NREMT Emergency Medical Technician (EMT) Cognitive Exam

A. Chronic obstructive pulmonary disease (COPD) exacerbation.

Pursed-lip breathing, a barrel chest, and accessory muscle use are classic signs of chronic obstructive pulmonary disease (COPD), particularly emphysema, as the patient struggles to exhale trapped air and increase ventilatory effort. These signs become more pronounced during an exacerbation.

C. Respiratory distress

This child is exhibiting classic signs of respiratory distress: nasal flaring, intercostal retractions, and an elevated respiratory rate (40 bpm is high for a 3-year-old but not necessarily indicative of failure yet). The child is still compensating, as evidenced by being awake, crying, and anxious (a sign of adequate brain oxygenation, though stressed). Respiratory failure would involve signs of decompensation such as lethargy, pallor, or a significantly decreased respiratory rate. Respiratory arrest means cessation of breathing.

D. Instruct the patient to inhale deeply as they depress the canister.

After shaking the MDI and instructing the patient to exhale completely, the next critical step is for the patient to begin a slow, deep inhalation while simultaneously depressing the canister to ensure the medication reaches the lower airways.

C. Prepare for needle decompression of the left chest.

The patient's presentation of sudden severe shortness of breath, diminished lung sounds on one side, tracheal deviation away from the affected side, hypotension, and tachycardia are classic signs of a tension pneumothorax. This is a life-threatening condition requiring immediate needle decompression to relieve pressure on the heart and lungs.

B. 10-12 breaths per minute.

For an adult patient with inadequate breathing and a pulse, the recommended ventilatory rate with a bag-valve mask is 10-12 breaths per minute (1 breath every 5-6 seconds). This rate is sufficient to provide adequate oxygenation and ventilation without causing hyperventilation, which can be detrimental in head injury patients.

B. Administer high-flow oxygen via non-rebreather mask or CPAP if available.

Acute pulmonary edema causes fluid accumulation in the lungs, leading to severe hypoxia. The patient's SpO2 of 85% indicates significant hypoxemia. High-flow oxygen via a non-rebreather mask is critical to improve oxygenation. Even better, Continuous Positive Airway Pressure (CPAP) is often the definitive prehospital treatment for pulmonary edema as it forces fluid back into the vasculature, reduces preload, and improves oxygenation, making it a primary intervention if available. Bronchodilators are for bronchoconstriction, not fluid. Supine positioning would worsen the dyspnea. Intubation is a last resort for respiratory failure, not the initial treatment for a conscious patient.

A. Suction the airway.

Gurgling sounds indicate the presence of liquid (blood, vomitus, or secretions) in the airway. The most appropriate immediate action to clear the airway and prevent aspiration is to suction the airway. This should be done before attempting to insert an airway adjunct or ventilate.

D. Transport rapidly in a position of comfort.

The symptoms described (stridor, drooling, high fever, anxious appearance, sitting upright) are classic for epiglottitis. Any attempt to visualize the airway or force a supine position could worsen airway obstruction. Rapid transport in a position of comfort is crucial.

A. Initiate positive pressure ventilation with a bag-valve mask.

Nasal flaring, grunting, and a respiratory rate of 60 breaths/min, especially with mottled skin, indicate severe respiratory distress and impending respiratory failure in an infant. The infant's compensatory mechanisms are failing, and they require immediate ventilatory support with a bag-valve mask to prevent respiratory arrest.

D. Nasal cannula at 2-4 LPM

For COPD patients experiencing an exacerbation, the goal is to carefully administer oxygen to improve saturation without completely suppressing their hypoxic drive. An SpO2 of 88% warrants oxygen, but starting with a low-flow device like a nasal cannula at 2-4 LPM is appropriate. This allows for gradual increase or adjustment based on SpO2 response, aiming for an SpO2 target of 88-92%. A non-rebreather mask might deliver too much oxygen too quickly, potentially worsening CO2 retention, while a Venturi mask would be a good next step if the nasal cannula is insufficient but starting with the least invasive, controlled method is preferred.

A. Administer epinephrine via auto-injector.

The patient is experiencing anaphylaxis with signs of airway compromise (stridor, facial edema) and circulatory shock (hypotension, tachycardia). Epinephrine is the definitive treatment for anaphylaxis as it addresses both bronchoconstriction and vasodilation, making it the most immediate life-saving intervention.

C. Transport immediately in a position of comfort and avoid agitating the child.

These symptoms (inspiratory stridor, drooling, high fever, ill appearance, reluctance to lie down) are highly suggestive of epiglottitis. This is a life-threatening airway emergency. The MOST critical immediate action is to avoid any intervention that might agitate the child or provoke laryngospasm, which could lead to complete airway obstruction. This includes attempting to visualize the airway or forcing an oxygen mask. Rapid transport in a position of comfort while minimizing agitation is paramount. Oxygen should be offered passively (e.g., blow-by) if tolerated, but not forced.

B. Tension pneumothorax.

The combination of sudden shortness of breath, pleuritic chest pain, diminished breath sounds on one side, tracheal deviation, and jugular venous distension is the classic presentation of a tension pneumothorax. This is a life-threatening condition where air accumulates in the pleural space under pressure, collapsing the lung and shifting mediastinal structures.

B. Jaw-thrust maneuver.

Given the suspected cervical spine injury, a jaw-thrust maneuver is the preferred method to open the airway as it minimizes movement of the cervical spine. The gurgling respirations indicate fluid in the airway, which requires suctioning after the airway is opened, but opening the airway is the first step.

A. 10-12 breaths per minute (1 breath every 5-6 seconds).

For an adult patient with inadequate spontaneous breathing, the recommended ventilation rate using a bag-valve mask is 10-12 breaths per minute, or approximately one breath every 5-6 seconds. This rate provides adequate ventilation without causing hyperventilation.

B. Perform abdominal thrusts (Heimlich maneuver).

For a conscious child (over 1 year old) with a severe foreign body airway obstruction (unable to speak, cough, or cry, and turning cyanotic), abdominal thrusts (Heimlich maneuver) are the recommended initial intervention to dislodge the object.

D. Insert a nasopharyngeal airway (NPA) and begin positive pressure ventilation.

The patient's respiratory rate of 6 breaths per minute indicates severe respiratory depression and inadequate breathing, which is a life-threatening condition. Even after naloxone, if respiratory effort has not improved, positive pressure ventilation (assisted breathing) is immediately required. An NPA can help maintain an open airway during ventilation.

A. Venturi mask set to deliver 28% oxygen.

For a COPD patient in distress who is breathing spontaneously, a Venturi mask is often preferred because it delivers a precise, controlled concentration of oxygen, typically starting with a lower concentration (like 28%) to avoid depressing the hypoxic drive. While a non-rebreather provides higher oxygen, it may be detrimental to CO2 retainers. The patient is alert and breathing, so BVM is not indicated yet, and a nasal cannula at 6L/min provides an uncontrolled, higher FiO2 than desired for initial treatment.

C. Shallow tidal volume with minimal chest wall movement.

Inadequate ventilation is characterized by insufficient air movement to meet the body's metabolic needs. Shallow tidal volume with minimal chest wall movement directly indicates that the patient is not moving enough air with each breath, regardless of the respiratory rate, leading to poor gas exchange.

D. Non-rebreather mask at 15 L/min.

The patient has significant respiratory distress with an SpO2 of 88% and wheezing, indicating hypoxemia. A non-rebreather mask at 15 L/min provides the highest concentration of supplemental oxygen to rapidly improve oxygenation. While a Venturi mask can provide precise concentrations, the immediate need for high oxygen saturation outweighs the need for precision in this acute setting.

B. Pulmonary embolism

The sudden onset of dyspnea, chest pain, a feeling of impending doom, and a history of recent surgery (a risk factor for DVT leading to PE) with clear lung sounds is highly suggestive of a pulmonary embolism. The clear lung sounds help differentiate it from conditions like CHF or pneumonia which would typically have abnormal lung sounds.

C. Insert an oropharyngeal airway and begin positive pressure ventilation.

The patient has shallow, gurgling respirations and a very low respiratory rate, indicating inadequate breathing and a likely airway obstruction from the tongue or secretions. Positive pressure ventilation is needed, and an OPA will help maintain an open airway.

C. Venturi mask at 28% FiO2.

Patients with COPD often rely on hypoxic drive for breathing. While high-flow oxygen might seem appropriate for an SpO2 of 88%, a Venturi mask allows for precise control of FiO2 (fraction of inspired oxygen), preventing over-oxygenation that could suppress their respiratory drive. A 28% FiO2 setting is a common starting point for controlled oxygen in COPD exacerbations.

B. Croup (Laryngotracheobronchitis).

The symptoms of a barking, seal-like cough, inspiratory stridor, low-grade fever, and the child's ability to be comfortable between episodes are classic for croup (laryngotracheobronchitis), which is typically viral.

B. Jaw-thrust maneuver

Snoring respirations indicate that the tongue is likely blocking the airway. In a trauma patient, especially one with a fall from a height and obvious facial trauma, a cervical spine injury must be assumed. Therefore, the head-tilt, chin-lift maneuver, which involves hyperextension of the neck, is contraindicated. The jaw-thrust maneuver opens the airway by displacing the mandible forward without extending the neck, making it the most appropriate choice to maintain cervical spine precautions.