PM TEST 3

Test 3

1. While performing CPR on a patient you should use a ______ ratio for compressions

to ventilations for the adult patient and _____ ratio for a child patient?

2. What is the most appropriate tidal volume to administer during artificial ventilations

to a patient whose weight is 400 lbs?

3. When performing tracheobronchial suctioning on an adult, you should:

30:2, 5:1

15:2, 5_1

30:2, 30:2

15:2, 3:1

Rationale

The current American Heart Association standards for compression/ventilation ratio for
one person CPR is 30:2 for adults and children. If two rescuers are present to provide
care, the rate can be 15:2.

(Dot Objective 2-1.19)

Enough to get the chest to rise and fall

Enough to provide bronchiole breath sounds

400 cc

800 cc

Rationale

When ventilating a patient mechanically, you should only administer enough oxygen to
get the patient’s chest to rise and fall. It should not matter if the patient weighs 10
pounds or 400 pounds. Chest rise is an appropriate indicator of proper tidal volume. If
breath sounds are only located to the bronchiole areas, that does not mean specifically
that the alveoli are being ventilated.

(Dot Objective 2-1.19)

use a rotating motion during the insertion of the suction catheter.

use a Yankauer suction catheter.

apply suction for no greater than 15 seconds.

apply suction on both the insertion and extraction of the catheter.

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4. You are caring for a 68-year-old female patient complaining of difficulty breathing.

The patient presents with labored respirations at a rate of 36 per minute, a pulse of
122 beats per minute, and a blood pressure of 98/56 mmHg. Pulse oximetry shows
an SPO

of 84%. Auscultation of the lungs reveals wheezing and rhonchi in all fields,

and the patient is pursing her lips upon expiration. She states that she was a smoker
for 32 years. You place the patient on oxygen via nonrebreather mask at 15 lpm and
initiate an intravenous line of normal saline at a keep vein open rate. What would be
your next immediate action?

5. Which of the following physical assessment findings would you note if a cancerous

tumor is found to be almost totally occluding both mainstem bronchi?

Rationale

In order to prevent hypoxia, suction should never be applied for longer than a 15 second
period. The correct type of suction catheter for use in tracheobronchial suctioning is the
“soft-tip” catheter, as opposed to the Yankauer or “Tonsil-Tip” catheter, which is used for
suctioning of the oropharynx. Suction is only applied during extraction of the catheter
from the endotracheal tube.

(Dot Objective 2-1.36)

Initiate immediate transport to the nearest hospital

Solu-Medrol 1 mg/kg intravenously

Ipratropium Bromide 4.0 mg via nebulizer

Albuterol 2.5 mg via nebulizer

Rationale

Based upon the patient’s presentation and history, it is likely that you are dealing with an
acute exacerbation of a chronic obstructive pulmonary disorder, such as emphysema.
Initiation of transport is certainly something to consider early, but failure to administer a
bronchodilator to this patient may lead to complete respiratory failure. Ipratropium
Bromide (Atrovent) is an acceptable bronchodilator to administer, but the dose listed is
incorrect. Solu-Medrol, or other corticosteroids, may also be considered, but will do
nothing to treat the immediate respiratory compromise this patient faces. Albuterol
(Proventil, Ventolin) is an appropriate bronchodilator and is shown at the correct dosage.

(Dot Objective 5-1.1)

Jugular venous distention

A decrease in bronchovesicular sounds

Increased bronchial mucous production

An increased pulse oximeter reading

Rationale

Bronchovesicular sounds are those heard normally when auscultating over the lung fields
consistent with bronchial locations (generally, mid-chest on the anterior or posterior

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6. What should the vacuum be set at when suctioning the oropharynx using a rigid

catheter?

7. An endotracheal tube, in conjunction with bag-mask ventilation, would:

surfaces). If a tumor is blocking the bronchi and causing a decrease in air movement, it
will result in a diminishment in auscultated sounds.

(Dot Objective 2-1.24)

Less than – 100 mmHg

Greater than -120 mmHg

At least -100 mmHg

Less than – 80 mmHg

Rationale

Suctioning out the oropharynx with the large bore rigid tip catheter, necessitates the use
of greater suctioning levels (in order to remove the fluid volume as well as larger
particulate matter). As such, the vacuum on the suction unit should be set at a level of at
least -120 mmHg. The soft tipped catheter used for nasal and tracheal suctioning only
requires vacuum levels between -80 mmHg and -120 mmHg. With either catheter,
suctioning should be performed for less than 15 seconds in the adult prior to
reoxygenation.

(Dot Objective 2-1.34)

decrease mechanical dead air space.

require higher ventilation pressures.

increase airway resistance.

improve patient lung compliance.

Rationale

One benefit of endotracheal intubation beyond providing a patent airway, a route for
tracheal suctioning, and medication administration, is the ability to eliminate the
physiologic dead space created by the nasal and oral cavities. This results in a greater
volume of ventilation being delivered to the lungs with the same degree of bagging as
compared to the non-intubated patient. The end result naturally is the improvement in
alveolar ventilation.

(Dot Objective 2-1.58)

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8. A patient that presents with unilateral diminished breath sounds to the apical region,

bilaterally equal resonance to percussion, mild respiratory distress, and a history of
obstructive lung disorders is most likely suffering from:

9. Beta 2-specific bronchodilators can be used for the following symptomatic respiratory

distress patients, except those with:

10. You are called to a residence for a 74-year-old male patient who was found

unresponsive in his front yard by a neighbor. The neighbor is unfamiliar with the
patient’s medical history, but did state he saw the patient up on the roof of the
garage about 30 minutes prior to finding him. Upon determining that the scene is
safe and donning appropriate BSI precautions, you begin your assessment. During
your general impression, you note that the patient has snoring respirations. What is
the best method to initally open the airway?

simple pneumothorax.

unilateral pneumonia.

a pulmonary emboli.

exacerbation of emphysema.

Rationale

A patient with emphysema has weakened lung parenchyma from the disease process, and
has increased susceptibility to a rupture of an emphysemic bleb causing a pneumothorax.
As in this patient, they would present with unilateral breath sound diminishment,
respiratory distress, and equal resonance if it were only a simple pneumothorax.

(Dot Objective 4-7.14)

bronchiolitis.

pleurisy.

bronchial asthma.

emphysema.

Rationale

Pleurisy is an infection of the pleural linings that surround the lung, and will typically
occur secondary to some other infectious process (for example, pneumonia). As such, the
administration of beta 2 bronchodilators will not help since the dyspnea is from the pain
experienced by the patient with breathing (causing them to take shallower breaths). The
other conditions (bronchial asthma, emphysema, and bronchiolitis) may respond to the
beta 2 drug since they may have a bronchoconstrictive component that may be causing
the dyspnea.

(Dot Objective 5-1.1)

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11. You are caring for a 14-year-old male patient complaining of difficulty breathing. The

patient was pitching at a baseball game when he was struck in the anterior neck by a
line drive. The patient’s lips appear cyanotic, he has audible stridor with each
inspiration, he is experiencing severe dyspnea which appears to be rapidly
worsening, and he is becoming combative. What is your recommended treatment?

12. You are caring for a 14-year-old male patient complaining of difficulty breathing. The

Insert a tracheal tube.

Insert an oropharyngeal airway.

Perform a jaw-thrust.

Perform a head-tilt, chin-lift maneuver.

Rationale

As the mechanism of illness or injury is completely unknown in this scenario, it is
impossible to rule out the possibility of a spine injury. This makes the modified jaw thrust
the appropriate choice of airway management initially. Prior to inserting a mechanical
device, the airway is first opened with a manual maneuver. If the patient continues to
have sonorous respirations after two attempts at opening the airway with a manual
maneuver, a mechanical airway will then be inserted.

(Dot Objective 2-1.6)

Needle cricothyrotomy

Place the patient on oxygen via nonrebreather mask at 15 lpm

Place a Laryngeal Mask Airway

Endotracheal intubation

Rationale

With a rapidly worsening patient, complete airway obstruction may be imminent. Time is
critical, and the airway must be completely secured as rapidly as possible. Placing the
patient on oxygen may certainly assist with the patient’s hypoxia, but does nothing to
protect the airway from complete obstruction. Laryngeal mask airways do not isolate the
trachea, and may therefore continue to allow the airway obstruction to progress. Needle
cricothyrotomy is only indicated when all other airway management procedures have
failed. Endotracheal intubation is considered to be the best means at isolating and
securing the progressively worsening airway obstruction.

(Dot Objective 2-1.6)

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utilizing all other techniques have failed. Medical direction has ordered you to
perform a needle cricothyrotomy. Where would you find the anatomical landmark for
insertion of the catheter?

13. You are seated at a restaurant with your EMT partner when a 40-year-old woman at

the next table begins to choke. You immediately proceed to her table and find her in
a standing position, in obvious distress, and coughing forcefully. What is your next
immediate action?

14. You are seated at a restaurant with your EMT partner when a 40-year-old woman at

the next table begins to choke. You immediately proceed to her table and find her in
a standing position, in obvious distress, and coughing forcefully. The patient is now
unresponsive, and repeated efforts to remove the obstruction utilizing abdominal

Immediately inferior to the thyroid cartilage

Immediately inferior to the cricoid cartilage

Immediately superior to the thyroid cartilage

Immediately superior to the sternal notch

Rationale

The cricothyroid membrane can be located on the anterior aspect of the neck immediately
inferior to the thyroid cartilage and immediately superior to the cricoid ring. It is further
noted as there is a slight depression of the membrane between the cartilage boarders on
either side.

(Dot Objective 2-1.7)

Tell her to cough as forcefully as possible.

Remove the foreign body with Magill forceps.

Perform immediate abdominal thrusts.

Perform immediate back blows.

Rationale

If the patient is still conscious and able to cough, all interventions should be withheld
other than reassuring the patient and coaching her in forceful coughing. At this early
stage of choking, the natural cough provides the best opportunity for clearance of the
foreign body. As long as the patient is able to speak and/or produce an adequate cough,
abdominal thrusts are not indicated. Back blows are not indicated in the treatment of
adult airway obstruction. Direct removal of obstruction utilizing laryngoscopy and Magill
forceps is only indicated following unsuccessful attempts to clear the obstruction using
less invasive interventions.

(Dot Objective 5-1.3)

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thrusts have failed. What is the next most appropriate intervention?

15. You are seated at a restaurant with your EMT partner when a 40-year-old woman at

the next table begins to choke. You immediately proceed to her table and find her in
a standing position, in obvious distress, and coughing forcefully. All other efforts to
clear the airway obstruction have failed and you have decided to perform a surgical
cricothyrotomy. Which of the following is true regarding this procedure?

16. You are called to a local restaurant for a choking victim. Upon arrival you find a 34-

year-old female patient complaining of difficulty breathing. The patient tells you that
she had shellfish as part or her meal, despite the fact that she has a known allergy
to them. The patient states that this is the worst reaction she has ever had. Upon
assessment, you note that the patient’s voice is hoarse, and bystanders tell you that

Perform an open cricothyrotomy.

Roll the patient into a left lateral recumbent position and perform 5 back blows.

Perform a needle cricothyrotomy.

Perform direct laryngoscopy and attempt to remove the obstruction with Magill forceps.

Rationale

When basic airway maneuvers such as abdominal thrusts, finger sweeps, and chest
thrusts have failed to clear an obstruction, direct laryngoscopy and attempts to remove
the obstruction with Magill forceps become the most reasonable next action. Utilization of
a surgical airway should only be attempted after all other possible treatment options have
been exhausted.

(Dot Objective 2-1.6)

This procedure can only be performed on patients older than 8 years of age.

Only an uncuffed endotracheal tube should be used.

The incision is made just superior to the cricoid ring of the trachea.

The initial incision is a 1-2 cm vertical incision in the region of the supra-sternal notch.

Rationale

The correct landmark for performing an surgical cricothyrotomy is the cricothyroid
membrane, also known as the cricothyroid ligament, located immediately inferior to the
larynx and immediately superior to the cricoid ring of the trachea. Either a size 6.0 or 7.0
mm cuffed endotracheal tube or a size 6 or 8 Shiley tracheostomy tube should be utilized.
The procedure should not be performed on patients under the age of 12 because the
cricothyroid membrane is small and underdeveloped in children. The initial incision is
typically a 1 to 2 cm vertical incision immediately over the cricothyroid membrane.

(Dot Objective 2-1.7)

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her face and neck has swollen over the past 15 minutes. Wheezing is heard in all
lung fields, and a fine, red rash is observed on the neck and upper extremities. What
is your next immediate intervention?

17. A 57-year-old male patient with a known history of COPD and hypertension has just

collapsed in a busy shopping mall. Bystanders assisted the man to the ground and
quickly notified 911 of the emergency. Upon arrival, you find the patient is not
responding to painful stimuli, there is no chest wall movement, no respiratory effort,
and the carotid pulse is slow and very weak. What is your first immediate action in
treatment of the patient?

18. A 57-year-old male patient with a known history of COPD and hypertension has just

collapsed in a busy shopping mall. Bystanders assisted the man to the ground and
quickly notified 911 of the emergency. Upon arrival, you find the patient is not

Initiate an intravenous line for use as a medication route.

Apply high-flow oxygen and be prepared for endotracheal intubation.

Administer 0.3 to 0.5 mg 1:1000 epinephrine subcutaneously.

Administer 25 to 50 milligrams diphenhydramine hydrochloride intramuscularly.

Rationale

Although all of the treatment options listed may be considered as part of the treatment
regimen for acute allergic reaction or anaphylaxis, ensuring adequate oxygenation and
protecting the airway must be considered paramount among your treatment goals.
Pharmacological therapy should be considered only after further assessment has been
completed and oxygenation and ventilation have been insured.

(Dot Objective 5-5.16)

Insert an oropharyngeal airway and place the patient on a nonrebreather mask.

Open the patient’s airway using a jaw-thrust maneuver, insert an oropharyngeal
airway, and initiate an intravenous line of normal saline.

Open the patient’s airway with a head-tilt, chin-lift maneuver, insert an oropharyngeal
airway, and provide positive pressure ventilations.

Perform a laryngoscopy and insert an 8.0 mm tracheal tube.

Rationale

The primary approach to treating this patent is airway management and pre-oxygenation
to prepare the patent for intubation. Although laryngoscopy and intravenous access are
correct measures in the care of this patient, airway management and pre-intubation
measures must be observed first

(Dot Objective 2-1)

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responding to painful stimuli, there is no chest wall movement, no respiratory effort,
and the carotid pulse is slow and very weak. What would you likely suspect the
patient’s blood pH and carbon dioxide level to be?

19. You have a sixty-year-old male patient in your care that suffered cardiac arrest while

working in his yard. He has a history of a myocardial infarction one year ago. The
patient is intubated and CPR is in progress. He has been in asystole for the last 5
minutes. Your partner reports that the patient suddenly became very difficult to
ventilate and his skin color quickly turned from pink to cyanotic. Upon direct
visualization of the glottis, the endotracheal tube appears to pass through the vocal
cords. If you discovered that your patient had no breath sounds on either side, what
is the most likely reason the patient became cyanotic and hard to ventilate.

20. You have a sixty-year-old male patient in your care that suffered cardiac arrest while

working in his yard. He has a history of a myocardial infarction one year ago. The

Increased carbon dioxide level and increased pH value

Decreased carbon dioxide level and decreased pH value

Increased carbon dioxide level and decreased pH value

No change in carbon dioxide level or pH is expected

Rationale

Since the patent collapsed and stopped breathing his carbon dioxide level will increase as
the waste products builds up in the patient’s body, and his oxygen level will decrease. The
increase in carbon dioxide will thus lead to a greater production of carbonic acid from the
bicarbonate buffer system and thus decreasing the pH of the blood.

(Dot Objective 2-10)

The patient's endotracheal tube is obstructed.

The patient has developed a tension pneumothorax.

The equipment used to ventilate the patient is beginning to fail.

The patient's endotracheal tube is displaced.

Rationale

Since the tube is visualized passing the vocal cords at the glottis, it is not completely
displaced nor has it passed into one of the main stem bronchi since the patient has no
breath sounds. It is highly unlikely that the patient has developed bilateral tension
pneumothorax. There is no evidence of equipment failure at this time. It is most likely
that the patient has an obstructed endotracheal tube. The obstruction could be as simple
as a mucus plug.

(Dot Objective 2-1)

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patient is intubated and CPR is in progress. He has been in asystole for the last 5
minutes. Your partner reports that the patient suddenly became very difficult to
ventilate and his skin color quickly turned from pink to cyanotic. Upon direct
visualization of the glottis, the endotracheal tube appears to pass through the vocal
cords. What is the benefit of inserting a nasogastric tube into this patient?

21. Hypoperfusion that is the result of a myocardial infarction is often the result of what

type of shock?

22. A 49-year-old male patient that has a history of angina pectoris has chest pain that

has not been relieved by rest. Upon your arrival, the patient is supine on the ground,
pale, cool, and diaphoretic. His vital signs are as follows: BP 68/40mm Hg,
respiratory rate of 28/minute, and heart rate 42/minute. His EKG is as follows: What
stage of cardiogenic shock is the patient currently experiencing?

It can serve as a medication route.

It will decrease the amount of stomach secretions and reduce the risk of aspiration.

It will provide relief to possible gastric inflation from prolonged ventilation.

It will provide a means of gastric lavage in the case of an overdose.

Rationale

Gastric inflation is the result of air passing into the stomach during mechanical
ventilations. By inflating the stomach, upward pressure is to the diaphragm decreasing
the capacity of the thoracic cavity. Gastric inflation also increases the risk of vomiting and
aspiration. By removing the air from the stomach, the risk of vomiting and aspiration is
reduced as well making the patient easier to ventilate.

(Dot Objective 2-1.4)

Hypovolemic

Neurogenic

Vasogenic

Cardiogenic

Rationale

Cardiogenic shock is most often the result of pump or heart failure associated with a
myocardial infarction. Vasogenic and neurogenic shock is the result of spinal injury.
Hypovolemic shock occurs when the body has lost too much fluid volume.

(Dot Objective 5-2.115)

Lethal

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23. A 49-year-old male patient that has a history of angina pectoris has chest pain that

has not been relieved by rest. Upon your arrival, the patient is supine on the ground,
pale, cool, and diaphoretic. His vital signs are as follows: BP 68/40mm Hg,
respiratory rate of 28/minute, and heart rate 42/minute. His EKG is as follows:
Which of the following treatments should be administered first to this patient?

24. You have a 56-year-old chest pain patient that just went into cardiac arrest in your

ambulance with a presenting rhythm of ventricular fibrillation. What is your first step
in treatment?

Compensated

Decompensated

Irreversible

Rationale

Decompensated shock is often associated with late signs of shock such as a falling blood
pressure and falling heart rate. Compensated shock is the early stage of shock often
associated with an increased BP, HR and RR. If shock is treated in these early stages the
overall mortality rate decreases. Irreversible shock occurs when the shock cannot be
treated and death is very probable.

(Dot Objective 5-2.115)

Establish an intravenous line of normal saline and start a dopamine drip at 10-20
mg/kg/min.

Establish an intravenous line of normal saline and administer 1mg atropine.

Establish an intravenous line of normal saline and bolus 20cc/kg.

Establish an intravenous line of normal saline at 30cc/hr.

Rationale

Atropine is the initial treatment for this patient that suffers bradycardia. The most
appropriate treatment is transcutaneous pacing since this patient is very symptomatic.
Dopamine would then be indicated if atropine and or TCP are unsuccessful.

(Dot Objective 5-2.95)

Oxygen by positive pressure ventilations

Defibrillate at 360 joules

Verify that the cardiac rhythm is the same in another lead

Two minutes of cardiopulmonary resuscitation

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25. You respond to the home of a 56-year-old found in cardiac arrest. Pharmacological

management of this patient should include which of the following drugs?

26. Cardiac chest pain is usually felt in the jaw and the left arm. This is known as:

27. You respond to the scene of a possible overdose. On your arrival, you find a 19-year-

old male patient lying supine and unresponsive on his bed with snoring respirations.
His pupils are sluggish to light and dilated. His friend stated that he only drank a

Rationale

A patient that is in a witnessed cardiac arrest with ventricular fibrillation presenting, they
should be immediately defibrillated with 360 Joules. If defibrillation is successfull and the
patient is in a perfusing rhythm, patient’s airway should be controlled, positive pressure
ventilations initiated, and prepare the patient for intubation. In this situation of a
witnessed cardiac arrest, CPR should not delay the initial defibrillation attempt.

(Dot Objective 5-2.125)

Oxygen, epinephrine, lidocaine, dopamine

Adenosine, Lidocaine, Verapamil

Oxygen, epinephrine, lidocaine, Amiodarone

Oxygen, cortisone, epinephrine, lidocaine

Rationale

When considering proper management of this patient with pharmacologic therapy, the
correct drugs to use include oxygen, epinephrine, lidocaine and Amiodarone.

(Dot Objective 5-2.125)

point tenderness.

sympathy pain.

associated pain.

referred pain.

Rationale

Referred pain is the pain associated with an illness such as left arm pain and jaw pain
associated with a myocardial infarction. This is often the result of nerve pathways.
Another example of referred pain is right shoulder pain associated with an ill gall bladder.

(Dot Objective 5-2.165)

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small amount of alcohol this evening, but they believe he might have taken
something else. His vital signs are as follows: blood pressure 80/40 mm Hg, heart
rate 44/minute, and respiratory rate 6/minute. His EKG is as follows: What possibly
could be the other substance the patient ingested?

28. You respond to the scene of a possible overdose. On your arrival, you find a 19-year-

old male patient lying supine and unresponsive on his bed with snoring respirations.
His pupils are sluggish to light and dilated. His friend stated that he only drank a
small amount of alcohol this evening, but they believe he might have taken
something else. His vital signs are as follows: blood pressure 80/40 mm Hg, heart
rate 44/minute, and respiratory rate 6/minute. His EKG is as follows: What is your
initial treatment in the care of this patient?

29. Your patient is a conscious and alert 48-year-old female who denies chest pain or

Methamphetamine

Cocaine

Phencyclidine (PCP)

Diazepam

Rationale

Diazepam or Valium™ is a benzodiazepine that is classically has a downing or tranquilizing
affect. When mixed with alcohol, it can produce respiratory depression or even arrest.
Cocaine and PCP are both highly addictive and can produce extreme agitation,
hypertension, and even lead the patient to be unresponsive to pain.

(Dot Objective 5-2.35)

1g/kg of activated charcoal

1mg of intravenous atropine

PPV with endotracheal Intubation

intravenous line of normal saline and a 20cc/kg bolus

Rationale

Your primary concern when dealing with this patient is to provide ventilations and control
the patient’s airway with an endotracheal tube. This patient is unresponsive and unable to
protect his own airway. Once you have the airway controlled, you should focus on
managing the hemodynamic status of your patient. Activated charcoal is not indicated
because this overdose was not ingested and the patient is unresponsive even if it was
ingested. Focus on airway control and then treat the patient’s perfusion status. Atropine
would be considered, BUT only after intubation

(Dot Objective 5-2.95)

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30. Your patient is a conscious and alert 48-year-old female who denies chest pain or

difficulty breathing. She is displaying the following rhythm on the cardiac monitor.
Her blood pressure is 104/72 mmHg, skin is warm and dry, and respiratory rate is 24
per minute. This patient weighs 176 pounds. Based upon this information, which of
the following would be an appropriate treatment:

31. Your patient is a conscious and alert 48-year-old female who denies chest pain or

difficulty breathing. She is displaying the following rhythm on the cardiac monitor.
Her blood pressure is 104/72 mmHg, skin is warm and dry, and respiratory rate is 24
per minute. This patient weighs 176 pounds. Immediately following the
administration of this medication, your patient becomes unresponsive. Although the
rhythm on the cardiac monitor has not changed, the patient is now found to have no

Unstable supraventricular tachycardia

Stable supraventricular tachycardia

Unstable ventricular tachycardia

Stable ventricular tachycardia

Rationale

Obviously the increased rate of this rhythm qualifies it as a tachycardia. The widening of
the QRS complexes to a width > .10 seconds is indicative of a ventricular origin for this
dysrhythmia. Since the patient does not complain of chest pain or dyspnea, and has an
adequate blood pressure and good perfusion, they would have to be categorized as
stable.

(Dot Objective 5-2.42)

Procainamide

Lidocaine

Amiodarone

Adenosine

Rationale

Since this patient is suffering from a Stable Monomorphic Ventricular Tachycardia. ACLS
2005 Guidelines advocate the initial use of Amiodarone as the primary pharmacological
intervention. The correct initial dosage of Amiodarone in this situation is 150 mg
administered over 10 minutes.

(Dot Objective 1-8.6)

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pulse and respirations have ceased. What is your next immediate action?

32. What characteristic ECG findings would indicate slowing of conduction through the

AV node in the cardiac conduction system?

33. You are called for a patient experiencing chest discomfort. Upon arrival, you find a

57-year-old male patient with pale, diaphoretic skin complaining of a crushing
sensation in his chest radiating into his left shoulder, as well as moderate shortness
of breath. His radial pulse is 124 beats per minute, blood pressure is 108/54 mmHg,
and respirations are 32 per minute. The patient states that he has a prior cardiac
history and had taken three nitroglycerin tablets prior to your arrival without relief.
You place the patient on a nonrebreather mask at 15 lpm and establish an
intravenous line of normal saline at a keep vein open rate. The cardiac monitor
shows the following: How would you describe the ectopic beats on the rhythm strip?

Repeat Amiodarone at 300 mg

Epinephrine 1.0 mg intravenously

Defibrillate at 360 joules

Repeat procainamide at 50 mg/min

Rationale

Since pulseless ventricular tachycardia is treated in the same manner as pulseless
ventricular fibrillation, the next immediate action would be to immediately defibrillate the
patient at 360 joules. Following the first defibrillation attempt, it would be appropriate
perform 2 minutes of high quality CPR and prepare to administer epinephrine at 1.0 mg
intravenously.

(Dot Objective 5-2.52)

QRS complex width > 0.12 sec

PR interval > 0.20 sec

QRS complex will be notched or slurred

P wave inversion

Rationale

The impulse delay caused by the AV node / junction is demonstrated on the ECG by the
PR Interval. A QRS complex width of > 0.12 sec indicates abnormal conduction within the
ventricles. Inversion of the P-wave is indicative of origination of the electrical activity from
within the AV node / junction. Notching or Slurring of the QRS complex indicates the
presence of a conduction defect within the ventricles such as a Bundle Branch Block.

(Dot Objective 5-2.32)

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34. You are called for a patient experiencing chest discomfort. Upon arrival, you find a

57-year-old male patient with pale, diaphoretic skin complaining of a crushing
sensation in his chest radiating into his left shoulder, as well as moderate shortness
of breath. His radial pulse is 124 beats per minute, blood pressure is 108/54 mmHg,
and respirations are 32 per minute. The patient states that he has a prior cardiac
history and had taken three nitroglycerin tablets prior to your arrival without relief.
You place the patient on a nonrebreather mask at 15 lpm and establish an
intravenous line of normal saline at a keep vein open rate. The cardiac monitor
shows the following: Based upon all of the information currently available, what
would be your next immediate action?

Unifocal PVCs

PJCs

PACs

Multifocal PVCs

Rationale

The ectopic beats present with QRS widths of greater than .11 second, and are not
preceded by a P wave. This pattern is indicative of ventricular origin, making PVC’s the
correct interpretation of these beats. Since all of the ectopic beats look similar in
morphology, we must assume that they are originating from the same irritable foci with
the ventricle, and therefore refer to them as unifocal. Multifocal PVC’s would have QRS
complexes of >.11 seconds, but would also differ in shape when compared to one
another. PAC’s and PJC’s would both present with narrow (<.11 sec) QRS complexes.

(Dot Objective 5-2.82)

Administer 1.0 to 1.5 mg/kg Lidocaine slow IV push

Administer 635 mg chewable baby Aspirin

Administer 0.3 to 0.4 mg Nitroglycerin sublingual

Administer 5.0 mg Morphine Sulfate slow IV push

Rationale

Nitroglycerin should be administered to this patient regardless of the fact that he had self-
administered three tablets prior to EMS arrival. It is important to accept the possibility
that the patient's nitroglycerin may have been expired or deactivated by prolonged
exposure to the environment. Although Aspirin therapy is also an acceptable alternative at
this point in your patient management, the correct dose is 160-325mg. Administration of
Lidocaine in order to treat the PVC's must not take priority over adherence to initial
therapy guidelines established by the American Heart Assn. This patient's PVC's are likely
due to increased myocardial oxygen consumption, and may be corrected following oxygen
and nitroglycerin therapy. Morphine Sulfate should be administered following Oxygen,
Nitroglycerin, and Aspirin therapy, and at a dose of 2.0 to 4.0 mg.

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35. When conduction defects occur to the heart’s electrical system as a result of

myocardial ischemia, which bundle branch is most likely involved?

36. Which coronary artery is most likely occluded in this patient?

37. Which of the following interventions would least likely increase the heart rate in this

patient?

(Dot Objective 5-2.162)

The posterior fascicle of the left bundle branch

The anterior fascicle of the left bundle branch

The Bundle of His

The right bundle branch

Rationale

The right bundle branch of the ventricular conduction system is most commonly the
bundle branch affected by periods of ventricular ischemia. This is for two reasons, first the
right bundle branch is smaller in diameter and longer in length as compared to the left
(thus making it more susceptible to injury), and secondly because the right ventricle is
not as well perfused as the larger, thicker left wall, periods of ischemia tends to affect
more tissue (and hence the bundle branch).

(Dot Objective 4-2.2)

Left anterior descending artery

Left posterior descending artery

Left circumflex artery

Right coronary artery

Rationale

The left anterior descending artery is the branch of the left common coronary artery that
perfuses both the septum and anterior wall of the left ventricle. Since the bundle branches
are embedded within the septum of the heart, occlusion of this artery can cause the
precipitation of a bundle branch block, which in turn can lead to an “infranodal” heart
block, which is what type the 3rd degree heart block is. The other infranodal block
common to left anterior descending occlusion is the 2nd degree Type II (Mobitz II) heart
block.

(Dot Objective 5-2.1)

Epinephrine infusion

Atropine intravenously

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38. Excessive parasympathetic stimulation would have what effect on the cardiac

conduction system?

39. Which of the following clinical findings cannot be determined by interpreting a 12-

Lead ECG tracing?

Transcutaneous pacing

Dopamine infusion

Rationale

Atropine is routinely avoided with infranodal blocks because of the relative lack of
parasympathetic tone in the ventricles. If atropine were to be administered, it would
increase sinoatrial node discharge and enhance atrioventricular node conduction, but not
help ventricular conduction down the bundle branch. What is needed for this patient is
direct sympathomimetic stimulation by way of dopamine or epinephrine infusions. Of
course though, don’t forget to attempt transcutaneous pacing first.

(Dot Objective 5-2.1)

Ventricular ectopy would occur due to heightened autonomic discharge.

The heart rate would decrease and AV blocks may present.

The ventricular conduction would slow, but SA and AV conduction would increase.

There would be an increase in the heart rate due to enhanced SA node.

Rationale

Excessive parasympathetic tone or stimulation would not only slow down the rate of SA
node discharge (decrease automaticity), it would also slow conduction speed through the
heart and may cause a conduction defect through the AV node (decreased conduction
velocity). The end result is a slower beating, weaker heart. This may cause enough
compromise in the cardiac output to make the patient symptomatic for bradycardia.

(Dot Objective 5-2.2)

Force of ventricular contraction

Rate of SA node discharge

Posterior wall infarction

Ventricular hypertrophy

Rationale

There is no ECG machine that has the capability to determine the strength or force of
ventricular contraction in the patient. All the ECG machine can do is display the electrical
forces of the heart during the cardiac cycle, or display disturbances to the electrical forces

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40. You are assessing the ECG rhythm of a patient with symptomatic hypoperfusion

secondary to a bradycardic rhythm. The ECG tracing demonstrates normal sinus
discharge with a progressively lengthening PR interval and occasional dropped QRS
complexes. The conducted QRS complexes are 0.10 seconds in duration. The name
of this ECG rhythm is:

41. What is your initial field impression of this patient’s problem?

(such as seen with an MI). To determine the force of contraction, the paramedic must use
clinical findings.

(Dot Objective 5-2.3)

third degree heart block.

second degree heart block, Type II.

first degree heart block.

second degree heart block, Type I.

Rationale

The second degree heart block - Type I (or Mobitz I), is identified on the ECG by following
the above listed rules. The clinical problem with this rhythm is that it typically becomes
bradycardiac and the patient’s cardiac output and blood pressure suffers. In the clinically
symptomatic patient, they should receive oxygen, IV therapy, TCP, atropine as early as
possible (the vagolytic drug atropine is appropriate because this is a “nodal block”, where
there is still parasympathetic tone).

(Dot Objective 5-2.5)

Prinzmetal’s angina

Stable angina

Unstable angina

Evolving myocardial infarction

Rationale

Stable angina presents the same as the clinical indications of myocardial ischemia or
infarction, the difference being that angina typically subsides within minutes of ceasing
physical activity and resting. This is because resting diminishes myocardial work load and
provides a closer match between oxygen supply and demand to the heart. Since the signs
of angina are initially the same as myocardial ischemia or infarction, management should
still be geared towards treating the MI as long as the symptoms persist.

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42. The medication that would be provided first by the EMT-Paramedic would be:

43. Which of the following alterations to the physiology of normal cardiac output in a

person suffering from an acute cardiovascular emergency, would contribute to the
development of pulmonary edema?

44. A patient who displays electrical alternans, chest pain, hypotension, and tachycardia

is most likely experiencing:

(Dot Objective 5-2.7)

normal saline.

oxygen.

nitrous oxide.

nitroglycerin.

Rationale

Like all other medical and traumatic emergencies, the first drug that should be given to
the patient suffering from either an anginal attack or an MI, is oxygen. The other drugs
may be warranted later if the pain does not subside, but always start with oxygen.

(Dot Objective 5-2.7)

A decrease in right ventricular ejection fraction

An increase in right ventricular afterload

An increase in left diastolic filling pressure

A decrease in left ventricular ejection fraction

Rationale

Left ventricular ejection fraction refers to the amount of blood (in percentage form) that
the heart ejects given its preload volume. Whenever there is a drop in left ventricular
ejection, then blood volume will start backing up in the left ventricle, and the rise in
pressure will communicate backwards through the left atrium, into the pulmonary veins,
and finally into the perialveolar capillary membranes. Here it will increase hydrostatic
pressure and cause fluid to shift out of the vascular bed and into the alveoli, causing
pulmonary edema.

(Dot Objective 5-2.9)

a myocardial infarction.

mitral valve prolapse.

angina pectoris.

pericardial tamponade.

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45. What is most likely the patient’s presenting problem?

46. Initial treatment for this patient should include:

Rationale

Electrical alternans is a finding seen on the ECG machine of a patient who has significant
pericardial tamponade. What happens is the heart cannot accommodate a good preload
due to the tamponade, and the ECG waveform amplitude is lower. Then, because the
ventricles are essentially empty from the ventricular contraction, a larger preload is
delivered by the atria which requires a stronger ventricular contraction. This stronger
contraction results in an ECG tracing of higher QRS amplitude. The process repeats itself
with an ECG showing an alternating height and depth of the QRS (hence electrical
alternans). The other findings, chest pain, hypotension, and tachycardia are relatively
non-descriptive, but do commonly accompany a patient with pericardial tamponade.

(Dot Objective 5-2.1)

Exacerbation of COPD

Terminal septic shock

Pulmonary edema

Significant bilateral pneumonia

Rationale

The patients presentation is characteristic of fluid backup behind the left side of the heart,
causing the development of pulmonary edema.

(Dot Objective 5-2.12)

oxygen via a nonrebreather, intravenous initiation, and rapid transport.

positive pressure ventilation and intravenous initiation.

fluid bolus of NaCl, intubation, and lidocaine via IVP.

supine positioning and IV nitroglycerin.

Rationale

The treatment for this patient should include (but may not be limited to) positive pressure
ventilation and intravenous initiation. The positive pressure ventilation is needed to
immediately reverse the critical finding of inadequate breathing, and the intravenous
access will be necessary for the probable administration of a diuretic.

(Dot Objective 5-2.12)

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47. You are en route to the hospital with a 32-year-old female patient who was

complaining of respiratory distress. To this point, you have her on high-concentration
oxygen, a cardiac monitor, an IV of NaCl, pulse oximetry, and have placed her in a
semi-Fowlers position. You are completing your detailed physical exam when she
starts to complain of right lateral chest pain that is pleuritic in nature. You identify no
changes on the monitor, the pulse oximeter dropped from 98% to 92%, and the
patient is starting to demonstrate expiratory wheezing in the immediate vicinity of
the chest pain. The heart rate is 110 bpm, respirations are 32 per minute and absent
accessory muscle use, and her blood pressure which was initially 140/80 mmHg is
now found to be 100/72 mmHg. Which cause of life-threatening chest pain is this
patient most likely experiencing?

48. You are en route to the hospital with a 32-year-old female patient who was

complaining of respiratory distress. To this point, you have her on high-concentration
oxygen, a cardiac monitor, an IV of NaCl, pulse oximetry, and have placed her in a
semi-Fowlers position. You are completing your detailed physical exam when she
starts to complain of right lateral chest pain that is pleuritic in nature. You identify no
changes on the monitor, the pulse oximeter dropped from 98% to 92%, and the
patient is starting to demonstrate expiratory wheezing in the immediate vicinity of
the chest pain. The heart rate is 110 bpm, respirations are 32 per minute and absent
accessory muscle use, and her blood pressure which was initially 140/80 mmHg is
now found to be 100/72 mmHg. What is the most probable cause for the drop in her
systolic blood pressure?

Myocardial infarction

Spontaneous pneumothorax

Pulmonary embolism

Pneumonia

Rationale

The combination of sudden dyspnea, deteriorating pulse oximetry reading, sharp and
localized chest pain, and expiratory wheezing in the immediate area of chest pain are all
consistent with a pulmonary embolism. Pneumonia would have a more gradual onset, the
breath sound changes are not consistent with a pneumothorax, and the chest pain is
uncharacteristic to an MI, so these differential diagnosis would be ruled out.

(Dot Objective 5-2.15)

Extreme tachycardia from hypoxemia

A decrease in left ventricular preload

A decrease in sympathetic stimulation

Hypercapnia induced vasodilation to pulmonary vasculature

Rationale

One problem with a pulmonary emboli is that is impedes blood flow through the lungs

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49. You have been resuscitating a 85-year- old male patient that was found by a family

member in cardiac arrest. An ALS unit was first on scene and initiated arrest
management with CPR, positive pressure ventilation with oxygen therapy,
endotracheal intubation, and IV therapy. After 30 minutes now, a total of 5
milligrams of epinephrine has been administered, 3 milligrams of atropine has been
administered, and 100 mEq of sodium bicarbonate has been administered. To this
moment, there has been no cardiovascular response to the therapy. Given the
entirety of the above scenario, what is the most likely ECG rhythm the patient is
currently in?

50. You have been resuscitating a 85-year-old male patient that was found by a family

which causes hypoxemia and hypercapnia as blood gets shunted through other functional
aspects of the pulmonary vasculature. The second problem, is that the blockage (when
large enough), impedes blood flow to such an extent through the lungs that the left side
of the heart starts to suffer from a drop in preload. Since the left side of the heart can
only pump out what it receives, then cardiac output drops and hypotension ensues.

(Dot Objective 5-2.16)

Ventricular asystole

Pulseless electrical activity with a rate of 70 per minute

Ventricular tachycardia

Ventricular fibrillation

Rationale

After this appropriately run but lengthy arrest situation, the most logical rhythm the
patient would be in is ventricular asystole. Generally speaking, if the patient does not
have any cardiovascular response after 20 minutes of arrest management, they probably
will not have a response at all. The rhythm at this time, is asystole (remember also that
asystole is not an electrical rhythm per-se, rather it is the ECG evidence that there is NO
electrical activity in the heart left).

(Dot Objective 5-2.18)

Transport the patient to the hospital

Terminate resuscitation efforts

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51. What criteria must be present that requires removal of the facemask of a football

helmet?

52. Your patient has sustained a myocardial contusion secondary to trauma sustained

from being struck by a car while attempting to cross a busy intersection. What injury
is most likely to be found that may be associated with the myocardial contusion?

Contact the patient’s family physician for orders

Continue following the appropriate treatment algorithm

Rationale

It is becoming an increasingly prevalent practice in prehospital medicine to terminate the
resuscitation of an arrested victim after 20 minutes of appropriately administered BCLS
and ACLS without any cardiovascular response. Upon decision to terminate, the
paramedic is usually required to first communicate with the receiving hospital physician.
The patient following arrest may still be transported (non emergently) to the hospital, per
protocol, to assure endotracheal tube placement was achieved. Follow local protocol.

(Dot Objective 5-2.18)

The patient is in need of airway maintenance.

The patient must be a minor.

There must be a facial injury.

You have at least 3 people present to complete the task.

Rationale

Generally speaking, the protective head and body equipment worn by players can be left
in place so long as adjustments in immobilization are made, to ensure maintenance of
inline positioning. One exception to this is when the patient has also sustained some type
of facial trauma that is compromising the airway, or if the patient is unresponsive and you
need to assure an airway. In these situations, the facemask should be removed as rapidly
as possible to give the paramedic access to the airway.

(Dot Objective 4-5.62)

Right thoracic flail segment

Bilateral clavicular fractures

Pelvic fracture

Sternal body fracture

Rationale

A myocardial contusion occurs when the heart either collides with the sternum in a rapid

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53. A patient presents with hypotension, tachycardia, altered mental status, and poor

peripheral perfusion. The patient was injured when he fell about 20 feet from a tree.
If the patient exhibits no visual signs of trauma, what region of the body would most
likely contain the hemorrhage?

54. When pelvic trauma results in death, what is the most common etiology behind the

death?

deceleration accident (such as a motor vehicle collision), or when the sternum is driven
backwards from blunt chest trauma and the sternum collides with the heart. In either
situation, the transfer of energy from the sternum to the right ventricle commonly causes
a myocardial contusion. Since the sternum is located anterior to the heart, there may also
be a sternal body fracture from the same mechanism of injury.

(Dot Objective 4-7.9)

Intracranial

Pericardial sac

Esophageal

Retroperitoneal

Rationale

A patient who falls a significant distance and lands on their feet is susceptible to
damaging the kidneys as they pull down at the hilum the patient landing on his feet. The
resultant hemorrhage, would be retroperitoneal, and as such, be more difficult to discern
as there would be no external signs of trauma, nor the characteristic abdominal distension
from an intra-abdominal bleed. In these types of situations, the paramedic needs to
maintain a high index of suspicion for internal hemorrhaging.

(Dot Objective 4-8.5)

Nerve damage

Associated hemorrhage

Diaphragmatic injury

Structural instability of the pelvic ring

Rationale

While the structural instability of the pelvic ring or girdle would be the most common
clinically evident finding with assessment, the most common cause of death in the pelvic
fractured patient will be from associated blood loss due to associate vascular trauma that
bleeds into the pelvic cavity, or from hemorrhaging from the large medullary cavities of
the pelvic bones themselves.

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55. Which of the following patients should be transported first should they all be involved

in the same high-speed motor vehicle collision?

56. Your patient has deformity, angulation, and edema to the mid-shaft of the right

femur following a motorcycle accident. Additionally, she has pain to the right knee
which is worse with palpation, and has an overlying hematoma. Regarding these
injuries to the right leg, how will they best be managed?

(Dot Objective 4-8.25)

Female with significant dyspnea, a scaffold abdomen, and diminished breath sounds to
left basal region

Female with sharp midgastric pain and mild dyspnea

Male with periumbilical pain, tachycardia, and a heart rate of 86 per

Male with upper left abdominal pain, contusions noted to the site

Rationale

All of these patients have clinical findings indicative of abdominal trauma that may be
severe. Of the list however, the one in most immediate danger would be the female with
the scaffold abdomen, dyspnea, and diminished basal breath sounds to the left. The
clinical picture this paints is on of a ruptured diaphragm with potential herniation of bowel
into the left hemithorax.

(Dot Objective 4-8.35)

Apply and maintain traction manually, do not apply a traction splint.

Use a bi-pole SAGAR splint, and apply traction to both legs.

Do not apply traction, rather splint in position found.

Use a Hare traction on the right leg only.

Rationale

While the traction splint is warranted with a mid-shaft femur fracture, it can only be used
if there is no other injury to the leg. In this patient, there is a suspected joint injury to the
knee that may be aggravated by the application of manual and mechanical traction during
traction splint application. In this instance, the best course of action is to splint the leg in
the position found (since one of the injuries is to a joint, which are not routinely
straightened or realigned).

(Dot Objective 4-9.22)

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57. Following a prolonged auto extrication, your partner is complaining of pain and

discomfort to his upper arm from trying to hold a damaged car door ajar while the
patient was being disentangled and extricated from the automobile. This injury, most
likely caused from muscular overexertion, is known as a:

58. You are called to a private residence following a domestic dispute to care for a

patient who was “stabbed with a kitchen knife.” Upon arrival, you find a 36-year-old
male patient seated on the front porch holding a towel to his anterior abdomen. He
states that he was stabbed in his abdomen with a “steak knife.” His skin is pale, cool,
and clammy, airway is open and patent, breath sounds are clear and equal
bilaterally, respiratory rate is 36 with adequate tidal volume, radial pulse is thready
at a rate of 114, and blood pressure is 96/70 mmHg. You note a 6-cm laceration to
the right lower quadrant at an 8 o’clock position from his navel. A small portion of
intestine is found to be protruding from the injury site. Which of the following best
describes this patient’s hemodynamic condition?

sprain.

strain.

hairline fracture.

muscular crick.

Rationale

A muscle strain occurs when muscle fibers are stretched beyond their normal limits, or an
excessive or prolonged physical demand is place upon them. The injury is typically
painful, but heals quickly with appropriate rest and rehabilitation. The best thing to do is
not overexert your capabilities to avoid personal injury, but if it occurs, allow the body
time it needs to heal appropriately. Failure to do so will result in increased risk of re-
injuring the same muscle.

(Dot Objective 4-9.32)

Decompensated shock

Abdominal shock

Compensated shock

Irreversible shock

Rationale

A patient who is displaying the primary signs and symptoms of shock but has not yet
become hypotensive is typically described as suffering from compensated shock. These
patients will typically present with tachycardia, tachypnea, and skin that is pale, cool, and
clammy. Only when presenting with significant hypotension would we consider a patient
to be in decompensated shock. Irreversible shock is very difficult to discern in the field
setting, but closely mimics the presentation of decompensated shock.

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59. You are called to a private residence following a domestic dispute to care for a

patient who was “stabbed with a kitchen knife.” Upon arrival, you find a 36-year-old
male patient seated on the front porch holding a towel to his anterior abdomen. He
states that he was stabbed in his abdomen with a “steak knife.” His skin is pale, cool,
and clammy, airway is open and patent, breath sounds are clear and equal
bilaterally, respiratory rate is 36 with adequate tidal volume, radial pulse is thready
at a rate of 114, and blood pressure is 96/70 mmHg. You note a 6-cm laceration to
the right lower quadrant at an 8 o’clock position from his navel. A small portion of
intestine is found to be protruding from the injury site. What steps would you take to
protect this patient’s exposed intestine?

60. You are called to a private residence following a domestic dispute to care for a

patient who was “stabbed with a kitchen knife.” Upon arrival, you find a 36-year-old
male patient seated on the front porch holding a towel to his anterior abdomen. He
states that he was stabbed in his abdomen with a “steak knife.” His skin is pale, cool,
and clammy, airway is open and patent, breath sounds are clear and equal
bilaterally, respiratory rate is 36 with adequate tidal volume, radial pulse is thready
at a rate of 114, and blood pressure is 96/70 mmHg. You note a 6-cm laceration to
the right lower quadrant at an 8 o’clock position from his navel. A small portion of
intestine is found to be protruding from the injury site. Which of the following is an
acceptable plan for management of this patient?

(Dot Objective 4-2.34)

Cover it loosely with a sterile dressing moistened with saline.

Cover it loosely with a dry sterile dressing and plastic wrap.

Apply a pressure dressing.

Attempt to replace the exposed abdominal contents.

Rationale

Care of protruding abdominal organs should include covering the area loosely with a
sterile dressing soaked in sterile saline. In addition, the paramedic may place a sterile
occlusive dressing such as plastic wrap over the moist dressing to aid in keeping the area
clean and retaining moisture. Dry dressings, pressure dressings, and replacement of
abdominal contents are all contraindicated.

(Dot Objective 4-8.38)

Administer oxygen at 15 lpm via nonrebreather mask, begin transport to a trauma
center, and initiate a 14 gauge intravenous line of normal saline.

Administer oxygen at 6 lpm via nasal cannula, begin transport to a trauma center,
initiate a 14 gauge intravenous line, and administer a 100 ml bolus of lactated ringers
solution at a wide-open rate.

Administer oxygen at 6 lpm via nasal cannula, begin transport to a trauma center,
initiate an 18 gauge intravenous line and administer a 250 ml bolus of normal saline at

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61. You are called to the scene of a motorcycle accident. Bystanders state that the

62. You are called to the scene of a motorcycle accident. Bystanders state that the

patient was the operator of a motorcycle that lost control and struck a tree. Your
patient is a 28-year-old male found lying supine on the street. He is complaining of
extreme abdominal and pelvic pain. Your assessment reveals that the skin is pale,
cool, and clammy, airway is open and patent, breath sounds are clear and equal
bilaterally, respiratory rate is 28 with adequate tidal volume, radial pulse is thready
at a rate of 136, and blood pressure is 98/70 mmHg. You note that the patient has a
large contusion to his left anterior thorax, his abdomen is tender and rigid, and his

a wide-open rate.

Administer oxygen at 15 lpm via nonrebreather mask, initiate a 14 gauge intravenous
line, administer a 250 ml bolus of lactated ringers solution at a wide-open rate, and
begin transport to a trauma center.

Rationale

The patient’s skin condition, tachycardia, and mechanism of injury indicate that he is
likely to be suffering from compensated shock. Administration of oxygen at 12-15 lpm via
non-rebreather should be performed rapidly. Since this patient is in need of rapid surgical
intervention, transport to a trauma center should not be delayed while initiating
intravenous therapy and fluid administration.

(Dot Objective 4-2.14)

Perform focused examination of abdomen and pelvis.

Assess the airway.

Place patient on backboard and begin transport.

Provide manual stabilization of the spine.

Rationale

Based upon this patient’s apparently significant mechanism of injury, an assumption of
possible spinal injury must be made. Upon initial approach to the patient, manual cervical
spine immobilization should be taken and maintained until the patient is fully immobilized.
Assessment of the patient’s airway would be the next immediate step. Examination of the
abdomen and pelvis will be integrated as part of the rapid trauma assessment, which
should culminate with full spinal immobilization and initiation of transport to an
appropriate facility.

(Dot Objective 4-6.8)

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pelvis is unstable. Oxygen has been administered via nonrebreather at 15 lpm, a
pulse oximeter has been applied and shows an SpO

of 97%, spinal immobilization

has been completed, and transport has been initiated. What is your next immediate
action while en route?

63. You are called to the scene of a motorcycle accident. Bystanders state that the

patient was the operator of a motorcycle that lost control and struck a tree. Your
patient is a 28-year-old male found lying supine on the street. He is complaining of
extreme abdominal and pelvic pain. Suddenly your patient develops extreme
dyspnea, the pulse oximeter reading begins to decrease, and the patient’s
respiratory rate increases to 36 breaths per minute with inadequate tidal volume.
What is your next immediate action?

64. You are called to a parking lot for an approximately 40-year-old male who was found

Initiate an intravenous line and administer 2 – 5 mg of morphine sulfate.

Initiate an intravenous line and administer 6 mg adenosine via rapid intravenous bolus.

Hyperventilate at a rate of 24 – 30 breaths per minute.

Initiate a large bore intravenous line of normal saline.

Rationale

The patient’s signs and symptoms are consistent with compensated shock. Narcotics, such
as morphine sulfate, should be avoided in multiple system trauma patients as they may
decrease the effectiveness of respiratory and cardiac compensation mechanisms. If
endotracheal intubation is considered, hyperventile at a rate of 20 may be considered
prior to intubation, but it would not be appropriate at a rate of 24 – 30 breath per minute.
The patient’s tachycardia is most likely a secondary effect of hypovolemic shock, and
would therefore not be treated with adenosine.

(Dot Objective 4-8.7)

Perform an ongoing assessment to determine the cause of deterioration.

Perform synchronized cardioversion at 100 joules.

Begin to hyperventilate at a rate of 30 breaths per minute.

Perform a needle decompression to the left thorax.

Rationale

As the sudden deterioration of your patient could stem from many different causes,
performing an ongoing assessment will help you in pinpointing the reason for the status
change. Prior to completion of this assessment, the paramedic will not have enough
information to determine to correct course of action.

(Dot Objective 4-7.16)

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lying behind a dumpster. Assessment reveals an open and patent airway,
respirations of 28 breaths per minute with inadequate tidal volume, radial pulse of
64 beats per minute, and a blood pressure of 78/46 mHg. The patient’s skin is warm,
dry, and flushed. Based upon this limited information, what condition do you suspect
that the patient is suffering from?

65. Your patient has been exposed to a radioactive material that emits beta radiation.

Which of the following is true of beta radiation?

66. You are called to care for a patient who has fallen down a flight of stairs. Upon

Anaphylactic shock

Hypovolemic shock

Cardiogenic shock

Neurogenic shock

Rationale

Neurogenic shock is caused by a disruption in the function of the spinal cord, and typically
presents with hypotension, slow or normal heart rate, and skin that is warm, dry, and
flushed. Cardiogenic shock will typically present with cool and clammy skin, and is often
associated with tachycardia or other dysrhythmias as well as peripheral or pulmonary
edema. Hypovolemic shock is also typically associated with tachycardia and pale, cool,
and clammy skin. Anaphylactic shock typically involves significant dyspnea and airway
compromise, and is associated with additional findings of tachycardia and urticaria.

(Dot Objective 4-6.8)

Very weak, easily stopped by paper, clothing, or the epidermis

Typically only associated with nuclear reactors and bombs

Penetrates the first layer of the skin causing injury similar to thermal burns

Powerful penetrating properties stopped only by thick concrete or lead

Rationale

Neutron radiation is typically only found in association with nuclear weapons or reactors.
Gamma radiation is very powerful, and is only protected against by using thick concrete
or lead shielding. Alpha radiation is very weak, and is not able to penetrate clothing or the
epidermis. Beta radiation will travel 6 to 10 feet through the air and can penetrate some
clothing and the first few millimeters of the skin, causing external injuries very similar in
appearance to thermal burns.

(Dot Objective 4-4.49)

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questions. His only complaint is that of pain to his pelvic region, respiratory rate is
24 with adequate tidal volume, radial pulse is 110 beats per minute, and blood
pressure is 98/60 mmHg. During your exam, you notice that the patient has bruises
located on multiple areas of his body that appear to be in various stages of healing,
palpation of the pelvis causes an acute increase in pain, instability of the pelvis is
noted, and abdominal guarding is present. Based upon your assessment findings,
what poses the most significant immediate threat to this patient?

67. You are called to care for a patient who has fallen down a flight of stairs. Upon

arrival, you find a 9-year-old male patient lying at the base of a flight of 15 stairs.
The patient’s father calmly states that the patient was “screwing around again” and
must have “just slipped.” The patient is very calm and hesitant to answer your
questions. His only complaint is that of pain to his pelvic region, respiratory rate is
24 with adequate tidal volume, radial pulse is 110 beats per minute, and blood
pressure is 98/60 mmHg. During your exam, you notice that the patient has bruises
located on multiple areas of his body that appear to be in various stages of healing,
palpation of the pelvis causes an acute increase in pain, instability of the pelvis is
noted, and abdominal guarding is present. When asked, the patient’s father states
that the patient weighs 77 pounds. If this patient were to need fluid resuscitation,
which of the following would be the most appropriate initial fluid bolus?

Internal hemorrhage

Airway compromise

Spinal trauma

Injury to hollow abdominal organs

Rationale

The most significant risk associated with potential abdominal and pelvic injuries is
hypovolemia secondary to abdominal solid organ injury or vascular injury secondary to
pelvic fracture. Injury to hollow abdominal organs may cause spillage of contents and
chemical irritation of the abdominal cavity, and may even lead to sepsis, but this does not
typically pose an immediate threat. Spinal trauma and airway compromise both may
cause immediate risk to the patient, but the patient is not displaying any signs or
symptoms indicating that he may have suffered either of these conditions.

(Dot Objective 4-8.27)

500 ml bolus of 0.9% sodium chloride solution

250 ml bolus of lactated Ringers solution

700 ml bolus of lactated Ringers solution

350 ml bolus of 0.9% sodium chloride solution

Rationale

An appropriate fluid bolus for children experiencing hypovolemic shock is 20 ml/kg of a
crystalloid intravenous solution. The patient weight of approximately 77 pounds converts
to 35 kg. Multiplying 35 kg by a dose of 20 ml/kg yields a bolus dose of 700 ml of an
appropriate crystalloid solution such as 0.9 % sodium chloride or lactated ringers solution

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68. You are called to care for a patient who has fallen down a flight of stairs. Upon

arrival, you find a 9-year-old male patient lying at the base of a flight of 15 stairs.
The patient’s father calmly states that the patient was “screwing around again” and
must have “just slipped.” The patient is very calm and hesitant to answer your
questions. His only complaint is that of pain to his pelvic region, respiratory rate is
24 with adequate tidal volume, radial pulse is 110 beats per minute, and blood
pressure is 98/60 mmHg. During your exam, you notice that the patient has bruises
located on multiple areas of his body that appear to be in various stages of healing,
palpation of the pelvis causes an acute increase in pain, instability of the pelvis is
noted, and abdominal guarding is present. Based upon the patient’s injury patterns,
behavior, and relative lack of parental concern regarding the injury, you feel that this
patient may be the victim of child abuse. What immediate actions would you take in
order to address these concerns prior to initiation of transport?

69. You are called to care for a patient who has fallen down a flight of stairs. Upon

(Dot Objective 6-2.35)

Contact local child services organization, requesting that they immediately meet you at
the residence.

Directly question the patient’s father regarding the potential for abuse.

Directly ask the patient if his father is abusing him.

Transport to the hospital and report the potential abuse to the appropriate authorities.

Rationale

Situations where abuse is suspected must be handled in a non-judgmental manner. It is
not the role of the paramedic to directly question the parent regarding abuse. Paramedics
should obtain as much information as possible while being supportive of the parent and
child. Directly confronting the situation prior to initiation of patient transport, either by
direct questioning of the child or parent, or by premature contact with investigative
agencies, may put the ambulance crew at unnecessary risk, and may prevent the parent
from permitting patient transport to occur. Your goals are the immediate treatment of
injuries, protection of the child from further abuse, and notification of proper authorities
at an appropriate time.

(Dot Objective 6-2.75)

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noted, and abdominal guarding is present. Which of the following is most likely true
regarding the abuser?

70. You are called to a local park for a 24-year-old female who has fallen while

rollerblading. She is complaining of extreme pain to her left ankle. While obtaining a
medical history, your patient informs you that she recently suffered a Grade II sprain
of her left ankle. How would you describe this previous injury?

71. You are called to a local park for a 24-year-old female who has fallen while

rollerblading. She is complaining of extreme pain to her left ankle. While obtaining a
medical history, your patient informs you that she recently suffered a grade II sprain
of her left ankle. Assessment reveals edema and slight ecchymosis to the patient’s
lateral left ankle. You decide to splint the ankle and apply a cold pack to the affected
area. In what way might application of the cold pack benefit the patient?

Is likely to be uneducated

Will show concern regarding the child’s injuries

Is a member of a low socio-economic class

Was abused as a child

Rationale

Common characteristics of child abusers include a history of being an abused child, a lack
of concern regarding the child’s injury, and a lack of guilt or remorse. Child abuse in not
related to socio-economic class, income, or education level.

(Dot Objective 6-4.9)

Incomplete tear of a ligament

Incomplete tear of a tendon

Overstretching of muscle tissue

Partial dislocation of a bone

Rationale

A sprain is defined as a tearing of a ligament. Grades I and II sprains refer to partial
ligament tear, while Grade III refers to a complete tear. Injuries to tendons and muscles
are actually referred to as strains. A partial dislocation of a bone end is referred to as a
subluxation.

(Dot Objective 4-9.4)

Attracts fibroblasts to begin healing

No physiological benefit, only provided for psychological support

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72. You are called to a local skilled nursing facility to care for a fall victim. Upon arrival,

you find a 78-year-old male patient lying in a left lateral recumbent position on the
floor. Nursing staff states that he was found in this position during morning
medication rounds. Physical assessment reveals that the patient’s right leg is
outwardly rotated with a large palpable mass found in the right inguinal area. No
pelvic instability is noted. Pedal pulses, sensation, and motor response are all
present in the affected limb. The patient complains of extreme pain in the right hip
and an inability to move his right leg. Based upon your physical exam findings, what
condition is the patient most likely to be experiencing?

73. You are called to a local skilled nursing facility to care for a fall victim. Upon arrival,

Reduce local edema

Enhance circulation

Rationale

Application of cold therapy serves two purposes in musculoskeletal injuries, it aids in
reduction of local edema and it decreases patient discomfort. Application of heat may be
utilized after 48 hours to aid in healing and increase local circulation.

(Dot Objective 4-9.14)

Posterior hip dislocation

Fracture of the ischium

Anterior hip dislocation

Rotational fracture of the right femur

Rationale

Anterior hip dislocation is characterized by outward foot rotation and the ability to palpate
the head of the femur in the inguinal area of the affected side. During posterior hip
dislocations the knee is typically flexed and the foot is rotated internally. The head of the
femur typically cannot be palpated in posterior hip dislocations, as it is buried in the
muscle of the buttocks. Femur or ischial fracture would not typically present with a
palpable mass in the inguinal area.

(Dot Objective 4-9.24)

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include which of the following?

74. Upon examination of a trauma patient’s nose, which of the following findings would

be consistent with a skull fracture?

75. You are dispatched to a local nightclub where a 21-year-old male has been assaulted

Re-align leg to anatomical position, pad and splint to backboard.

Attempt reduction of dislocation prior to splinting.

Apply traction splint.

Pad and splint in position found.

Rationale

In any type of hip dislocation that is not complicated with neurovascular deficits distal to
the injury, the best treatment strategy is to apply appropriate padding and splint in the
position found to a long backboard. Re-alignment into a normal anatomical position may,
in fact, cause neurovascular compromise. Attempts at reduction should only be attempted
in posterior hip dislocations, and only if the patient does not have intact pulse, motor
function, or sensation distal to the injury. Traction splints should never be applied in
situations that involve pelvic or hip injury, even if accompanied by obvious mid-shaft
femur fracture.

(Dot Objective 6-3)

Heavy bleeding

Bleeding from only one nostril

Nasal bleeding is not expected from a skull fracture

Blood mixed with spinal fluid

Rationale

Bleeding mixed with a clear to pale yellow fluid is a sign of a skull fracture. This same
bleeding may also be from the patient’s ears. You should not apply direct pressure to stop
this bleeding. Instead just place gauze around the nose to gather the blood. Even if there
is no evidence of a pale yellow fluid in the blood, do not assume the patient does not have
a basilar skull fracture. Always treat the patient according to the "worst case scenario".

(Dot Objective 3-2.19)

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76. You are dispatched to a local nightclub where a 21-year-old male has been assaulted

with a baseball bat. After the police department notifies you that it is safe to
approach the scene, you find the patient in a small alley beside the club. He appears
to be motionless and supine on the ground surrounded by 3 police officers. Upon
examination of his chest, you note that he has a large contusion over his left upper
chest. Upon auscultation of his chest, you note that he has normal breath sounds but
his heart tones seem muffled. His chest is stable to palpation. You noted jugular vein
distention upon evaluation of his neck. His initial vital signs are as follows: Blood
pressure 104/62 mmHg, heart rate 126/minute, and respiratory rate 24/minute.
After five minutes, his blood pressure is 94/76 mmHg. From the given information,
the patient most likely is suffering from what traumatic injury?

77. Which of the following factors most greatly affects the kinetic energy of a bullet fired

from a medium-caliber handgun.

Look for obvious injuries, listen to breath sounds and heart tones, and palpate for
stability.

Look for obvious injuries, palpate for stability, and then listen to breath sounds and
heart tones.

Palpate for stability, listen to his breath sounds and heart tones, and then look for
obvious injuries.

Listen to his breath sounds and heart tones, palpate for stability, and then look for
obvious injuries.

Rationale

It is very important when assessing the anterior chest to look, listen and then palpate the
chest. One must always look and listen before palpating to prevent guarding. Guarding
may lead to false observation of the patient’s respiratory status.

(Dot Objective 3-2.29)

Traumatic asphyxia

Tension pneumothorax

Pericardial tamponade

Flail segment

Rationale

This is because the major cause of a pericardial tamponade is blunt force trauma of the
chest that results in narrowing pulse pressure, positive jugular vein distention, and
muffled heart tones. The patient has good breath sounds eliminating a tension
pneumothorax. The mechanism of injury does not indicate traumatic asphyxia.

(Dot Objective 3-2.29)

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78. A 25-year-old male patient was shot in the chest during a bank robbery. The patient

is alert to painful stimuli and has very labored breathing upon your arrival. There is
moderate bleeding noted from the chest wound. The patient has no medical history
and no known drug allergies. What should be done to control the patient’s bleeding?

79. A 25-year-old male patient was shot in the chest during a bank robbery. The patient

is alert to painful stimuli and has very labored breathing upon your arrival. There is
moderate bleeding noted from the chest wound. The patient has no medical history
and no known drug allergies. The patient’s vital signs are as follows: blood pressure
72/38 mmHg, heart rate 52/minute, and respiratory rate 4/min. Is the patient in
compensated shock?

The bullet’s shape

The bullet’s mass

The bullet’s moment of inertia

The bullet’s velocity

Rationale

The formula for kinetic energy is as follows: KE=(m * V2)/2. Knowing this formula it can
be concluded that kinetic energy is most greatly affected by the squared velocity factor.
Also note that the bullet’s shape and inertia have no effect on the kinetic energy of the
bullet.

(Dot Objective 4-1.11)

Application of a moist dressing

Direct pressure and PASG application

Two large bore intravenous lines with a 20cc/kg fluid bolus

Direct pressure

Rationale

The first step in hemorrhage control is applying direct pressure to the wound. Since this is
a chest wound, an occlusive dressing should be applied once bleeding is reduced. PASG
should not be applied to patients with chest wounds. The PASG applies pressure to the
diaphragm making it more difficult to breath. The application of a moist dressing is
contraindicated in a patient with an open chest wound.

(Dot Objective 4-2.8)

Yes, his heart rate is compensating for his blood pressure.

There is not enough information to determine if the patient is in compensated shock.

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80. Which of the following statements best describes the effects of shock on peripheral

circulation?

81. Which of the following functions is not a function of the integumentary system?

Yes, he still has a pulse.

No, he is in decompensated shock.

Rationale

The patient is in decompensated shock. This is obvious because of his falling blood
pressure, heart rate, and respiratory rate. This patient would require aggressive therapy
to overcome decompensated shock. As long as a patient is able to compensate, his blood
pressure will be normal or slightly elevated.

(Dot Objective 4-2.28)

It causes a decrease in peripheral constriction.

It stimulates the release of clotting factors from peripheral circulation.

There will not be any effects of shock noted in peripheral circulation, only in central
circulation.

It causes an increase in peripheral constriction.

Rationale

The affects of shock on the peripheral circulatory system result in peripheral vascular
constriction. This constriction of the vascular shunts blood from the extremities to the
core in an attempt to provide ongoing oxygenation to the brain and heart. This is often
the reason why cyanosis is noted in the peripheral aspects of the body prior to central
cyanosis.

(Dot Objective 4-2.18)

Protection

Thermoregulation

Sebum formation

Calcium production

Rationale

The skin serves several important functions. Some include insulation of the body from the
fat layer, heat generation, heat loss, sensory and many more. The skin does not produce
calcium. It is stored and released from bone tissue.

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82. Which of the following is the proper way to care for, and transport, an amputated

digit?

83. A male patient was attempting to burn leaves when he tossed a small cup of gasoline

on to the fire. The gas ignited in a large flash. The patient immediately rolled on the
ground to stop the fire. Upon your arrival at the patient’s side, you discover that he
has a very raspy voice, difficulty breathing, and is coughing black sputum. His vital
signs are as follows: blood pressure 140/70 mmHg, respiratory rate 32/minute, and
heart rate 130/minute with the following EKG. Which of the following should you do
first?

(Dot Objective 4-3.3)

Wrapped in petroleum gauze, placed on ice

Wrapped in saline soaked gauze, and placed on a bed of ice.

Packaged in ice

Packaged in milk, with ice added

Rationale

An amputated part should be place in saline soaked gauze. It should never be placed
directly on ice, rather is should be placed on some insulating material (like a trauma pad)
which is lying over the ice. If allowd to lay directly on the ice, freezing could cause the
destruction of tissue and impede any reattachment efforts. Milk should only be used for
teeth that have been displaced.

(Dot Objective 4-3.12F)

Insure that the patient is located a safe distance from the fire and that the burning
process has been stopped.

Insert a Combitube or other blind intubation device and high-flow oxygen.

Perform an immediate laryngoscopy and insert an endotracheal tube.

Apply oxygen immediately via nonrebreather mask.

Rationale

First, the scene must be secured and the patient must be out of harms way. This means
removing the patient away from the fire and smothering or douse the patient with water if
needed. After the scene is secure, the patents airway must be quickly secured.

(Dot Objective 4-4.13)

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84. A male patient was attempting to burn leaves when he tossed a small cup of gasoline

85. During your detailed physical assessment of the head, you utilize a penlight to

examine the patient’s eyes. You find them to be equal in size, 2 mm in diameter, and
unreactive to light. This finding may indicate?

Administer oxygen via a nonrebreather mask.

Insert a 14 gauge IV needle into the thyrocricoid membrane.

Administer oxygen via nasal cannula at 4 L.

Intubate the patient via the nasotracheal route.

Rationale

The patient needs nasal intubation due to his severe airway burns. Due to the risk of
airway swelling, the patient needs intubation immediately. Since oral intubation was not
successful, nasal intubation should be attempted. The patient is breathing which should
aid in nasal intubation. The use of a nonrebreather mask and/or BVM alone may not be
effective enough if the patent’s airway was to occlude due to swelling.

(Dot Objective 4-4.13)

Compression of the oculomotor nerve

A normal finding for a patient

Narcotic drug overdose

Excessive sympathetic stimulation

Rationale

The normal size of the pupil, devoid on disease or injury is usually between 3 to 5
millimeters in diameter, and they should respond consensually to light. If a patient
displays bilateral papillary constriction (miosis), that is unresponsive to light, the
paramedic should consider a pathology that is causing CNS depression, the kind
consistent with a narcotic overdose. Oculomotor nerve damage results typically in
unilateral dilation, and excessive sympathetic stimulation results in pupillary dilation
(mydriasis).

(Dot Objective 3-2.13)

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86. Your patient is experiencing severe dizziness and hypotension secondary to unstable

paroxysmal supraventricular tachycardia. Which pulse would be the most difficult to
palpate?

87. If a patient is suffering from continued hemorrhage of gastric ulcers, which of the

following vital sign would best indicate the patient is entering the decompensated
stage of shock?

88. Which of the following assessment findings is most consistent with a patient who is

suffering from hemorrhagic shock?

Femoral

Radial

Brachial

Carotid

Rationale

With excessive tachycardia, the patient will experience a drop in stroke volume (from a
shortened diastole), and the drop in cardiac output (from the decreased stroke volume).
This results in poor peripheral perfusion, and probable loss of the most distal pulse
location from the heart. In this situation, the most distal pulse would be the radial pulse.

(Dot Objective 3-3.22)

Blood pressure of 102/72 mmHg

Blood pressure of 82/66 mmHg

Heart rate of 112 per minute, and irregular

Heart rate of 126 per minute

Rationale

Decompensated shock physiologically occurs as the precapillary sphincters that guard the
peripheral capillary beds relax secondary to local blood chemistry changes due to shock.
The opening of these sphincters allows blood to flow back into the stagnant capillary beds
which decreases the available blood volume for core perfusion, and, results in a significant
drop in systemic vascular resistance. Thus the clinical finding consistent with
decompensated drop is a sudden decrease in blood pressure (hypotension).

(Dot Objective 4-2.12)

Deteriorating pulse oximeter reading

Skin that is cool, diaphoretic, and pale

Heart rate greater than 120 beats per minute

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89. Which of the following vital signs would be most indicative of a patient who has

entered the decompensated stage of shock?

90. If the patient’s Pa

CO2

is 55 mmHg, what effect will this have on his intracranial

pressure (ICP)?

Alteration in mental status

Rationale

Hemorrhagic shock as it progresses will cause the skin to become cool, diaphoretic, and
pale due to the drop in peripheral perfusion from sympathetic stimulation and the
shunting of blood away from the periphery. And although the findings of mental status
changes, a dropping pulse oximeter reading, and tachycardia may also accompany this,
those findings can also be seen in numerous other medical or traumatic problems.

(Dot Objective 4-2.22)

Heart rate of 128, respirations of 26, and a blood pressure of 82/62 mmHg

Heart rate 64, respirations of 8, and a blood pressure of 82/40 mmHg

Heart rate of 110, respirations of 24, and a blood pressure of 128/90 mmHg

Heart rate of 92, respirations of 18, and a blood pressure of 124/72 mmHg

Rationale

(Dot Objective 4-2.42)

ICP level will increase.

ICP levels will decrease.

ICP levels will cyclically increase and decrease.

ICP levels will not be affected.

Rationale

Because carbon dioxide causes capillary vasodilation, this will promote an increase in the
blood flow through the brain. Because the cranial vault is nondistensible, this increase in
blood flow through the brain results in an elevation in intracranial pressure that may be
detrimental should the pressure rise to greatly.

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91. The patient should be initially ventilated at a rate of?

92. If a 48-year-old male patient suffered a generalized tonic clonic seizure for the first

time, which of the following causes is LEAST likely the reason for the seizure?

93. A patient diagnosed with breast cancer a year ago is now found to have cancerous

tumors that have spread to the brain. The best description of this type of cancer is:

(Dot Objective 4-5.58)

30/minute

greater than 30/minute

20/minute

10/minute

Rationale

Because this patient is displaying signs of herniation due to the elevation in intracranial
pressure, the patient should be ventilated at a rate not to exceed 20 breaths per minute
(with oxygen). This mild hyperventilation will help lower carbon dioxide by increase
alveolar ventilation as well as promote hyperoxygenation – which also helps to promote
cerebral vasoconstriction to lower the ICP. The end result is hopefully a chance for an
improved neurological outcome.

(Dot Objective 4-5.58)

Hyperpyrexia

Hypoglycemia

Head trauma

Alcohol withdrawal

Rationale

The causes of seizure activity in the adult patient varies greatly, and in the incidence of
just one seizure episode, may go undiagnosed. But one of the least common reasons,
would be that of an elevated temperature (hyperpyrexia). Pediatrics are more susceptible
to this due to their immature nervous system, but that is not the same for the adult.

(Dot Objective 5-3.16)

neoplastic.

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94. A patient presents to you with classic neurological signs of a cerebral tumor.

However, the patient also has a fever. The elevated temperature may reflect that:

95. Your elderly male patient suddenly becomes unresponsive at dinner after

complaining of a headache. By the time you arrive on the scene, the patient displays
an irregular breathing pattern and is found to be hypertensive and bradycardic. The
patient also has repeated episodes of vomiting while under your care. Of the
following list, which is the most likely cause for the patient’s presentation?

metastatic.

benign.

malignant.

Rationale

Metastatic cancer is the type that spreads from one body location to another, either
through the blood stream or lymphatic flow. Metastatic cancer is typically the worst kind
as it invades the organs and tissues it encounters as it courses through the body. This
typically hastens death. The other terms are also used in conjuction with describing
cancer, but none refer to the process of the cancer spreading elsewhere in the body.

(Dot Objective 5-3.26)

the hypothalamus is becoming hypoactive.

the cause for the symptoms may be a cerebral abscess.

there is a hyperdynamic cardiovascular state.

the immune system is not responding.

Rationale

A cerebral abscess is the accumulation of infectious material (like pus) in an encapsulated
area of the brain. This space occupying lesion will compress surrounding tissue causing
various findings of a cerebral tumor, but because it started as an infectious process, the
patient’s core temperature may be elevated in an attempt to help ward off the infection.

(Dot Objective 5-3.36)

A hemorrhagic stroke

A thrombotic stroke

A brain abscess

A brain tumor

Rationale

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96. Your elderly male patient suddenly becomes unresponsive at dinner after

97. The neurological disorder characterized by progressive muscle weakness and

degeneration of the voluntary muscle fibers is called?

The key assessment finding with this patient is the speed in which the neurologic
symptoms developed in an otherwise asymptomatic male. A hemorrhagic stroke typically
starts as a bad headache, and as blood accumulates outside the vascular system, it
compresses the normal brain tissue and can cause herniation of the brain stem through
the foramen magnum (causing the Cushing’s triad findings as seen in this patient).

(Dot Objective 5-3.46)

hyperventilation, IV of NaCl, Procardia sublingually, and rapid transport.

oxygen via nasal cannula, IV D5W, and rapid transport.

oxygen via a nonrebreather mask, IV therapy, and pulse oximeter monitoring.

positive pressure ventilation, elevation of the head, and immediate transport.

Rationale

The use of controlled positive pressure ventilation will allow the removal of excess carbon
dioxide in the body from the irregular ventilations (this helps reduce ICP). The elevation
of the head will help promote venous draining from the head (also helping to reduce ICP),
and rapid transport to the ED will give the staff there as much time as possible to
determine if additional therapies for reducing the ICP and evacuating the cerebral
hematoma are warranted.

(Dot Objective 5-3.46)

Alzheimer’s disease

Parkinson’s disease

Multiple sclerosis

Muscular dystrophy

Rationale

The muscular dystrophies (MD) are a group of genetic diseases characterized by
progressive weakness and degeneration of the skeletal muscles which control movement.
There are many forms of muscular dystrophy, some noticeable at birth (congenital
muscular dystrophy) and others in adolescence (Becker MD). The 3 most common types
however are called either Duchenne, facioscapulohumeral, or myotonic. These three types
differ in terms of pattern of inheritance, age of onset, rate of progression, and distribution

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98. A diabetic patient who is insulin dependent is found with a blood glucose level of 35

mg/dl. This glucose level was most likely caused by:

99. As the blood glucose level in the body starts to decrease, what organ and hormone

responds in order to maintain adequate blood glucose levels?

100. A patient presents with a blood glucose reading of 195 mg/dl. What would be an

expected complaint of the patient?

of weakness. The focus by the paramedic however, should be on supporting lost function
– such as breathing inadequacy – when caring for them.

(Dot Objective 5-3.66)

accidentally missing an insulin injection.

injecting too small a dose of insulin after eating.

injection of insulin, but not eating.

eating a high carbohydrate meal prior to insulin injection.

Rationale

An episode of hypoglycemia in a diabetic patient is almost always a preventable episode
by the patient. What happens is that there is too much insulin for the amount of glucose
in the body, so dangerously low blood glucose levels result. In this situation, a patient
who injected their dose of insulin, but did not consume enough glucose will experience a
hypoglycemic episode.

(Dot Objective 5-4.11)

The pancreas secretes glucagon.

The muscles release stored glycogen.

The hypothalamus secretes ACTH.

The liver secretes glucose phosphatase.

Rationale

As the blood glucose level (BGL) drops, the pancreas secretes glucagon from the Islets of
Langerhans. This hormone travels to the liver and liberates stored glycogen back into the
blood stream. Then, with the actions of the enzyme glucose phosphatase, the glycogen is
converted back into free glucose for cellular metabolism. This process, then results in an
elevation in the BGL level.

(Dot Objective 5-4.21)

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101. An unresponsive patient has a blood glucose level of 560 mg/dl. The patient is also

unresponsive, hypotensive, and tachycardic. Your treatment should include:

102. Cushing’s syndrome causes a disturbance to the endocrine system that results in

excessive levels of what hormone in the body?

Increased frequency of headaches

Decreased appetite

Decreased respiratory rate

Increased urine output

Rationale

As the blood sugar level nears 200 mg/dl, glucose molecules begin to spill over into the
urine as the kidneys attempt to eliminate this increasing glucose level. In order to do this
however (because glucose is a larger molecule that can be hypertonic), the kidneys also
need to excrete higher levels of water. This combination, the excretion of glucose and
large quantities of water produces polyuria, and the complaint of increased urinary
output.

(Dot Objective 5-4.31)

initiation of dopamine at 5 mcg/kg/min.

Trendelenburg positioning.

administration of 40 units insulin.

a fluid bolus of normal saline.

Rationale

A patient with an elevated glucose level like that will most likely be dehydrated due to
volume loss through the kidneys as it excretes the high levels of circulating glucose. As
such, the treatment should be aimed towards replacing lost intravascular volume by way
of a fluid bolus. Insulin is not administered by paramedics, nor would the initiation of
dopamine be appropriate. Trendelenburg positioning would be warranted to help with
blood pressure, but the intravenous fluids will have a greater impact on elevating
intravascular volume and peripheral perfusion pressures.

(Dot Objective 5-4.41)

Cortisol

Thyroxin

Triodothyronine

Insulin

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103. Dysrhythmias seen in a patient with adrenal insufficiency Addison’s disease that may

need pharmacological management are most likely due to:

104. Which of the following patients will most likely suffer a severe anaphylactic reaction?

Rationale

Cushing's syndrome is a hormonal disorder caused by prolonged exposure of the body's
tissues to high levels of the hormone cortisol. Sometimes called "hypercortisolism," it is
relatively rare and most commonly affects adults aged 20 to 50. Symptoms vary, but
most people have upper body obesity, rounded face, increased fat around the neck, and
thinning arms and legs.

(Dot Objective 5-4.61)

elevations in serum potassium levels.

depression of the autonomic nervous system.

changes in norepinephrine secretion.

diminished renal excretion causing fluid overload.

Rationale

The adrenal medulla, which is the inner core of the adrenal glands that sit atop each
kidney are necessary to produce the hormones that are part of the sympathetic nervous
system. If this function is loss, there is a diminishment or depression of the autonomic
nervous system, and the patient may start to suffer from cardiovascular depression.

(Dot Objective 5-4.71)

Male patient with urticaria 30 minutes after eating shellfish

Female patient with angioneurotic edema two days following ingestion of a newly
prescribed medication

Child with bilateral wheezing minutes after being stung by a wasp

Elderly patient with history of latex allergy displaying hives and itching

Rationale

A sever allergic reaction is suspected when the patient displays findings of acute
deterioration shortly after exposure to the antigen. These findings include dyspnea,
wheezing, and skin changes. The most common route of antigen entry into the body that
causes the anaphylactic reaction is injection, because this allows for immediate absorption
and distribution throughout the body. As such, the child with the wheezing that started
minutes after being stung, will most likely suffer a severe anaphylactic reaction.

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105. A patient who has an inflamed appendix will most likely experience initial pain

described as:

106. You are called for an elderly male complaining of weakness and dizziness. Upon

arrival, the patient is found lying in bed with blood-tinged fecal matter on his
clothing and bedding. The patient states he had a colonoscopy yesterday due to his
diverticulitis. Today, however, he states “I keep having diarrhea that hits before I
can even get out of bed.” The patient is cool to the touch, has a 4-second capillary
refill, pulse oximeter reading of 93% on room air, blood pressure of 100/82 mmHg,
heart rate of 132 beats per minute, and respirations of 30 and unlabored. Abdomen
reveals diffuse tenderness upon palpation. The weakness and dizziness experienced
by this patient is due to:

107. You are called for an elderly male complaining of weakness and dizziness. Upon

(Dot Objective 5-5.4)

sharp with radiation.

dull and crampy.

dull, but easy to localize.

sharp and intense.

Rationale

An inflamed appendix usually starts with the general findings of abdominal pain, fever,
and vomiting. The abdominal pain usually begins in the center of the abdomen, around
the area of the umbilicus, and later, the pain radiates downward and to the right - to an
area called McBurney's point. This roughly corresponds to the location of the appendix in
the lower right portion of the abdomen.

(Dot Objective 5-6.4)

volume loss

mild hypoxemia

excessive tachycardia.

septicemia.

Rationale

Since the patient has a history consistent with potential GI bleeding, and the clinical
symptoms indicate the same (cool skin, delayed capillary refill, tachycardia, and
narrowing blood pressure), the paramedic should be prepared to treat the patient for a
hypovolemic episode.

(Dot Objective 5-6.24)

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arrival, the patient is found lying in bed with blood-tinged fecal matter on his
clothing and bedding. The patient states he had a colonoscopy yesterday due to his
diverticulitis. Today, however, he states “I keep having diarrhea that hits before I
can even get out of bed.” The patient is cool to the touch, has a 4-second capillary
refill, pulse oximeter reading of 93% on room air, blood pressure of 100/82 mmHg,
heart rate of 102 beats per minute, and respirations of 30 and unlabored. Abdomen
reveals diffuse tenderness upon palpation. The first step in managing this patient
with weakness and dizziness is to:

108. You are called for an elderly male complaining of weakness and dizziness. Upon

arrival, the patient is found lying in bed with blood-tinged fecal matter on his
clothing and bedding. The patient states he had a colonoscopy yesterday due to his
diverticulitis. Today, however, he states “I keep having diarrhea that hits before I
can even get out of bed.” The patient is cool to the touch, has a 4-second capillary
refill, pulse oximeter reading of 93% on room air, blood pressure of 100/82 mmHg,
heart rate of 102 beats per minute, and respirations of 30 and unlabored. Abdomen
reveals diffuse tenderness upon palpation. The most important intervention that
could be provided for this patient while en route to the hospital over 30 miles away
is:

administer oxygen via a nonrebreather mask.

obtain a 12-lead ECG to rule out a cardiac cause.

place him in a semi-Fowler’s position.

initiate an IV of normal saline.

Rationale

Although the patient is presenting with classic signs of hypovolemia, for which fluid
therapy would be appropriate, the paramedic mustn’t forget about assuring oxygenation.
The first step in managing this patient should be to place them on high flow oxygen via a
nonrebreather mask.

(Dot Objective 5-6.44)

administer dobutamine to raise blood pressure slightly.

administer IV analgesics to keep the patient comfortable.

packing the rectum to tamponade the bleed.

initiate an intravenous line of a crystalloid solution.

Rationale

The administration of intravenous fluids en route to the hospital will increase preload by
expanding the venous volume of blood. In turn this will enhance cardiac output and
perfusion pressures, and some of the symptoms will start to ameliorate. The definitive
goal is to stop the bleeding (at the hospital), but en route the paramedic needs to keep
the patient viable with controlled use of intravenous fluids.

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109. You are called to a private residence for a 47-year-old male patient who has “fallen

down the stairs.” Following your initial entry into the kitchen, you are able to see the
patient lying on a concrete floor in a left lateral recumbent position at the bottom of
the stairway leading to the basement. The patient’s wife is in the basement with him
crying for help. The patient’s airway is now clear and the respiratory rate is irregular
at 12 per minute with an adequate tidal volume. Blood pressure is 192/82 mmHg
and the patient has a strong radial pulse at a rate of 56 bpm. The patient is
unresponsive to painful stimuli. The cardiac monitor displays the following rhythm.
Based upon these findings, what condition is the patient most likely to be
experiencing?

110. You are called to a private residence for a 47-year-old male patient who has “fallen

(Dot Objective 5-6.44)

Concussion

Postictal state

Syncope secondary to bradycardia

Intracranial hemorrhage

Rationale

Based upon the history of a significant fall coupled with the findings of Cushing’s reflex
(increased blood pressure, decreased pulse rate, irregular respirations) the patient is
most likely suffering from an acute intracranial hemorrhage. A postictal state would not
explain the variations in vital signs, and syncope secondary to symptomatic bradycardia is
likely to manifest with hypotension. A concussion may result in a period of
unconsciousness, but would not yield the findings of increased intracranial pressure being
exhibited.

(Dot Objective 4-5.43)

Mannitol 1 mg/kg intravenously

Atropine 0.5 mg intravenously

Oral intubation and ventilation

Diazepam 5 mg intravenously

Rationale

Although mannitol may be indicated for increased intracranial pressure, the correct
dosage is 1 gm/kg. In addition, it’s use for intracranial hemorrhage in the prehospital

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111. You are called to a local chemical plant to care for a patient who has experienced a

seizure. Upon arrival, bystanders describe that the patient was found unconscious in
a storeroom displaying generalized, full-body tonic-clonic muscle spasms. The
patient was removed from the storeroom and is found in the first aid room. He is
currently unresponsive and displaying no further muscle spasms. Lungs are clear to
auscultation. Respirations are present at a rate of 8 per minute with decreased tidal
volume, radial pulse is regular at a rate of 122, and blood pressure is 154/96 mmHg.
Pupils are equal, round and reactive, and the pulse oximeter shows a Sp

of 99%.

What is your best immediate action?

112. You are called to a local chemical plant to care for a patient who has experienced a

of 99%.

The patient’s supervisor reveals that an unmarked 55-gallon drum of an unknown
chemical was found leaking in the storeroom where the patient was found. Based
upon his symptoms, which of the following substances would you suspect he was

setting is not recommended. Diazepam could be considered if the patient was actively
seizing. Atropine is not called for in this situation because the decrease in heart rate is not
due to cardiac causes, but a direct effect of the herniation syndrome. Oral intubation and
ventilation will aid in reducing intracranial pressure by avoiding hypercapnea induced
cerebral vasodilation which can increase intracrainal pressure.

(Dot Objective 4-5.53)

Initiation of an intravenous line

Placement of an ammonia inhalant near the patient’s nose to determine responsiveness

Insertion of an oral airway and ventilation with a bag-valve-mask device and
supplemental oxygen

Oxygen via nonrebreather mask at 12 liters per minute

Rationale

Since the patient’s respiratory rate is diminished and his tidal volume is decreased,
management of breathing becomes your paramount concern. Placement of a
nonrebreather mask will not correct the inadequate ventilation this patient is
experiencing. Responsiveness can be determined utilizing verbal and painful stimuli.
Although an IV line will likely need to be initiated in this patient, this procedure should
occur after airway and breathing control is secured.

(Dot Objective 2-1.16)

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exposed to?

113. You are called to a local chemical plant to care for a patient who has experienced a

of 99%.

The patient’s spontaneous respiratory rate continues to decrease. You choose to
perform endotracheal intubation and establish an intravenous line. The cardiac
monitor displays the following rhythm: What else may be considered as part of your
treatment?

Ammonia

Organophosphate pesticide

Cyanide

Chlorine

Rationale

The effects of chlorine and ammonia exposure typically revolve around the respiratory
system, and are both likely to cause pulmonary edema. Neither of these substances is
likely to produce seizures. Organophosphate pesticides have a direct effect on the central
nervous system, and although are know to cause seizures, they would also produce
SLUDGE type symptoms, including salivation, tearing, incontinence, gastric upset,
vomiting, as well as constricted pupils. Cyanide poisoning can cause seizure and coma,
but will not have an effect on pupil constriction or yield SLUDGE symptoms.

(Dot Objective 5-8.2)

Sodium nitrite 300 mg intravenously

Pralidoxime chloride 1.0 gram intravenously

Atropine sulfate 2 – 5 mg intravenously

Amyl thiosulfate 1.2 grams intravenously

Rationale

As this patient has likely been exposed to cyanide, utilization of a cyanide antidote kit
should be considered. Sodium Nitrite at a dose of 300 mg intravenously is one of the
components of the antidote kit, along with Amyl Nitrite inhalants and Sodium Thiosulfate
injectable. Atropine Sulfate and Pralidoxime Chloride are components of treatment for
organophosphate overdose, but do nothing to help the cyanide poisoning patient.

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114. You are called to the scene of a domestic violence incident, where you find a 36-

115. You are called to the scene of a domestic violence incident, where you find a 36-

year-old male patient lying supine in the grass. The patient is conscious and alert,
and states that he was “attacked” by a neighbor. You find that the patient’s airway is
open and patent, respiratory rate is 32 with adequate tidal volume, and the radial
pulse is thready at a rate of 126. You note that there is a large incision to the medial
aspect of the patient’s left thigh from which bright-red blood is spurting. As you
obtain further patient history and complete a rapid trauma assessment, you find that
the patient has no other injuries. Serial examination reveals that respirations are
now 36 with adequate tidal volume, carotid pulse is 130, radial pulse is absent, blood
pressure is 76/56 mmHg, and the patient is now unresponsive but alert to verbal
stimuli. The wound continues to bleed despite the application of a pressure dressing
and elevation of the extremity. Which of the following actions would you consider
next?

(Dot Objective 5-8.1)

Apply the PASG’s.

Apply pressure to a proximal pressure point.

Apply direct pressure to the wound.

Perform a rapid trauma assessment.

Rationale

Ignoring the apparent arterial hemorrhage from the femoral region while you continue
complete a rapid trauma assessment may have a detrimental impact on the patient’s
outcome. The application of initial hemorrhage control techniques can be performed
rapidly, without causing unnecessary delay to continuation of the examination process.
Application of direct pressure, potentially combined with elevation, is an appropriate
action to take in this patient as it allows you to gain initial control of the patient’s
hemorrhage and only takes a few seconds to perform. Following this procedure,
continuation of the initial assessment is imperative. It is not appropriate at this time to
utilize pressure points or apply the PASG’s.

(Dot Objective 3-3.24)

Application of pressure to the femoral artery

Application of a tourniquet

Application of pressure to the popliteal artery

Removal and re-application of the pressure dressing

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116. You are called to the scene of a domestic violence incident, where you find a 36-

Rationale

Hemorrhage control should follow a progression which begins with the application of direct
pressure and a pressure dressing, often combined with elevation. When these techniques
do not prove adequate at stopping the hemorrhage, application of pressure to a proximal
pressure point should be attempted. In this case, the femoral artery would be the
appropriate proximal pressure point, as the popliteal artery is distal to the injury site.
Typically, removal of an existing pressure dressing is not recommended, as it is likely to
disrupt to clotting process and prolong the hemorrhage. Application of a tourniquet is
considered only as a last resort, after all other attempts to control hemorrhage have
failed.

(Dot Objective 4-3.31)

Initiation of a 16 gauge intravenous line and administration of AB positive blood at a
“wide open” rate

Initiation of two 14 gauge intravenous lines and administration of a 20ml/kg bolus of
0.9% sodium chloride

Initiation of a 14 gauge intravenous line and administration of a 200 ml bolus of
lactated Ringers solution

Application and inflation of the PASG’s

Rationale

Based upon the patient’s hypotension, tachycardia, tachypnea, and mechanism of injury,
it is reasonable to conclude that he is suffering from hypovolemic shock, and has likely
reached the point of decompensatory shock. Prehospital fluid resuscitation for the
hemorrhagic hypovolemic shock patient typically involves initiation of two intravenous
lines and administration of a crystalloid intravenous solution at a volume and rate based
upon clinical presentation. This patient’s clinical presentation would warrant
administration of crystalloid fluid bolus at a volume of 20ml/kg initially, with adjustments
made based upon clinical response. Although blood is the preferred solution for fluid
resuscitation, administration of AB positive blood in a patient who does not have the AB
positive blood type is never indicated. O negative blood is considered to be the “universal
donor” and could be administered in dire emergency without typing and cross-matching,
but AB positive blood cannot be used in this manner. Application of the PASG’s may be
appropriate in conjunction with fluid resuscitation, but use of this device is very
controversial, and does not constitute an adequate replacement for fluid resuscitation.

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117. While interviewing your patient, you echo back their responses to your questions

utilizing your own words, in order to ensure that you understand what they have told
you. What is this technique called?

118. Your patient has indicated fear about his illness, stating that he is afraid that he may

die. This has made the interview difficult, as you have been unable to get the patient
to give you many details regarding his symptoms or the events preceding them.
Which of the following techniques is an acceptable method to focus the interview and
get the needed information?

(Dot Objective 4-2.44)

Facilitation

Empathy

Reflection

Confrontation

Rationale

Reflection is the act of repeating back a patient’s message using your own words in order
to ensure understanding. Facilitation is used when you encourage the patient to give you
more information. Confrontation is used when you focus the patient on a particular factor
of the interview. Empathy is using your body language to make the patient feel as if you
understand their situation.

(Dot Objective 3-1.3)

Repeat back to the patient whatever relevant information you have obtained, and then
ask him for further information.

Reassure the patient by telling him “everything will be fine.”

Decrease the physical distance between you and the patient, and relay to him that he
may get worse if you can’t obtain the needed information.

Sternly tell the patient that he must focus and tell you what you need to know.

Rationale

Repeating your understanding of the situation back to the patient is useful is helping them
realize what relevant information they have not yet revealed. It is typically not advisable
to take an authoritarian role with a patient, as this may add to their emotional distress
and worsen their communication ability. It is also not a good idea to give patients false
assurances, such as telling them that they will be fine. Decreasing the physical distance
can be intimidating to the patient, as can telling them that they may worsen if you can’t
get the necessary information. Both of these techniques will increase patient
apprehension and will likely have a negative impact on communication.

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119. You are called to a private residence for a patient who is complaining of generalized

weakness. You arrive to find a 44-year-old female patient who is unable to ambulate.
During your exam, you note that the patient’s speech is incomprehensible. She is
suffering from obvious left-sided hemiparesis, but will move all extremities upon
command. The patient opens her eyes spontaneously, and pupils appear to be equal
in size. She also appears to have left-sided facial drooping. The patient’s husband
states that these symptoms appeared suddenly and have persisted for approximately
one hour without any change. Respiratory rate is 16 and non-labored with adequate
tidal volume, radial pulse is 92 beats per minute, and blood pressure is 160/98
mmHg. What is this patient’s Glasgow Coma Scale score?

120. You are called to a private residence for a patient who is complaining of generalized

weakness. You arrive to find a 44-year-old female patient who is unable to ambulate.
During your exam you note that the patient’s speech is incomprehensible. She is
suffering from obvious left-sided hemiparesis, but will move all extremities upon
command. The patient opens her eyes spontaneously, and pupils appear to be equal
in size. She also appears to have left-sided facial drooping. The patient’s husband
states that these symptoms appeared suddenly and have persisted for approximately
one hour without any change. Respiratory rate is 16 and non-labored with adequate
tidal volume, radial pulse is 92 beats per minute, and blood pressure is 160/98
mmHg. Based upon your findings, what condition do you suspect that the patient is
likely experiencing?

(Dot Objective 3-1.3)

Rationale

The Glasgow Coma Scale (GCS) uses the criteria of eye opening, verbal response, and
motor response in assessing the patient’s neurological status. The maximum score for eye
opening is four (4), which is achieved if the patient’s eyes open spontaneously, as is the
case with this patient. This patient also achieves the maximum score of six (6) under the
category of motor response due to her ability to follow your commands. Under the
category of verbal response, a maximum score of five (5) would be achieved if the patient
exhibited “oriented” verbal responses. This patient is able to speak only incomprehensible
words, however, which correlates to a score of two (2). Following these criteria, this
patient’s GCS would be 12

(Dot Objective 3-2.55)

Bell’s palsy

Occlusive stroke

Spinal cord injury

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121. You are called to a private residence for a patient who is complaining of generalized

weakness. You arrive to find a 44-year-old female patient who is unable to ambulate.
During your exam you note that the patient’s speech is incomprehensible. She is
suffering from obvious left-sided hemiparesis, but will move all extremities upon
command. The patient opens her eyes spontaneously, and pupils appear to be equal
in size. She also appears to have left-sided facial drooping. The patient’s husband
states that these symptoms appeared suddenly and have persisted for approximately
one hour without any change. Respiratory rate is 16 and non-labored with adequate
tidal volume, radial pulse is 92 beats per minute, and blood pressure is 160/98
mmHg. How would you determine if this patient were actually suffering from a
transient ischemic attack (TIA)?

122. You are called to the local bingo hall for a 65-year-old female patient who is

unresponsive. Upon arrival, you find your patient supine on the floor. Bystanders
state that the patient’s symptoms began 15 minutes prior to your arrival and have
progressed rapidly. The patient’s airway is open and clear, respirations are irregular
and characterized by periods of apparent hyperventilation followed by periods of
apnea in a repetitive pattern, radial pulse is present and bounding at a rate of 56,
and blood pressure is 162/128 mmHg. The patient’s right pupil is dilated and

Intracranial hemorrhage

Rationale

Intracranial hemorrhage with increased intracranial pressure would likely cause additional
signs and symptoms, such as an increase in unilateral pupil size or bradycardia. Bells’
palsy is indicated by unilateral facial paralysis, and is not consistent with the patient’s
other symptoms. A problem effecting the spinal cord would not account for the facial
droop and verbal disturbances experienced in this scenario. Occlusive stroke, such as
those caused by embolus or thrombosis, can account for this patient’s presentation.

(Dot Objective 5-3.48)

Symptoms resolve within 24 hours

Symptoms remain unchanged for 12 hours

Motor symptoms resolve, while verbal symptoms remain

Symptoms resolve within 48 hours

Rationale

Transient ischemic attacks will cause symptoms that appear completely consistent with
those of stroke, however the symptoms will resolve within 24 hours without residual
neurological damage. Other than this resolution of symptoms, there is no way of
differentiating between stroke and TIA.

(Dot Objective 5-3.58)

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nonreactive while the left pupil appears normal. Which of the following terms would
you use to describe the patient’s respiratory pattern?

123. You are called to the local bingo hall for a 65-year-old female patient who is

unresponsive. Upon arrival you find your patient supine on the floor. Bystanders
state that the patient’s symptoms began 15 minutes prior to your arrival and have
progressed rapidly. The patient’s airway is open and clear, respirations are irregular
and characterized by periods of apparent hyperventilation followed by periods of
apnea in a repetitive pattern, radial pulse is present and bounding at a rate of 56,
and blood pressure is 162/128 mmHg. The patient’s right pupil is dilated and
nonreactive while the left pupil appears normal. What would be your next immediate
action?

124. You are called to the local bingo hall for a 65-year-old female patient who is

Central neurogenic hyperventilation

Biot’s breathing

Cheyne-Stokes breathing

Kussmaul’s respirations

Rationale

Cheyne-Stokes breathing is characterized by periods of hyperventilation followed by
periods of apnea in a crescendo – decrescendo pattern. Kussmaul’s respirations refers to
rapid, deep breathing typically associated with metabolic acidosis. Central neurogenic
hyperventilation produce rapid and deep respirations and are typically associated with
strokes or brainstem injury. Biot’s breathing is characterized by episodes of gasping
interspersed with periods of apnea in an irregular pattern.

(Dot Objective 5-1.3)

Initiate an intravenous line.

Hyperventilate at 30 breaths per minute.

Immediately transport.

Begin to ventilate at no greater than 20 breaths per minute.

Rationale

Ensuring adequate airway and ventilation is always considered your primary intervention
goal, and should precede initiation of transport and attempts at intravenous line
placement. Hyperventilation at a rate above 24 per minute may cause excessive cerebral
vasoconstriction resulting in decreased oxygen delivery to the brain, and should therefore
be avoided. Hence a ventilatory rate of 20/minute is advocated.

(Dot Objective 5-2.172)

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125. You are called to a private residence for a patient experiencing difficulty breathing.

Upon arrival you find a 74-year-old female patient with a history of emphysema in a
full-Fowler position on a kitchen chair. Assessment reveals accessory muscle usage,
cyanosis to the lips and fingertips, and a pulse oximeter reading of 74%. Respiratory
rate is 32 with decreased tidal volume, pulse is irregular at a rate of 118 beats per
minute, and blood pressure is 104/82 mmHg. The patient is on home oxygen at 4
lpm via nasal cannula. The cardiac monitor displays the following rhythm: Which of
the following describes the correct approach to oxygen therapy in this patient?

Transient ischemic attack

Intracranial hemorrhage

Hypoxia secondary to pulmonary embolism

Metabolic acidosis

Rationale

The presence of Cheyne-Stokes respirations coupled with increased blood pressure,
decreased pulse rate and unilateral pupil dilation is consistent with increased intracranial
pressure secondary to intracranial hemorrhage. Transient ischemic attacks, pulmonary
embolus, and metabolic acidosis can all cause changes to respiratory patterns and
decreased level of consciousness, but will not cause the increased blood pressure and
bradycardia associated with increased intracranial pressure.

(Dot Objective 5-3.8)

The patient should remain on her physician-prescribed oxygen dose of 4 liters per
minute via nasal cannula.

Apply high-flow oxygen via nonrebreather at 12–15 liters per minute.

Oxygen should be withheld in order to prevent further depression of the respiratory
drive.

Immediate endotracheal intubation is indicated.

Rationale

Regardless of past medical history, high flow oxygen should never be withheld from a
patient who is in acute respiratory distress. Application of high flow oxygen via non-
rebreather at 12-15 lpm is indicated in this patient. If the patient condition does not
improve following oxygen therapy, then ventilation and intubation may be indicated. With

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126. You are called to a private residence for a patient experiencing difficulty breathing.

Upon arrival you find a 74-year-old female patient with a history of emphysema in a
full-Fowler position on a kitchen chair. Assessment reveals accessory muscle usage,
cyanosis to the lips and fingertips, and a pulse oximeter reading of 74%. Respiratory
rate is 32 with decreased tidal volume, pulse is irregular at a rate of 118 beats per
minute, and blood pressure is 104/82 mmHg. The patient is on home oxygen at 4
lpm via nasal cannula. The cardiac monitor displays the following rhythm: The
patient condition has not improved following appropriate oxygenation. Your standing
orders indicate that you should administer 2.5 mg of Albuterol via nebulizer. Which
of the following correctly describes Albuterol’s beneficial mechanism of action in
emphysema?

127. Which of the following is true relative to the use of long-term oxygen in chronic

obstructive pulmonary disease patients?

the apparent hypoxia indicated by the patient condition and pulse oximetry reading, a
nasal cannula will not supply enough oxygen to have an appropriate effect on this
patient’s physiological status.

(Dot Objective 5-1.1)

Stimulation of beta 1 receptors

Stimulation of beta 2 receptors

Inhibition of parasympathetic nervous system

Suppression of inflammatory response

Rationale

Albuterol is a beta 2 specific agonist. Stimulation of the beta 2 sympathetic nervous
system receptor site relaxes the smooth muscle contained within the bronchioles, thereby
increasing the diameter of the breathing passages. Stimulation of beta 1 receptor sites
would elicit increased cardiac output, and have little effect on the respiratory passages.
Corticosteroids are sometimes used in emphysema patients in order to suppress the
inflammatory response. Medication such as atropine will suppress the parasympathetic
nervous system, but are not typically indicated for respiratory disorders.

(Dot Objective 5-1.1)

It may suppress the hypercarbic drive leading to decreased respirations.

It should only be administered via nasal cannula or Venturi mask.

High-oxygen concentration should only be administered in association with ventilatory
support via bag-valve device

It may decrease respirations by causing suppression of the hypoxic drive.

Rationale

COPD causes a chronic increase in carbon dioxide levels in the blood. This condition
typically causes respirations to be driven by the hypoxic drive, where the lack of oxygen

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128. You are called to a skilled nursing facility to care for a patient who is having difficulty

breathing. Upon arrival, you find a 76-year-old male patient seated in a chair. The
patient is thin, his skin is pink and warm, his chest is barrel-shaped, and initial
observation shows that he has labored respirations with suprasternal retraction and
accessory muscle usage. Based upon this limited information, what is your initial
impression of the patient’s underlying condition?

129. You are called to a skilled nursing facility to care for a patient who is having difficulty

breathing. Upon arrival, you find a 76-year-old male patient seated in a chair. The
patient is thin, his skin is pink and warm, his chest is barrel-shaped, and initial
observation shows that he has labored respirations with suprasternal retraction and
accessory muscle usage. Further assessment reveals that the patient has diminished
breath sounds bilaterally with wheezing present in upper lung fields, a pulse
oximeter reading of 85% SpO

, prolonged expiration, and 1 – 2 word dyspnea.

Respirations are 28 with adequate tidal volume, radial pulse is irregular at 100 beats
per minute, and blood pressure is 104/90 mmHg. The cardiac monitor shows the
following rhythm: What is your interpretation of the cardiac rhythm?

in the body actually serves as the trigger for initiation of ventilation. Application of high
flow oxygen can cause suppression of this hypoxic ventilatory drive, and thereby decrease
the respiratory rate and depth. In spite of this risk, oxygen should never be withheld from
COPD patients who present in acute distress. It is perfectly acceptable to administer
oxygen via nonrebreather mask at 12-15 liters per minute in attempts to maintain
adequate oxygenation of COPD patients. Despite the respirations may become depressed,
this effect is usually after about 24 hours of high concentraion oxygen administration.

(Dot Objective 5-1.1)

Pulmonary embolism

Emphysema

Pulmonary edema

Chronic bronchitis

Rationale

Chronic emphysema patients typically have a barrel chest, are often thin, and have a pink
color to their skin. This typical presentation has earned them the nickname of “pink-
puffers”. Chronic bronchitis patients, on the other hand, are typically overweight and
often cyanotic, earning them the nickname of “blue-bloaters”. Pulmonary edema and
pulmonary embolism are not associated with barrel chest and will often be pale or
cyanotic.

(Dot Objective 5-1.1)

Sinus tachycardia with premature ventricular complexes

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130. You are called to a skilled nursing facility to care for a patient who is having difficulty

breathing. Upon arrival, you find a 76-year-old male patient seated in a chair. The
patient is thin, his skin is pink and warm, his chest is barrel-shaped, and initial
observation shows that he has labored respirations with suprasternal retraction and
accessory muscle usage. Further assessment reveals that the patient has diminished
breath sounds bilaterally with wheezing present in upper lung fields, a pulse
oximeter reading of 85% SpO

, prolonged expiration, and 1 – 2 word dyspnea.

Atrial flutter with premature junctional complexes

Sinus arrhythmia with premature junctional complexes

Atrial fibrillation with premature ventricular complexes

Rationale

An irregular rhythm comprised of narrow QRS complexes which are not preceded by
discernable P-waves indicates an underlying rhythm of atrial fibrillation. The ectopic beats
present with QRS width of greater than .10 second, and are not preceded by a P wave.
This pattern is indicative of ventricular origin, making PVC’s the correct interpretation of
these beats. Premature junctional complexes would have narrow QRS complexes that are
preceded by inverted P-waves at a decreased PR interval, would not display any preceding
P-waves, or may display P-waves flowing the onset of the QRS complex. Atrial fibrillation
typically presents with P-waves in a characteristic saw-tooth pattern. The QRS complexes
of both sinus tachycardia and sinus arrhythmia are preceded by upright P-waves at a PR
interval of between .12 and .20 seconds.

(Dot Objective 5-2.32)

Procainamide 20 mg/min

Proventil 2.5 mg nebulized

Lidocaine 0.50 to 0.75 mg/kg

Nitroglycerin 0.4 mg sublingual

Rationale

This patient appears to be suffering from a primary respiratory disorder, likely stemming
from an acute exacerbation of emphysema. As such, improving oxygenation and
ventilation are paramount in executing a treatment plan. Administration of a beta 2
specific medication such as proventil should be effective in improving the patient’s
hypoxia. Lidocaine and Procainamide are ventricular anti-arrhythmic drugs, and although
medications of this class may be considered for treatment of malignant PVC’s, this patient
is likely displaying ventricular ectopy secondary to hypoxia. This patient displays no
indications for the administration of nitroglycerin.

(Dot Objective 5-1.1)

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131. You are called to a private residence for an elderly patient who was found

unresponsive by a neighbor. Upon arrival, you note that the ambient temperature in
the residence is approximately 55 degrees Fahrenheit. The neighbor tells you that
the patient has not been seen for several days, and that the heat has apparently
been turned off for several weeks. The patient is found in a right lateral recumbent
position on the sofa covered with several blankets and is responsive only to loud
verbal stimuli. Skin is pale, cold and dry, respiratory rate is 10 with decreased tidal
volume, radial pulse is weak and regular at a rate of 62, blood pressure is 92/60
mmHg. You place the patient on oxygen via nonrebreather mask at 12 liters per
minute. The cardiac monitor is applied, and shows the following rhythm: What is
your interpretation of the cardiac rhythm?

132. You are called to a private residence for an elderly patient who was found

unresponsive by a neighbor. Upon arrival you note that the ambient temperature in
the residence is approximately 55 degrees Fahrenheit. The neighbor tells you that
the patient has not been seen for several days, and that the heat has apparently
been turned off for several weeks. The patient is found in a right lateral recumbent
position on the sofa covered with several blankets and is responsive only to loud
verbal stimuli. Skin is pale, cold and dry, respiratory rate is 10 with decreased tidal
volume, radial pulse is weak and regular at a rate of 62, blood pressure is 92/60
mmHg. You place the patient on oxygen via nonrebreather mask at 12 liters per
minute. The cardiac monitor is applied, and shows the following rhythm: The
patient’s body core temperature is determined to be 89.6 degrees Fahrenheit (32
Celsius) rectally. Bag-valve-mask ventilation and subsequent endotracheal intubation
have been performed successfully. An intravenous line is initiated using 0.9%
sodium chloride at a keep open rate. What is your next immediate action?

Sinus rhythm with J point elevation

Left bundle branch block

Right bundle branch block

Sinus rhythm with Osborn waves

Rationale

The rhythm meets all of the standard requirements for interpretation as a normal sinus
rhythm; upright P waves preceding each QRS, PR interval between .12 and .20 seconds,
QRS complex width less than .12 seconds. The additional wave located at the trailing end
of the QRS complex, at the junction of the QRS and the ST segment, is known as a J wave
or Osborn wave. The J point is the term used to describe the transition between the
baseline of the EKG tracing and the very beginning of the QRS complex. Left and right
bundle branch cannot truly be diagnosed when looking at only a single cardiac lead.

(Dot Objective 5-2.32)

Administer Lidocaine 0.5 to 0.75 mg/kg intravenously.

Apply heat packs to the groin, axilla, and neck areas.

Administer atropine sulfate 0.5 to 1.0 mg intravenously.

Administer intravenous fluids warmed to no greater than 108 degrees Fahrenheit (42
degrees Celsius).

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133. You are called to a private residence for an elderly patient who was found

unresponsive by a neighbor. Upon arrival you note that the ambient temperature in
the residence is approximately 55 degrees Fahrenheit. The neighbor tells you that
the patient has not been seen for several days, and that the heat has apparently
been turned off for several weeks. The patient is found in a right lateral recumbent
position on the sofa covered with several blankets and is responsive only to loud
verbal stimuli. Skin is pale, cold and dry, respiratory rate is 10 with decreased tidal
volume, radial pulse is weak and regular at a rate of 62, blood pressure is 92/60
mmHg. You place the patient on oxygen via nonrebreather mask at 12 liters per
minute. Immediately following transfer of the patient to the ambulance cot, you note
that the cardiac rhythm has changed to the following: What is your next immediate
action?

134. You are called to a private residence for an unresponsive diabetic patient. Upon

Rationale

Active external rewarming is called for in the moderate hypothermia patient. Typically, in
the prehospital setting, this is accomplished by placement of heat packs into area of high
heat exchange with the external environment, such as the neck, axilla, and groin. Heated
intravenous fluids could also be administered, but should not exceed 104 degrees
Fahrenheit (40 degrees Celsius) in temperature. Atropine is not indicated as the heart
rate is above 60. Lidocaine is also not indicated in this patient.

(Dot Objective 5-10.41)

Defibrillate at 200 joules

Treated no differently than in a patient with a normal body core temperature.

Administer atropine

Defibrillation at 360 joules

Rationale

Initial treatment of this patient, who has converted into ventricular fibrillation, should
consist of one monophasic shock at 360 J. As the airway has already been controlled and
an intravenous line has been placed, the next action should initiate CPR and administer 1
mg of epinephrine (1:10,000) intravenously. This may be followed with standard
ventricular anti-arrhythmic medications such as lidocaine, keeping in mind that the repeat
intervals for medications may need to be increased in order to avoid accumulation to toxic
levels.

(Dot Objective 5-10.41)

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per minute, and blood pressure is 96/64 mmHg. A blood glucometer reading shows a
blood glucose level of 548 mg/dl, and you notice a fruity odor to the patient’s breath.
Skin is pink, warm and dry. What condition do you suspect?

135. You are called to a private residence for an unresponsive diabetic patient. Upon

arrival, you find an unresponsive 44-year-old female patient supine in bed. Her
husband states that she has been ill for several days with influenza and has gotten
progressively worse over the past 12 hours. Respiratory rate is 36 breaths per
minute with an increased tidal volume, radial pulse is regular at a rate of 124 beats
per minute, and blood pressure is 96/64 mmHg. A blood glucometer reading shows a
blood glucose level of 548 mg/dl, and you notice a fruity odor to the patient’s breath.
Skin is pink, warm and dry. The patient has been placed on oxygen via
nonrebreather mask at 12 liters per minute and an intravenous line has been
initiated utilizing 0.9% sodium chloride at a keep vein open rate. Further treatment
of this patient may include intravenous administration of which of the following?

Diabetic ketoacidosis

Hyperglycemic hyperosmolar nonketotic coma

Insulin shock

Hypoglycemia

Rationale

Diabetic ketoacidosis is characterized by progressive onset of symptoms over 12 to 24
hours. Symptoms include rapid and deep respirations, , a fruity odor to the breath,
tachycardia, hyperglycemia, and dehydration. Hypoglycemia, also known as insulin shock,
is characterized by an acute onset of neurological symptoms that may include headache,
irritability, and unconsciousness, as well as decreased blood glucose levels and normal or
shallow respirations. Hyperglycemic hyperosmolar nonketotic coma appears very similar
to diabetic ketoacidosis, but is not associated with rapid, deep respirations or a fruity
breath odor.

(Dot Objective 5-4.33)

Fluid resuscitation with 0.9% sodium chloride

1 mEq/kg sodium bicarbonate

25 grams of 50% dextrose

100 mg thiamine

Rationale

In an effort to correct for the inevitable dehydration associated with diabetic ketoacidosis,
fluid resuscitation should be initiated. Despite the patient’s acidotic state, sodium
bicarbonate is not indicated in diabetic ketoacidosis. If blood glucose level could not have
been quickly determined, administration of 50% dextrose could be administered, and in a
known alcoholic patient should be administered in conjunction with 100 mg of thiamine.

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136. You are called to a local restaurant for a choking victim. Upon arrival you find a 34-

year-old female patient complaining of difficulty breathing. The patient tells you that
she had shellfish as part of her meal, despite the fact that she has a known allergy to
it. The patient states that this is the worst reaction she has ever had. Upon
assessment, you note that the patient’s voice is hoarse, and bystanders tell you that
her face and neck has swollen over the past 15 minutes. Wheezing is heard in all
lung fields, and a fine, red rash is observed on the neck and upper extremities.
Additional assessment reveals that the patient’s respirations are labored at a rate of
30 per minute with accessory muscle usage present, radial pulse is present and
regular at a rate of 118 beats per minute, and blood pressure is 118/72 mmHg. The
pulse oximeter is applied, showing an SpO

of 89%. Urticaria have begun to develop

on the anterior thorax and upper extremities. Oxygen has been applied via
nonrebreather mask at 15 liters per minute and an intravenous line has been
initiated. What is the next best intervention?

137. You are called to a local restaurant for a choking victim. Upon arrival you find a 34-

year-old female patient complaining of difficulty breathing. The patient tells you that
she had shellfish as part of her meal, despite the fact that she has a known allergy to
it. The patient states that this is the worst reaction she has ever had. Upon
assessment, you note that the patient’s voice is hoarse, and bystanders tell you that
her face and neck has swollen over the past 15 minutes. Wheezing is heard in all
lung fields, and a fine, red rash is observed on the neck and upper extremities. Your
patient responds favorably to your interventions, and states that her difficulty
breathing has begun to subside. Your pulse oximeter displays an SpO

of 93%,

respiratory rate is 28 breaths per minute with adequate tidal volume, radial pulse is

(Dot Objective 5-4.43)

25 to 50 mg diphenhydramine hydrochloride

125 to 250 mg methylprednisolone (Solu-Cortef) intravenously

0.3 to 0.5 mg epinephrine 1:1000 IM

0.1 mg/kg epinephrine 1:10,000 intravenously

Rationale

Following oxygen, the primary drug for treatment of severe allergic reactions and
anaphylaxis is epinephrine. In moderate reactions, epinephrine may be administered at
0.3 to 0.5 mg of 1:1000 solution IM, while in severe reactions which include hypotension
and/or airway obstruction, intravenous administration of 0.3 to 0.5 mg of 1:10,000
epinephrine may be called for. Benadryl (diphenhydramine hydrochloride) is an
antihistamine, and considered a second line agent in these cases. Corticosteroids such as
Solu-Cortef also serve an important role in the treatment of anaphylaxis and

(Dot Objective 5-5.16)

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present at a rate of 126 beats per minute, and blood pressure is 124/90 mmHg.
Medical command has ordered the administration of diphenhydramine hydrochloride
(Benadryl). What is the pharmacological action of Benadryl?

138. Your patient is complaining of a dull, generalized pain in her abdomen. She is unable

indicate any specific location of the discomfort. Which term could be used to describe
this pain?

Suppresses the inflammatory response

Stabilizes the membranes of the mast cells, preventing further histamine release

Directly stimulates the Beta 2 receptors of the sympathetic nervous system

Blocks both the H1 and H2 histamine receptor sites

Rationale

Benadryl is a non-selective histamine blocker, acting on both the H1 and H2 histamine
receptor sites within the body. Cromolyn sodium is a drug that stabilizes the membranes
of the mast cells, preventing further histamine release, and is sometimes used in the
prevention of allergic reactions. Corticosteroids may be used to suppress the
inflammatory response, and are helpful in the later stages of allergic reaction /
anaphylaxis treatment. Beta 2 specific agonists such as albuterol or metaproterenol serve
to directly stimulate the Beta 2 receptors of the sympathetic nervous system, decreasing
bronchoconstriction.

(Dot Objective 5-5.16)

Visceral pain

Somatic pain

Referred pain

Rebound tenderness

Rationale

Dull, poorly localized pain is referred to as visceral pain, and in the abdomen is typically
associated with pain that originates from the walls of hollow organs. Somatic is the term
used to describe sharp, easily localized pain. Somatic pain usually originates in solid areas
of the body such as skeletal muscle and solid organs. Referred pain is pain that is felt in
an area which is distant from the origin, and typically unrelated to the actual illness or
injury. An example of referred pain is diaphragmatic injury, which often causes the
patient to feel pain in their neck and shoulders. Rebound tenderness is a specific finding
of increased pain upon release of the pressure exerted by the examiner’s hand. It is
typically associated with peritoneal irritation from conditions such as peritonitis and
appendicitis

(Dot Objective 5-6.6)

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139. You are called to a skilled nursing facility for a patient in acute abdominal distress.

Upon arrival, you find a 72-year-old male patient complaining of severe, generalized
abdominal discomfort and nausea that has worsened over the past several days. The
nursing staff states that the patient has excreted dark, tarry, foul-smelling stools
several times over the past 48 hours and has vomited twice today, both times
producing hematemesis. The patient’s skin is pale and cool, respiratory rate is 18
breaths per minute with adequate tidal volume, radial pulse is present at a rate of
120 beats per minute, and blood pressure is 96/78 mmHg. Based upon the limited
information you have collected thus far, what condition do you suspect?

140. You are in the process of delivering twins in the field setting. Which of the following

indicates the most appropriate management of the umbilical cords?

Appendicitis

Lower gastrointestinal bleeding

Diverticulitis

Upper gastrointestinal bleeding

Rationale

The presentation of upper gastrointestinal bleeding will vary depending on the origin of
the bleeding. Generally, it is typically associated with abdominal discomfort, nausea and
vomiting, hematemesis, and will cause dark, tarry, foul-smelling stools to be produced if
the bleeding is significant. Appendicitis is characterized by diffuse abdominal pain, nausea
and emesis without the presence of blood, tenderness and guarding around the umbilical
region, and possibly rebound tenderness. Lower gastrointestinal bleeding and diverticulitis
will appear in a manner very similar to upper gastrointestinal bleeding, but is more likely
to produce blood streaked stools, as opposed to the dark, tarry stools associated with
upper gastrointestinal bleeds. The differentiating factor in the scenario is the presence of
dark, tarry stools and hematemesis, indicating that the bleeding is occurring higher in the
gastrointestinal tract.

(Dot Objective 5-6.16)

Leave the cords attached to the placenta(s) until arrival at the hospital.

Clamp and cut the first baby’s cord prior to the delivery of the second baby.

Wait until the delivery of the second baby to cut both cords.

Clamp and cut both cords prior to the delivery of either baby.

Rationale

When delivering twins (or triplets), the paramedic should clamps and cut the first baby’s
cord prior to the delivery of the second baby. This holds true regardless of whether or not
the placenta is shared or each baby has its own placenta. Doing so will enable the
paramedic to move the first baby from the vaginal area for routine or resuscitative care
and focus on delivery of the second (or third) baby. It is not necessary to wait until both
babies have been delivered to clamp and cut the cords. There is no reason to leave both
cords intact until arrival at the hospital. Clamping and cutting the umbilical cords prior to
delivery of the baby is not possible.

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141. An 11-year-old boy has been seizing continuously for the past 30 minutes. He has a

142. An 11-year-old boy has been seizing continuously for the past 30 minutes. He has a

history of seizure activity secondary to a head injury 7 years ago. Assessment
reveals him to be unresponsive and exhibiting trismus. Slight myoclonic movements
are noted to the extremities. Last week, his primary care physician lowered his daily
dose of Tegretol to see how the boy responded. Oxygen has been applied, but
attempts at placing an IV are unsuccessful. After administering the diazepam, the
child stops seizing. Reassessment reveals him to be responsive to painful stimuli and
breathing at a rate of 10 breaths per minute, so you begin to assist ventilations with
the bag-mask and high-flow oxygen. Since after 10 minutes the child’s level of
consciousness does not change, you elect to place a tracheal tube for ventilatory
support as well as aspiration precautions. While performing laryngoscopy, you note
that the patient’s blood pressure suddenly drops to 76/50 mmHg accompanied by an
oxygen saturation is 98%. The cardiac monitor shows the rhythm as below. Which of
the following is the most likely cause of this change in clinical status?

(Dot Objective 5-14.14)

Intramuscular

Intraosseous

Subcutaneous

Rectal

Rationale

Diazepam administered the rectal route would be the next appropriate action since an IV
cannot be established and the patient is actively seizing. The rectum is extremely vascular
which permits the moderate absorption of medications into the body. Diazepam can be
administered intramuscularly, however, absorption on to the body would take longer than
through the rectum. Administering diazepam via the subcutaneous route is not
recommended and similarly to the intramuscular route, would take much to long to
absorb into the body to provide real benefit for the active seizures. Since the patient is 11
years old, placement of an intraosseous needle is not recommended.

(Dot Objective 6-2.5)

Postictal hypoglycemia

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143. An 11-year-old boy has been seizing continuously for the past 30 minutes. He has a

144. While assessing a 7-year-old patient involved in a motor vehicle collision, you note

that the patient is waning in and out of consciousness and she has obvious deformity

Side effect of valium

Increased vagal tone

Severe hypoxia

Rationale

The sudden drop in blood pressure and heart rate is most likely the result of vagal
stimulation. The posterior pharynx contains vagal receptors that when stimulated can
cause a sudden drop in blood pressure and heart rate. When this occurs, the paramedic
should stop the laryngoscopy and ventilate. This is not so much to provide oxygen to the
body, but to stop the vagal stimulation thus allowing the heart rate and blood pressure to
return to normal. With a SpO2 of 98%, the patient is not severely hypoxic. At therapeutic
doses, diazepam should not produce bradycardia and/or hypotension. Hypoglycemia tens
to produce tachycardia and a normal to slightly elevated blood pressure due to a
sympathetic discharge, not bradycardia and hypotension.

(Dot Objective 6-2.2)

Dopamine infusion

Atropine at 0.02 mg/kg

Begin BVM ventilation with supplemental oxygen

Epinephrine 0.01 mg/kg (1:10,000)

Rationale

The sudden onset of vagal tone (as evidenced by hypotension and bradycardia) should
prompt the paramedic to stop laryngoscopy and ventilate. This is not so much to provide
oxygen to the body, but to decrease vagal stimulation, which will allow the heart rate and
blood pressure to return to normal. In the absence of vagal stimulation, the heart rate
and blood pressure should return to normal, eliminating the need for atropine,
epinephrine, and dopamine. An IV fluid challenge could be administered and may help
increase the blood pressure. A fluid challenge may also be beneficial given the duration of
the seizure activity and possibility associated dehydration.

(Dot Objective 6-2.1)

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to both of her upper legs. Based on just this information, what is the most
appropriate facility to which to transport this patient?

145. What is the single most preventable cause of cardiac dysrhythmia and death in the

pediatric patient?

146. You have responded to the scene for a 9-month-old involved in a motor vehicle

collision. The child is unresponsive and has angulation to both of her upper legs and
her pelvis is unstable. The patient’s vital signs include a heart rate of 162,
respirations of 38, and a blood pressure of 60/40 mmHg. What type of fluid is
normal saline, and how much of this fluid would you administer to this child?

Level I trauma center

Pediatric trauma center

Closest hospital

Pediatric hospital

Rationale

The most appropriate facility for this child is the pediatric trauma center. While he other
facilities may be able to provide basic patient stabilization interventions, doubtly would
any of them want to receive a patient with significant trauma, especially of this age
bracket.

(Dot Objective 6-2.51)

Hypothermia

Trauma

Drug toxicity

Hypoxia

Rationale

Hypoxia should be corrected as early as possible and can prevent the development of
arrhythmias and ultimately death in the pediatric patient.

(Dot Objective 6-2.61)

Crystalloid fluids at 10 cc/kg

Colloid fluids at 10 cc/kg

Colloid fluids at 20 cc/kg

Crystalloid fluids at 20 cc/kg

Rationale

Normal Saline and Lactated Ringers are both crystalloid solutions. The standard bolus for
a crystalloid solution is 20cc/kg until a core organ perfusion pressure is met.

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147. Bulging fontanels in an infant are a sign of what condition?

148. Which of the following is a common sign of hypoxia in children?

149. You are dispatched to the scene of a possible choking. Upon arrival you discover a 1-

year-old child unresponsive and limp, lying on the floor. The patient has a weak
pulse, but he is not breathing. His mother stated that he was eating a hot dog and
then she thinks he began to choke. You open the airway and are unable to get
ventilations into the patient. What should you do next?

(Dot Objective 6-2.71)

High fever

Infantile hypertension

Meningitis

Dehydration

Rationale

Meningitis is an infection of the meninges or covering that surrounds the brain. This
results in increased intracranial pressure and therefore causes the fontanels to bulge out.
If the patient were dehydrated, you would expect to find sunken fontanels.

(Dot Objective 6-2.68)

Tachycardia

Tachypnea

Bradycardia

Bradypnea

Rationale

It is expected that when a child becomes hypoxic that his heart rate will quickly decrease.
You should always treat the airway of a child very aggressively. The patient’s heart rate
usually quickly returns to normal once oxygen has been administered. Always remember
that respiratory arrest leads to cardiac arrest in children.

(Dot Objective 6-2.8)

Perform direct laryngoscopy and possible intubation.

Prepare to perform a needle cricothyrotomy.

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150. You are dispatched to the scene of a possible choking. Upon arrival you discover a 1-

year-old child unresponsive and limp, lying on the floor. The patient has a weak
pulse, but he is not breathing. His mother stated that he was eating a hot dog and
then she thinks he began to choke. During direct laryngoscopy of this patient, you
see a piece of hot dog lodged in the trachea. What should you do next?

151. Your patient is a 29-year-old woman complaining of severe, diffuse, lower abdominal

pain. The patient states that her menstrual periods have been occurring at normal
intervals. Additionally, she states that pain increases during sexual activity and
following her menstrual period, and that she has recently experienced a yellow,
vaginal discharge. Her skin is warm and slightly diaphoretic, respiratory rate is 14
breaths per minute with adequate tidal volume, radial pulse is 112 beats per minute,
and blood pressure is 110/90 mmHg. What is the most likely cause of this patient’s
symptoms?

Reposition the head.

Deliver 30 chest compressions

Rationale

When ventilations will not enter into a patient you should immediately reposition his head
in an effort to lift the tongue out of the airway. After this is accomplished and air will still
not enter into the airway, you should begin to clear the airway by performing chest
compressions.

(Dot Objective 6-2.18)

Provide positive pressure ventilations.

Perform a blind finger sweep.

Perform a needle cricothyrotomy.

Remove it with Magill forceps.

Rationale

If during direct laryngoscopy you see a foreign body airway obstruction, you should
immediately use McGill forceps to attempt to remove the object from the airway. PPV and
a blind finger sweep would not be helpful and maybe harmful in attempting to remove the
object. It could result in lodging the object deeper in the trachea.

(Dot Objective 6-2.18)

Spontaneous abortion

Endometriosis

Pelvic inflammatory disease

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152. Which of the following is the correct dose of subcutaneous epinephrine for a child

suffering anaphylaxis?

153. You are called to a private residence for a 42-year-old female patient with vaginal

bleeding. Upon arrival you find your patient supine on the bed, complaining of
moderate-to-severe vaginal bleeding for several hours. The patient is pregnant and
states that her due date is in approximately 2 weeks, however she has had no
prenatal care. Patient is gravida 4, para 2. Assessment reveals moderate vaginal
bleeding, however the patient denies pain and is experiencing no contractions.
Respiratory rate is 18 breaths per minute with adequate tidal volume, radial pulse is
110 beats per minute, and blood pressure is 126/94 mmHg. What condition is the
patient likely experiencing?

Cystitis

Rationale

Pelvic inflammatory disease is an infection of the female reproductive tract, often caused
by gonorrhea or chlamydia. It typically presents with diffuse lower abdominal pain that
can be severe, often increasing with sexual activity. Pain may also intensify either
immediately before or after menstrual period. Other associated symptoms include fever,
chills, nausea, vomiting, and sepsis. Cystitis is an infection of the urinary bladder, causing
pain immediately superior to the symphysis pubis. Endometriosis is a condition in which
endometrial tissue grows outside the uterus causing inflammation and bleeding.
Spontaneous abortion (miscarriage) is typically characterized by cramping abdominal pain
and vaginal bleeding, often accompanied by passage of clots and tissue.

(Dot Objective 5-13.6)

0.30 mg

0.15 mcg

150 mg

150 mcg

Rationale

The patient should receive 150mcg or 0.15mg of SQ epinephrine in the case of
anaphylaxis. You must remember that a microgram is 1/1000 of a milligram. The
standard packaging of epinephrine is in milligrams, but you should be able to calculate
these conversions quickly.

(Dot Objective 6-4.28)

Placenta previa

Cephalopelvic disproportion

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154. You are called to a private residence for a 42-year-old female patient with vaginal

155. You are called to care for a 7-month-old male patient suffering from difficulty

Uterine rupture

Abruptio placenta

Rationale

Placenta previa is characterized by bright red vaginal blood flow without pain or uterine
contractions. It is associated with both increasing age and multiparity. Abruptio placenta
typically presents with third trimester bleeding, an acute alteration in the contraction
pattern, and symptoms of shock inconsistent with amount of visible bleeding. In addition,
the uterus is typically tender and potentially board like. Cephalopelvic disproportion is
characterized by a lack of progress through stages of delivery and frequent, prolonged
contractions. Uterine rupture is characterized by severe, sudden, shearing pain occurring
during strong contraction. Typically the uterus can be palpated as hard mass next to
fetus, and rapid onset of shock is not uncommon.

(Dot Objective 5-14.19)

Perform internal vaginal exam to determine position of fetus.

Initiate a 20 ml/kg bolus of 0.9% sodium chloride.

Mix 20 mg of oxytocin in 1 liter of normal saline and infuse at 125 cc/hr.

Transport to a facility with obstetric surgical capability.

Rationale

Based upon the vital signs and presentation, the patient does not appear to be in shock.
Fluid resuscitation is therefore not necessary at this time. Although oxytocin is indicated
for control of post-partum hemorrhage that is unresponsive to other therapies, the patient
has not delivered her infant yet. Internal vaginal examination should never be attempter,
since an examining finger could puncture the placenta and cause fatal hemorrhage.
Definitive care of placenta previa is delivery of the fetus via cesarean section, making
transport to a facility with obstetric surgical capability the priority.

(Dot Objective 5-14.19)

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pulse is 126 beats per minute. The mother states that the patient has had a case of
“the sniffles” for the past few days including a low-grade fever, and that nothing else
has changed within their environment. Based upon these findings, what condition is
the patient most likely to be experiencing?

156. You are called to care for a 7-month-old male patient suffering from difficulty

breathing. Your assessment reveals an anxious child with obvious respiratory
distress, including accessory muscle use and retractions. You auscultate the chest to
find prominent expiratory wheezing. Respiratory rate is 48 per minute and brachial
pulse is 126 beats per minute. The mother states that the patient has had a case of
“the sniffles” for the past few days including a low-grade fever, and that nothing else
has changed within their environment. Following administration of oxygen via blow-
by method, what is the next best immediate action?

157. A 3-month-old male patient was found in cardiac arrest in his crib by his parents.

Pneumonia

Asthma

Croup

Bronchiolitis

Rationale

Bronchiolitis typically affects children less than 2 years old, and is characterized by
prominent expiratory wheezing, clinically resembling Asthma. Asthma, although similar in
presentation to Bronchiolitis, is uncommon below the age of 2, and is usually associated
with a trigger. Pneumonia is characterized by rales and rhonchi and is associated with a
recent history of lower respiratory tract infection. Croup is characterized by a harsh,
barking cough and inspiratory stridor, neither of which were found in this patient.

(Dot Objective 6-2.55)

Rapid transport for administration of intravenous antibiotics

Immediate endotracheal intubation

Administration of albuterol via nebulizer

Administration of subcutaneous epinephrine

Rationale

Much like asthma, bronchiolitis can be treated utilizing a beta 2 specific agent such as
albuterol given via nebulizer. The moderate level of respiratory distress in this patient
does not warrant immediate intubation, although continued symptom progression to the
point of patient exhaustion may make intubation a suitable option in the future. The
potential for serious side effects with subcutaneous epinephrine administration prevent it
from being considered as a primary treatment in this patient. Intravenous antibiotics
would do nothing to address the immediate need for management of the respiratory
distress.

(Dot Objective 6-2.55)

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Upon your arrival, the pediatric patient was found in a prone position with mottled
skin, blood-tinged and frothy fluid around the nose and mouth, and vomitus beside
his head. The distraught parents state that the baby has no medical or congenital
problems, and was fine when they laid him down to sleep. What would be the most
likely cause of death in this patient?

158. You are called to a private residence for a 22-year-old female patient with severe

abdominal pain. Upon arrival, you find your patient in a left lateral recumbent
position on the bedroom floor. A family member tells you that she “fainted”
approximately 5 minute prior to your arrival. The patient is conscious and alert, and
is complaining of sharp abdominal pain in her lower left quadrant. The patient denies
pregnancy and states that her last menstrual period was 6 weeks ago, however her
menstrual flow was brownish in color and her menstrual period was short in
duration. Patient is gravida 1, para 1. Assessment reveals a rigid abdomen, and the
patient also complains of pain to the left shoulder. Respiratory rate is 26 breaths per
minute with adequate tidal volume, radial pulse is 126 beats per minute, and blood
pressure is 84/62 mmHg. What condition is the patient likely experiencing?

Severe head trauma from child abuse

Bradycardia leading to cardiac arrest

Extreme nutritional deprivation leading to arrest

Sudden Infant Death Syndrome

Rationale

Key to any field impression is incorporating as much information as possible from the on-
scene dynamics, history, and physical finding in arriving at a correct conclusion. Given
this, the absence of identifiable severe head trauma, malnutrition, and preexisting
medical problems (sleep apnea) would all contribute to the conclusion that SIDS may be
the cause. Beyond this, the infants age, gender, position, evidence of vomiting, and
finding of blood-tinged fluid about the mouth and nose help to confirm this most likely is a
SIDS baby.

(Dot Objective 6-2.43)

Abruptio placenta

Ruptured ectopic pregnancy

Spontaneous abortion

Uterine rupture

Rationale

Ectopic pregnancy refers to implantation of a fetus outside of the uterus, often within the
fallopian tubes, and is characterized by severe unilateral abdominal pain. If the ectopic
pregnancy causes rupture of the affected fallopian tube, serious intra-abdominal bleeding
can occur. These patients may present with a rigid abdomen, syncope, vaginal bleeding,
shock, and referred pain such as into the shoulder. Spontaneous abortion (miscarriage) is
typically characterized by cramping abdominal pain and vaginal bleeding, often

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159. The use of nasogastric tubes (NG tube) in neonatal patients receiving aggressive

resuscitation is important because:

160. You are called to a private residence for a 36-year-old female patient in labor. Upon

arrival, you find your patient supine on the bed, complaining of severe abdominal
pain. The patient states that her pregnancy is full-term, and that her contractions
started approximately 45 minutes prior to your arrival. As she was preparing to leave
for the hospital, she suddenly felt a sharp tearing pain in her abdomen. The patient
is gravida 3, para 3. Currently, the patient complains of generalized pain to the lower
abdomen and lower back. The patient’s abdomen is stiff and board-like, no vaginal
bleeding is present, and contractions appear to be continuing in a rhythmic manner
that the patient states is much slower than it was prior to the tearing pain.
Respiratory rate is 22 breaths per minute with adequate tidal volume, radial pulse is
98 beats per minute, and blood pressure is 116/84 mmHg. What condition is the
patient likely experiencing?

accompanied by passage of clots and tissue. Uterine rupture is characterized by severe,
sudden, shearing pain occurring during strong contraction. Typically the uterus can be
palpated as hard mass next to fetus, and rapid onset of shock is not uncommon. Abruptio
placenta typically presents with third trimester bleeding, an acute alteration in the
contraction pattern, and symptoms of shock inconsistent with amount of visible bleeding.
In addition, the uterus is typically tender and potentially board like.

(Dot Objective 5-14.19)

The ability to aspirate gastric juices from the stomach prevents acidosis.

It allows better lung inflation due to gastric decompression.

It allows for removal of ingested toxins causing the neonate to deteriorate.

The insertion of an NG tube down the esophagus increases the likelihood of proper
endotracheal tube placement.

Rationale

Although the use of an NG tube in a pediatric may serve many purposes, one of the most
important when ventilating them is to remove any gastric insufflation present from the
positive pressure ventilation. Too much air in the stomach will inhibit diaphragmatic
excursion and impair ventilations.

(Dot Objective 6-1.53)

Ruptured ectopic pregnancy

Braxton-Hicks contractions

Placenta previa

Abruptio placenta

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161. A frantic mother summons EMS for her two-month-old child who just had a seizure.

Upon your arrival, the infant is conscious but lethargic in her mother’s arms. The
mother states the baby has not been acting well or eating well the past few days.
The mother adds that she has had a temperature, but it has been well controlled
with over-the-counter medications. This morning however, her temperature
continued to rise, and currently you find it to be 104 degrees Fahrenheit. The mother
states she has an appointment tomorrow at the pediatrician for her daughter. The
most likely cause for the elevated temperature is:

162. You are called to a private residence for a 36-year-old female patient in labor. Upon

arrival, you find your patient supine on the bed. A rapid assessment for crowning
reveals a prolapes of the umbilical cord. The mother's respiratory rate is 22 breaths
per minute with adequate tidal volume, radial pulse is 98 beats per minute, and
blood pressure is 116/84 mmHg. What is your next immediate action?

Rationale

Abruptio placenta can occur in many forms, all of which have slightly different
presentations. Marginal partial abruptions will cause vaginal bleeding but no increase in
pain. Central partial abruptions will cause no vaginal bleeding, but typically will initially
present with a sharp, tearing abdominal pain followed by development of a stiff and
board-like abdomen. Complete abruption will cause massive vaginal bleeding and may
lead to profound maternal shock. Placenta previa is characterized by bright red vaginal
blood flow without pain or uterine contractions. Braxton-Hicks contractions are irregular,
painless contractions that occur prior to actual labor. Ectopic pregnancy refers to
implantation of a fetus outside of the uterus, often within the fallopian tubes, and is
characterized by severe unilateral abdominal pain. If the ectopic pregnancy causes
rupture of the affected fallopian tube, serious intra-abdominal bleeding can occur, causing
the patient to present with a rigid abdomen, syncope, vaginal bleeding, shock, and
referred pain.

(Dot Objective 5-14.19)

viral or bacterial infection.

allergic reaction to infant skin care products.

accidental poisoning.

physical child abuse.

Rationale

Given the history and physical findings, the most logical differential diagnosis would be
that of an infection. Bacterial infections typically raise the core temperature more rapidly
than a viral infection would, but to that extent it still won’t change the prehospital
treatment.

(Dot Objective 6-1.63)

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163. You are called to a private residence for a 36-year-old female patient in labor. Upon

164. A frantic mother summons EMS for her two-month-old child who just had a seizure.

Place the cord back into the vagina, taking care to ensure that the head of the fetus will
clear the cord during delivery.

Insert two gloved fingers into the vagina to raise the fetus off of the cord, if it is
impinging on it.

Retrieve the obstetrical kit and prepare for delivery.

Provide gentle traction on the cord to assist with delivery.

Rationale

Prolapsed cord, or presentation of the cord preceding the fetus, is a serious emergency.
The cord is likely to be compressed by the delivering fetus, shutting off fetal circulation.
When the umbilical cord is visible upon inspection of the vagina, emergent treatment
includes insertion of two fingers into the vagina in order to raise the presenting part of the
fetus off of the cord. Presentation of a prolapsed cord makes delivery in the field
impossible. Under no circumstances should you pull on the cord or attempt to push it back
into the vagina.

(Dot Objective 5-14.19)

Semi-Fowler

Left-lateral recumbent

Trendelenburg

Prone

Rationale

In order to further reduce pressure from the prolapsed portion of umbilical cord, the
patient should be placed into either a Trendelenburg or a knee-chest position. Recumbent,
semi-fowler, and prone positions do not allow for this beneficial reduction of pressure
from the cord.

(Dot Objective 5-14.19)

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continued to rise, and currently you find it to be 104 degrees Fahrenheit. The mother
states she has an appointment tomorrow at the pediatrician for her daughter. What
is the paramedic’s primary way to lower body core temperature in a neonate patient?

165. You are called to a private residence for a child who has been burned. Upon arrival,

the patient’s mother presents you with a 16-month-old female patient who was
burned by boiling water when she pulled a pot from the stove-top. Your patient is
conscious, you note erythema and blistering to the anterior aspects of both legs, and
the anterior thorax and abdomen. Based upon your assessment, what percentage of
the patient’s body surface area would you estimate has been burned?

166. You are called to a private residence for a child who has been burned. Upon arrival

the patient’s mother presents you with a 16-month-old female patient who was
burned by boiling water when she pulled a pot from the stove-top. Your patient is

Initiate an IV and administer a 10 ml/kg fluid bolus.

Sponge the infant with rubbing alcohol.

Remove any heavy clothing and reduce ambient temperature.

Place the infant in a bath with ice added.

Rationale

One extremely important consideration when dealing with pediatric fevers is to not
accidentally lower the core temperature too rapidly or lower it too far. The best way to
avoid this is by removing clothing and reducing the ambient temperature. Never use any
submersion or sponging technique with alcohol.

(Dot Objective 6-1.63)

36%

28%

32%

40%

Rationale

In small children, body surface area estimation must follow a modified “rule of nines”
which takes into account the increased proportion of the child’s head and proportionally
smaller legs of children when compared to an adult. Using the rule of nines for children,
9% is assigned for the anterior thorax, 9% for the abdomen, and 7% for the anterior
aspect of each leg – giving us a total of 32%. In and adult, the anterior aspect of each leg
is equivalent to 9% BSA, which would give us an estimation of 36% had this been an
adult patient.

(Dot Objective 4-4.9)

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conscious and crying loudly. Upon physical exam, you note erythema and blistering
to the anterior aspects of both legs, and the anterior thorax and abdomen. In what
manner would you describe the degree of burn injury?

167. You are called to a private residence for a 27-year-old female in labor. Upon arrival,

you find your patient lying supine in bed. The patient is 2 weeks past her estimated
date of confinement, and is complaining of frequent, strong contractions that occur
every 2 minutes and last for approximately 60-75 seconds. In addition, the patient
states that her membranes ruptured 30 minutes ago. She also states that she
currently has an urge to push. Upon examination for crowning, you note that the leg
of the fetus is protruding from the vagina. Oxygen has been applied via
nonrebreather mask at 15 liters per minute. What is your next immediate action?

Partial, full-thickness

Full-thickness

Superficial

Partial-thickness

Rationale

Partial thickness burns are characterized by erythema, blisters and intense pain to the
affected area. Superficial burns will not yield blisters, and full thickness burns will cause a
white, dark brown, or charred appearance to the skin.

(Dot Objective 4-4.19)

Proceed with procedures for breech delivery.

Transport immediately.

Attempt to place the limb back into the vagina.

Insert two gloved fingers into the vagina to reduce pressure on the presenting limb.

Rationale

When examination of the perineum reveals limb presentation, a cesarean section is
necessary and field delivery should not be attempted. Treatment for limb presentation
includes application of oxygen, placing the patient into a knee-chest or Trendelenburg
position, and immediately initiating transport. Under no circumstances should attempts be
made to re-insert the extremity into the vagina. In fact, the paramedic should even avoid
simply touching the exposed extremity, as doing so may stimulate the infant to gasp and
aspirate amniotic fluid. If the umbilical cord were visible instead of an extremity, then
insertion of two fingers into the vagina in order to raise the presenting part of the fetus
off of the cord would be appropriate.

(Dot Objective 5-14.19)

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168. You are called to a local day-care for an infant who is choking. Upon arrival you find

a 6-month-old female who is unconscious, unresponsive, apneic, and cyanotic. The
caretaker states that she saw the infant place a small ball into her mouth, at which
point she began to forcefully cough and gasp. After approximately 30 seconds, the
infant stopped breathing and the caretaker’s attempts to clear the obstruction have
been unsuccessful. Brachial pulse is present at a rate of 80 beats per minute. What
is your next immediate action?

169. You are called to a local day-care for an infant who is choking. Upon arrival you find

Perform a head-tilt chin-lift and assess airway and breathing.

Place the infant on your arm and attempt 5 chest thrusts.

Place the infant in a supine position and attempt 5 chest thrusts.

Place the infant on your arm and attempt 5 back blows.

Rationale

Your interventions must always begin with an assessment of the patient’s airway and
breathing. Attempts to clear an obstruction should be performed only after you have
determined that the infant is not breathing and attempts to ventilate have failed.
Abdominal thrusts are not indicated in the treatment of infant airway obstruction.

(Dot Objective 6-2.25)

Place the infant on your arm and attempt 5 back blows.

Immediately attempt endotracheal intubation.

Place the infant on your arm and attempt 5 chest thrusts.

Place the infant on your arm and attempt 5 abdominal thrusts.

Rationale

Following the determination that airway obstruction has occurred, attempts to clear the
obstruction should follow. Current guidelines call for administration of 5 back blows,
followed by administration of 5 chest thrusts. Following this sequence, inspection of the
airway and attempts to ventilate should follow. Abdominal thrusts are not indicated in the
treatment of infant airway obstruction. If attempts to clear the obstruction fail after
several attempts, laryngoscopy and use of Magill forceps can be considered.

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170. Your patient is a 25-year-old woman complaining of generalized, cramping

abdominal pain and heavy vaginal bleeding. The patient states that her last
menstrual period was approximately 90 days ago and that she believes that she is
pregnant, although she has not yet had any prenatal care. Her skin is warm and
slightly diaphoretic, respiratory rate is 18 breaths per minute with adequate tidal
volume, radial pulse is 106 beats per minute, and blood pressure is 108/86 mmHg.
What is the most likely cause of this patient’s symptoms?

171. The patient you are treating is experiencing a suspected anterior wall myocardial

infarction. Why is it important to transmit the 12-lead ECG to the hospital prior to
your arrival?

(Dot Objective 6-2.55)

Spontaneous abortion

Ectopic pregnancy

Endometriosis

Cystitis

Rationale

The most common cause of non-traumatic vaginal bleeding is spontaneous abortion
(miscarriage). It is typically characterized by cramping abdominal pain and vaginal
bleeding, often accompanied by passage of clots and tissue. Endometriosis is a condition
in which endometrial tissue grows outside the uterus causing inflammation and bleeding.
Ectopic pregnancy refers to implantation of a fetus outside of the uterus, often within the
fallopian tubes, and is characterized by severe unilateral abdominal pain. Cystitis is an
infection of the urinary bladder, causing pain immediately superior to the symphysis
pubis.

(Dot Objective 5-13.6)

It provides for continuous quality improvement.

So you can get the medical director’s permission to administer morphine.

It helps the physician decide the need for fibrinolytics.

It increases the likelihood of a correct interpretation.

Rationale

The successful management of a myocardial infarction many times relies heavily on rapid
identification, prehospital treatment, and administration of fibrinolytic drugs. In order for
this to occur, many times the paramedic will transmit the 12-lead ECG to the receiving
hospital for ED physician interpretation. If an MI is suspected, the ED staff will begin the
process of preparing the medications for your arrival, to decrease the “door to drug” time.

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172. At the scene of an motor vehicle collision where you have four patients, which one is

most likely going to be treated last?

173. What region of the spinal column is most frequently injured due to improper lifting

techniques?

174. At about 0530 hours, you are dispatched to a motor vehicle crash on a nearby

freeway. As you arrive on scene, bystanders are waving at you and pointing to a
male patient lying prone on the ground near an overturned tractor-trailer. Although

(Dot Objective 3-5.13)

Restrained front seat occupant, alert oriented, complaining of abdominal pain where the
seat belt rode across the abdominal wall.

Driver-side rear passenger with bilateral open tibia fractures.

Unrestrained driver that star-bursted the windshield, and presents with sonorous
breathing.

Passenger-side rear occupant who has deep laceration to the lateral neck, and has
repeated episodes of brief syncope.

Rationale

The patient with the open tibial fractures should be the last to be transported because
that injury, however graphic, should be easy to manage with direct pressure and
splinting. The two patients with alterations in mental status should be the first priority,
and the patient with abdominal pain – which may indicate significant intra-abdominal
trauma, should be the third patient transported.

(Dot Objective 4-3.43)

Cervical region

Coccyx and sacral region

Thoracic region

Lumbar region

Rationale

Important for paramedics and other health care providers to know, is that the lumbar
region is the most common location for back injuries from improper lifting techniques.
Since the lumbar region flexes the most during lifting, an improper technique may cause a
disk to herniated and damage the spinal cord. Yearly, too many providers are injured or
have to leave their job because of debilitating back injuries. The best way to avoid this is
by following good, safe lifting techniques.

(Dot Objective 4-6.2)

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the overturned vehicle does not appear to be on fire or emitting any smoke, you do
notice a puncture to the trailer that is leaking clear liquid onto the pavement.

175. At about 0530 hours, you are dispatched to a motor vehicle crash on a nearby

freeway. As you arrive on scene, bystanders are waving at you and pointing to a
male patient lying prone on the ground near an overturned tractor-trailer. Although
the overturned vehicle does not appear to be on fire or emitting any smoke, you do
notice a puncture to the trailer that is leaking clear liquid onto the pavement. After
properly positioning the ambulance, you see a red placard with the number “2” and a
flame symbol affixed to the trailer of the overturned tractor-trailer. This placard
means the vehicle is carrying a substance that:

176. At about 0530 hours, you are dispatched to a motor vehicle crash on a nearby

freeway. As you arrive on scene, bystanders are waving at you and pointing to a

Downhill and downwind

Downhill and upwind

Uphill and upwind

Uphill and downwind

Rationale

Whenever you are approaching a potentially hazardous scene in your ambulance, it is
always best to position the unit at a location which affords you the best possible safety.
Parking uphill from the incident will prevent liquids or gases that are heavier than air from
traveling to your location. Equally important is parking upwind from the scene so that any
hazardous material or gases are not carried by the wind to your present position. How
should the ambulance be positioned in relation to the incident?

(Dot Objective 7-1.12)

is extremely flammable.

oxidizes when released into the air.

is radioactive.

reacts with water.

Rationale

A placard with a flame symbol is the official designation that the contents of the container
is highly flammable. A “W” with a strike through it refers to a substance that reacts with
water, reactive material is identified by a propeller shape, and a ball on fire refers to an
oxidative agent. Knowledge of these and other common placard symbols will help prevent
unexpected and preventable injuries to care providers initially arriving on scene.

(Dot Objective 7-1.12)

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male patient lying prone on the ground near an overturned tractor-trailer. Although
the overturned vehicle does not appear to be on fire or emitting any smoke, you do
notice a puncture to the trailer that is leaking clear liquid onto the pavement. After
scene safety is ensured, you approach the patient. Which of the following would be
your first immediate action?

177. At about 0530 hours, you are dispatched to a motor vehicle crash on a nearby

freeway. As you arrive on scene, bystanders are waving at you and pointing to a
male patient lying prone on the ground near an overturned tractor-trailer. Although
the overturned vehicle does not appear to be on fire or emitting any smoke, you do
notice a puncture to the trailer that is leaking clear liquid onto the pavement. What
would be the greatest immediate hazard to the bystanders that were present at the
scene when you arrived?

178. Which of the following agencies is responsible for regulation of EMS radio

Establish manual spinal stabilization

Flush his entire body with water

Expose him to assess for any life threats

Apply a nonrebreather mask at 15 lpm

Rationale

Once concerns of hazardous material exposure has been eliminated, the EMT-Paramedic
will initiate assessment and care in the same fashion as would be done for any patient
suspect to trauma. In this situation, since the patient was found prone after being thrown
from the vehicle, the first step is to take control manual spinal stabilization so the patient
can be further assessed and log rolled into a supine position when appropriate.

(Dot Objective 7-1.12)

Inhalation injuries from the toxic chemicals

Fire or explosion of the semi-tractor

Radiation injuries from the leaking material

Corrosive burns from contact with the toxic material

Rationale

Most liquid chemicals that are flammable also evaporate very rapidly into the air. As such,
the vapor may be carried by the wind and be inhaled by unsuspecting bystanders on
scene that are just trying to help out. Since it can rapidly cross the alveolar membrane
and enters the blood stream, inhalation injuries would be the greatest immediate danger
to them.

(Dot Objective 8-4.2)

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communications?

179. When requesting physician medical direction via radio, which of the following

procedures should be used?

180. Several days after treating a chest pain patient, you realize that you had made an

error on the patient care report. The patient care report has already been submitted
to the hospital and your department administration. What procedure should be
followed when attempting to correct your documentation?

National Highway Traffic Safety Administration (NHTSA)

Federal Emergency Management Agency (FEMA)

Federal Communications Commission (FCC)

National Association of Emergency Medical Technicians (NAEMT)

Rationale

The Federal Communications Commission (FCC) is responsible for the control and
regulation of all nongovernmental radio communications within the United States. The
National Highway Traffic Safety Administration (NHTSA) is the governmental agency
responsible for developing EMS curricula. The Federal Emergency Management Agency
(FEMA) is responsible for disaster response and management. The National Association of
Emergency Medical Technicians (NAEMT) is a nongovernmental professional organization
dedicated to the advancement of EMS as a profession.

(Dot Objective 3-5.18)

Echo all orders immediately back to the physician.

Transmit extensive medical history information, even if you feel it is not pertinent.

Give the patient’s name so the physician can retrieve previous medical information, if
available.

Use radio codes as much as possible to ensure patient privacy.

Rationale

Using the echo procedure, where you immediately repeat all orders given back to the
physician, will help ensure that you understand orders accurately and completely. Under
no circumstances is it acceptable to transmit the name of a patient via radio, as this is a
violation of FCC regulations. Radio transmissions should be brief and concise, therefore
you should not limit transmission of medical history to that which is pertinent to the
current condition. Radio codes often lead to misunderstanding, and should be avoided
unless they are standardized and fully understood within your system.

(Dot Objective 3-5.5)

Page 90 of 91

Test 3

3/31/2007

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

Retrieve the original patient care report, “white out” and correct the error.

Complete and submit an addendum or supplement to the original patient care report.

Disregard the error in documentation, as patient care reports are considered final once
submitted.

Retrieve the original patient care report, draw a line through the error, correct the
information, and initial the correction.

Rationale

If an error is made during the initial completion of a patient care report, it is typically
acceptable to draw a line through the error, correct it, and initial the correction. Once the
report has been submitted to the hospital and departmental administration, however, it
should not be modified. This situation requires completion of an addendum or supplement
to the original report. Under no circumstances should you scribble out or “white-out” an
error, as that may leave question as to what was originally written. It is never acceptable
to disregard errors in documentation, regardless of the time that has elapsed since
originally submitted.

(Dot Objective 3-6.21)

Page 91 of 91

Test 3

3/31/2007

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

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