, Question 1
A patient in refractory ventricular fibrillation has received three defibrillation
attempts, epinephrine, and amiodarone. According to Thurston County EMS
protocols, which intervention is indicated next if the rhythm remains
shockable?
A. Administer a 300 mg bolus of amiodarone
B. Administer 1 mg/kg lidocaine IV/IO
C. Administer 2 g magnesium sulfate IV/IO
D. Administer 1 mEq/kg sodium bicarbonate IV/IO
Correct Answer: B - Administer 1 mg/kg lidocaine IV/IO
RATIONALE
Thurston County protocols follow ACLS guidelines where lidocaine is
an alternative antiarrhythmic after amiodarone, and 1 mg/kg is the
correct initial dose. Amiodarone is typically capped at 450 mg total,
and magnesium is for torsades. Sodium bicarbonate is not routine for
VF/VT.
Question 2
A trauma patient with a gunshot wound to the abdomen is hypotensive and
tachycardic. Per Thurston County trauma triage protocols, which destination
decision is most appropriate?
A. Transport to the closest Level III trauma center for stabilization
B. Transport to the closest Level I or Level II trauma center, bypassing
closer facilities if necessary
C. Transport to the closest emergency department regardless of trauma
designation
D. Transport to a Level IV trauma center for initial evaluation
Correct Answer: B - Transport to the closest Level I or Level II
trauma center, bypassing closer facilities if necessary
Page 2
, RATIONALE
Thurston County protocols direct major trauma with hemodynamic
instability to the highest-level trauma center within the region, even if
it requires bypassing closer hospitals. Level III and IV centers lack
immediate surgical capability. Transport to a non-trauma center delays
definitive care.
Question 3
A patient with severe respiratory distress from an asthma exacerbation is not
responding to albuterol. According to Thurston County protocols, which
adjunct medication is indicated next?
A. Methylprednisolone 125 mg IV
B. Ipratropium bromide 0.5 mg nebulized
C. Epinephrine 0.3 mg IM
D. Magnesium sulfate 2 g IV
Correct Answer: B - Ipratropium bromide 0.5 mg nebulized
RATIONALE
Thurston County protocols recommend adding ipratropium to
albuterol for severe asthma not responding to beta-agonists alone.
Corticosteroids are indicated but may be given later; IM epinephrine is
for anaphylaxis. IV magnesium is reserved for refractory cases per
medical direction.
Question 4
A patient with suspected opioid overdose has been given naloxone with
improvement in respirations but remains unresponsive. Per Thurston County
protocol, what is the appropriate next action?
A. Administer an additional 2 mg naloxone IV/IO
B. Begin bag-valve-mask ventilation and transport
C. Administer flumazenil 0.2 mg IV
D. Place the patient in the recovery position and monitor
Page 3
, Correct Answer: B - Begin bag-valve-mask ventilation and
transport
RATIONALE
Thurston County protocol emphasizes that naloxone reverses
respiratory depression, not sedation; if respirations are adequate,
further naloxone is unnecessary. BVM support and transport are
indicated for persistent unresponsiveness. Flumazenil is
contraindicated in opioid co-ingestion due to seizure risk.
Question 5
A patient with a suspected cervical spine injury requires airway management.
According to Thurston County EMS protocols, which technique is preferred to
maintain spinal motion restriction during intubation?
A. Manual in-line stabilization with video laryngoscopy
B. Direct laryngoscopy with cricoid pressure
C. Blind nasotracheal intubation
D. Retrograde intubation
Correct Answer: A - Manual in-line stabilization with video
laryngoscopy
RATIONALE
Thurston County protocols endorse manual in-line stabilization with
video laryngoscopy to minimize cervical movement. Cricoid pressure
is no longer routinely recommended. Blind nasotracheal and
retrograde intubation are not first-line and carry higher risk.
Question 6
A patient with chest pain has a 12-lead ECG showing ST elevation in leads II,
III, and aVF. Per Thurston County protocols, which destination is most
appropriate if the local hospital does not have PCI capability?
A. Transport to the closest emergency department for thrombolytics
Page 4
A patient in refractory ventricular fibrillation has received three defibrillation
attempts, epinephrine, and amiodarone. According to Thurston County EMS
protocols, which intervention is indicated next if the rhythm remains
shockable?
A. Administer a 300 mg bolus of amiodarone
B. Administer 1 mg/kg lidocaine IV/IO
C. Administer 2 g magnesium sulfate IV/IO
D. Administer 1 mEq/kg sodium bicarbonate IV/IO
Correct Answer: B - Administer 1 mg/kg lidocaine IV/IO
RATIONALE
Thurston County protocols follow ACLS guidelines where lidocaine is
an alternative antiarrhythmic after amiodarone, and 1 mg/kg is the
correct initial dose. Amiodarone is typically capped at 450 mg total,
and magnesium is for torsades. Sodium bicarbonate is not routine for
VF/VT.
Question 2
A trauma patient with a gunshot wound to the abdomen is hypotensive and
tachycardic. Per Thurston County trauma triage protocols, which destination
decision is most appropriate?
A. Transport to the closest Level III trauma center for stabilization
B. Transport to the closest Level I or Level II trauma center, bypassing
closer facilities if necessary
C. Transport to the closest emergency department regardless of trauma
designation
D. Transport to a Level IV trauma center for initial evaluation
Correct Answer: B - Transport to the closest Level I or Level II
trauma center, bypassing closer facilities if necessary
Page 2
, RATIONALE
Thurston County protocols direct major trauma with hemodynamic
instability to the highest-level trauma center within the region, even if
it requires bypassing closer hospitals. Level III and IV centers lack
immediate surgical capability. Transport to a non-trauma center delays
definitive care.
Question 3
A patient with severe respiratory distress from an asthma exacerbation is not
responding to albuterol. According to Thurston County protocols, which
adjunct medication is indicated next?
A. Methylprednisolone 125 mg IV
B. Ipratropium bromide 0.5 mg nebulized
C. Epinephrine 0.3 mg IM
D. Magnesium sulfate 2 g IV
Correct Answer: B - Ipratropium bromide 0.5 mg nebulized
RATIONALE
Thurston County protocols recommend adding ipratropium to
albuterol for severe asthma not responding to beta-agonists alone.
Corticosteroids are indicated but may be given later; IM epinephrine is
for anaphylaxis. IV magnesium is reserved for refractory cases per
medical direction.
Question 4
A patient with suspected opioid overdose has been given naloxone with
improvement in respirations but remains unresponsive. Per Thurston County
protocol, what is the appropriate next action?
A. Administer an additional 2 mg naloxone IV/IO
B. Begin bag-valve-mask ventilation and transport
C. Administer flumazenil 0.2 mg IV
D. Place the patient in the recovery position and monitor
Page 3
, Correct Answer: B - Begin bag-valve-mask ventilation and
transport
RATIONALE
Thurston County protocol emphasizes that naloxone reverses
respiratory depression, not sedation; if respirations are adequate,
further naloxone is unnecessary. BVM support and transport are
indicated for persistent unresponsiveness. Flumazenil is
contraindicated in opioid co-ingestion due to seizure risk.
Question 5
A patient with a suspected cervical spine injury requires airway management.
According to Thurston County EMS protocols, which technique is preferred to
maintain spinal motion restriction during intubation?
A. Manual in-line stabilization with video laryngoscopy
B. Direct laryngoscopy with cricoid pressure
C. Blind nasotracheal intubation
D. Retrograde intubation
Correct Answer: A - Manual in-line stabilization with video
laryngoscopy
RATIONALE
Thurston County protocols endorse manual in-line stabilization with
video laryngoscopy to minimize cervical movement. Cricoid pressure
is no longer routinely recommended. Blind nasotracheal and
retrograde intubation are not first-line and carry higher risk.
Question 6
A patient with chest pain has a 12-lead ECG showing ST elevation in leads II,
III, and aVF. Per Thurston County protocols, which destination is most
appropriate if the local hospital does not have PCI capability?
A. Transport to the closest emergency department for thrombolytics
Page 4
