NREMT EMT — All Questions

Several sites in the heart can generate their own electrical impulses, yet in a healthy adult the sinoatrial node sets the heart rate. What explains that?

• a.The sinoatrial node is the only cardiac tissue that can generate an impulse without a nerve signal reaching it first
• b.The sinoatrial node lies in the left atrium, where each cardiac cycle begins before spreading to the right side
• c.The sinoatrial node alone receives a sympathetic nerve supply, so only its rate can be driven upward
• d.The sinoatrial node depolarizes at a faster intrinsic rate than the other pacemaker sites, so it reaches threshold and fires before they do✓

Every pacemaker site has its own intrinsic rate — the sinoatrial node fastest, the atrioventricular junction slower, the ventricles slowest — and the fastest site drives the heart because it resets the others before they can fire on their own. The idea that the sinoatrial node is the only tissue with automaticity is the common misconception: the junction and the ventricles both take over when the node fails, just at a slower escape rate. The node sits in the right atrium, not the left, and both sympathetic and parasympathetic fibers reach far more of the heart than the node alone.

Impulses arriving from the atria are briefly held up at the atrioventricular node before passing on to the ventricles. What does that delay accomplish in a normal beat?

• a.It lets the atria finish emptying into the ventricles before the ventricles contract✓
• b.It gives the ventricular muscle time to repolarize fully so that the next impulse is not blocked
• c.It slows conduction enough for the coronary arteries to fill with blood while the atria are contracting
• d.It blocks impulses that arrive from the atria too quickly

The pause at the atrioventricular node lasts only a fraction of a second, and in that time the atria squeeze their remaining volume into the ventricles, adding to the stroke volume before ventricular contraction begins. The node does limit how many impulses reach the ventricles when the atria fire very fast, which makes the blocking answer tempting, but that protection is a consequence of the same slow conduction rather than the purpose of the normal beat-to-beat delay. Coronary filling occurs during ventricular relaxation and is not produced by the nodal delay, and ventricular repolarization is governed by the muscle's own refractory period.

An adult trauma patient has a strong carotid pulse but no palpable radial pulse at either wrist. Which conclusion is best supported by that finding alone?

• a.The systolic pressure is between 60 and 80 mmHg, the range in which the radial pulse disappears
• b.Perfusion at the periphery is poor and a blood pressure must actually be measured✓
• c.The arm is injured; the blood pressure is normal
• d.This finding by itself establishes decompensated shock

A carotid pulse with no radial pulse tells the EMT that blood is being shunted centrally, which is a real warning of poor peripheral perfusion — but it is a sign, not a number, and the pressure still has to be measured with a cuff. The old teaching that carotid, femoral and radial pulses correspond to systolic pressures of roughly 60, 70 and 80 mmHg has been tested against measured pressures and was found to overestimate them, so it should not be used to assign a value. Shock is staged from the whole picture, including mental status and an actual blood pressure, rather than from one missing pulse, and an isolated arm injury would not explain central shunting in both arms.

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.

A 79-year-old with type 2 diabetes has become gradually more confused over three days. His mouth and skin are very dry, his heart rate is 116 and his blood pressure is 96/58. His breathing is of normal depth with no unusual odor, and his home meter reads 'HI'. What should the EMT most suspect?

• a.A hyperosmolar hyperglycemic state, in which extreme dehydration develops without significant ketosis✓
• b.Diabetic ketoacidosis, since a sugar too high for the home meter to read must be producing ketones and deep rapid breathing
• c.Hypoglycemia, because confusion with a fast pulse and a low blood pressure is the classic picture of a low sugar
• d.Dehydration from poor intake alone, with the meter reading an error

Type 2 diabetics can drift over days into a hyperosmolar hyperglycemic state: the glucose climbs very high, the osmotic diuresis strips out water, and the patient becomes profoundly dehydrated and confused, yet enough insulin remains to prevent significant ketone production, so there is no acetone odor and no deep, rapid Kussmaul breathing. Ketoacidosis is the tempting answer whenever a meter reads too high to display, which is exactly why the breathing pattern and the absent odor matter here. A hypoglycemic patient does not produce an unreadably high meter result, and simple poor intake would not explain it either. EMT care is airway, oxygen if indicated, positioning and prompt transport, because these patients need intravenous fluid.

A teenager swallowed a large number of acetaminophen (paracetamol) tablets about two hours ago. She is alert, her vital signs are normal, and she says she feels fine and does not want to go to hospital. What is the most important point for the EMT to make?

• a.Severe liver injury can develop over the days that follow even though she feels well now✓
• b.She is out of danger, because acetaminophen becomes toxic only when it is taken with alcohol or another drug
• c.Feeling well two hours after the overdose shows the amount taken was below the toxic dose for her weight
• d.She should be made to vomit at home and then watched by her family for the next several hours

Acetaminophen poisoning is dangerous precisely because the first hours are quiet — nausea at most, then an apparently well patient — while a toxic metabolite injures the liver over the days that follow. The antidote works best when it is started early, so assessment, blood testing and the transport decision cannot wait for symptoms to appear. Alcohol and poor nutrition increase the risk but are not required for toxicity, and inducing vomiting at home is not recommended, since it delays definitive care and risks aspiration.

An EMT is called for a 22-year-old who told a friend he wanted to end his life. He is calm and cooperative, has no injuries and answers questions politely. What is the most appropriate way to assess his risk?

• a.Avoid raising the subject of suicide, since asking can plant the idea in a vulnerable patient's mind
• b.Ask him directly whether he has a plan and the means to carry it out✓
• c.Rely on the friend's account rather than questioning him, so that he is not made defensive
• d.Treat his calm manner as reassuring, since a patient at genuine risk is agitated and visibly distressed

Asking plainly about suicidal thoughts, a specific plan and access to the means does not increase risk — it is how risk is assessed, and a definite plan with the means at hand marks high risk. The calm, cooperative manner is the trap in this scenario: composure can follow a decision to act, so it is not evidence of safety. A friend's account is useful but does not replace speaking with the patient himself, and the crew still keeps the scene safe and removes obvious means where it can do so safely.

During an unavoidable field delivery the baby's buttocks present first and the body delivers as far as the shoulders, but the head does not follow. Under most EMS protocols, what should the EMT do?

• a.Support the body and slip a gloved hand in to make an airway space at the baby's face, then transport at once✓
• b.Pull steadily on the baby's body with each contraction until the head delivers, keeping the traction in line with the spine
• c.Push the baby back into the birth canal and hold it there until arrival at the hospital
• d.Wait without touching the baby for the mother to deliver the head herself

Once a breech body has delivered and the head has not followed, the cord is compressed between the head and the pelvis and the baby's face is pressed against the vaginal wall, so most protocols have the EMT support the body, insert a gloved hand palm-toward-the-face to push the tissue away from the nose and mouth, and transport immediately while maintaining that space. Traction on the body is the intuitive response and is the one thing that must not be done, because it can trap the head further and injure the neck and spinal cord. Pushing the baby back is not an EMT procedure, and waiting passively leaves both the airway and the cord obstructed.

An 84-year-old who takes a beta blocker fell at home and has a painful, swollen thigh. He is pale and sweaty, his skin is cool, his heart rate is 74 and his blood pressure is 104/86. How should the EMT interpret that heart rate?

• a.It rules out serious blood loss, since an injury bad enough to cause shock always drives the pulse up
• b.It shows he is compensating well, since a normal rate in an older adult means cardiac output is being maintained
• c.It may be blunted by his medication, so the other signs of poor perfusion carry more weight✓
• d.It points to neurogenic shock from a spine injury in the fall

Beta blockers prevent the heart-rate response that normally signals blood loss, so an older patient can be bleeding significantly with a pulse in the seventies; the pale, cool, sweaty skin and the narrow pulse pressure of 104/86 are the findings that carry the weight here. Reading the normal rate as evidence of good compensation is the tempting error, and it is the one most likely to slow the transport decision. A closed femur injury can hold a large volume of blood, and nothing here suggests a cord injury, which would give warm, dry skin rather than cool and sweaty.

A 55-year-old who has taken prednisone every day for years for an autoimmune illness has had two days of vomiting and has not kept her tablets down. She is weak, with a blood pressure of 82/54, a heart rate of 122 and warm skin. What should the EMT most suspect?

• a.An adrenal crisis brought on by stopping the steroid✓
• b.Simple dehydration from the vomiting, which will settle once she can drink again at home
• c.A vasovagal episode caused by the repeated vomiting, needing only supine positioning
• d.A late allergic reaction to the medication she has taken for years

Long-term steroid therapy suppresses the body's own cortisol production, so a patient who cannot keep the tablets down during an illness can lose the hormone that helps maintain blood pressure and blood sugar, producing weakness, vomiting and hypotension out of proportion to the fluid loss. Dehydration is the strong competing answer and is genuinely part of the picture, but the degree of hypotension in a steroid-dependent patient who has missed doses points beyond simple fluid loss, and these patients need hospital steroid replacement rather than fluids at home. EMT care is supportive: position, oxygen if indicated, warmth, a glucose check where a meter is carried, and prompt transport.

An EMT is inserting a nasopharyngeal airway in an unresponsive adult. Which insertion technique is correct?

• a.Insert it dry, because lubricant lets the airway slide too far and enter the esophagus
• b.Insert it only in a patient who has no gag reflex
• c.Aim the tip upward toward the bridge of the nose, then turn it downward once the resistance eases
• d.Lubricate it and advance it straight back along the floor of the nostril✓

A nasal airway is coated with a water-soluble lubricant and advanced straight back along the floor of the nasal cavity, perpendicular to the plane of the face, with the bevel turned toward the nasal septum; it is sized from the nostril to the earlobe and should fit the nostril without blanching the skin. Aiming upward toward the bridge of the nose drives the tip into the turbinates and causes bleeding that then has to be suctioned. Inserting it dry tears the mucosa. Tolerance in a patient who still has a gag reflex is the main advantage of a nasal airway over an oral one, not a restriction on its use.

An unresponsive head-injured patient has snoring respirations. Which finding would lead most EMS protocols to avoid a nasopharyngeal airway?

• a.A gag reflex that is still intact when the mouth is opened
• b.Clear fluid draining from the nose✓
• c.A history of chronic obstructive pulmonary disease with home oxygen
• d.Snoring that stops when the jaw is lifted forward

Clear or blood-tinged fluid from the nose or ear after a head injury suggests cerebrospinal fluid leaking through a basilar skull fracture, and most protocols avoid the nasal route in that situation because the floor of the cranial vault may no longer be intact. Raccoon eyes and bruising behind the ear point the same way. An intact gag reflex rules out an oral airway, not a nasal one. Snoring that clears with a jaw lift shows the tongue is the obstruction, which is a reason to place an adjunct rather than to withhold one, and lung disease has no bearing on the choice of adjunct.

An EMT is inserting an oropharyngeal airway in an unresponsive 3-year-old. Which technique is recommended at this age?

• a.Depress the tongue with a tongue blade and insert the airway in its anatomical position✓
• b.Insert it upside down and rotate it 180 degrees once the tip reaches the back of the throat
• c.Hyperextend the head first so the airway follows the curve of the pharynx
• d.Use a nasal airway instead, since oral airways are not used under eight years of age

In a small child the palate and posterior pharynx are soft and are easily torn by the rotation method, so the tongue is held down with a tongue blade and the airway is slid in following the natural curve of the mouth, curve down. Inserting it upside down and rotating it is the adult technique and is the answer most candidates carry over. Hyperextending a young child's head kinks the soft trachea and obstructs rather than opens the airway, which is why a neutral position is used. An oral airway is appropriate at any age once the gag reflex is absent, sized from the corner of the mouth to the earlobe or the angle of the jaw.

An unresponsive patient thrown from a motorcycle has snoring respirations, and a jaw-thrust maneuver does not open the airway. Under current resuscitation guidance, the EMT should:

• a.Continue the jaw thrust and ventilate with greater force to push air past the obstruction
• b.Roll the patient onto one side so the tongue falls forward
• c.Use a head-tilt/chin-lift, accepting the spinal risk in order to obtain an open airway✓
• d.Keep the jaw thrust and add an oral airway without moving the head

Resuscitation guidance is explicit that when a jaw thrust fails to open the airway of a patient with suspected spinal injury, the rescuer uses a head-tilt/chin-lift, because an airway that will not open kills far faster than the small additional risk of moving the neck. Adding an oral airway is the answer worth weighing and is reasonable alongside the maneuver, but an adjunct lies along the tongue and does nothing for soft tissue that a failed jaw thrust has left obstructing, so it cannot be the substitute for opening the airway. Ventilating harder raises airway pressure, inflates the stomach and still does not move air past a closed airway. Rolling a patient with a possible spinal injury to manage the tongue is neither necessary nor safe when a manual maneuver will do it.

A 9-month-old lying on a firm flat backboard keeps flexing the head forward, and bag-valve-mask ventilation is becoming difficult. What should the EMT do?

• a.Place padding under the infant's shoulders and back to bring the head neutral✓
• b.Tilt the head as far back as it will go, since a fully extended neck opens the small airway
• c.Slide a folded towel under the back of the head, the way an adult is placed in the sniffing position
• d.Turn the head to one side so the tongue falls forward

An infant's occiput is large relative to the body, so lying flat on a hard surface pushes the head forward and closes the airway; padding under the shoulders and torso lifts the body to meet the head and restores a neutral position. Padding behind the head is the adult adjustment and makes an infant's flexion worse, which is exactly the trap here. Hyperextending an infant's neck kinks the soft trachea and obstructs it. Turning the head does not lift the tongue off the posterior pharynx and would be unacceptable if any spinal injury were suspected.

Under current American Heart Association guidance, an apneic 4-year-old who still has a strong pulse should receive rescue breaths at about:

• a.One breath every 2 to 3 seconds✓
• b.One breath every 6 seconds, the same as an adult
• c.Two breaths after every 30 chest compressions
• d.One breath every 3 to 5 seconds, matching a child's normal rate

The 2020 guidelines raised rescue breathing for infants and children with a pulse to 20 to 30 breaths a minute, which is one breath every 2 to 3 seconds. One breath every 3 to 5 seconds, or 12 to 20 a minute, was the previous recommendation and is still printed in many older study guides, which makes it the answer worth pausing over; it was superseded. One every 6 seconds is the adult rate. Compressions are not started for a child who has a strong pulse, although they are added if the pulse falls below 60 with signs of poor perfusion despite oxygenation and ventilation.

How much volume should an EMT deliver with each bag-valve-mask breath to an adult, and over what time?

• a.The full contents of the bag, squeezed with both hands to guarantee an adequate volume
• b.Enough to make the chest just visibly rise, delivered over about one second✓
• c.Half the bag over about three seconds, so that airway pressure stays low
• d.As much as the bag delivers before resistance is felt

Each breath is given over about one second and only until the chest visibly rises, which is roughly 500 to 600 mL in an average adult. Larger or faster breaths raise pressure in the airway above what the esophagus holds shut, inflate the stomach and reduce the blood returning to the heart. Slowing each breath to three seconds is the tempting answer because a slower breath does lower peak pressure, but it delivers far more volume than the lungs need and, during CPR, keeps compressions interrupted for too long. Squeezing until resistance is felt means the lungs are already full and the excess is going into the stomach.

Why does a bag-valve mask running on oxygen need its reservoir bag attached?

• a.It vents excess pressure so a forceful squeeze cannot inflate the stomach
• b.Without it, the bag refills partly with room air, roughly halving the oxygen delivered✓
• c.Without it, the bag cannot be squeezed fast enough to keep up with a high ventilation rate
• d.It shows the rescuer that the mask seal is holding on each breath

The reservoir fills with oxygen between squeezes so the next breath is drawn from oxygen rather than from room air: with a reservoir and 15 L/min a bag-valve mask delivers roughly 90 percent or more, against about 40 to 60 percent without one. Pressure relief is the job of a pop-off valve fitted to some bags, particularly pediatric ones, and it is a separate part from the reservoir. The rate at which a bag can be refilled is not what the reservoir addresses, and the adequacy of the mask seal is judged by watching the chest rise.

An EMT is holding the mask for bag-valve-mask ventilation of a 5-year-old. Which part of the technique most often obstructs a child's airway?

• a.Ventilating with a bag intended for adults rather than a pediatric bag
• b.Pressing the fingers into the soft tissue under the chin✓
• c.Using a mask that covers the mouth and nose but not the eyes
• d.Holding the mask down with the thumb and index finger in a C shape

The fingers lifting the jaw must sit on the bony ridge of the mandible; pressed into the soft tissue under the chin they push the tongue up against the palate and close the airway, and a child's floor of mouth is small enough that this happens easily. A mask that covers the mouth and nose without covering the eyes or overhanging the chin is the correct fit, and the thumb and index finger forming a C over the mask with the remaining fingers on the jaw is the standard grip. An adult bag may be used on a child provided the squeeze stops as soon as the chest rises, because the delivered volume is controlled by the rescuer's hand rather than by the size of the bag.

While an EMT is suctioning a 4-year-old's airway, the heart rate falls from 130 to 68. What should the EMT do?

• a.Stop suctioning at once and ventilate the child with oxygen✓
• b.Continue suctioning until the airway is clear, since the secretions are what caused the drop
• c.Reduce the vacuum setting and continue the attempt
• d.Switch to a soft catheter and continue

Suctioning removes oxygen along with the secretions, and stimulating the posterior pharynx can produce a vagal bradycardia, which children show readily; stopping and oxygenating addresses both mechanisms at once. Continuing because the secretions caused the bradycardia is the choice worth weighing, and it is true that hypoxia from an obstructed airway is the commonest cause of bradycardia in a child, but the child cannot be oxygenated while the catheter is in the airway, so the safe order is to stop, oxygenate, then resume in short attempts. Lowering the vacuum or changing to a softer catheter leaves the child unoxygenated for just as long.

An unresponsive adult is vomiting large amounts of partly digested food, and the rigid suction catheter keeps clogging. What should the EMT do?

• a.Set the vacuum to its maximum and keep suctioning with the rigid catheter until the mouth clears
• b.Change to a soft flexible catheter, which passes more easily through the debris
• c.Ventilate through the vomit with the bag-valve mask to clear it
• d.Log-roll the patient as a unit and suction through the wide-bore tubing with the tip removed✓

Vomit with solid particles exceeds what any catheter tip will pass, so the tip is taken off and the wide-bore tubing used directly, while the patient is rolled so that gravity does most of the work; where spinal injury is possible the roll is done as a unit with the head and body in line. Raising the vacuum does not widen the catheter and the clog stays where it is. A soft catheter has a narrower lumen still and clogs sooner, which is why it is reserved for the nose and for suctioning through a tube. Ventilating over the vomit drives it into the lungs.

An unresponsive adult has loud gurgling with every breath. What is the EMT's immediate action?

• a.Suction the airway✓
• b.Perform a jaw-thrust maneuver to lift the tongue off the pharynx
• c.Apply a nonrebreather mask at 15 liters per minute
• d.Insert an oropharyngeal airway and begin bag-valve-mask ventilation

Gurgling is the sound of liquid in the airway, and nothing is delivered into that airway until the liquid is removed, because ventilating or running oxygen over it pushes the fluid into the lungs. Snoring is the sound that a jaw thrust or an adjunct relieves, which is why the two noises must be told apart rather than treated alike. Suction is applied while withdrawing the catheter, in short attempts commonly taught as roughly 10 to 15 seconds in an adult with the exact limit set by local protocol, and the patient is reoxygenated between attempts.

In an EMS system whose EMTs use waveform capnography, what does it show that pulse oximetry does not?

• a.The oxygen concentration the bag-valve mask is delivering
• b.The percentage of the patient's hemoglobin that is carrying oxygen right now
• c.Whether carbon monoxide is bound to the hemoglobin instead of oxygen
• d.How effectively the patient is being ventilated, breath by breath✓

Capnography measures the carbon dioxide the patient breathes out, so it reports ventilation, normally about 35 to 45 mmHg, and it changes within a breath or two of the patient's condition changing. A pulse oximeter reports the saturation of hemoglobin with oxygen, and it lags behind events by a minute or more, so a patient whose ventilation has just failed still reads well. Carbon monoxide bound to hemoglobin is detected by a CO-oximeter, and neither device reports the concentration of oxygen a bag or mask is delivering, which is a property of the device and the flow rate.

During CPR on an adult with waveform capnography in place, end-tidal carbon dioxide rises abruptly from 11 to 42 mmHg and stays there. What does this most likely mean?

• a.The rescuer is ventilating too rapidly and carbon dioxide is accumulating
• b.Compressions have become too shallow to circulate blood
• c.The airway device has been displaced and ventilation is now ineffective
• d.Circulation may have returned✓

A sudden sustained rise in end-tidal carbon dioxide during CPR usually means blood is circulating again and carrying carbon dioxide back to the lungs, so the finding is confirmed at the next scheduled rhythm check rather than by stopping compressions to feel for a pulse. A displaced airway makes the waveform disappear or fall toward zero, which is the opposite change. Ventilating too fast blows carbon dioxide off and lowers the number. Shallow or tiring compressions likewise show a persistently low value, often under 10 mmHg, and are a prompt to change compressors rather than an explanation for a rise.

A 19-year-old in a severe asthma attack was agitated and wheezing loudly on arrival. Ten minutes later he is drowsy, breathing 8 shallow times a minute, and the wheeze is barely audible. The EMT should:

• a.Keep the nonrebreather in place and let him rest, as the calmer breathing shows improvement
• b.Sit him upright and coach him to slow his breathing
• c.Assist him with a second dose from his inhaler before doing anything else
• d.Begin bag-valve-mask ventilation with high-flow oxygen and transport urgently✓

Drowsiness, a falling rate and a chest that has gone quiet are the signs of a patient who is exhausted and about to arrest, not of a patient improving: the wheeze fades because too little air is moving to make the sound. Ventilation with a bag-valve mask, oxygen and rapid transport is what this patient needs. Assisting the inhaler is the option worth weighing, since a bronchodilator is the treatment for the bronchospasm itself, but a drowsy patient cannot generate the inspiratory flow a metered-dose inhaler requires, and where scope permits, medication follows assisted ventilation rather than replacing it. Coaching a rate of 8 to slow further would worsen an already inadequate minute volume.

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.