-year-old patient that has been ill with a

fever for the last two days, and who started complaining of periumbilical abdominal
cramping. On your arrival, the patient is complaining of left shoulder pain and
minimal abdominal pain. Your assessment reveals abdominal distention that is

(Dot Objective 5-5.2)

Meconium

Hematochezia

Hematemesis

Melena

Rationale

Hematochezia is bright red or dark red stool, normally consisting of undigested blood.
Hematochezia suggests brisk bleeding or vigorous peristalsis. Melena are dark stools from
the presence of digested blood. Hematemesis is the vomiting of blood, and meconium is
the material present on newborns that indicates a distress infant and/or delivery.

(Dot Objective 5-6.22)

Cirrhosis of the liver

Stomach cancer

Liver cancer

Esophageal cancer

Rationale

Esophageal varices are caused by chronic portal hypertension. High pressures within the
portal circulation lead to progressive dilation of esophageal vessels and ultimately the
development of varices. This is commonly caused by cirrhosis of the liver.

(Dot Objective 5-6.72)

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tender but nonlocalizable. The patient s heart rate is 136, respirations are 22, and
his blood pressure is 96/70 mmHg. What is the most likely cause of this patient s
pain?

96. After pulling a victim from a structure fire, the patient complains of a pounding

headache, nausea, and difficulty with fine motor control. Vital signs include a heart
rate of 110, respirations of 24, blood pressure of 126/74 mmHg, and the pulse
oximeter reads 96% on room air. What do you expect this patient to be most likely
suffering from?

97. You are called to the scene where a female patient has reportedly injected herself

with heroin. She is exhibiting signs and symptoms of anaphylaxis. How should this
patient be managed in the prehospital setting?

Cholecystitis

Appendicitis

Urinary tract infection

Pancreatitis

Rationale

The history of illness and fever coupled with periumbilical pain are concerning and point to
an appendicitis. The additional presentation of referred shoulder pain and the absence of
abdominal pain suggest a ruptured appendix and solidify your field diagnosis in this
scenario.

(Dot Objective 5-6.92)

Carbon dioxide poisoning

Carbon monoxide poisoning

Inhalation injuries

Myocardial infarction

Rationale

The signs and symptoms exhibited by this patient are commonly seen in cellular hypoxia.
The patient has normal vital signs with a normal pulse oximetry reading. These signs
would suggest that a cellular asphyxiant has bound to the patient’s hemoglobin. The only
option for this grouping of signs and symptoms is carbon monoxide poisoning.

(Dot Objective 5-8.16)

By administering Benadryl and epinephrine

By administering Lidocaine and Benadryl

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98. You have responded to a juvenile detention center for a teenager who has reportedly

injected himself with some form of opiates. Which of the following drugs would be
classified as an opiate?

99. You are called to the local jail for a 22-year-old male who was arrested for drug

possession/use. Police report the patient has been acting crazy since he was
arrested, and was combative and aggressive while being arrested. The police state
that they called the ambulance while the patient was seizing in his cell. On your
arrival, the patient is alert and agitated. His vital signs include a heart rate of 146,
respirations of 24, and a blood pressure of 180/100 mmHg. What type of exposure
do you expect this patient to be most likely suffering from?

By administering Narcan and Syrup of Ipecac

By administering low-flow oxygen and transporting immediately

Rationale

An anaphylactic reaction, regardless of the cause, should be managed with a combination
of Benadryl and epinephrine. This patient should receive high-flow oxygen. Lidocaine,
Narcan, and Syrup of Ipecac are not indicated in this scenario.

(Dot Objective 5-8.26)

Cocaine

Ativan

Heroin

Librium

Rationale

Heroin is classified as an opiate. The other drugs, although there is an abuse potential for
each, are not opiates.

(Dot Objective 5-8.56g)

Acid

Heroin

Cocaine

Marijuana

Rationale

This patient is most likely suffering from a cocaine exposure as evidenced by his vital
signs. The vital signs are indicative of a sympathetic response, which would most likely be

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100. You have been called to a local urgent care center to transport a major trauma

victim. Dispatch advises you that the patient is hypotensive and will be going directly
to the operating room on arrival to the trauma center. After arrival at the urgent
care center, you note that the patient has only been given crystalloid infusions and is
continuing to decompensate. You make the decision to give this patient an infusion
of Packed Red Blood Cells (PRBC). Since this patient has not been typed or cross-
matched, which of the following blood types would you administer to this patient?

101. You have responded to the residence of a 19-year-old African-American male with

the complaint of sickle cell crisis. After determining that this crisis is similar to his
previous episodes, how would you treat this patient?

produced by cocaine in this patient.

(Dot Objective 5-8.61)

O negative

AB positive

O positive

AB negative

Rationale

O negative is considered to be the universal donor because it does not contain the A, B, or
Rh antigens. If blood containing a different type of antigen were administered, it would
cause a hemolytic (blood cell destroying) reaction and the patient could die if the error
were not caught in time.

(Dot Objective 5-9.18)

Oxygen, administration of D5W solution, and Versed

Oxygen, administration of D5W solution, and morphine sulfate

Oxygen, administration of crystalloid solutions, and Versed

Oxygen, administration of crystalloid solutions, and morphine sulfate

Rationale

Pain associated with a sickle cell crisis is almost always ischemic in origin. The ischemia
comes from the lack of oxygen carrying capability on the sickle-shaped red blood cell and
infarction of vessels and organs that the sickle-shaped cells cannot pass through.
Treatment therefore is aimed at increasing oxygen flow, diluting the blood to decrease the
viscosity, and providing pain relief.

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102. What is the process by which the body attempts to maintain a constant state of

regulation?

103. What is a difference between heat exhaustion and heat stroke?

104. When assessing the patient who has experienced an exertional heat stroke, you

would expect his skin temperature to be:

(Dot Objective 5-9.22g)

Hypostasis

Homeostasis

Hyperstasis

Stasis

Rationale

Homeostasis is a mechanism for maintaining the body within a set range or parameters.

(Dot Objective 5-10.7)

In heat exhaustion, the patient is hypotensive.

In heat exhaustion, the patient stops sweating.

In heat stroke, the patient stops sweating.

In heat stroke, the patient is hypotensive.

Rationale

In heat stroke, the patient loses sweating as a compensatory mechanism and will
therefore stop sweating. After the patient stops sweating, the core body temperature will
elevate very quickly with little opposition.

(Dot Objective 5-10.17)

hot and dry.

hot and moist.

cool and moist.

cool and dry.

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105. How would you prevent the development of hypothermia in a cold environment?

106. Which of the following medical conditions increases the likelihood that a patient who

ascends to a very high altitude will develop some form of altitude sickness?

107. You have been called to the top of a mountain resort for a patient that is complaining

of a sudden onset of shortness of breath and coughing. Your assessment of the
patient reveals an anxious patient with basilar crackles in his lungs. The patient’s

Rationale

With exertional heat stroke, there is excessive ambient temperature as well as poor
acclimatization. In this type of heat stroke, although sweating has ceased and the skin is
hot, moisture from prior sweating may still be present.

(Dot Objective 5-10.27)

Emptying your bladder often

Increasing your metabolic rate by working out until you sweat

Dressing warmly

Eating high concentrations of sugar frequently

Rationale

Simply dressing warmly should be adequate to prevent hypothermia from developing. In
doing this, attempt to dress in layers so that if you become too warm, you can shed
layers of clothing before you start to become diaphoretic.

(Dot Objective 5-10.37)

Muscular dystrophy

Hypertension

Arthritis

Cerebral palsy

Rationale

When a patient with hypertension moves to higher altitudes, it will take a period of time
for the patient to become acclimated to the new altitude. An unacclimatized individual
who ascends too quickly may put too much stress on the heart, thus worsening his
hypertension and the potential for high altitude disease.

(Dot Objective 5-10.77)

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vital signs include a heart rate of 136, respirations of 28, and a blood pressure of
176/94 mmHg. What is your field diagnosis of this patient?

108. What does it mean when a paramedic tests positive for tuberculosis by PPD reading?

109. You have responded to the home of a 6-year-old male for a wet cough and general

weakness. The mother states that the child has had the cough with a fever for
several days. EMS was called today because the child had developed a red-colored
rash and spots in his mouth. Your assessment reveals a purulent drainage from the
eyes, and swelling of the eyelids. You also note a red, bumpy rash all over the child’s
body. What is your field diagnosis of this child?

High altitude congestive heart failure

Pneumonia

New onset congestive heart failure

High altitude pulmonary edema

Rationale

High-altitude pulmonary edema (HAPE) usually occurs in an unacclimatized individual who
rapidly ascends to an altitude that exceeds 8,000 feet. HAPE develops as a result of
increased pulmonary pressure and hypertension caused by changes in blood flow at high
altitudes.

(Dot Objective 5-10.87)

PPD readings are useless and do not mean anything.

The paramedic is a TB carrier.

The paramedic has developed antibodies from TB exposure.

The paramedic has active TB.

Rationale

A positive PPD reading means that the patient has developed antibodies to the TB
bacterium. If a PPD is read to be positive, the paramedic will likely have to get a chest x-
ray to verify that he or she does not have active TB or is not a carrier.

(Dot Objective 5-11.25)

Mumps

Polio

Chicken pox

Measles

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110. A middle-aged woman suddenly loses the ability to speak after witnessing her son

getting killed in an automobile collision. What behavioral illness may have caused her
problem?

111. After her son graduated from high school, her daughter announced her engagement,

and another child told her that she had a miscarriage, the 49- year-old female began
complaining of helplessness and hopelessness. What would best characterize these
feelings?

Rationale

This child is exhibiting the classic signs and symptoms of Measles. An additional symptom
may be sensitivity to light. Measles (rubeola, hard measles), a systemic disease caused by
the measles virus of the genus Morbilli, is highly communicable. It is most common in
children but may affect older persons who have not had it. Immunity following disease is
usually lifelong. Maternal antibodies protect neonates for about 4 to 5 months after birth.

(Dot Objective 5-11.35)

Depression

Phobia

Conversion disorder

Panic attack

Rationale

In a conversion disorder, a patient loses the ability to function without any identifiable
medical etiology. Objective factors that may indicate a behavioral or psychological
condition secondary to a conversion disorder include actions or situations that interfere
with core life functions (eating, sleeping, ability to maintain housing, and interpersonal or
sexual relations).

(Dot Objective 5-12.2)

Schizophrenia

Anxiety

Mania

Depression

Rationale

Depression is a state of profound sadness that can be brought on by a single event or a
combination of multiple events. When depression becomes prolonged or severe, however,
it is diagnosed as a major depressive episode. The symptoms of major depressive
disorder include: depressed mood most of the day, nearly every day, and there is marked
diminished interest in pleasure of all, or almost all, activities most of the day.

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112. A 24-year –old male patient was a restrained driver of a two-car motor vehicle

collision. The patient’s car struck the other car at a high rate of speed in the rear.
The patient’s car has significant damage to the front end and hood. You note that the
patient’s vehicle was not equipped with an airbag. Your patient was found
unresponsive upon your arrival. What injuries would you expect to find on this
patient from the mechanism of injury?

113. Which of the following etiologies is associated with vasogenic shock?

114. Which of the following is the primary reason for repeating your trauma assessment

in the ongoing physical exam?

(Dot Objective 5-12.8e)

Upper extremity injuries

Head injuries

Lower extremity injuries

Chest injuries

Rationale

In a frontal impact MVA involving a restrained driver, lower extremity and pelvis injuries
are expected. Head, chest, and pelvis injuries are most often associated with unrestrained
patients, as they tend to go up and over the dash. The injury pattern expected with a
restrained patient can be classified as down and under the dash.

(Dot Objective 4-4.12)

Spinal injuries

Abdominal injuries

Head injuries

Chest injuries

Rationale

Vasogenic (aka neurogenic and spinal shock) is characterized by spinal injury. The spinal
injury that usually results is vasodilatation, which produces shock. The skin will often
remain warm and pink during vasogenic shock. All of the other signs and symptoms will
be present or develop other than the cool, pale, moist skin.

(Dot Objective 3-2.17)

To discover any changes in the patient’s status and trends

To reduce the time required before the patient receives surgery

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115. Which of the following is NOT a cause of an ischemic cerebrovascular accident?

116. Status epilepticus is a seizure that:

To provide valuable information to the emergency department staff

To splint any fractures and treat minor wounds

Rationale

The ongoing assessment is necessary to discover any changes in the patient s status and
to trend his vital statistics. During the ongoing assessment, you should also re-evaluate
any of your treatments already rendered. This trending provides information to the entire
medical staff including the surgeon and ER physicians and provides valuable information
about the patient s overall condition.

(Dot Objective 3-2.1)

Aneurysm

Cancerous tumor

Embolism

Thrombosis

Rationale

An aneurysm is a form of a CVA, but it does not result in ischemia. It is a form of a
hemorrhagic stroke. An embolism and thrombus produces a direct ischemic stroke by
occluding blood flow, and a tumor can press against a cerebral artery and occlude the
blood flow producing ischemia.

(Dot Objective 5-3.71)

produces apnea.

is experienced only on one side of the body.

begins again after one seizure stops without the patient regaining consciousness.

lasts longer than 5 minutes.

Rationale

Status epilepticus is defined as a seizure that lasts longer than 10 minutes or a seizure
that begins again after one seizure stops without that patient regaining consciousness. It
is a dire medical emergency, as the patient may sustain bone fractures, airway occulsion,
and possible death.

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117. You respond to the scene of a 62-year-old female patient who has a history of

transient ischemic attacks and hypertension. She called 911 after she developed a
severe headache and slurred speech about 2 hours ago. Upon your arrival, she has
an obvious facial droop and slurred speech. Her vital signs are as follows: blood
pressure 170/100 mmHg, respiratory rate 24/minute, and a heart rate of 94/minute.
What would be your initial treatment administered to this patient?

118. Which of the following is a finding in the assessment of a patient experiencing

diabetic ketoacidosis?

119. You have a patient that has a knife impaled in his right upper abdominal quadrant

after an altercation. Which organ is most likely to be injured, resulting in shock?

(Dot Objective 5-3.11)

Intravenous access with normal saline at a rate of 30 cc/hr

0.4 mg of sublingual nitroglycerine

15 lpm of oxygen via non-rebreather mask and immediate transport

Bag-valve-mask and start IV

Rationale

Although the patient does require oxygen, it should be administered via a nonrebreather
mask if the breathing is still adequate. 6 lpm is the maximum flow rate through a nasal
cannula. This patient must be transported immediately because medications are available
to reverse the effects of the CVA if given within the first 3 hours after the onset of a
stroke. All interventions, such as intravenous access, should be administered en route to
the hospital.

(Dot Objective 5-3.61)

A fruity smell on the patient’s breath

A blood sugar level greater than 700 mg/dl

A blood sugar of less than 60 mg/dl

Hypoventilation

Rationale

Diabetic Ketoacidosis is a state in which the body starts producing ketone bodies such as
acetone. A blood sugar level between 300 and 600 mg/dl characterizes DKA. A fruity
smell on the patient s breath is produced as the body tries to remove excess ketones
through the respiratory system. The ketone acid is created by the body when it converts
non-carbohydrates into glucose.

(Dot Objective 5-4.16)

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120. What would be your initial shock management treatment for the patient with a knife

imbedded in the right upper abdominal quadrant?

121. You have a patient complaining of right upper quadrant abdominal pain after eating,

nausea, vomiting, and intense pain in his right shoulder. His vital signs are within
normal limits and his EKG is as follows: What is the most likely cause of these signs
and symptoms?

Lung

Spleen

Diaphragm

Liver

Rationale

The liver is a very large internal organ that is located in the right upper abdominal
quadrant. The liver is a solid organ that is very vascular and when injured can produce
deadly internal bleeding if it is not controlled. Look for signs of internal bleeding like a
rigid and distended abdomen, as well as other signs of shock.

(Dot Objective 5-2.17)

Oxygen via a non-rebreather mask or positive pressure ventilations

Establishing two intravenous lines of normal saline and bolus

Stabilizing the knife with a bulky dressing

Covering the patient with a blanket and considering positioning the patient in the shock
position

Rationale

During your initial assessment of this patient, you should administer oxygen, due to the
serious mechanism of injury and the possibility of developing shock. After this, the knife
should be stabilized and 2 intravenous lines established and a 20cc/kg bolus
administered. The patient should also be covered to preserve body heat and the shock
position may be considered if it is not contraindicated. All of the treatments are
acceptable, but oxygen should be administered first.

(Dot Objective 5-2.17)

Allergic reaction

Cholecystitis

Myocardial infarction

Abdominal aneurysm

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122. What is the most appropriate prehospital treatment that you should render to a

conscious adult patient who intentionally ingested 100 baby aspirin that were 81 mg
each, about 45 minutes earlier?

123. You have a patient who was bitten on the hand by a rattlesnake approximately 20

minutes ago. Which of the following treatments should be provided?

Rationale

Cholecystitis is an inflamed gall bladder that produces pain in the right upper quadrant,
nausea, vomiting, and sometimes, right shoulder pain called Kerr’s sign. It classically
flares up after the ingestion of a meal high in fat content. Care should be supportive. The
vital signs should remain within normal limits. If signs and symptoms of shock develop,
investigate into other causes of this pain.

(Dot Objective 5-2.17)

Rapid transport to the emergency department

1g/kg of activated charcoal

30 ml of syrup of Ipecac

50 mEq of intravenous sodium bicarbonate

Rationale

A patient that has ingested such a large quantity of a medication should receive 1g/kg of
activated charcoal orally or via a nasogastric tube. Activated charcoal works by binding to
the toxins and other stomach contents and passing out through the intestines. It should
not be mixed or diluted since this can deactivate the binding sights of the charcoal. The
patient should be transported rapidly on their left side to the most appropriate emergency
care facility.

(Dot Objective 5-8.18)

Starting an IV bolus of 1000 cc normal saline

Applying ice to the bite to reduce swelling

Splinting the extremity and lowering the hand below the level of the heart

Applying a venous tourniquet proximal to the bite

Rationale

Ice should never be applied to a poisonous reptile bit. Ice on the extremity will cause the
venom-contaminated blood to move away from the area and proceed back to the core
and central circulation. Instead, the extremity should be placed below the level of the
heart, the extremity splinted to prevent any unnecessary movement, and a venous
tourniquet applied proximal to the site of injection.

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124. Heat stroke develops when the body does which of the following?

125. A stretcher decon pool is most commonly used to:

126. You are transporting a patient that is having night sweats, mild fever, and a

productive cough. He states that the health department has been treating him at
home for a respiratory condition. How should the patient be transported to the
hospital?

(Dot Objective 5-8.13)

Loses the ability to regulate heat loss

Has a syncopal episode

Has seizure-like activity

Produces severe nausea and vomiting develops

Rationale

Heat stroke develops when the body loses the ability to regulate heat loss, which occurs
largely through sweating. Sweating is one of the most common mechanisms by which the
body loses heat. When the patient is unable to sweat, his core body temperature will rise
to dangerously high levels. The patient may develop seizures after he loses the ability to
sweat and his temperature rises to dangerously high levels.

(Dot Objective 5-10.14)

decontaminate ambulance personnel and patients prior to transport.

neutralize contaminated substances.

protect ambulance personnel during transport.

decontaminate the outside and inside of the unit.

Rationale

In the back of the ambulance unit, a decon pool may be used to protect the crew from
secondary contamination during transport by isolating potentially contaminated body
fluids.

(Dot Objective 1-4.21)

In a position of comfort

With a mask on the patient and the paramedic

In a calm, passive manner

In the left lateral recumbent position

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127. When assessing your trauma patient’s neck, you notice that his trachea is on the left

side. What does this indicate?

128. What types of cells are neutrophils, eosinophils, and basophils?

129. You are called for a 34-year-old unresponsive female patient. Upon arrival the

Rationale

The patient that has possible TB should wear either a surgical mask or a nonrebreather
mask. This is used to prevent the spread of the disease and to protect the safety of the
health care provider.

(Dot Objective 5-11.2)

Cardiac tamponade

Fractured trachea

Tension pneumothorax on the left side

Tension pneumothorax on the right side

Rationale

A tension pneumothorax is a collapsed lung that is pushing or applying tension to the
other lung and causing the trachea to shift to the good lung. You should also expect to
here decreased or absent breath sounds on the affected side, as well as positive jugular
vein distention. Remember, however, that tracheal deviation is a very late sign of a
tension pneumothorax and appropriate interventions should be employed before the
development of this sign.

(Dot Objective 4-545)

Erythrocytes

Leukocytes

Plasmadonacytes

Thrombocytes

Rationale

Leukocytes are simply white blood cells. All of these cells are different forms of white
blood cells with very different functions. Erythrocytes are red blood cells and platelets are
thrombocytes.

(Dot Objective 1-6.13)

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patient’s husband informs you that his wife is diabetic, and that he found her in this
condition upon his return from a 3-day business trip. The patient’s skin is pale, cool,
and diaphoretic. Her blood pressure is 96/54 mmHg, radial pulse is 118 beats per
minute, and respirations are 12 per minute with a barely adequate tidal volume. You
place the patient on a nonrebreather mask at 15 lpm, and attempt initiation of an
intravenous line, but are unsuccessful after 3 attempts. You are able to obtain a
blood glucose level of 40 mg/dl. What would be your next immediate action?

130. You are caring for a patient who is suspected of experiencing an internal

hemorrhage, and is showing early signs and symptoms of hypovolemic shock. The
patient s heart rate and respiratory rate are increased. You recognize that these
physiological responses are an attempt by the body to maintain what?

Administer 25 grams of 50% dextrose intramuscularly.

Immediately package and transport the patient to the hospital.

Administer 1 mg of glucagon intramuscularly.

Attempt to administer oral glucose.

Rationale

Glucagon administration, although not as reliable a therapy as administration of 50%
dextrose intravenously, is an acceptable alternative in a patient without IV access. Under
no circumstances should an oral solution be administered to an unresponsive patient who
cannot protect herself from aspiration. Administered intramuscularly, glucose may cause
necrosis of muscle tissue. This is not an acceptable route of administration. Deferring
treatment in a patient with a blood glucose level of 40 mg/dl prior to exhausting all
treatment options could result in the worsening of the patient s condition, and may result
in a hypoglycemic seizure or comatose state.

(Dot Objective 5-4.13)

Hypotonicity

Hemostasis

Hematopoiesis

Homeostasis

Rationale

The concept of homeostasis refers to attempts made by the body to maintain itself in a
steady state. Compensatory responses to hypovolemia, such as tachycardia and
tachypnea, are attempts by the body to maintain blood pressure at a steady level, or
homeostatic state. Hemostasis is the body’s ability to stop bleeding. Hypotonicity is a
state in which a solution has a lower solute concentration than a comparable fluid.
Hematopoiesis is part of the process related to differentiation of various types of blood
cells within the body.

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131. You are called into a rural area to care for an unresponsive patient. During the

132. You are called into a rural area to care for an unresponsive patient. During the

assessment of your patient, you notice that she has experienced both bowel and
bladder incontinence, is salivating and tearing, and appears to have vomited prior to
your arrival. Muscle fasciculations are present to both hands. Her husband states
that she was working in their greenhouse all morning, and stated that she was not
feeling well when she came in for lunch approximately one hour ago. You have
secured the patient s airway. Respirations are spontaneous and moderately labored
at a rate of 36, blood pressure is 112/88 mmHg, and the radial pulse is 98 beats per
minute. Assessment of lung sounds reveals bilateral wheezing and rhonchi. You
assist the patient s ventilations with a bag-valve-mask and high concentration
oxygen. The cardiac monitor shows a sinus rhythm with frequent unifocal PVC s. An
intravenous line is initiated. What would be your next immediate action?

(Dot Objective 1-6.26)

Carbon monoxide exposure

Organophosphate exposure

Cyanide exposure

Subarachnoid hemorrhage

Rationale

The patient is presenting with the classic signs and symptoms of exposure to an
organophosphate pesticide. This symptom pattern is easily recognized by recalling the
pneumonic “SLUDGE,” which refers to salivation, lacrimation, urination, defecation,
gastrointestinal distress, and emesis. In addition, muscle fasciculations are common with
exposure to organophosphates. The symptom patterns for the other options would vary
significantly. With Subarachnoid hemorrhage, the paramedic would expect to see signs of
intracranial hemorrhage coupled with severe headache. Cyanide may produce seizures or
unconsciousness, but would not result in increased salivation or gastrointestinal
symptoms. Carbon Monoxide exposure may cause vomiting and alterations in mental
status, but would not produce the salivation, lacrimation, and incontinence associated
with organophosphates.

(Dot Objective 1-7.25)

Diazepam 5.0 mg IV

Sodium nitrite 300 mg IV

Physostigmine 0.5 – 2.0 mg IV

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133. You are called for a 17-year-old female patient who is experiencing difficulty

breathing. She is in moderate distress, displaying accessory muscle usage, and a
pulse-oximeter reading of 92%. You have placed the patient on oxygen via
nonrebreather mask at 12 lpm. You are attempting to interview your patient, and yet
she is remaining completely silent, refusing to answer any questions regarding her
current condition or past history. Which of the following techniques should you
consider in order to obtain this information from the patient?

134. You are performing a physical assessment of a 12-year-old male patient who has a

small laceration to his right index finger. How would you expect this 12-year-old’s
normal assessment findings to differ from an adult patient?

Atropine sulfate 2.0 mg IV

Rationale

As this patient is suffering the effects of organophosphate exposure, Atropine is the
preferred antidote. Atropine doses for organophosphate exposure are typically higher than
standard cardiac dosing. Initial doses can range between 2 and 5 mg, although care
should be taken to administer it slowly when given intravenously in a hypoxic patient.
Diazepam would be an appropriate follow-up intervention in the organophosphate
exposure patient who was experiencing active seizures. Sodium nitrite is given for victims
of cyanide exposure, and Physostigmine is a possible antidote for atropine overdose.

(Dot Objective 5-8)

Explain that she is likely to die if she does not answer your questions

Ask more simple and direct “yes or no” questions

Disregard attempts to obtain patient history

Assume the role of authority figure, demanding that she answer

Rationale

Utilizing tactics such as sternly demanding answers or inducing fear are typically counter-
productive to attaining the information you desire. These tactics have a negative impact
on building rapport and trust with your patient. Maintaining a calm demeanor and asking
questions in a different manner may, however, allow the paramedic to obtain some
minimal information, even if it is not as detailed as would be preferred. Providing optimal
patient care dictates that we must continue attempts to obtain a patient history, so giving
up on attempts is not an option.

(Dot Objective 1-9.9)

Blood pressure would be higher than an adult

Average resting respiratory rate would be lower than an adult

Body temperature would be higher than an adult

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135. Your patient in irreversible hypovolemic shock is going into disseminated

intravascular coagulation (DIC). One of the precipitating causes of this would be:

136. A patient experiences a severe allergic reaction. What immunoglobulin is most likely

the cause of this reaction?

Average resting heart rate would be higher than an adult

Rationale

Typically we find that, as children age, a relatively consistent pattern of changes to vital
signs ensues. Generally, children have higher resting heart rates, higher respiratory rates,
and lower blood pressures than their adult counterparts. After approximately age 6,
normal body temperature is consistent throughout the age ranges.

(Dot Objective 1-10.5)

depletion of clotting factors within the capillaries.

failure of the sodium-potassium pump and cellular dehydration.

aerobic metabolism leading to mitochondria failure.

release of myocardial toxin factor from ischemic pancreatic cells.

Rationale

There are many disturbances in the body that occur secondary to prolonged
hypoperfusion to the capillary beds. One of these disturbances is clumping together of red
blood cells and the depletion of normal clotting factors (DIC). The end result is continued
hemorrhage as the body can no longer clot off the blood. This is usually a morbid finding
in the patient.

(Dot Objective 1-6.4)

IgM

IgA

IgE

IgD

Rationale

Antibodies are protein molecules (called immunoglobulins Ig) produced by the B-cells.
There are five classes of antibodies: IgA, IgD, IgE, IgG, and IgM. IgE is our first defense
against allergies, and it is thought that as many as half a million IgE molecules can bind
to a single mast cell (mast cells act as sentinels - they trigger a quick response to an
invasion of allergens, and it is the immunoglobulin E that triggers the release of
histamines).

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137. Which property of epinephrine is an undesired side effect in the management of an

acute anaphylactic patient?

138. You are assessing a patient with severe dyspnea that started while he was sweeping

out his garage. The patient has a history of asthma, myocardial infarction, and
hypertension. Upon asking for the patient’s medications, the patient’s spouse hands
you his MDI along with a small bag of pill bottles. Which one of the following
medications would be contraindicated given this patient’s medical history?

(Dot Objective 1-6.24)

Beta 1 properties

Alpha 1 properties

Alpha 2 properties

Beta 2 properties

Rationale

The drug epinephrine has both alpha and beta stimulatory effects on the sympathetic
nervous system. In an anaphylactic patient, these effects are beneficial as the alpha
properties promote vasoconstriction, which reduces edema and elevates systemic vascular
resistance. The beta 2 properties of epinephrine promote smooth muscle relaxation, which
allows the bronchioles to dilate to decrease airway resistance. The effect of beta 1
stimulation, which results in increased myocardial workload, is the undesired side effect
since typically in the anaphylactic patient, the heart is already working hard in order to try
to maintain perfusion pressures.

(Dot Objective 1-7.13)

Acetaminophen

Nitroglycerin

MDI inhaler

Labetalol

Rationale

It is not uncommon for the paramedic to get numerous pill bottles from patients, nor is it
uncommon to note that some medications administered by one doctor may be detrimental
or contraindicated given the other medication the patient is on (a common problem with
polypharmacy). In this situation, the drug labetalol is a beta-blocking agent, which will
diminish the degree of bronchial dilation from beta 2 stimulation. As such, the use of beta
blockers in patients with reactive airway diseases (such as asthma), should be avoided.

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139. Upon your assessment, you find an infant s temperature to be 41.1 degrees Celsius,

according to a tympanic membrane thermometer. You know that the infant s
temperature is:

140. After a trauma call, you are decontaminating your ambulance where large amounts

of blood are found on the floor. Upon completion, the towels soiled with the patient’s
blood and other debris should be disposed of:

141. Which of the following would most likely be a physical finding associated with

atelectasis?

(Dot Objective 1-7.23)

two degrees above normal.

normal.

at least six degrees above normal.

four degrees above normal.

Rationale

A normal body temperature in Celsius is 37 degrees (98.6 degrees F). A Celsius reading of
41.1 is about 4 degrees higher than normal (and corresponds to about 106 degrees F).

(Dot Objective 1-8.4)

by laundering them first, then placing them in a biohazard bag.

in a plastic bag and then in a container for normal garbage.

in a biohazard.

in a sharps container.

Rationale

Because of the soft tissue, long bone, and body cavity trauma seen in multi-system
trauma patients, there is a great risk of contamination to the paramedics caring for the
patient. To help minimize this risk, the paramedic should first take all necessary BSI
precautions during management, and then, following the call while the unit is being
disinfected, all soiled (non-sharps) material should be placed directly into a biohazard
bag.

(Dot Objective 1-8.24)

Displacement of the apical impulse

Hyperpnea and bradypnea

Hyperresonance to the thoracic wall

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142. When cutting the cord of a newborn, you must:

143. A 3-year-old boy choked on a pill and went into cardiac arrest prior to the arrival of

first responders. Once on the scene, first responders were able to dislodge the
obstruction and start basic life support, including CPR and ventilation with high-flow
oxygen. Once on the scene, you attached the cardiac monitor and found the boy to
be in asystole. The patient was intubated and an IV established. You have just
administered the third round of IV epinephrine when you note the following rhythm
on the cardiac monitor: What is your next step?

An increase in tactile fremitus

Rationale

Atelectasis is the collapse of the alveoli for one of numerous reasons. The end result is an
absence of aeration of the alveoli, which causes a change in how vibrations will penetrate
through the now “denser” tissues. Tactile fremitus is the technique where the hands are
laid on the thorax while the patient speaks, and an increase in vibration amplitude felt by
the hands indicates the consolidation of tissues, and is termed an “increase” in tactile
fremitus. Of course, the paramedic provider needs to routinely assess for fremitus in
order to reliably say if the vibrations felt in this patient are normal or not.

(Dot Objective 2-1.14)

cut the cord and then clamp it at least one inch from the baby.

clamp and cut the cord after the placenta has delivered.

cut the cord so that six inches remains attached to the baby.

clamp and cut the cord so it is flush with the abdomen.

Rationale

Proper cord management following delivery mandates that the paramedic clamp and cut
the cord so that approximately 6 inches remains attached to the baby. If the baby is
distressed and medications are required, this enables an umbilical catheter to be placed
for resuscitations (should an IV or IO not be possible). Also, by clamping and cutting the
cord six inches from the baby, there is less chance of injuring the baby s abdomen or
chest when separating the baby from the placenta (although this is less of an issue now
that scalpels are used less frequently). The paramedic would never first cut the cord and
then clamp it, especially one inch from the baby s abdomen. Likewise, the cord is never
cut flush with the baby s skin. It is not necessary to wait until the placenta is delivered to
clamp and cut the umbilical cord.

(Dot Objective 5-14.14)

Check for a pulse.

Remove the endotracheal tube.

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144. A 3-year-old boy choked on a pill and went into cardiac arrest prior to the arrival of

145. A 3-year-old boy was found in cardiac arrest after being struck by a car. Once on the

scene, first responders were able to start basic life support, including CPR and
ventilation with high-flow oxygen. Once on the scene, you attached the cardiac

Hang an epinephrine infusion.

Obtain a blood pressure.

Rationale

With any change of rhythm, the paramedic must immediately determine the presence or
absence of a pulse. Doing so enables the paramedic to determine if the rhythm is
circulating blood throughout the body or is a continuation of cardiac arrest in the form of
pulseless electrical activity. Obtaining a blood pressure takes more time than palpating a
pulse and should be attempted after the paramedic has determined that a pulse is indeed
present. There is no indication to extubate the patient (which is only performed in rare
situations). Epinephrine infusions are not administered in the post-resuscitation phase of
emergency cardiac care.

(Dot Objective 6-2.1)

Blood pressure 54/38 mmHg

Blood sugar 80 mg/dl

Pupillary dilation

Heart rate 160 beats per minute

Rationale

A blood pressure of 54/38 mmHg indicates significant hypotension and must be
immediately addressed to prevent the recurrence of cardiac arrest. Hypotension relates to
poor perfusion of the vital organs (brain, heart, and kidneys) and if uncorrected,
predisposes the patient to the recurrence of cardiac arrest. The rapid heart rate is most
likely a response to the epinephrine and does not represent a problem in and among
itself. The paramedic should expect some pupillary dilation due to the epinephrine as well
as the hypoxic state that the patient has suffered (sympathetic discharge). A blood sugar
of 80 mg/dl is normal and does not constitute a significant problem, as does the
hypotension.

(Dot Objective 6-2.1)

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monitor and found the boy to be in asystole. The patient was intubated and an IV
established. You have just administered the third round of IV epinephrine when you
note the following rhythm on the cardiac monitor: Continued treatment of this
patient would include:

146. Assessment of a 9-month-old male with a decreased level of consciousness reveals

him to be responsive to painful stimuli and covered with a petechial rash. His skin is
hot and flushed, and breath sounds are clear. Vital signs are pulse 160 beats per
minute, respirations 40 per minute, and blood pressure 56/40 mmHg. His axillary
temperature is 103.6 degrees F. His mother states that the child has been sick for
several days, but cannot elaborate further. What is your initial field diagnosis?

adenosine.

synchronized cardioversion.

anticonvulsant.

fluid bolus.

Rationale

Continued treatment of this patient must focus on increasing the blood pressure through
the initial administration of intravenous fluids. Failure to correct the hypotension risks the
chance of relapse into cardiac arrest. Dopamine may be considered after a fluid challenge
has proven ineffective in raising the blood pressure. Adenosine for the heart rate is not
indicated since the fast heart rate is not considered a supraventricular tachycardia in a
three-year-old and is most likely a response to the epinephrine administered previously.
Similarly, synchronized cardioversion would be inappropriate as well as dangerous to the
patient’s fragile condition. Anticonvulsants may be indicated, but are reserved for the
hospital setting following physician and specialist evaluation.

(Dot Objective 6-2.1)

Hypotension

Aspiration

Hyperpyrexia

Allergic Reaction

Rationale

Given the presentation of the patient (decreased level of consciousness, rash, fever,
tachycardia, and hypotension), the paramedic should recognize the presence of septic
shock. As such, the most immediate threat to the patient s life is poor tissue perfusion
secondary to the hypotension (caused by systemic vasodilation). Accordingly, the
paramedic must focus on restoring adequate perfusion to the vital organs by taking
measures to increase the blood pressure (e.g., IV fluid boluses). Although the
temperature of 103.6 is a concern, it does not present the immediate threat to life that
the hypotension and shock do. Therefore, treatment of the hyperpyrexia would be
provided after measures geared towards increasing the blood pressure have been
undertaken. The rash is secondary to the infection, not an allergic reaction. Given the
clear breath sounds, aspiration has most likely not occurred.

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147. Assessment of a 9-month-old male with a decreased level of consciousness reveals

148. You have just delivered a 32-week gestation infant and note that the body is

cyanotic and the infant’s respirations are 20 and shallow. The infant’s grandmother
tells you that the infant’s mother is a chronic narcotic drug abuser. You begin to
ventilate the infant while attempting to ascertain the last time the mother used
narcotics. The infant’s mother pleads with you to do something for her baby as she
confirms that she took 2 Percocet and an Ativan 25 minutes ago. What would you do
to manage this infant?

(Dot Objective 6-2.1)

Subcutaneous epinephrine.

An antipyretic.

A dopamine infusion.

A fluid bolus.

Rationale

Since the patient is hypotensive and in septic shock, the paramedic must gear immediate
treatment towards oxygenation and restoration of the blood pressure. This initially
involves 20 ml/kg fluid boluses of an isotonic crystalloid, like 0.9% normal saline solution
or lactated ringers. If several boluses of fluid fail to increase the blood pressure or the
patient begins to become fluid overloaded, the paramedic would move to dopamine or
another vasopressor. An antipyretic, like a Tylenol suppository, would most likely be
beneficial, but would be administered after the initial fluid bolus. Since the patient is not
experiencing an allergic reaction, subcutaneous epinephrine is not indicated.

(Dot Objective 6-2.6)

Intubate the infant and continue providing ventilatory support and administer
Romazicon.

Intubate the infant and continue providing ventilatory support.

Intubate the infant and continue providing ventilatory support and administer Narcan.

Intubate the infant and continue providing ventilatory support and administer 20cc/kg
in a fluid bolus.

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149. In the management of a neonate with a blood glucose level of 30, how would you

manage the glucose deficiency?

150. You have responded to the residence of a 4-month-old infant who is reportedly not

acting right. The infant s mother tells you that the baby has been sick for the last
week and that she has been dehydrated from diarrhea. The infant s vital signs are
difficult to obtain, but she has a heart rate of 160, a respiratory rate of 32, and the
blood pressure is unobtainable. Respirations are unlabored, with no accessory
muscle use. What would you do first to manage this infant?

Rationale

Since the mother was a chronic drug user, it should be assumed that the newborn is
addicted to the narcotics that it s mother has been taking, so it is not advocated to
administer any reversal agents at this point in time. The most correct intervention is to
provide continuous airway and ventilatory support to the infant.

(Dot Objective 6-1.31)

Administer D10W until the infant becomes more responsive.

Administer D5W until the infant becomes more responsive.

Administer D25W until the infant becomes more responsive.

Administer D50W until the infant becomes more responsive.

Rationale

The administration of D25W or D50W is contraindicated in the neonate because these
solutions can cause significant increases in the plasma osmolarity. This increase in
osmolarity may lead to hypernatremia and ultimately cerebral and systemic cellular
edema.

(Dot Objective 6-1.71)

Initiate an IV and administer a fluid bolus of 600 cc.

Intubate the infant and provide ventilatory support.

Initiate an IV and administer Atropine, .01mg IVP.

Apply oxygen therapy.

Rationale

Initial treatment for this child should be to provide 100% oxygen.

(Dot Objective 6-2.1)

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151. Shortly after arrival to a multi-vehicle collision, you are approached by the mother of

one of the teenage victims involved in a fatal accident. The mother wants to know
why you are transporting the driver of the vehicle that struck her daughter. She is
concerned because the driver has minor injuries and her daughter needs immediate
care. As the first paramedic on-scene, you triage the patients and determine that the
woman’s daughter has injuries incompatible with life and the driver of the vehicle
has significant injuries that will require surgical intervention. How would you address
the mother’s concerns?

152. You are caring for a 4-year-old male patient who has reportedly fallen out of a tree

and injured his hand. During your exam you note small, round burns to the boy’s
upper legs. There are also several bruises in various stages of healing on his upper
legs and arms. His parents state that he is clumsy and falls frequently. The hand
injury for which you were called appears insignificant. What does this scene suggest
to you about the child?

Explain that the driver’s injuries are more significant than her daughter's and as a
result, by protocol, he must be transported ahead of her daughter.

Explain that her daughter is already dead and that this man needs to be treated
immediately despite her concerns.

Assuming your transport ambulances have arrived, transport the woman’s daughter
immediately without regard for the driver.

Assuming your transport ambulances have arrived, transport the woman’s daughter
and the driver simultaneously in different ambulances.

Rationale

Although the woman s daughter is clinically dead and under normal circumstances would
not be transported, in this case, it is appropriate and humane to transport the woman s
daughter for the mother s benefit. It may foster closure for the mother to see that all
efforts have been made to save her daughter s life. Despite the fact that you (the
paramedic) know the patient is not viable, transporting her is more for the mother than it
is for the daughter.

(Dot Objective 6-2.11)

The child is coordinated.

The child is very uncoordinated.

The child is developmentally delayed.

The child is being abused.

Rationale

The bruises in various stages of healing, which is somewhat concerning but could be
present in a child who falls frequently. The concerning aspect of the bruises is that they
are isolated to his upper legs, you should expect to see bruising on the lower legs more

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153. Which of the following mechanisms contribute the greatest in an attempt to increase

the cardiac output in the pediatric patient?

154. Malfeasance may be a component of:

155. What is a person under the age of 18, who the courts have determined can make his

or her own medical decisions, called?

than the upper legs if the child is constantly running into things or falling. Most concerning
in this scenario are the burns on the child’s upper legs. It is difficult to imagine these
burns occurred accidentally. You should suspect child abuse in this scenario.

(Dot Objective 6-2.41)

Increased strength of cardiac contraction

Stimulation of the sympathetic nervous system

Increased rate of cardiac contraction

Increased peripheral vasoconstriction

Rationale

An increase in the heart rate contributes the greatest in an attempt to increase the
cardiac output in the pediatric patient. The cardiac muscle of the young child is
underdeveloped and as a result, less capable of increasing the contractile force necessary
to increase cardiac output. Starling’s law does not apply until the child ages and the
myocardium enlarges and strengthens.

(Dot Objective 6-3.26)

breach of duty.

abandonment.

negligence.

deviation from standard of care.

Rationale

Breach of duty by definition is “an action or inaction that violates the standard of care that
would be expected of a paramedic”.

(Dot Objective 1-4.7e)

Emancipated minor

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156. You and your partner respond to a cardiac arrest. During the arrest, you are unable

to defibrillate the patient because the defibrillator will not charge. Later the patient
dies, and the family learns that you forgot to replace the defibrillator battery that
morning according to routine procedures. What can the family sue you for?

157. Once a patient has given approval for treatment under the guidelines for informed

consent, when, if at all, can they decline consent?

Independent

Minor

Ward of the state

Rationale

An emancipated minor is authorized by the state to act as his or her own guardian with
regard to making medical decisions. Since they have a demonstrated capability to
manage their own lives without the majority of support or control coming from their
parents or gardians, the state allows them to answer for themselves.

(Dot Objective 1-4.7o)

Malpractice

Tort violation

Negligence

Abandonment

Rationale

Maintaining equipment and ensuring that you are prepared to respond to an emergency is
the responsibility of the duty medic. If you do not meet these standards, you can be held
liable and found negligent.

(Dot Objective 1-4.11)

The patient can deny consent at any point in their care.

The patient can only deny treatments that are not considered life saving.

The patient cannot deny treatments once they have consented.

In a life-threatening situation, the patient cannot decline treatment that is in the
patient’s best interest.

Rationale

A patient can deny consent at any point in their care. It is ultimately up to the patient to
choose to receive or not receive any care. And although they may approve of only certain
aspects of their care, they may withdraw the consent at any time. The key, though, is
that the patient must have a normal mental status in order to make the decision. If they
are incompetent, then "implied consent" can be assumed.

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158. What are the rules or standards that govern the conduct of EMS professionals?

159. The patient care report (PCR) is a legal document and, as such, it should include

information that effectively reflects the occurrences of the scene. What information
must be documented to maintain the integrity of the PCR as a legal document?

160. What is the greatest disadvantage to using a cellular telephone in the EMS

environment?

(Dot Objective 1-4.21)

Morals

Codes

Ethics

Standards

Rationale

Ethics are rules or standards that govern professional conduct, whereas morals are the
individual's perceptions of what is right and wrong. Neither standards nor codes are terms
applicable to the concept of the question.

(Dot Objective 1-5)

Subjective determinations made by the crew

EMS crew credentials

Insurance policy numbers

Incident times

Rationale

All incident times should be recorded; this includes any dispatch times, transport times,
times of interventions, and times of medication administration. Subjective assessments, if
they are made by the crew, should not be included in the PCR. If they are stated by the
patient then they could be included in the patient care report.

(Dot Objective 3-5.11)

Communications may be impeded by geography.

On-line systems are reserved for future communications.

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161. In calling in your medical assessment, the on-line physician will find specific

information helpful in triaging the patient. What information is most relevant to the
medical control physician?

162. Upon arrival at a local residence, you hear three possible gunshots in your vicinity.

What should be your immediate next action?

Informal communications.

Unnecessary use of communications systems.

Rationale

Cellular towers are not universally compatible or available and as a result,
communications may be lost in poor service areas due to building density, mountain
terrain, and the like. There should always be a primary and secondary communications
system available to each EMS crew.

(Dot Objective 3-5.16f)

Patient’s allergies

Patient age

Vital signs

Past Medical History

Rationale

Of the 4 choices, the patient s vital signs are the most important information to the
physician because they allow the physician to determine the patient s hemodynamic
status.

(Dot Objective 3-5.24)

Notify the local law enforcement agency.

Proceed into the house since no shooter is visible.

Leave the scene until it can be secured by law enforcement.

Notify dispatch of the situation.

Rationale

If you enter a dangerous scene, you should leave the scene in the ambulance and
immediately then notify law enforcement so that the scene can be secured. Although it is
true that dispatch and law enforcement should be notified, you must first ensure that your
safety has been secured.

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163. Which of the following medication route sequences is in the correct order for speed

of absorption from fastest to slowest?

164. Recognition as a paramedic by the National Registry of Emergency Medical

Technicians benefits the paramedic in which of the following manners?

(Dot Objective 1-4.8)

IV, IO, ET, IM, SQ

IV, ET, IO, SQ, IM

IV, IO, ET, SQ, IM

IV, ET, IO, IM, SQ

Rationale

Intravenous medication provides the quickest onset of action and subcutaneous
medication administration provides the slowest absorption. Notice that endotracheal
administration is also very quick and this should be taken advantage of in the case of
cardiac arrest when patients are intubated and do not have intravenous access. You
should at least double the dose when administering medications down an endotracheal
tube.

(Dot Objective 1-7.16)

Demonstrates a higher level of training than nonregistered paramedics

As a tool for receiving certification reciprocity in many states

Serves as a national certification, superseding individual state certification and licensure
regulations

Access to reduced rate EMS malpractice insurance

Rationale

The National Registry of Emergency Medical Technicians administers examinations,
establishes registration guidelines for various EMS provider levels, and acts as a major
tool for reciprocity between states. Although the majority of states utilize National
Registry examinations, and many states recognize national registration for direct
reciprocity, attaining national registration does not guarantee that all states will
immediately recognize the paramedic’s ability to function. National registration is not
accepted as a universal certification, nor does it give the holder access to reduced rates
on insurance or other special benefits.

(Dot Objective 1-1.11)

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165. You are called to the scene of a car versus tree accident. Upon arrival, you find the

car to be engulfed in flames, with fire showing from underneath the hood and inside
the passenger compartment. You can see that the operator of this vehicle is
unconscious and slumped over the steering wheel. Which of the following is your first
priority?

166. You are driving, utilizing your lights and siren, to a call for a confirmed pediatric

cardiac arrest. As you proceed, you employ the concept of “due regard” to determine
how you will approach the next busy intersection. What is the primary principal of
“due regard”?

Ensuring safety of you and your partner

Effecting immediate rescue of the patient

Ensuring safety of any by-standers

Ensuring safety of the fire department

Rationale

While all of the answers listed are considered priorities in this scenario, the safety of
yourself and your crew must always come first. Your primary responsibility is always to
ensure the safety of yourself and your crew. Once this is completed, then the focus can
turn to the extrication and management of the patient. Always stay attentive to the
scene, however, as things may suddenly change for the worse.

(Dot Objective 1-1.31)

Ambulances are typically not held accountable for accidents that occur while responding
to emergencies, giving them due regard for their special status as providers of public
safety.

Traffic warning devices at intersections do not apply to responding emergency vehicles,
and other drivers must therefore yield right of way, giving due regard to ambulances
passing through intersections.

Ambulances responding to critical emergencies, such as cardiac arrests, are typically
exempt from following most traffic regulations, giving due regard to the seriousness of
the emergency for which they are responding.

Ambulances responding to emergencies are typically held to a standard of driving at
least equal to that of other vehicles, and must therefore operate with due regard for
the safety of all vehicles on the road.

Rationale

Although most states grant emergency vehicles certain exemptions from following some
traffic regulations while responding to emergencies, the drivers of these vehicles must
operate with the due regard for the safety of all persons at all times. The concept of “due
regard” sets a higher standard for the driver of an emergency vehicle, implying their legal
responsibility for the safety of other motorists and bystanders.

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167. You are called to respond to a motor vehicle accident involving another ambulance.

Upon arrival, you find the crew members, both of whom you know, to be in serious
condition. Despite your best efforts, one of the crew members dies and the other is
left in critical condition. A critical incident stress debriefing is arranged. Which of the
following best describes a critical incident stress debriefing?

168. You are called to a private residence to care for the victim of an assault. Upon

arrival, you notice a crowd of approximately 20 people gathered in front of the
residence. The crowd appears to be agitated. You also see a victim lying motionless
on the sidewalk with a small pool of blood under his head. What would be your first
immediate action?

(Dot Objective 1-2.14)

Formal, structured discussion including responders from all involved agencies

Public review of the incident involving the media

One-on-one interview with a specially-trained mental health worker

Private, informal discussion including only the involved EMS crew and healthcare
workers

Rationale

One of the components of the critical incident stress management system is the critical
incident stress debriefing (CISD). A CISD is a formal, structured, closed discussion, which
typically involves responders from all of the agencies involved in the critical incident.
CISD’s are mediated by specially trained mental health workers, and typically also involve
peer counselors. At no time are they open to the public or media, nor is a true CISD ever
held on a one-on-one basis.

(Dot Objective 1-2.24)

Maintain manual stabilization of the cervical spine.

Determine the source of the blood loss and apply direct pressure.

Depart the area and request law enforcement for crowd control.

Evaluate the victim’s airway, breathing, and circulatory status.

Rationale

Although our initial desire is typically to assist a patient in need of our care, it is of
paramount importance to ensure our own safety prior to engaging in any patient
assessment or patient care activities. In the scenario, the crowd cannot be overlooked as
a real threat, and taking definitive measures to ensure the safety of yourself and your
crew must come first. Of the options presented, only departure and request for law
enforcement afford you the opportunity to guarantee that safety.

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169. After releasing care of a possible child abuse victim over to the emergency

department staff, you are having a discussion with another ambulance crew who was
not present at the incident. As you are describing your suspicion that the child’s
mother is the perpetrator of child abuse, you are overheard by one of the child’s
family members. What legal violation have you possibly committed?

170. You are called to a private residence for a patient suffering from an unknown medical

problem. Upon assessment, you find a 72-year-old female patient who is pulseless
and apneic. The patient s husband states that she has a valid Do-Not-Resuscitate
order and that he wishes for you to provide no resuscitative efforts. However, he is
unable to produce any documentation confirming his claim. He states that his
daughter is on the way to the residence with the documents and should arrive within
15 minutes. Your best immediate action would be to:

(Dot Objective 1-3.1)

Malfeasance

Libel

Slander

Negligence

Rationale

Slander is the act of injuring a person s character, name, or reputation by making a false
or malicious statement with malicious intent or reckless disregard for the falsity of the
statement. If you had put the statement into writing, that would constitute possible Libel.
Negligence is a deviation from accepted standards of care. Malfeasance is a form of
negligence involving the performance of a wrongful or unlawful act.

(Dot Objective 1-4.7)

Honor his request and await the arrival of the appropriate documentation.

Disregard his request and engage in full resuscitative efforts.

Attempt to contact the patient’s family physician to obtain a verbal order to withhold
resuscitative efforts.

Withhold advanced life support interventions, performing standard CPR until able to
confirm the presence of a valid DNR order.

Rationale

Although laws may vary in different jurisdictions, it is generally accepted that any form of
advanced directive, including DNR orders, may only be honored in the pre-hospital setting
when proper documentation is immediately available and appears valid. The risk of
honoring the husband s request without any proof of a valid DNR order opens the

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171. Of the following, which item is not a desired outcome of continued quality

improvement (CQI) programs in an EMS system?

172. You arrive on scene for an elderly patient with extreme respiratory distress. Although

your patient cannot verbalize many words to you at once, he motions you closer and
nods “yes” when you tell him you are here to help. The type of consent that this
patient is providing can be described as:

paramedic up to undue legal risk. As cardiac resuscitation must be implemented
immediately and completely in order to optimize chance at success, any other option
presented that would cause a delay in full ALS resuscitative efforts is also considered
dangerous. It is best to engage in full resuscitative efforts until the presence of a valid
DNR order can be confirmed, at which point termination of resuscitation should be
governed by local protocol or consultation with medical command.

(Dot Objective 1-4.25)

Provide statistics on call volume, patient profiles, and skills performed.

Allow the opportunity to identify potential topics for continuing education for the
system’s emergency providers.

Develop and implement a disciplinary policy for any type of variance in care rendered
by the EMS providers.

Provide a system of internal checks and balances that assures quality care is delivered,
and system weaknesses are identified.

Rationale

The benefits of a well-run Continuous Quality Improvement program for an Emergency
Medical Service system goes well beyond the ability to assess system performance. It
allows for the collection of data for statistical analysis, provides a means by which areas
of system weakness can be determined and addressed in a “checks and balance” manner,
and also allows the ability to determine what type of continuing education courses may be
offered since many times case studies are done on interesting calls. One thing that
Continuous Quality Improvement programs should not do is develop and implement
punitive recourses, should an area of improvement be identified. This would lead to
providers who get better at “hiding” system weaknesses through inaccurate patient care
reports and who are apprehensive to bring up concerns with management.

(Dot Objective 1-1.29)

involuntary.

implied.

expressed.

informed.

Rationale

Expressed consent is the type given by patients that are capable of only indicating to you
by body motions that they want your assistance. As in this example, the patient was so

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173. Which of the following configurations of EMS providers will best limit their risk of

injury while carrying a patient on a backboard?

174. Standards practiced by many medical professions are established by findings of

clinical research. When looking at clinical research, what is an important
characteristic to determine the applicability of the research to EMS?

dyspneic that they were unable to talk in complete sentences but made it clear to you (by
nodding and waving you closer) that they wanted your help. The other type of consent a
conscious patient can provide is informed consent, which typically occurs after there has
been a dialogue between you and the patient regarding you caring for them.

(Dot Objective 1-4.3)

One provider on each side of the backboard.

Two providers on each end while one of the providers carries in the middle.

One provider carries the head while one provider carries at the feet.

Two providers, who have matching height and strength, on each end.

Rationale

When it is necessary to lift and carry a patient on a backboard, the best way to do so is
by using multiple providers to help share the weight. The optimal positioning of the
providers would find two paramedics at each end, and the providers at each end should
be matched as best as possible according to height and strength capabilities. Anything
less than this may cause an injury.

(Dot Objective 3-3.2)

Discussion

Introduction

Methodology

Abstract

Rationale

Paramedics should focus on the methodology of the study when reviewing research
literature. Methodology is what explains the methods used to conduct the study and
explains how the study was conducted. This information will help the paramedic
determine if the findings of this study would be representative of occurrences in the field.

(Dot Objective 1-1.37)

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175. During completion of your patient care report, you write the following statement,

“The patient was obviously intoxicated and intentionally uncooperative.” Subjective
statements such as this can open the paramedic up to which of the following legal
charges?

176. You are called to a private residence for a patient with weakness. Upon arrival you

find a 38-year-old male patient supine in bed. A family member relates that the
patient has a history of malignant cancer in the brain, liver, and lymphatic system.
The patient received a chemotherapy treatment earlier today, and, per the family
member, has ingested 12 - 15 Darvocet tablets since returning home 4 hours ago.
The patient is difficult to arouse and is responsive only to painful stimuli. You also
note that the patient has an indwelling catheter entering into the left subclavian
area. Respiratory rate is 8 breaths per minute with decreased minute volume, radial
pulse is 62 beats per minute, and blood pressure is 86/52 mmHg. As you begin your
resuscitation, the patient s family member suddenly tells you to stop, citing that the
patient has a Do-Not-Resuscitate order. You are presented with a document that
appears to be a valid and current Do-Not-Resuscitate order in compliance with your
local laws. Your best immediate action would be to:

Res ipsa loquitur

Malfeasance

Slander

Libel

Rationale

Libel is the act of injuring a patient s character through written statements. Documenting
personal opinion and derogatory statements expose the paramedic to Libel. Slander is
similar to Libel, but refers to false or malicious statements made verbally. Malfeasance is
defined as breach of duty by performing a wrongful or unlawful act. Res ipsa loquitur is a
legal doctrine sometimes used in support of negligence claims.

(Dot Objective 3-6.1)

Enact the order and cease resuscitative efforts.

Disregard the order and engage in full resuscitative efforts.

Withhold advanced life support interventions, performing only basic resuscitative skills.

Attempt to contact the patient’s family physician to obtain a verbal order to withhold
resuscitative efforts.

Rationale

Although laws vary in different jurisdictions, it is generally accepted that a do-not-
resuscitate (DNR) order can only be acted upon when the patient’s heart and/or
respiratory functions have ceased. DNR orders should not be mistaken for “do-not-treat”
orders. In a gray area such as this situation presents, it is completely acceptable to
contact a medical command physician for consultation, but you should not delay advanced

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177. Which of the following patients best meets the criteria for air medical transport?

178. You have been tasked with setting up a landing zone for an incoming helicopter.

Which of the following is true regarding landing zone set-up and operations?

life support resuscitative efforts while attempting this contact. It is best to delicately
explain the limitations of the DNR order to the family while you continue to administer
care.

(Dot Objective 6-6.11)

22-year-old female struck by a vehicle traveling 15 miles per hour, suffering from a
femur fracture

44-year-old female involved in an accident at home, suffering from traumatic
amputation of three fingers

35-year-old male patient involved in a scuba diving incident, suffering from an arterial
gas embolism

60-year-old male patient involved in a roll-over accident, suffering a pelvic fracture

Rationale

Typically, a single isolated long bone fracture, such as a single femur fracture, does not
warrant air medical transportation. When dealing with acute illnesses associated with
scuba diving, air medical evacuation is typically avoided due to the fact that decreases in
atmospheric pressure at high altitudes can actually worsen many conditions. Although
partial or total amputation of an extremity may meet criteria for air medical transport,
amputation of the digits typically does not. Fracture of the pelvis associated with a
significant mechanism of injury will meet the criteria for air medical transport under most
circumstances.

(Dot Objective 8-1.5)

A typical landing zone should be approximately 100 by 100 feet in size.

Landing zones should be set up on a site with an incline of less than 18%.

If the landing zone is on an incline, always approach the helicopter from the uphill side.

A helicopter should always be approached from the rear.

Rationale

Although some helicopters in use for air medical purposes today do not require such a
large area, a typical safe size for a landing zone is 100 by 100 feet. Landing zones should
typically not be set up in areas with an incline of greater than 8%. Approach to a
helicopter should always occur from the front, where the pilot and crew can see the
approach. In the case where the helicopter has landed on an incline, approach should
always be made from the downhill side.

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179. You have been called to the scene of a bus accident involving approximately 25

victims. You are the second ambulance to arrive, and your supervisor designates you
as the triage officer. All of the ambulatory have already been removed from the bus,
leaving 12 patients for you to perform primary triage on. The first patient that you
come across is a non-ambulatory 30-year-old male complaining of pain in his right
leg. You notice an obvious deformity to his mid-shaft right femur. The patient’s
respiratory rate is 26 with adequate tidal volume, radial pulse is 98 beats per
minute, capillary refill is less than 2 seconds, and the patient is conscious and able to
follow your commands. Using the START triage method, into what triage category
would you place this patient?

180. You have been called to the scene of a bus accident involving approximately 25

victims. You are the second ambulance to arrive, and your supervisor designates you
as the triage officer. All of the ambulatory have already been removed from the bus,
leaving 12 patients for you to perform primary triage on. The next patient you come
to is an unresponsive 58-year-old female. Respiratory rate is 12 breaths per minute
with decreased tidal volume, radial pulse is absent, and capillary refill is greater than
2 seconds. Using the START triage method, into what triage category would you
place this patient?

(Dot Objective 8-1.5)

Delayed / Yellow

Deceased / Black

Immediate / Red

Minor / Green

Rationale

Patients in the minor, or green, category are those who are able to walk. Regardless of
injuries, if the patient self-extricates from the situation and comes to you when
requested, they are placed within the green category. When performing primary triage on
the remaining patients, those with respiratory rates greater than 30 breaths per minute
are tagged as immediate, or red. Additionally, if further assessment reveals that the
patient is experiencing delayed capillary refill, greater than two seconds, or if radial pulse
is absent, the patient again gets placed into the immediate category. Finally, patients with
decreased level of consciousness who are unable to follow commands are placed into the
immediate category. If a patient is non-ambulatory, but does not meet the criteria
described above for placement into the immediate category, then they are placed into the
delayed, or yellow, category. Patients who are apneic and/or pulseless are placed into the
deceased, or black, category.

(Dot Objective 8-2.22)

Delayed / Yellow

Page 82 of 83

Test 2

3/31/2007

http://pmtachieve.pearsoncmg.com/assessedhtml.php

Immediate / Red

Deceased / Black

Minor / Green

Rationale

Patients in the minor, or green, category are those who are able to walk. Regardless of
injuries, if the patient self-extricates from the situation and comes to you when
requested, they are placed within the green category. When performing primary triage on
the remaining patients, those with respiratory rates greater than 30 breaths per minute
are tagged as immediate, or red. Additionally, if further assessment reveals that the
patient is experiencing delayed capillary refill, greater than two seconds, or if radial pulse
is absent, the patient again gets placed into the immediate category. Finally, patients with
decreased levels of consciousness who are unable to follow commands are placed into the
immediate category. If a patient is non-ambulatory, but does not meet the criteria
described above for placement into the immediate category, then they are placed into the
delayed, or yellow, category. Patients who are apneic and/or pulseless are placed into the
deceased, or black, category.

(Dot Objective 8-2.22)

Page 83 of 83

Test 2

3/31/2007

http://pmtachieve.pearsoncmg.com/assessedhtml.php

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