Elite Tennessee EMS
Paramedic Test Bank
Protocol: 2026/2027
Standards
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Hard-deck definitions,
2026 formulary updates, airway pharmacology, and high-performance resuscitation
metrics.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Hemodynamic shifting,
algorithmic sequencing, destination triage, and pediatric physiological variations.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-system failure
scenarios requiring immediate synthesis of competing priorities, pharmacology, and
procedural interventions.
PART I: THE PRIMER
Mastery of this material forges the gap between basic algorithmic compliance and elite,
autonomous resuscitation science. By internalizing the 2026/2027 Tennessee Emergency
Medical Services protocols, clinicians transition from reactionary technicians into proactive,
high-performance resuscitation specialists.
● The Ketamine Mandate: Etomidate is completely removed from the 2026 formulary;
Ketamine (2 mg/kg) is the exclusive induction agent for all advanced airways.
● High-Performance CPR: Resuscitation demands 2–3 minutes of supine CPR followed by
a 30-degree head-and-shoulder elevation to optimize cerebral perfusion.
● The ETCO2 Hard-Deck: Continuous waveform capnography is mandatory; readings <20
mmHg indicate ineffective compressions, and <10 mmHg precludes the return of
spontaneous circulation (ROSC).
● Push-Dose Pressors: Septic shock refractory to fluid boluses requires early aggressive
intervention utilizing push-dose Epinephrine (5–10 mcg) to maintain a target systolic blood
pressure (SBP) of 90–110 mmHg.
● C-STAT Validation: The Cincinnati Stroke Triage Assessment Tool (C-STAT) dictates that
a score of ≥2 indicates a Large Vessel Occlusion (LVO), mandating bypass to a
thrombectomy-capable center.
,PART II: THE ELITE TEST BANK
Q1: A patient requires Rapid Sequence Intubation (RSI). Based on the 2026 Tennessee EMS
Protocols, which induction agent is MOST APPROPRIATE? A) Etomidate 0.3 mg/kg IV B)
Midazolam 5 mg IV C) Ketamine 2 mg/kg IV D) Fentanyl 100 mcg IV
● The Answer: C (Ketamine 2 mg/kg IV)
● Distractor Analysis:
○ A is incorrect: Etomidate has been explicitly removed from the 2026 Tennessee
prehospital formulary.
○ B is incorrect: Midazolam is for post-intubation sedation in normotensive patients,
not primary induction.
○ D is incorrect: Fentanyl provides analgesia, not deep dissociation for intubation.
The Mentor's Analysis: The state has unified its airway pharmacology. Ketamine provides
excellent dissociation while maintaining respiratory drive. Professional/Academic Intuition:
Etomidate is obsolete; Ketamine is the universal induction hard-deck.
Q2: During an RSI attempt, the clinician must optimize oxygenation reserves. According to
Tennessee guidelines, what action must occur IMMEDIATELY during the laryngoscopy attempt?
A) Remove all oxygen delivery devices to visualize the cords. B) Apply high-flow oxygen via a
nasal cannula at 8-10 Lpm. C) Administer bag-valve-mask ventilations simultaneously. D)
Hyperventilate the patient to an ETCO2 of 25 mmHg.
● The Answer: B (Apply high-flow oxygen via a nasal cannula at 8-10 Lpm.)
● Distractor Analysis:
○ A is incorrect: Removing all oxygen rapidly induces fatal hypoxia.
○ C is incorrect: Positive pressure ventilation must pause during direct laryngoscopy.
○ D is incorrect: Hyperventilation causes cerebral vasoconstriction.
The Mentor's Analysis: Apneic oxygenation prevents precipitous desaturation via mass flow. By
utilizing a nasal cannula, you bypass the common trap of hypoxic peri-intubation arrests.
Professional/Academic Intuition: Never remove the nasal cannula during airway
instrumentation.
Q3: Following successful intubation, a trauma patient's SBP drops to 82 mmHg. To maintain
continuous sedation, which medication is MOST APPROPRIATE? A) Midazolam 0.1 mg/kg IV
B) Ketamine 2 mg/kg slow IV C) Fentanyl 5 mcg/kg IV D) Propofol 1 mg/kg IV
● The Answer: B (Ketamine 2 mg/kg slow IV)
● Distractor Analysis:
○ A is incorrect: Midazolam (Versed) is indicated for post-intubation sedation only if
the SBP is strictly >90 mmHg.
○ C is incorrect: Fentanyl addresses pain but fails to ensure deep sedation.
○ D is incorrect: Propofol is not a standard Tennessee EMS ALS induction agent.
The Mentor's Analysis: Hypotension dictates your sedation pathway. When facing a hypotensive
intubated patient, the immediate priority is preserving sympathetic tone. Professional/Academic
Intuition: Hypotension eliminates Versed; default to Ketamine for continued sedation.
Q4: A cardiac arrest patient has received 2 minutes of high-performance CPR in the supine
position. What is the NEXT positional requirement per Tennessee protocol? A) Place the patient
in the Trendelenburg position. B) Elevate the patient's head and shoulders approximately 30
degrees. C) Roll the patient into the left lateral recumbent position. D) Elevate the patient's legs
45 degrees.
, ● The Answer: B (Elevate the patient's head and shoulders approximately 30 degrees.)
● Distractor Analysis:
○ A is incorrect: Trendelenburg increases intracranial pressure, severely reducing
cerebral perfusion.
○ C is incorrect: Lateral recumbent is for the pregnant patient with a pulse.
○ D is incorrect: Passive leg raises do not optimize venous drainage from the brain.
The Mentor's Analysis: Elevating the head reduces intracranial venous pooling, creating a
pressure gradient that allows forward arterial flow to the brain. Professional/Academic Intuition:
Gravity is an active resuscitation drug; elevate the head 30 degrees.
Q5: While performing compressions on an intubated patient, the monitor displays an ETCO2 of
15 mmHg. What does this value IMMEDIATELY indicate? A) The patient is achieving ROSC. B)
The patient is hyperventilating. C) The chest compressions are ineffective and must be
optimized. D) The patient has profound metabolic alkalosis.
● The Answer: C (The chest compressions are ineffective and must be optimized.)
● Distractor Analysis:
○ A is incorrect: ROSC is indicated by a sudden spike in ETCO2 (e.g., >35-40
mmHg).
○ B is incorrect: Hyperventilation occurs in perfusing patients, not during arrest.
○ D is incorrect: ETCO2 measures ventilation and perfusion, not primary alkalosis.
The Mentor's Analysis: Capnography evaluates cardiac output during arrest. An ETCO2 <20
mmHg means the heart is not being squeezed effectively. Professional/Academic Intuition:
ETCO2 below 20 means your compressions are failing the patient.
Q6: You are managing a patient in septic shock. After administering a 20 cc/kg bolus of Normal
Saline, the SBP remains 78 mmHg. Which action is MOST APPROPRIATE? A) Administer a
third 20 cc/kg fluid bolus rapidly. B) Administer push-dose Epinephrine 5-10 mcg IV. C)
Administer Amiodarone 150 mg IV. D) Administer Atropine 1 mg IV.
● The Answer: B (Administer push-dose Epinephrine 5-10 mcg IV.)
● Distractor Analysis:
○ A is incorrect: Protocol caps initial fluid resuscitation before initiating vasopressors
to prevent pulmonary edema.
○ C is incorrect: Amiodarone is an antiarrhythmic.
○ D is incorrect: Atropine treats symptomatic bradycardia, not distributive shock.
The Mentor's Analysis: Distributive shock eventually requires vascular clamping, not just volume
filling. By utilizing push-dose Epinephrine, you bypass the common trap of fluid-overloading a
leaking vascular bed. Professional/Academic Intuition: If the tank is full but the pipes are
wide, squeeze the pipes with Epinephrine.
Q7: You are treating a pediatric patient (15 kg) suffering from severe anaphylaxis. They are
hypotensive and wheezing. What is the FIRST appropriate dose of Epinephrine 1:1,000? A) 0.3
mg IM B) 0.15 mg IM C) 0.01 mg/kg IM D) 0.5 mg IV
● The Answer: C (0.01 mg/kg IM)
● Distractor Analysis:
○ A is incorrect: 0.3 mg is the standard adult dose, which is excessive for a 15 kg
child.
○ B is incorrect: While 0.15 mg is an auto-injector dose, protocol mandates precise
weight-based calculation.
○ D is incorrect: 1:1,000 concentration given IV causes lethal arrhythmias.
The Mentor's Analysis: Pediatric resuscitation demands strict weight-based pharmacology.
When facing anaphylaxis, the immediate priority is halting mast cell degranulation.
Paramedic Test Bank
Protocol: 2026/2027
Standards
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Hard-deck definitions,
2026 formulary updates, airway pharmacology, and high-performance resuscitation
metrics.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Hemodynamic shifting,
algorithmic sequencing, destination triage, and pediatric physiological variations.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-system failure
scenarios requiring immediate synthesis of competing priorities, pharmacology, and
procedural interventions.
PART I: THE PRIMER
Mastery of this material forges the gap between basic algorithmic compliance and elite,
autonomous resuscitation science. By internalizing the 2026/2027 Tennessee Emergency
Medical Services protocols, clinicians transition from reactionary technicians into proactive,
high-performance resuscitation specialists.
● The Ketamine Mandate: Etomidate is completely removed from the 2026 formulary;
Ketamine (2 mg/kg) is the exclusive induction agent for all advanced airways.
● High-Performance CPR: Resuscitation demands 2–3 minutes of supine CPR followed by
a 30-degree head-and-shoulder elevation to optimize cerebral perfusion.
● The ETCO2 Hard-Deck: Continuous waveform capnography is mandatory; readings <20
mmHg indicate ineffective compressions, and <10 mmHg precludes the return of
spontaneous circulation (ROSC).
● Push-Dose Pressors: Septic shock refractory to fluid boluses requires early aggressive
intervention utilizing push-dose Epinephrine (5–10 mcg) to maintain a target systolic blood
pressure (SBP) of 90–110 mmHg.
● C-STAT Validation: The Cincinnati Stroke Triage Assessment Tool (C-STAT) dictates that
a score of ≥2 indicates a Large Vessel Occlusion (LVO), mandating bypass to a
thrombectomy-capable center.
,PART II: THE ELITE TEST BANK
Q1: A patient requires Rapid Sequence Intubation (RSI). Based on the 2026 Tennessee EMS
Protocols, which induction agent is MOST APPROPRIATE? A) Etomidate 0.3 mg/kg IV B)
Midazolam 5 mg IV C) Ketamine 2 mg/kg IV D) Fentanyl 100 mcg IV
● The Answer: C (Ketamine 2 mg/kg IV)
● Distractor Analysis:
○ A is incorrect: Etomidate has been explicitly removed from the 2026 Tennessee
prehospital formulary.
○ B is incorrect: Midazolam is for post-intubation sedation in normotensive patients,
not primary induction.
○ D is incorrect: Fentanyl provides analgesia, not deep dissociation for intubation.
The Mentor's Analysis: The state has unified its airway pharmacology. Ketamine provides
excellent dissociation while maintaining respiratory drive. Professional/Academic Intuition:
Etomidate is obsolete; Ketamine is the universal induction hard-deck.
Q2: During an RSI attempt, the clinician must optimize oxygenation reserves. According to
Tennessee guidelines, what action must occur IMMEDIATELY during the laryngoscopy attempt?
A) Remove all oxygen delivery devices to visualize the cords. B) Apply high-flow oxygen via a
nasal cannula at 8-10 Lpm. C) Administer bag-valve-mask ventilations simultaneously. D)
Hyperventilate the patient to an ETCO2 of 25 mmHg.
● The Answer: B (Apply high-flow oxygen via a nasal cannula at 8-10 Lpm.)
● Distractor Analysis:
○ A is incorrect: Removing all oxygen rapidly induces fatal hypoxia.
○ C is incorrect: Positive pressure ventilation must pause during direct laryngoscopy.
○ D is incorrect: Hyperventilation causes cerebral vasoconstriction.
The Mentor's Analysis: Apneic oxygenation prevents precipitous desaturation via mass flow. By
utilizing a nasal cannula, you bypass the common trap of hypoxic peri-intubation arrests.
Professional/Academic Intuition: Never remove the nasal cannula during airway
instrumentation.
Q3: Following successful intubation, a trauma patient's SBP drops to 82 mmHg. To maintain
continuous sedation, which medication is MOST APPROPRIATE? A) Midazolam 0.1 mg/kg IV
B) Ketamine 2 mg/kg slow IV C) Fentanyl 5 mcg/kg IV D) Propofol 1 mg/kg IV
● The Answer: B (Ketamine 2 mg/kg slow IV)
● Distractor Analysis:
○ A is incorrect: Midazolam (Versed) is indicated for post-intubation sedation only if
the SBP is strictly >90 mmHg.
○ C is incorrect: Fentanyl addresses pain but fails to ensure deep sedation.
○ D is incorrect: Propofol is not a standard Tennessee EMS ALS induction agent.
The Mentor's Analysis: Hypotension dictates your sedation pathway. When facing a hypotensive
intubated patient, the immediate priority is preserving sympathetic tone. Professional/Academic
Intuition: Hypotension eliminates Versed; default to Ketamine for continued sedation.
Q4: A cardiac arrest patient has received 2 minutes of high-performance CPR in the supine
position. What is the NEXT positional requirement per Tennessee protocol? A) Place the patient
in the Trendelenburg position. B) Elevate the patient's head and shoulders approximately 30
degrees. C) Roll the patient into the left lateral recumbent position. D) Elevate the patient's legs
45 degrees.
, ● The Answer: B (Elevate the patient's head and shoulders approximately 30 degrees.)
● Distractor Analysis:
○ A is incorrect: Trendelenburg increases intracranial pressure, severely reducing
cerebral perfusion.
○ C is incorrect: Lateral recumbent is for the pregnant patient with a pulse.
○ D is incorrect: Passive leg raises do not optimize venous drainage from the brain.
The Mentor's Analysis: Elevating the head reduces intracranial venous pooling, creating a
pressure gradient that allows forward arterial flow to the brain. Professional/Academic Intuition:
Gravity is an active resuscitation drug; elevate the head 30 degrees.
Q5: While performing compressions on an intubated patient, the monitor displays an ETCO2 of
15 mmHg. What does this value IMMEDIATELY indicate? A) The patient is achieving ROSC. B)
The patient is hyperventilating. C) The chest compressions are ineffective and must be
optimized. D) The patient has profound metabolic alkalosis.
● The Answer: C (The chest compressions are ineffective and must be optimized.)
● Distractor Analysis:
○ A is incorrect: ROSC is indicated by a sudden spike in ETCO2 (e.g., >35-40
mmHg).
○ B is incorrect: Hyperventilation occurs in perfusing patients, not during arrest.
○ D is incorrect: ETCO2 measures ventilation and perfusion, not primary alkalosis.
The Mentor's Analysis: Capnography evaluates cardiac output during arrest. An ETCO2 <20
mmHg means the heart is not being squeezed effectively. Professional/Academic Intuition:
ETCO2 below 20 means your compressions are failing the patient.
Q6: You are managing a patient in septic shock. After administering a 20 cc/kg bolus of Normal
Saline, the SBP remains 78 mmHg. Which action is MOST APPROPRIATE? A) Administer a
third 20 cc/kg fluid bolus rapidly. B) Administer push-dose Epinephrine 5-10 mcg IV. C)
Administer Amiodarone 150 mg IV. D) Administer Atropine 1 mg IV.
● The Answer: B (Administer push-dose Epinephrine 5-10 mcg IV.)
● Distractor Analysis:
○ A is incorrect: Protocol caps initial fluid resuscitation before initiating vasopressors
to prevent pulmonary edema.
○ C is incorrect: Amiodarone is an antiarrhythmic.
○ D is incorrect: Atropine treats symptomatic bradycardia, not distributive shock.
The Mentor's Analysis: Distributive shock eventually requires vascular clamping, not just volume
filling. By utilizing push-dose Epinephrine, you bypass the common trap of fluid-overloading a
leaking vascular bed. Professional/Academic Intuition: If the tank is full but the pipes are
wide, squeeze the pipes with Epinephrine.
Q7: You are treating a pediatric patient (15 kg) suffering from severe anaphylaxis. They are
hypotensive and wheezing. What is the FIRST appropriate dose of Epinephrine 1:1,000? A) 0.3
mg IM B) 0.15 mg IM C) 0.01 mg/kg IM D) 0.5 mg IV
● The Answer: C (0.01 mg/kg IM)
● Distractor Analysis:
○ A is incorrect: 0.3 mg is the standard adult dose, which is excessive for a 15 kg
child.
○ B is incorrect: While 0.15 mg is an auto-injector dose, protocol mandates precise
weight-based calculation.
○ D is incorrect: 1:1,000 concentration given IV causes lethal arrhythmias.
The Mentor's Analysis: Pediatric resuscitation demands strict weight-based pharmacology.
When facing anaphylaxis, the immediate priority is halting mast cell degranulation.
