Comprehensive Paramedic Review: Patient Assessment, Airway Management, Medication Administration, and Critical Decision Making

Comprehensive practice flashcards for paramedic students covering physical examination findings, pharmacology math, vascular and intraosseous access, critical thinking, patient assessment protocols, and basic through advanced airway management.

What are the four cornerstones of effective paramedic practice?

1. Gathering, evaluating, and synthesizing (processing) information
2. Developing and implementing a patient care plan
3. Using judgment and independent decision making
4. Thinking and working under pressure

What are the five sequential stages of the critical thinking process in prehospital care?

1. Concept formation (gathering sensory data and diagnostic information)
2. Data interpretation (evaluating data and forming conclusions based on anatomy/pathophysiology)
3. Application of principle (converting field impressions into a working diagnosis and treatment plan)
4. Reflection in action (actively treating while monitoring and adjusting for intervention effects)
5. Reflection on action (evaluating decisions and performance after the call is over)

What are 'The Six Rs' of clinical decision making?

1. Read the scene
2. Read the patient
3. React
4. Reevaluate
5. Revise the treatment plan
6. Review performance

What are the five phases of the comprehensive patient assessment process?

1. Scene Size-up
2. Primary Assessment
3. History Taking
4. Secondary Assessment
5. Reassessment

What are the recommended reassessment intervals for stable versus unstable patients?

Stable patients should be reassessed every $15\,\text{minutes}$, while unstable patients must be reassessed every $5\,\text{minutes}$.

What is the minimum estimated systolic blood pressure associated with palpable pulses at the carotid, femoral, radial, and pedal arteries?

• Carotid artery: $\ge 60\,mm\,Hg$
• Femoral artery: $\ge 70\,mm\,Hg$
• Radial artery: $\ge 80\,mm\,Hg$
• Pedal (dorsalis pedis) artery: $\ge 90\,mm\,Hg$

What formulas are used to calculate the normal and hypotensive systolic blood pressures in pediatric patients?

• Normal systolic BP: $90 + (2 \times \text{age in years})$
• Hypotensive systolic BP: $70 + (2 \times \text{age in years})$

Where should a pulse be palpated on an infant during primary assessment?

Over the brachial artery on the inner upper arm.

What defines pulsus paradoxus, and what does it indicate?

A drop of more than $10\,mm\,Hg$ in systolic blood pressure during inhalation, typically seen in severe asthma, COPD, or cardiac tamponade.

What does each letter represent in the COASTMAP mental status examination mnemonic?

• C: Consciousness
• O: Orientation
• A: Activity
• S: Speech
• T: Thought
• M: Memory
• A: Affect (mood)
• P: Perception

In what chronological order do acutely altered patients lose orientation?

In reverse order of assessment: first situation, then time, followed by place, and finally person.

Which cranial nerves are responsible for eye movement, and what specific action does each perform?

• Oculomotor nerve (CN III): Upward and downward gaze, pupillary constriction, and accommodation
• Trochlear nerve (CN IV): Inward (inferomedial) gaze
• Abducens nerve (CN VI): Outward (lateral) gaze

What is a vascular bruit, and what physiological condition does it indicate?

An abnormal whooshing sound caused by turbulent blood flow through a narrowed or partially occluded artery, most commonly auscultated over the carotid arteries.

What clinical findings characterize Cullen sign and Grey Turner sign, and what pathologies do they indicate?

• Cullen sign: Periumbilical ecchymosis
• Grey Turner sign: Flank ecchymosis Both indicate retroperitoneal hemorrhage resulting from conditions such as acute pancreatitis or a ruptured ectopic pregnancy.

What criteria indicate a positive orthostatic vital sign (tilt) test?

Upon moving from supine to a sitting or standing position:

• A decrease in systolic blood pressure
• An increase in diastolic blood pressure of $10\,mm\,Hg$
• An increase in pulse rate of at least $20\,\text{beats/min}$

How are the four grades of pitting edema defined by depth and duration of indention?

• Grade 1+: Mild pitting; $2\,mm$ depression that disappears rapidly
• Grade 2+: Moderate pitting; $4\,mm$ depression that disappears in $10\text{--}15\,\text{seconds}$
• Grade 3+: Moderately severe pitting; $6\,mm$ depression lasting more than $1\,\text{minute}$
• Grade 4+: Severe pitting; $8\,mm$ depression lasting more than $2\,\text{minutes}$

What are the '5 Ps' of acute arterial insufficiency?

1. Pain
2. Pallor
3. Paresthesia
4. Paresis
5. Pulselessness

How are the three pathological curvatures of the spine distinguished?

• Scoliosis: Lateral 'S'-shaped curvature when viewed from the posterior aspect
• Kyphosis: Exaggerated outward (convex) thoracic curvature ('hunchback')
• Lordosis: Exaggerated inward (concave) lumbar curvature ('swayback')

What constitutes a normal finding versus a clubbing finding during Schamroth's window test?

Normally, placing opposing dorsal terminal phalanges together produces a small diamond-shaped window with a nailbed angle of $160^\circ$. In clubbing, the window disappears and the angle exceeds $180^\circ$, indicating chronic hypoxemia.

What is the ABCDE rule used to evaluate concerning skin lesions and melanoma?

• A: Asymmetry (one half does not match the other)
• B: Border (irregular, scalloped, or poorly defined border)
• C: Color (varied shades of tan, brown, black, white, red, or blue)
• D: Diameter (usually greater than $6\,mm$, roughly the size of a pencil eraser)
• E: Evolving (lesion changing in size, shape, or color over time)

What clinical characteristics differentiate the four grades of pressure ulcers according to the EPUAP system?

• Grade 1: Non-blanchable erythema of intact skin
• Grade 2: Partial thickness skin loss involving epidermis, dermis, or both; presents as an abrasion or blister
• Grade 3: Full thickness skin loss involving necrosis of subcutaneous tissue extending down to, but not through, underlying fascia
• Grade 4: Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures

What characteristic facial presentation is associated with Bell's palsy?

Unilateral facial weakness or paralysis presenting with smoothing of the forehead wrinkles, drooping of the eyebrow, inability to close the eye, and drooping of the corner of the mouth.

What anatomic landmark demarcates the transition between the upper airway and the lower airway?

The glottic opening (or vocal cords/larynx). Structures above the glottis constitute the upper airway; structures below constitute the lower airway.

What is the narrowest portion of the human airway in adults compared to infants and young children?

• Adults: The glottis (the space between the vocal cords)
• Infants and young children: The funnel-shaped cricoid ring

What is the normal inspiratory to expiratory (I:E) ratio, and how does it change during lower airway obstruction?

The normal I:E ratio is $1:2$. In the presence of lower airway obstruction, the expiratory phase prolongs significantly to an I:E ratio of $1:4$ or $1:5$.

What are the distinguishing characteristics of bronchial, bronchovesicular, and vesicular breath sounds?

• Bronchial: Loud, harsh, high-pitched, hollow, and tubular sounds heard over the trachea; expiration is equal to or longer than inspiration
• Bronchovesicular: Medium pitch and intensity heard over mainstem bronchi (1st and 2nd intercostal spaces anteriorly); I:E ratio is equal
• Vesicular: Soft, low-pitched, swishing or rustling sounds heard over peripheral lung fields; inspiration is longer and louder than expiration

What causes the adventitious sounds stridor, wheezes, rhonchi, and crackles (rales)?

• Stridor: Harsh, high-pitched sound heard on inspiration due to upper airway narrowing or obstruction
• Wheezes: Continuous high-pitched whistling sounds primarily during expiration caused by constricted lower airways (bronchi/bronchioles)
• Rhonchi: Low-pitched snoring or rattling sounds originating from secretions or mucus in larger airways
• Crackles (rales): Discontinuous popping or hair-crinkling sounds heard predominantly on inspiration caused by fluid in the alveoli

What are the standard reference values for arterial blood gases (ABGs)?

• pH: $7.35\text{--}7.45$
• $\text{PaO}_2$: $80\text{--}100\,mm\,Hg$
• $\text{PaCO}_2$: $35\text{--}45\,mm\,Hg$
• $\text{HCO}_3^-$: $22\text{--}26\,mEq/L$
• $\text{SaO}_2$: $\ge 95\%$

What physiological event occurs during each phase of a normal capnographic waveform?

• Phase I (A-B): Respiratory baseline; exhalation of CO2-free anatomic dead space gas
• Phase II (B-C): Expiratory upslope; mixture of alveolar gas and dead space gas causing a rapid rise in detected CO2
• Phase III (C-D): Alveolar plateau; exhalation of pure alveolar gas, where point D represents maximal end-tidal CO2 (ETCO2)
• Phase IV / 0 (D-E): Inspiratory downstroke; rapid drop to zero as fresh oxygenated gas is inspired

How does end-tidal carbon dioxide (ETCO2) reflect ventilation and perfusion status?

• Hypoventilation causes ETCO2 accumulation ($> 45\,mm\,Hg$)
• Hyperventilation eliminates CO2 faster than production ($< 35\,mm\,Hg$)
• Hypoperfusion (shock) reduces blood return to lungs, causing low ETCO2 ($< 35\,mm\,Hg$)
• In cardiac arrest, ETCO2 drops to near zero; high-quality CPR should produce readings $> 10\,mm\,Hg$, and a sudden spike indicates return of spontaneous circulation (ROSC)

What are the total gas volume, delivered flow rate, and delivered oxygen percentage for standard portable oxygen cylinders and adjuncts?

• D-cylinder capacity: $350\,L$; M-cylinder capacity: $3000\,L$
• Working regulator reduction: Cylinder pressure of $\approx 2000\,psi$ is reduced to $\approx 50\,psi$
• Safe cylinder replacement threshold: $\le 200\,psi$
• Nasal cannula: $1\text{--}6\,L/min$ delivering $24\text{--}44\%\,\text{FiO}_2$
• Nonrebreather mask (NRB): $12\text{--}15\,L/min$ delivering $90\text{--}100\%\,\text{FiO}_2$
• High-flow nasal cannula (HFNC): Up to $60\,L/min$ delivering $21\text{--}100\%\,\text{FiO}_2$
• Bag-valve-mask (BVM): $15\text{--}16\,L/min$ with reservoir delivering up to $100\%\,\text{FiO}_2$

What are the proper assisted ventilation rates for adults, children, infants, and neonates?

• Adults: 1 breath every $6\,\text{seconds}$ ($10\,\text{breaths/min}$, or $1:6$)
• Pediatrics/Children: 1 breath every $3\,\text{seconds}$ ($20\,\text{breaths/min}$, or $1:3$)
• Infants: 1 breath every $2\,\text{seconds}$ ($30\,\text{breaths/min}$, or $1:2$)
• Neonates: 1 breath every $1\,\text{second}$ ($60\,\text{breaths/min}$, or $1:1$)

What are the indications and contraindications for choosing an orogastric (OG) versus nasogastric (NG) tube for gastric decompression?

• Orogastric (OG) tube: Preferred in unresponsive patients and strictly required in the presence of severe facial or head trauma/basilar skull fracture
• Nasogastric (NG) tube: Tolerated in responsive patients with an intact gag reflex, but contraindicated in facial/nasal trauma and basilar skull fractures

What parameters are evaluated in the LEMON mnemonic for predicting a difficult airway?

• L: Look externally (short, thick neck, morbid obesity, facial trauma, micrognathia)
• E: Evaluate 3-3-2 rule (mouth opening $\ge 3$ fingerbreadths, hyoid-mental distance $\ge 3$ fingerbreadths, thyroid-to-hyoid distance $\ge 2$ fingerbreadths)
• M: Mallampati score (class I to IV visual assessment of posterior pharynx)
• O: Obstruction (foreign bodies, angioedema, tumors, hematomas)
• N: Neck mobility (restricted movement from cervical collars, arthritis, trauma)

What are the standard endotracheal tube (ETT) sizes and depth insertion markers for adult males and females?

• Adult female: $7.0\text{--}7.5\,mm$ internal diameter; typical depth marking at teeth is $21\,cm$
• Adult male: $7.5\text{--}8.0\,mm$ internal diameter; typical depth marking at teeth is $23\,cm$ (Sizing can also be approximated by the diameter of the patient's pinky finger or nostril)

Where are Macintosh (curved) and Miller (straight) laryngoscope blades positioned during direct laryngoscopy?

• Macintosh (curved) blade: The tip is placed into the vallecula to indirectly elevate the epiglottis by tension on the hyoepiglottic ligament
• Miller (straight) blade: The tip is passed directly beneath the epiglottis to physically lift it anteriorly

What what does the BURP maneuver stand for, and what is its clinical purpose?

Backward, Upward, Rightward, and Posterior pressure applied externally to the thyroid cartilage to improve glottic visualization during laryngoscopy.

What are the '7 Ps' of Rapid Sequence Intubation (RSI)?

1. Preparation
2. Preoxygenation
3. Pretreatment
4. Paralysis with induction
5. Protection and positioning
6. Placement with proof
7. Post-intubation management

What are the pharmacological properties, onset times, and durations of common RSI induction/sedative agents?

• Ketamine: Dissociative anesthetic, bronchodilator with sympathomimetic stability; onset $10\text{--}30\,\text{seconds}$, duration $10\text{--}15\,\text{minutes}$
• Etomidate: Sedative-hypnotic, hemodynamically neutral with no drop in blood pressure; onset $30\text{--}60\,\text{seconds}$, duration $5\text{--}10\,\text{minutes}$
• Midazolam: Benzodiazepine providing sedation and retrograde amnesia; onset $120\text{--}180\,\text{seconds}$, duration $20\text{--}30\,\text{minutes}$

How does succinylcholine differ pharmacologically from rocuronium and vecuronium?

• Succinylcholine: The only depolarizing neuromuscular blocker; competitively binds ACh receptors, stimulates depolarization causing transient visible fasciculations; onset $30\text{--}60\,\text{seconds}$, short duration $4\text{--}10\,\text{minutes}$
• Rocuronium / Vecuronium: Non-depolarizing agents; competitively block ACh receptors without depolarization (no fasciculations); rocuronium onset $45\text{--}90\,\text{seconds}$, vecuronium onset $90\text{--}120\,\text{seconds}$, duration $45\text{--}60\,\text{minutes}$

What equipment is required to perform a surgical cricothyrotomy, and in what patient population is it contraindicated?

Equipment: #10 scalpel, gum elastic bougie, $6.0\,mm$ cuffed ETT (or tracheostomy tube), $10\,mL$ syringe, and BVM with PEEP. Contraindication: Children younger than $8\,\text{years}$ of age (who require needle cricothyrotomy instead).

What are the formulas for converting pounds to kilograms, Fahrenheit to Celsius, and Celsius to Fahrenheit?

• Pounds to kilograms: $\text{Weight in kg} = \frac{\text{Weight in lbs}}{2.2}$ (or divide by $2$ and subtract $10\%$
• Fahrenheit to Celsius: $^\circ C = (^\circ F - 32) \times 0.555$
• Celsius to Fahrenheit: $^\circ F = (^\circ C \times 1.8) + 32$

What formula calculates the intravenous fluid infusion flow rate in drops per minute (gtt/min)?

$$\text{Flow rate (gtt/min)} = \frac{\text{Volume to be infused (mL)} \times \text{Drip set factor (gtt/mL)}}{\text{Total infusion time (minutes)}}$$

How do isotonic, hypotonic, and hypertonic intravenous solutions affect red blood cells and fluid compartments?

• Isotonic (e.g., $0.9\%\,\text{NS}$, LR): Same osmolarity as serum; no net fluid shift; cell shape unchanged
• Hypotonic (e.g., $0.45\%\,\text{NS}$, D5W): Lower osmolarity than serum; fluid shifts from intravascular space into intracellular fluid, causing cells to swell
• Hypertonic (e.g., $3\%\,\text{NS}$): Higher osmolarity than serum; pulls fluid from intracellular and interstitial spaces into intravascular volume, causing cells to crenate (shrink)

What needle insertion angles are standard for intramuscular (IM), subcutaneous (SQ), intravenous (IV), and intradermal (ID) injections?

• Intramuscular (IM): $90^\circ$
• Subcutaneous (SQ): $45^\circ$
• Intravenous (IV): Insert at $35^\circ\text{--}45^\circ$, drop to $15^\circ$ once flashback is observed
• Intradermal (ID): $10^\circ\text{--}15^\circ$ with bevel up

What is the recommended prehospital order of draw for vacuum blood collection tubes?

'Red Blood Gives Life':

1. Red (no additive / clot activator)
2. Blue (sodium citrate)
3. Green (heparin)
4. Lavender (EDTA) (Tubes must be filled to at least three-fourths capacity; do not shake the red tube)

What needle lengths and anatomical landmarks are utilized for adult intraosseous (IO) access at the proximal humerus, proximal tibia, and distal femur?

• Proximal humerus ($45\,mm$ yellow needle): Greater tubercle of the humeral head; arm adducted across abdomen to rotate biceps tendon medially
• Proximal tibia ($25\,mm$ blue or $15\,mm$ pink needle): Flat surface approximately $2\,cm$ medial and $1\text{--}2\,cm$ distal to the tibial tuberosity
• Distal femur ($25\,mm$ or $45\,mm$ needle): Anterior midline $2\text{--}3\,cm$ above the external condyle

How should a patient be positioned if an air embolism is suspected during IV therapy?

Place the patient in the left lateral Trendelenburg position (left lateral recumbent with head down) and administer $100\%$\ oxygen to trap air bubbles in the right atrium.

How does the dosage of medications administered via the intranasal (IN) route compare to intravenous (IV) dosing?

Intranasal administration using a mucosal atomizer device (MAD) typically requires $2$ to $2.5$ times the standard intravenous dose.

Where are the six precordial leads placed when acquiring a standard 12-lead ECG?

• $V_1$: 4th intercostal space, right sternal border
• $V_2$: 4th intercostal space, left sternal border
• $V_3$: Directly midway between $V_2$ and $V_4$
• $V_4$: 5th intercostal space, left midclavicular line
• $V_5$: Horizontal to $V_4$ at the anterior axillary line
• $V_6$: Horizontal to $V_4$ and $V_5$ at the midaxillary line