Continuing Education

Anaphylaxis: Vicious chain reaction

You are dispatched to the home of an 11-year old girl who was found by her mother lying on the couch complaining of a stomach ache and a dizzy feeling. She then became lethargic and later unresponsive. You assess the airway and your partner asks pertinent history from the mother. She says that she had taken her daughter to the hospital/health center yesterday and was given a prescription for penicillin for strep throat.

Chest auscultation reveals diffuse wheezing, decreased breath sounds, and tachycardia. You place the patient in the ambulance and transport code three.

What would your emergency care plan be for this patient:

 

 

 

 

 

 

 

 

 

 

 

Try to answer these questions. Some research may be required.

1. Most deaths secondary to anaphylaxis occur within______ of symptom onset.
  1. 5 minutes
  2. 10 minutes
  3. 30 minutes
  4. 1 hour
2. Anaphylaxis occurs when:
  1. A reaction causes release of vasoactive substance through lgE
  2. A patient becomes hypotensive after exposure to an antigen
  3. Poor perfusion leads to loss of consciousness
  4. Wheezing develops secondary to constricted airways
3. Hemodynamic changes occur in anaphylactic shock due to:
  1. The hearts inability to pump effectively
  2. Poor oxygenation of tissues secondary to bronchconstriction
  3. Destruction of the lining of small blood vessels
  4. Large quantities of intravascular fluid leaking from blood vessels
4. A hapten is:
  1. A complete antigen that causes anaphylaxis
  2. A vasoactive substance released during anaphylaxis
  3. An incomplete antigen that combines with a natural protein
  4. An lgE molecule on the surface of circulating mast cells
5. The most common cause of an anaphylactic reaction is hypersensitivity to:
  1. Food
  2. Latex
  3. Insect stings
  4. Medications
6. Patients in the early stages of anaphylaxis may present with:
  1. Altered mental status
  2. Apnea from laryngeal edema
  3. Shortness of breath
  4. Upper airway stridor
7. Which of the following is the most serious sign of anaphylaxis?
  1. Urticaria
  2. Hypotension
  3. Flushed skin
  4. Tachypnea
8. Angioedema is defined as:
  1. Subcutaneous edema usually around the lips
  2. An eruption of itching wheals, usually of systemic origin
  3. Flushed skin in conjunction with hypotension
  4. Sneezing, tearing and watery mucous
9. The primary cause of death in anaphylaxis is:
  1. Vasodilation
  2. Hypotension
  3. Upper airway obstruction
  4. Bronchiole constriction
10. Opthalmic signs of anaphylaxis include:
  1. Excessive dryness
  2. Conjunctivitis and tearing
  3. Pupil constriction
  4. Double vision
11. Multiphasic anaphylaxis means the patient:
  1. Experiences a reoccurrence of symptoms
  2. Has previously had an anaphylactic reaction
  3. Has been exposed to antigens without a reaction
  4. Requires advanced airway procedures to maintain oxygenation
12. Patients whose anaphylactic symptoms resolve in the field after administration of epinephrine should be:
  1. Allowed to remain at home if no symptoms return in 15 minutes
  2. Transported to an emergency department for observation
  3. Instructed to drive to the hospital if symptoms return
  4. Instructed to follow up with their family physician
13. Epinephrine acts to:
  1. Dilate blood vessels
  2. Dilate bronchioles
  3. Decrease cardiac contractions
  4. Cause meditator release from sensitized mast cells
14. Epinephrine targets which of the following receptors?
  1. Alpha
  2. Alpha and Beta 1
  3. Alpha and Beta 2
  4. Alpha, Beta 1 and Beta 2
15. Side effects of epinephrine in patients older than 35 include:
  1. intracranial bleed
  2. decreased heart rate
  3. bronchconstriction
  4. hypotension
16. Epinephrine should be administered:
  1. As soon as you determine the patient is experiencing anaphylaxis
  2. Before IV fluids, diphenhydramine or steroids
  3. Even if only minor symptoms present
  4. In the presence of marked hypotension after IV fluid administration
17. Epinephrine is most effective when administered:
  1. Subcutaneously in the arm
  2. Subcutaneously in the thigh
  3. By intramuscular injection in the deltoid muscle
  4. By intramuscular injection in the thigh
18. Diphenhydramine can be administered in anaphylaxis by:
  1. IV push, 100mg
  2. Endotracheal route, 5mg/kg
  3. IM injection, 50mg
  4. Subcutaneous injection, 25 – 50mg
19. Aerosol beta receptor agonists:
  1. can be used to treat bronchspasm associated with anaphylaxis
  2. are not effective for bronchspasm associated with anaphylaxis
  3. can be used to treat bronchspasm from anaphylaxis at twice the usual dose
  4. are contraindicated in anaphylaxis due to rebound bronchspasm
20. Glucogon may be of particular use for the patient with anaphylaxis who:
  1. is younger than 30
  2. takes beta blockers
  3. has a past medical history of asthma
  4. is not hypotensive.

Answers:1.c, 2.a, 3.d, 4.c, 5.d, 6.c, 7.c, 8.a, 9.c, 10.b, 11.a, 12.b, 13.b, 14.d, 15.a, 16.a, 17.d, 18.d, 19.a, 20.b

Emergency childbirth

Childbirth is usually a natural process that requires compassion and assistance from EMS providers. However, complicated births do occur. EMS personnel must draw on their knowledge and skills to assist both the mother and child throughout the process, regardless of the type of delivery.

Try these questions, you may have to do some research to answer the questions.

1. The condition that occurs when the uterus compresses the expectant mother’s inferior vena cava and decreases venous return to her heart is:
  1. Lateral pressure dependence
  2. Supine tachycardic syndrome
  3. Supine hypertensive syndrome
  4. Supine hypotensive syndrome
2. A woman may need 10 to 20 percent more oxygen when she is pregnant, have her respiratory rate increase by as much as 15 percent and be in a chronic state of hyperventilation.
  1. True
  2. False
3. The first three months of a woman’s pregnancy is called:
  1. First gestation cycle
  2. First eclampsic cycle
  3. First trimester
  4. First stage of labor
4. The muscular organ that contracts during labor to expel the fetus is:
  1. Ulna
  2. Vagina
  3. Uterus
  4. Placenta
5. An expectant mother’s pulse can be expected to range from____beats per minute when either awake or asleep:
  1. 60 – 80
  2. 80 – 95
  3. 70 – 80
  4. 90 – 110
6. Vena cava compression by the uterus that results in increased pelvic and peripheral pressures and congestion in the lower extremities, may cause:
  1. Increased bleeding from soft tissue injuries
  2. Varicose veins
  3. Leg cramps
  4. All of the above
7. Conception normally takes place when an egg and sperm unite in the:
  1. Uterus
  2. Fallopian tubes
  3. Ovaries
  4. Amniotic sac
8. A woman pregnant for the second time is referred to as a:
  1. Primagravida
  2. Multipara
  3. Primipara
  4. Multigravida
9. Because the hypotension that occurs when a pregnant woman is in a supine position may be due to supine hypotensive syndrome, it is recommended that her blood pressure be taken:
  1. While she is on her side
  2. While in a seated position
  3. While she is prone
  4. While flat on her back
10. During what stage of childbirth is the baby delivered?
  1. Stage 1
  2. Stage 2
  3. Stage 3
  4. Stage 4
11. Meconium staining:
  1. Is caused by the premature rupture of the bag of waters
  2. Occurs when fetal stool stains the amnotic fluid green or brownish-yellow
  3. Indicates fetal distress
  4. Both b and c
12. False labor is also referred to as:
  1. Braxter-Lamon contractions
  2. Preavera contractions
  3. Vulvine contractions
  4. Braxton-Hicks contractions
13. The fetus is connected to the placenta by the:
  1. Bag of waters
  2. Amniotic sac
  3. Fallopian tubes
  4. Umbilical cord
14. During fetal development, the mother’s blood does not flow directly through the infant:
  1. True
  2. False
15. Because her blood volume increases during the third trimester of pregnancy, an expectant mother’s heart rate increases____beats per minute:
  1. 10 – 20
  2. 15 – 20
  3. 30 – 40
  4. 10 – 15
16. Maternal shock results in____percent mortality:
  1. 35%
  2. 50%
  3. 60%
  4. 80%
17. An expectant mother in her second trimester with a sustained heart rate of 110/min:
  1. Is considered to have a normal heart rate
  2. Is suffering from hypertensive gestation
  3. May be hypovolemic
  4. May be suffering from fetal odnetnin
18. The average pregnant mother can tolerate a _____ml (30 to 35 percent) volume loss before becoming hypotensive:
  1. 500
  2. 1,000
  3. 1,300
  4. 1,500
19. If an expectant mothers contractions remain two to three minutes apart for over 20 minutes and the child is not delivered:
  1. Prepare for imminent delivery of the child
  2. Suspect the child has suffered positional asphyxia
  3. Transport without further delay
  4. Assume the infant is in acute distress and in danger of suffocation

Answers: 1.d, 2.a, 3.c, 4.c, 5.b, 6.a, 7.b, 8.a, 9.a, 10.b, 11.d, 12.d, 13.d, 14.a, 15.b, 16.d, 17.c, 18.d, 19.c

Gastrointestinal hemorrhage

You are dispatched at 0500 hrs to a residence of a concerned family whose 68-year-old grandfather has been vomiting blood for the last two hours. You find an alert and orientated elderly male who appears jaundiced, has a distended abdomen and is complaining of abdominal discomfort. His family reports he has a history of cirrhosis from many years of alcohol abuse. As you load him in the ambulance, he vomits bright red blood, his blood pressure drops to 70/40, and he loses consciousness. On further examination you find his pulse thready and regular at 135/min, respirations shallow and regular at 28 /min.

What would your definitive care be for this patient?

 

 

 

 

 

 

 

 

 

 

 

This will take a bit of research to answer the questions, but this is not an uncommon medical problem in your communities.

1. Upper GI bleeds are separated from lower GI bleeds by the:
  1. Ligament of Treitz
  2. Stomach
  3. Duodenum
  4. Sphlanic artery
2. Bleeding of which of the following locations would constitute an upper GI bleed?
  1. Jejunum
  2. Duodenum
  3. Ileum
  4. Colon
3. Lower GI bleeds:
  1. Are common in the very young
  2. Occur at a steady rate across all ages
  3. Are slightly more likely to occur in the elderly
  4. Increase dramatically as age increases
4. Which of the following terms means bright red blood found in the feces?
  1. Hematochezia
  2. Hematemisis
  3. Melena
  4. Melemesis
5. Which of the following is a classic sign of a brisk, upper GI bleed?
  1. Hematochezia
  2. Melena
  3. Hematemesis
  4. “Coffee-grounds” vomit
6. What is the most common cause of upper GI bleed?
  1. Gastric ulcer hemorrhage
  2. Duodenal ulcer
  3. Diverticulosis
  4. Peptic ulcer
7. Gastroesophageal variceal bleeding:
  1. Is a minor disease with low mortality
  2. Has a fatality rate of about 5%
  3. Leads to death only if untreated for long time periods
  4. Has a high mortality rate -- from 30% to 50%
8. Repeated bouts of forceful retching are a likely cause of:
  1. Mallory-Weiss syndrome
  2. Angiodysplasia
  3. Aortoenteric fistulas
  4. Duodenal ulcers
9. Which of the following is a classic sign of a lower GI bleed?
  1. Melena
  2. Hematemesis
  3. “coffee-grounds” vomit
  4. hematochezia
10. The most common cause of lower GI bleeds is:
  1. Angiodysplasia
  2. Diverticulosis
  3. Inflammatory bowel disease
  4. Tumors
11. A 20 – 25% loss of blood volume is likely to cause orthostatic changes of:
  1. An increase of heart rate of more than 10 beats per minute
  2. Capillary refill time increased to more than five seconds
  3. An increase in respiratory rate of more than five breathes per minute
  4. A decrease in blood pressure of more than 30 mmHg
12. Which of the following statements is accurate?
  1. Patients cannot tolerate large losses of blood volume without vital sign changes
  2. Heart rate may not change with blood loss, but blood pressure always will
  3. Blood pressure may not change with blood loss, but heart rate always will
  4. Some patients can tolerate large blood loss without changes in their vital signs
13. Bleeding over a large period of time will cause:
  1. No change in hematocrit level
  2. An increase in fluids shifting into the extravascular space
  3. A decrease in hematocrit level
  4. An increase in the number of red blood cells in the blood
14. A history of excessive use of NSAIDS (non steroidal anti inflammatory drugs) followed by sharp midepigastric pain would lead you to suspect:
  1. Lower GI bleed
  2. Helicobacter pylori infection
  3. Duodenal ulcer
  4. Erosive gastritis
15. Rebleeding from a gastroesophageal hemorrhage is:
  1. A rare event
  2. Common in the first day or two following the initial bleed
  3. Not likely to be serious
  4. Common for up to six weeks after the initial event
16. Acutely, the most predictive factor associated with a significant volume loss is:
  1. Increase in heart rate with positional change
  2. Increased respiratory rate
  3. Change in mental status
  4. Cool, pale skin
17. A conversion from tachycardia to bradycardia in a GI bleed patient with inadequate blood volume indicates:
  1. The circulating blood volume is severely compromised
  2. The patient is tolerating the blood loss relatively well
  3. No further fluid resuscitation is necessary
  4. Oxygen administration should be discontinued

Answers: 1.a, 2.b, 3.d, 4.a, 5.c, 6.d, 7.d, 8.a, 9.d, 10.b, 11.a, 12.d, 13.c, 14.c, 15.d, 16.a, 17.a

How sweet is your patient?

While travelling on a rural two-lane road, a car weaves back and forth for miles. Other drivers assume the driver is drunk and give him a wide berth. Suddenly, the swerving car crosses the center lane and slams head-on into another car. Two elderly occupants of the other car die instantly.

You arrive at the scene, assess the scene and triage the injured. Your crew begins work on the only viable patient – the driver. You carefully immobilize his spine and follow appropriate trauma protocols.

The patient persists with an altered mental status throughout care and transport. The police presume he is intoxicated. You assess the patient’s blood sugar and it measures 2. 5 minmol/liter. A single 50cc bolus of 50% dextrose (D50) restores the patient’s mental status. He has only vague recollections of how he was injured and how he got to the hospital.

Try to answer these questions, you may have to research for the information.

1. The organ that chiefly monitors and regulates blood glucose levels is:
  1. Brain
  2. Pancreas
  3. Liver
  4. Kidney
2. The predominant hormone involved in the lowering of the blood glucose level is:
  1. Insulin
  2. Glucogon
  3. Cortisol
  4. Epinephrine
  5. A an B
3. The normal blood glucose range is:
  1. 1. 5 – 3. 0minmol/liter
  2. 3. 5 – 5. 0minmol/liter
  3. 4. 0 – 7. 0minmol/liter
  4. 4. 0 – 7. 5minmol/liter
4. If a patient with Insulin Dependent Diabetic Mellitus increases their activity level without changing diet or insulin injections, their blood glucose level will:
  1. Increase
  2. Decrease
  3. Remain the same
  4. Not be affected
5. The physical findings in the severely hyperglycemic patient with diabetic ketoacidosis would usually include all of the following except:
  1. Warm, dry skin
  2. Fruity odor on the breath
  3. Moist mucous membranes
  4. Weak, thready pulses
6. The primary consideration in the initial assessment and treatment of a hypoglycemic patient is to:
  1. Restore the blood glucose levels to a normal range
  2. Lower the blood glucose level to prevent shock
  3. Measure the blood sugar level with a glucometer
  4. Protect the patient’s airway
7. An unconscious patient with extremely dry mucous membranes, thready pulses and decreased level of consciousness should be suspected of suffering from:
  1. Severe hyperglycemia
  2. Severe hypoglycemia
  3. Alkalosis
  4. None of the above
8. As sugar levels begin to rise, which cells in the pancreas produce the hormone that will begin to lower the blood glucose level and direct the liver to begin storing glucose?
  1. Alpha cells
  2. Beta cells
  3. Gamma cells
  4. Delta cells
9. The care of the unconscious diabetic patient suffering from hypoglycemia begins with:
  1. Maintaining the airway
  2. Assessing the breathing pattern
  3. Checking the blood glucose level
  4. Checking the vital signs
10. Patients who have profound thiamine deficiency, such as alcoholics, are at risk to develop a life threatening swelling of the brain if they receive a large glucose load. This condition is called:
  1. Diabetic ketoacidosis
  2. Cerebral hyperglycemia
  3. Wernicke’s encephalopathy
  4. Diabetic meningitis
11. Kussmaul’s respirations are a respiratory pattern best described by:
  1. Deep, slow breathing
  2. Shallow, slow breathing
  3. Deep, rapid breathing
  4. Shallow, rapid breathing
12. Its more acutely dangerous for a patient to be:
  1. Hypoglycemic
  2. Hyperglycemic
  3. Both are equally dangerous in the short term
  4. None of the above
13. Which of the following can cause altered mental status?
  1. Hypoglycemia
  2. Alcohol intoxication
  3. New onset stroke
  4. All of the above
14. Which system of the body is responsible for the regulation of blood sugar, chiefly through the action of the pancreas and liver?
  1. Digestive
  2. Circulatory
  3. Nervous
  4. Endocrine
15. In awake but confused hypoglycemic Patient, who can manage their airway, which of the following treatment is most appropriate?
  1. Call for advance life support to initiate an IV
  2. Administer orange juice orally
  3. Administer nothing but water by mouth
  4. None of the above
16. An accident victim who is confused, diaphoretic and combative may be suffering from:
  1. Respiratory distress with hypoxia
  2. Hypoglycemia
  3. Head injury
  4. All of the above
17. The initial care for a patient suffering from diabetic ketoacidosis includes:
  1. Initiation of an IV and a bolus of Dextrose 5%
  2. Initiation of an IV and then administering the patient’s insulin
  3. Initiation of an IV followed by infusion of a large volume of fluid infusion
  4. Initiation of an IV followed by a subcutaneous injection of glucogon
18. If there is no improvement after the second dose of D50 is given to the patient with altered mental status, one should:
  1. Continue to administer D50
  2. Reevaluate the cause of mental status change
  3. Administer glucogon
  4. None of the above
19. To prevent Wernicke’s encephalopathy, ___________is often administered prior to D50:
  1. Glucagon
  2. Thiamine
  3. Insulin
  4. None of the above
20. One of the serious complications of D50 administration is:
  1. Hyperglycemia
  2. Diabetic ketoacidosis
  3. Local tissue destruction if the IV site infiltratesduring drug administration
  4. None of the above are complications of the administration of Dextrose 50%.

Answers: 1. b, 2. e, 3. c, 4. b, 5. c, 6. d, 7. b, 8. b, 9. a, 10. C, 11. c, 12. c, 13. d, 14. d, 15. b, 16. d, 17. a, 18. b, 19. b, 20. c

Identification and management of facial fractures

You and your crew respond code three to a motorcycle crash. You arrive to find an unresponsive, unhelmeted patient, who was thrown from his motorcycle after hitting a large road defect. His jaw is grossly deformed and obviously unstable, and he as multiple lacerations around his face and eyes. Initial vital signs are within normal limits, pulse strong and regular at 88, respiration’s deep and easy at 20 breathes per minute. His SPO2 Sats were 85%. Your partner stabilizes the C-spine. While suctioning the airway and applying highflow O2, you notice a significant jaw deformity. You open your airway bag and anticipate a difficult intubation.

What would your emergency care plan be for this patient:

 

 

 

 

 

 

 

 

 

 

 

Try to answer these questions, you may need to do some extra research to answer the questions.

1. EMS in urban areas most often encounter facial fractures secondary to:
  1. Assault
  2. Motor vehicle crashes
  3. Sporting injuries
  4. Falls
2. Sutures between bones are:
  1. Especially strong and not prone to injury
  2. Weak points susceptible to fracture
  3. Only present following injury
  4. Not present between facial bones
3. The only mobile joint in the face is the:
  1. Temporomandibular joint
  2. Zygomatic joint
  3. Maxillary joint
  4. Mandibular joint
4. The zygomatic bones are also known as the:
  1. Jawbones
  2. Cheekbones
  3. Nasal bones
  4. Frontal bones
5. Cervical spine injuries associated with facial fractures are:
  1. Common – almost all facial injuries have associated C-spine injuries
  2. Frequent – about half of facial fractures have associated C-spine injuries
  3. Usual – about 25% of facial fractures have associated C-spine injuries
  4. Rare – about 1 – 2% of facial fractures have associated C-spine injuries
6. Brain injuries occur in what percentage of facial fractures?
  1. 10 – 15%
  2. 20 – 50%
  3. 50 – 60%
  4. 60 – 75%
7. Scalp injuries:
  1. Bleed very little and can be ignored
  2. Commonly cause life-threatening bleeding
  3. Bleed profusely even if relatively minor
  4. Should be clamped as soon as practical to avoid hypovolemia
8. To stop nosebleeds, apply pressure:
  1. Just below the nasal bones
  2. To the cheekbones on both sides
  3. Directly to the bleeding by packing the nostrils
  4. Directly between the eyes, over the nasal bones
9. Occlusion of the teeth relates to:
  1. Pain experienced with biting down
  2. How well teeth fit together
  3. Loose teeth still in the oral cavity
  4. Teeth that have become dislodged from their sockets
10. In awake, mentating patients, prehospital providers:
  1. Will be unable to tell if a fracture exists until a CT scan is completed
  2. Shouldn’t evaluate for facial fractures – an ED X-ray will be performed
  3. Will be able to identify most facial fractures by palpation of the bones
  4. Should suspect facial fractures only if fluid is leaking from the ears and nose.
11. The injury most commonly associated with facial fracture is:
  1. Cervical spine injury
  2. Eye injury
  3. Head injury
  4. Soft tissue injury to the neck
12. Orbital floor or blowout fractures:
  1. Are a rare type of fracture
  2. Are most commonly caused by pressure on the zygomatic arch
  3. Often cause the eyeball to sink into the orbit
  4. Look frightening but rarely have serious complications
13. Le Fort fractures describe:
  1. Fractures of the maxilla
  2. Types of mandibular fractures
  3. Fractures of the cribriform plate
  4. Degrees of orbital fractures
14. The most frequently fractured facial bone is the:
  1. Maxilla
  2. Frontal bone
  3. Mandible
  4. Nasal bone
15. In an alert patient, subluxed teeth should be:
  1. Immediately removed
  2. Left in place unless there is a potential for aspiration
  3. Removed and cleaned vigorously
  4. Transported under the tongue
16. Managing the airway of a patient with facial fractures usually requires:
  1. Orotracheal intubation
  2. Nasotracheal intubation
  3. Surgical airway procedures
  4. Suction and oxygenation
17. Nasotracheal intubation can cause problems if:
  1. The cibriform plate is fractured
  2. Extensive bleeding obstructs the view of the vocal cords
  3. The mandible is fractured
  4. Attempted in a breathing patient
18. The drug most often administered to blunt an elevation in ICP during larynoscopy is:
  1. Etomidate
  2. Lidocaine
  3. Succinylcholine
  4. Fentanyl
19. Which of the following would be recommended?
  1. A cricothyrotomy in a child with facial injuries
  2. Retrograde intubation in the presence of facial deformities
  3. Paralyzing a patient when BVM ventilations are difficult
  4. Administering low-flow oxygen to avoid raising ICP
20. Fentanyl is a good choice for analgesia for trauma patients because it:
  1. Lasts for a long time, providing continual relief
  2. Lowers the patient’s blood pressure and ICP
  3. Causes hypotension less often than morphine
  4. Have amnestic effect as well as analgesic effects

Answers: 1.a, 2.b, 3.a, 4.b, 5.d, 6.b, 7.c, 8.a, 9.d, 10,c, 11.c, 12.b, 13.a, 14.b, 15.b, 16.d, 17.a, 18.b, 19.b, 20.c

Ischemic chest pain

You are dispatched for a 52 year-old male complaining of chest pain. On arrival, you find him sitting at the dining room table, complaining of vise-like pain that started 30 minutes before he called for an ambulance.

He tells you the pain radiates through the jaw and down the left arm, and he is experiencing shortness of breath, sweating and nausea.

He states he has never had heart problems, did not do any unusual lifting or straining and is not on any medications.

His vital signs reveal a strong, regular pulse of 52, respirations 24 and labored, and a blood pressure of 160/90.

What would your emergency care plan look like:

 

 

 

 

 

 

 

 

 

 

 

Try these questions, you may have to do some research for some of the answers.

1. The most critical factor to the prevention and treatment of sudden cardiac death is:
  1. Early administration of O2
  2. Early call for ambulance or 911 access
  3. Early access to advanced care
  4. Early recognition of an MI
2. Angina can occur when:
  1. A thrombus obstructs blood flow to the muscle of the heart
  2. An increase in the heart’s work is not met with a corresponding increase in blood supply
  3. The heart’s ordinary needs at rest are not met because of a blockage of blood flow through the coronary arteries
  4. All of the above
3. A thrombus is a cluster of platelets, fibrin, clotting factors and other cell attributes of the blood and is also referred to as:
  1. A myocardial infarction
  2. A subdural hematoma
  3. A cluster pack
  4. A blood clot
4. Which of the following can cause cardiac ischemia?
  1. Arterial occlusion
  2. Vasoconstriction
  3. Glaucoma
  4. A) and B)
5. Angina pectoris is the name given to myocardiac ischema causing:
  1. Pain but no permanent damage
  2. Paralysis of the capillary sphincters
  3. Permanent damage to the ventricles
  4. Cardiac asphyxia post childbirth
6. Myocardial infarction occurs when there is severe and sustained oxygen deprivation of the myocardium that results in:
  1. Increase in pulmonary perfusion
  2. Death of heart cells
  3. Loss of kinins
  4. A) and C)
7. The chief complaint most common to diseases of the coronary arteries is:
  1. Sudden cardiac death
  2. Cardiac dysrhythmias
  3. Shortness of breath
  4. Chest pain
8. The term used to describe the characteristic pain resulting from inadequate blood supply to the myocardium is:
  1. Ischemic chest pain
  2. Myocardial infarction
  3. Angioplasty
  4. Non-radiating retinal occlusion
9. Ischemic pain is believed to be caused by the release of lactic acid and other pain-provoking substances, such as histamine or kinins, which:
  1. Irritates the atrial valves of the heart muscle
  2. Stimulate the pain endings in the cardiac muscle
  3. Dissipate the cardiac receptors and reduce oxygen consumption
  4. Increase the linkage of thrombus clusters in the ventricles
10. Patients most likely not to complain while suffering from an MI are usually:
  1. Males between the age of 50 and 60 years of age
  2. Patients in their thirties with cardiac myopathy
  3. Elderly patients with diabetes and presenting with shortness of breath, weakness or an altered mental state
  4. None of the above
11. Referred pain on the patient’s left side is thought to be due to the fact that:
  1. The descending aorta extends through the left intercostal space
  2. The pulmonary artery is located on the left side of the heart
  3. Most myocardial infarctions occur on the left side of the heart
  4. The carotid artery is located on the left side of the heart
12. There are times when the pain from a myocardial infarction:
  1. Radiates to the back of a patient
  2. Radiates to the arms or jaw and is not specifically felt in the anterior chest
  3. Radiates to the neck, jaw, either arm or shoulder
  4. All of the above
13. Pain may not be the chief complaint in______% of MI patients:
  1. 10 – 20%
  2. 20 – 30%
  3. 30 – 40%
  4. 40 – 50%
14. Nitroglycerin decreases the workload of the heart by:
  1. Constricting peripheral vessels and decreasing oxygen consumption
  2. Dissolving blood clots and increasing blood flow to the brain
  3. Dilating peripheral vessels and decreasing resistance
  4. Diverting blood flow through the right atrium
15. The most common time of day for a myocardial infarction to occur is:
  1. In the early morning after the person wakes up
  2. In the afternoon after the person finishes a days work
  3. In the evening just after eating the evening meal
  4. In the middle of the night while the person is sleeping
16. An altered mental state, lethargy or drowsiness may be indicative of:
  1. Impending ventricular fibrillation and sudden death
  2. Low cardiac output from associated heart failure or dysrhythmias
  3. An accelerated junctional rhythm with periods of atrial fibrillation
  4. A pulmonary contusion secondary to closed chest trauma
17. Vital signs encountered when dealing with chest pain patients may vary due to:
  1. Associated pre-existing medical conditions, such as hypertension
  2. The patient’s psychological response to chest pain
  3. The location of the infarction within the heart
  4. All of the above
18. 12-lead ECG units help facilitate the early recognition and treatment of ischemic heart disease and identify ischemic events that:
  1. Are related to a transected aorta
  2. Are related to a patient’s age
  3. Are not affected by the administration of oxygen
  4. Are transient in nature

Answers: 1.d, 2.d, 3.c, 4.d, 5.a, 6.b, 7.d, 8.a, 9.b, 10.c, 11.d, 12.d, 13.a, 14.c, 15.a, 16.b, 17.d, 18.d

Pelvic plights

Your dispatcher/nurse sends you to the scene of a motor vehicle crash involving an overturned vehicle and a tanker truck. On arrival you find the tanker resting on its roof. You and your crew approach with due caution. Water pours from the tankers fill caps and floods down the road. Your thoughts quickly shift from the potential for a serious HAZMAT scene to the driver, who remains trapped in the vehicle’s cab.

You find the driver pinned beneath the top of the passenger seat in the prone position. He wasn’t wearing a seat belt at the time of the crash. The top of the passenger seat presses into the middle of the victim’s back, and his legs – from the belt line down – extend through the driver’s side door. Fire department crews arrive, and a firefighter pops the rear window for access. The driver screams in pain and calls for help as you begin your initial assessment.

You ask your partners to hold manual stabilization and apply a non-rebreather mask and a rigid cervical collar is installed by your other partner while you continue to assess the patient.

You find the patient tachycardic and tachypneic with a BP of 80/60. His pelvis is unstable and painful on palpation. You also find bleeding from the urethra, with bloodstains on the front of the patient’s underwear. These findings lead you to suspect pelvic fracture.

As you continue care and begin to immobilize the victim, you call for aeromedical evacuation and advise the rescue crew you’ll need to extricate the patient rapidly.

What is your definitive care for this patient:

 

 

 

 

 

 

 

 

 

 

Please try to answer these questions. You may require further research.

1. The mechanism of injury that causes most pelvic fractures is:
  1. Vehicular trauma
  2. A fall from a great height
  3. A sports-related injury
  4. A gunshot wound
2. Which of the following is true?
  1. Most patients with closed pelvic fractures will die.
  2. Hypotension associated with pelvic fracture has a poor prognosis
  3. Hemodynamically stable patients with pelvic trauma have a high mortality rate
  4. Closed pelvic fractures have a higher mortality rate than open pelvic fractures
3. Major pelvic fractures are usually accompanied by:
  1. Only minor associate injuries
  2. No other injuries – pelvic injury is usually an isolated injury
  3. Injuries limited to the legs and abdomen
  4. Other serious injuries based on a serious mechanisms of involvement
4. The largest bone in the pelvis is:
  1. Sacrum
  2. Ischium
  3. Pubis
  4. Ilium
5. The point of the pelvis that bears the weight when we sit is the:
  1. Sacrum
  2. Ischium
  3. Pubis
  4. Ilium
6. The sacrum articulates with the:
  1. Fifth lumbar vertebrae
  2. 12th thoracic vertebrae
  3. Head of the femur
  4. Pubic symphysis
7. Which of the following structures is not located within the bony pelvis?
  1. Iliac artery
  2. Cervix
  3. Aortic bifurcation
  4. Rectum
8. Pelvic fractures can lead to massive hemorrhage because:
  1. Small blood vessels are located close to the bones
  2. Large blood vessels are abundant in the pelvis
  3. The organs located within the bony pelvis are prone to heavy bleeding
  4. The blood vessels are securely anchored within the pelvis
9. A low-energy mechanism of injury:
  1. Is caused by a motor vehicle collision
  2. Results in multiple pelvic bone fractures
  3. Causes complete pelvic ring disruption
  4. Involves individual pelvic bones.
10. Crush injuries occur when:
  1. An object rolls over a patient
  2. The pelvis is fractured from a frontal impact
  3. A patient falls from a distance greater than their own height
  4. There’s direct impact on the iliac crest
11. An avulsion fracture occurs when:
  1. A piece of bone is ripped away
  2. An object rolls over a patient’s pelvis
  3. The patient falls from a height
  4. The pelvis is fractured in more than two places
12. An open-book fracture means:
  1. Lateral force collapses the pelvis
  2. Frontal force shears the bones causing unilateral disruption
  3. Posterior forces separate the sacrum from the ilium
  4. Anterior forces rotate the bones of the pelvis posteriorly
13. A patient struck from the side by a car will suffer:
  1. Anterior compression
  2. Lateral compression
  3. Vertical shear
  4. Combined forces
14. Evaluation of the stability of the pelvic bones should:
  1. Not be assessed if the patient has no complaints of pain
  2. Be assessed one time only to avoid further injury or hemorrhage
  3. Not be assessed if the patient is unresponsive
  4. Be assessed every five minutes for unstable patients
15. The most serious complications of pelvis fractures is:
  1. Infection
  2. Loss of function
  3. Hemorrhage
  4. Blood clots
16. To avoid causing pain to patients with a suspected pelvic fracture:
  1. Lift the patient as a unit and slide the long board into position
  2. Logroll the patient onto the affected side to place the long board
  3. Logroll the patient onto the unaffected side to place the long board
  4. Do not place the patient on a long board
17. Simple pelvic fractures:
  1. Usually require surgical interventions
  2. Require three or four months traction
  3. Are commonly managed with non-surgical means
  4. Are repaired by placing pins through the bones
18. The most extreme and unstable pelvic fractures are treated in the hospital with:
  1. Hypnotism
  2. Internal fixation
  3. External flexation
  4. Traction

Answers: 1.a, 2.b, 3.d, 4.d, 5.b, 6.a, 7.d, 8.b, 9.d, 10.a, 11.a, 12.d, 13.b, 14.b, 15.c, 16.a, 17.b, 18.b.

Pre-hospital treatment for blunt and penetrating neck trauma

A 23-year-old male involved in a fight receives a single stab wound to the left side of the neck. On your arrival, you note the wound is still bleeding. You also note massive swelling and an expanding hematoma. The patient coughs up blood and is notably tachycardic and tachypneic. He says he feels like he can not breathe.

You place him on high flow oxygen while continuously suctioning his airway. You establish two large bore I Vs enroute to your medical facility. Your advanced care team attempts to intubate the patient but the attempt is unsuccessful, he is medevaced elsewhere.

What would your emergency care plan be prior to transporting this patient from the scene?

 

 

 

 

 

 

 

 

 

 

Try to answer the following questions. You may need to do some research to find the answers.

1. Trauma to the neck accounts to what percentage of all major trauma cases?
  1. 1 – 2%
  2. 5 – 10%
  3. 15 – 20%
  4. 20 – 25%
2. Blunt neck trauma is most commonly caused by:
  1. Motor vehicle crashes
  2. Falls
  3. Assaults
  4. Hangings
3. The platysma muscle is located:
  1. On the lateral aspect of the neck
  2. Deep under the airway structures of the neck
  3. Superficially under the skin of the anterior neck
  4. In the posterior neck close to the spinal column
4. If an injury penetrates the platysma muscle, we consider this a:
  1. Deep space injury
  2. Thoracic injury
  3. Fatal injury
  4. Spinal cord injury
5. The proper anatomical location to perform an emergent cricothyrotomy is in the:
  1. Thyroid membrane
  2. Cricoid cartilage
  3. Cricothyroid membrane
  4. Hyoid cartilage
6. The superior aspect of the trachea lies behind the:
  1. Thyroid cartilage
  2. Hyoid bone
  3. Cricothyroid membrane
  4. Cricoid cartilage
7. Laryngeal injuries following blunt trauma are:
  1. Rare, but have a high degree of morbidity and mortality
  2. Rare and usually not associated with serious injury
  3. Common and have a high degree of morbidity and mortality
  4. Common and usually not associated with serious injury
8. Gunshot wounds to the neck commonly cause injury by all of the following except:
  1. Direct tissue injury
  2. Cavitation
  3. Shock-wave transmission
  4. Shearing force
9. The most commonly occuring type of injury following penetrating neck trauma is:
  1. Tracheal injury
  2. Vascular injury
  3. Direct blunt trauma
  4. Esophageal injury
10. Spinal cord injury would most likely be due to which of the following mechanisms?
  1. Stabbing
  2. Gunshot
  3. Direct blunt trauma
  4. Penetrating injury
11. You should determine the mechanism of injury for a patient with neck injury during the:
  1. Scene assessment
  2. Initial assessment
  3. Focused assessment
  4. Detailed assessment
12. If you her stridor when assessing the neck-injured patient, you should suspect:
  1. Constricted lower airway structures
  2. Obstruction of the upper airway
  3. Damage to lung tissues
  4. Use of accessory muscles during breathing
13. Transection of a blood vessel will cause:
  1. Numbness and tingling in the immediate area
  2. The skin in the affected area to appear blue or pale
  3. Hypoxic brain injury
  4. Subcutaneous emphysema
14. Brown-Sequard syndrome results in:
  1. Paralysis in the lower extremities
  2. Difficulty breathing
  3. Inability to speak
  4. Sensory and motor loss on the injured side
15. An injury that causes greater weakness in the upper extremities than the lower extremities is called:
  1. Central cord syndrome
  2. Anterior cord syndrome
  3. Lateral cord syndrome
  4. Posterior cord syndrome
16. If you hear swishing sounds when auscultating over the carotid arteries, what would you suspect?
  1. Dilation of the blood vessels secondary to an obstruction
  2. Increased blood flow secondary to trauma
  3. A decrease in the diameter of the blood vessels
  4. Nothing – this is the normal sound of the carotid artery
17. Which if the following injuries would be consistent with laryngeal fracture?
  1. Hoarse voice and subcutaneous emphysema
  2. Carotid bruit and wheezing
  3. Crackles and abnormally high-pitched voice
  4. Respiratory distress and crackles
18. When performing a neurological evaluation, if the patient has a serious neck injury they:
  1. Will almost always have a neurological deficit
  2. May appear to have no neurological deficit in the prehospital setting
  3. Will reliably complain of motor deficits, but no sensory deficits
  4. Won’t have any neurological complaints unless they have spinal cord injury
19. Horner’s syndrome results when there is an injury to the:
  1. Thyroid gland
  2. Stellate ganglion
  3. Trachea
  4. Carotid arteries
20. If a patient has sustained a neck injury that compromises the airway:
  1. You need to perform a surgical airway
  2. Standard intubation procedures are usually successful
  3. Intubation must be accomplished via the nasal route
  4. The airway should be managed with an oral airway and a BVM

Answers: 1.b, 2.a, 3.c, 4.a, 5.c, 6.d, 7.a, 8.d, 9.b, 10.c, 11.a, 12.b, 13.c, 14.d, 15.a, 16.c, 17.a, 18.b, 19.d, 20.d

Sight-threatining injuries

You respond to a bar frequented by a rowdy crowd. Upon arrival, you find a police officer outside, talking to a man leaning against a motorcycle. You learn that a fight has taken place and the person speaking with the police officer was the one who has been injured.

The patient is a 31-year old male who had been drinking beer and throwing darts when a fistfight broke out over a dart game. No weapons were used, but the fight rolled out into the street and several chairs were broken on the way out. The other fighter is handcuffed in the back of the police car, beating his head against the window; he may soon become a patient himself.

The original patient complains of a headache and blurred vision. He has some bruises on his face and what appears to be blood around the orbit of the right eye, but no other evident injuries. Although the patient denies cervical spinal pain, you place him in C-spine control because of his apparent intoxication and belligerence.

Once in the ambulance, you examine the patient’s right eye more closely. The orbital rim around the right eye is bruised. Blood is present over the sclera (the white part of the eye). Likewise, a small amount of blood appears to be in the eye’s anterior chamber. You check the visual acuity and note that the patient can only see fingers held close to the right eye.

The patient is transported to your local facility. From there, medevaced to a trauma center. A computed tomogram (CT) of the head and facial bones is negative. After clearance by the trauma team, an opthamologist evaluates the patient. It is found that the patient has a subjunctive hemorrhage and a Grade 2 hyphema of the right eye. The patient’s retina of the right eye cannot be completely evaluated, but it is believed a retinal detachment is possible. The patient is admitted to the hospital, placed in a bed with the head elevated and started on pain medication and a diuretic acetazolamide (Diamox). His hyphema slowly resolves over the course of a week. His visual acuity in the affected eye remains 20/100, and damage may be permanent.

What would your on scene care be for this patient:

 

 

 

 

 

 

 

 

 

 

 

Try to answer the following questions, research may be necessary to help you find the answers.

1. Which muscle is responsible for moving the eye clockwise?
  1. Inferior rectus
  2. Superior rectus
  3. Interior oblique
  4. Superior oblique
2. Which cranial nerves control the extrinsic muscles of the eye?
  1. Cranial nerves I, II, IV
  2. Cranial nerves II, III, VII
  3. Cranial nerves III, IV, VI
  4. Cranial nerves IV, V, VI
3. The transparent covering of the portion of the eye where the light enters is called the:
  1. Cornea
  2. Sclera
  3. Pupil
  4. Retina
4. The intrinsic eye muscles are contained in which layer of the eye?
  1. Fibrous tunic
  2. Vascular tunic
  3. Inner tunic
  4. Neutral tunic
5. What is the function of the retina?
  1. To convert light images into neural impulses
  2. To transmit the neural impulses to the brain
  3. To process the neural impulses to meaningful images
  4. To store the images for retrieval by the brain
6. Visual acuity is the ability to distinguish between:
  1. Light and dark
  2. Moving and stationary objects
  3. Various colors
  4. Forms
7. Covering the patient’s left eye and determining when they can see your finger as it moves from an outer limit toward their nose and into their view tests their:
  1. Visual acuity
  2. Peripheral vision
  3. Papillary reaction
  4. Depth perception
8. What is the normal position of the eyelid in relation to the eyeball?
  1. Eyelids should not cover any portion of the iris
  2. Eyelids should cover the iris as far as the pupil
  3. Eyelids should cover only the whites of the eye
  4. Eyelids should cover the upper quarter of the iris
9. Conjunctiva colored bright red suggests:
  1. An allergic reaction
  2. Infectious conjunctivitis
  3. Bleeding under the conjunctiva
  4. Shock
10. Anisocoria means:
  1. Unequal pupils
  2. Opaque covering of the cornea
  3. Glaucoma
  4. Constricted pupils
11. When you shine a penlight in the patient’s right eye, you expect the pupil of the left eye to:
  1. Constrict
  2. Dilate
  3. Be unaffected by the light
  4. Dilate, then constrict
12. A single pupil reacting sluggishly to light suggests:
  1. Opiate overdose
  2. Lesion of the pons
  3. Pressure on the ocularmotor nerve
  4. Brain death
13. Asking a patient to follow an object as you move it from a distance toward the bridge of the nose allows you to assess:
  1. For the presence of glaucoma
  2. Visual acuity
  3. Processing speed of the retina
  4. Accommodation
14. Nystagmus, or a fine jerking of the eyes:
  1. May be normal if noted at the far extremes of the field of vision
  2. Indicates opiate overdose
  3. Occurs when foreign bodies are present in the eyes
  4. Is common in patients with hypoxic brain injuries
15. What is the treatment for subconjunctival hemorrhage?
  1. Immediate surgery
  2. Release pressure on the affected eye
  3. Irrigation with saline or water
  4. No treatment is necessary
16. What types of injuries commonly occur due to blunt trauma to the eye?
  1. Hyphemas and retinal detachments
  2. Lid lacerations
  3. Corneal and conjunctival abrasions
  4. Enucleated eye
17. A hyphema is:
  1. An accumulation of blood in the posterior chamber of the eye
  2. Usually associated with penetrating trauma
  3. Treated by lowering the patient’s head to allow for proper perfusion
  4. A serious injury that could threaten the patient’s sight
18. Which of the following is a common sign of a blowout fracture?
  1. Inability to look upward
  2. Difficulty closing the eyelids
  3. Excessive tearing
  4. Blood accumulation in the anterior chamber of the eye
19. Patients with retinal detachments complain of:
  1. A sensation of flashing lights
  2. Extreme eye pain
  3. Excessive tearing in the affected eye
  4. Difficulty with near vision, but not with far vision.

Answers: 1. c, 2. c, 3. a, 4. b, 5. A, 6. a, 7. b, 8. d, 9. c, 10. a, 11. a, 12. c, 13. D, 14. a, 15. d, 16. b, 17. a, 18. a, 19. a

Smoke inhalation and acute cyanide poisoning

The family had gone to bed only two hours before the fire had started. A space heater in the living room ignited a sofa cushion, which smoldered for a period of time, emitting toxic gases even before the flames appeared. Within minutes after the flames appeared the fire spread upward sofa cushions and ignited first the draperies, then the ceiling. As the fire gained force, toxic smoke filled the room and entered the hallway. The smoke detector located down the hallway finally activated and awakened the family. Meanwhile, a neighbor saw the flame while he was walking his dog and he alerted fire and EMS.

The fire’s heat and its dense black smoke prevented the family from exiting via the stairs. When the firefighters and ambulance arrived within five minutes of the call, they had to rescue the three victims through a second-story window. All were found huddled next to the window, disorientated or unconscious, with soot in their noses and mouths. The mother and the four-year-old boy were given oxygen and transported to the hospital/health center by one of your crews. The father, who had rushed into the hall and into his son's room in an attempt to rescue the boy, went into full respiratory arrest. He had only 10% burns on his face and hands, but his condition, which initially appeared to be stabilized, rapidly deteriorated en route to the hospital/health center, despite 100% oxygen and supportive care. He died without regaining consciousness.

What would your emergency care plan be for this patient:

 

 

 

 

 

 

 

 

 

 

 

Try to answer these questions, you may have to do some research to find the answers.

1. EMS providers are most likely to encounter acute cyanide poisoning in patients who:
  1. Intentionally overdose on cyanide in a suicide attempt
  2. Are accidentally poisoned through improper food storage
  3. Are poisoned through occupational exposures
  4. Are exposed to smoke from a closed-space fire.
2. Synthetics used in manufacturing today:
  1. Are heavier than traditional building materials
  2. Ignite slowly and burn with a low intensity
  3. Burn cleanly with little toxic chemical emission
  4. Burn hotter than traditional building materials
3. Two of the most prevalent gases in smoke from most fires are:
  1. Hydrogen cyanide and carbon monoxide
  2. Carbon dioxide and hydrogen sulphide
  3. Hydrogen sulphide and hydrogen chloride
  4. Hydrogen chloride and carbon dioxide
4. Hydrogen cyanide is likely to be produced:
  1. In low temperature fire conditions
  2. In fires with high oxygen content
  3. By burning synthetic materials, never natural materials
  4. By combustion of nitrogen-containing products
5. Which of the following is true of hydrogen cyanide?
  1. Hydrogen cyanide has a distinctive smell
  2. Hydrogen cyanide is colorless
  3. Hydrogen cyanide impairs muscular ability but not cognitive function
  4. Hydrogen cyanide plays no role in early fire-related deaths
6. Cyanide in the body:
  1. Is not metabolized – it must be removed with blood filtration
  2. Is metabolized less efficiently by patients with liver disease
  3. Remains active until an antidote is delivered
  4. Only presents a problem if CO is present
7. HbCO (carboxyhemoglobin) is a measure of:
  1. The interaction between cyanide and carbon monoxide
  2. Cyanide levels in the blood
  3. Carbon monoxide poisoning
  4. Cyanide levels in the air
8. Sub-lethal concentrations of cyanide can lead to:
  1. Rapid incapacitation
  2. Minor changes in alertness
  3. Changes in mental status, but are rarely life threatening
  4. Few changes in patient condition unless concentrations increase
9. Cyanide poisoning is especially likely in those patients who:
  1. Were in open air fires
  2. Have hypertension following exposure to smoke
  3. Have a normal level of consciousness following an enclosed space fire
  4. Have soot in their nose and mouth
10. Which of the following is typical of low concentration cyanide poisoning?
  1. Stupor
  2. Headache
  3. Tremors
  4. Respiratory depression
11. Organs most commonly affected by cyanide poisoning include the:
  1. Lungs and heart
  2. Liver and kidneys
  3. Heart and brain
  4. Stomach and intestines
12. Cyanide causes toxicity by:
  1. Blocking the release of neurotransmitters
  2. Deactivating the mechanism by which cells use oxygen
  3. Releasing histamine
  4. Causing cells to rapidly use all available oxygen
13. Patients with cyanide poisoning should be:
  1. Intubated only if they are in cardiac arrest
  2. Intubated if they cannot maintain their own airway
  3. Managed without intubation due to [potential damage to the trachea
  4. Managed with low flow oxygen to slowly restore oxygen levels
14. Known metabolic acidosis due to cyanide poisoning should be treated with:
  1. Vasopressors
  2. Anticonvulsants
  3. Epinephrine
  4. Sodium bicarbonate
15. Which medication from the cyanide poisoning antidote kit should not be administered in the prehospital setting?
  1. Amyl nitrate
  2. Thiosulphate
  3. Sodium nitrate
  4. Atropine

Answers: 1.d, 2.d, 3.a, 4.a, 5.b, 6.c, 7.b, 8.a, 9.c, 10.b, 11.c, 12.b, 13.b, 14.d, 15.c