Paramedic 2026 Clinical Judgment Exam
Prep: Practice Questions with Answer
Rationales Airway · Cardiology · Trauma ·
Pharmacology · Medical Emergencies ·
Clinical Scenarios · Study Guide
Section 1: Airway, Respiration & Ventilation (Questions 1–20)
1. A paramedic is performing rapid sequence intubation (RSI) on a patient
with a head injury and suspected elevated intracranial pressure. According to
2026 protocol updates, which induction agent is now PREFERRED?
A. Propofol
B. Etomidate
C. Ketamine
D. Midazolam
Answer: C
Rationale: The 2026 EMS airway update codifies a shift from etomidate to
ketamine as the preferred RSI induction agent. SPEMS's 2026 protocol removes
etomidate from the paramedic drug index and replaces it with ketamine for RSI
induction at 2 mg/kg slow IV/IO, max 500 mg. While etomidate provides
hemodynamic stability, its risk profile—including transient adrenal suppression—
is now consistently reproduced in prehospital and ED intubation research.
Ketamine's visible risk (post-intubation hypotension) is manageable with fluids and
push-dose pressors, whereas etomidate's adrenal suppression in septic patients is
invisible and cannot be fixed with a single intervention.
2. During RSI, which neuromuscular blocking agent is contraindicated in a
patient with a crush injury sustained 72 hours ago?
A. Rocuronium
B. Vecuronium
,C. Succinylcholine
D. Pancuronium
Answer: C
Rationale: Succinylcholine is contraindicated in patients with crush injuries older
than 24–48 hours due to the risk of life-threatening hyperkalemia. Denervated
muscle cells upregulate acetylcholine receptors, and succinylcholine causes
massive potassium efflux from these cells, potentially leading to hyperkalemic
cardiac arrest. Rocuronium is the preferred non-depolarizing alternative in these
patients.
3. A mechanically ventilated patient with ARDS has the following settings:
Volume Control, tidal volume 400 mL (6 mL/kg PBW), rate 20/min, PEEP 14
cmH₂O, FiO₂ 0.70. The plateau pressure is 30 cmH₂O. What is the driving
pressure?
A. 16 cmH₂O
B. 20 cmH₂O
C. 14 cmH₂O
D. 30 cmH₂O
Answer: A
Rationale: Driving pressure = Plateau pressure − PEEP. 30 − 14 = 16 cmH₂O. A
driving pressure above 15 cmH₂O is associated with increased mortality in ARDS
patients. The target is to keep driving pressure below 15 cmH₂O when possible.
Lung-protective ventilation focuses on limiting plateau pressure to ≤30 cmH₂O and
driving pressure to ≤15 cmH₂O.
4. A patient with COPD is being mechanically ventilated. Which ventilator
strategy is MOST appropriate to prevent air trapping?
A. High respiratory rate with low tidal volume
B. Low respiratory rate with prolonged expiratory time
C. High PEEP with high respiratory rate
D. Inverse ratio ventilation
Answer: B
,Rationale: In COPD, expiratory flow limitation leads to air trapping (auto-PEEP)
when the respiratory rate is too high or expiratory time is too short. A low
respiratory rate with prolonged expiratory time allows complete exhalation,
reducing dynamic hyperinflation and the risk of barotrauma. This is a critical
ventilator management strategy in obstructive lung disease. Monitoring plateau
pressure and auto-PEEP is essential.
5. A paramedic is performing waveform capnography on an intubated
patient. The waveform suddenly becomes flat. What is the MOST likely
cause?
A. Improved ventilation
B. Endotracheal tube dislodgement or obstruction
C. Increased cardiac output
D. Resolution of bronchospasm
Answer: B
Rationale: A flat capnography waveform (loss of end-tidal CO₂) indicates absent
exhaled CO₂, which is most commonly caused by endotracheal tube dislodgement,
obstruction, or cardiac arrest. Waveform capnography is the gold standard for
confirming and monitoring endotracheal tube placement. Immediate assessment of
tube position and patency is required.
6. A patient with severe asthma is in respiratory distress with a silent chest.
What does this finding indicate?
A. Mild asthma exacerbation
B. Moderate asthma exacerbation
C. Severe, life-threatening asthma exacerbation
D. The patient is improving
Answer: C
Rationale: A silent chest indicates that airflow is so severely compromised that air
is no longer moving through the airways, resulting in no audible wheezing. This is
a sign of a life-threatening asthma exacerbation requiring immediate intervention,
including BVM ventilation and possible epinephrine administration. The AHA
, 2025 Guidelines added two new recommendations for adults and children with
life-threatening asthma.
7. A paramedic is preparing to intubate a patient with a suspected cervical
spine injury. Which technique is MOST appropriate?
A. Direct laryngoscopy with head extension
B. Video laryngoscopy with manual in-line stabilization
C. Blind nasal intubation
D. Retrograde intubation
Answer: B
Rationale: Video laryngoscopy with manual in-line stabilization is the preferred
technique for intubating patients with suspected cervical spine injuries. Video
laryngoscopy improves visualization of the glottis while minimizing cervical spine
movement. Manual in-line stabilization is maintained throughout the procedure by
an assistant.
8. A patient with a tracheostomy requires suctioning. What is the maximum
recommended duration for each suction attempt?
A. 5 seconds
B. 10–15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10–15 seconds per attempt to prevent
hypoxemia and vagal stimulation. The patient should be pre-oxygenated before
suctioning. If additional suctioning is needed, allow the patient to recover and re-
oxygenate between attempts.
9. A patient is in respiratory arrest. After opening the airway and delivering
two rescue breaths, you note that the chest does not rise. What should you do
NEXT?
Prep: Practice Questions with Answer
Rationales Airway · Cardiology · Trauma ·
Pharmacology · Medical Emergencies ·
Clinical Scenarios · Study Guide
Section 1: Airway, Respiration & Ventilation (Questions 1–20)
1. A paramedic is performing rapid sequence intubation (RSI) on a patient
with a head injury and suspected elevated intracranial pressure. According to
2026 protocol updates, which induction agent is now PREFERRED?
A. Propofol
B. Etomidate
C. Ketamine
D. Midazolam
Answer: C
Rationale: The 2026 EMS airway update codifies a shift from etomidate to
ketamine as the preferred RSI induction agent. SPEMS's 2026 protocol removes
etomidate from the paramedic drug index and replaces it with ketamine for RSI
induction at 2 mg/kg slow IV/IO, max 500 mg. While etomidate provides
hemodynamic stability, its risk profile—including transient adrenal suppression—
is now consistently reproduced in prehospital and ED intubation research.
Ketamine's visible risk (post-intubation hypotension) is manageable with fluids and
push-dose pressors, whereas etomidate's adrenal suppression in septic patients is
invisible and cannot be fixed with a single intervention.
2. During RSI, which neuromuscular blocking agent is contraindicated in a
patient with a crush injury sustained 72 hours ago?
A. Rocuronium
B. Vecuronium
,C. Succinylcholine
D. Pancuronium
Answer: C
Rationale: Succinylcholine is contraindicated in patients with crush injuries older
than 24–48 hours due to the risk of life-threatening hyperkalemia. Denervated
muscle cells upregulate acetylcholine receptors, and succinylcholine causes
massive potassium efflux from these cells, potentially leading to hyperkalemic
cardiac arrest. Rocuronium is the preferred non-depolarizing alternative in these
patients.
3. A mechanically ventilated patient with ARDS has the following settings:
Volume Control, tidal volume 400 mL (6 mL/kg PBW), rate 20/min, PEEP 14
cmH₂O, FiO₂ 0.70. The plateau pressure is 30 cmH₂O. What is the driving
pressure?
A. 16 cmH₂O
B. 20 cmH₂O
C. 14 cmH₂O
D. 30 cmH₂O
Answer: A
Rationale: Driving pressure = Plateau pressure − PEEP. 30 − 14 = 16 cmH₂O. A
driving pressure above 15 cmH₂O is associated with increased mortality in ARDS
patients. The target is to keep driving pressure below 15 cmH₂O when possible.
Lung-protective ventilation focuses on limiting plateau pressure to ≤30 cmH₂O and
driving pressure to ≤15 cmH₂O.
4. A patient with COPD is being mechanically ventilated. Which ventilator
strategy is MOST appropriate to prevent air trapping?
A. High respiratory rate with low tidal volume
B. Low respiratory rate with prolonged expiratory time
C. High PEEP with high respiratory rate
D. Inverse ratio ventilation
Answer: B
,Rationale: In COPD, expiratory flow limitation leads to air trapping (auto-PEEP)
when the respiratory rate is too high or expiratory time is too short. A low
respiratory rate with prolonged expiratory time allows complete exhalation,
reducing dynamic hyperinflation and the risk of barotrauma. This is a critical
ventilator management strategy in obstructive lung disease. Monitoring plateau
pressure and auto-PEEP is essential.
5. A paramedic is performing waveform capnography on an intubated
patient. The waveform suddenly becomes flat. What is the MOST likely
cause?
A. Improved ventilation
B. Endotracheal tube dislodgement or obstruction
C. Increased cardiac output
D. Resolution of bronchospasm
Answer: B
Rationale: A flat capnography waveform (loss of end-tidal CO₂) indicates absent
exhaled CO₂, which is most commonly caused by endotracheal tube dislodgement,
obstruction, or cardiac arrest. Waveform capnography is the gold standard for
confirming and monitoring endotracheal tube placement. Immediate assessment of
tube position and patency is required.
6. A patient with severe asthma is in respiratory distress with a silent chest.
What does this finding indicate?
A. Mild asthma exacerbation
B. Moderate asthma exacerbation
C. Severe, life-threatening asthma exacerbation
D. The patient is improving
Answer: C
Rationale: A silent chest indicates that airflow is so severely compromised that air
is no longer moving through the airways, resulting in no audible wheezing. This is
a sign of a life-threatening asthma exacerbation requiring immediate intervention,
including BVM ventilation and possible epinephrine administration. The AHA
, 2025 Guidelines added two new recommendations for adults and children with
life-threatening asthma.
7. A paramedic is preparing to intubate a patient with a suspected cervical
spine injury. Which technique is MOST appropriate?
A. Direct laryngoscopy with head extension
B. Video laryngoscopy with manual in-line stabilization
C. Blind nasal intubation
D. Retrograde intubation
Answer: B
Rationale: Video laryngoscopy with manual in-line stabilization is the preferred
technique for intubating patients with suspected cervical spine injuries. Video
laryngoscopy improves visualization of the glottis while minimizing cervical spine
movement. Manual in-line stabilization is maintained throughout the procedure by
an assistant.
8. A patient with a tracheostomy requires suctioning. What is the maximum
recommended duration for each suction attempt?
A. 5 seconds
B. 10–15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10–15 seconds per attempt to prevent
hypoxemia and vagal stimulation. The patient should be pre-oxygenated before
suctioning. If additional suctioning is needed, allow the patient to recover and re-
oxygenate between attempts.
9. A patient is in respiratory arrest. After opening the airway and delivering
two rescue breaths, you note that the chest does not rise. What should you do
NEXT?
