What is your goal in treating this patient? How much naloxone will you use for this patient, and how will it be administered?

1. 1 mg = _____ mcg
2. 5 mcg = _____mg
3. 4 grams =______mcg
4. 0.005 grams =______mg
5. 0.15 liters =______mL
6. 850,000 mg =______grams
7. 37º C =______ºF
8. 103.6 ºF =______ºC
9. ¼ grain =______mg
10. 2 Tbsp =______mL
11. 165 lb =______kg
12. 8.5 lb =______kg
13. 500 mL =______ L
14. 800 mg =___________mcg
15. 80 kg =______lb
16. With a 60 gtt administration set, 45 gtt = __________mL
17. With a 15 gtt administration set, 15 gtt = __________mL
18. With a 10 gtt administration set, 5 gtt = ___________mL
19. Which catheter will deliver the most fluid in one minute when run wide open with a 10 gtt administration set?
20. 18 gauge 1.5 inch
21. 14 gauge 1.5 inch
22. Which catheter will deliver the most fluid in one minute when run wide open with a 15 gtt administration set?
23. 16 gauge 2 inch
24. 16 gauge 1.5 inch
25. Your 215 pound patient has burns over 45% of his body. Using the Parkland Burn Formula, answer the following:
26. How much fluid should be given during the first 24 hours post-burn?
27. How much fluid should be given during the first 8 hours post-burn?
28. What fluid does the Parkland Formula call for?
29. How much fluid should be given during the first hour post-burn?
30. Using a 10 gtt/mL administration set with one line, how many gtt/min would you run your IV to administer the amount determined in part “d” above?
31. How much fluid will you run in the second 8-hour period post-burn?
32. How much fluid will you run in the third 8-hour period post-burn?
33. How can the paramedic judge the adequacy of fluid therapy in a burn patient?
34. Give 0.3 mg of epinephrine 1:1000 from an ampule containing 1 mg epinephrine in 1 mL of fluid. How many mL will you give?
35. Assume that you are giving the amount of epinephrine in question 22 above to a patient who is having a severe allergic reaction. Name two routes by which this medication can be safely administered.

a.

b.

24. Name three routes for drug administration that avoid “first-pass metabolism.”

a.

b.

c.

25. Name three “central venous line” routes for IV administration.

a.

b.

c.

30. Relative to central venous access devices (CVAD):
31. Explain what the device is.
32. What are the advantages of such a device?
33. What are the disadvantages of such a device?
34. Explain what a peripherally inserted central catheter (PICC) line is and how and where it is placed.
35. Describe the technique for accessing a previously implanted CVAD in the field by paramedics.
36. Is the external jugular vein a central line or a peripheral line?
37. Discuss implanted vascular access devices (IVAD) as follows:
38. discuss the differences between CVAD and IVAD.
39. describe the procedure for accessing an IVAD by a paramedic in the field.
40. A special needle is required for access to IVAD devices.
41. name and describe this needle
42. You have started an IV in a dorsal metacarpal vein in the right hand which stops flowing periodically and seems “positional.” Describe actions you would take to alleviate this problem.
43. Your previously patent IV has stopped flowing and lowering the site below the level of the heart does not produce blood return in the line. Your partner recommends flushing the line forcibly with normal saline from a syringe.  Explain your reaction to this recommendation.
44. Describe a pyrogenic reaction and how you would recognize and deal with it.
45. You are called to a nursing home to see a patient who returned from a short stay in the hospital with an IV in place. The patient is complaining of pain in the arm with the IV.  Inspection shows a red arm with reddened and swollen tissues and “red streaks” running up the vein proximal to the IV site.  Discuss what these findings indicate.
46. You are enroute to a Level 1 trauma center with a patient who was extricated from an overturned car. The ambient temperature is 56º F outside and approximately 72º F in the ambulance.  The patient’s BP is 60/40 and you are administering normal saline with two 14 gauge lines in the antecubitals.  Your patient is awake and shivering uncontrollably in spite of two blankets over her.
47. Discuss the possible causes of her shivering and how you could prevent it.
48. Discuss the implications of hypothermia in a trauma patient. Hint:  Review the two posted articles prior to this assignment in this module of the course:  Hypothermia in Trauma Patients, and Triad of Death:  Cold ambulances and cold fluids.
49. You have a vial of a drug containing 25 mL of fluid. It contains 1 gram of medication.  How many mg of the drug are contained in each mL of fluid?
50. Give sodium bicarbonate at 1 mE1/kg to a patient who weighs 160 pounds. You have standard prefilled syringes of sodium bicarbonate that are labeled “50 mEq/50 mL.”  How many mL will you administer?
51. Your patient is in sinus bradycardia at a rate of 36 beats per minute when you arrive. She relates that she has been feeling weak and dizzy but otherwise seems fine.  You determine to start an IV and administer 0.5 mg of atropine.  Immediately after administration, your patient’s heart rate drops to 16 beats per minute and she loses consciousness.
52. what mistake did you must likely make?
53. what should you do to correct the situation?
54. What is the maximum recommended cumulative dose of atropine for a patient in vagally induced sinus bradycardia?
55. For a patient with organophosphate poisoning, how would your dosage differ from the patient in question 38?
56. Give 0.5 mg of atropine to a patient in sinus bradycardia. You have prefilled syringes containing 1 mg atropine in 10 mL of fluid.  How many mL will you give?

41. Your patient has crushing chest pain, shortness of breath, and signs of MI on the 12-lead ECG. You wish to administer aspirin.  How much will you administer and by what route?

42. You want to administer a Levophed infusion. Your protocols recommend placing 4 mg of Levophed into 250 mL of fluid.  However, your truck does not have any 250 mL bags on it today, but  you do have 500 mL bags of normal saline and several vials of Levophed, each containing 4 mg of the drug in 2 mL of fluid.

1. How much Levophed should you place in a 500 mL bag to achieve the same concentration as the protocol recommends?
2. You determine to start your Levophed infusion at 4 mcg/min. Using a 60 gtt/mL set, how many gtt/min will you run with the solution you made?

43. A 66-pound child has been stung by a bee and is experiencing a severe allergic reaction. You determine to administer epinephrine 1:1000 at 0.01 mg/kg of body weight.
44. How much epinephrine will you give this patient?
45. You have ampules of epinephrine 1:1000 each containing 1 mg epinephrine in 1 mL of fluid. How many mL of fluid will you inject and by what route?

44. How many mL of a 4% solution must be added to 500 mL of IV solution to achieve a solution concentration of 4 mg/mL?

45. Your 120 pound patient is in septic shock, and after one liter of normal saline still has a BP of 86/54.

1. What is her mean arterial pressure (MAP)?
2. Assuming an intracranial pressure (ICP) of 5 mmHg, what is her cerebral perfusion pressure (CPP)?
3. What is your target MAP for this patient in order to bring her CPP up to 80?
4. How many mL per kg of body weight of normal saline have you given her?
5. You determine to administer a dopamine drip starting at 10 mcg/kg. Using a 60 gtt set, and having on hand a premixed bag containing 800 mg of dopamine in 500 mL of fluid, how many gtt/min will you run your drip?
6. After 10 minutes, your patient’s BP has improved to 96/72. What is her MAP now?
7. Assuming that her ICP is still the same, what is her CPP now?
8. What additional measures would you take for this patient?

46. Your patient in SVT has had 6 mg of adenosine without result. You now determine to follow your protocol and administer 12 mg of adenosine.  You have adenosine in 2 mL vials containing 6 mg each.  Explain in detail how you will physically administer this dose.

47. Your patient has suffered an injury to his ribs, sustained when he was caught between a loading dock and a truck that was backing up. He complains of severe pain in the right rib-cage from ribs 4 to 8, and is having difficulty breathing due to extreme pain when he breathes.  You determine to administer fentanyl, titrated to pain relief and ease of breathing.  You determine to begin with 50 mcg.

1. You have vials containing 250 mcg of fentanyl in 5 mL of fluid. How many mL will you give for a dose of 50 mcg?
2. Describe, in terms of route and speed of administration, how you will administer this dose.
3. Describe possible adverse reactions to fentanyl when given by IV injection.
4. Describe the probable time of onset of your fentanyl dose and the duration of action.

48. Your patient is having an MI and you determine to administer 1-4 mg of morphine titrated to pain relief.
49. what is the expected onset of action of morphine?
50. given vials containing 10 mg of morphine in 1 mL of fluid, how many mL of fluid will you administer and how?
51. After administration of morphine for this patient he becomes nauseated.  Name two medications commonly carried on ambulances that you can give to alleviate his nausea.  State the dosage and route for each one.

49. You have a patient who is suffering nausea and vomiting after chemotherapy and promethazine has been ordered.

1. promethazine has been determined to be corrosive when given arterially.  Some patients have lost limbs as a result of inadvertent administration of promethazine into an artery.  How can you be sure that you are not injecting into an artery?
2. What alternative routes are available for promethazine administration?

50. Your 5 year old patient has had nausea and vomiting for one day and visited her pediatrician, who gave a prochlorperazine (Compazine) suppository to her, to be followed by oral Compazine in 4 hours. On arrival, her frantic parents lead you to their daughter who is lying on a sofa.  Her eyes are rolled upward so that only sclera is visible without lifting her eyelids.  Her tongue is protruding about 3 inches from her mouth, and her neck is stiff and rigid.  She has a temp of 99.4º F, respirations of 30 and non-labored, and a heart rate of 120.  BP is 90/60.  Pulse oxymeter is 98% on room air.  You immediately recognize the signs of extrapyramidal syndrome from prochlorperazine overdose, and determine to administer IM diphenhydramine.  You have diphenhydramine (Benadryl) 50 mg in 1 mL of fluid.  You determine to administer 25 mg of the drug IM.  Describe how you will accomplish this.  Discuss sites for injection, considerations, and so forth.

51. Your patient has accidentally overdosed with Cardizem. You determine to administer 300 mg of a 10 percent solution of calcium chloride IV.  How many mL will you administer?

52. You are about to transfer a patient from one ICU to another. The patient has a 500 mL bag of NS hanging that reads: “1 g lidocaine added.”  What is the concentration per milliliter in this solution?

53. You are about to transfer a patient from one ICU to another. The patient has a 500 mL bag of NS hanging that reads: “800 mg dopamine added.”  The bag has 150 mL of fluid left in it.  What is the drug concentration of dopamine left in the bag in terms of mcg/mL?

54. You have made an epinephrine drip by mixing 1 mg of epinephrine 1:1000 into a 250 mL bag of normal saline. You want to administer an infusion of 2 mcg/min.  With a 60 gtt/mL administration set, how many gtt/min will you give?

55. Your patient has had recurring PVCs and your medical director has ordered a lidocaine bolus of 1.0 mg/kg. Your patient appears to weigh about 150 pounds.

1. How many mg of lidocaine will you administer?
2. Given a vial of lidocaine that contains 100 mg in 5 mL, how many mL will you give?
3. Following administration of this dose, the patient still has PVCs, so your online medical director orders a second dose of lidocaine at ½ the initial dose. How many mL will you give?

56. Your patient has just delivered a baby, but after uterine massage and placing the baby at the mother’s breast, she continues to bleed vaginally. You determine to give 10 units of oxytocin IM.  You have on hand a vial that contains 5 units/mL.  How many mL will you inject?

57. Your patient stopped taking his phenytoin three weeks ago because he ran out of money, but got his prescription filled yesterday. He began taking his daily prescribed dose again last night but had a seizure today.

1. what is the most likely cause of his seizure today?
2. What is a “loading dose?
3. Give 15/mg/kg of phenytoin (Dilantin) to a 220 pound patient. You have on hand vials containing 250 mg in 5 mL of solution.  What will your total loading dose be?
4. How many mL of phenytoin will you give to complete the loading dose?
5. Over what period of time will you administer the loading dose?

58. Your patient has injected an unknown quantity of supposed heroin. He is unresponsive.  His respirations are 6 per minute.  His pupils are pinpoint.  As you look at his arms to try to find an IV site, you see that his veins are damaged and sclerotic.

1. What alternative drug administration routes can you use for naloxone?
2. What is your goal in treating this patient?
3. How much naloxone will you use for this patient, and how will it be administered?

59. What drugs can be delivered by atomized intranasal mist? List as many as possible.

60. Relative to intranasal mist drug administration:
61. what are the advantages of IN administration?
62. what are the disadvantages of IN administration?

61. You are giving an IM injection to an adult patient. You determine to use the “Z-track” method.  Explain how to accomplish a Z-track injection.

62. For a seizing patient you determine to give midazolam 10 mg IM. It is supplied in a multidose vial containing 5mg per mL in 2 mL single dose vials. How many milliliters would you administer?

63. You wish to give fentanyl 50 mcg IV to a patient with a fracture of the patella. You have a 2 mL ampule containing 25 mcg/mL.

1. How many mL would you administer?
2. Over what time period will you administer the dose?
3. Your patient is in sustained, hemodynamically stable ventricular tachycardia. You wish to give amiodarone 150 mg over 3-5 minutes.  Your patient weighs 80 kg.  You have a vial containing 15 mg/mL of amiodarone.  How many mL will you administer?
4. You want to give 2 mg/kg of succinylcholine to a patient who weighs 150 pounds. The succinylcholine concentration is 20 mg/mL.  How many mL will you give?
5. After administering the succinylcholine in the above question and successfully intubating your patient, you want to give vecuronium to continue the patient’s paralytic state. You want to give 0.1 mg/kg based upon his weight as noted above in question 65.  Norcuron is supplied at 10 mg/2mL.  How many mL will you give?

67. You have mixed 4 mg of norepinephrine with 250 mL of D5W. What is the concentration of norepinephrine per mL in the bag?
68. You are infusing a dopamine solution at 30 gtt/min with a 60 gtt set. Your solution contains 800 mg dopamine in 500 mL of D5W.  The patient weighs 176 pounds.  How much dopamine per kg of body weight are you giving?
69. You are preparing to insert a nasogastric tube in an adult. What are the sizes that adult NG tubes come in?
70. Name two premedications that should be used before attempting to insert a NG tube.

a.

b.

71. Describe how to measure (a) a nasogastric tube and (b) an orogastric tube.

a.

2. Describe the process for confirmation of proper placement of an NG or OG tube
3. Your service requires that you mix your own dopamine drips using 400 mg of dopamine in 250 mL of Normal Saline. What is the concentration of this mixture?
4. Your patient was rescued from a fire in a small apartment and is suffering from burns to face and head and coughing up black sooty mucus. Medical direction directs that you administer a Cyanokit.
5. what drug is contained in a Cyanokit?
6. How much of the drug will you administer?
7. How will you administer it and over what period of time?

75. Which of the following is a depolarizing neuromuscular blocking agent?
76. rocuronium
77. vecuronium
78. pancuronium
79. succinylcholine

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