NREMT EMT — All Questions

Where local protocol allows an EMT to apply CPAP for pulmonary edema, how does it help the patient?

• a.It delivers a set number of breaths each minute, so the patient's own effort is no longer needed
• b.It drives warm dry oxygen across the alveolar walls, which absorbs the fluid in the lungs
• c.It holds the alveoli open and pushes fluid out of them, easing the work of breathing✓
• d.It raises the oxygen concentration far beyond what a nonrebreather can supply

CPAP keeps a continuous pressure in the airway through the whole breathing cycle, which holds open alveoli that would otherwise collapse, drives edema fluid back across into the circulation and cuts the effort each breath takes. The patient goes on breathing for themselves, which is why they must be awake and cooperative. It is not a ventilator delivering set breaths. Raising the oxygen concentration is the tempting explanation, but a nonrebreather already gives a high concentration and does nothing for the patient whose alveoli are flooded, so concentration is not the mechanism. Nothing about the device dries the lungs out.

An EMT is preparing to assist an asthmatic patient with her own prescribed metered-dose inhaler, where protocol permits. Which finding means the EMT should not assist?

• a.She used the inhaler once about an hour ago with partial relief
• b.She is too drowsy to follow instructions✓
• c.Her heart rate has risen to 118 with the effort of breathing
• d.She is wheezing on both sides of the chest rather than one

Assisting with an inhaler requires a patient alert enough to seal her lips on the mouthpiece, inhale on cue and hold the breath; a drowsy patient cannot do any of that and needs her ventilations assisted instead. A dose an hour earlier is the finding worth pausing over, because protocols do cap how many doses may be assisted in a given period, but one dose an hour ago is normally within that limit and the number permitted is set by local protocol and medical direction. Wheezing on both sides and a tachycardia from the work of breathing are expected in an attack. The EMT must still confirm the inhaler is prescribed to this patient and is in date.

A patient on a nonrebreather mask is breathing deeply, and the reservoir bag collapses completely with each breath. What should the EMT do?

• a.Remove the mask and change to a nasal cannula, which the patient's breathing can keep up with
• b.Nothing, because a bag that empties shows the patient is receiving all the oxygen delivered
• c.Detach the reservoir bag so room air can be drawn in
• d.Increase the oxygen flow until the bag stays partly inflated✓

The reservoir must not empty; when it does, the patient is pulling room air in around the mask and the delivered concentration falls, so the flow is raised within the range the device is run at, commonly 10 to 15 L/min, and the bag is filled before the mask goes on the face. A collapsing bag looks like efficient use of the oxygen, which is why doing nothing is the tempting answer, but it means demand has outrun supply. Changing to a nasal cannula lowers the concentration for a patient who evidently needs more, and taking the reservoir off turns the device into a simple face mask.

A patient punched in the face is bleeding heavily into his mouth, has loose teeth and is spitting blood. He is alert and sitting up, and nothing suggests a spinal injury. What is the airway priority?

• a.Pack the bleeding sockets and the mouth with gauze to control the bleeding
• b.Suction as needed and let him sit leaning forward so blood drains out✓
• c.Insert a nasopharyngeal airway so blood drains down it instead of into the pharynx
• d.Lay him flat and apply direct pressure to the face

With bleeding into the mouth the airway is kept clear by suction and by gravity: an alert patient with no spinal concern is left sitting up and leaning slightly forward, with suction in the EMT's hand and the unit running. Packing the mouth is the answer that tempts a candidate who has learned direct pressure for bleeding elsewhere, but gauze in the mouth obstructs the very airway the crew is protecting and can be aspirated. A nasal airway is avoided when the midface may be fractured. Lying him flat lets blood pool in the pharynx and is the fastest way to lose the airway.

A patient has full-thickness burns encircling the entire chest. Apart from the burn injury itself, what makes this patient a high priority?

• a.The stiff burned skin can restrict chest movement and limit ventilation✓
• b.Burned skin over the chest loses so much fluid that shock develops within minutes
• c.The burn will have destroyed the nerves that supply the diaphragm
• d.Circumferential burns bleed heavily beneath the eschar

A full-thickness burn right around the chest leaves a rigid, inelastic eschar, and as the tissue underneath swells the chest wall can no longer expand, so tidal volume falls even though the airway itself is clear; chest rise, effort and oxygenation are watched closely and the patient goes to a facility that can perform an escharotomy. Fluid loss from burns is real but develops over hours and is not what threatens this patient's breathing in the first minutes. The phrenic nerves arise in the neck and reach the diaphragm from inside the chest, out of reach of a skin burn. Full-thickness burns are typically dry and insensate rather than heavy bleeders.

A patient in anaphylaxis has a swollen tongue and audible stridor. Why will inserting an airway adjunct not relieve the obstruction?

• a.The obstruction in anaphylaxis is in the small lower airways, where an adjunct cannot reach
• b.The swelling narrowing the airway is at the larynx, past where any adjunct ends✓
• c.Adjuncts are contraindicated once epinephrine has been given
• d.An adjunct can only be used in an unresponsive patient, and this patient is still alert

An oral or nasal airway ends in the pharynx, above the vocal cords, while the swelling that produces stridor in anaphylaxis sits at and below the larynx, so the adjunct simply stops short of the narrowing; epinephrine is the treatment that reverses it, given as early as scope and protocol allow. The point about an alert patient is the one to weigh, because an oral airway genuinely would not be tolerated here, but a nasal airway usually is tolerated and even an unresponsive patient's laryngeal swelling would not be bypassed, so tolerance is not the reason. Bronchospasm in the lower airways does occur in anaphylaxis, but stridor is an upper-airway sound. Epinephrine does not contraindicate an adjunct.

A woman in the last month of pregnancy is choking, cannot speak or cough, and is still standing. Which technique should the EMT use?

• a.Chest thrusts over the middle of the sternum✓
• b.Abdominal thrusts with the woman lying on her left side
• c.Abdominal thrusts placed higher, above the enlarged uterus
• d.Lay her down at once and start chest compressions

In late pregnancy, and in a patient too large for the rescuer's arms to encircle, thrusts are delivered on the chest with the hands on the middle of the sternum and repeated until the object comes out or the patient becomes unresponsive. Moving the hands higher on the abdomen is the tempting adaptation, but the uterus fills the abdomen at this stage and thrusts there would compress it without generating the pressure needed to expel the object. Lying her on her side does not solve the same problem and gives the rescuer a worse position. Compressions belong to the patient who has become unresponsive, and this one is conscious and standing.

A bystander relieved an adult's airway obstruction with abdominal thrusts. The patient is now alert, breathing normally, and says she feels fine and does not want to go to hospital. What should the EMT tell her?

• a.She should be examined, because the thrusts can injure organs inside the abdomen✓
• b.She needs to be seen only if the object was never coughed up
• c.She can stay if she remains well for twenty minutes
• d.She cannot refuse care after a choking episode, because consent is implied once EMS is called

Abdominal thrusts generate enough force to injure the liver, spleen or stomach or to fracture ribs, and material may also have been aspirated, so evaluation is advised even for a patient who now feels well. A competent adult may still decline, and the EMT explains the risk, documents an informed refusal and makes clear she can call back. Implied consent applies to a patient who cannot consent, not to an alert one, so telling her she has no choice is both wrong and likely to end the conversation. Watching her for a set number of minutes on scene does not exclude an internal injury that can declare itself hours later, and whether the object was recovered says nothing about injury from the thrusts.

A patient who breathes through a permanent neck stoma is short of breath and needs supplemental oxygen. How should it be delivered?

• a.Over the mouth and nose with a nonrebreather, because the upper airway still humidifies
• b.Over the stoma, using a small mask or a tracheostomy mask✓
• c.Through a nasal cannula, so that secretions can be cleared from the stoma
• d.Over the mouth and nose at 15 liters per minute

Oxygen has to go where the air goes, and in a neck breather that is the stoma, so a tracheostomy mask or a small pediatric mask is placed over it; the mask can be lifted for suctioning when secretions build up. Delivering oxygen to the face is the classic error with these patients, and the reasoning about warming and humidifying is backwards: air reaching a stoma bypasses the nose entirely, which is why these patients need humidification rather than a route through the nose. A nasal cannula sends oxygen to a passage that in a total laryngectomy does not connect to the lungs at all.

A standard nasal cannula is generally not run above about 6 liters per minute. Why?

• a.Flows that high suppress the drive to breathe in most patients
• b.Higher flows force air down the esophagus and inflate the stomach
• c.The tubing of a cannula cannot withstand the pressure of a higher flow
• d.Higher flows dry the nose without adding useful oxygen✓

Above roughly 6 L/min a standard cannula adds little to the delivered concentration, because the amount of room air the patient entrains around it is what sets the concentration, while the higher flow dries and irritates the nasal mucosa and quickly becomes intolerable. A patient who needs more than that is moved to a mask. The suppressed respiratory drive belongs to a different and much-overstated concern in chronic lung disease, not to a flow ceiling on a device. Cannula tubing tolerates far higher flows than any portable regulator delivers, and oxygen at these flows does not inflate the stomach; that happens with positive-pressure ventilation.