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It is a beautiful, warm, sunny evening. You are barbecuing steaks on the deck while the potatoes bake in the station oven. You are admiring the sunset and discussing what a great job you have that allows you to get paid for eating a gourmet meal when the tones go off.

You are dispatched to the local ball field for a 30-year-old male patient who is experiencing breathing difficulties. From the ball diamond you would be approximately 10 minutes to the nearest medical facility.

As you arrive on scene, a middle-aged female flags you down.She directs you over to the bench on the side of the playing field. A baseball game is still in progress but poses no threat to you or your patient. You can see a few people gathered around a 30-year-old gentleman who is sit­ting on the bench, leaning forward, in obvious distress. The people around him are attempting to calm him but they appear anxious as well.

Your patient is leaning forward in obvious respiratory distress with audible wheezing. He acknowledges your presence but appears to be concentrating heavily on breathing. He is able to speak in two-word sentences only. He appears orientated to person, place, time and situation. His friends tell you he was playing baseball and had just hit a home run. After arriving at home plate he appeared to be having difficulty breathing. He sat down on the bench and rapidly worsened to become as you find him. He first began experiencing difficulty approximately 10 minutes prior to your arrival. His friends were preparing to drive him to the hospital but were alarmed at his rapidly worsening condition and phoned you instead. Your patient reports he cannot breath. He states he has a history of asthma. He reports he hasn’t had an attack for approximately six months but his attacks are sometimes brought on by exercise, sometimes by environmental influences such as pollen or dust. He tells you he usually takes his “puffer” when he feels an attack coming on but he left it at home tonight. He reports no drug allergies, although exposure to dust, cats and pollen all have been known to precipi­tate an asthma attack. He has no other pertinent past medical history. Your patient reports he last ate approximately two hours ago, at which time he had his regular supper meal. He states he felt a slight “tightness” in his chest prior to running the bases. Primary survey reveals respiratory distress with accessory muscle use noted in neck and intercostals. Lung sounds are present in all lobes but wheezing is noted throughout on both inspiration and expiration. There is no J.V.D. or tracheal shift. Palpation of the chest and neck reveal no deformities and does not induce pain. The extremities are unremarkable, capillary refill is delayed. The abdomen is soft, non-distended and non-rigid. There is no edema noted to hands or feet, distal pulses present. Palpation of the head reveals no deformities, there are no rashes or hives, and pupils are equal and reactive to light at 4mm. The secondary survey is unremarkable.

Pulse	132 strong
Blood pressure	140/96
Respiration	32 shallow wheezing all lobes on both inspiration and expiration, diminished air entry in bases
Skin	warm, dry, cyanotic
Pupil Response	equal reactive to light at 4mm
Temperature	370 C
E.C.G.

1.Your tentative diagnosis for this patient would be:A. AnaphylaxisB. AsthmaC. C.O.P.D.D. Tension pneumothorax

2.This patient should be categorized as a stay and stabilize due to his age and past history of asthma.

A. TrueB. False

3.This patient’s pulse rate is elevated due to:A. AnxietyB. HypoxiaC. MedicationsD. A & BE. None of the above

4.This patient’s diastolic blood pressure is elevated due to:

A. Vasoconstriction B. VasodilationC. ExerciseD. Hypovolemia

5.When at rest, the average adult will breathe:A. 60 times a minuteB. 75 to 100 times a minuteC. 12 to 20 times a minuteD. 30 times a minuteE. 8 to 10 times a minute

6.In asthmatics the lower airway may be obstructed by:

A.  EdemaB.   MucusC.   Smooth muscle spasmD.  All of the aboveE.   None of the above

7.In the early stages of an asthma, attack the patient is more likely to experience:

A. Respiratory edema B.  Inspiratory wheezes C.  Expiratory wheezes

8.The “puffer” the patient refers to is most likely:

A. Inhaled bronchodilator medicationB. A device used to measure respiratory functionC. A broncho-constricting medicationD. An antidote for allergies

9.When auscultating lung sounds one should:

A. Listen to first the right, then the left sideB. Listen to first the left, then the right sideC. Listen posteriorly first, then anteriorlyD. Alternate from side to side moving down the chest wall

10. Normal lung sounds will reveal:A. Longer inspiration than expiration phaseB. Longer expiration than inspiration phaseC. Equal inspiration and expiration phaseD. None of the above

11. Your initial treatment should consist of:

A. Oxygen at 6 litres via nasal cannulaB. Oxygen at 4 litres via nasal cannulaC. Oxygen high flow via non-rebreather maskD. Transport only, do not give oxygen as it may shut down the patient’s respiratory drive.

12. The tiny air sacs at the ends of the bronchioles are the:A. Bronchi B.  PapillaeC.  MicrovilliD. Alveoli E.  Myocardium

13. A double-walled sac surrounds each lung. It is called the:A. PeritoneumB.  MeningesC.  Pericardium D. Pleura E.  Columna

14. Factors used to distinguish asthma from anaphylaxis include:

A. Past medical history B. Presence of hives and redness in anaphylaxis onlyC. Wheezing lung sounds in asthma onlyD. All of the above E.  A & B only

15. Status asthmaticus is:A. A life threatening prolonged asthmatic attackB. Often characterized by inaudible breath soundsC. Often characterized by decreased rate of respi­rationsD. All of the aboveE. A and B are correct

16. The E.C.G. reveals:

17. An I.V. for this patient:A. Is contraindicatedB. Should be established as a drug routeC. Should be established to infuse massive volume

18. Pulsus paradoxus, a decline in systolic blood pressure of 10-20 mmHg, may occur in asthmatics. This decline in pressure would occur on:

A. ExpirationB. InspirationC. When patient is supineD. When patient moves from supine to high fowlers

19. The alpha effects of epinephrine may cause:A. Bronchial constrictionB. Peripheral vasoconstrictionC. Bronchial dilationD. A & B are correctE. B & C are correct

20. The beta 2 effects of epinephrine may cause:A. Bronchial constrictionB. Peripheral vasoconstrictionC. Bronchial dilationD. A & B are correctE. B & C are correct

21. Bronchodilators reverse airway obstruction by:

A. Increasing breathing rate B. Reducing carbon dioxide contentC. Relaxing the bronchial smooth muscleD. Reducing edema

22. Aminophylline is contraindicated in patients:

A. Who have cardiac arrhythmias?B. Who have congestive heart failure?C. Who are over 60 years of age?D. Who have chronic hyper­tension?

23. The adult dosage for epinephrine to treat asthma is:A. 0.3-0.5mg 1:10,000 IVB.  0.3-0.5mg SC 1:1000C.  3-5mg SC 1:1000 D. 0.01mg/kg SC 1:1000

24. Ipratropium is:A. An anticholinergicB. A corticosteroidC. Usually given as a 500 mg nebulized doseD. All except AE. All except B

25. Your service could prepare for this call by:

A. In-service training in respiratory conditionsB. Knowing the asthmatics in your areaC. Volunteering to speak at local asthma group meetings.D.  All of the above

References

Bledsoe, Bryan E., Clayden and Papa; Prehospital Emergency Pharmacology Fourth Edition. Brady New Jersey: 1996.

Beck, Richard K. Pharmacology for Prehospital Emergency Care: F.A. Davis Company Philadelphia: 1992.

Karren, Keith J. and Brent Q. Hafen; First Responder A Skills Approach Third Edition; Morton

Publishing Company, Colorado: 1990.

Jones, Shirley et. al., Advanced Emergency Care For Paramedic Practice. Lippincott Company Philadelphia: 1992.

The answers to these questions are industry standards and may not necessarily be correct according to your local protocol.If there is any discrepancy between these answers and local protocol, please follow the protocol from your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic with over 18 years of EMS experience in Nova Scotia and Alberta.She has a Bachelor of Science Degree in Health Education from Dalhousie University, a diploma in Paramedicime from Northern Alberta Institute of Technology, and a certificate of Social Work from the University of Waterloo.Heather is an instructor for the Paramedic Program at Southern Alberta Institute of Technology.She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News.It originally appeared in theApril — May 1996 (volume 19, number 3).

C a n a d I a n Emergency News and the author of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re­publication without written consent is prohibited.