10 free Paramedic practice questions: Advanced Neurologic Emergencies

Give an antihypertensive for the bleed: Lowering the blood pressure is a real hospital treatment for a bleed in the brain. You cannot tell a bleed from a clot without imaging. If this stroke is a clot, the high pressure is what pushes blood to the brain tissue around the clot. The hospital sets a pressure goal once imaging shows which stroke this is.

Hyperventilate to lower intracranial pressure: Hyperventilation lowers carbon dioxide, and low carbon dioxide narrows the blood vessels in the brain. Narrow vessels cut blood flow to a brain that is already short on it. Hyperventilation is saved for a short time when a patient shows active signs of herniation. This patient shows no signs of herniation, so ventilate to a normal carbon dioxide level.

Position the patient flat for perfusion: Laying a patient flat comes from shock care, where the goal is raising perfusion. In a stroke, lying flat slows the blood draining out of the head, and the pressure inside the skull goes up. Raise the head about 30 degrees and keep the neck in line.

A vagal response to the vomiting: Vomiting can drop the heart rate through a vagal response, and this patient did vomit. A vagal response does not come with a systolic pressure of 198 and irregular breathing. A vagal response also does not make one pupil dilate.

Decompensated shock from the bleed: Decompensated shock is low blood pressure with a fast, weak pulse. This patient's pressure is 198/78 and the pulse is 44. A bleed inside the skull kills by raising pressure in a closed space, not by the volume of blood lost.

An opioid effect on the brainstem: Slow breathing at 8 in an unresponsive patient is the pattern you see with opioids. An opioid gives you small, equal pupils. This patient has a 6 mm pupil on one side, and a sudden severe headache came before the collapse.

Midazolam: the first line benzodiazepine on almost every seizure call. A benzodiazepine only quiets the convulsion. Midazolam does not fix the spasm in the brain's blood vessels that is driving this seizure. Magnesium sulfate goes first, and midazolam follows only if the seizures keep going.

Calcium gluconate: the antidote for magnesium toxicity. No magnesium has been given yet, so there is nothing to reverse. Once magnesium is running, lost deep tendon reflexes, a falling respiratory rate, or a dropping level of consciousness send you to calcium gluconate.

Dextrose: Checking the glucose on every seizure is correct practice, and dextrose fixes a low one. This patient's glucose is 98 mg/dL, which is normal. Dextrose has nothing to correct and only delays the magnesium.

Thiamine deficiency producing an encephalopathy: Heavy drinkers really are low on thiamine, and untreated thiamine deficiency causes Wernicke encephalopathy. Wernicke encephalopathy shows up as confusion, abnormal eye movements like nystagmus or ophthalmoplegia, and ataxia. A single generalized seizure that stops on its own after 90 seconds does not match. Nothing in this question describes eye or gait problems.

A first presentation of an ordinary seizure disorder: A first seizure in a 44-year-old does need a workup for a new seizure disorder. Here the seizure came about 30 hours after years of heavy daily drinking stopped. A new seizure disorder does not explain that timing, and the staff already gave you the drinking history.

Acute alcohol intoxication lowering the seizure threshold: Alcohol is a CNS depressant while it is in the system, and intoxication can lower the seizure threshold. Intoxication and withdrawal do opposite things to the brain. This patient's last drink was 30 hours ago, so this patient is in withdrawal, not intoxicated.

It is incidental here, since only a low glucose harms the brain: Most glucose checks in a stroke are looking for a low reading. Hypoglycemia is the stroke mimic you cannot miss. A high glucose also hurts brain tissue that is short on blood flow. This 268 is part of the injury.

It explains the weakness, so treat the high glucose as the problem: A diabetic with a sudden neurologic change often gets treated as a sugar emergency. A level of 268 does not cause weakness on one side or slurred speech. The pulse is 78, the skin is warm and dry, and the respirations are 18. None of those fit a hyperglycemic crisis. The high glucose did not cause this stroke.

It calls for a fluid bolus to bring the glucose down before arrival: A fluid bolus is the right treatment for diabetic ketoacidosis and hyperosmolar states, where a high glucose comes with dehydration. This patient has warm dry skin, a pulse of 78, and no signs of dehydration. There is no volume to replace. A bolus also will not bring a 268 down much on the way in.

A complete cord transection: means the cord is cut all the way through, and a stab wound to the back can do that. A complete transection leaves no movement and no feeling below the injury on either side. This patient still moves the right leg and still feels pinprick in the left leg. The injury is incomplete.

Anterior cord syndrome: takes away movement, pain, and temperature, while position sense, vibration, and light touch are kept. Anterior cord syndrome hits both sides the same way. This patient lost position sense on the left and pain on the right, and a split by side is a hemisection.

Central cord syndrome: causes weakness that is worse in the arms than in the legs. Central cord syndrome usually follows a hyperextension injury, often in an older patient with a narrow spinal canal. This patient is 24 with one stab wound to the back, and the findings are in the legs.

A subdural bleed, because venous blood collects over hours: A subdural bleed is common after a head strike and belongs on the list. A subdural bleed comes from veins, and venous pressure fills the space slowly. Subdurals take hours to days to show up, not 25 minutes.

A diffuse axonal injury, because shearing deficits appear early: Diffuse axonal injury comes from shearing during violent head movement, and it does cause a severe deficit. The deficit from shearing is there from the moment of injury. This patient talked normally for about 25 minutes first.

A subarachnoid bleed, because it is at its worst from the start: A subarachnoid bleed does start suddenly and severely, and those patients do get worse. A subarachnoid bleed is at its worst the moment it starts. This patient had a normal stretch before getting worse.

An epidural bleed from a torn middle meningeal artery: An epidural bleed is the classic fast decline after a head injury. This bleed usually comes from a blow to the side of the head that leaves a mark. An epidural also gives a lucid interval, where the patient talks normally before getting worse. This patient's deficit has been there from the start.

A basilar skull fracture with bleeding into the sinuses: A basilar skull fracture can come from a serious crash like this one. A basilar fracture shows bruising around the eyes or behind the ears, or fluid from the nose or ears. None of those findings are present.

A depressed skull fracture pressing on the motor cortex: A depressed skull fracture presses on brain tissue and can cause a focal deficit. You can usually see or feel the depression. This patient's head has no wound, no swelling, and no deformity.

Hyperventilate through the attempt to hold the pressure down: Hyperventilation does lower the pressure inside the skull, and it has a narrow role when a patient is actively herniating. Routine hyperventilation narrows the blood vessels in the brain and cuts blood flow to tissue that is already short on blood flow. This patient has no signs of herniation.

Use a full induction dose so the first attempt is not interrupted: A full induction dose makes the patient easier to intubate, and a failed first attempt costs time. At 86 systolic, a full dose gets you that first pass along with a hypotensive episode. One hypotensive episode roughly doubles the death rate in a severe head injury.

Skip preoxygenation to shorten the time without ventilation: Speed does matter when a patient is desaturating, and a shorter time without breaths sounds safer. Preoxygenation is what gives you safe seconds during the attempt. Skipping preoxygenation at 87% guarantees the hypoxic episode you were trying to avoid.

Remove the collar and hold manual stabilization instead: Manual stabilization is a real technique, and holding the head by hand avoids the pressure a collar puts on the neck. Holding a head by hand for a whole transport is not practical. Manual stabilization also leaves the real problem in place, which is the tight straps and a head that is not midline.

Tighten the straps further and pad under the head: Secure packaging matters, and a patient who shifts during transport is a real problem. Tightening the straps squeezes the same neck veins the head drains through, and the pressure inside the skull goes up.

Leave the packaging as it is and raise the foot end: Raising the foot end moves blood toward the core in a patient with a pressure problem. Putting a head injured patient head down raises the pressure inside the skull.