Paramedic exam prep: airway management, ACLS, trauma, and prehospital emergency care

Airway management hierarchy (prehospital): Basic (positioning, chin lift, jaw thrust, airway adjuncts — OPA, NPA) → Supraglottic airway (SGAs: laryngeal mask airway [LMA], King airway, i-gel) → Definitive airway (endotracheal intubation [ETI]).

Rapid Sequence Intubation (RSI): Drug-facilitated intubation. Sequence: preparation, preoxygenation, pretreatment (optional — lidocaine, atropine in specific situations), paralysis with induction (sedative + neuromuscular blocking agent), protection (Sellick manoeuvre — controversial), placement with proof (waveform capnography confirms ETT placement), post-intubation management. Common sedatives: ketamine (1–2 mg/kg IV — analgesic + dissociative, preferred in haemodynamically compromised), etomidate (0.3 mg/kg IV — haemodynamically neutral). NMBAs: succinylcholine (1.5 mg/kg IV — rapid onset 60 s, short duration 10–15 min; contraindicated in crush injury, burns, hyperK+) or rocuronium (1.2 mg/kg IV — onset 60 s, longer duration — reversed with sugammadex).

Waveform capnography: Gold standard for ETT placement confirmation AND ongoing monitoring during transport. Normal ETCO2: 35–45 mmHg. Increasing ETCO2 during CPR suggests improving cardiac output — good prognostic sign. Absence of waveform after intubation = oesophageal intubation until proven otherwise — remove tube immediately.

Adult cardiac arrest algorithm (AHA ACLS 2020): High-quality CPR (rate 100–120/min, depth 2–2.4 inches, full recoil, minimise interruptions <10s), defibrillation for shockable rhythms (VF/pulseless VT — biphasic 120–200 J; monophasic 360 J), vasopressors (epinephrine 1 mg IV q3–5 min for any rhythm; vasopressin 40 units can replace first or second epinephrine dose — removed from AHA 2020 algorithm), antiarrhythmics for VF/pVT refractory to 3 shocks (amiodarone 300 mg IV push, second dose 150 mg; or lidocaine 1–1.5 mg/kg).

Shockable vs. non-shockable rhythms: Shockable: VF (chaotic irregular baseline, no identifiable complexes), pulseless VT (wide complex tachycardia, no pulse). Non-shockable: PEA (organised ECG, no palpable pulse), Asystole (flatline).

STEMI recognition and prehospital management: 12-lead ECG in the field — ST elevation in ≥2 contiguous leads (limb leads ≥1 mm, precordial ≥2 mm). Transmit 12-lead to receiving facility. Aspirin 324 mg PO (chewable) unless allergy/active bleeding. IV access, supplemental O2 only if SpO2 <90%. Alert cath lab — door-to-balloon goal <90 minutes from hospital arrival; first-medical-contact-to-balloon <120 minutes.

ITLS/PHTLS primary survey (ABCDE + haemorrhage control): Simultaneous scene safety + mechanism of injury assessment. C-A-B-C (Circulation/haemorrhage control before Airway in exsanguinating haemorrhage): Control haemorrhage (tourniquet for extremity, wound packing, direct pressure), Airway (open/maintain), Breathing (ventilation, oxygen, chest decompression), Circulation (IV access, fluid management), Disability (GCS, pupils), Expose (full body assessment).

Haemorrhage control — prehospital: Direct pressure for all wounds. Tourniquet for extremity haemorrhage (CoTCCC/TCCC recommendation — apply high and tight, 2–3 inches above wound). Junctional tourniquet (JUNCTIONAL — SAM or COMBAT-T) for groin/axillary junctions. Wound packing with haemostatic gauze (QuikClot, Celox) for junctional wounds not amenable to tourniquet. Pelvic binder for pelvic fractures. Permissive hypotension for penetrating trauma (target SBP 80–90 mmHg) — avoid excessive fluids that dilute clotting factors.

Tension pneumothorax: Absent unilateral breath sounds + haemodynamic instability (hypotension, tachycardia, distended neck veins) + tracheal deviation (late sign). Prehospital management: needle decompression (2nd intercostal space, midclavicular line, or 4th–5th ICS anterior axillary line per TCCC — preferred) followed by chest seal or finger thoracostomy.