10 free EMT practice questions: Toxicology & Substance Use Emergencies

Acute alcohol intoxication with a declining level of consciousness: Acute intoxication fits a heavy drinker who has been drinking recently. This patient's last drink was about 40 hours ago, and there is no alcohol on the breath. The alcohol has already cleared, and what you are seeing is withdrawal.

Wernicke encephalopathy from chronic thiamine deficiency: Chronic drinkers are at real risk for Wernicke encephalopathy, which comes from a lack of thiamine. Wernicke encephalopathy causes confusion, an unsteady walk, and abnormal eye movements like nystagmus. This patient has none of those.

Delirium tremens, which begins within 6 hours of the last drink: Delirium tremens has the same tremor, fast pulse, high blood pressure, and sweating. Delirium tremens also has disorientation and severe confusion, and this patient is clear enough to describe the insects. Delirium tremens usually starts 48 to 96 hours after the last drink, not within 6 hours. At 40 hours, this patient has withdrawal with hallucinosis and has not reached delirium tremens.

The ingestion occurred too recently for charcoal to be effective: Timing does matter for charcoal. Charcoal works best while the drug is still in the stomach. This ingestion was only about 20 minutes ago, so most of the drug is likely still there. Timing would be a reason to hold charcoal for an ingestion many hours old.

The patient took an over-the-counter rather than a prescription medication: Whether charcoal binds a drug depends on the drug itself. Over the counter or prescription does not change that. Charcoal is commonly used for over-the-counter pain relievers. This option also ignores the drop in mental status.

Activated charcoal is only effective for ingested corrosive substances: Corrosive substances are a classic reason not to give charcoal. Charcoal binds corrosives poorly and blocks the view during the endoscopy those patients need. Calling corrosives the one thing charcoal treats gets the rule backwards. This patient also swallowed a pain reliever, not a corrosive.

Administer naloxone by the intramuscular route: Intramuscular naloxone is a real route, and the paramedic meeting you will likely use it. At the EMT level, epinephrine is the only medication you give intramuscularly. IM naloxone is outside your scope. This patient is already being ventilated, and calling ALS gets naloxone to the patient from someone licensed to give it.

Place naloxone under the tongue to be absorbed through the oral mucosa: Under the tongue is a real route. Nitroglycerin is given that way, because nitroglycerin is made to absorb through the lining of the mouth. Naloxone is not made or approved for use under the tongue, so it does not absorb reliably. This patient is unresponsive and cannot protect their own airway. Putting anything in the mouth to dissolve risks aspiration on top of the overdose.

Delay transport until naloxone can be given by an available route: Delaying makes sense when a treatment can safely wait. Respirations of 4 a minute cannot wait. A nosebleed from a facial injury may not stop in the field at all. Ventilation and transport keep going whether or not naloxone is ever given.

Nausea and occasional vomiting without other symptoms: Vomiting is dangerous in a patient who is too drowsy to protect the airway, because the vomit can go into the lungs. This option gives nausea and occasional vomiting with no other symptoms. Nothing in this option says the mental status is down, so the patient can still protect the airway. Charcoal is withheld for an airway the patient cannot protect. Watch closely for more vomiting after a dose, and follow your protocol and Poison Control on timing.

Mild abdominal cramping without other symptoms: Abdominal pain becomes a red flag when the abdomen is rigid or the patient shows signs of shock. This patient has mild cramping with no other symptoms. Charcoal is held for an airway the patient cannot protect, and it does nothing for a caustic or a hydrocarbon. Mild cramping is not on that list.

Chronic constipation with no associated abdominal pain: Constipation matters with charcoal because repeated doses can cause constipation and bowel obstruction. A true bowel obstruction would cause abdominal pain and distension. This option says there is no abdominal pain. Chronic constipation by itself is not a reason to withhold a dose.

Dilated pupils: go with sympathomimetic overdoses, the stimulant drugs, and with anticholinergic overdoses. An opioid overdose makes the pupils small, not large.

Hypertension: shows up with sympathomimetic or anticholinergic poisoning. Opioids usually drop the blood pressure instead of raising it.

Hyperthermia: a sign of a sympathomimetic or anticholinergic overdose too. A high body temperature does not fit an opioid overdose.

Anticholinergic toxidrome (dry mouth, dilated pupils, agitation, rapid heart rate): Anticholinergic poisoning, like from an antihistamine or belladonna, gives you a dry mouth, flushed dry skin, dilated pupils, agitation, and a fast heart rate. This couple has the opposite. They have excessive salivation and pinpoint pupils. Anticholinergic and cholinergic effects sit at opposite ends of the same receptor system, so one patient cannot have both.

Sympathomimetic toxidrome (dilated pupils, tachycardia, hypertension, agitation): Sympathomimetic poisoning comes from stimulants like cocaine or amphetamines. Those patients have dilated pupils, a fast heart rate, high blood pressure, and agitation. These patients have pinpoint pupils and are confused, not agitated. The diarrhea and salivation come from the parasympathetic side being overloaded.

Sedative-hypnotic toxidrome (lethargy, respiratory depression, hypotension): A sedative-hypnotic, like a benzodiazepine or a barbiturate, depresses the central nervous system. You see lethargy, slow breathing, and low blood pressure. A sedative-hypnotic does not explain salivation, muscle twitching, or diarrhea. Those findings come from the nervous system being overstimulated, not depressed.

Administer high-flow oxygen by NRB to slow the rapid heart rate and reduce the patient's agitation: High-flow oxygen by NRB is for hypoxia or trouble breathing. The question gives no low SpO2 and no breathing complaint. The fast heart rate comes from the stimulant, and oxygen does nothing to the catecholamine surge.

Apply physical restraints immediately to prevent the patient from causing harm to themselves or to the crew: Restraints are for a patient who is combative and an immediate danger to self or the crew. The question says this patient is only verbally hostile and not an immediate danger. Force is not justified here. Restraining a patient full of catecholamines pushes the catecholamines even higher and raises the risk of sudden cardiac arrest.

Administer a dose of intranasal naloxone to reverse the effects of the powdered substance the patient used: Naloxone reverses an opioid overdose. An opioid overdose gives you a slow heart rate, low blood pressure, slow breathing, and pinpoint pupils. This patient has a fast pulse, high blood pressure, and a fever. Those are stimulant signs, so naloxone has nothing to reverse.

The naloxone has completely reversed the opioid effect, and the patient may now safely refuse further evaluation and transport: Waking up and breathing 16 times a minute looked like full reversal. The drowsiness coming back minutes later shows the opioid is still working. This patient is drowsy again right now, and the level of consciousness is falling. A patient who is not alert cannot give a valid refusal.

The patient is now experiencing acute opioid withdrawal, which shows the overdose has resolved and the crisis has passed: Opioid withdrawal makes a patient agitated and aggressive, and it can cause vomiting. Withdrawal does not cause drowsiness. This patient's renewed drowsiness is the opioid toxicity still going. The crisis has not passed.

The recurring drowsiness indicates the naloxone dose was ineffective and a different medication is needed to reverse the substance: An ineffective dose would fit a patient who never responded at all. This patient woke up and the breathing rate rose to 16, so the naloxone worked on this opioid. The drowsiness means there is still opioid on board, not that naloxone is the wrong drug. If the breathing slows again, the answer is another naloxone dose per protocol.

Withhold ventilatory support until naloxone takes effect: Waiting to see if a drug works before adding support is fine when the patient is holding their own. A patient breathing well while nitroglycerin takes effect is an example. This patient is breathing 6 times a minute with an SpO₂ of 82% on room air. The brain is hypoxic the whole time you wait. Ventilating keeps the patient alive during the minutes the naloxone needs.

Administer oral glucose: Oral glucose is for an altered patient with a low blood glucose who can still protect the airway. Pinpoint pupils point to opioids, not hypoglycemia. An unresponsive patient breathing 6 times a minute cannot safely take anything by mouth. Giving glucose would also delay the ventilations this patient needs right now.

Apply a tourniquet to the affected extremity: A tourniquet is for life-threatening bleeding from an arm or leg that direct pressure cannot control. This question describes no injury, no bleeding, and no trauma. The life threat on this call is a respiratory rate of 6.

Approach and administer intranasal naloxone: Naloxone is the right drug for an opioid overdose, and pinpoint pupils with slow breathing can look like one. This worker smells of chemicals and has a pesticide sprayer next to them. The chemical smell and the sprayer point to a pesticide exposure, not an opioid. Naloxone has no effect on cholinergic toxicity.

Begin positive pressure ventilations without protective equipment: This worker does need ventilations, and they come right after decontamination. The chemical soaking the coveralls can get onto you the moment you make contact without protection. That's why decontamination comes before hands-on ventilation.

Perform a rapid trauma assessment for open wounds: A rapid trauma assessment is for a patient with a mechanism of injury, like a fall or a crash. Nothing on this call describes a mechanism of injury. A trauma assessment also puts your hands on a worker who is still covered in the chemical. The trauma assessment does nothing for the contamination or the failing breathing.