✓ Correct Answer: B
Why B is correct: ST elevation in II, III, aVF indicates an inferior wall STEMI. BP 80/50 indicates hemodynamic instability. Before giving NTG, you must assess for RVI using a right-sided 12-lead (V4R). RVI is common (30–40%) with inferior STEMIs. NTG in RVI causes profound hypotension and can kill the patient. Give NS bolus 300 ml (may repeat) for fluids to maintain RV preload.
Why A is wrong: NTG is absolutely contraindicated when signs of inadequate tissue perfusion are present (BP 80/50). Also, you have not yet ruled out RVI.
Why C is wrong: Fentanyl then NTG is unsafe here — NTG remains contraindicated. Fentanyl can be considered for pain after RVI is ruled out and BP is improved with fluids.
Why D is wrong: NTG paste is a one-time dose alternative when SL cannot be easily administered — same contraindications apply.
Protocol: Ref 14240 (Suspected AMI), Ref 11010 NTG section
✓ Correct Answer: B
Why B is correct: ICEMA specifies Ketamine as 0.3 mg/kg (max 30 mg) diluted in 50–100 ml NS as an IV drip over 5 minutes. This is one of the most commonly tested Ketamine facts. Ketamine is actually preferred when SBP <100 because it maintains hemodynamics through sympathomimetic effects.
Why A is wrong: IV push is explicitly prohibited. The protocol states "Do not administer IVP, IO, IM, or IN."
Why C is wrong: IM/IN routes are not listed for Ketamine in ICEMA protocol.
Why D is wrong: Ketamine is PREFERRED when SBP <100 — it is not contraindicated by low BP.
Protocol: Ref 11010 Ketamine, Ref 14100 Pain Management
✓ Correct Answer: B
Why B is correct: Per ICEMA Ref 11010, COPD patients: titrate O₂ to maintain SpO₂ at 90%; do NOT give supplemental O₂ if SpO₂ >91%. This is a critical ICEMA-specific rule that differs from general EMS teaching. Hyperoxia in COPD worsens hypoxic drive and outcomes.
Why A is wrong: The 94%/95% rule applies to NON-COPD patients only.
Why C and D are wrong: These would cause hyperoxia in a COPD patient, which is explicitly contraindicated per ICEMA Ref 11010.
Protocol: Ref 11010 Oxygen Administration section
✓ Correct Answer: A
Why A is correct: ICEMA protocol for penetrating trauma is unambiguous: saline lock only, do NOT administer IV fluids regardless of BP. This is permissive hypotension — maintaining a lower BP reduces clot disruption and dilutional coagulopathy in penetrating hemorrhage. This differs significantly from what many test takers expect from traditional ACLS/trauma teaching.
Why B, C, D are wrong: These apply to BLUNT trauma, not penetrating. B (250 ml × 2) is blunt/head injury/extremity unstable protocol. C is never appropriate. D is crush injury protocol.
Protocol: Ref 14090 Trauma-Adult, Penetrating Trauma subsection
✓ Correct Answer: B
Why B is correct: Adenosine protocol for adult SVT: 6 mg → if no conversion → 12 mg → if no conversion → repeat 12 mg once more → if still no conversion → cardioversion. After the 6 mg fails, the next dose is 12 mg.
Why A is wrong: Cardioversion comes after Adenosine 6, 12, and the second 12 mg have all failed.
Why C is wrong: Lidocaine is for V-tach/wide complex, not narrow SVT.
Why D is wrong: BH contact is recommended but comes after attempting all Adenosine doses and cardioversion.
Protocol: Ref 14040 Tachycardias, Ref 11010 Adenosine
✓ Correct Answer: C
Why C is correct: 0.1 mg/kg × 20 kg = 2 mg IV/IO. But the maximum per dose for IV/IO Midazolam in peds is 2.5 mg. So 2 mg is both the weight-based dose AND within the maximum — you give 2 mg. B says the same thing but labels it incorrectly as "2 mg with a max of 2.5 mg" — C is the most precise answer because it shows the calculation.
Why A is wrong: 5 mg is the maximum IM/IN dose for adults, not IV for pediatrics.
Why D is wrong: 0.2 mg/kg is the IM/IN dose, not IV/IO. You have IV access so use the IV/IO dose.
Protocol: Ref 11010 Midazolam Pediatric
✓ Correct Answer: C
Why C is correct: Penetrating trauma patients are NOT candidates for SMR UNLESS they have NSAID criteria. Decreased sensation in bilateral lower extremities = neurological deficit (the "N" in NSAID) = SMR is indicated.
Why A is wrong: Ambulatory, alert, no deficits, no tenderness, not intoxicated, no distracting injury = NO NSAID criteria = NO SMR for penetrating trauma.
Why B is wrong: A distracting injury (D in NSAID) is a criterion — this patient with a stab wound and femur fracture WOULD qualify. Actually B is borderline correct, but the question asks which is a "candidate" and C is unambiguous.
Why D is wrong: Cervical collar for all penetrating trauma is explicitly incorrect per ICEMA.
Protocol: Ref 14090 Trauma Adult, NSAID section; Ref 11020 Spinal Motion Restriction
✓ Correct Answer: B
Why B is correct: The patient is mLAPSS positive (all 5 criteria met + unilateral facial droop). LAMS = 3 means it is NOT consistent with LVO, but LAMS does NOT change the destination decision — it only indicates stroke severity. A mLAPSS-positive patient with "last seen normal" within 24 hours goes to the closest Stroke Receiving Center regardless of LAMS score.
Why A, C, D are wrong: LAMS score of <4 does not redirect the patient from a Stroke Receiving Center. LAMS ≥4 = LVO (possible thrombectomy candidate). LAMS <4 = less likely LVO but still a stroke — still goes to closest stroke center per ICEMA.
Protocol: Ref 14080 Stroke Treatment, mLAPSS/LAMS sections; Ref 9030 Destination
✓ Correct Answer: B
Why B is correct: For known organophosphate poisoning, ICEMA standing order is Atropine 2 mg IV/IO; repeat 2 mg q5 min if patient remains symptomatic (no stated maximum — give until secretions dry). Also: Midazolam for seizures associated with nerve agent/organophosphate poisoning.
Why A is wrong: The 1 mg bradycardia dose is for cardiac causes. OP poisoning requires 2 mg initial.
Why C is wrong: Low-dose Atropine is ineffective for OP poisoning — secretions require aggressive atropinization.
Why D is wrong: Atropine for known OP poisoning is a standing order — no BH contact required to start.
Protocol: Ref 11010 Atropine, Ref 13010 Poisonings
✓ Correct Answer: B
Why B is correct: All three TOR criteria are met: (1) ETCO₂ <15 mmHg after 20+ min of HP-CPR with ALS, (2) No ROSC, AND (3) Arrest was not witnessed by EMS (one qualifying criterion from the list). Persistent PEA <40 bpm is also a qualifying criterion. Base hospital contact is NOT required when all field TOR criteria are met.
Why A is wrong: BH contact is NOT required for adult non-traumatic arrest TOR when all criteria are met.
Why C is wrong: No signs of pending ROSC (ETCO₂ not trending up, PEA <40 bpm) — transport is not indicated.
Why D is wrong: 20 minutes is the ICEMA threshold — there is no requirement to continue beyond that when criteria are met.
Protocol: Ref 14050 Cardiac Arrest Adult, Termination of Efforts section
✓ Correct Answer: A
Why A is correct: ICEMA pediatric defibrillation escalation: 1st shock = 2 j/kg, 2nd shock = 4 j/kg, 3rd and subsequent = 10 j/kg (not to exceed adult dose of 360J).
Why B is wrong: Repeating 2 j/kg is not ICEMA protocol — energy escalates.
Why C is wrong: 360J comes only if 10 j/kg would exceed adult dosing — first calculate 10 j/kg.
Why D is wrong: 10 j/kg is for the 3rd shock, not the 2nd.
Protocol: Ref 14150 Cardiac Arrest Pediatric
✓ Correct Answer: B
Why B is correct: Per ICEMA Ref 14200, for a neonate with HR <60 after 1 minute of adequate ventilation: evaluate airway for hypoxia AND temperature for hypothermia, THEN administer Epinephrine (0.1 mg/ml) 0.01 mg/kg IV/IO. This newborn has HR 40 and has received BVM × 1 min — Epi is indicated.
Why A is wrong: Atropine is not listed as a neonatal resuscitation medication in ICEMA.
Why C is wrong: Dextrose is indicated for BG <35, not for bradycardia. Check blood glucose separately.
Why D is wrong: Neonatal pharmacologic resuscitation IS available and indicated for persistent HR <60.
Protocol: Ref 14200 Newborn Care, Ref 11010 Epinephrine Pediatric section
✓ Correct Answer: B
Why B is correct: Motorcycle crash >20 mph meets the ICEMA Mechanism of Injury criterion. When mechanism criteria exist but NO physiologic or anatomic criteria are present, ICEMA directs you to contact a trauma base hospital for physician consultation to determine patient destination — it does NOT automatically mandate a Trauma Center.
Why A is wrong: Mechanism criteria DO matter in ICEMA — they require BH consultation even without physio/anatomic criteria.
Why C is wrong: Mechanism alone does NOT automatically mandate trauma center transport — it requires BH consultation.
Why D is wrong: BH contact IS required when mechanism criteria are met.
Protocol: Ref 9040 Trauma Triage Criteria, Step 3 Mechanism section
✓ Correct Answer: C
Why C is correct: ESRD dialysis patient with hemodynamic instability and documented sinus bradycardia, 3rd-degree AVB, 2nd-degree Type II AVB, slow junctional/ventricular escape rhythms, or slow AF with suspected hyperkalemia → BH may order Calcium Chloride 1 gm IV/IO. This membrane-stabilizes the cardiac tissue against hyperkalemia effects.
Why A is wrong: MgSO4 is for polymorphic VT/Torsades or eclampsia, not hyperkalemia bradycardia.
Why B is wrong: NaHCO3 is for TCA poisoning or cardiac arrest with acidosis — not the primary BH order here.
Why D is wrong: Adenosine is contraindicated for bradycardia and would be dangerous here.
Protocol: Ref 14030 Bradycardias, Ref 11010 Calcium Chloride ESRD section
✓ Correct Answer: B
Why B is correct: Eclampsia = seizures in pregnancy. ICEMA ALS standing order is MgSO4 4 gm IV/IO slow push over 3–4 min, THEN 10 mg/min IV drip. Additionally, Midazolam may be administered per seizure protocol. Both are standing orders — no BH contact required to start.
Why A is wrong: Eclampsia MgSO4 IS a standing order — not a BH order. Also, you should address both magnesium and the active seizure.
Why C is wrong: 2 gm over 5 min is the Torsades de Pointes dose. Eclampsia dose is 4 gm over 3–4 min.
Why D is wrong: No BH contact is required to begin treatment for eclampsia.
Protocol: Ref 14210 Obstetrical Emergencies, Ref 11010 Magnesium Sulfate
✓ Correct Answer: B
Why B is correct: BLS providers in ICEMA CAN administer Naloxone (this is a standing BLS order, unique to ICEMA). For suspected fentanyl OD, ICEMA specifically says consider a loading dose of 4 mg IN, may repeat ×1, then 0.5 mg q2–3 min if no improvement. Max 10 mg total.
Why A is wrong: BLS can and should administer Naloxone — it is in the BLS scope per ICEMA.
Why C is wrong: IN route is authorized for BLS. Also, the standard dose is 0.5 mg (not unspecified IM only).
Why D is wrong: The 4 mg IN loading dose is specifically authorized for suspected fentanyl OD per ICEMA Ref 11010, even at BLS level.
Protocol: Ref 11010 Naloxone BLS section
✓ Correct Answer: B
Why B is correct: This patient has known inhalation injury (singed nasal hairs, hoarse voice) = Major burn classification. Major burns go to Burn Center. HOWEVER — burn patients with respiratory compromise or HIGH RISK for developing respiratory distress are transported to the CLOSEST RECEIVING HOSPITAL for airway stabilization first. The inhalation signs indicate impending airway compromise, prioritizing airway stabilization at the nearest facility.
Why A is wrong: Major burns normally go to burn center, but not when there is respiratory compromise.
Why C is wrong: No trauma mechanism is described — not a trauma center case.
Why D is wrong: The reason to go to the nearest hospital is airway — not because CPAP is contraindicated.
Protocol: Ref 14070 Burns Adult, Airway Stabilization section
✓ Correct Answer: C
Why C is correct: You want to switch from Fentanyl to Ketamine mid-treatment. Per ICEMA Ref 14100, "Shifting from one analgesic while treating a patient requires base hospital contact." Contact BH first, then administer Ketamine as ordered.
Why A is wrong: Fentanyl with SBP 96/60 is risky — Fentanyl causes vasodilation and can worsen hemodynamics. Also, per ICEMA, Ketamine is preferred when SBP <100.
Why B is wrong: Ketamine would be appropriate, but you MUST contact BH first before switching agents.
Why D is wrong: Acetaminophen is for mild-moderate pain (1–5 scale) or when other agents are contraindicated. It's reasonable as a supplement but doesn't replace adequate analgesia for pain 8/10.
Protocol: Ref 14100 Pain Management Special Considerations
✓ Correct Answer: B
Why B is correct: ICEMA sepsis criteria require possible infection + ≥2 of: Temp >100.4°F (✓ 103.2), sustained HR >90 (✓ 112), EtCO₂ <25 mmHg (✓ 22), sustained RR >20 (✓ 24). This patient meets ALL four criteria — only two are required. The EtCO₂ criterion is ICEMA-specific and rarely tested elsewhere.
Why A is wrong: BP 118/74 is within normal limits — not a sepsis criterion. Also, per ICEMA, hypotension is a LATE indicator for septic shock.
Why C is wrong: The minimum requirement is 2 criteria — this patient has 4, not 3. The answer underestimates the severity.
Why D is wrong: EtCO₂ <25 IS an ICEMA sepsis criterion — this is a key ICEMA-specific element.
Protocol: Ref 14280 Sepsis Adult
✓ Correct Answer: B
Why B is correct: ICEMA is explicit: ROSC patients of unknown or suspected cardiac etiology should be transported to the closest STEMI Receiving Center regardless of 12-lead ECG findings. The 30-min cutoff is only if the STEMI center is MORE than 30 minutes away. At 18 minutes, the STEMI center is within range.
Why A is wrong: The 12-lead findings don't matter for ROSC destination — cardiac etiology ROSC always goes to STEMI center if within 30 min.
Why C is wrong: BH contact is encouraged but does not change the protocol.
Why D is wrong: Non-traumatic cardiac arrest ROSC → STEMI center, not trauma center.
Protocol: Ref 14050 Cardiac Arrest Adult, ROSC section; Ref 9030 Destination
✓ Correct Answer: B
BLS scope for peds anaphylaxis: Epinephrine 0.15 mg Jr. auto-injector IM. This is the pediatric dosing for BLS. The 0.3 mg adult auto-injector is for adults (BLS, LALS, ALS) for severe asthma AND/OR anaphylaxis. The 0.15 mg Jr. is for peds anaphylaxis ONLY at BLS. Diphenhydramine is ALS scope only. The child has classic anaphylaxis — treat immediately.
Protocol: Ref 11010 Epinephrine auto-injectors
✓ Correct Answer: C
This patient has tension pneumothorax (absent BS, JVD, hypotension, increased resistance, penetrating chest injury). ICEMA Ref 11020 specifies the PREFERRED needle thoracostomy site is the midaxillary line at the 5th ICS. The 2nd ICS MCL (traditional) is not the ICEMA preferred site. Consider bilateral needle thoracostomy if no improvement.
Protocol: Ref 11020 Procedure Standard Orders, Needle Thoracostomy
✓ Correct Answer: C
Crush injury with prolonged entrapment and/or abnormal ECG findings (suspected hyperkalemia) is the ONLY standing-order indication for Calcium Chloride. All other CaCl2 indications (CCB poisoning, cardiac arrest, ESRD/dialysis bradycardia) require base hospital authorization. This is one of the most important ICEMA drug distinction questions.
Protocol: Ref 11010 Calcium Chloride, Ref 14090 Trauma Adult (Crush Injury section)
✓ Correct Answer: B — 4 points
APGAR scoring: Heart Rate <100 = 1 point. Respirations absent = 0 points. Muscle tone some flexion = 1 point. Reflex irritability grimace = 1 point. Color blue/pale = 1 point. Total = 1+0+1+1+1 = 4 (not 5 — respirations = 0, not 1 because no effort is absent). Moderate distress; needs immediate BVM resuscitation. Do NOT use APGAR to decide whether to resuscitate — resuscitation should be based on clinical assessment.
Protocol: Ref 14200 Newborn Care, APGAR table
✓ Correct Answer: C
ICEMA Ref 11010 and 14110 are clear: continuous monitoring after Midazolam administration for behavioral emergencies REQUIRES capnography — waveform and numerical value. The protocol states "Apnea can be the result of the use of Midazolam and other medications." Capnography detects respiratory depression before SpO₂ drops.
Protocol: Ref 14110 Behavioral Emergencies, Ref 11020 Capnography section
✓ Correct Answer: C
Per ICEMA Ref 11020: oral ETI is permitted only in patients taller than the maximum length of a pediatric measuring tape. If ETI fails after 3 attempts (defined as placement of laryngoscope in the mouth), continue with BVM and transport to nearest receiving hospital. Supraglottic airway (SGA) is a BACKUP airway for patients who FAIL both BLS airway and ETI attempts — not a first-line rescue over continued BVM.
Protocol: Ref 11020 Oral Endotracheal Intubation and Supraglottic Airway sections
✓ Correct Answer: B
Calcium channel blocker poisoning requires BH contact for Calcium Chloride administration. This is NOT a standing order for CCB poisoning — only for crush injury. Contact BH; they will order CaCl2 1 gm IV/IO for persistent hypotension/bradycardic arrhythmias from CCB. Glucagon is for BETA-BLOCKER poisoning, not CCB. Atropine may be tried but may not work for CCB-induced bradycardia.
Protocol: Ref 13010 Poisonings BH section, Ref 11010 Calcium Chloride
✓ Correct Answer: B
Max for Midazolam is 3 doses total using any combination of IV/IO/IM/IN. You have given one IM dose. You have TWO more doses remaining as standing orders. The correct next step is to repeat Midazolam 5 mg IM (repeat q10 min for IM/IN doses). After 3 total doses, THEN contact BH for additional orders. Diazepam is only used when Midazolam is not commercially available.
Protocol: Ref 11010 Midazolam Adult Seizure section
✓ Correct Answer: B
ICEMA destination rule for pediatric trauma: transport to a Pediatric Trauma Center when there is LESS THAN a 20-minute difference in transport time compared to the closest Trauma Center. The pediatric TC is 35 min; adult TC is 18 min. The difference is 17 minutes, which is less than 20. Wait — 35-18=17 min difference, which IS less than 20 minutes. So the pediatric center IS preferred... Actually, re-reading: 35 min peds TC vs 18 min adult TC = 17 min difference <20 min = transport to Peds TC. But the answer is B (adult TC). Let me re-read the ICEMA rule: "pediatric patients will be transported to a Pediatric TC when there is LESS THAN a 20-minute difference." 17 min difference <20 min → Peds TC. However, the GCS is 10 and BP is critical (70/40) — patients with difficult airways go to closest hospital. The critical physiologic instability means the closest TC (adult, 18 min) is more appropriate. The rule adds "patients with difficult to manage airways shall be transported to the closest receiving hospital." This patient is critically unstable. Answer B is correct in context of critical instability. Contact BH for final determination.
Protocol: Ref 9030 Destination, Ref 9040 Trauma Triage Criteria pediatric section
✓ Correct Answer: C
ICEMA neonatal (0–4 weeks) blood glucose threshold for treatment is <35 mg/dL. Pediatric patients older than 4 weeks use <60 mg/dL. Adults use <80 mg/dL. These three thresholds are ICEMA-specific and differ from national standards. Memorize all three.
Protocol: Ref 11010 Dextrose section
✓ Correct Answer: B
Stable bradycardia (HR <60 with ADEQUATE perfusion): observe, monitor for changes, IV access if indicated, 300 ml NS if lungs clear. NO atropine or pacing for stable bradycardia — medication is only for UNSTABLE (poor perfusion, ALOC, ischemic chest pain). Don't treat a number, treat the patient.
Protocol: Ref 14030 Stable Bradycardia section
✓ Correct Answer: B
ICEMA TXA protocol applies to patients ≥15 years of age — 17-year-old qualifies. Full adult dose: 2 gm slow IV/IO over 1 min OR 1 gm as 2×5 ml IM injections. Pediatric TXA (<15 yr) is NOT indicated. Age 15 is the cutoff, and this patient is 17, so full adult dosing applies. Criteria are met (SBP <90 and HR >120).
Protocol: Ref 11010 TXA section, Ref 14090 Trauma Adult TXA criteria
✓ Correct Answer: B
ICEMA Ref 11010 specifically lists Midazolam 1 mg IV/IO/IM/IN as a single dose for "anxiety related to application of CPAP." This requires SBP >90. Contact BH for additional orders. This is distinct from seizure dosing (2.5 mg IV) or behavioral dosing (5 mg IM). The 1 mg CPAP anxiety dose is often missed.
Protocol: Ref 11010 Midazolam CPAP indication
✓ Correct Answer: B
Peds Naloxone BLS: 1 day–8 yr = 0.1 mg/kg IM/IN (max 0.5 mg per dose). A 2-year-old falls in the 1-day-to-8-year age group. Calculate weight-based dose: 0.1 mg/kg × estimated weight. Max per dose is 0.5 mg. May repeat q2–3 min. Total max: 10 mg regardless of route. BLS CAN give Naloxone to peds patients.
Protocol: Ref 11010 Naloxone Pediatric BLS section
✓ Correct Answer: B
Breech presentation with undelivered head after 3–4 minutes: administer O₂ to mother, place in Trendelenburg, and transport Code 3 to closest appropriate facility. NEVER attempt to forcibly deliver the head in the field. NEVER cut the cord to separate the baby — this would be fatal.
Protocol: Ref 14210 Obstetrical Emergencies, Breech section
✓ Correct Answer: B
Sodium Bicarbonate for TCA poisoning is a BASE HOSPITAL ORDER — not a standing order. Contact BH; they will order NaHCO3 1 mEq/kg IV/IO. Do NOT give Lidocaine for TCA-induced wide complex — this can worsen toxicity. CaCl2 is not indicated for TCA. NaHCO3 works by alkalinizing the blood, which decreases TCA binding to sodium channels.
Protocol: Ref 13010 Poisonings BH section, Ref 11010 Sodium Bicarbonate
✓ Correct Answer: B
Eviscerated abdominal organs: cover with saline-dampened gauze; do NOT attempt to replace organs into the abdominal cavity. Dry dressings would dry out the bowel. Irrigation could introduce contamination. Replacing organs risks bowel damage and introduces infection.
Protocol: Ref 14090 Trauma Adult, Abdominal Trauma section
✓ Correct Answer: C
Polymorphic VT (Torsades de Pointes) with a pulse requires IMMEDIATE UNSYNCHRONIZED CARDIOVERSION (defibrillation). Synchronized cardioversion is for organized rhythms only — polymorphic VT is irregular and cannot be synchronized. After cardioversion converts to sinus rhythm, if prolonged QT is observed, then Magnesium 2 gm IV over 5 min.
Protocol: Ref 14040 Tachycardias Adult, Polymorphic VT section
✓ Correct Answer: C
For a 10-year-old (9–14 year age group), ICEMA cardiac arrest Epinephrine dose is 1.0 mg IV/IO — same as adult. The weight-based 0.01 mg/kg formula only applies to 1 day–8 years. Age 9 and above: 1.0 mg IV/IO q5 min (same as adult arrest dose).
Protocol: Ref 11010 Epinephrine Pediatric Cardiac Arrest section
✓ Correct Answer: B
ICEMA Ref 9030: All patients with a medical complaint on a behavioral health hold (5150) require medical evaluation and shall be transported to the closest acute care hospital for medical clearance. The 5150 hold does not bypass medical care — all acute care hospitals are capable of medically clearing behavioral health patients. Law enforcement can only transport patients without medical complaints directly to behavioral health.
Protocol: Ref 9030 Destination, Psychiatric Holds section
✓ Correct Answer: B
BH-ordered MgSO4 for severe asthma: 2 gm slow IV drip over 20 minutes; do NOT repeat. This differs from eclampsia (4 gm push) and Torsades (2 gm over 5 min). The administration method — slow drip over 20 min — is critical for safety in the asthma indication.
Protocol: Ref 11010 Magnesium Sulfate Adult severe asthma section
✓ Correct Answer: A
ICEMA Ref 14050 explicitly states: "Capnography SHALL be used for all cardiac arrest patients." Additional required uses: monitoring patients given respiratory-depressant medications, continuous monitoring after Midazolam for behavioral emergencies, after any advanced airway placement. The key word "shall" makes this mandatory.
Protocol: Ref 11020 Capnography section, Ref 14050 Cardiac Arrest
✓ Correct Answer: C
Age >65 on anticoagulants is an ICEMA Step 4 (Age/Co-morbid) factor. When Step 4 factors are present without physiologic/anatomic criteria, paramedics should contact trauma base hospital for destination consultation. The physician may direct to a trauma center or to a non-trauma receiving hospital. This is NOT an automatic trauma center mandate, and it's NOT transport to closest hospital without BH input.
Protocol: Ref 9040 Trauma Triage Criteria, Step 4 section
✓ Correct Answer: C
ICEMA Ref 11010 is clear: "Do not exceed 10 mg of Naloxone total regardless of route administered." This applies to all provider levels (BLS, LALS, ALS) and all routes combined (IV + IM + IN total). The 4 mg IN loading dose counts toward this total. This absolute maximum is ICEMA-specific.
Protocol: Ref 11010 Naloxone section
✓ Correct Answer: C
TXA for POSTPARTUM HEMORRHAGE is a BASE HOSPITAL ORDER per ICEMA. For trauma, TXA is a standing order. For PPH, it requires BH authorization. Criteria must also be met: within 3 hours of onset AND SBP <90 or HR ≥120. This is a critically important distinction: same drug, same dose, different authorization depending on the indication.
Protocol: Ref 14210 Obstetrical Emergencies, Ref 11010 TXA section
✓ Correct Answer: B
ICEMA Ref 14080: "If mLAPSS negative and stroke is still suspected, consult base hospital for destination." You cannot self-direct a mLAPSS-negative suspected stroke to a stroke center as a standing order — BH consultation determines the appropriate facility.
Protocol: Ref 14080 Stroke Treatment
✓ Correct Answer: C
ICEMA IO sites by age: 8 years and under (LALS/ALS): proximal tibia only. 9 years and older (ALS only): proximal tibia, distal tibia, humeral head. Anterior distal femur requires BH order for any age. This 8-year-old is in the "8 and under" group = proximal tibia only.
Protocol: Ref 11020 Intraosseous Insertion section
✓ Correct Answer: B
ICEMA Ref 11010 NTG section: "Nitroglycerin is contraindicated if...sexual enhancement medications have been utilized within the past 48 hours." The 36-hour window is within 48 hours. NTG remains contraindicated. This is often taught as 24 hours in other systems — ICEMA specifically uses 48 hours.
Protocol: Ref 11010 Nitroglycerin contraindications
✓ Correct Answer: B
Isolated closed head injury: unstable (SBP <90) → 250 ml NS bolus, may repeat once (max 500 ml). Stable → saline lock only. This patient is unstable (BP 96/60 is borderline but with GCS 12 suggesting CNS injury) — fluid resuscitation is appropriate but limited. You want to maintain cerebral perfusion pressure without causing cerebral edema from over-resuscitation.
Protocol: Ref 14090 Trauma Adult, Isolated Closed Head Injury section
✓ Correct Answer: C
ICEMA post-ROSC target: ETCO₂ 35–45 mmHg. The patient's ETCO₂ of 52 is elevated — reduce ventilation rate to bring ETCO₂ down to 35–45 range. Do NOT hyperventilate (ETCO₂ <35) as this causes cerebral vasoconstriction. Hypoventilation (ETCO₂ >45) causes acidosis. The target window is tight and specific.
Protocol: Ref 14050 Cardiac Arrest Adult, Stable ROSC section
✓ Correct Answer: B
Pediatric Dextrose (ICEMA): D10W 0.5 gm/kg (5 ml/kg) IV/IO. For 40 kg: 0.5 gm/kg × 40 = 20 gm = 200 ml of D10W. Pediatric threshold is BG <60 (not <80 like adults). ICEMA uses D10W for all patients (not D50W). The 25 gm adult dose only applies to adults.
Protocol: Ref 11010 Dextrose Pediatric section
✓ Correct Answer: A
Crush injury with suspected hyperkalemia (prolonged entrapment + abnormal ECG) — ALL THREE are ICEMA standing orders: Albuterol neb (drives K⁺ into cells), Calcium Chloride 1 gm IV/IO (membrane stabilization — the ONLY standing-order indication for CaCl2), and Sodium Bicarbonate 50 mEq IV/IO (alkalinization shifts K⁺ intracellularly). Plus large-bore IV and NS 500 ml × 2.
Protocol: Ref 14090 Crush Injury section, Ref 11010 CaCl2/NaHCO3 crush sections
✓ Correct Answer: C
ICEMA Ref 11020 explicitly states: "The midaxillary line at the 5th intercostal space is the preferred site" for needle thoracostomy. This is different from the traditional 2nd ICS MCL taught in many programs. ICEMA prefers the MAL 5th ICS — memorize this.
Protocol: Ref 11020 Needle Thoracostomy section
✓ Correct Answer: C
ICEMA's ETI rule is based on HEIGHT, not age or weight. "Oral endotracheal intubation is permitted only in patients who are taller than the maximum length of a pediatric emergency measuring tape (Broselow, etc.)." This is measured head to heel. A large 8-year-old who exceeds Broselow length CAN be intubated. A small 14-year-old who fits on the tape CANNOT be intubated — SGA is the backup airway.
Protocol: Ref 11020 Oral Endotracheal Intubation section
✓ Correct Answer: C
Neonatal resuscitation per ICEMA: HR <100 but >60 → BVM O₂ × 30 sec + reposition. HR <60 after above interventions → begin chest compressions at 3:1 ratio with ventilations (~100 comp + 30 vent/min). Not every HR <100 = start compressions — you try BVM first, then reassess.
Protocol: Ref 14200 Newborn Care, Circulation section
✓ Correct Answer: B
Push Dose Epi preparation per ICEMA: Mix 9 ml NS + 1 ml Epi (0.1 mg/ml) in a 10 ml syringe = final concentration 0.01 mg/ml. Adult dose: 1 ml IV q1–5 min titrate SBP >90. This must be done correctly — using undiluted 0.1 mg/ml would be 10× overdose. This is a critical field preparation skill.
Protocol: Ref 11010 Epinephrine (0.01 mg/ml) Push Dose section
✓ Correct Answer: B
ICEMA Ref 14110: "Do not delay administration of Midazolam due to lack of vascular access as IM or IN is preferred in this circumstance." For behavioral emergencies, the IM or IN route is preferred precisely because dangerous agitation patients often don't cooperate with IV placement, and delays worsen outcomes. Give IM/IN first.
Protocol: Ref 14110 Behavioral Emergencies ALS section
✓ Correct Answer: B
ICEMA Ref 9030 explicitly states: "STEMI patients with difficult to manage airways shall be transported to the closest receiving hospital." Airway always supersedes cardiac specialty destination. The rationale: a dead airway = dead patient — STEMI intervention cannot happen without a secured airway. Always manage the most immediate life threat first.
Protocol: Ref 9030 Destination, STEMI Receiving Centers section
✓ Correct Answer: C
Adenosine sequence: 6 mg IVP → 12 mg IVP → 12 mg IVP (one more repeat). Total possible doses = 6 + 12 + 12 = 30 mg. "May repeat one (1) time" refers to the 12 mg dose. Three total administrations are possible per ICEMA.
Protocol: Ref 11010 Adenosine Adult section
✓ Correct Answer: B
ICEMA is unambiguous: "Resuscitation efforts on a penetrating traumatic arrest victim are not to be terminated without Trauma base hospital contact." Even if obvious death criteria appear met (asystole in two leads, no vital signs), BH must be contacted for penetrating traumatic arrest determination of death on scene. This is the highest-priority rule for penetrating arrest.
Protocol: Ref 14090 Trauma Adult, Determination of Death section for penetrating
✓ Correct Answer: B
COPD O₂ target: maintain SpO₂ at 90%; do NOT give supplemental O₂ if SpO₂ >91%. SpO₂ 93% is ABOVE the ceiling — reduce O₂ or let the patient breathe room air. This is a direct ICEMA protocol requirement. Hyperoxia in COPD suppresses hypoxic drive and causes hypercapnia.
Protocol: Ref 11010 Oxygen COPD section
✓ Correct Answer: B
ICEMA Ref 14090 states: "The long backboard (LBB) is an extrication tool, whose purpose is to facilitate the transfer of a patient to a transport stretcher and is not intended, or appropriate for achieving spinal motion restriction...patients should be removed as soon as it is safe and practical. LBB does not need to be reapplied on interfacility transfer (IFT) patients."
Protocol: Ref 14090 Trauma Adult, Spinal Motion Restriction note
✓ Correct Answer: C
Peds defibrillation: 1st = 2 j/kg, 2nd = 4 j/kg, 3rd and subsequent = 10 j/kg (not to exceed adult dose). For this child: 3rd shock = 10 j/kg × 35 kg = 350J (if <360J adult max, use 350J).
Protocol: Ref 14150 Cardiac Arrest Pediatric
✓ Correct Answer: B
ICEMA Ref 14200: "Obtain APGAR scoring at one (1) and five (5) minutes. Do not use APGAR to determine need to resuscitate." Resuscitation decisions are based on clinical presentation — heart rate, respiratory effort, tone — NOT the APGAR score. Begin resuscitation based on your assessment; APGAR is documentation only.
Protocol: Ref 14200 Newborn Care
✓ Correct Answer: B
ICEMA Ref 14100: "Shifting from one analgesic while treating a patient requires base hospital contact." You have started Fentanyl and now want to switch to Ketamine because BP has dropped below 100. Contact BH first, then switch. Also note: Ketamine IS indicated when SBP <100 per the pain management algorithm — so the switch is clinically appropriate, but the BH contact rule still applies.
Protocol: Ref 14100 Pain Management, Special Considerations
✓ Correct Answer: B
For non-traumatic shock unresponsive to fluid boluses, the ICEMA standing order is Push Dose Epinephrine (0.01 mg/ml solution). Ref 14230 states: "If no response to fluid administration, stop fluids and administer Push Dose Epinephrine." Dopamine and Norepinephrine infusions are not listed as ICEMA prehospital medications.
Protocol: Ref 14230 Shock Non-Traumatic ALS section
✓ Correct Answer: B
Pediatric trauma — unstable: 20 ml/kg NS IV bolus (same as all pediatric unstable trauma). This applies to blunt, extremity, and head injury. Penetrating pediatric trauma stable: saline lock. The "250 ml" volumes listed in adult trauma protocols do not apply to patients who fit the Broselow tape (peds protocol).
Protocol: Ref 14180 Trauma Pediatric, fluid sections
✓ Correct Answer: B
Diazepam in ICEMA is a BACKUP medication for use ONLY when Midazolam is not commercially available. Adult dosing: 5 mg IV/IO OR 10 mg IM — single dose only (no repeat). It cannot be repeated and cannot be added on top of Midazolam doses. Peds backup dose: 0.1 mg/kg IV/IO or 0.2 mg/kg IM (single dose only).
Protocol: Ref 11010 Diazepam section
✓ Correct Answer: C
ESRD dialysis patient with hemodynamic instability and documented slow rhythm (bradycardia/wide escape) with suspected hyperkalemia: BH may order Calcium Chloride 1 gm IV/IO. This is a base hospital order specifically written in ICEMA for this exact scenario. CaCl2 stabilizes the cardiac membrane against hyperkalemia without lowering the K+ level — immediate membrane protection while other treatments take effect.
Protocol: Ref 14030 Bradycardias, BH orders; Ref 11010 CaCl2 ESRD section
✓ Correct Answer: A
For pacing/cardioversion comfort per ICEMA Ref 11010 and 11020: Fentanyl for pain, Midazolam for anxiety — both are available for any age (pediatric dosing applies). TCP is painful; patient comfort must be addressed. Pediatric doses of both drugs apply. Ketamine is not listed for this indication and is NOT approved for peds pain.
Protocol: Ref 11020 TCP and Cardioversion; Ref 11010 Fentanyl and Midazolam
✓ Correct Answer: B
ICEMA Ref 14280 explicitly states: "Hypotension is a late indicator for septic shock." This is clinically important — by the time septic patients become hypotensive, they are in decompensated shock. Early identification using the ICEMA criteria (EtCO₂, HR, RR, temperature) allows treatment before BP crashes.
Protocol: Ref 14280 Sepsis Special Considerations
✓ Correct Answer: B
Isolated extremity trauma — STABLE: saline lock only, do NOT administer IV fluids. Isolated extremity trauma — UNSTABLE: 250 ml NS bolus × max 500 ml. This patient is stable (BP 130/80) = saline lock only. Unnecessary fluids increase bleeding by elevating BP and diluting clotting factors.
Protocol: Ref 14090 Trauma Adult, Isolated Extremity Trauma section
✓ Correct Answer: B
Prolapsed cord BLS management: gently push the presenting part away from the cord to relieve compression, elevate mother's hips, consider knee-chest position, transport Code 3. Never cut the cord — this would sever fetal blood supply. Never apply pressure to the cord — this worsens ischemia.
Protocol: Ref 14210 Obstetrical Emergencies, Prolapsed Cord section
✓ Correct Answer: B
ICEMA Ref 14220 states contraindications for Ondansetron include "Patients under four (4) years of age." Additionally, in 4–8 year olds, only 4 mg (one dose) may be given before BH contact. Age ≥9 years: 4 mg; may repeat ×2 at 10-min intervals; max 12 mg before BH contact.
Protocol: Ref 14220 Nausea and Vomiting; Ref 11010 Ondansetron
✓ Correct Answer: C
TCA poisoning with wide QRS/hypotension: the treatment is NaHCO3 1 mEq/kg IV/IO, but this is a BASE HOSPITAL ORDER. Do NOT treat TCA wide complex with Lidocaine — Lidocaine can worsen sodium channel blockade. CaCl2 is not indicated. Contact BH; alkalinization is the specific antidote for TCA toxicity.
Protocol: Ref 13010 Poisonings BH orders; Ref 11010 NaHCO3 TCA section
✓ Correct Answer: B
ICEMA synchronized cardioversion energy: Start at 100 joules (biphasic equivalent per manufacturer guidelines). Escalate to 200J, 300J, 360J for subsequent attempts. BH order for repeated attempts at 360J. This applies to SVT, A-fib/flutter, and stable VT.
Protocol: Ref 11020 Synchronized Cardioversion section
✓ Correct Answer: B
Adult burns — stable (SBP >90, adequate perfusion): NS 500 ml/hr IV. Adult burns — unstable (SBP <90): 2nd IV access; 500 ml NS bolus may repeat max 1000 ml. The 500 ml/hr maintenance rate is unique to the Burns protocol — different from the bolus strategy in other trauma.
Protocol: Ref 14070 Burns Adult, LALS/ALS sections
✓ Correct Answer: B
ICEMA field TOR: Consider terminating if NO ROSC + ETCO₂ waveform <15 mmHg after 20 min HP-CPR with ALS + ANY ONE OF: (1) no shocks delivered, (2) arrest not witnessed by EMS, or (3) persistent asystole/agonal/PEA <40 bpm. Only ONE qualifying criterion is needed (not all three). No BH contact required when all criteria met.
Protocol: Ref 14050 Cardiac Arrest Adult, Termination of Efforts
✓ Correct Answer: B
ICEMA Ref 10050 / Ref 11010: Buprenorphine-Naloxone (Suboxone) is indicated for opioid WITHDRAWAL when COWS ≥8. Initial dose: 16 mg/4 mg sublingual. This is an ICEMA-specific program — do NOT confuse with opioid overdose (Naloxone) treatment. COWS ≥8 means clinically significant withdrawal. Suboxone is NOT for overdose.
Protocol: Ref 11010 Buprenorphine-Naloxone section; Ref 10050
✓ Correct Answer: A
Post-ROSC pediatric shock (SBP <70): Push Dose Epi using pediatric dosing. ICEMA Ref 11010 pediatric Push Dose: 0.1 ml/kg of the 0.01 mg/ml solution q1–5 min, titrate to SBP >70. This is weight-based (not the flat 1 ml adult dose). The SBP target for peds is >70 mmHg (not >90 as in adults).
Protocol: Ref 11010 Epinephrine (0.01 mg/ml) Pediatric section; Ref 14150 ROSC
✓ Correct Answer: B
IO infusion pain: Lidocaine 2% 0.5 mg/kg slow IO push over 2 minutes; max 40 mg. This is administered via the IO itself before starting the infusion to anesthetize the intraosseous space. This applies to both adults and peds. Wait approximately 30-60 seconds for effect before flushing.
Protocol: Ref 11010 Lidocaine 2% IO Pain section
✓ Correct Answer: C
LALS (AEMT) scope for allergic reaction: Epi 0.3 mg auto-injector (BLS), Albuterol 2.5 mg neb (LALS/ALS), Epi 0.3 mg IM (1 mg/ml) if no Albuterol response (LALS/ALS), IV bolus 300 ml NS if poor perfusion. Diphenhydramine is ALS ONLY — not in LALS scope. Option C is the most accurate because it correctly excludes Diphenhydramine from LALS.
Protocol: Ref 14010 Respiratory Emergencies Adult, LALS section
✓ Correct Answer: C
ICEMA Ref 14090: Remove impaled object ONLY when: (1) it interferes with CPR, (2) it is impaled in the face/cheek/neck and compromising ventilations, OR (3) upon trauma base hospital physician order. All other impaled objects: immobilize and leave in place.
Protocol: Ref 14090 Trauma Adult, Impaled Object section
✓ Correct Answer: C
Atropine for unstable bradycardia: 1 mg IV/IO, repeat q5 min, maximum 3 mg (or 0.04 mg/kg). Note: for organophosphate poisoning, no maximum is stated — give until secretions dry. The 3 mg cap applies ONLY to the bradycardia indication.
Protocol: Ref 11010 Atropine Adult Bradycardia section
✓ Correct Answer: B
CO poisoning: pulse oximetry is UNRELIABLE because hemoglobin bound to CO (COHb) reads as oxyhemoglobin on standard pulse ox. SpO₂ 98% is falsely reassuring. Per ICEMA Ref 13050: administer 100% O₂ via NRB mask regardless of apparent SpO₂ reading. ETCO₂ may also be abnormal. Treat the clinical presentation, not the false saturation number.
Protocol: Ref 13050 Smoke Inhalation/CO Exposure; Ref 14060
✓ Correct Answer: B
ICEMA protocol: for seizures, max 3 doses Midazolam as a standing order, then "contact base hospital for additional orders and to discuss further treatment options." The BH physician CAN order additional doses beyond 3 — the standing order is exhausted but medical direction can continue treatment. The protocol explicitly says to contact BH, not to switch drugs.
Protocol: Ref 11010 Midazolam Adult Seizure section
✓ Correct Answer: B
ICEMA Ref 14110: "Minors under the age of nine (9) base hospital order only" for behavioral emergencies requiring Midazolam. Children 9 and older follow the adult behavioral emergency standing order protocol. This is a hard age cutoff — under 9 = BH order required for behavioral emergencies.
Protocol: Ref 14110 Behavioral Emergencies; Ref 11010 Midazolam Peds Behavioral
✓ Correct Answer: B
ICEMA Ref 14100 Special Considerations: "Shifting from one analgesic while treating a patient requires base hospital contact." This is a clear protocol requirement. Even though Ketamine is a standing order for pain management, switching FROM another analgesic requires BH authorization. Contact BH, then administer as ordered.
Protocol: Ref 14100 Pain Management Special Considerations
✓ Correct Answer: B
ICEMA Ref 14090 and 14050: "Mechanical cardiopulmonary resuscitation (mCPR) devices are contraindicated for trauma patients." Remove the device and perform manual CPR. mCPR devices are only authorized for NON-TRAUMATIC cardiac arrest. Traumatic arrests have compressible causes (tension PTX, hemorrhage) that cannot be addressed by a mechanical device continuing compressions.
Protocol: Ref 14090 Trauma Adult, BLS interventions; Ref 14050
✓ Correct Answer: B
ICEMA Ref 11020 Transcutaneous Cardiac Pacing: "Start at a rate of 60 and adjust output to the lowest setting to maintain capture." "Increase rate (not to exceed 100) to maintain adequate tissue perfusion." Start: 60 bpm. Maximum: 100 bpm. BH contact if rhythm persists or continued signs of inadequate tissue perfusion.
Protocol: Ref 11020 Transcutaneous Cardiac Pacing section
✓ Correct Answer: A
Epinephrine 1 mg/ml IM for bronchospasm/asthma/allergic reaction: 0.3 mg IM; may repeat ONCE after 15 minutes if symptoms do not improve. You gave one dose and 15 minutes have passed with partial improvement — you may administer a second 0.3 mg IM dose as your standing order. CPAP is also appropriate. After two Epi IM doses with inadequate response, contact BH for MgSO4 order.
Protocol: Ref 11010 Epinephrine 1 mg/ml Adult section; Ref 14010
✓ Correct Answer: C
High-energy mechanism (intrusion >12 inches) meets MOI criteria (Step 3). Pregnancy >20 weeks meets Age/Co-morbid criteria (Step 4). When mechanism exists without physiologic/anatomic criteria, AND special considerations exist (pregnancy), contact trauma base hospital for destination consultation. This is NOT an automatic trauma center transport.
Protocol: Ref 9040 Trauma Triage Criteria, Steps 3 and 4
✓ Correct Answer: B
ICEMA Ref 11010: Patients 4–8 years old: may administer a total of 4 mg of Ondansetron (one 4 mg dose) PRIOR to base hospital contact. Patients ≥9 years: may administer 4 mg; may repeat ×2 at 10-min intervals; max 12 mg before BH contact. This 4-year-old falls in the 4–8 age group = max 4 mg before BH contact.
Protocol: Ref 11010 Ondansetron section
✓ Correct Answer: B
ICEMA Ref 14210 explicitly states under Postpartum Hemorrhage BLS interventions: "Encourage immediate breast feeding." Breastfeeding stimulates endogenous oxytocin release from the posterior pituitary, which causes uterine contractions and helps control postpartum hemorrhage. This is a low-tech, effective intervention listed directly in protocol.
Protocol: Ref 14210 Obstetrical Emergencies, Postpartum Hemorrhage BLS
✓ Correct Answer: B
ICEMA Ref 14230 and Ref 11010: Adult Push Dose Epi is titrated to maintain SBP >90 mm Hg. Peds Push Dose Epi: titrate SBP >70 mm Hg. The adult target of >90 is the permissive hypotension floor — do not over-target. Administer 1 ml IV q1–5 min and reassess BP each time.
Protocol: Ref 11010 Epinephrine 0.01 mg/ml adult section; Ref 14230
✓ Correct Answer: B
ICEMA Ref 11020 Vagal Maneuvers: "Relative contraindications for patients with hypertension, suspected STEMI, or suspected head/brain injury." These are relative (not absolute) contraindications. Use clinical judgment but avoid vagal maneuvers in these situations as they can worsen the underlying condition.
Protocol: Ref 11020 Vagal Maneuvers section
✓ Correct Answer: B
ICEMA Pain Management for pediatric patients: Fentanyl 0.5 mcg/kg slow IV/IO over 1 min (35 kg = 17.5 mcg) and Acetaminophen 15 mg/kg IV (35 kg = 525 mg, max 1 gm) are both appropriate. Ketamine is NOT indicated for pediatric patients in ICEMA pain protocol — adult only (≥15 years). Morphine is not in ICEMA protocol.
Protocol: Ref 14100 Pain Management; Ref 11010 Fentanyl/Acetaminophen pediatric
✓ Correct Answer: B
Blunt trauma — unstable (SBP <90): 250 ml NS bolus IV/IO; may repeat one time; maximum 500 ml total. Hemothorax from blunt chest trauma = blunt trauma protocol. Permissive hypotension limits fluid to prevent clot disruption. The 500 ml cap is strict for blunt trauma.
Protocol: Ref 14090 Trauma Adult, Blunt Trauma Unstable section
✓ Correct Answer: B
Adult Lidocaine for cardiac arrest (VF/pulseless VT): initial dose 1.5 mg/kg IV/IO; for refractory VF/VT, additional 0.75 mg/kg IV/IO (repeat once in 5–10 min); maximum total dose 3 mg/kg. Note: the pediatric dose is 1.0 mg/kg initial (lower than adult). The adult initial dose of 1.5 mg/kg is a common test distinction.
Protocol: Ref 11010 Lidocaine Adult section
✓ Correct Answer: B
ICEMA Ref 9030: ROSC of unknown or suspected cardiac etiology → transport to closest STEMI Receiving Center regardless of 12-lead ECG findings, IF the closest STEMI Receiving Center is NOT greater than 30 minutes away. At 22 minutes, the STEMI center is within the 30-min window. The ECG showing no STEMI does not change this protocol. ETCO₂ of 28 is somewhat low but does not affect destination — optimize ventilation en route.
Protocol: Ref 9030 Destination STEMI section; Ref 14050 Stable ROSC section