Cardiology and Resuscitation
A patient exhibits tachycardia, tachypnea, and a decreased level of consciousness. Their skin is cool and clammy. This patient is most likely in which stage of shock?
Compensated shock
Compensated shock is an earlier stage, as the body can compensate for blood loss. Signs and symptoms of compensated shock include restlessness; agitation/anxiety; a feeling of impending doom; altered mental status; shallow, rapid breathing; shortness of breath; a weak, rapid, or absent pulse; narrowing pulse pressures; cool, clammy skin; pallor/ cyanosis; capillary refill greater than two seconds in infants/children; nausea/vomiting; and marked thirst.
Decompensated shock occurs when the body is unable to compensate; it is a later form of shock. Signs and symptoms include falling blood pressure, labored or irregular breathing, thready or absent peripheral pulses, dull eyes and dilated pupils, ashen/mottled/cyanotic skin, and poor urinary output.
When providing assisted ventilation to an adult via a bag-valve mask, which approximate tidal volume will cause a noticeable rise of the chest?
A. 500mL
B. 800mL
C. 400mL
D. 1000mL
500 mL
An adult bag-valve mask has a volume capacity of between 1200 and 1600 mL. When providing assisted ventilation via a bag-valve mask, squeeze the bag to cause a noticeable rise of the patient's chest. The approximate volume is about 500 mL provided over one second. This tidal volume helps reduce the risk of gastric distension.
Where should you position when arriving at a scene with suspected hazardous material?
Remain upwind and uphill
When dealing with hazardous materials, scene safety is important. Remain upwind and uphill of the scene. Keep a safe distance, retreating if danger is noted. Contact dispatch and request additional resources. Do not enter the scene until it is deemed safe by trained hazardous materials experts.
Leaving the scene may constitute abandonment, as patients may require care, and trained individuals have not been contacted to attempt to secure the scene.
You arrive at the scene where a pregnant woman is experiencing mild abdominal discomfort and vaginal bleeding. She is at 30 weeks gestation. Her vital signs are BP 90/60 mmHg, pulse 110 beats/min, and respirations 22/min. Which condition should you suspect most?
A. Preterm labor
B. Uterine rupture
C. Placenta previa
D. Ectopic pregnancy
C. Placenta previa
Placenta previa is the most likely condition, particularly in the third trimester, as it is characterized by painless vaginal bleeding due to the placenta partially or completely covering the cervical opening. The patient's mild abdominal discomfort could indicate complications, but the bleeding without severe pain aligns with placenta previa.
Uterine rupture usually presents with sudden, intense abdominal pain, loss of uterine tone, and signs of shock. It is more likely in patients with a history of cesarean section or uterine surgery, and it typically involves severe pain rather than mild discomfort.
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in a fallopian tube. It is almost always diagnosed in the first trimester and would not be a consideration at 30 weeks gestation.
Preterm labor could be considered at 30 weeks gestation, but it is typically accompanied by regular contractions and would not involve significant vaginal bleeding unless a complication like placental abruption occurs.
A 24-year-old male is found semi-conscious after an assault. Minimal external blood loss is noted, his skin is cool and clammy, and his heart rate is fast. What is the most likely cause of his symptoms?
Internal bleeding
A high-energy mechanism of injury increases the likelihood of unseen injuries, such as internal bleeding; however, internal bleeding should always be suspected in cases of blunt trauma or penetrating injury. Because there is minimal external bleeding and the patient is exhibiting signs of shock (cool, clammy skin and tachycardia), internal bleeding is likely.
Acute respiratory distress syndrome (ARDS) is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event such as trauma, sepsis, or drug overdose, which is not a likely cause of this patient's hypotension.
While a spinal injury is possible, neurogenic shock (which can be associated with spinal injuries) results in a loss of sympathetic tone, leading to vascular dilation (relative hypovolemia), hypotension, and bradycardia.
There is no indication of head trauma provoking increased intracranial pressure. An increase in intracranial pressure is also associated with bradycardia.
Neurogenic shock is diagnosed with evidence of central nervous system injury and persistent hypotension despite adequate volume resuscitation.
An adult patient with a cardiac history presents with cyanotic, clammy skin and audible crackles throughout his lung fields. They have a productive cough and distended jugular veins. Which of the following conditions would most likely cause these findings?
Congestive heart failure
Congestive heart failure (CHF) occurs when the ventricular heart muscle is permanently damaged and can no longer keep up with the return flow of the blood from the atria. It can occur after myocardial infarction, heart valve damage, or long-standing hypertension. When the ventricular muscle can no longer contract effectively, the body attempts to maintain cardiac output by increasing heart rate and/or enlarging the left ventricle. Eventually, these adaptations no longer maintain cardiac output, and congestive heart failure develops. Pulmonary and peripheral edema, breathing easier while sitting up, distended neck veins, hypertension, tachycardia, tachypnea, retractions, cyanosis, diaphoresis, and crackles on auscultation are common; chest pain may or may not develop.
An acute myocardial infarction (AMI) is a medical emergency, as heart muscle can be permanently damaged within 30 minutes. It can cause chest pain/discomfort that is typically described as pressure or heaviness, nausea and vomiting, and sweating. Pain associated with AMI can last for several hours.
A pulmonary embolism is a sudden blockage of an artery within the lungs by a clot. These clots can develop in the veins of the legs or pelvis and then embolize (move) through the pulmonary artery or one of its branches. A pulmonary embolism will commonly cause dyspnea and chest pain. Top risk factors include recent hospitalization or living in a nursing home, trauma, cancer, a history of blood clots or heart failure, the presence of a pacemaker or central venous catheter, paralysis of the extremities, obesity, a sedentary lifestyle, traveling a long distance, and recent surgery.
Chronic renal failure is irreversible damage to the kidneys. Common causes include hemorrhage, dehydration, drug abuse, and kidney stones. Signs and symptoms vary by severity of the disease but can include malaise, lethargy, nausea, headaches, cramps, extremity and facial edema, and altered level of consciousness.
A nasal cannula is an appropriate oxygenation method for which of the following patients?
A. A geriatric patient who is confused and feeling short of breath
B. A COPD patient with 89% pulse oximetry reading
C. A patient with mild respiratory distress and adequate pulse oximetry who cannot tolerate devices over their mouth
D. An unresponsive patient with unobtainable pulse oximetry
C. A patient with mild respiratory distress and adequate pulse oximetry who cannot tolerate devices over their mouth
A nasal cannula delivers 24% to 44% oxygen, with a supplemental flow of one to six liters per minute. A nasal cannula should be used if the patient has adequate oxygenation and is unable to tolerate a non-rebreather mask. A nasal obstruction will not allow adequate oxygenation to be obtained from a nasal cannula. Primarily, a non-rebreather mask should be used.
For a patient in respiratory distress (e.g., a severely dyspneic patient, pulse oximetry less than 90%), assisted ventilation, likely from a bag-valve-mask with a reservoir bag, is appropriate to deliver nearly 100% oxygen and provide the appropriate rate of ventilation.
Confusion and other altered mental statuses or unresponsiveness are potential signs of hypoxia and should be treated with high-flow oxygenation until an alternate cause can be determined or the patient has appropriate oxygenation.
What is the first priority in regard to scene safety?
The safety of oneself
Personal safety is the first responsibility of EMS personnel. An injury to EMS personnel requires additional resources, delays emergency medical care, and causes potentially unnecessary injury or death. The safety of patients and bystanders is also vital but not as important as the safety of EMS personnel.
Personal property does not take precedence over emergency medical care. Triage and extrication are important parts of the assessment and care of patients; however, scene safety takes priority.
An 18-year-old female has had diarrhea for three days. She complains of dizziness and a dry mouth. Bystanders confirm that close contacts have had gastroenteritis.
What most likely causing this patient's dizziness and dry mouth?
Dehydration
Gastroenteritis is a family of conditions that typically involve an infection combined with gastrointestinal complaints. Some cases of gastroenteritis are not caused by infectious conditions (e.g., adverse reactions to medications, exposure to toxins, chemotherapy). Cases vary in duration from a few days to several weeks. Common signs and symptoms include abdominal pain, nausea, vomiting, diarrhea, anorexia, and fevers. If diarrhea or vomiting persists, dehydration can occur. Shock can result.
Pregnancy and food poisoning can both cause these symptoms, but there is no evidence of these.
Volume loss from diarrhea can cause electrolyte imbalance, but this would not cause a dry mouth.
A 24-year-old female patient fell asleep while tanning at the beach. Her skin is red, and she reports pain all over. She denies the presence of blisters. What type of burn does she most likely have?
Superficial burn (1st degree)
In most cases, prehospital care of a superficial burn (also known as first-degree) involves providing simple first aid to treat symptoms. In severe cases, patients may develop second-degree burns, which could require aggressive fluid resuscitation and skin care.
A superficial burn involves the epidermis. The skin will turn red but does not blister. The burn site can be quite painful. Sunburn is a common example of a superficial burn.
A partial-thickness burn (also known as second-degree) involves the epidermis and some portion of the dermis. The skin is moist, mottled, and white to red. Blisters are common. These burns cause intense pain.
Full-thickness burns (also known as third-degree) extend through all skin layers and may involve the subcutaneous tissue, muscle, bone, or internal organs. The skin is dry and leathery and may appear white, dark brown, or even charred. Some full-thickness burns are hard to the touch. If the nerve endings are destroyed, the severely burned section may not have sensation, while the surrounding area will be extremely painful.
Which of the following is not a common side effect of nitroglycerin?
A. Hypertension
B. Headache
C. Vasodilation
D. Tachycardia
A. Hypertension
Common side effects of nitroglycerin include hypotension, headaches, and changes in heart rate ( tachycardia or bradycardia).
Which anatomical structure marks the end of the upper airway and the beginning of the lower airway?
Larynx
The larynx is a structure formed by independent cartilaginous structures, the epiglottis, the glottis, and the vocal cords (superior aspect); the thyroid cartilage (middle structure); and the cricoid cartilage (inferior aspect), which lies opposite the sixth cervical vertebra. The cricoid cartilage of the larynx marks the end of the upper respiratory tract.
The lower respiratory tract includes the trachea, bronchi, bronchioles (23 bifurcations), and alveoli.
The carina is where the trachea divides into the two mainstem bronchi. The glottis is the space between the vocal cords and the narrowest portion of the adult airway, forming the superior part of the larynx. The oropharynx is the posterior portion of the oral cavity; it lies above the larynx and is also part of the upper airway.
A patient is found supine in a dangerous location and requires an emergency move. What is the most appropriate way to move the patient safely?
Pull the patient along the line of the body’s long axis
An emergency move should be performed if there is a risk of serious harm or death (e.g., fire, explosives, hazardous materials), if there is an inability to gain access to other patients who need lifesaving care, or if life-threatening conditions cannot be assessed and/or treated. The patient should be dragged along the long axis of the body. This method keeps the spinal column in line as much as possible.
The patient's clothing in the neck and shoulder area can be used to pull them; ensure a top button is undone, if present, to prevent choking. The patient may also be placed on a blanket or coat to be pulled. If no material is available for pulling, the patient's arms can be rotated above their head. Then, grasp the wrists and drag the patient.
Alternatively, the EMT can place their arms under the patient's shoulders and through the armpits and drag the patient backward. It is inappropriate to wait for further assistance if an emergency move is required.
During an emergency move, there is no time to immobilize a patient on a long backboard or scoop stretcher.
A female patient is complaining of stomach pain. She reports a history of peptic ulcers. In which region of the abdomen is the stomach located?
Left upper quadrant
The left upper quadrant contains the stomach, spleen, and a portion of the pancreas.
The right upper quadrant contains the liver, gallbladder, duodenum of the small intestine, and a portion of the pancreas.
The left lower quadrant contains the large and small intestines. Of the large intestines, the left lower quadrant contains the descending and left half of the transverse colon.
The right lower quadrant contains the large and small intestines. Of the large intestines, the right lower quadrant contains the ascending colon, the right half of the transverse colon, and the appendix.
When is it not appropriate to apply pressure to a bleeding head wound?
When a skull fracture is suspected
Excessive pressure on an open bleeding head wound is inappropriate if a skull fracture is suspected. Intracranial pressure may be increased, or bone fragments may be pushed into the brain.
A cervical spine injury, neurological deficits, or an altered mental status do not prohibit the use of direct pressure on an open head wound. However, neurological deficits or an altered mental status may suggest a skull fracture.
An adult patient is found pulseless and apneic. CPR was initiated by bystanders. Which of the following is appropriate during automated external defibrillator ( AED) use?
A. Always place the pads in an anterior/posterior position
B. Ensure no one is touching the patient during analysis and defibrillation
C. Remove the patient if found in the snow
D. Get the patient away from any water, even small puddles
B. Ensure no one is touching the patient during analysis and defibrillation
No one should touch the patient during analysis and defibrillation. Touching the patient during analysis may alter the AED's ability to assess a cardiac rhythm appropriately. Touching the patient during defibrillation may cause the rescuer to be shocked by the AED. If a shock is advised, chest compressions should be resumed while the AED is charging.
Not all AEDs use the anterior/posterior position for pad placement. Studies have shown that the apex/sternal positions have better defibrillation success rates with biphasic shocks.
An AED may be used if a patient is in a small puddle of water or in the snow; however, the patient’s chest should be dried as much as possible. It is not appropriate to use an AED if a patient is submerged in water.
If a peanut is aspirated, where is it most likely to become lodged?
Right mainstem bronchus
Aspiration of a foreign body, such as a solid or semisolid object, may lodge in the larynx or trachea and can be a life-threatening emergency if the object is large enough to obstruct the airway completely. Smaller objects create less obstruction and may pass beyond the carina, resulting in less severe signs and symptoms. Because the right main bronchus is in almost a direct line with the trachea, foreign objects traversing the trachea are more likely to enter the right main bronchus. Complications of a foreign body aspiration depend on the dimensions and orientation of the object and include coughing, hemoptysis, asphyxia, pneumothorax, tracheobronchial rupture, or cardiac arrest.
Which of the following is not an appropriate strategy for managing stress?
A. Limit physical exercise until you feel better
B. Talk about feelings with trusted people
C. Limit tobacco use
D. Practice meditation
Limit physical exercise until you feel better
Most studies estimate the prevalence of post-traumatic stress disorder ( PTSD) among EMS personnel as ranging from 15% to 20%. Taking steps to reduce the negative effects of stress is critical. Symptoms of stress can be physical, mental/emotional, and behavioral and may include the following:
Appropriate strategies to manage stress include the following:
A patient is exposed to a chemical that overstimulates the parasympathetic nervous system. Which of the following signs is expected?
A. Tachycardia
B. Bronchodilation
C. Bradycardia
D. Cool, clammy skin
Bradycardia
Overstimulation of the parasympathetic nervous system ( organophosphate poisoning) will increase salivation, bronchorrhea, bronchospasm, sweating, abdominal pain, diarrhea, miosis, muscle paralysis, and bradycardia. Ultimately, the patient dies from asystole.
Stimulation of the sympathetic nervous system will produce effects opposite to the parasympathetic response (i.e., constricted blood vessels causing pale, cool, clammy skin; tachycardia; increased force of heart contraction; and bronchodilation).
An adult male trauma patient does not respond verbally or with eye-opening to painful stimuli and speech. He extends his arms and legs during the motor response test. What is his Glasgow Coma Scale (GCS) score?
Four
The GCS is an evaluation tool that can determine the level of consciousness. It evaluates eye-opening, verbal response, and motor response. A lower score suggests a more severe extent of brain injury. Survivability is not assessed with GCS but is assessed via the Revised Trauma Score.
Eye-opening scoring:
Verbal response scoring:
Motor response scoring:
This patient gains a point for not opening his eyes to stimuli (both verbal and pain), a point for no verbal response to verbal stimuli, and 2 points for abnormal extension of his extremities (decerebrate posturing).
Which of the following are indicators of the return of spontaneous circulation ( ROSC) in an adult cardiac arrest patient?
Select the two answer options which are correct.
1. SpO2 suddenly decreases
2. The pulses become palpable
3. PETCO2 suddenly increases
4. Chest compressions become easier
5. Ventilations become harder
6. Ventilations become easier
2 and 3
Signs of ROSC include an organized ECG rhythm with a palpable pulse and blood pressure, an abrupt and sustained increase in PETCO2 (typically 40 mm Hg or higher), or spontaneous arterial pressure waves with intra-arterial monitoring.
A sudden drop in SpO2 may indicate insufficient airway management. If chest compressions become easier, check for proper hand placement. This finding is not an indicator of ROSC.
A patient is receiving artificial ventilation via a bag-valve mask (BVM). If they start gurgling, what should you do?
Suction patient
A gurgling sound suggests fluid or secretions in the patient's airway. If gurgling sounds are heard, the oropharynx should be inspected, and appropriate suction should be administered. Fluids and secretions may cause complete airway obstruction or be aspirated into the lung.
A bag-valve mask (BVM) should be used with supplemental oxygen at a flow of 15 liters per minute; the appropriate rate depends on the patient.
Compression / Ventilation Ratio (with advanced airway)
Compression / Ventilation Ratio (without advanced airway)
These rates mimic normal ventilation rates. Any rate lower than these values may not provide adequate oxygenation.
Ventilation should cause the chest to rise and fall and avoid gastric distension. Gastric distension may lead to vomiting and subsequent aspiration. Rapid ventilation should be avoided due to the risk of gastric distension.
Which of the following situations constitutes a breach of confidentiality?
A. Informing and emergency department nurse about a patient's medical history and allergies
B. Discussing the treatment provided on a call in a public area
C. Informing a social worker at the receiving facility about a patient's symptoms
D. Discussing a repeat patient's potential communicable diseases with an ambulance partner en route to the scene.
B. Discussing the treatment provided on a call in a public area
Confidential information includes patient information (e.g., name, date of birth, demographics) and history, assessment findings, and treatment provided. If this information is disclosed without appropriate authorization, it may constitute a breach of confidentiality. Commonly, a subpoena or signed written release from the patient is required for the release of patient information. Third-party billing personnel also have access to patient information.
Discussing patient information with receiving hospital personnel is appropriate and part of the continuity of care.
If information is known about a patient or scene prior to arrival, this information may help all involved parties to prepare and ensure appropriate scene safety. Preparation, both mentally and physically, will help alleviate potential dangers upon entering a scene.
What is the definition of a postictal state?
The period following a seizure characterized by labored breathing and altered mental status
The postictal state is the period following a seizure, typically lasting five to 30 minutes. It is characterized by lethargy, poor muscle tone, confusion, nausea, hypertension, headaches, and other symptoms of disorientation. Because of the lactic acidosis created by sustained muscular contraction, breathing typically becomes fast and deep in an effort to reduce CO2 levels and compensate for changes in pH.
An aura is a sensation experienced prior to a seizure that can often serve as a warning sign.
Status epilepticus is a condition in which seizures recur every few minutes or a seizure lasts longer than 30 minutes.
Epilepsy is a disorder in which abnormal electrical discharges occur in the brain, causing seizures and possibly unconsciousness.
A 70-year-old male was trimming a tree branch when it broke and fell on him. His wife called because he seemed confused immediately after the incident, but he insisted that he felt fine and refused transport. Two days later, you are called to his home again, where he is clearly confused. During your assessment, he vomits once and then becomes somnolent. The patient's medical history includes a cardiac stent placed eight months ago. Ecchymosis at the site of the injury is noted, but no further ecchymosis is visible. Which of the following is most likely?
A. Subdural hematoma
B. Basilar skull fracture
C. Concussion
D. Epidural hematoma
A. Subdural hematoma
In addition to Subdural Hematoma (SDH), head trauma is a major cause of Epidural Hematoma (EDH), Subarachnoid Hemorrhage (SAH), cerebral contusion, diffuse brain swelling, and fractures. Any of these injuries may coexist in a patient following trauma, and their clinical manifestations can be difficult to distinguish. Patients with head trauma should be transported to a hospital with a dedicated trauma team, if feasible, to promote significantly better outcomes.
Subdural hematoma typically occurs with a sudden acceleration/deceleration injury, and tearing of the bridging veins of the dura, resulting in a hematoma between the dura mater and arachnoid. Because these are commonly venous injuries, they often present more slowly; acute symptoms usually develop gradually one to two days after the initial injury. Because of the mechanism of injury, however, they also typically have accompanying parenchymal damage. The elderly and alcoholics tend to have more extensive brain atrophy and are more susceptible to the development of acute SDH. Children under two years of age are also at increased risk. Immediate evaluation is critical, as the diagnosis is based on CT scan results.
An epidural hematoma results from a collection of blood in the potential space between the skull and the dura mater. Blunt trauma to the temporal or temporoparietal area with an associated skull fracture and disruption of the middle meningeal artery is the primary mechanism of injury. The classic presentation of EDH involves significant blunt trauma, with a loss of consciousness or altered mental status, followed by a “ lucid interval” of indeterminate duration; the patient then quickly declines in status, with a rapid neurologic demise. High-pressure arterial bleeding can lead to herniation of the brain within hours after injury. While the “lucid interval” is regularly taught to healthcare practitioners, this presentation occurs in a minority of cases (<20%).
A basilar skull fracture is associated with high-energy trauma and occurs following diffuse impact to the head. Signs and symptoms include Cerebrospinal Fluid (CSF) draining from the ears, “raccoon eyes,” or a Battle sign (ecchymosis behind one ear over the mastoid process). Patients with leaking CSF are at risk for bacterial meningitis. These symptoms may not occur until 24 hours after the incident.
A concussion is a mild traumatic brain injury, leading to impairment of brain function without overt hemorrhage or gross lesion and resulting in a GCS ( Glasgow Coma Scale) score of 14 or 15. Signs and symptoms include confusion and alterations in consciousness. The patient may refer to the incident in terms of having their “bell rung” or “seeing stars.” The presence of vomiting, a headache, loss of consciousness, focal neurologic deficit, or a dangerous mechanism of injury indicates an increased risk of serious injury.