Critical Thinking Exercises

Question 1

i-STAT indicates a Hgb 6.2 and Hct 21.2. Your patient has had bright red rectal bleeding for 2 days. BP 60/40 HR 140 RR 14 T 96.9. List diagnoses for this patient.

Answer 1

Anemia, gastrointestinal bleeding, hypothermia, hypovolemic shock

Question 2

You are preparing a patient for interfacility transport. Prior to leaving the facility you must dress the large amount of partial thickness burns. What dressing should you use?

Answer 2

Dry sterile dressings

Question 3

A patient presents with chest pain three days ago that eventually subsided, however, the patient complains of just not feeling right. Cardiac enzymes reveal CK 654 CK-MB 10 and Troponin 0.01. What do you suspect occurred based on these results.

Answer 3

The patient suffered a myocardial infarction three days ago

Question 4

You are transporting a patient with a needle cricothyrotomy for an airway and you observe the neck circumference is beginning to increase in size. What is the likely cause?

Answer 4

The catheter tip has become dislodged from the trachea

Question 5

Which type blood should be available on hand when expecting a trauma patient?

Answer 5

Type O negative

Question 6

Prior to electively intubating your conscious patient, you assess the Mallampati Classification System and visualize the tonsils, uvula, and soft palate. What is their Mallampati score?

Answer 6

Class I

Question 7

Upon intubating a patient you choose to utilize a colorimetric end-tidal CO2 detector to evaluate proper tube placement. The color on the detector remains purple. What should the critical care paramedic do?

Answer 7

Reintubate since the endotracheal tube is not in the trachea

Question 8

During transport of a patient with an intraaortic balloon pump (IABP) you observe blood in the connecting tubing. What do you believe to be the problem and what should be your first course of action?

Answer 8

The balloon has ruptured and the counterpulsation should be stopped immediately to prevent emboli

Question 9

While reviewing lab and radiology results prior to transferring a patient, you observe the following results: WBC 22,000, Na+ 157 BUN 30, Cr 1.0. Upon looking over the x-ray image you observe a white out in the left lung base. What do you suspect is the diagnosis?

Answer 9

Pneumonia

Question 10

Which central venous catheter is preferred in a trauma patient, triple lumen catheter or introducer? Why?

Answer 10

Introducer which is a single lumen large-bore catheter that allows for more rapid volume resuscitation as compared to a triple lumen catheter

Question 11

You are present while a physician places a central venous catheter prior to transportation of your mechanically ventilated patient. What ventilator adjustment can facilitate preventing the complication of a pneumothorax during insertion?

Answer 11

Decreasing the tidal volume so that the apex of the lung is not maximally inflated to where the needle is being inserted into the thorax

Question 12

After being evaluated for six hours in the emergency department, a patient now has the following cardiac enzyme results: CK 565, CK-MB 16, Troponin I 4.6. What is your diagnosis?

Answer 12

Non-ST-elevated myocardial infarction

Question 13

Upon approaching a patient involved in a motor vehicle crash, you observe the patient’s eyes are closed until you apply deep nail bed pressure, they pull their arm away, and their speech is incomprehensible. What Glasgow Coma Scale would you assign to this patient?

Answer 13

8

Question 14

A patient with a history of COPD is being transferred for acute myocardial infarction. His vital signs are as follows: BP 102/62, HR 116, PAP 34/22, PAWP 20 mmHg, RAP 12 mmHg, CI 2 L/min/m2. Dobutamine has been started. What would you anticipate if the dobutamine is working?

Answer 14

Increase in heart rate

Question 15

You are transporting a trauma patient to a Level I Trauma Center. Assessment reveals a new finding of Grey Turner’s sign. Where do you suspect the patient’s injury is?

Answer 15

Retroperitoneal

Question 16

You have determined that your intubated patient has a leak in the endotracheal cuff. What adjunct can be utilized to facilitate reintubating the patient with a new endotracheal tube?

Answer 16

Gum elastic bougie or Eschmann tracheal tube

Question 17

List treatment interventions for a patient in sickle cell crisis.

Answer 17

Oxygen therapy, IV therapy, intravenous pain management

Question 18

Your mechanically ventilated and paralyzed trauma patient begins eliciting signs of tachycardia, hypotension, and increased airway pressures. What is a possible cause of such findings?

Answer 18

Pneumothorax

Question 19

What is often the drug of choice to anesthetize pediatric patients and facilitate with procedures?

Answer 19

Ketamine

Question 20

While transporting a patient with an arterial line you observe the hand distal to the site become blanched and cool to touch. What should you do to trouble shoot this complication?

Answer 20

Remove the arterial line and hold direct pressure for 5-10 minutes until bleeding has stopped

Question 21

A patient with a history of liver cirrhosis presents with altered mental status. While awaiting the bloodwork results, what do you predict the ammonia level to be, low or high?

Answer 21

High

Question 22

You are transporting a patient from the emergency department to a hospice care facility for end of life. What continuous intravenous medication should you be prepared to manage?

Answer 22

Morphine

Question 23

Which valve must the pulmonary artery catheter pass through to reach the right ventricle?

Answer 23

Tricuspid valve

Question 24

A patient presents with excruciating epigastric pain and nausea. History reveals the patient drank excessively yesterday and has not been feeling well since. You suspect the patient is suffering from pancreatitis. What two lab values will be elevated?

Answer 24

Amylase and lipase

Question 25

A six year old child presents with tachypnea, drooling, and 102.5F fever. Caregiver states the signs and symptoms began suddenly approximately 30 minutes ago. What do you suspect is wrong with the child?

Answer 25

Epiglottitis

Question 26

Metoprolol (Lopressor) administration is the standard of care in acute coronary syndrome however your patient’s heart rate is 56. Why should you not administer the medication in this scenario?

Answer 26

Metoprolol (Lopressor) is a beta blocker and would lower the heart rate even further

Question 27

A female patient presents as four months gestation with bright red vaginal bleeding. She is awake and alert with a BP 80/48 HR 128 RR 18 SpO2 96%. What treatment should you provide to this patient?

Answer 27

High-flow oxygen, intravenous fluid bolus, cardiac monitoring, frequent reassessment of interventions, repeat fluid bolus as deemed appropriate

Question 28

An 18 year old male complains of sudden onset left groin pain and scrotal edema. What is likely to be the cause?

Answer 28

Testicular torsion

Question 29

A two month old child has had diarrhea for four days, is lethargic, and hypotensive. Which acid-base imbalance is most likely?

Answer 29

Metabolic acidosis

Question 30

A pregnant female is determined to be AB negative. What medication must this patient receive prior to delivery?

Answer 30

Rhogam

Question 31

Your patient is showing signs of heart failure and cardiogenic shock. You are transferring them on a dobutamine drip at 5 mcg/kg/min. Hemodynamic monitoring reveals the following: BP 88/58, RAP 8 mmHg, PAP 40/20 mmHg, PAWP 21 mmHg, SVRI 2500 dynes/sec/cm-5/m2, CI 1.8 L/min/m2. How should you titrate the dobutamine?

Answer 31

Increase the dobutamine

Question 32

A 26 year old female presents with sudden onset of delusions, pacing with head down looking at the floor, and thought that is difficult to follow. What is likely to be her psychological emergency?

Answer 32

Schizophrenia

Question 33

While attempting to intubate a large patient with a short neck and what appears to be an extremely anterior trachea, what maneuver may be utilized to facilitate visualization of the vocal cords?

Answer 33

BURP maneuver

Question 34

Enroute interfacility, your patient on a mechanical ventilator setting of pressure support becomes grossly restless and agitated requiring sedation and paralysis to protect the airway. What ventilator adjustment is imperative?

Answer 34

Changing the mode from pressure support to assist control since the patient is paralyzed and no longer able to initiate breaths.

Question 35

Upon receiving report for a transfer of a head injury patient to a Level I Trauma Center, the referring facility lists a cooling blanket as a part of the equipment necessary for transport. Why would this equipment be necessary?

Answer 35

To help manage cerebral edema and metabolic rate

Question 36

A patient begins complaining of shortness of breath and has runs of ventricular tachycardia. Hemodynamic monitoring reveals the following: BP 102/62, HR 112, RAP 8 mmHg, PAWP 22 mmHg, CI 1.8 L/min/m2, SVRI 3300 dynes/sec/cm-5/m2. What compensatory mechanism did not activate in this patient?

Answer 36

Increased contractility

Question 37

When attempting to obtain a pulmonary artery wedge pressure, where must the balloon lodge?

Answer 37

In a branch of the pulmonary artery

Question 38

During transport to a cardiovascular lab, your acute myocardial infarction patient begins oozing from their IV site. The patient is currently receiving nitroglycerin, heparin and oxygen . Which medication from the list included is causing the hemorrhage?

Answer 38

Heparin (anticoagulant)

Question 39

Your patient is entrapped from a MVC. You have access to the seated patient from the rear compartment. What is your best intubation option?

Answer 39

Digital intubation

Question 40

During transportation of your mechanically ventilated patient, your patient becomes restless, biting the endotracheal tube, and asynchronous with the ventilator causing poor delivery of tidal volume. What medications should you consider?

Answer 40

Sedative and neuromuscular blockade agent

Question 41

During transport of a status post thoracotomy patient with bilateral chest tubes, you observe that the waterseal drainage system no longer has a steady flow of air bubbles in the chamber. How do you troubleshoot this equipment malfunction?

Answer 41

Check the wall suction to ensure it is on and at the correct setting. Check the suction tubing to ensure it is still properly attached to the drainage system.

Question 42

While transporting a status post trauma arrest to a Level I Trauma Center, you observe the end-tidal CO2 begin to decline. What does can this imply?

Answer 42

Impending cardiac arrest

Question 43

Which valve must the pulmonary artery catheter pass through to reach the pulmonary vasculature?

Answer 43

Pulmonic valve

Question 44

During transport your patient’s peripheral intravenous site accidently becomes dislodged and you are unable to successfully restart a peripheral site. However, the patient does have an existing triple lumen catheter. Why is it important to aspirate and discard 10cc of blood before utilizing the line?

Answer 44

You are unsure what the lumen of the access device is dwelled with (i.e. heparin) and therefore do not want to bolus the patient with whatever lies in the lumen of the device

Question 45

A patient is diagnosed with an intracranial bleed. The INR value is 6.8. What blood component should be considered for administration?

Answer 45

Fresh frozen plasma

Question 46

While transporting a patient on a mechanical ventilator, the high pressure alarm is frequently triggered. What are the potential causes for this alarm?

Answer 46

Kinked ventilator circuit, patient coughing during inspiration, bronchospasm, increased secretions

Question 47

You are transporting a pregnant, eclamptic patient on a magnesium sulfate drip. The infusion bag is labeled as having 4g of magnesium sulfate. Is this an appropriate dose?

Answer 47

Yes.

Question 48

During transit of a patient suffering from an acute myocardial infarction, you observe the following: HR 114, RR 22, BP 88/48, CI 1.9 L/min/m2, PAWP 20 mmHg, SVR 2000 dynes/sec/cm-5. What is the overall goal with your treatment?

Answer 48

Increase myocardial perfusion

Question 49

While at the bedside in the emergency department assisting a physician with endotracheal intubation, several attempts at placement have failed. What should you prepare for next?

Answer 49

Blind Insertion Airway Device (BIAD) and/or Surgical airway

Question 50

You are transporting a neonate with respiratory distress syndrome. While on a nonrebreather mask with high flow oxygen, you observe the pulse oximetry reading decline to 88%. What steps will you take to correct the desaturation?

Answer 50

Ensure the oxygen source and adjunct are functioning properly. Assess the airway for occlusion. Assess the breathing and respiratory effort to ensure it is efficient. Positive pressure ventilation and intubation as necessary

Question 51

i-STAT reveals an elevated CK total. Clinically the patient was found on the floor after falling two days ago. She has nausea, vomiting, muscle aches, and tea-colored urine. What do you suspect to be a potential diagnosis?

Answer 51

Rhabdomyolysis

Question 52

What is your treatment for a 55 year old patient complaining of bright red rectal bleeding for 2 days. BP 60/40 HR 140 RR 14 T 96.9?

Answer 52

High-flow oxygen, intravenous fluid bolus, cardiac monitoring, warming measures, frequent reassessment of interventions, repeat fluid bolus as deemed appropriate. Type and cross for blood product administration