, Question 1
A patient in respiratory distress has a SpO2 of 88% on room air and is being
ventilated with a BVM at 16 breaths/min. Capnography shows an ETCO2
waveform that is progressively widening with a shark-fin upslope. What is the
most appropriate interpretation and action?
A. Normal waveform; continue current ventilation rate.
B. Bronchospasm; administer a bronchodilator and continue assisted
ventilations.
C. Hyperventilation; reduce rate to 10 breaths/min.
D. Esophageal intubation; remove the airway adjunct and re-ventilate.
Correct Answer: B - Bronchospasm; administer a bronchodilator
and continue assisted ventilations.
RATIONALE
The shark-fin (or sloping) upstroke on capnography is a classic
indicator of obstructive airway disease (bronchospasm), requiring
bronchodilator therapy while maintaining ventilation. A normal
waveform is rectangular; hyperventilation lowers ETCO2 without
changing morphology; esophageal intubation produces absent or
rapidly declining ETCO2.
Question 2
A patient with a suspected opioid overdose presents with pinpoint pupils,
respiratory depression, and a respiratory rate of 6/min. After one dose of
naloxone 0.4 mg IV, the patient's respiratory rate rises to 14/min but the patient
remains unresponsive. What is the best next action?
A. Administer a second dose of naloxone 0.4 mg IV and continue
monitoring.
B. Begin bag-valve-mask ventilation and withhold further naloxone.
C. Insert an oropharyngeal airway and transport without further
medication.
Page 2
, D. Administer flumazenil 0.2 mg IV to reverse possible benzodiazepine
co-ingestion.
Correct Answer: B - Begin bag-valve-mask ventilation and
withhold further naloxone.
RATIONALE
The goal of naloxone is to restore adequate spontaneous ventilation,
not full consciousness. Since the respiratory rate is now 14/min, the
patient is ventilating adequately; additional naloxone risks acute
withdrawal and seizures. BVM ventilation is appropriate if breathing
is inadequate, but here it is adequate; flumazenil is contraindicated in
mixed overdose due to seizure risk.
Question 3
A patient with a suspected cervical spine injury is being immobilized. Which
of the following best describes the current evidence-based recommendation for
spinal motion restriction (SMR) in the prehospital setting?
A. Routine backboard immobilization for all trauma patients with any
mechanism of injury.
B. SMR should be applied selectively based on validated clinical criteria
(e.g., NEXUS or Canadian C-Spine Rule).
C. Manual stabilization alone is sufficient for all patients with neck pain.
D. A rigid collar alone provides adequate spinal motion restriction.
Correct Answer: B - SMR should be applied selectively based on
validated clinical criteria (e.g., NEXUS or Canadian C-Spine
Rule).
Page 3
, RATIONALE
Current guidelines endorse selective spinal motion restriction using
validated decision rules (NEXUS, Canadian C-Spine Rule) to reduce
unnecessary immobilization and its complications. Routine
backboarding is no longer recommended; manual stabilization is used
during assessment, and a collar alone does not provide full restriction.
Question 4
A patient with a history of heart failure presents with severe dyspnea,
orthopnea, and pink frothy sputum. Vital signs: BP 180/100, HR 120, RR 32,
SpO2 82% on room air. Which intervention is most appropriate?
A. Administer 0.4 mg nitroglycerin sublingual and apply CPAP.
B. Administer 1 mg epinephrine 1:10,000 IV push.
C. Administer 500 mL normal saline bolus.
D. Administer 2 mg morphine IV push.
Correct Answer: A - Administer 0.4 mg nitroglycerin sublingual
and apply CPAP.
RATIONALE
This presentation is acute cardiogenic pulmonary edema. CPAP
improves oxygenation and reduces preload/afterload; nitroglycerin
reduces preload. Epinephrine is for anaphylaxis/cardiac arrest; fluid
bolus worsens pulmonary edema; morphine is no longer routinely
recommended due to adverse outcomes.
Question 5
A patient with a suspected tension pneumothorax presents with severe dyspnea,
absent breath sounds on the right, hypotension, and tracheal deviation to the
left. What is the most appropriate immediate intervention?
A. Needle decompression at the 2nd intercostal space, midclavicular line.
B. Needle decompression at the 5th intercostal space, anterior axillary
line.
Page 4
A patient in respiratory distress has a SpO2 of 88% on room air and is being
ventilated with a BVM at 16 breaths/min. Capnography shows an ETCO2
waveform that is progressively widening with a shark-fin upslope. What is the
most appropriate interpretation and action?
A. Normal waveform; continue current ventilation rate.
B. Bronchospasm; administer a bronchodilator and continue assisted
ventilations.
C. Hyperventilation; reduce rate to 10 breaths/min.
D. Esophageal intubation; remove the airway adjunct and re-ventilate.
Correct Answer: B - Bronchospasm; administer a bronchodilator
and continue assisted ventilations.
RATIONALE
The shark-fin (or sloping) upstroke on capnography is a classic
indicator of obstructive airway disease (bronchospasm), requiring
bronchodilator therapy while maintaining ventilation. A normal
waveform is rectangular; hyperventilation lowers ETCO2 without
changing morphology; esophageal intubation produces absent or
rapidly declining ETCO2.
Question 2
A patient with a suspected opioid overdose presents with pinpoint pupils,
respiratory depression, and a respiratory rate of 6/min. After one dose of
naloxone 0.4 mg IV, the patient's respiratory rate rises to 14/min but the patient
remains unresponsive. What is the best next action?
A. Administer a second dose of naloxone 0.4 mg IV and continue
monitoring.
B. Begin bag-valve-mask ventilation and withhold further naloxone.
C. Insert an oropharyngeal airway and transport without further
medication.
Page 2
, D. Administer flumazenil 0.2 mg IV to reverse possible benzodiazepine
co-ingestion.
Correct Answer: B - Begin bag-valve-mask ventilation and
withhold further naloxone.
RATIONALE
The goal of naloxone is to restore adequate spontaneous ventilation,
not full consciousness. Since the respiratory rate is now 14/min, the
patient is ventilating adequately; additional naloxone risks acute
withdrawal and seizures. BVM ventilation is appropriate if breathing
is inadequate, but here it is adequate; flumazenil is contraindicated in
mixed overdose due to seizure risk.
Question 3
A patient with a suspected cervical spine injury is being immobilized. Which
of the following best describes the current evidence-based recommendation for
spinal motion restriction (SMR) in the prehospital setting?
A. Routine backboard immobilization for all trauma patients with any
mechanism of injury.
B. SMR should be applied selectively based on validated clinical criteria
(e.g., NEXUS or Canadian C-Spine Rule).
C. Manual stabilization alone is sufficient for all patients with neck pain.
D. A rigid collar alone provides adequate spinal motion restriction.
Correct Answer: B - SMR should be applied selectively based on
validated clinical criteria (e.g., NEXUS or Canadian C-Spine
Rule).
Page 3
, RATIONALE
Current guidelines endorse selective spinal motion restriction using
validated decision rules (NEXUS, Canadian C-Spine Rule) to reduce
unnecessary immobilization and its complications. Routine
backboarding is no longer recommended; manual stabilization is used
during assessment, and a collar alone does not provide full restriction.
Question 4
A patient with a history of heart failure presents with severe dyspnea,
orthopnea, and pink frothy sputum. Vital signs: BP 180/100, HR 120, RR 32,
SpO2 82% on room air. Which intervention is most appropriate?
A. Administer 0.4 mg nitroglycerin sublingual and apply CPAP.
B. Administer 1 mg epinephrine 1:10,000 IV push.
C. Administer 500 mL normal saline bolus.
D. Administer 2 mg morphine IV push.
Correct Answer: A - Administer 0.4 mg nitroglycerin sublingual
and apply CPAP.
RATIONALE
This presentation is acute cardiogenic pulmonary edema. CPAP
improves oxygenation and reduces preload/afterload; nitroglycerin
reduces preload. Epinephrine is for anaphylaxis/cardiac arrest; fluid
bolus worsens pulmonary edema; morphine is no longer routinely
recommended due to adverse outcomes.
Question 5
A patient with a suspected tension pneumothorax presents with severe dyspnea,
absent breath sounds on the right, hypotension, and tracheal deviation to the
left. What is the most appropriate immediate intervention?
A. Needle decompression at the 2nd intercostal space, midclavicular line.
B. Needle decompression at the 5th intercostal space, anterior axillary
line.
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