ICEMA TREATMENT TEST

Scenario A — Adult Cardiac Arrest (Non-Traumatic)

REF #14050 · CARDIAC ARREST - ADULT · HP CPR PROTOCOL

You arrive on scene to find a 58-year-old male unresponsive and pulseless. Rank the ALS interventions in order of priority:

⠿?Start High-Performance CPR (100–120/min, 2–2.5" depth, full recoil)

⠿?Establish IV/IO access

⠿?Administer Epinephrine 1mg IV/IO every 5 minutes

⠿?Apply cardiac monitor / AED — defibrillate if VF/pVT

⠿?Manage BLS airway (BVM) — delay ETT until ROSC if BVM effective

⠿?Consider Lidocaine 1.5mg/kg IV/IO after 2 cycles for refractory VF/VT

⠿?Apply waveform capnography (required for all cardiac arrest)

⠿?Transport to STEMI Receiving Center on ROSC + obtain 12-lead ECG

Scenario B — Adult Respiratory Failure (CHF / Pulmonary Edema)

REF #14010 · RESPIRATORY EMERGENCIES - ADULT · ACUTE PULMONARY EDEMA

72-year-old female with CHF history, SpO₂ 82%, severe respiratory distress, rales bilaterally, JVD. SBP 145. Rank ALS interventions:

⠿?Position of comfort (sitting upright) — reduce anxiety

⠿?Apply CPAP — start at lowest setting, increase to max 15 cm H₂O

⠿?Consider advanced airway (ETT/SGA) if CPAP fails

⠿?Oxygen — titrate to SpO₂ 94% (COPD: maintain 90%)

⠿?Nitroglycerin 0.4mg SL if SBP ≥100 (contraindicated if SBP <100)

⠿?Midazolam 1mg IV/IO/IM/IN (once) if SBP >90 for CPAP anxiety

Scenario C — Unstable Bradycardia

REF #14030 · BRADYCARDIAS - ADULT

HR 32 bpm, BP 74/40, altered mental status, diaphoretic. Rank the correct ALS intervention sequence:

⠿?Administer Atropine 1mg IV/IO (repeat q5min, max 3mg)

⠿?Fentanyl for pain / Midazolam for anxiety if pacing

⠿?O₂, position of comfort, cardiac monitor

⠿?Transcutaneous Cardiac Pacing if Atropine fails or 3°AV Block/2° Type II

⠿?IV access — 300ml NS bolus if lungs clear

⠿?Contact base hospital if interventions unsuccessful

Scenario D — Trauma Adult (Hemorrhagic Shock)

REF #14090 · TRAUMA - ADULT

MVC patient, suspected internal bleeding, BP 78/52, HR 130, GCS 12. Rank ALS interventions:

⠿?Spinal motion restriction (if neuro deficits, spinal tenderness, ALOC, or distracting injury)

⠿?Tranexamic Acid (TXA) 2gm IV/IO over 1 min or 1gm IM (if hemorrhagic shock criteria met)

⠿?Scene safety — control major hemorrhage (tourniquets, wound packing, direct pressure)

⠿?Push-dose Epinephrine 0.01mg/ml if cardiac arrest imminent from persistent shock

⠿?O₂, two large-bore IVs — permissive hypotension strategy (SBP 80–90)

⠿?Rapid transport — minimize on-scene time

⠿?Advanced airway only if unable to maintain oxygenation with BLS adjuncts

Scenario E — Suspected Stroke Alert

REF #14080 · STROKE TREATMENT - ADULT · LOS ANGELES MOTOR SCORE

68-year-old male, sudden facial droop, right arm weakness, slurred speech. Last seen normal 45 min ago. Rank ALS priorities:

⠿?Apply mLAPSS (Cincinnati/LA Prehospital Stroke Screen) — document findings

⠿?Complete thrombolytic assessment criteria if time permits; document "last seen normal"

⠿?Scene safety, ABCs — O₂ to maintain SpO₂ ≥94%, position of comfort

⠿?Blood glucose check — treat hypoglycemia if present (may mimic stroke)

⠿?If mLAPSS positive → apply LAMS score (≥4 = Large Vessel Occlusion); notify Stroke Center

⠿?Establish IV access, cardiac monitor, 12-lead ECG (ALS)

⠿?Expedite transport to closest Stroke Receiving Center (last seen normal + transport <24hr)

Scenario F — Suspected Acute Myocardial Infarction (STEMI)

REF #14240 · SUSPECTED AMI | REF #4040 · STEMI SYSTEM

55-year-old female, crushing chest pain radiating to left arm, diaphoretic, BP 118/72, HR 88. 12-lead shows ST elevation in II, III, aVF. Rank ALS interventions:

⠿?Aspirin 325mg PO chewed — administer as soon as possible

⠿?Fentanyl 50mcg IV/IO for pain if NTG contraindicated or inadequate relief

⠿?Position of comfort, O₂ to maintain SpO₂ 94%, reduce anxiety

⠿?Right-sided 12-lead (V4R) if inferior STEMI — rule out RVI before NTG

⠿?IV access (+ saline lock second site), 12-lead ECG — do NOT disconnect cables

⠿?NTG 0.4mg SL q3 min — if SBP ≥100 and no RVI; contraindicated in RVI/hypotension/PDE-5 use

⠿?Early STEMI notification to STEMI Receiving Center; expedite transport — do not delay

Scenario G — Sepsis (Adult)

REF #14280 · SEPSIS - ADULT

78-year-old from nursing home, suspected UTI, T=102.6°F, HR 108, RR 24, BP 84/52, EtCO₂ 18 mmHg, ALOC. Rank interventions:

⠿?IV access — 500ml NS bolus, may repeat ×1; monitor for signs of pulmonary edema

⠿?Push-dose Epinephrine 0.01mg/ml if profound hypotension unresponsive to fluids

⠿?O₂ as indicated, position patient, cover to prevent shivering; place in left lateral if ALOC

⠿?Cardiac monitor, 12-lead ECG, monitor EtCO₂ continuously

⠿?Blood glucose — treat hypoglycemia (Dextrose/Glucagon); treat hyperglycemia with fluids only

⠿?Early hospital notification, rapid transport — hypotension is a LATE sign of septic shock

Scenario H — Non-Traumatic Shock

REF #14230 · SHOCK (NON-TRAUMATIC)

60-year-old male, history of GI bleeding, BP 72/40, HR 128, pale/cool/diaphoretic, no trauma. Rank ALS interventions:

⠿?IV/IO access — fluid challenge 500ml bolus, may repeat ×1 until perfusion improves

⠿?Push-dose Epi 0.01mg/ml if profound shock persists and cardiac arrest is imminent

⠿?ABCs — O₂, airway (advanced airway if indicated), AED pads as precaution

⠿?Cardiac monitor — identify and treat reversible arrhythmias

⠿?Blood glucose — check and treat hypoglycemia; assess for narcotic overdose (Naloxone)

⠿?Base hospital contact, rapid transport to appropriate facility

Scenario I — Behavioral Emergency / Excited Delirium

REF #14110 · BEHAVIORAL EMERGENCIES | REF #6060 · PATIENT RESTRAINTS

30-year-old male, naked, thrashing, profuse diaphoresis, hyperthermia, extraordinary strength, shouting incoherently. Suspected excited delirium. Rank ALS interventions:

⠿?If meets criteria for potentially fatal/dangerous agitation: Midazolam IM/IN (preferred — do NOT delay for IV)

⠿?Apply cardiac monitor — continuous monitoring required after Midazolam

⠿?Base hospital may order NaHCO₃ if suspected metabolic acidosis/hyperkalemia

⠿?Scene safety — law enforcement restraint first (4-point padded/soft restraints); NEVER prone position

⠿?Airway, SpO₂, O₂ as needed; cooling measures; blood glucose if hypoglycemia suspected

⠿?Establish waveform capnography — apnea risk after Midazolam; monitor continuously

⠿?Once safe: establish IV access; transport in low-to-high Fowler's (semi-upright) position

Scenario J — Obstetrical Emergency (Eclampsia + Imminent Delivery)

REF #14210 · OBSTETRICAL EMERGENCIES | REF #11010 · MAGNESIUM SULFATE

32-year-old, 36 weeks pregnant, active generalized seizure, BP 182/114, crowning visible. Rank interventions:

⠿?Magnesium Sulfate 4gm IV slow push over 3-4 min for eclamptic seizure

⠿?Prepare for imminent delivery — support head, check for cord around neck, suction mouth then nose

⠿?Position left lateral (uterine displacement) — protect from injury during seizure

⠿?After delivery: clamp/cut cord; Apgar at 1 and 5 minutes; newborn resuscitation if needed

⠿?ABCs, O₂ high-flow, suction airway, IV access — obtain fetal heart tones if possible

⠿?Midazolam for seizure if MgSO4 unavailable or still seizing (Midazolam 2.5mg IV or 5mg IM)

⠿?TXA for postpartum hemorrhage (base hospital order) + MgSO4 10mg/min drip to prevent recurrence

Scenario K — Newborn Resuscitation

REF #14200 · NEWBORN CARE · APGAR SCORING

Field delivery. Newborn is limp, not crying, cyanotic, HR 50 bpm after initial drying/stimulation. Rank ALS resuscitation steps:

⠿?HR <60 after ventilation — begin compressions at 3:1 ratio (≈100 compressions + 30 ventilations/min)

⠿?Check blood glucose (heel stick); Dextrose if BG <35 mg/dL

⠿?Dry, warm, stimulate — remove wet towels; suction mouth then nose; evaluate breathing

⠿?IV/IO access — consider Epinephrine 0.01mg/kg IV/IO if HR still <60 after 1 min of intervention

⠿?BVM with 100% O₂ for 30 sec — reassess HR; if HR <100 but >60 reposition airway and continue BVM

⠿?Apgar at 1 and 5 minutes (do NOT use to determine when to begin resuscitation); contact base hospital

Scenario L — Ventricular Assist Device (VAD) Emergency

REF #14270 · VENTRICULAR ASSIST DEVICE (VAD)

VAD patient found unresponsive. No palpable pulse. Device not producing audible "hum." EtCO₂ = 8 mmHg, MAP <50. Rank assessment and treatment steps:

⠿?Assess all device connections and cables — check for device alarms, battery status

⠿?If device is confirmed non-functional + unresponsive + asystole + EtCO₂ <10 + MAP <50 → chest compressions as last resort

⠿?Assess PATIENT FIRST (C-A-B + Connections): level of consciousness, skin signs, perfusion

⠿?Contact VAD Coordinator (info in patient's equipment bag); follow their guidance

⠿?Waveform capnography (preferred over pulse ox — may be inaccurate); MAP via auscultation (target 70-90)

⠿?Cardiac monitor — treat arrhythmias per protocol; defibrillation/cardioversion safe (pump is insulated)

⠿?Transport to VAD Implant Center (LLUH in ICEMA region) with ALL device equipment — coordinator + base hospital determine destination

Scenario M — SVT / Tachycardia Adult

REF #14040 · TACHYCARDIAS - ADULT

46-year-old female, HR 186 bpm, narrow complex SVT on monitor, BP 108/68, alert, mild palpitations. Rank ALS interventions:

⠿?Valsalva/vagal maneuvers — if no conversion in 10 seconds, proceed to Adenosine

⠿?If Adenosine fails: Lidocaine or Synchronized Cardioversion (sedation first)

⠿?O₂, cardiac monitor, 12-lead ECG; AED pads precautionary; reduce anxiety, position of comfort

⠿?Adenosine 6mg rapid IVP + 20cc NS flush; may repeat 12mg IVP × 2 if no conversion

⠿?IV access — NS 300ml bolus if signs of inadequate perfusion; blood glucose if indicated

⠿?Contact base hospital; transport to appropriate receiving facility

Scenario N — Altered Level of Consciousness / Status Epilepticus

REF #14060 · ALTERED LOC / SEIZURES - ADULT

45-year-old male, found convulsing. GCS 8. Duration unknown. History of epilepsy and diabetes. Rank ALS interventions:

⠿?Midazolam 2.5mg IV/IO or 5mg IM/IN for active seizure; max 3 doses; monitor RR and BP

⠿?Cardiac monitor + 12-lead ECG — look for cardiac etiology

⠿?O₂, position patient (left lateral if no trauma and altered gag); protect from injury; suction PRN

⠿?IV/IO access; blood glucose — treat hypoglycemia (BG <80: Oral glucose if gag intact; D10W IV if not)

⠿?Naloxone if suspected opioid overdose contributing to decreased respiratory drive

⠿?Spinal motion restriction if trauma mechanism present or if found down — assess for injury

⠿?Contact base hospital for continued seizure activity after 3 doses of Midazolam

Scenario O — Burns Adult (Thermal)

REF #14070 · BURNS - ADULT (15+ years)

House fire victim, 40% TBSA 2nd/3rd degree burns, singed nasal hair, hoarse voice, suspected inhalation injury, GCS 14. Rank ALS interventions:

⠿?Estimate % TBSA using Rule of Nines; cover with dry sterile dressings; keep patient WARM

⠿?Pain management: Fentanyl IV/IM/IN per protocol; consider Ketamine if Fentanyl contraindicated

⠿?Remove from burning source; stop burn process; 100% O₂ via NRB (CO/cyanide exposure suspected)

⠿?Albuterol/Atrovent if bronchospasm from inhalation injury is present

⠿?Airway assessment — hoarse voice/stridor = EARLY intubation before edema occludes airway

⠿?IV access — fluid resuscitation (NS); cardiac monitor; do NOT break blisters

⠿?Rapid transport to burn center; early communication — do not delay transport for dressings

Scenario P — Poisoning / Opioid Overdose

REF #13010 · POISONINGS | REF #14060 · ALOC

Found unresponsive with track marks, RR 4, SpO₂ 74%, pinpoint pupils, paraphernalia present. Suspected fentanyl overdose. Rank ALS interventions:

⠿?Naloxone — consider 4mg IN loading dose for suspected fentanyl; may repeat + 0.5mg IV/IO/IM/IN q2-3min; max 10mg

⠿?If no response to Naloxone: consider advanced airway; contact Poison Control (1-800-222-1222)

⠿?Scene safety; airway — position, suction; BVM ventilation with 100% O₂ (PRIORITY — correct hypoxia first)

⠿?IV/IO access; blood glucose; cardiac monitor — assess for polysubstance involvement

⠿?Obtain history: substance, amount, time elapsed, route; bring container/pills to hospital

⠿?Monitor for re-narcotization (Naloxone half-life < fentanyl); consider leave-behind Naloxone kit if refuses transport

Scenario Q — Unstable Bradycardia (Atropine-Refractory)

REF #14030 · BRADYCARDIAS - ADULT · UNSTABLE

68-year-old dialysis patient, HR 34, BP 72/40, wide QRS, altered mental status. Atropine 1mg × 3 given — no improvement. Rank the ALS interventions in priority order:

⠿?BLS + oxygen; IV access; 300ml NS bolus for signs of inadequate tissue perfusion

⠿?Cardiac monitor + 12-lead ECG to define rhythm; confirm 3° AV block or Mobitz II

⠿?Transcutaneous Cardiac Pacing (TCP) — Atropine max (3mg) exceeded, refractory bradycardia

⠿?Atropine 1mg IV — first pharmacologic attempt (repeat up to 3mg total max)

⠿?Contact base hospital — request CaCl₂ order for ESRD/suspected hyperkalemia

⠿?Analgesia/sedation for TCP: Fentanyl + Midazolam per #11010; transport to receiving facility

Scenario R — Unstable SVT

REF #14040 · TACHYCARDIAS - ADULT · NARROW COMPLEX SVT

45-year-old female, HR 188, narrow complex regular rhythm on monitor, BP 86/50, diaphoretic, altered. Vagal failed. Rank ALS interventions:

⠿?Adenosine 6mg rapid IVP + flush — first pharmacologic attempt for narrow complex SVT

⠿?Cardiac monitor; obtain 12-lead ECG; establish IV access; 300ml NS bolus

⠿?Vagal/Valsalva maneuver — first-line before medications in stable SVT (already failed here)

⠿?If Adenosine fails: Adenosine 12mg rapid IVP × 1; may repeat 12mg once more

⠿?Sedation: Fentanyl 50mcg IV + Midazolam 2.5mg IV prior to cardioversion

⠿?Synchronized cardioversion 100J → 200J → 300J → 360J if hemodynamically unstable

Scenario S — Suspected STEMI / Acute MI

REF #14240 · SUSPECTED AMI · STEMI NOTIFICATION

63-year-old male, crushing chest pain radiating to jaw, diaphoretic, 12-lead shows ST elevation in II, III, aVF. BP 82/60. Rank ALS interventions:

⠿?O₂ as clinically indicated; reduce anxiety; position of comfort; obtain SpO₂

⠿?Obtain right-sided 12-lead (V4R) — inferior STEMI + hypotension = suspect RVI; NTG contraindicated with RVI

⠿?Early STEMI notification to STEMI Receiving Center; do not delay transport

⠿?Aspirin 324mg PO chewed (per #11010); establish IV access

⠿?12-lead ECG — obtain, upload to ePCR, leave cables in place throughout transport

⠿?300ml NS bolus for RVI with signs of inadequate perfusion (NTG CONTRAINDICATED here); Fentanyl for pain if NTG not given

⠿?Repeat 12-lead ECGs en route; saline lock secondary IV site; transport expeditiously

Scenario T — Suspected Stroke (mLAPSS+)

REF #14080 · STROKE TREATMENT - ADULT · mLAPSS / LAMS

78-year-old male, sudden left-sided facial droop, left arm weakness, dysarthria. Last seen normal 1.5 hours ago. BG 102. Rank ALS interventions in correct order:

⠿?Apply LAMS scoring — if score ≥ 4 consider Large Vessel Occlusion (LVO); determines receiving center

⠿?Obtain SpO₂ on room air; titrate O₂ to maintain ≥94%; obtain blood glucose

⠿?Scene safety; ABCs; establish IV/IO; cardiac monitor

⠿?Apply mLAPSS screening — confirm positive (age >17, no seizure Hx, new onset neuro sx, ambulatory at baseline, BG 60-400, unilateral weakness)

⠿?Establish "last seen normal" time — if <24hrs or wake-up stroke → closest Stroke Receiving Center

⠿?12-lead ECG (ALS); Thrombolytic Assessment if time permits; obtain family phone number / bring patient's phone

⠿?Expedite transport; pre-notify Stroke Receiving Center with LAMS score and last seen normal time

Scenario U — Non-Traumatic Shock (Fluid-Refractory)

REF #14230 · SHOCK (NON-TRAUMATIC)

52-year-old male, GI bleed history, BP 72/40, HR 128, pale/diaphoretic, no respiratory difficulty. 1,000ml NS given — BP now 76/42. Rank ALS interventions in order:

⠿?IV access; administer 500ml NS bolus — may repeat ×1 to sustain SBP >90 or improve perfusion

⠿?Airway; O₂; position patient appropriately; SpO₂; AED pads as precaution

⠿?If no response to fluid (max 2 boluses): stop fluids; administer Push-Dose Epinephrine per #11010

⠿?Cardiac monitor; blood glucose; assess for hemorrhagic, distributive, or cardiogenic etiology

⠿?Contact base hospital — may order 2nd large-bore IV en route

⠿?Rapid transport; reassess vitals every 5 minutes; document response to all interventions

Scenario V — Behavioral Emergency / Excited Delirium

REF #14110 · BEHAVIORAL EMERGENCIES · EXCITED DELIRIUM

28-year-old male found naked outside, superhuman strength, profuse diaphoresis, hyperthermia, incoherent shouting, thrashing against law enforcement restraints. Rank ALS interventions:

⠿?Capnography — required after Midazolam; monitor for apnea continuously

⠿?Scene safety; law enforcement to apply restraints; approach patient calmly; SpO₂; airway

⠿?Midazolam IM/IN (preferred — do NOT delay for IV access) for dangerous agitation meeting criteria

⠿?4-point soft restraints in position of comfort (Fowler's); cooling measures; blood glucose; cardiac monitor

⠿?Once safe: establish IV; monitor waveform capnography, SpO₂, and ECG continuously

⠿?Contact base hospital — never transport prone while restrained; reassess respiratory status en route

Scenario W — Obstetrical Emergency / Eclampsia

REF #14210 · OBSTETRICAL EMERGENCIES · ECLAMPSIA

32-year-old female, 36 weeks pregnant, BP 174/114, generalized tonic-clonic seizure now active. Rank ALS interventions in correct priority order:

⠿?Magnesium Sulfate IV per #11010 — primary anticonvulsant for eclampsia

⠿?Airway; O₂; left lateral position to offload aortocaval compression; seizure precautions

⠿?Obtain rhythm strip; monitor BP every 5 minutes; do NOT aggressively lower BP prehospital

⠿?Reduce stimuli; IV TKO (limit fluids); O₂ saturation on room air; blood glucose

⠿?IV/IO access; establish 2nd large bore IV en route; consider immediate base hospital notification

⠿?Midazolam per #11010 if seizure refractory to Magnesium or uncontrolled

⠿?Transport Code 3 to appropriate OB-capable facility; pre-notify; continuous fetal and maternal monitoring