Emergency Medicine Shock 3rd Year 2nd Semester

Question 1

What is the primary danger of shock if left untreated?

A. Mild fatigue and muscle cramps
B. Cellular injury, organ dysfunction, and possible death
C. Temporary dizziness that resolves quickly
D. Mild allergic reaction

Answer 1

✅ B. Correct – Shock leads to inadequate oxygen delivery → cellular injury → organ failure → death.
Explanation:

A. Incorrect – Fatigue isn’t the main concern in shock; it’s far more serious.

C. Incorrect – Temporary dizziness is more characteristic of syncope, not true shock.

D. Incorrect – An allergic reaction can cause anaphylactic shock, but isn’t the outcome of all types of shock.

WHAT IS SHOCK?
Shock is a critical medical emergency where the circulatory system fails to deliver enough oxygen-rich blood to the body’s tissues and organs.
Without enough oxygen and nutrients, cells cannot function properly, leading
to:
* Cellular injury.
* Tissue damage.
* Organ dysfunction.
* Ultimately, death if not promptly treated

Question 2

Which of the following is most characteristic of early distributive shock (e.g., septic or anaphylactic)?

A. Cold, pale skin
✅ B. Warm, flushed skin
C. Jugular venous distension
D. Bradycardia with pulmonary edema

Answer 2

✅ B. Correct – In early distributive shock, systemic vasodilation causes warm, flushed skin.
Explanation:

A. Incorrect – Cold, pale skin is more common in hypovolemic or cardiogenic shock.

C. Incorrect – JVD is seen in cardiogenic or obstructive shock, not distributive.

D. Incorrect – Bradycardia and pulmonary edema are features of neurogenic or cardiogenic shock respectively.

DISTRIBUTIVE SHOCK
Etiology: Pathologic vasodilation causing blood pooling and relative hypovolemia.
Common Causes:
* Septic Shock – infection triggers systemic inflammatory response.
* Neurogenic Shock – spinal cord injury leads to loss of sympathetic
tone.
* Anaphylactic Shock – severe allergic reaction causes massive
histamine release.

HEMODYNAMICS OF DISTRIBUTIVE SHOCK
* Systemic vasodilation → decreased systemic vascular
resistance (SVR)
* Relative hypovolemia → inadequate perfusion
* Compensation: Increased cardiac output (except neurogenic shock)

DISTRIBUTIVE SHOCK
Clinical Presentation:
* Warm, flushed skin (early stages).
* Hypotension unresponsive to fluid resuscitation.
* Tachycardia (except in neurogenic shock where bradycardia may be
present).
* Altered mental status.
* Fever or hypothermia (septic).
* Rash, angioedema, respiratory distress (anaphylactic).

Question 3

What best distinguishes cardiogenic shock from hypovolemic shock?

A. Both present with warm, flushed skin
✅ B. Cardiogenic shock often shows jugular venous distension and pulmonary crackles
C. Hypovolemic shock has bradycardia
D. Hypovolemic shock increases jugular venous pressure

Answer 3

✅ B. Correct – Cardiogenic shock causes JVD and pulmonary edema, which are not seen in hypovolemic shock.
Explanation:

A. Incorrect – Neither presents with warm skin; both typically show cool, clammy skin.

C. Incorrect – Hypovolemic shock usually causes tachycardia, not bradycardia.

D. Incorrect – JVD is not typical in hypovolemic shock due to low venous volume.

CARDIOGENIC SHOCK
Cardiogenic Shock
* Etiology: Pump failure leading to inadequate tissue perfusion.
* Common Causes: Acute MI, arrhythmias, decompensated heart failure.
* Clinical Presentation:
◦ Cool, clammy skin.
◦ Hypotension.
◦ Jugular venous distension (JVD).
◦ Pulmonary edema with dyspnea and crackles.
◦ Weak, thready pulse.

HYPOVOLEMIC SHOCK
Etiology: Loss of intravascular volume reducing preload and cardiac output.
Common Causes: Hemorrhage (trauma, GI bleed), dehydration, burns.
Clinical Presentation:
* Cold, pale, clammy skin.
* Tachycardia, hypotension.
* Decreased urine output (oliguria).
* Delayed capillary refill.
* Altered mental status.

Question 4

What is the best immediate intervention for someone experiencing psychogenic shock (syncope)?

A. Begin CPR
B. Lay them supine and elevate their legs
C. Give them a sugary drink
D. Apply cold packs to their neck

Answer 4

✅ B. Correct – Syncope from vasovagal response resolves with supine positioning + leg elevation to improve cerebral blood flow.
Explanation:

A. Incorrect – CPR is not required for brief syncope unless they’re unresponsive for prolonged time.

C. Incorrect – Sugar isn’t the issue; this isn’t a hypoglycemic episode.

D. Incorrect – Not harmful but not the priority; positioning is more effective.

PSYCHOGENIC SHOCK (SYNCOPE)
Definition: Transient, self-limited loss of consciousness due to sudden drop in cerebral perfusion, often in response to emotional stress.
Pathophysiology: Vasovagal reaction → bradycardia and vasodilation → decreased blood flow to the brain.
Common Triggers:
* Emotional distress (fear, anxiety).
* Pain.
* Visual stimuli (blood, injury).
* Prolonged standing.

PSYCHOGENIC SHOCK (SYNCOPE)
Signs and Symptoms:
* Lightheadedness, dizziness.
* Pale, clammy skin.
* Sweating (diaphoresis).
* Nausea.
* Brief loss of consciousness (typically <1 minute).

PSYCHOGENIC SHOCK (SYNCOPE)
Clinical Importance:
* Common in patients and bystanders.
* Usually self-limiting but must rule out true shock states.
* Reposition supine, elevate legs, monitor vitals.

Question 5

Which combination of symptoms most suggests obstructive shock (e.g., cardiac tamponade or PE)?

A. Low BP, warm skin, fever
✅ B. Severe hypotension, muffled heart sounds, JVD
C. Lightheadedness, nausea, bradycardia
D. Dehydration, delayed cap refill, cold skin

Answer 5

✅ B. Correct – Muffled heart sounds, JVD, and severe hypotension are hallmark signs of obstructive shock like cardiac tamponade.
Explanation:

A. Incorrect – Suggestive of early septic shock, not obstructive.

C. Incorrect – Fits psychogenic shock (syncope), not obstructive.

D. More characteristic of hypovolemic shock due to fluid loss.

Question 6

Recognizing the Early Stage of Shock

A 30-year-old patient presents with tachycardia, tachypnea, cool extremities, and delayed capillary refill. Blood pressure is normal. What stage of shock is this most consistent with?

A. Irreversible shock
B. Decompensated shock
C. Compensated shock
D. Cardiogenic shock

Answer 6

✅ Correct Answer: C. Compensated shock – ✔️ Vital signs like BP remain normal due to compensation, but signs like tachycardia and cool extremities are present.

Explanation:
A. Irreversible shock – ❌ Occurs later with bradycardia, organ failure, and unresponsiveness.

B. Decompensated shock – ❌ Associated with hypotension and worsening mental status.

D. Cardiogenic shock – ❌ This is a type of shock, not a stage.

STAGE 1: COMPENSATED SHOCK (EARLY)
In this stage, the body activates compensatory mechanisms to maintain vital organ perfusion, despite decreased circulating volume or cardiac output.
Key Features:
* Tachycardia (increased heart rate).
* Tachypnea (rapid breathing).
* Peripheral vasoconstriction (cool, pale extremities).
* Normal blood pressure (for now).
* Mild anxiety, restlessness, or altered mental status.
* Capillary refill >2 seconds.
The patient may appear stable, but danger is building.

Question 7

Which of the following clinical features is most indicative of irreversible (refractory) shock?

A. Tachycardia with confusion
B. Hypotension with cyanosis
C. Bradycardia, coma, and multi-organ failure
D. Mild anxiety and delayed capillary refill

Answer 7

✅ Correct Answer: C. Bradycardia, coma, and multi-organ failure
✅ C. ✔️ Late, severe findings of irreversible shock where perfusion cannot be restored.

Explanation:

A. ❌ Seen in decompensated shock, not irreversible.

B. ❌ Still consistent with decompensated stage.

D. ❌ Consistent with compensated (early) shock.

It’s called “irreversible shock” (or refractory shock) because by this stage, the body has suffered so much prolonged, inadequate blood flow (hypoperfusion) that the damage to vital organs and tissues becomes permanent — and cannot be undone, even with the best medical interventions.

STAGE 3: IRREVERSIBLE SHOCK (REFRACTORY)
At this stage, prolonged, severe hypoperfusion causes permanent, widespread cellular damage and organ failure.
Key Features:
* Profound hypotension.
* Bradycardia (heart rate begins to slow as the heart fails).
* Coma or unresponsiveness.
* Multi-organ failure (renal failure, liver failure, cardiac arrest).
* No urine output.
* Skin: mottled, cyanotic, cold.
Recovery is unlikely, even with advanced medical care.

Here’s the breakdown of why it’s irreversible:
🚨 1. Prolonged Hypoperfusion = Tissue Death
Organs like the brain, kidneys, heart, and liver rely on constant blood flow.

When blood flow is severely reduced for too long, cells die from lack of oxygen and nutrients.

Dying cells release toxic substances that worsen inflammation and damage.

🧠 2. Brain & Heart Start Failing
The brain can become unresponsive or enter a coma.

The heart slows (bradycardia) because it’s not getting oxygen — eventually, it can stop.

Multi-organ failure kicks in — kidneys stop making urine, liver can’t detoxify, etc.

🧊 3. Clinical Signs Reflect Collapse
Profound hypotension: blood pressure so low it can’t support life.

Cold, mottled, cyanotic skin: blood isn’t reaching the surface.

No urine output: kidney failure is a very late, serious sign.

❌ Why Treatment Doesn’t Help Now
Even IV fluids, vasopressors, oxygen, and advanced ICU care can’t restart dead cells or organs.

Too much damage has already happened — that’s why recovery is “unlikely.”

Think of it like a house fire:

Early stages = smoke → still reversible

Later = flames → damage starting

Irreversible stage = house has collapsed → can’t save it

Question 8

Emergency First Step in Suspected Shock in a Solo ND Clinic
You are working alone in your clinic and suspect shock. What is your first priority?

A. Start an IV and administer fluids
B. Confirm diagnosis before doing anything
C. Activate EMS and begin basic stabilization
D. Perform a full physical exam

Answer 8

✅ Correct Answer: C. Activate EMS and begin basic stabilization

Explanation:

A. ❌ Helpful if trained, but not the first priority.

B. ❌ Do not delay treatment waiting for diagnosis.

✅ C. ✔️ Immediate EMS activation is crucial in solo settings. Begin stabilization (oxygen, positioning).

D. ❌ Exam is secondary to life-saving interventions.

Question 9

Which of the following best distinguishes decompensated shock from compensated shock?

A. Elevated heart rate
B. Cool extremities
C. Normal blood pressure
D. Hypotension and altered mental status

Answer 9

✅ Correct Answer: D. Hypotension and altered mental status. Indicates compensation has failed — a medical emergency

Explanation:
A. ❌ Present in both compensated and decompensated stages.

B. ❌ Also seen in early shock due to vasoconstriction.

C. ❌ Suggests the patient is still compensating.

STAGE 2: DECOMPENSATED SHOCK (PROGRESSIVE)
At this stage, compensatory mechanisms fail and perfusion to vital organs drops. Key Features:
* Hypotension (falling blood pressure).
* Severe tachycardia.
* Weak, thready pulse.
* Worsening mental status (confusion, lethargy).
* Oliguria (low urine output).
* Rapid, shallow breathing.
* Cool, clammy skin.
* Possible cyanosis (blue lips/nails).
This is a medical emergency. Immediate intervention is required.

Question 10

A 45-year-old patient suddenly becomes hypotensive and short of breath. Suspecting an obstructive cause, which of the following is most likely?

A. Neurogenic shock
B. Adrenal insufficiency
C. Pulmonary embolism
D. Myocardial infarction

Answer 10

✅ Correct Answer: C. Pulmonary embolism. ✔️ PE is a classic obstructive shock cause — blocks pulmonary flow.

Explanation:
A. ❌ Neurogenic shock involves spinal trauma and vasodilation, not obstruction.
B. ❌ A metabolic cause, not obstructive.
D. ❌ MI is cardiogenic, not obstructive.

Question 11

What is the FIRST step in the management of a patient suspected to be in shock?
A. Establish IV access
B. Ensure scene safety
C. Assess airway and breathing
D. Provide high-flow oxygen

Answer 11

Correct Answer: B. Ensure scene safety

✅ Explanation: Before approaching a patient, ensuring scene safety is essential to avoid putting yourself or others at risk.
❌ A is incorrect because establishing IV access is important, but not the first priority.
❌ C is incorrect; assessing airway and breathing follows scene safety.
❌ D is incorrect because oxygen is part of immediate support after initial assessment.

Question 12

When positioning a patient in shock, when should you AVOID elevating their legs?
A. In cases of anaphylactic shock
B. If the patient is unresponsive
C. If cardiogenic shock is suspected
D. If the patient has hypotension

Answer 12

Correct Answer: C. If cardiogenic shock is suspected
✅ Explanation: Leg elevation may worsen pulmonary congestion in cardiogenic shock due to fluid overload.

❌ A is incorrect; leg elevation is generally appropriate in anaphylaxis.
❌ B is incorrect; responsiveness isn’t a contraindication unless combined with a specific shock type.
❌ D is incorrect; hypotension usually benefits from leg elevation unless there’s a contraindication.

Question 13

Which of the following is NOT a typical feature of anaphylactic shock?
A. Wheezing and stridor
B. Bradycardia
C. Urticaria
D. Hypotension

Answer 13

Correct Answer: B. Bradycardia
✅ Explanation: Anaphylaxis typically causes tachycardia, not bradycardia.
❌ A is incorrect because wheezing and stridor indicate airway compromise.
❌ C is incorrect as urticaria (hives) is a hallmark skin symptom.
❌ D is incorrect because hypotension is a key feature.

ANAPHYLACTIC SHOCK: RECOGNITION AND
HOSPITAL MANAGEMENT
Etiology: Severe IgE-mediated allergic reaction causing widespread
vasodilation and airway compromise.
Signs and Symptoms:
* Urticaria, angioedema.
* Wheezing, stridor.
* Hypotension, tachycardia.
* Gastrointestinal symptoms (vomiting, diarrhea).

• IM Epinephrine 0.3–0.5 mg ASAP.
• High-flow oxygen.
• IV fluids for volume support.
• Antihistamines and corticosteroids.
• Airway management as needed.

Question 14

Which fluid resuscitation strategy is correct for septic shock in the hospital setting?
A. Administer 30 mL/kg crystalloid bolus
B. Give 500 mL bolus and reassess after 1 hour
C. Avoid fluids; prioritize vasopressors
D. Provide oral rehydration first

Answer 14

Correct Answer: A. Administer 30 mL/kg crystalloid bolus
✅ Explanation: Aggressive fluid resuscitation is crucial in septic shock to restore perfusion.
❌ B underestimates the urgent volume needed.
❌ C is incorrect because vasopressors are second-line if fluids fail.
❌ D is inappropriate in shock; IV fluids are needed.

SEPTIC SHOCK: RECOGNITION AND HOSPITAL
MANAGEMENT
* Etiology: Life-threatening organ dysfunction due to dysregulated
host response to infection.
* Signs and Symptoms:
◦ Fever, chills, or hypothermia.
◦ Tachycardia, hypotension.
◦ Confusion, lethargy.
◦ Elevated lactate (>2 mmol/L).

Diagnostic Criteria (Sepsis-3):
◦ Suspected infection.
◦ Organ dysfunction.
◦ Persistent hypotension after fluid resuscitation.
* Hospital Care:
◦ Broad-spectrum antibiotics within 1 hour.
◦ Aggressive IV fluids (30 mL/kg crystalloid bolus).
◦ Vasopressors (norepinephrine) if hypotension persists.
◦ Monitor lactate levels and urine output.

Question 15

Which of the following best describes hypotension?
A. Systolic BP < 100 mmHg
B. MAP < 70 mmHg
C. Systolic BP < 90 mmHg or MAP < 65 mmHg
D. Diastolic BP < 50 mmHg

Answer 15

Correct Answer: C. Systolic BP < 90 mmHg or MAP < 65 mmHg
✅ Explanation: These are the accepted definitions of clinically significant hypotension.
❌ A and B are above standard thresholds.
❌ D focuses only on diastolic pressure, which is less critical in isolation.

Question 16

Which of the following causes of hypotension is classified as “obstructive”?
A. Sepsis
B. Myocardial infarction
C. Pulmonary embolism
D. Addison’s disease

Answer 16

Correct Answer: C. Pulmonary embolism
✅ Explanation: Obstructive shock is due to physical blockages, and PE fits this category.
❌ A is distributive, B is cardiogenic, and D is endocrine-related.

OBSTRUCTIVE SHOCK
Etiology: Physical obstruction to blood flow affecting cardiac output.
Common Causes: Pulmonary embolism (PE), cardiac tamponade, tension pneumothorax. Clinical Presentation:
* Severe hypotension.
* JVD.
* Pulsus paradoxus (drop in BP with inspiration).
* Muffled heart sounds (tamponade).
* Absent unilateral breath sounds (pneumothorax).

Question 17

In a solo-practice ND setting, what is the top priority when a patient is in shock?
A. Start IV fluids immediately
B. Apply defibrillation
C. Activate EMS promptly
D. Monitor patient with ECG

Answer 17

Correct Answer: C. Activate EMS promptly
✅ Explanation: Without full resources, the best chance of survival lies in early EMS activation.
❌ A and B may be out of scope.
❌ D is helpful but secondary.

Question 18

Which of the following is a late sign of hypotension?
A. Dizziness
B. Tachycardia
C. Decreased urine output
D. Nausea

Answer 18

HYPOTENSION - SYMPTOMS
* Dizziness or lightheadedness.
* Weakness and fatigue.
* Blurred vision.
* Nausea.
* Cold, clammy, pale, or mottled skin.
* Rapid heart rate (tachycardia).
* Confusion, disorientation, or decreased consciousness.
* Fainting (syncope) or near-syncope.
Decreased urine output (later finding).

🔍 Why these are symptoms of hypotension:
Hypotension = low blood pressure, meaning there’s reduced blood flow to organs and tissues. Your body will try to compensate for this drop, which leads to the symptoms.

🌀 Dizziness, lightheadedness, blurred vision, fainting (syncope):
These occur because less blood (and oxygen) reaches the brain.

The brain is extremely sensitive to reduced perfusion, so symptoms show up quickly.

🪫 Weakness and fatigue:
Muscles aren’t getting enough oxygen and nutrients due to poor circulation.

Energy levels drop, especially with movement or standing.

🤢 Nausea:
The GI tract also becomes under-perfused, which can lead to nausea and discomfort.

❄️ Cold, clammy, pale, or mottled skin:
The body redirects blood away from the skin to vital organs like the heart and brain (called peripheral vasoconstriction).

This causes skin to feel cool and look pale or blotchy.

❤️‍🔥 Tachycardia (fast heart rate):
This is a compensatory response.

The heart beats faster to try and maintain cardiac output and deliver enough oxygen.

😵‍💫 Confusion, disorientation, decreased consciousness:
A sign the brain isn’t getting enough oxygen or glucose.

If hypotension worsens, these symptoms become more severe.

🚽 Why decreased urine output is a later finding:
The kidneys need a certain blood pressure (and perfusion pressure) to filter blood and produce urine.

In early hypotension, your body preserves blood flow to the heart and brain, sacrificing the kidneys temporarily.

As hypotension persists or worsens, blood flow to the kidneys drops, and urine output declines (called oliguria).

It’s considered a late sign because by the time the kidneys are affected, hypotension is usually more advanced and systemic.

Think of it as the body’s triage:

💡 Brain & heart first, kidneys and skin later.

Question 19

What is the first step in managing a patient with suspected hypotension?

A. Administer IV fluids immediately
B. Lay the patient supine with leg elevation
C. Provide broad-spectrum antibiotics
D. Monitor lactate levels

Answer 19

Correct Answer: B. Lay the patient supine with leg elevation. This helps increase venous return and support blood pressure.
Explanation:

A is incorrect: IV fluids may help, but positioning comes first in basic management.

C is incorrect: Antibiotics are for septic shock, not general hypotension.

D is incorrect: Lactate is monitored in shock, especially septic, but not the first step.

HYPOTENSION - MANAGEMENT
1. Lay patient supine, elevate legs if appropriate.
2. Provide high-flow oxygen (if available).
3. Monitor vitals (BP, HR, respiratory rate, mental status).
4. Identify obvious causes and intervene if within scope.
5. Activate EMS early.

Question 20

Which intervention is essential within the first hour of diagnosing septic shock in the hospital?

A. Administer IM epinephrine
B. Start IV corticosteroids
C. Begin broad-spectrum antibiotics
D. Insert a chest tube

Answer 20

Correct Answer: C. Begin broad-spectrum antibiotics. Early antibiotics within 1 hour is critical in sepsis care.

Explanation:

A is incorrect: IM epinephrine is for anaphylaxis, not sepsis.

B is incorrect: Corticosteroids are sometimes used but not the initial step.

D is incorrect: Chest tubes are used for pneumothorax, not sepsis.

SEPTIC SHOCK: RECOGNITION AND HOSPITAL
MANAGEMENT
* Diagnostic Criteria (Sepsis-3):
◦ Suspected infection.
◦ Organ dysfunction.
◦ Persistent hypotension after fluid resuscitation.
* Hospital Care:
◦ Broad-spectrum antibiotics within 1 hour.
◦ Aggressive IV fluids (30 mL/kg crystalloid bolus).
◦ Vasopressors (norepinephrine) if hypotension persists.
◦ Monitor lactate levels and urine output

Question 21

Which shock type requires cautious fluid administration due to risk of fluid overload?

A. Hypovolemic shock
B. Anaphylactic shock
C. Cardiogenic shock
D. Septic shock

Answer 21

Correct Answer: C. Cardiogenic shock. The heart is failing; fluids can worsen pulmonary edema.

Explanation:
A is incorrect: Requires aggressive fluid resuscitation.

B is incorrect: Needs IV fluids and epinephrine.

D is incorrect: Also managed with aggressive fluids initially.

SHOCK MANAGEMENT ALGORITHM
* Step 1: Ensure Scene Safety
* Step 2: Initial Assessment
→ Check Airway, Breathing, Circulation, Disability, Exposure
(ABCDE)
* Step 3: Provide Immediate Support
→ High-flow oxygen (NRB mask)
→ Supine position with leg elevation (if no contraindications)
* Step 4: Establish IV Access (if trained)
→ Begin fluid resuscitation (unless cardiogenic shock is
suspected)
* Step 5: Identify the Type of Shock
→ Rapid history, focused physical exam
* Step 6: Provide Targeted Intervention
- Septic Shock: IV fluids + early antibiotics
- Anaphylactic Shock: IM epinephrine + airway management
- Hypovolemic Shock: Control bleeding + IV fluids
- Cardiogenic Shock: Oxygen, cautious fluids, cardiac support
- Obstructive Shock: Relieve obstruction (e.g., decompress
pneumothorax

• Step 7: Continuous Reassessment
• Step 8: Prepare for EMS Transport/Advanced Care

Question 22

What is the priority emergency medication for a patient in anaphylactic shock?

A. IV diphenhydramine
B. IM epinephrine
C. Oral corticosteroids
D. IV antibiotics

Answer 22

Correct Answer: B. IM epinephrine is the first-line treatment for anaphylaxis. This is the first and most critical step in managing anaphylaxis. It addresses airway swelling, hypotension, and bronchospasm.

Explanation:
A is incorrect: Diphenhydramine is supportive but not first-line. Antihistamines – Help with rash/itching but do not reverse airway/blood pressure issues.

C is incorrect: Oral corticosteroids are slower acting. Useful but act slowly (hours); not for immediate stabilization.

D is incorrect: Antibiotics are for infections, not allergic reactions.

More information: Albuterol – May help bronchospasm but not systemic vasodilation or airway swelling.

ANAPHYLACTIC SHOCK: RECOGNITION AND
HOSPITAL MANAGEMENT
Etiology: Severe IgE-mediated allergic reaction causing widespread
vasodilation and airway compromise.
Signs and Symptoms:
* Urticaria, angioedema.
* Wheezing, stridor.
* Hypotension, tachycardia.
* Gastrointestinal symptoms (vomiting, diarrhea).

ANAPHYLACTIC SHOCK: RECOGNITION AND
HOSPITAL MANAGEMENT
Hospital Care:
* IM Epinephrine 0.3–0.5 mg ASAP.
* High-flow oxygen.
* IV fluids for volume support.
* Antihistamines and corticosteroids.
* Airway management as needed.

Question 23

Which of the following is included in the initial ABCDE assessment for shock?

A. Administer IV antibiotics
B. Check for JVD
C. Assess airway patency
D. Start vasopressors

Answer 23

Correct Answer: C. Assess airway patency “A” in ABCDE stands for Airway; it’s the first check.

PRIMARY RESPONSE STEPS:
* Ensure Scene Safety.
* Assess Airway, Breathing, Circulation, Disability, Exposure
(ABCDEs).
* Place the patient supine; elevate legs if no contraindications (cardiogenic shock, increased intracranial pressure).
* Apply high-flow oxygen via non-rebreather mask (10-15 L/min).
* Establish large-bore IV access (if trained).

Question 24

In a solo ND practice, what is the most appropriate first action when encountering shock?

A. Initiate IV fluids
B. Refer to cardiology
C. Immediately activate EMS
D. Administer magnesium sulfate

Answer 24

Correct Answer: C. Immediately activate EMS. Solo NDs must prioritize rapid EMS activation due to limited resources.
Explanation:

A is incorrect: IV fluids may be out of scope or unavailable in this setting.

B is incorrect: Not appropriate during an emergency.

D is incorrect: Magnesium sulfate is for severe asthma, not general shock.

CLINIC CONSIDERATIONS: TEAM SIZE AND SHOCK
MANAGEMENT
Solo ND Practice:
* Prioritize rapid EMS activation.
* Begin oxygen therapy and basic supportive measures.
* Apply algorithm while waiting for transport.
* Recognize limitations (no IV fluids unless within scope and
equipped).

CLINIC CONSIDERATIONS: TEAM SIZE AND SHOCK
MANAGEMENT
Team-Based Clinic (ND + Staff):
* Assign roles (airway management, vitals monitoring, EMS
communication).
* Initiate IV fluids if trained and equipped.
* Monitor patient continuously with documentation of vitals and
response.
* Prepare handover notes for EMS.

CLINIC CONSIDERATIONS: TEAM SIZE AND SHOCK
MANAGEMENT
Key Considerations:
* Always work within your scope of practice.
* Early EMS activation is critical regardless of clinic size.
* Equipment and staff availability impact intervention depth.

Question 25

PART 1: Explanation about IM Epinephrine in Anaphylactic Shock Question: Is the reason intramuscular (IM) epinephrine is given first in anaphylactic shock because it keeps the airway open?

Answer 25

Answer: ✅ Yes, that's part of it — and there are multiple reasons: Bronchodilation: Epinephrine activates β2 receptors in the lungs → bronchodilation → keeps the airway open and improves breathing. Vasoconstriction: It activates α1 receptors → counteracts vasodilation and capillary leak → helps maintain blood pressure. Stabilizes mast cells and basophils: Reduces further histamine and mediator release. Fast absorption via IM route: IM administration (especially into the thigh) gives rapid systemic uptake, faster than subcutaneous. 🚫 IV epinephrine is used only in hospital settings when the patient is unresponsive to IM epinephrine or when they are crashing — because of its higher risk for arrhythmias.

Question 26

A patient presents with suspected sepsis and hypotension. What is the first fluid management step? A) Restrict fluids to avoid overload B) Administer 30 mL/kg IV crystalloid bolus C) Start vasopressors immediately D) Give IM epinephrine

Answer 26

**Answer: ✅ B) Administer 30 mL/kg IV crystalloid bolus – Standard first step in septic shock to restore perfusion.** ❌ A) Restricting fluids is inappropriate initially in sepsis. ❌ C) Vasopressors like norepinephrine are added only if hypotension persists after fluids. ❌ D) IM epinephrine is for anaphylaxis, not sepsis.

Question 27

In hypertensive emergency with dyspnea and pulmonary edema, what is the most likely mechanism? A) Decreased preload B) Bradycardia C) Increased afterload D) Hyperkalemia

Answer 27

**Answer: ✅ C) Increased afterload – Severe hypertension increases afterload → worsens left ventricular function → pulmonary edema.** ❌ A) Preload is often elevated. ❌ B) Bradycardia is not typical in hypertensive emergency. ❌ D) Hyperkalemia might co-exist but isn’t the main cause here.

Question 28

What is the immediate ND management for acute decompensated heart failure? A) Lay patient supine B) Administer large IV fluid bolus C) Oxygen therapy and upright positioning D) Start beta-blockers immediately

Answer 28

**Answer: ✅ C) Oxygen therapy and upright positioning – Relieves pulmonary congestion and improves oxygenation.** ❌ A) Supine position can worsen pulmonary edema. ❌ B) Fluids worsen the overload. ❌ D) Beta-blockers are contraindicated in acute episodes; used in chronic management.

Question 29

A patient with suspected pulmonary embolism presents with severe hypoxia. What is the most appropriate outpatient action? A) Give IM epinephrine B) Administer anticoagulants immediately C) Provide high-flow oxygen and refer to ER D) Delay referral and monitor overnight

Answer 29

**Answer: ✅ C) Provide high-flow oxygen and refer to ER – PE needs imaging and hospital-based anticoagulation or thrombolysis.** ❌ A) Epinephrine is for anaphylaxis. ❌ B) Anticoagulation in clinic is not appropriate without diagnosis confirmation. ❌ D) Delaying care could be fatal.

Question 30

In a solo ND practice setting, what is the most appropriate initial response to a patient in shock? A) Begin IV fluid resuscitation immediately B) Administer high-dose corticosteroids C) Activate EMS, administer oxygen, and apply supportive measures D) Perform endotracheal intubation

Answer 30

**C is correct: Solo NDs should focus on activating EMS, giving oxygen, and initiating basic supportive care while awaiting advanced help.** ✅ Explanation: A is incorrect: IV fluids should only be administered if within the ND’s scope and if the clinic is equipped; not all solo practices are. B is incorrect: Corticosteroids are not first-line in shock management unless a specific cause (like adrenal insufficiency) is identified. D is incorrect: Endotracheal intubation is outside the ND’s scope and requires EMS or hospital-level care.

Question 31

What role does team size play in shock management within a clinic setting? A) Larger teams should delay EMS activation in favor of onsite stabilization B) Team-based clinics can assign roles like airway management and vitals monitoring C) In solo practices, shock management is usually unnecessary D) Only hospitals can manage shock effectively

Answer 31

**B is correct: A team allows for delegation—airway, vitals, EMS communication, documentation—improving efficiency and care.** ✅ Explanation: A is incorrect: EMS should be activated early regardless of team size. C is incorrect: Shock must be managed even in solo clinics using basic support and EMS. D is incorrect: Clinics can begin initial stabilization even if they cannot provide definitive treatment.

Question 32

Which oxygen delivery method is best for a conscious patient with mild hypoxia who tolerates low-flow oxygen? A) Bag-valve mask (BVM) B) Nasal cannula C) Non-rebreather mask D) Endotracheal intubation

Answer 32

**B is correct: A nasal cannula (1–6 L/min) is appropriate for mild hypoxia and is well tolerated by conscious patients.** ✅ Explanation: A is incorrect: BVM is for unconscious/apneic patients needing assisted ventilation. C is incorrect: Non-rebreather is for severe hypoxia or shock. D is incorrect: Intubation is invasive and reserved for patients in respiratory failure.

Question 33

Which of the following is a primary effect of epinephrine in respiratory emergencies? A) Bronchoconstriction B) Vasodilation C) Bronchodilation D) Decreased heart rate

Answer 33

**Answer: C) Bronchodilation Epinephrine stimulates β₂-adrenergic receptors, resulting in bronchodilation, which is beneficial in respiratory distress.** Explanation: A) Incorrect. Epinephrine causes bronchial smooth muscle relaxation, leading to bronchodilation. B) Incorrect. Epinephrine induces vasoconstriction, not vasodilation. D) Incorrect. Epinephrine increases heart rate by stimulating β₁-adrenergic receptors.

Question 34

Salbutamol is primarily used to: A) Reduce mucus secretion B) Induce sedation C) Relax bronchial smooth muscle D) Stimulate histamine release​

Answer 34

**Answer: C) Relax bronchial smooth muscle. Salbutamol is a β₂-adrenergic agonist that relaxes bronchial smooth muscle, easing airflow in conditions like asthma.** Explanation: A) Incorrect. Salbutamol does not significantly affect mucus secretion. B) Incorrect. Salbutamol is a bronchodilator and does not have sedative properties. D) Incorrect. Salbutamol does not stimulate histamine release; it helps counteract its effects. **SALBUTAMOL – SIDE EFFECTS & CONTRAINDICATIONS** Contraindications: * Severe tachyarrhythmias (e.g., SVT, VT). * Severe hypersensitivity to salbutamol or beta-agonists. * Caution in patients with hyperthyroidism or cardiac disease (can worsen tachycardia). Side Effects: * Tachycardia, palpitations (due to beta-1 stimulation). * Tremors, restlessness, headache (from beta-2 activation). * Hypokalemia (shifts potassium intracellularly). * Paradoxical bronchospasm (rare).

Question 35

Which medication is contraindicated in patients with glaucoma due to the risk of increased intraocular pressure? A) Salbutamol B) Ipratropium C) Epinephrine D) Diphenhydramine

Answer 35

**Answer: B) Ipratropium, an anticholinergic agent, can increase intraocular pressure, posing a risk in glaucoma patients.** Explanation: A) Incorrect. Salbutamol does not significantly affect intraocular pressure. C) Incorrect. Epinephrine is not contraindicated in glaucoma; it may be used cautiously. D) Incorrect. Diphenhydramine has anticholinergic effects but is less likely to impact intraocular pressure significantly.​ IPRATROPIUM – ROLE IN RESPIRATORY EMERGENCIES Class: Anticholinergic bronchodilator. Mechanism: * Inhibits vagal-mediated bronchoconstriction. * Reduces mucus secretion. Indications: * Adjunct therapy in asthma or COPD exacerbations.

Question 36

Diphenhydramine is primarily used in respiratory emergencies to: A) Stimulate β₂ receptors B) Block H₁ histamine receptors C) Activate cholinergic pathways D) Inhibit β₁ adrenergic receptors

Answer 36

Answer: B) Block H₁ histamine receptors. Diphenhydramine is an H₁ receptor antagonist, reducing histamine-mediated symptoms in allergic reactions. Explanation: A) Incorrect. Diphenhydramine does not stimulate β₂ receptors. C) Incorrect. Diphenhydramine has anticholinergic, not cholinergic, effects. D) Incorrect. Diphenhydramine does not inhibit β₁ adrenergic receptors.

Question 37

Which of the following is a potential side effect of salbutamol? A) Bradycardia B) Hyperkalemia C) Tremors D) Sedation

Answer 37

**C) Tremors are a common side effect due to β₂ receptor stimulation.** Explanation: A) Incorrect. Salbutamol may cause tachycardia, not bradycardia. B) Incorrect. Salbutamol can cause hypokalemia, not hyperkalemia. D) Incorrect. Salbutamol does not have sedative properties. **Why do β₂ receptor agonists (like salbutamol) cause tremors? Great observation — this is a classic side effect.** ✅ How it works: β₂ receptors are found on smooth muscle (like in the bronchi) but also on skeletal muscle. When you use a β₂ agonist like salbutamol, it stimulates these skeletal muscle receptors too. This increases neuromuscular excitability, especially in fine motor muscles like those in the hands. Result: muscle tremors (usually mild, rhythmic shaking, especially in the fingers or hands). 🧪 Why this happens more with higher doses: At higher doses, salbutamol loses selectivity, meaning it might start to affect β₁ receptors (causing tachycardia) and increase β₂ effects on skeletal muscle — causing more pronounced tremors. 🧠 Bonus point: These tremors are usually temporary, dose-dependent, and not dangerous — but they can be annoying for patients, especially when using nebulized or frequent inhaled doses.

Question 38

Which of the following is part of the initial triage algorithm for a patient with respiratory distress due to suspected pulmonary embolism (PE)? A. Administer diphenhydramine and observe. B. Administer oxygen and call EMS. ✅ C. Give salbutamol and monitor response. D. Start IV fluids and reassess in 10 minutes.

Answer 38

**Correct Answer: B. Administer oxygen and call EMS. PE is a medical emergency. Immediate oxygen and EMS activation are critical.** A: Incorrect – Diphenhydramine treats allergic reactions, not PE. C: Incorrect – Salbutamol is used in asthma, not PE. D: Incorrect – IV fluids are not primary for PE and may worsen right heart strain.

Question 39

Which medication is contraindicated in patients with angle-closure glaucoma due to its anticholinergic effects? A. Epinephrine B. Salbutamol C. Ipratropium ✅ D. Diphenhydramine

Answer 39

**Correct Answer: C. Ipratropium can worsen angle-closure glaucoma due to its anticholinergic effects.** A: Incorrect – Epinephrine has minimal anticholinergic activity. B: Incorrect – Salbutamol is a beta-agonist, not anticholinergic. D: Incorrect – Diphenhydramine does have anticholinergic effects but is more likely to cause sedation than precipitate glaucoma. **IPRATROPIUM – SIDE EFFECTS & CONTRAINDICATIONS** Contraindications: * Soy or peanut allergy (rare, but some formulations contain soya lecithin). * Glaucoma (can cause acute angle-closure crisis). * Prostatic hyperplasia (BPH) and urinary retention risk. Side Effects: * Dry mouth, throat irritation. * Blurred vision (from anticholinergic effects). * Urinary retention (caution in older men with BPH). * Paradoxical bronchospasm (rare).

Question 40

Which medication can paradoxically worsen airway obstruction in acute asthma due to thickening of mucus? A. Salbutamol B. Ipratropium C. Epinephrine D. Diphenhydramine

Answer 40

**Correct Answer: D. Diphenhydramine – Diphenhydramine can thicken mucus, worsening obstruction in asthma.** A: Incorrect – Salbutamol relaxes bronchial muscles and is first-line for asthma. B: Incorrect – Ipratropium is an adjunct in asthma and COPD. C: Incorrect – Epinephrine reduces bronchial edema. **DIPHENHYDRAMINE – USE IN RESPIRATORY EMERGENCIES** Class: First-generation antihistamine. Mechanism: Blocks H1 receptors → reduces histamine effects. Indications: * Adjunct in anaphylaxis (with epinephrine). * Allergic reactions DIPHENHYDRAMINE – DOSING, SIDE EFFECTS & CONTRAINDICATIONS Contraindications: * Acute asthma exacerbation (can thicken mucus and worsen airway obstruction). * Glaucoma (increases intraocular pressure, risk of angle-closure crisis). * BPH & urinary retention (anticholinergic effect can worsen symptoms). * Caution in elderly (higher risk of sedation, falls, cognitive impairment). Side Effects: * Sedation, dizziness, confusion (antihistaminic & anticholinergic effects). * Dry mouth, urinary retention, constipation (anticholinergic effects). * Paradoxical excitation in children (hyperactivity, restlessness). * Blurred vision, worsening glaucoma.

Question 41

What is a potential side effect of salbutamol due to its action on potassium distribution? A. Hyperkalemia B. Hypokalemia C. Hyponatremia D. Hypernatremia

Answer 41

Correct Answer: B. Hypokalemia A: Incorrect – Salbutamol lowers serum potassium by shifting it into cells. B: ✅ Correct – Beta-2 agonists like salbutamol cause hypokalemia by driving potassium into cells. C/D: Incorrect – Salbutamol does not significantly affect sodium levels.

Question 42

A 68-year-old male presents with acute shortness of breath, orthopnea, and bilateral leg swelling. On exam, he has an elevated JVP, S3 gallop, and bilateral basal crackles. What is the most likely diagnosis? A) Acute coronary syndrome B) Heart failure exacerbation C) Pulmonary embolism D) Asthma exacerbation

Answer 42

**✅ Correct Answer: B) Heart failure exacerbation Explanation: The combination of orthopnea, elevated JVP, S3, and crackles strongly suggests congestive heart failure.** A is possible but doesn’t explain JVP or S3 without chest pain. C typically lacks JVP or S3 and often presents with pleuritic pain. D is more common in younger patients and lacks peripheral edema/JVP.

Question 43

In triage, which of the following signs would indicate the need for immediate resuscitation in a patient with dyspnea? A) Respiratory rate of 24/min B) SpO₂ of 92% on room air C) Inability to speak full sentences D) Bilateral wheezing on auscultation

Answer 43

**✅ Correct Answer: C) Inability to speak full sentences Explanation: This indicates severe respiratory distress and may warrant airway support or code response.** A and B are abnormal but not critical. D suggests bronchospasm but not necessarily life-threatening.

Question 44

Which of the following history findings most strongly suggests pulmonary embolism? A) Recent upper respiratory infection B) Sudden onset dyspnea with pleuritic chest pain and hemoptysis C) Gradual onset orthopnea and PND D) Productive cough with green sputum and fever

Answer 44

**✅ Correct Answer: B) Sudden onset dyspnea with pleuritic chest pain and hemoptysis Explanation: Classic triad for PE: sudden dyspnea, pleuritic pain, hemoptysis (though rare).** A fits viral illness. C suggests CHF. D suggests pneumonia. **CLINICAL HISTORY CLUES FOR DYSPNEA** * Sudden onset → PE, pneumothorax, anaphylaxis. * Progressive over days → pneumonia, heart failure, COPD exacerbation. * Triggers: allergens (anaphylaxis), exertion (heart failure), infection (pneumonia). * Associated symptoms: ◦ Chest pain → PE, pneumothorax. ◦ Wheeze → asthma, anaphylaxis. ◦ Fever → pneumonia. ◦ Orthopnea → heart failure.

Question 45

A 32-year-old woman presents with pleuritic chest pain and dyspnea. You calculate her Wells Score as 4.5. What is the next best step? A) Send D-dimer B) Start anticoagulation immediately C) Perform CT pulmonary angiography (CTPA) D) Rule out PE using the PERC rule

Answer 45

✅ Correct Answer: C) Perform CT pulmonary angiography (CTPA) Explanation: A Wells score >4 is considered “PE likely”; skip D-dimer and proceed to imaging. A is only appropriate if Wells ≤4. B may be premature without imaging unless unstable. D applies only if Wells score is low.

Question 46

Which physical exam finding is most specific for tension pneumothorax? A) Diminished breath sounds B) Hyperresonance on percussion C) Tracheal deviation D) Tachypnea

Answer 46

✅ Correct Answer: C) Tracheal deviation Explanation: Tracheal deviation is a late and specific sign of tension pneumothorax. A and B are seen in simple pneumothorax too. D is nonspecific. **PNEUMOTHORAX Pathophysiology:** * Air accumulation in pleural space collapses lung. Clinical Presentation: * Sudden sharp chest pain, dyspnea, absent breath sounds. * Tracheal deviation (tension pneumothorax). PNEUMOTHORAX Risk Factors: Primary Spontaneous Pneumothorax * Tall, thin males (10 to 30 years old) * Smoking * Family history of pneumothorax * Underlying lung disease (Marfan syndrome, Ehlers-Danlos syndrome) Secondary Pneumothorax * COPD (bullae rupture most common cause) * Cystic fibrosis, tuberculosis, lung cancer Traumatic Pneumothorax * Blunt or penetrating chest trauma * Mechanical ventilation (barotrauma)

Question 47

CURB-65 is used to assess severity in which of the following conditions? A) Heart failure B) Pulmonary embolism C) Community-acquired pneumonia D) Asthma

Answer 47

**✅ Correct Answer: C) Community-acquired pneumonia Explanation: CURB-65 is used to predict mortality and guide inpatient vs outpatient treatment of pneumonia.** Not validated for other conditions. **USE OF DECISION TOOLS PE Rule-Out Criteria (PERC)** Wells Score for PE CURB-65 for Pneumonia Severity Canadian Syncope Risk Score (for arrhythmia-related syncope and dyspnea) CLINICAL DECISION TOOLS FOR DYSPNEA & RESPIRATORY EMERGENCIES CURB-65 (Pneumonia Severity Assessment) * Determines whether a patient with community-acquired pneumonia (CAP) needs hospitalization. * Each factor = 1 point: ◦ Confusion (new-onset) ◦ Urea >7 mmol/L (BUN >20 mg/dL) ◦ Respiratory rate ≥30 bpm ◦ Blood pressure <90/60 mmHg ◦ Age ≥65 Scoring & Management: * 0-1 points: Outpatient treatment * 2 points: Consider hospitalization * ≥3 points: Hospital admission required * ≥4-5 points: ICU consideration Higher scores indicate a need for aggressive management.

Question 48

A 45-year-old asthmatic patient presents in respiratory distress. Which sign would indicate impending respiratory arrest? A) Use of accessory muscles B) Tachypnea C) Silent chest D) Expiratory wheeze

Answer 48

**✅ Correct Answer: C) Silent chest Explanation: A “silent chest” means no air movement and is a pre-arrest sign.** A, B, and D indicate distress but not failure. **ACUTE ASTHMA ATTACK Pathophysiology:** * Bronchoconstriction, airway inflammation, and mucus hypersecretion narrow airways, causing airflow limitation and hypoxia. Clinical Presentation: * Wheezing, prolonged expiratory phase. * Accessory muscle use, tachypnea, tachycardia. * Severe cases: Cyanosis, silent chest (ominous sign). **ACUTE ASTHMA ATTACK Pathophysiology:** * Bronchoconstriction, airway inflammation, and mucus hypersecretion narrow airways, causing airflow limitation and hypoxia. Clinical Presentation: * Wheezing, prolonged expiratory phase. * Accessory muscle use, tachypnea, tachycardia. * Severe cases: Cyanosis, silent chest (ominous sign).

Question 49

Which of the following best differentiates COPD exacerbation from asthma on physical exam? A) Prolonged expiratory phase B) Wheezing C) Clubbing of fingers D) Pursed-lip breathing and barrel chest

Answer 49

✅ Correct Answer: D) Pursed-lip breathing and barrel chest Explanation: These are typical of chronic COPD, not asthma. A and B are seen in both. C is nonspecific and not diagnostic.

Question 50

A patient with dyspnea has a Wells Score of 3 and a negative PERC rule. What should you do next? A) Order D-dimer B) Order CTPA C) Discharge with reassurance D) Start empiric anticoagulation

Answer 50

**✅ Correct Answer: A) Order D-dimer Explanation: A Wells score of 3 is intermediate probability. If PERC is negative, PE is unlikely, but still need D-dimer to rule out.** B would be if D-dimer is positive. C is premature. D is not indicated unless very high suspicion or unstable. **CLINICAL DECISION TOOLS FOR DYSPNEA & RESPIRATORY EMERGENCIES PERC Rule (PE Exclusion in Low-Risk Patients)** * Use in patients with Wells Score ≤4 to rule out PE without further testing. * If all 8 criteria are negative, PE can be ruled out. * Criteria (all must be NO): ◦ Age ≥50 ◦ HR ≥100 bpm ◦ SpO₂ <95% ◦ Unilateral leg swelling ◦ Recent trauma/surgery ◦ Prior DVT/PE ◦ Hemoptysis ◦ Estrogen use If ANY criterion is YES → Order D-dimer or imaging.