10 free Paramedic practice questions: Advanced Airway Management and Rapid Sequence Intubation Concepts

Withhold the paralytic and attempt an awake look with topical anesthesia alone: An awake look does not fix the hemodynamics, and it gives up the conditions that make a first-pass success likely in a patient who cannot tolerate a second attempt.

Increase the oxygen flow and defer the airway until the emergency department: The level of consciousness is falling and the saturation is 88% on high-flow oxygen. Waiting hands over an unprotected airway and a patient who is still deteriorating.

Give the full induction dose so the airway is secured before the pressure falls: A full dose in a patient with no reserve is the thing most likely to stop this heart. Speed does not protect a pressure of 78 systolic.

Reposition the supraglottic airway: Repositioning the supraglottic airway is worth trying only if it hasn't already failed to ventilate. Here it's already produced no chest rise and no waveform, meaning it isn't working at all.

Attempt a third laryngoscopy: A third laryngoscopy attempt burns more of this patient's rapidly falling oxygen reserve on a technique that's already failed twice against distorted anatomy that repeat attempts won't fix.

Increase the ventilation rate with the BVM: Increasing the BVM ventilation rate doesn't help when the fundamental problem is that ventilations aren't producing any chest rise at all. More attempts at a technique that isn't working doesn't make it work.

Administer diphenhydramine intravenously: An H1 antihistamine is genuinely indicated in anaphylaxis and will be given. It blocks histamine at the receptor and blunts the next round of mediator effect. It does nothing about the histamine already bound and already producing the stridor and the 82/50 in front of you, and its onset is far longer than the minutes this airway has. Both drugs are indicated; this one comes after, and the item is asking what comes first.

Administer nebulized albuterol: Albuterol is the right answer for lower-airway bronchospasm, and if this patient were wheezing after epinephrine it would be a reasonable adjunct. The question describes stridor, which is a high-pitched sound generated at and above the cords by upper-airway swelling, and a nebulized beta-2 agonist does not shrink laryngeal and tongue edema. It also does nothing for the hypotension, which is the other half of what is killing this patient.

Perform rapid sequence intubation: Rapid sequence intubation is what you prepare for when anaphylactic airway swelling does not respond to epinephrine, and it may still be needed. Paralyzing a patient whose glottis is already narrowed by edema turns a partially obstructed airway into a can't-intubate, can't-ventilate emergency, and it does nothing for the shock. Give the drug that can reverse the swelling first, and keep the airway plan ready in case it does not.

Instill sterile saline and suction the tube again: Repeating suction is the right move when the catheter passes and you are simply clearing more secretions than one pass removed. Here the catheter already met a firm obstruction and suctioning already failed to improve ventilation, so this repeats an intervention that has failed while a restless, pale patient goes without ventilation. Saline instillation is also not supported as a way to break up a plug and can drive debris further in. The key removes the plug bodily instead of trying to negotiate with it.

Ventilate through the mouth and nose with a mask: Ventilating from above is a legitimate rescue for a tracheostomy patient, but only for one with a patent upper airway: a connection between the pharynx and trachea that a total laryngectomy patient does not have, and it requires occluding the stoma or the air simply escapes. It is the workaround for a tube you cannot fix. This tube is fixable in seconds, so bypassing it before trying the single step most likely to restore it adds an assumption and a delay for no gain.

Remove the entire tracheostomy tube from the stoma: Removing the whole tube is the correct escalation once the inner cannula is out and the obstruction persists, or when the tube is clearly displaced into a false passage. It is also the destructive option: pulling the outer cannula risks losing the stoma tract, and if the tract closes you own an airway you may not be able to re-enter. The principle is to take the least destructive step likely to work first: inner cannula out, and only then the whole tube.

An inflatable cuff that seals the hypopharynx: The hypopharyngeal seal is what makes any supraglottic airway work at all: without it your ventilation pressure leaks out around the device instead of going into the lungs, so this is a real and necessary feature and the strongest distractor here. Two problems: essentially every supraglottic airway in use has some form of seal, so it does not distinguish one device from another, and a seal above the esophagus stops gas escaping upward rather than draining what is already in the stomach. It addresses ventilation quality, not this patient's specific danger.

A color-coded sizing scale based on weight: Correct sizing genuinely matters, since an undersized device leaks and an oversized one seats poorly, so a weight-based scale is a useful design feature and part of using the device well. Sizing is a general requirement for any patient, not a feature aimed at this one's problem. The question asks what matters most in a patient with a full stomach who has already vomited, and sizing is neutral to that.

A reinforced tube that resists kinking: Kink resistance is a genuine advantage in a transported patient whose head may be turned, because an occluded tube ventilates nothing. It protects against a mechanical problem that might happen. Aspiration in this patient is a problem that is already actively developing: the vomiting has already started, so the feature that addresses the present threat outranks the one that addresses a possible future threat.

Perform a jaw-thrust maneuver and reattempt: A jaw thrust is the correct maneuver for the most common cause of a chest that will not rise, which is the tongue falling back and occluding the pharynx in an unresponsive patient, and it is the preferred version when a spinal injury is suspected. It works by opening a pathway between the mouth and the trachea. This patient has no such pathway, because it was surgically removed, so opening the pharynx improves nothing while the key delivers air to the only opening that reaches the lungs.

Insert an oropharyngeal airway and reattempt: An oropharyngeal airway solves the same problem the jaw thrust does, mechanically holding the tongue off the posterior pharynx, and it is a reasonable next adjunct in an ordinary failed-ventilation sequence. It rests on the same fatal assumption: that maintaining a route from the mouth leads somewhere. The question has also already told you the airway was repositioned and the mouth is clear, which is the item's way of eliminating every explanation on the face side of the problem.

Suction the mouth and reattempt: Suctioning is right when the chest is not rising because something is physically in the way, such as blood, vomit, or secretions, and it should always be considered early. The question states that the mouth is clear of fluid and debris, so there is nothing to suction and no obstruction to clear. Repeating a face-side intervention is the specific error this item is built to catch, and the key changes where the air is delivered, which is the only change that alters the outcome.

Have the assistant increase the pressure: More pressure is what you would ask for if the problem were an anteriorly positioned larynx, and it is very easy to confuse cricoid pressure with external laryngeal manipulation, where a second set of hands genuinely does improve the view. The difference is direction and purpose: laryngeal manipulation moves the thyroid cartilage to optimize what you see, while cricoid pressure pushes the airway backward to try to occlude the esophagus behind it. Increasing the force that is already flattening the inlet drives the view further in the wrong direction.

Withdraw and reattempt with a smaller blade: Changing equipment is a legitimate response to a failed attempt, and blade type and size do matter to the view. This treats the attempt as failed when it has not failed yet: the saturation is 97% and the operator is still looking, and it costs the whole attempt plus the time to swap gear. One variable in this picture is obviously wrong and is attached to the assistant's hand; fix the free variable inside the attempt before restarting the attempt.

Abandon the attempt and place a supraglottic airway: Abandoning laryngoscopy for a rescue device is correct when the patient is desaturating, the attempt has run long, or repeated attempts have failed. None of that is true here: the saturation is 97%, this is one ongoing attempt, and there is an obvious correctable cause of the poor view. Escalating past a fix that takes one sentence to communicate gives up a definitive airway for no reason.

Etomidate will suppress breathing for an hour: Etomidate is why this patient is unaware, and sedation does contribute to apnea, so suspecting the induction agent is not unreasonable. The duration is wrong by a wide margin: a single induction dose of etomidate produces only a few minutes of unconsciousness, nowhere near an hour. Even if the sedation had fully worn off, the paralysis would still prevent a breath, so the key names the drug whose duration actually blocks the plan.

Rocuronium does not affect the diaphragm: This statement gets the pharmacology backwards. Non-depolarizing blockade takes the diaphragm along with every other skeletal muscle; the diaphragm is simply among the more resistant muscles and among the first to recover, which is likely where the idea comes from. If rocuronium truly spared the diaphragm the crew member's plan would work, and it is the falsity of this statement that makes the plan unavailable.

BVM ventilation prevents spontaneous effort: BVM ventilation supports a patient rather than suppressing respiratory drive. Overventilating can blunt drive by dropping carbon dioxide in a patient who is not paralyzed, but the BVM is not why this patient is apneic, and right now it is the only reason the SpO2 is sitting at 97%. The obstacle is pharmacologic, not the device holding the saturation up, so the key points at the paralytic instead of the bag.

Advance the tube 1 cm to reseat the cuff: Advancing the tube is the correction for a tube that has migrated outward: a cuff sitting at or above the cords, an audible leak, a changed depth marking at the teeth. The question closes that door explicitly: the depth at the teeth is unchanged and breath sounds are still equal. Advancing without an indication risks a mainstem intubation, and it would not lower the cuff pressure anyway, because the pressure came from expanding gas rather than from position.

Leave the cuff alone and recheck after landing: Watchful waiting is defensible for a borderline pressure or one that is trending down, and it is true this patient is currently well oxygenated and well ventilated. The problem is that mucosal ischemia is time-dependent and silent. Nothing on the monitor will change while the injury develops, and the aircraft stays at altitude. You have a manometer in your hand and a two-second correction, so there is no reason to accept a known injurious pressure for the length of the transport.

Deflate the cuff completely until the aircraft descends: Full deflation is done deliberately in a few narrow situations, such as troubleshooting the cuff or preparing to extubate. Doing it here trades a slow problem for a fast one: with no seal, delivered volume leaks past the tube and your ventilation becomes unreliable, and gastric contents and oral secretions have a direct path into the trachea. The goal is to normalize the pressure, not to eliminate the seal, and the key adjusts the same variable by the right amount.

Withdraw the bougie a few centimeters and readvance it: Moving the bougie moves the guide rather than the part that is stuck. The tube bevel is still oriented the same way when it reaches the same structure, and withdrawing the bougie risks losing the tracheal access that is already established.

Push the tube firmly past the resistance: Force does not change the geometry that is causing the hang-up. The bevel stays hooked on the same cartilage and the added pressure is what dislocates an arytenoid or tears laryngeal mucosa, producing bleeding that makes the remaining attempts harder.

Remove the bougie and reattempt with a stylet: The bougie has already done the difficult part and its position in the trachea is confirmed by the clicks. Discarding it restarts the intubation from the beginning, and a stylet does nothing about a bevel caught on the arytenoid.