NREMT EMT — All Questions

A crew checks capillary refill on the fingernail of an adult found outdoors on a cold night. Which statement about that finding is correct?

• a.Cold surroundings slow refill on their own, so it must be read alongside the rest of the perfusion picture✓
• b.Refill time is the single most reliable indicator of perfusion in adults, so a delayed result confirms shock whatever the conditions
• c.A refill time over two seconds in an adult establishes that the patient is hypovolemic
• d.Refill is more useful in adults than in young children

Capillary refill is slowed by cold ambient temperature, by age and by peripheral vascular disease, so on a cold night a delayed result may say more about the environment than about cardiac output; it belongs in the perfusion picture beside skin color and temperature, mental status, pulse quality and blood pressure. Treating it as the single most reliable adult indicator is the tempting error — it is one of the better bedside signs in young children and least reliable in exactly the setting described here. The two-second figure is a rough guide rather than a threshold that establishes hypovolaemia on its own.

A patient with a very large upper arm is assessed with the standard adult cuff, the only size carried on the ambulance. The reading is 168/96, although she feels well and has never been told she has high blood pressure. What is the most likely explanation?

• a.The reading is accurate and simply reflects the extra work of perfusing a larger body
• b.A cuff that is too small leaks pressure as it deflates, so the true pressure is higher than the reading shown
• c.Arm circumference does not affect the reading as long as the bladder is centered over the brachial artery
• d.The cuff is too small for her arm, which pushes the reading up✓

A cuff whose bladder is too narrow for the arm has to be inflated to a higher pressure before it compresses the brachial artery, so it reads falsely high; a cuff that is too large for the arm reads falsely low. The reading should be repeated with a large adult cuff before hypertension is reported or acted on. Centring the bladder over the artery does matter, but it does not cancel out the wrong cuff size, and body size by itself does not produce a genuinely elevated pressure in a well patient.

In some patients the Korotkoff sounds fade out just below the true systolic pressure and reappear again lower down — an auscultatory gap. If the cuff is not inflated above that silent interval, what happens to the reading, and what prevents the error?

• a.The diastolic pressure is underestimated; deflating the cuff more slowly through the lower range prevents it
• b.The pulse pressure is exaggerated; switching to a wider cuff and repeating the measurement prevents it
• c.The systolic reading comes out too low; palpating the systolic first prevents it✓
• d.Neither number is affected; the gap only delays the reading

If the cuff is inflated only into the silent interval, the first sound heard on deflation is the return of sounds below the gap, so the systolic pressure is recorded lower than it truly is. Palpating the radial pulse, noting the pressure at which it disappears and then inflating roughly 30 mmHg above that point puts the cuff safely above the gap before deflation begins. An auscultatory gap tends to make the diastolic value read high rather than low, and cuff width is a separate source of error that does not create the silent interval.

A 30-year-old struck in the abdomen has a heart rate of 124, a blood pressure of 116/94, cool moist skin, and is anxious and repeatedly asking what happened. How should the EMT read this set of numbers?

• a.Adequate perfusion, since the systolic pressure is within the normal adult range and he is awake and talking
• b.Compensated shock, with the narrow pulse pressure showing that vasoconstriction is holding the systolic up✓
• c.Decompensated shock, since a diastolic above 90 marks the point where compensation has failed
• d.Anxiety alone, which raises both the pulse and the diastolic pressure

Vasoconstriction raises the diastolic pressure while the systolic is defended, so the pulse pressure narrows — here 116 minus 94 leaves 22 mmHg — and that narrowing, together with tachycardia, cool moist skin and anxiety, is the picture of compensated shock. A systolic of 116 looks reassuring, which is precisely the trap: in decompensated shock the systolic falls, and waiting for that means waiting until compensation has already failed. No diastolic number defines decompensation, and anxiety alone does not produce cool, moist skin after abdominal trauma.

A 74-year-old, two days after a heart attack, is confused, with a blood pressure of 78/56, a heart rate of 118, cold grey skin, and crackles heard part way up both lung fields. Under a typical EMS protocol, what does this patient need from the EMT?

• a.Supine with the legs raised, the standard response to any patient whose systolic pressure is below 90
• b.Assisting him with his own nitroglycerin, since reducing the heart's workload is the priority in cardiogenic shock
• c.Oxygen titrated to his saturation, a position that eases his breathing, and rapid transport✓
• d.Warm blankets and a flat position while ALS is awaited

This is cardiogenic shock: the damaged pump cannot maintain output, so pressure falls while blood backs up into the lungs. EMT care is supportive — oxygen guided by the saturation, a position the patient can breathe in, warmth, and fast transport to a facility that can treat the pump, with an ALS intercept where one is available. Raising the legs is the tempting move because the pressure is low, but in a patient whose lungs are already wet it pushes more volume back toward a failing left ventricle, and nitroglycerin lowers the pressure further and is contraindicated at this blood pressure.

A patient thrown from a motorcycle cannot move his legs. His blood pressure is 84/60, his heart rate is 58, and his skin is warm and dry below the nipple line. Which explanation fits the findings best?

• a.A faint brought on by pain, which lifts once he is lying flat
• b.Hypovolemic shock from an unrecognised abdominal bleed, since hemorrhage is by far the commonest cause of hypotension after trauma
• c.Spinal shock, the temporary loss of reflexes and movement below the level of injury
• d.Neurogenic shock, in which lost sympathetic tone leaves the vessels dilated and prevents the usual rise in heart rate✓

Warm, dry skin below the injury, hypotension without tachycardia, and a motor deficit point to neurogenic shock, where the injury has interrupted sympathetic outflow so the vessels dilate and the heart cannot speed up to compensate. Occult hemorrhage is the strong competing answer and must still be assumed and treated in any thrown rider — but bleeding produces cool, pale, sweaty skin and a fast pulse, and the picture here is the opposite. Spinal shock names the loss of reflex activity below a cord injury and is not a circulatory diagnosis, and a simple faint does not leave a patient hypotensive and paralysed.

Which pairing of a type of shock with the skin findings usually seen early in it is correct?

• a.Cardiogenic shock — warm, dry, flushed skin produced by blood backing up behind the failing heart
• b.Hypovolemic shock — flushed skin produced by stored red cells released from the spleen
• c.Septic shock — skin that is warm and flushed early, turning cool and mottled later✓
• d.Anaphylactic shock — cold, pale, dry skin from the histamine release

Septic shock, like the other distributive shocks, begins with widespread vasodilation, so the skin is often warm, flushed and dry early on and only becomes cool and mottled as the patient deteriorates — which is why a warm patient can still be in profound shock. Cardiogenic and hypovolemic shock both drive intense vasoconstriction and give the cold, pale, sweaty skin that most candidates associate with shock in general. Anaphylaxis is also distributive, so it typically flushes the skin and adds hives rather than making it cold and dry.

An 80-year-old is dizzy and nearly fainting when she sits up. Her pulse is regular at 38 and her blood pressure is 82/50. No cardiac monitor is available. Under a typical EMS protocol, what should the EMT do?

• a.Keep her supine, give oxygen if she is hypoxic, and request ALS✓
• b.Walk her to the ambulance, since activity raises the heart rate through the sympathetic response
• c.Apply the AED, which will pace the heart once the pads are attached
• d.Withhold treatment unless the rate falls below 30, the point at which bradycardia becomes symptomatic

A regular rate of 38 with hypotension and near-syncope is symptomatic bradycardia, and the EMT's part is supportive — supine positioning, oxygen if the saturation is low, close reassessment — plus getting her to definitive care or to a paramedic crew, since the drugs and pacing that treat the rhythm sit above the EMT scope in essentially every system. Applying the AED is the tempting action because it is the cardiac device on the truck, but an automated external defibrillator analyzes for shockable rhythms and has no pacing function. Bradycardia is called symptomatic because of the symptoms rather than because the rate crosses a set figure, and making a hypotensive patient stand invites a syncopal fall.

A 40-year-old says her heart suddenly started racing while she sat watching television. The radial pulse is regular and too fast to count reliably; a carotid count gives about 190. She is alert, with a blood pressure of 108/70, no fever, no pain, no blood loss and no exertion. Without a monitor, what should the EMT suspect?

• a.Sinus tachycardia from anxiety, which commonly drives an adult resting heart rate to around 190
• b.Atrial fibrillation, which characteristically produces a rapid but perfectly regular pulse at the wrist
• c.A normal finding, since she is alert with an acceptable blood pressure
• d.A supraventricular tachycardia, given the abrupt onset at rest and the very high rate✓

An abrupt onset at rest and a regular rate near 190 in an adult with no fever, pain, bleeding or exertion fit a supraventricular tachycardia; sinus tachycardia has an identifiable cause, comes on gradually and rarely reaches that rate at rest in an adult of this age. Anxiety is the strong competing answer and certainly produces a fast pulse, but the switch-on-while-sitting-quietly history and the rate itself argue against it. Atrial fibrillation gives an irregularly irregular pulse, and a rate near 190 is not a normal finding even in a patient who currently looks well; EMT care here is oxygen if indicated, a position of comfort and transport with ALS where available.

A hiker is dug out of a snowdrift, unresponsive, with no breathing and no pulse detected over a careful 45-second check. He is profoundly cold and stiff, with no rigor mortis, no lividity and no obviously lethal injury. Under most EMS protocols, how does the crew's approach differ from an ordinary cardiac arrest?

• a.Move him quickly and vigorously into the warm ambulance so that rewarming can begin at once
• b.Withhold resuscitation, since a cold and pulseless patient recovered from snow meets the usual criteria for obvious death
• c.Start compressions and ventilations, handle him gently, and continue while he is rewarmed during transport✓
• d.Compress at half the usual rate to match his slowed metabolism

Severe hypothermia slows metabolism enough that a pulse and respirations can be undetectable in a patient who is still salvageable, so resuscitation is started and continued with active rewarming, and the decision to stop is generally deferred to the hospital. Withholding care is tempting because the patient is cold and stiff, but stiffness from cold is not rigor mortis and none of the usual signs of irreversible death are present here. A profoundly cold heart is irritable and rough handling can precipitate ventricular fibrillation, and compressions are still delivered at the standard rate and depth.

A child is pulled from a lake unresponsive, not breathing and pulseless. Compared with a witnessed adult collapse from a suspected cardiac cause, what does the drowning change about the resuscitation?

• a.Nothing changes; compression-only CPR is preferred after drowning just as it is for a witnessed adult collapse
• b.Ventilations matter more, because the arrest follows a period of hypoxia✓
• c.The AED is left off because the chest is wet
• d.Abdominal thrusts are given first to clear water from the lungs before compressions begin

Drowning kills by hypoxia, so the blood is already desaturated by the time the heart stops and rescue breaths are an essential part of the resuscitation rather than an optional extra — compressions combined with ventilations, not compression-only CPR, are what this child needs. Trying to expel water first is the classic error: water in the lungs cannot be drained out, and abdominal thrusts delay compressions and invite vomiting and aspiration. The AED is still applied; the chest is simply dried before the pads go on.

A woman who appears to be near term collapses in cardiac arrest in a shop. Two rescuers are present. Besides high-quality CPR and rapid transport, what does the pregnancy add?

• a.Tilt the whole backboard about 30 degrees to the left, which is preferred to manual displacement because it frees a rescuer
• b.Have one rescuer manually displace the uterus to her left while compressions continue✓
• c.Hold defibrillation until after delivery, because the shock can reach the fetus
• d.Compress over the xiphoid to reach the displaced heart

Near term the uterus compresses the inferior vena cava when the patient is supine, cutting off the venous return that chest compressions depend on, so a dedicated rescuer holds the uterus displaced to the patient's left throughout. Tilting the board is the older technique and is the tempting answer, but a tilted torso makes effective compressions much harder, so continuous manual displacement on a flat, firm surface is now preferred. Defibrillation is delivered in the usual way, and compressions are given on the lower half of the sternum rather than over the xiphoid process.

A service equips some of its ambulances with a mechanical chest-compression device. Which statement reflects current guidance on how such a device should be used?

• a.Applying it takes priority over starting manual compressions, since it delivers a consistent depth and rate from the first minute
• b.It has been shown to improve survival with good neurological recovery compared with high-quality manual compressions
• c.Once it is running, ventilations are no longer needed because it moves enough air on its own
• d.It is a reasonable alternative to manual compressions in particular situations✓

Trials comparing mechanical compression devices with high-quality manual CPR have not shown better survival or better neurological outcome, so guidelines treat them as a reasonable alternative in specific circumstances — a moving ambulance, a prolonged resuscitation, too few rescuers, or a place where a rescuer cannot kneel safely — rather than as a routine upgrade. Because of that, manual compressions begin at once and the device is fitted with only a brief planned pause. The device compresses the chest; it does not ventilate the patient, so ventilations continue as the protocol directs.

Cardiac arrest in children usually develops differently from arrest in adults. What follows from that for an EMT at the side of an unresponsive, pulseless 5-year-old?

• a.Compressions must be paired with effective ventilations, because the arrest usually began with hypoxia✓
• b.Compression-only CPR is preferred for children too, since pausing to ventilate lowers the perfusion pressure
• c.The AED should go on before compressions, because a shockable rhythm is the commonest cause of arrest at this age
• d.Ventilations alone are given until a pulse returns

Most pediatric arrests are the end point of respiratory failure or shock rather than a sudden rhythm problem, so the child is profoundly hypoxic by the time the pulse is lost and oxygen has to be put back in: compressions together with ventilations, at the ratio local guidelines set for one or two rescuers. That is why compression-only CPR, a reasonable option for an untrained bystander at an adult collapse, is not the preferred approach here. A shockable rhythm is uncommon at this age, so the defibrillator does not come ahead of compressions, and ventilations alone cannot circulate the oxygen once the pulse is gone.

A crew is shown a signed POLST form for a nursing-home resident who is in cardiac arrest. In most states, how does a POLST form differ from a traditional do-not-resuscitate order?

• a.It is a statement of the patient's wishes written by the patient or family, which the crew may honour only after medical direction agrees
• b.It applies only inside the facility that issued it
• c.It is a portable medical order covering several treatment decisions, not only resuscitation✓
• d.It authorises the crew to withhold comfort measures as well as resuscitation

In most states a POLST — also called a MOLST or POST — is a portable medical order signed by a physician or other authorised clinician that travels with the patient and addresses more than code status, recording decisions about intubation, other interventions and sometimes transport, whereas a traditional do-not-resuscitate order addresses resuscitation alone. Which forms are valid, whose signature is required and whether the original must be produced are set by state law and local protocol, so crews follow their own state's rules. The form is a clinician's order rather than a family's statement of wishes, it follows the patient between settings, and comfort care is given whatever the form says.

A crew finds an unresponsive man with no pulse and no breathing, cool skin, a stiff jaw and stiff limbs, and dark purple discolouration along the back where he lies. Under the resuscitation policies used in most states, what is appropriate?

• a.Begin CPR and continue until a physician orders it stopped, since only a physician may declare a patient dead
• b.Begin CPR, since rigor and lividity are unreliable in a cool room and the arrest may be recent
• c.Withhold resuscitation and follow local policy for a death on scene✓
• d.Begin CPR and stop only after the AED has advised no shock on three consecutive analyzes

Rigor mortis together with dependent lividity are among the signs of irreversible death that EMS protocols in most states allow a crew to recognize without starting resuscitation; the crew then preserves the scene, makes the notifications its policy requires and supports the family. Beginning CPR is the safe default and is the right choice whenever the findings are equivocal, which is what makes that answer tempting — but here two independent signs of prolonged death are present together. Who may pronounce death, and who may authorise stopping a resuscitation once it has begun, are matters of state law and local protocol, and neither is settled by counting AED analyzes.