NREMT EMT Exam Questions

Correct answer: Subdural hematoma

In addition to Subdural Hematoma (SDH), head trauma is a major cause of Epidural Hematoma (EDH), Subarachnoid Hemorrhage (SAH), cerebral contusion, diffuse brain swelling, and fractures. Any of these injuries may coexist in a patient following trauma, and their clinical manifestations can be difficult to distinguish. Patients with head trauma should be transported to a hospital with a dedicated trauma team, if feasible, to promote significantly better outcomes.

Subdural hematoma typically occurs with a sudden acceleration/deceleration injury, and tearing of the bridging veins of the dura, resulting in a hematoma between the dura mater and arachnoid. Because these are commonly venous injuries, they often present more slowly; acute symptoms usually develop gradually one to two days after the initial injury. Because of the mechanism of injury, however, they also typically have accompanying parenchymal damage. The elderly and alcoholics tend to have more extensive brain atrophy and are more susceptible to the development of acute SDH. Children under two years of age are also at increased risk. Immediate evaluation is critical, as the diagnosis is based on CT scan results.

An epidural hematoma results from a collection of blood in the potential space between the skull and the dura mater. Blunt trauma to the temporal or temporoparietal area with an associated skull fracture and disruption of the middle meningeal artery is the primary mechanism of injury. The classic presentation of EDH involves significant blunt trauma, with a loss of consciousness or altered mental status, followed by a “lucid interval” of indeterminate duration; the patient then quickly declines in status, with a rapid neurologic demise. High-pressure arterial bleeding can lead to herniation of the brain within hours after injury. While the “lucid interval” is regularly taught to healthcare practitioners, this presentation occurs in a minority of cases (<20%).

A basilar skull fracture is associated with high-energy trauma and occurs following diffuse impact to the head. Signs and symptoms include Cerebrospinal Fluid (CSF) draining from the ears, “raccoon eyes,” or a Battle sign (ecchymosis behind one ear over the mastoid process). Patients with leaking CSF are at risk for bacterial meningitis. These symptoms may not occur until 24 hours after the incident.

A concussion is a mild traumatic brain injury, leading to impairment of brain function without overt hemorrhage or gross lesion and resulting in a GCS (Glasgow Coma Scale) score of 14 or 15. Signs and symptoms include confusion and alterations in consciousness. The patient may refer to the incident in terms of having their “bell rung” or “seeing stars.” The presence of vomiting, a headache, loss of consciousness, focal neurologic deficit, or a dangerous mechanism of injury indicates an increased risk of serious injury.

Correct answer: Abdominal pain

A symptom is a subjective finding that the patient feels. It can be identified only by the patient.

A sign is an objective finding that can be seen, heard, felt, smelled, or measured.

Correct answer: Wrap the amputated finger in a sterile dressing, place it in a plastic bag, and lay the bag on ice

If an amputation is partial, stabilize the amputated part with bulky compression dressings and splints to prevent further injury. If a complete amputation occurs, wrap the amputated part in a sterile dressing (wet or dry, depending on local protocols), place the wrapped part into a plastic bag, and put the bag on a bed of ice. It is not appropriate to pack the bag in ice. Finally, the amputated part should be transported to the hospital with the patient.

It is rare to need a tourniquet for a finger amputation, but it may be considered if life-threatening bleeding is present. Traumatic amputations may not bleed if the blood vessels spasm, especially in a complete amputation with a clean cut. Since there is no indication there is life-threatening bleeding in this case, a tourniquet would not be needed.

Correct answer: Seizures

Basilar skull fractures are associated with high-energy trauma to the head (e.g., falls, motor vehicle crashes). A linear fracture can occur at the base of the skull; the diagnosis is made with a CT scan. General signs and symptoms of a head injury can occur (e.g., visible injury, altered mental status, widening pulse pressure, bradycardia, unreactive pupils, amnesia, seizures, numbness/tingling in the extremities, visual complaints, nausea/vomiting, posturing).

Additionally, specific signs of a basilar skull fracture include cerebrospinal fluid drainage from the ears, raccoon eyes (ecchymosis under the eyes), and the Battle sign (ecchymosis behind one ear over the mastoid process). Depending on the severity of the injury, some specific signs may not appear until up to 24 hours after the injury. Treatment should be focused on supporting ABCs, spinal motion restriction, and rapid transport to a trauma center. 

Seizures can occur in all types of head injuries.

Correct answer: Radius

The radius is the lateral bone in the forearm (lower arm).

The ulna is the medial bone in the forearm. The humerus is the bone in the upper arm. The tibia and the fibula make up the bones of the lower leg.

Correct answer: Tuberculosis

Gloves are used for all forms of contact with a patient, regardless of the presence of bodily fluids. Gloves should be changed if they have been exposed to blood/bodily fluid, motor oil, gasoline, petroleum-based products, or other patients. It is not appropriate to use the same set of gloves on multiple patients. 

Eye protection and face shields should be used any time that bodily fluid may splatter. This potential exists primarily in cases of uncontrolled arterial bleeding, active vomiting, and suctioning. If tuberculosis is suspected, a surgical mask should be placed on the patient, and providers should use a particulate air respirator, such as an N95 mask.

A surgical mask or a mask with a face shield is adequate for patients with pneumonia, pertussis, or diptheria.

Correct answer: Placenta previa; provide supportive care and rapid transport.

Placenta previa, the condition where the placenta covers the cervix, can cause painless, heavy vaginal bleeding in the third trimester. Supportive care and rapid transport to a medical facility are essential due to the risk of significant blood loss and fetal distress. If signs of shock are present, treat with oxygen and keep her warm.

Ectopic pregnancies typically present with pain and occur outside the uterus, not in the third trimester. Immediate oxygen and transport are appropriate but not specifically for ectopic pregnancy in this context.

Abruptio placentae, the premature separation of the placenta from the uterus, usually presents with pain and bleeding. While rapid transport is necessary, encouraging fluid intake for an actively bleeding patient should be managed with caution, and the focus should be on immediate transport rather than oral fluids.

Uterine rupture would likely present with severe abdominal pain and signs of shock, not just bleeding. Fundal massage is not appropriate for uncontrolled bleeding and suspected uterine rupture; immediate transport is the priority.

Correct answer: A child not seeking comfort from their caregiver

Never leave a suspected victim of child maltreatment. Transport every child, even if their injuries are trivial. Factors associated with maltreatment are as follows:

• Does the story change over time? 
• Was there a delay in seeking care, or was the closest treatment center bypassed? 
• Are there injuries at multiple stages of healing? 
• Does the story fit the child's developmental ability? 
• Do the injuries fit the story? 
• Does the child not seek comfort from the caregiver?

Physical findings that suggest inflicted injuries include bruises located on soft tissues such as the neck, back, thighs, genitalia, or buttocks or behind the ears; facial bruises (from slapping), or bruises in a child under four months of age. Other physical findings include unusual patterns of injuries, such as femoral fractures without obvious trauma.

Developmental milestones are useful in assessing possible abuse. "Those who don't cruise rarely bruise"; in other words, for a child who cannot yet pull to stand and walk while holding onto furniture (cruise), a bruising injury is rare. Most infants do not start "cruising" until they are about 9 months of age.

Elbow and knee bruises are common for a child playing.

Fatigue and fevers in a child can be caused by various issues, not necessarily child abuse.

Correct answer: All cardiac arrest patients require immediate transport.

Local protocols should always be followed. However, general guidelines for transport of a cardiac patient during resuscitation/defibrillation efforts include the following: 

• if the return of spontaneous circulation (ROSC) occurs 
• if six to nine shocks have been delivered and the patient remains in cardiac arrest 
• if the AED gives three consecutive “no shock advised” messages that are separated by five cycles (two minutes) of CPR

Patients who do not regain a pulse on the scene typically do not survive; it is imperative to attempt CPR/defibrillation early to improve outcomes.

Correct answer: Aorta

Oxygenated blood is pumped from the left ventricle of the heart to the body via the aorta. Deoxygenated blood flows back from the body to the heart via the superior and inferior vena cavae. Deoxygenated blood then flows through the right atrium, to the right ventricle, and then to the lungs via the pulmonary artery. Oxygenated blood returns from the lungs to the left atrium via the pulmonary vein.

Correct answer: Between V2 and V4

An electrocardiogram is a form of cardiac monitoring that can be used in the prehospital setting. In order for the monitoring to be accurate, reliable, and useful, the electrodes must be placed in the appropriate positions. There are four limb electrodes: white (placed on the right arm), black (placed on the left arm), green (placed on the right leg or lower right abdomen), and red (placed on the left leg or lower left abdomen). The remaining leads are listed below with their respective placement:

• V1: fourth intercostal space, right sternal border
• V2: fourth intercostal space, left sternal border
• V3: between V2 and V4 (between the fifth and sixth ribs)
• V4: fifth intercostal space, left midclavicular line
• V5: fifth intercostal space at the anterior axillary line
• V6: fifth intercostal space (V4, V5, and V6 are all on the same horizontal level) on the midaxillary line

Correct answer: Automated external defibrillator pads should not be placed directly over a pacemaker.

An internal cardiac pacemaker is a device implanted beneath a patient's skin to regulate their heart rate. It typically resembles a small silver dollar under the skin in the upper left chest, under a heavy muscle or a fold of skin. Some pacemakers include an automated implanted cardioverter defibrillator, which monitors the patient's heart rhythm and can slow at an accelerated rate. Automated External Defibrillator (AED) pads or defibrillator paddles should not be placed directly over pacemakers during defibrillation.

Correct answer: Apply pressure to the wound on the back of the skull

If an open or compressed skull injury is likely, do not apply pressure to the skull. This patient likely has a basilar fracture based on bleeding mixed with clear fluid (cerebrospinal fluid) from the ears. Alternate signs of a basilar skull fracture include raccoon eyes or Battle's sign (bruising).

With all head injuries, continue to assess the patient's level of consciousness and XABCs, prepare for vomiting (to prevent aspiration), and transport the patient promptly.

Correct answer: Brachial pulse

A brachial pulse is assessed in an infant to determine pulse rate. CPR should be initiated on an infant without a palpable pulse or a pulse below 60 beats per minute.

A carotid or a femoral pulse is not typically palpable in a child under one year of age. The radial pulse is not used to assess the need for CPR in any age group.

Patients with acute ischemic stroke have a time-dependent benefit for reperfusion therapy that is similar to that of patients with STEMI (ST-Segment Elevation Myocardial Infarction), but this time-dependent benefit is much shorter. The critical period for the administration of reperfusion therapy begins with the onset of symptoms. 

EMS should identify the last known normal on scene whenever possible but not delay transport. Patients with a suspected stroke should be transported to an appropriate facility capable of stroke intervention. EMS crews need to notify the receiving facility as soon as possible when transporting a suspected stroke. This will allow time to activate personnel as needed, such as CT techs, neurologists, etc. The timeframe for ischemic stroke interventions may be between 3 and 6 hours, depending on the system.  In some cases, the window of time may be as much as 24 hours. 

 It is helpful to obtain a 12 lead ECG for suspected stroke patients, but it is not required within ten minutes (as with a suspected STEMI). 

Correct answer: Smoke inhalation

Patients who are involved in a fire are likely to inhale smoke and experience respiratory distress or arrest; smoke inhalation is the most frequent cause of death in patients who are involved in a fire.

Dehydration, hypovolemic shock, and septic shock are possible outcomes for patients with burns; however, the frequency of death from each of these causes does not surpass that of smoke inhalation.

Correct answer: Deflection

The five stages of the grieving process are denial, anger, bargaining, depression, and acceptance, per Dr. Kübler-Ross's theory. These stages can occur in any order, occur simultaneously, and/or be repeated.

Correct answer: A 32-year-old with partial-thickness burns covering 36% of the body

Severe burns are classified as follows:

• full-thickness burns that involve the hands, feet, face, upper airway, or genitalia or circumferential burns
• full-thickness burns that cover more than 5% of the body surface area
• partial-thickness burns that cover more than 20% of the body surface area
• burns associated with respiratory injury or complicated by fractures
• burns in patients younger than 5 years or older than 55 years that would otherwise be classified as moderate

Moderate burns are classified as follows:

• full-thickness burns that involve 2-10% of the body surface area (excluding areas mentioned above)
• partial-thickness burns that involve 15-30% of the body surface area
• superficial burns that involve more than 50% of the body surface area

Minor burns are classified as follows:

• full-thickness burns that involve under 2% of the body surface area (excluding areas mentioned above)
• partial-thickness burns that involve under 15% of the body surface area
• superficial burns that involve under 50% of the body surface area

The DOT marking system is an identification protocol characterized by labels, markings, and placards. 

A waybill is carried by the conductor of a train and describes the materials being transported. It can be a useful source of information regarding the material involved in an incident, but it is not part of the DOT marking system. 

Correct answer: Anaphylactic shock

Anaphylaxis, or anaphylactic shock, is a violent reaction to an allergen. Common causes of anaphylaxis include injections (e.g., tetanus antitoxin, penicillin), stings from insects, ingestion of foods, and inhalation of particles (e.g., dust, pollen, mold). It may develop within seconds or minutes of contact with the allergen. A repeat phase 1-8 hours after exposure is possible. Flushed, itchy skin, urticaria (hives), edema, pallor, cyanosis, hypotension, weak or almost impalpable pulse, sneezing, stridor/airway obstruction, chest tightness, dyspnea, coughing, wheezing, respiratory arrest, abdominal cramping, nausea/vomiting, altered mental status, dizziness, syncope, and coma are possible.

Asthma is an acute spasm of bronchioles associated with excessive mucus production and swelling of the respiratory mucosal lining. Wheezing, dyspnea, cyanosis, and respiratory arrest may occur. Urticaria is not commonly associated with asthma.

Syncope is fainting (a near or brief loss of consciousness) and can be a sign of many medical emergencies. 

Heat exhaustion is the most common heat emergency. It is caused by heat exposure, stress, and fatigue. Hypovolemia is common due to the loss of water and electrolytes via sweating. Dizziness, weakness, syncope, muscle cramping, a dry tongue/thirst, and tachycardia are common.