NREMT critical thinking Flashcards
You have a 45-year-old patient with an altered mental status and minimal information or history available on-scene. List several potential causes of altered mental status.
Stroke, diabetes, seizure, overdose, fainting, cardiac and many others.
Being able to think of possible causes is helpful to provide ideas on what physical examinations to perform and which history questions to explore.
Your patient has increasing intracranial pressure. Would you expect the pulse pressure to widen or narrow?
When intracranial pressure increases, pulse pressure widens. An example is a blood pressure initially of 142/90 (pulse pressure of 52) and a second blood pressure of 186/100 (pulse pressure of 86).
Why would a patient who has worsening asthma stop wheezing?
Remember that wheezing is the sound of air being forced through narrowed air passages.
Wheezing stops for two reasons. The good reason is when the bronchoconstriction improves. This may be the result of an inhaler or nebulized medication. Wheezing diminishes when the airways dilate.
The bad reason is when the airways have become so narrow hardly any air can move through them. This patient is critical and will require ventilation.
Your patient’s first set of vital signs were:
P 76, R 20, BP 134/78, skin warm and dry, pupils equal and react to light.
The second set of vital signs are:
P 62, R 24, BP 170/96, skin warm and dry, pupils sluggish but react to light.
What is the patient’s likely problem?
This patient appears to be developing increasing intracranial pressure. The pulse has dropped, blood pressure went up and the pupils became sluggish.
This could be from trauma or from a medical problem (e.g. hemorrhagic stroke or tumor).
You would likely also see a decrease in mental status between these two sets of vitals.
One of your instructors tells you to suction for no longer than 15 seconds. Another tells you that you may have to suction for longer if vomit is present. Who do you agree with?
There are times you may have to suction for longer than 15 seconds. It isn’t ideal but it is probably better than bagging vomit into the lungs.
There is no easy answer–and sometimes educators don’t agree.
The best answer is to suction quickly and efficiently and ventilate as soon as possible to limit both hypoxia and aspiration.
Your respiratory distress patient has a history of COPD and congestive heart failure (CHF). He has a prescribed rescue inhaler.
Which condition is this rescue inhaler prescribed for?
How would you determine whether the patient has the condition the inhaler is prescribed for?
The inhaler is prescribed for bronchoconstriction that occurs with COPD.
The second part of the question can be challenging–even in the hospital.
When COPD exacerbates (or worsens) it may be as a result of a respiratory infection. This may result in cough, fever and mucus production. Lungs sounds may be loud and rattly (rhonchi).
CHF may result in edema in the ankles or lower back, weight gain and jugular venous distention. Depending on the extent of the congestion in the lungs you may hear rales or crackles–especially in the lower lung fields.
Both will present with dyspnea on exertion and orthopnea. Both can present with wheezing (CHF more in the initial stages).
The patient may provide information in reference to what problem is the issue (e.g. what he has been seen by a physician for recently, which is more severe or problematic). You should also contact medical direction for advice or clarification–even if not required by protoc
Carbon monoxide is a colorless, odorless gas. How would you determine it may have caused your patient’s condition?
Multiple patients complaining of illness at the same time is one situation you should suspect CO. Another is a situation where exposure is possible (heating season, exhaust nearby, fire, new heat source, etc.). CO poisoning patients often present with flu-like symptoms or fatigue.
There are pulse oximeters on the market that also detect carbon monoxide attached to hemoglobin (carboxyhemoglobin).
Why does a patient who faints regain consciousness after he falls to the ground?
Fainting is usually caused by reduced blood flow to the brain. The patient “passes out” to a recumbent position which makes it easier to perfuse the brain and restore consciousness.
Why can’t you develop shock from a closed head injury?
You can’t develop shock from a closed head injury because the cranium is a closed space and there is no place for the blood to go.
It only takes about 50 - 75ml of blood to begin to put pressure on the brain. Death would occur from the brain compression caused by a subdural hematoma long before the patient lost enough blood to develop shock.
You are called for a patient with an “allergic reaction.” The patient is holding an epinephrine auto-injector asking, “Should I use it?”
How would you decide?
Not all allergic reactions are life-threatening. You would only administer the auto-injector if the reaction was anaphylaxis. This is determined by two main life threats:
Respiratory involvement - a threat to close the airway. This may be felt as tightness, hoarseness or wheezing. You may also see swelling around the neck, lips, tongue and face.
Hypoperfusion - signs of shock including rapid pulse and breathing, low blood pressure and altered mental status.
You are treating a patient with signs of stroke and a blood glucose of 42mg/dL. Do you administer glucose?
Yes. While glucose should be avoided in stroke, it should be administered in hypoglycemia. There are times that hypoglycemia can mimic stroke symptoms. Even in the event of stroke, the blood glucose should be brought to normal, but not elevated, levels.
Your critical trauma patient requires ventilation. You are unable to maintain an airway and ventilate using the jaw thrust. What should you do?
If you have tried to use a jaw thrust but can’t ventilate your patient you would next use a head-tilt, chin lift. Even though this may aggravate a spinal injury, not being able to ventilate is worse.
The jaw thrust is a difficult technique and is best performed with two rescuers.
Your patient’s pulse and respirations have increased. The skin is cool and moist. What is the most likely cause of this?
Shock.
Note that blood pressure wasn’t included. Decreasing blood pressure is a late sign of shock (hypoperfusion).
There is limited history available for your patient with an altered mental status. You believe it is the result of a medical condition.
List several possible causes of altered mental status and one way to test for each.
This concept (sometimes called differential diagnosis) is critical to the EMT in order to provide accurate assessment and care. By thinking of possible causes of the patient’s condition you will have a better idea what to ask the patient–and what to assess for.
Some examples in this case:
Diabetes - blood glucose monitoring
Stroke - stroke scale
Seizure - evidence of incontinence, injury from the seizure or a post-ictal presentation
Alcohol or drugs - breath odors, paraphernalia at scene, pinpoint pupils, track marks, vital signs
Cardiac - ask about palpitations, chest pain or discomfort and difficulty breathing. Check vital signs.
Hypoxia or hypovolemia - check circulation (pulse, skin color, temperature and condition), oxygen saturation, blood in vomit or stool.
Although you suspect a medical problem you should also be alert for trauma (e.g. a head injury) which could cause the symptoms.
When speaking with online medical control you receive an order that you believe includes an improper dose. What should you do?
Confirm the order with the physician before administering any medication. If you believe the order may be in error you should respectfully express your concern to the physician and ask for clarification.
