FISDAP OKC STUDENT Missed Test Questions

Question 1

Managing Chronic Bronchitis and Emphysema

Specifically know what is the initial treatment of a pt with Chronic Bronchitis

Answer 1

The goal of treating emphysema or chronic bronchitis is to relieve hypoxia and reverse any bronchoconstriction.

Remember that these pts may be dependent on a hypoxic respiratory drive (their decreased levels of O2 stimulate respiration actions instead of a high CO2).

First treat with establishing an airway and then positioning them in a seated or semi-seated position to help the accessory muscle use.

Low flow O2 with a NC or CPAP with a peep of 10cm/H2O should be used and if medication is needed you may use:

• Bronchodilator (albuterol, levalbuterol, or metaproterenol)
• Ipratropium Bromide (Atrovent) to dry secretions (this is an anticholinergic drug)
• Corticosteroids for longer lasting relief

Question 2

Indications for CPAP

Answer 2

Remember CPAP can only be used on a pt who is alert and able to follow commands.

CPAP helps to keep the upper airway structures open, which is especially beneficial for people with sleep apnea caused by a relaxation of upper airway structures that leads to blockage

It is helpful to reduce the work of breathing for pts with COPD or CHF, as well as infants that may have bronchiolitis or pneumonia. This can also be helpful for pts who are breathing too fast.

Question 3

Physiology of the Pulmonary System

Answer 3

The upper airway parts are:

• Nasal Cavity
• Pharynx (Naso, oro, and Laryngopharynx)
• Larynx (Has 3 pieces of cartilage top to bottom is thyroid cartilage (arytenoid), cricoid (corniculate), and epiglottis (cuneiform); there are 2 folds within the larynx the Vestibule (false vocal chords) and the lower pair that are the True vocal chords)

The lower airway parts are:

• Trachea (composed of C shaped cartilaginous rings carina, has cilia to move particles up, stimulation will cause coughing reflex, but damage from things like smoking can reduce this reflex)
• Bronchi (L.&R. mainstem bronchi (R. stem is more straight while the left angles off), Lobar bronchi, segmental bronchi, bronchioles)
• Alveoli (from bronchioles to alveolar ducts, to alveolar sacs, to alveoli; respiratory membrane is made up of alveolar lining, supportive tissue, and the capillaries; physiologic shunt refers to blood that passes by alveoli without gas exchange b/c not all alveoli are recruited at the same time)
• Lungs (R. lung has 3 lobes, L. lung has 2 lobes; covered by connective tissue called pleura which attaches at the Hilum; the visceral pleura covers the lungs and does not have nerve fibers, the parietal pleura lines the thoracic cavity and has nerve fibers)

Medulla (lower part of brain stem) controls ventilation!

Question 4

Signs and symptoms of Pneumonia

Answer 4

• Pneumonia is an infection of the lungs, bacterial or viral. It is primarily a ventilatory disorder caused by inflammation and fluid accumulation in the alveoli.
• At high risk include those with immunodeficiencies, alcoholics, smokers, and exposure to cold temps; basically anything that defects mucus production and/or ciliary action
• Pt will show signs and symptoms of:
  Appear ill, gen weakness, malaise
  Fever/Chills
  Deep, PRODUCTIVE cough with yellow/brown sputum that can sometimes be tinged with blood
  Pleuritic chest pain
  Tachypnea/Tachycardia
  Crackles (rales) but wheezing or rhonchi can sometimes be heard

- Management:
Place in position of comfort
Supp O2, vent or intubate as needed
IV access and fluids as needed
Beta agonist
Antipyretic

Question 5

Signs and Symptoms of Pulmonary Edema

Answer 5

• Shortness of breath
• cough, with pink frothy sputum
• decreased exercise tolerance
• chest pain
• excessive sweating
• anxiety and restlessness
• feelings of suffocation
• pale skin
• Crackles (rales)
• rapid or irregular heart rhythm (palpitations)
• fatigue
• nocturnal dyspnea
• pedal or leg edema
• rapid weight gain from excess fluids

Question 6

Suctioning a pt with trismus

Answer 6

You just RSI them

Question 7

Treating a pt with a stoma

Answer 7

The most common problem with them is a mucus plug forming in the internal cannula b/c of a reduced coughing reflex. To solve this just remove the internal cannula and clean it, DO NOT REMOVE THE EXTERNAL CANNULA.

If the external cannula becomes dislodged you can use the largest size ET tube that will fit fast the stoma, insert 1-2cm past the end and inflate the tube, ensuring comfort and patency.

If bleeding at a stoma site occurs it is not a big deal if it is external but internal bleeding requires transport.

Some other questions that have popped up is how to ventilate with a stoma in place. Just remember that the mouth and nose must be closed in order to ventilate through one and it is best done with a Pediatric mask but an ADULT bad.

Question 8

Identifying and treating v-tach

Answer 8

Rules for V-Tach:
Regularity - Regular
Rate - 100+
P waves - none
PRI - none
QRS - 0.12+ (wide)

ACLS:

• Heart rate must be above 150 before major treatment
• IF SYMPTOMATIC:
  a) Synchronized cardiovert (consider sedation but do not prolong care if it is needed)
  b) if regular and NARROW complex, consider adenosine (6,12,12)
• IF NOT SYMPTOMATIC: IS IT WIDE?
  a) if YES then, Adenosine (6,12,12)only if also regular and monomorphic; next move to antiarrhythmic procainamide IV (20-50mg/min), Amiodarone (150 over 10min), or Sotalol (100mg over 5 minutes), next move to expert consultation
  b) if NO then, vagal maneuvers (if regular), then Adenosine (if regular), then B-Blocker or CCB, then expert consultation

Question 9

Anatomy and Physiology of the Cardiovascular System

Answer 9

Anatomy and Physiology of the Cardiovascular System on pg 53 vol.3

Question 10

Identify and treat SYMPTOMATIC Bradycardia

Answer 10

RULES: (if sinus)
regularity - regular
rate - less than 60
P waves - 1 per QRS
PRI - 0.12-0.20sec
QRS - less than 0.12sec

ACLS:

• Must be under 50bpm
• SYMPTOMATIC?
• if NO then monitor and observe
• if YES then Atropine (1mg every 3-5min up to 3mg); if Atropine is ineffective then move to TCPacing and/or dopamine (5-20mcg/kg/min) or epinephrine infusion (2-10mcg/min)

Question 11

Medication for Cardiac Arrest

Answer 11

• Epinephrine 1mg every 3-5min (remember only epi for asystole or PEA)
• Amiodarone 300mg then 150mg, max 450mg
• Lidocaine 1-1.5mg/kg then 0.5-0.75mg/kg for 2nd dose

Question 12

Risk Factors for Strokes

Answer 12

From Book:

• Hypertension (the biggest one)
• A-Fib (second biggest one)
• Middle aged and older patients due to disability
• Atherosclerosis
• Heart disease

From Online:

• Diabetes
• Smoking
• Birth Control Pills
• History of TIAs
• High counts of RBCs, cholesterol, or lipids

Question 13

Signs and Symptoms of a stroke

Answer 13

• Facial Drooping
• Headache
• Confusion and agitation
• Dysphasia (difficulty speaking)
• Aphasia (cannot speak)
• Dysarthria (impairment of tongue and muscles essential for speech)
• Vision Problems
• Hemiparesis (one sided weakness)
• Hemiplegia (paralysis of one side)
• Paresthesia (numbness or tingling)
• Inability to recognize by touch
• Gait disturbances
• Dizziness
• Incontinence
• Coma

Question 14

Treating a pt with unstable angina

Answer 14

Angina = “pain in the chest”
Occurs when the heart’s blood supply is transiently exceeded by myocardial O2 demands. This can result from atherosclerosis (mostly) or Prinzmetal’s angina (vasospastic angina).

Stable angina occurs during activity when the O2 demands of the heart are increased, this is often precipitated by physical or emotional stress and responds readily to treatment.

Unstable angina occurs at rest and may not readily respond to treatments. B/c this is often caused by severe atherosclerosis it is often also called Preinfarction angina.

To treat angina, place in a position of rest and administer O2, then without delay in transport get a 12 lead and start an IV. Next administer Nitro as this will decrease the heart’s workload and may have some dilatory effects on the coronary arteries. IF the pts pain persists after Nitro then consider using a CCB as a vasodilator. If chest pain still persists after Nitro and a CCB then try Morphine or Fentanyl. Aspirin may also be a good idea in the thoughts of reducing any damage by the possibility of an MI especially if CP is refractory to treatment.

If the Angina is new in onset or persists after O2 and Nitro then the pt needs to be immediately transported.

Question 15

How to communicate with a pt that has a language barrier

Answer 15

• Never assume the person lacks intelligent
• Do not rush the pt or predict the answer
• Try to form questions that require a short, direct answer
• Prepare to spend extra time during your interview
• If you did not understand the pt politely ask them to
  repeat the question

Question 16

Components to a complete scene size up

Answer 16

• Standard precautions
• Scene safety
• Resource determination
• Location of patients
• MOI/NOI

Question 17

SOAP

Answer 17

Subjective: (SYMPTOMS not signs) What the patient says about the complaint/problem and interventions. EX. Chief complaint, history of present illness, history, review of systems, current meds, allergies.

Objective: (SIGNS not symptoms) the factual observations EX. vital signs, physical exam findings, lab data, imaging results, diagnostic data, review of documentation from other doctors

Assessment: problem, differential diagnosis

Plan: details the need for additional testing

Question 18

Positioning vehicle at a scene

Answer 18

Park at least 100ft uphill and upwind from a hazardous scene

If there are no fire, fluids, or fumes that could be
hazardous you can park 50ft away PAST THE WRECKAGE

If you are first on scene park in front (with the wreck in front of you) of the wreckage so that your lights may be seen. If you are second then park beyond the wreckage (with the wreck behind you) to protect yourself and your vehicle.

Question 19

Assessing an adult with abdominal pain

Answer 19

• Often the positioning and general appearance will tell you a lot. Often if severe they will be still and in the fetal position (moving around will increase pain).
• Visually inspect before auscultating, palpating, or moving the pt
• Auscultate before palpating (starting furthest away from affected area and doing affected area last)
• Palpate with gentle pressure to feel for muscle tension, loss of muscle tone, rebound tenderness, pulsation, ect.; also start furthest away from affected area last and move towards it doing the affected area last.
• Look for Cullen’s Sign (ecchymosis around the belly button) and Grey Turner’s Sign (ecchymosis on the flanks)

Question 20

Effects of alcoholism on the CNS

Answer 20

• Contracts brain tissues
• Destroys brain cells
• Depresses the central nervous system.
• Problems with cognition and memory
• Alcohol interacts with the brain receptors, interfering with the communication between nerve cells, and suppressing excitatory nerve pathway activity

From the book:
- it interferes with the intake, absorption, and use of thiamine (this can cause Wernicke’s Syndrome - acute but reversible encephalopathy, or brain disease, characterized by ataxia, eye muscle weakness, and mental derangement; or Korsakoff’s Psychosis - a memory disorder that may be irreversible)

(Remember that alcoholic pts may need thiamine and D50)

Question 21

Pathophysiology of an over stimulated Autonomic NS

Question 22

S&Ss of Hypoglycemia

Answer 22

• AMS is the biggest/most important, often showing as confusion
• early stages may show restlessness, impatient, or hungry
• As it falls it may become inappropriate anger or bizarre behavior
• At extreme lows it may result in seizures or coma
• Physical exam findings may include: diaphoresis and tachycardia

SYMPTOMS WILL BE ACUTE IN ONSET

Question 23

Assisting with a normal delivery

Answer 23

PREPARATION:

• Don sterile gloves, gown, and face shield/goggles
• Set up delivery area out of public view, if there is time drape a towel over the mother, place a towel under the butt, one under the vag opening, and another across the lower abdomen
• Give the mother O2 via NC and if you can start an IV with open fluids if possible
• Place pt with knees and hips flexed with butt slightly elevated
• Monitor fetal heart tones until crowning (if drops below 90 transport immediately in L. Lateral recumbent)

DELIVERY:

• Coach mom to breath deep between contractions and push with contractions
• IF THE BABY DOES NOT DELIVER AFTER 20 MINUTES OF CONTRACTIONS EVERY 2-3MIN THEN TRANSPORT IMMEDIATELY
• As crowning begins, control head with gentle pressure (this helps prevent perineal tearing or fetal intracranial injury from a precipitous delivery)
• As the head comes out support it as it turns, if you note the bag of waters has not ruptured, tear it open with your fingers
• Gently run your fingers along the head and neck to check for a nuchal chord (remember that you can clamp and cut a nuchal chord if it prevents delivery, just NOT a prolapsed chord)
• After the head is delivered tell the mother to pause pushing for a moment before continuing; once she starts again guide the child’s head DOWN to help deliver the UPPER shoulder and then upward to deliver the lower shoulder; DO NOT PULL!

POST DELIVERY:

• Keep the baby at the vaginal level to prevent over or under transfusion of blood
• DO NOT MILK OR PULL THE CHORD
• To cut the chord: place first clamp about 10cm from the baby, place the second 5cm above the first, then cut between them.
• You should then immediately dry the baby with a towel and wrap them in blankets or give to mom to place on her chest to give warmth
• Wait for placental detachment which will cause the chord to lengthen, after delivery of the placenta, place it in a plastic bag and bring to hospital, they will check to make sure no parts were left in the mother that may cause infection.
• Now massage the uterine fundus by placing one hand immediately above the pubic symphysis and the other on the fundus, continue massage until the uterus assumes a woody hardness. Placing the baby on the mother’s breast can also stimulate uterine contractions
• Check the mother’s perinium for tearing, if there is then apply firm pressure with gauze.
• If bleeding continues postpartum, you can administer Oxytocin (Pitocin) to facilitate contraction to help

Question 24

Manifestations of Pregnancy Induced Hypertension

Answer 24

• PREECLAMPSIA: (most common)
  Preeclampsia is defined as an increase in systolic by 30mmHg and diastolic of 15mmHg above baseline on at least 2 occasions within 6 hours of each other. If there is no baseline, then 140/90 or higher is considered hypertensive. (REMEMBER that hypotension is normal in early and late pregnancy, so a normal 120/80 might by hypertensive if the pt had like 90/75 before at rest. Preeclampsia is normally seen in the last 10 weeks or 48hours postpartum. It can be MILD (hypertension, edema, and protein in urine) or SEVERE (BP of 160/110 or higher, generalized edema, and spiked protein in urine). It is thought to be caused by vasospasms which causes a decrease in placental blood flow.
• ECLAMPSIA:
  This is preeclampsia but with seizure activity (general tonic-clonic) that has occurred secondary to the hypertension. Pain in the upper right quadrant and visual disturbances typically are signs of an impending seizure. Risk of fetal mortality raises by 10% with each seizure.
• CHORNIC HYPERTENSION:
  is when the mother has 140/90mmHg BP preceding pregnancy, prior to the 20th week, or if it lasts more than 42 days postpartum. As a general rule, if the diastolic is above 80 during the second trimester, chronic hypertension is likely
• CHRONIC HYPERTENSION SUPERIMPOSED W/ PREECLAMPSIA:
  Self explanatory
• TRANSIENT HYPERTENSION:
  A temporary rise in BP that occurs during labor or early in postpartum and NORMALIZES WITHIN 10 DAYS

Question 25

Predispositions for antepartum bleeding

Answer 25

• Advanced Maternal Age
• Previous C Sections
• Previous abortions
• Hypertension
• Multiparity

Question 26

Treating a pregnant pt with a traumatic injury

Answer 26

Because of the changes in the circulatory system (increase in circulating blood) you should anticipate the development of shock based on the MOI rather than waiting for S&Ss of shock because they may not appear till late in the process after there has already been injury or death of the fetus.

Syncope and falls can be common b/c the gravid uterus can compress the inferior vena cava reducing blood return (supine hypotension syndrome) and the excess anterior weight of the belly can change their gait.

Management include:

• C-spine & long back board
• Admin O2 if hypoxic
• Initiate 2 large bore IVs for fluid admin
• Transport tilted to the left to minimize supine hypotension
• Reassess frequently
• monitor fetus

Question 27

Differentiating types of traumatic brain hemorrhages (pediatric)

Answer 27

EPIDURAL Hematoma:
Patients with epidural hematoma report a history of a focal head injury such as blunt trauma from a hammer or baseball bat, fall, or motor vehicle collision. The classic presentation of an epidural hematoma is a loss of consciousness after the injury, followed by a lucid interval then neurologic deterioration. This classic presentation only occurs in less than 20% of patients. Other symptoms that are common include severe headache, nausea, vomiting, lethargy, and seizure.

SUBDURAL Hematoma:
A history of either major or minor head injury can often be found in cases of subdural hematoma. In older patients, a subdural hematoma can occur after trivial head injuries including bumping of the head on a cabinet or running into a door or wall. An acute subdural can present with recent trauma, headache, nausea, vomiting, altered mental status, seizure, and/or lethargy. A chronic subdural hematoma can present with a headache, nausea, vomiting, confusion, decreased consciousness, lethargy, motor deficits, aphasia, seizure, or personality changes. A physical exam may demonstrate a focal motor deficit, neurologic deficits, lethargy, or altered consciousness.

SUBARACHNOID Hemorrhage:
A thunderclap headache (sudden severe headache or worst headache of life) is the classic presentation of subarachnoid hemorrhage. Other symptoms include dizziness, nausea, vomiting, diplopia, seizures, loss of consciousness, or nuchal rigidity. Physical exam findings may include focal neurologic deficits, cranial nerve palsies, nuchal rigidity, or decreased or altered consciousness.

INTRAPARENCHYMAL Hemorrhage:
Non-traumatic intraparenchymal hemorrhages typically present with a history of sudden onset of stroke symptoms including a headache, nausea, vomiting, focal neurologic deficits, lethargy, weakness, slurred speech, syncope, vertigo, or changes in sensation.

Question 28

How to treat a pediatric patient with a partially obstructed airway

Answer 28

• Make child as comfortable as possible and administer humified O2
• DO NOT ATTEMPT TO LOOK INTO THE MOUTH
• Intubation equipment should be ready
• Allow pt to try to remove the FBAO by coughing
• Transport he pt to the hospital so the foreign body can be removed in a controlled setting

Question 29

Identifying and treating Heat Stroke

Answer 29

Heat (muscle) Cramps: This occurs after sweat and salt have left the body in quantities that lead to enough electrolyte loss that muscle cramping can occur. Remove them from the heat, give them a sports drink (or IV fluid if needed), educate them. NO SALT TABLETS EVER

Heat Exhaustion: When enough sweat and salt are lost and in combination with vasodilation leads to decreased blood volume, venous pooling, and reduced cardiac output. Can be rapid, shallow breathing, cool/clammy skin, weak pulse, increased body temp, can be diarrhea or muscle cramps, may feel weak or loose consciousness. Remove pt from environment, place in supine position, administer a sports drink (or IV fluids if needed), remove some clothing and fan, Treat for shock if shock is suspected.

Heat Stroke: Heat stroke occurs when the hypothalamus temperature regulation is lost causing uncompensated hypothermia, This causes cell death and damage to the brain, liver, and kidneys. At this point the skin will be hot but it CAN still be wet from earlier sweating, but new sweat will often not form.

S&Ss:

• stop sweating (skin may still be wet from previous sweat)
• hot skin skin, very high core temp
• deep resps that become shallow, rapid at first but may become low
• Hypotension with low or absent diastolic reading
• Confusion, disorientation, or unconsciousness
• CNS symptoms such as headache, anxiety, paresthesia, impaired judgement, psychosis
• Possible seizures

Treatment:

• Remove the pt from the environment
• Initiate rapid active cooling (done by removing cloths, fanning, misting, and putting a damp blanked on them; BE CAREFUL to not cause reflex hypothermia by cooling too fast which causes shivering and can increase core temp, which is why ice packs and cold water immersion are not used, the target temp is to reduce to 102F)
• Admin oxygen if the pt is hypoxic
• Admin fluid therapy if the pt is alert and able to swallow (use sports drinks if possible but if not use IV fluids)
• Monitor ECG
• Avoid vasopressors and anticholinergic drugs
• Monitor body temps

Question 30

S&Ss of a Cervical Spine injury

Answer 30

C1-C5: Paralysis of muscles used for breathing and of all arm and leg muscles, usually fatal

C5-C6: Leg paralyzed, slight inability to flex arms

C6-C7: Paralysis of legs and part of wrists and hands, shoulder movement and elbow bending relatively preserved

C8-T1: Legs and trunk paralyzed, eyelids droop, loss of sweating to the forehead, hands paralyzed (can look like hand clawing)

Question 31

Treatment of a tension pneumothorax

Answer 31

Treatment need rapid recognition and pleural decompression.

Before decompressing the pt should be placed on O2 and if necessary ventilate or intubate as needed.

Only decompress the pt if they are symptomatic and showing signs of dyspnea.

You can confirm a tension pneumo by auscultating the lungs for diminished lung sounds, percussing for hyper-resonance, and observing for severe dyspnea, chest hyperinflation, and JVD.

Try not to give fluids to these pts as the trauma could also have caused a cardiac contusion that will be made worse by increased fluids. However, if they are hypotensive you should assume a possible internal bleed and give fluids carefully

Question 32

Treating a pt with a traumatic brain injury

Answer 32

Airway and ventilation is big for these guys, use of a supraglottic airway and intubation is called for if needed, especially RSI if the pt cannot protect their own airway but are not completely unresponsive.

Make sure to keep you O2 and CO2 levels within normal ranges while ventilating, you don’t want to high or to low but with a TBI you definitely DO NOT want hypercapnia.

Possibly the most important thing is to maintain perfusion to the brain as best you can. This is best done by maintaining a BP of at LEAST 90mmhg to keep up perfusion pressure. Do this by bolusing serial doses of 500mL of an isotonic solution titrated to the goal target of at least 90mmhg.

IF you see a pt with a TBI and the BP actually RISES, this is a reflex response to the rising ICP and the body trying to maintain perfusion of the brain. ONLY TREAT THIS by raising the head 30 degrees, you do not want to risk bottoming out the blood pressure.