Category: Podcast

Host 2: Alright, welcome back. Today, abdominal pain in adults, paramedic side. And let's be honest, belly pain is one of the most common calls we run, and one of the easiest to get lazy on.

Host 1: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 2: This is education, not medical direction. Follow your local protocols.

Host 1: So here's the plan. We'll start with the stuff you do on every one of these calls, BLS first, then ALS. Then we'll run through the conditions the Registry likes to test. Gallbladder, pancreas, ectopic pregnancy, Crohn's, Cullen's and Grey Turner's signs, kidney stones, hepatitis, peptic ulcers, and diverticulitis.

Host 2: And the big rule today. BLS before ALS. Every time. As a paramedic, you start with basic life support. Scene safety, B S I, primary assessment, airway, breathing, circulation. Then you add the advanced stuff.

Host 1: And on abdominal calls, B S I is not a throwaway line. Vomit, diarrhea, blood. Gloves at minimum, and eye protection if anybody is vomiting.

Host 2: So walk in, general impression. How is the patient lying? That alone tells you a ton.

Host 1: Patient lying perfectly still, knees pulled up, afraid to move? Think peritonitis. Something is irritating the lining of the abdomen, and every movement hurts.

Host 2: Patient who can't sit still, writhing, pacing, can't get comfortable? Think colic. Kidney stone is the classic.

Host 1: Then the primary. Airway first, especially if they're vomiting. Have suction ready. Breathing, and if they're hypoxic, give oxygen per your protocol. Circulation, and that's where you're hunting for shock. Skin color, temperature, moisture, heart rate, cap refill, mental status.

Host 2: Position of comfort for most of these. If they're showing signs of shock, lay them flat. If they're vomiting with a decreased level of consciousness, get them on their side so they don't aspirate.

Host 1: Nothing by mouth. These patients may be going to surgery.

Host 2: Then the history. OPQRST for the pain. SAMPLE. And for every woman of childbearing age, ask about her last menstrual period and the chance of pregnancy. Every one. No exceptions.

Host 1: Gentle palpation of all four quadrants, and you palpate the painful area last. You're looking for tenderness, guarding, rigidity, distension, and a pulsating mass. If you feel a pulsating mass, stop pressing.

Host 2: Now ALS. IV access. Cardiac monitor. And get a twelve-lead on the older patient with epigastric pain, especially diabetics, women, and the elderly, because an inferior MI can show up as a bellyache.

Host 1: Check a blood glucose. Fluids if they're hypotensive or showing signs of shock, per protocol. For suspected internal bleeding, a lot of systems titrate fluids to perfusion, like a radial pulse and mentation, rather than chasing a normal blood pressure. Pain management and antiemetics per your protocol. And reassess.

Host 2: Okay. Now the conditions. Let's start with the gallbladder. Cholecystitis.

Host 1: Inflamed gallbladder, usually from a gallstone blocking the outflow. Classic presentation is right upper quadrant pain, sometimes epigastric, often after a fatty or greasy meal. Nausea and vomiting. Fever if it's infected.

Host 2: And the referred pain is the test question. Gallbladder pain classically refers to the right shoulder, the right scapula, or that spot between the shoulder blades.

Host 1: And then Murphy's sign. You press on the right upper quadrant, under the rib margin, and have the patient take a deep breath. As the gallbladder moves down and hits your fingers, they catch their breath and stop inhaling because it hurts. That's a positive Murphy's sign.

Host 2: You'll also hear the old mnemonic, female, forty, fertile, and fat. Know it for the test, but don't let it blind you. Men, thin people, and young people get gallstones too.

Host 1: Now, here's a judgment call worth getting right. A lot of people mix up Kehr's sign with gallbladder pain. Kehr's sign, K E H R, is pain in the left shoulder. It comes from blood or irritation under the left side of the diaphragm, and the classic cause is a ruptured spleen.

Host 2: It can also show up with a ruptured ectopic pregnancy, when blood in the abdomen irritates the diaphragm. So Kehr's sign is left shoulder, and it's a red flag for bleeding. Gallbladder is right shoulder and between the scapulae.

Host 1: Next. Pancreatitis. Inflamed pancreas.

Host 2: Severe epigastric pain that often bores straight through to the back. Nausea and vomiting, sometimes a lot. The patient might be leaning forward or curled up with their knees to their chest, because lying flat makes it worse.

Host 1: The two big causes you'll see on the exam are alcohol and gallstones. And severe pancreatitis can make the patient really sick. Fluid shifts, shock, and in the hemorrhagic form, bleeding into the retroperitoneum.

Host 2: Which takes us right into Cullen's sign and Grey Turner's sign.

Host 1: Cullen's sign is bruising around the umbilicus, the belly button. Grey Turner's sign is bruising on the flanks.

Host 2: Memory trick. Cullen, C for center. Grey Turner, you have to turn the patient to see the flanks.

Host 1: Both point to bleeding in the abdomen or retroperitoneum. Hemorrhagic pancreatitis, ruptured ectopic pregnancy, ruptured abdominal aortic aneurysm, trauma.

Host 2: And the catch is these are usually late signs. They can take hours to days to develop. So if you don't see them, it doesn't rule anything out. If you do see them, that patient needs your attention.

Host 1: Next. Ectopic pregnancy.

Host 2: A fertilized egg implants outside the uterus, most often in a fallopian tube. As it grows, the tube can rupture, and that can cause life-threatening internal bleeding.

Host 1: Classic picture. Woman of childbearing age, missed or late period, sudden one-sided lower abdominal pain, and maybe some vaginal bleeding, which can be light or absent. Signs of shock if it's ruptured. And that left shoulder pain, Kehr's sign, if blood is irritating the diaphragm.

Host 2: She might not know she's pregnant. That's why you always ask about the last period.

Host 1: Treatment is hemorrhagic shock care. BLS first. Lay her flat, keep her warm, oxygen if hypoxic per protocol. Then ALS, I V access, fluids titrated per protocol, and rapid transport to a facility that can take her to surgery.

Host 2: Next. Crohn's disease.

Host 1: Crohn's is a chronic inflammatory bowel disease. It can affect any part of the G I tract, from the mouth to the anus, but it classically hits the end of the small intestine, the terminal ileum.

Host 2: So you can get right lower quadrant pain that looks a lot like appendicitis. Plus cramping, chronic diarrhea, sometimes bloody, weight loss, fatigue, and fever during a flare.

Host 1: And the patient usually knows they have it. What you're worried about on scene is the complications. Dehydration from all that diarrhea, bowel obstruction, abscess, and fistulas.

Host 2: And the comparison the exam may throw at you is ulcerative colitis. U C is limited to the colon and is known for bloody diarrhea. Crohn's can be anywhere in the tract.

Host 1: Next. Kidney stones.

Host 2: Sudden, severe flank pain that comes in waves and radiates down toward the groin. Nausea and vomiting. Blood in the urine. And that restless patient who can't find a comfortable position.

Host 1: And here's the paramedic-level catch. Older patient, first-ever kidney stone, especially with a history of hypertension or vascular disease? Think about an abdominal aortic aneurysm. A leaking triple A can look exactly like a kidney stone. Check pulses, check pressures, and look for that pulsating mass.

Host 2: Next. Hepatitis.

Host 1: Inflammation of the liver. Viral causes are the big ones for the test, plus alcohol and medications like acetaminophen in overdose.

Host 2: Signs and symptoms. Right upper quadrant pain or tenderness. Jaundice, yellow skin and yellow sclera. Dark urine. Clay-colored or pale stools. Fatigue, nausea, loss of appetite, and sometimes fever.

Host 1: And the scene safety part. Hepatitis A spreads mainly by the fecal-oral route. Hepatitis B and C spread through blood and body fluids. So B S I, sharps safety, and make sure your hepatitis B vaccination is current.

Host 2: Next. Peptic ulcers.

Host 1: An erosion in the lining of the stomach or the first part of the small intestine, the duodenum. The two big causes are H. pylori bacteria and NSAIDs, like ibuprofen and aspirin.

Host 2: Classic complaint is a burning or gnawing epigastric pain. The textbook teaching is that duodenal ulcer pain often gets better with food and comes back a couple hours later, and gastric ulcer pain can get worse with eating.

Host 1: The complications are what get you. G I bleeding, so ask about vomiting blood, coffee-ground emesis, and black, tarry stools, which we call melena. And perforation. Sudden, severe pain, and a rigid, board-like abdomen. That's peritonitis, and that's a surgical emergency.

Host 2: Next. Diverticulitis.

Host 1: Diverticula are little pouches in the wall of the colon. When they get inflamed or infected, that's diverticulitis. It's more common in older adults.

Host 2: Classic presentation is left lower quadrant pain. Some people call it left-sided appendicitis. Fever, nausea, and a change in bowel habits, constipation or diarrhea.

Host 1: And the related thing to know is diverticular bleeding, which can cause a lot of painless, bright red blood from the rectum. If there's enough of it, you've got a shock patient.

Host 2: Okay, let's wrap it. On every abdominal call, BLS first. Scene safety and B S I. Airway, especially with vomiting. Breathing, with oxygen if hypoxic. Circulation, and look hard for shock. Position of comfort, nothing by mouth.

Host 1: Then ALS. I V, monitor, twelve-lead when the heart could be the cause, glucose, fluids for shock, and pain and nausea management per protocol.

Host 2: And for the exam. Right shoulder and between the scapulae, think gallbladder. Left shoulder, Kehr's sign, think blood under the diaphragm, like a spleen or a ruptured ectopic. Murphy's sign is the gallbladder breath-catch. Cullen's is the belly button, Grey Turner's is the flanks. Pancreatitis bores to the back. Kidney stones writhe. Peritonitis lies still.

Host 1: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 2: This is education, not medical direction. Follow your local protocols. Stay safe out there.

Host 1: Hey, welcome back. Today is abdominal pain in adults, EMT side. This is the basic life support version, so no IVs, no ALS meds. Just what you do as an EMT, and what the National Registry expects you to do.

Host 2: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 1: This is education, not medical direction. Follow your local protocols.

Host 2: And here's the good news for EMTs. You don't have to diagnose the belly. Nobody expects you to tell gallbladder from pancreas in the back of the ambulance. Your job is to recognize a sick patient, treat what you can, and get them to the right hospital.

Host 1: Right. The Registry is testing whether you can spot shock, protect the airway, keep the patient comfortable, and not delay transport.

Host 2: So let's walk the call. Scene size-up first. Scene safety and B S I. With belly pain, you're dealing with vomit, diarrhea, and sometimes blood. Gloves at minimum. Eye protection and a mask if they're vomiting.

Host 1: And look around. Buckets, vomit, medication bottles, alcohol, blood in the toilet. The scene tells you a story.

Host 2: Then the general impression, and this is where your eyes do a lot of work. How is the patient lying?

Host 1: Lying very still, knees pulled up, guarding the belly, scared to move? That's often irritation of the abdominal lining, like peritonitis. Moving hurts.

Host 2: Restless, rolling around, can't get comfortable? That's more like colic, kidney stone being the classic example.

Host 1: Now the visual signs. Skin first. Pale, cool, clammy skin is a shock sign until proven otherwise. Yellow skin or yellow eyes is jaundice, which points to the liver.

Host 2: Look at the abdomen itself. Is it distended, swollen? Any bruising? Bruising around the belly button or on the flanks can mean bleeding inside the abdomen. Those are called Cullen's sign and Grey Turner's sign, and you just report what you see.

Host 1: Look at what's come out. Vomit that looks like coffee grounds is old, partially digested blood. Bright red blood is active bleeding. Black, tarry stool, if the patient tells you about it, is also a sign of bleeding higher up in the G I tract.

Host 2: Then the primary assessment. Airway first. And on these calls, the airway hazard is vomiting. A patient who's vomiting with a decreased level of consciousness can aspirate.

Host 1: So have suction ready. Literally, set it up and turn it on before you need it. If they're vomiting and not fully alert, put them on their side, in the recovery position, so the vomit drains out instead of going down into the lungs.

Host 2: Breathing. Look at the rate and the effort. Give oxygen if they're hypoxic or showing signs of shock, per your protocol.

Host 1: Circulation. Pulse rate and quality, skin, and cap refill. And now you're asking the big question. Is this patient in shock?

Host 2: Early shock signs. Fast heart rate. Anxiety, restlessness. Pale, cool, sweaty skin. Thirst. Delayed cap refill. The blood pressure can still look normal early, so don't wait for it to drop.

Host 1: Late shock signs. Falling blood pressure. Altered mental status. Weak or absent radial pulses.

Host 2: And treating shock as an EMT. Lay them flat. Keep them warm, put a blanket on them, even if the room feels warm. Give oxygen per protocol. Nothing by mouth. Request ALS per your protocol. And rapid transport.

Host 1: Some protocols let you raise the legs a little if there's no trauma. That's a local protocol call. And no Trendelenburg, the old tilt-the-whole-stretcher position.

Host 2: Now, if they're not in shock, position of comfort. Most belly pain patients want to lie on their side or on their back with their knees bent. Let them. That's one of your best pain management tools.

Host 1: Now the history. OPQRST for the pain. Onset, provocation, quality, region and radiation, severity, and time. Then SAMPLE.

Host 2: And for any woman of childbearing age, ask about her last menstrual period and the chance she could be pregnant. Belly pain plus a missed period plus signs of shock, think ectopic pregnancy, and that's a rapid transport.

Host 1: Then the physical exam. Gently palpate all four quadrants, and save the painful one for last. If you press the painful area first, they'll guard everywhere and you won't learn anything.

Host 2: Feel for tenderness, rigidity, and distension. If you feel a pulsating mass, stop. Don't keep pressing on it. That could be an abdominal aortic aneurysm, and that's a load and go patient.

Host 1: Now let's talk about dehydration, because a lot of belly pain patients have been vomiting or having diarrhea for hours or days.

Host 2: Signs of dehydration. Dry mouth and dry mucous membranes. Poor skin turgor. Fast heart rate. Dizziness or lightheadedness, especially when they stand up. Not peeing much. And in older adults, confusion can be the main sign.

Host 1: And dehydration can turn into shock, especially in the very old and the very young. So the same rules apply. Watch the vitals, treat for shock, nothing by mouth.

Host 2: Diarrhea and vomiting also mean infection control. Some bugs, like C. diff, aren't killed well by alcohol hand gel. Soap and water after the call. And clean your stretcher and your ambulance per your agency's policy.

Host 1: Okay, pain management within EMT scope. This is a common test question, and the answer is not a medication.

Host 2: Right. In the National EMS Scope of Practice, EMTs aren't giving pain medication for this. Your pain management tools are position of comfort, a calm voice, reassurance, explaining what you're doing, coaching their breathing, a smooth ride, and getting them to definitive care.

Host 1: If your state or agency adds something to your scope, that's local protocol. For the Registry, think non-medication comfort measures and transport.

Host 2: And rate their pain on a zero to ten scale. Document it, and reassess. A good rule is reassessing vitals every five minutes for an unstable patient and every fifteen for a stable one.

Host 1: One more red flag. Upper belly pain or indigestion in an older patient, a diabetic, or a woman can be a heart attack. If it sounds cardiac, follow your chest pain protocol.

Host 1: Let's do a quick practice scenario, Registry style. You're called to a twenty-eight-year-old woman with sudden lower abdominal pain on her right side. She's pale, sweaty, and anxious. Her heart rate is one-twenty, and her pressure is still normal. She says her period is late. What do you do first?

Host 2: First, don't get distracted by the normal pressure. She's tachycardic, pale, and sweaty. That's early shock. And belly pain with a late period, you think ectopic pregnancy.

Host 1: So, primary assessment, airway and breathing, oxygen per protocol. Lay her flat, keep her warm, nothing by mouth. Request ALS per protocol, and rapid transport. Reassess every five minutes.

Host 2: And notice what's not in that answer. You're not spending ten minutes on scene doing a detailed exam. The Registry wants you moving.

Host 2: Alright, the quick EMT recap. Scene safety and B S I. Read how they're lying. Look for shock, and remember the pressure drops late. Protect the airway, suction ready, recovery position if they're vomiting and not alert. Oxygen per protocol. Treat shock. Lay them flat, keep them warm, nothing by mouth. Position of comfort if they're stable. Ask every woman of childbearing age about pregnancy. Palpate gently, painful area last, and don't push on a pulsating mass. Watch for dehydration. And rapid transport for anybody who looks sick.

Host 1: You don't need a diagnosis to save this patient. You need good BLS.

Host 2: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 1: This is education, not medical direction. Follow your local protocols. Take care of each other out there.

Host 1: Welcome back. Today is all about dosages. The top ten most common dosages you absolutely have to know for the National Registry exam, plus three that people frequently forget.

Host 2: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 1: This is education, not medical direction. Follow your local protocols.

Host 2: And that matters more today than any other episode, because doses are exactly where your local protocol can be different from the textbook. So here's how we're doing it. When we say AHA, that's the 2025 American Heart Association guidelines, ACLS and PALS. When AHA doesn't give a dose, we'll fall back on the National Model EMS Clinical Guidelines or standard National Registry level teaching, and we'll tell you when we're doing that.

Host 1: Perfect. Let's go. Number one. Epinephrine in adult cardiac arrest.

Host 2: AHA says one milligram IV or IO, every three to five minutes. That's the one milligram per ten milliliter concentration, point one milligrams per mL.

Host 1: And the timing question. For a non-shockable rhythm, asystole or P E A, AHA says give epi as soon as possible. For a shockable rhythm, V fib or pulseless V tach, you prioritize defibrillation, and epi comes after the initial shocks haven't worked.

Host 2: And the trap here is concentration. Your arrest epi is the point one milligram per mL. The one milligram per mL concentration is what you use for IM in anaphylaxis. Mixing those up is a dangerous error, and the exam knows it.

Host 1: Number two. Amiodarone in arrest.

Host 2: AHA says first dose three hundred milligrams IV or IO bolus. Second dose one-fifty.

Host 1: And that's for V fib or pulseless V tach that doesn't respond to defibrillation. Not asystole. Not P E A.

Host 2: And while we're on amiodarone, the stable wide complex tachycardia dose is different. AHA says one-fifty milligrams over ten minutes, repeat as needed if V tach recurs. So three hundred is the arrest dose, one-fifty slow is the pulse dose.

Host 1: Number three. Adenosine.

Host 2: AHA says six milligrams rapid IV push, follow it with a normal saline flush. If that doesn't work, twelve milligrams.

Host 1: And the technique is part of the question. Rapid push, as close to the heart as you can get, usually an antecubital vein, followed immediately by a flush. Adenosine has a very short half-life, so if you push it slowly, it's gone before it gets there.

Host 2: And warn your patient. That feeling of impending doom for a few seconds is normal. And remember from the stumpers episode, adenosine is for regular, narrow complex rhythms, and for a regular monomorphic wide rhythm. Not for an irregular, wide, very fast rhythm that could be pre-excited A fib.

Host 1: Number four. Atropine for symptomatic bradycardia.

Host 2: AHA says first dose one milligram IV bolus. Repeat every three to five minutes, maximum total dose three milligrams.

Host 1: And that's a change people miss. Older materials said point five milligrams. The current AHA dose is one milligram.

Host 2: And atropine might not work in some patients, like heart transplant patients or high-degree blocks. If it doesn't work, AHA says move to transcutaneous pacing or an infusion, which we'll hit in the forgotten section.

Host 1: Number five. Epinephrine for anaphylaxis.

Host 2: This is IM, into the lateral thigh, using the one milligram per mL concentration. The standard weight-based dose is point zero one milligrams per kilogram. Maximum single dose is point five milligrams for an adult, and point three milligrams for a child. That dosing comes from standard anaphylaxis guidance like the National Model EMS Clinical Guidelines.

Host 1: And the auto-injectors are point three milligrams for adults and point one-five for smaller children.

Host 2: And if the patient isn't improving, the dose can be repeated, commonly in about five to fifteen minutes, per your protocol. Don't hold epi in anaphylaxis because you're worried about the heart rate. It's the first-line drug.

Host 1: Number six. Aspirin for suspected acute coronary syndrome.

Host 2: AHA says one-sixty-two to three-twenty-five milligrams, non-enteric coated, chewed. A lot of systems use four baby aspirin, which is three-twenty-four milligrams.

Host 1: And the reason for chewing is speed. It gets absorbed faster. The contraindications to watch for are a true aspirin allergy and active bleeding, per your protocol.

Host 2: Number seven. Nitroglycerin.

Host 1: Point four milligrams sublingual, tablet or spray. Repeat every five minutes, up to three doses, if the pain continues and the pressure holds.

Host 2: And the holds are the real test question. Systolic under ninety, or a big drop from baseline, commonly thirty or more below. A suspected right ventricular infarct. And phosphodiesterase inhibitors. Sildenafil or vardenafil in the last twenty-four hours, tadalafil in the last forty-eight.

Host 1: Number eight. Glucose and dextrose for hypoglycemia.

Host 2: For a patient who's awake and can swallow, AHA first aid guidance says about fifteen to twenty grams of oral glucose.

Host 1: And for the patient who can't swallow safely, it's IV dextrose. The AHA doesn't print a prehospital dextrose dose, so this is protocol territory. A very common adult dose is twenty-five grams, which is fifty mL of D fifty, or two-fifty mL of D ten, often given in smaller increments and rechecked.

Host 2: Recheck the glucose after you treat it. And watch that IV site. Dextrose that leaks out of the vein can damage tissue, which is one reason a lot of systems moved to D ten.

Host 1: Number nine. Naloxone.

Host 2: AHA doesn't give an exact naloxone dose either, so here we lean on the National Model EMS Clinical Guidelines. Point four to two milligrams IV, IM, or intranasal, and the intranasal devices are commonly four milligrams.

Host 1: And the goal is the part that gets tested. You titrate to adequate breathing. Not to waking them up swinging.

Host 2: And BLS before ALS again. If they're not breathing well, you bag them first. AHA says for suspected opioid overdose with a pulse but abnormal breathing, support ventilation, and naloxone is reasonable. If they're in cardiac arrest, high quality CPR comes first, and naloxone does not replace it.

Host 1: Number ten. Pediatric cardiac arrest drugs.

Host 2: AHA PALS says epinephrine point zero one milligrams per kilogram IV or IO. That's point one mL per kilogram of the point one milligram per mL concentration. Maximum single dose one milligram. Every three to five minutes.

Host 1: And amiodarone for shock-refractory V fib or pulseless V tach in kids is five milligrams per kilogram bolus, and it can be repeated up to three total doses. Lidocaine is the alternative, one milligram per kilogram.

Host 2: And the energy, even though it's not a drug, always comes up with these. AHA says first shock two joules per kilogram, second shock four joules per kilogram, and subsequent shocks four or more, up to ten joules per kilogram or the adult dose.

Host 1: Okay. The three frequently forgotten dosages. Forgotten number one. Lidocaine in adult arrest.

Host 2: People memorize amiodarone and forget lidocaine is right there in the same AHA box as the alternative. First dose one to one and a half milligrams per kilogram. Second dose point five to point seven-five milligrams per kilogram.

Host 1: Forgotten number two. Pediatric adenosine.

Host 2: AHA says point one milligram per kilogram rapid push, maximum first dose six milligrams. Second dose point two milligrams per kilogram, maximum twelve. Same rapid push and flush technique.

Host 1: And notice the maximums are just the adult doses. That's an easy way to remember it.

Host 2: Forgotten number three. The bradycardia infusions. When atropine fails.

Host 1: AHA says dopamine at five to twenty micrograms per kilogram per minute, or epinephrine at two to ten micrograms per minute. Titrate to the patient's response.

Host 2: And the trick is the units. Dopamine is weight based. Micrograms per kilogram per minute. Epi infusion for bradycardia is not weight based in adults. It's just micrograms per minute. The exam loves to swap those.

Host 1: Alright, let's run it back fast. Arrest epi, one milligram every three to five. Amio, three hundred then one-fifty. Adenosine, six then twelve. Atropine, one milligram, max three. Anaphylaxis epi, point zero one per kilo IM, max point five adult. Aspirin, one-sixty-two to three-twenty-five chewed. Nitro, point four every five, up to three. Oral glucose fifteen to twenty grams. Naloxone, titrate to breathing. And peds epi, point zero one per kilo.

Host 2: Plus lidocaine, peds adenosine, and the bradycardia infusions.

Host 1: And one last time. Your local protocols and your medical director decide what you actually give in the field. Know the AHA numbers for the test, and know your protocol book for the street.

Host 2: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 1: This is education, not medical direction. Follow your local protocols. See you next time.

Host 2: Alright, welcome in. Today we're doing one that I get asked about constantly. The top ten questions that frequently stump paramedics on the National Registry exam.

Host 1: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 2: And quick ground rule before we start. This is education, not medical direction. Follow your local protocols.

Host 1: And one more thing to be upfront about. The Registry doesn't publish a list of its most-missed questions. So what we're covering today are the concept areas that candidates and instructors commonly report as stumbling points. Not official data. Just the stuff that trips people up, over and over.

Host 2: Yeah. And honestly, most of these aren't about knowing some obscure fact. They're about thinking in the right order. The Registry loves asking, what do you do next? Not, what do you eventually do.

Host 1: Right. So keep that in your head the whole episode. Next best step. Okay, number one.

Host 2: Number one. Stable versus unstable. You get a patient with a fast rhythm, and the question is really asking, is this rhythm the reason the patient is in trouble?

Host 1: And the AHA gives you the signs to look for. Hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, and acute heart failure.

Host 2: If the tachycardia is causing those, the patient is unstable, and the answer is synchronized cardioversion. Not adenosine. Not another drug while they crash.

Host 1: The trap is that the stem gives you a regular narrow complex rhythm at, say, one-eighty, and you see adenosine in the answers and you just grab it.

Host 2: Exactly. Read the vitals first. If the pressure is in the toilet and they're confused, that's cardioversion. If they're talking to you, warm, with a decent pressure, that's when vagal maneuvers and adenosine come into play for a regular narrow rhythm.

Host 1: And one nuance. The AHA does say you can consider adenosine for a regular narrow complex rhythm while you're getting ready to cardiovert, but it should never delay the shock. Okay, number two.

Host 2: Number two. BLS before ALS. This one gets people who are really proud of their new drug box.

Host 1: Ha. We've all been there.

Host 2: The question gives you a patient who's hypoxic, maybe a kid with a slow heart rate, and the answer choices are atropine, epinephrine, pacing, and, quote, ensure adequate oxygenation and ventilation.

Host 1: And the oxygenation answer is right more often than people expect. In kids especially, bradycardia is usually a hypoxia problem. Fix the airway and the breathing, and the heart rate often comes right back up.

Host 2: And for the pediatric rule, the AHA says if a child's heart rate is under sixty with signs of poor perfusion despite oxygenation and ventilation, you start CPR.

Host 1: So the order is airway, breathing, then drugs. The monitor doesn't get to skip the line.

Host 2: Number three. Shock that hasn't dropped the blood pressure yet. Compensated shock.

Host 1: This is a big one. People wait for hypotension to call it shock. But by the time an adult's pressure drops, they've already burned through a lot of their compensation.

Host 2: So you're looking for the early stuff. Tachycardia. Anxiety or restlessness. Pale, cool, clammy skin. Delayed capillary refill, especially in kids. Narrowing pulse pressure.

Host 1: And in kids, hypotension is a late, scary sign. The PALS definition of hypotension for kids one to ten years old is a systolic pressure under seventy plus two times the age in years. So a four-year-old under seventy-eight is hypotensive.

Host 2: And for infants, one month to one year, it's under seventy. Over ten years, under ninety.

Host 1: If a question has a tachycardic, anxious kid with a normal pressure and delayed cap refill, that's compensated shock, and you treat it like shock.

Host 2: Number four. The right ventricular infarct. The inferior STEMI trap.

Host 1: Okay, I love this one.

Host 2: You get ST elevation in leads two, three, and aVF. That's the inferior wall. The question then says, the patient is having chest pain, what do you do? And nitroglycerin is sitting right there in the choices.

Host 1: And the right answer is often, get a right-sided twelve-lead first. Look at V4R.

Host 2: Because if the right ventricle is involved, that patient is preload dependent. They need volume in the tank to push blood forward. Nitro drops preload, and their pressure can fall off a cliff.

Host 1: So the classic picture is inferior STEMI, hypotension, clear lungs, maybe JVD. That's your right-sided MI. Careful with nitrates, and fluids may be part of the plan per protocol.

Host 2: Number five. The triad mix-up. Beck's versus Cushing's.

Host 1: This one is pure memory, but people swap them all the time.

Host 2: Beck's triad is cardiac tamponade. Hypotension, J V D, and muffled heart sounds. Think heart, because Beck sounds like beat.

Host 1: And Cushing's triad is increased intracranial pressure. Hypertension with a widening pulse pressure, bradycardia, and irregular respirations.

Host 2: So one triad has the pressure going down, the other has it going up. If the stem gives you a head injury with a climbing pressure and a dropping heart rate, that's Cushing's, and that brain is in serious trouble.

Host 1: And while we're in trauma, tension pneumothorax gets mixed in. Absent breath sounds on one side, worsening respiratory distress, hypotension, J V D, and tracheal deviation as a late sign. The fix there is needle decompression per your protocol.

Host 2: Number six. Acid-base. The ABG questions.

Host 1: People freeze on these. But you can do it in three steps.

Host 2: Step one, look at the pH. Normal is seven-thirty-five to seven-forty-five. Under seven-thirty-five is acidosis, over seven-forty-five is alkalosis.

Host 1: Step two, look at the carbon dioxide. Normal is thirty-five to forty-five. C O two is an acid. If the pH is low and the C O two is high, it's respiratory acidosis. Think of a patient who isn't breathing enough, like an opioid overdose or C O P D.

Host 2: Step three, look at the bicarb. Normal is twenty-two to twenty-six. Bicarb is a base. If the pH is low and the bicarb is low, it's metabolic acidosis. Think D K A, sepsis, lactic acid.

Host 1: And the memory trick a lot of people use is ROME. Respiratory opposite, metabolic equal. In respiratory problems, the pH and C O two move in opposite directions. In metabolic problems, the pH and bicarb move in the same direction.

Host 2: And the one that trips people up clinically is Kussmaul breathing in D K A. That deep, fast breathing is the patient blowing off C O two to compensate. If you take over that airway and ventilate them slower than they were breathing, you can make the acidosis worse.

Host 1: Number seven. Hyperkalemia on the ECG.

Host 2: Peaked T waves first. Then as it gets worse, the P waves flatten out, the P R gets longer, and the Q R S widens. Eventually you can get that sine wave pattern, and then arrest.

Host 1: And who's the patient? Dialysis patient who missed a session. Renal failure. Crush injury. Some medications.

Host 2: The question will give you a dialysis patient who's weak with tall, tented T waves and wide Q R S complexes. Recognize it. And then the treatment, per your protocols, is aimed at stabilizing the heart and shifting potassium, which is where calcium, sodium bicarbonate, and albuterol come up.

Host 1: Number eight. Drug contraindications hiding in the history.

Host 2: The answer isn't the drug. The answer is the reason you don't give the drug.

Host 1: Two classics. Nitroglycerin and erectile dysfunction drugs. If the patient took sildenafil or vardenafil in the last twenty-four hours, or tadalafil in the last forty-eight, nitro can cause profound hypotension.

Host 2: And the other one, adenosine and A V nodal blockers in an irregular, wide, really fast rhythm. That's the possible pre-excited atrial fibrillation, W P W picture. The AHA specifically says to avoid adenosine and A V nodal blockers there, because blocking the node can push conduction down the accessory pathway.

Host 1: So read the med list in the stem. It's there for a reason.

Host 2: Number nine. Airway confirmation and E T C O two.

Host 1: The Registry wants you to know that continuous waveform capnography is the way to confirm and monitor tube placement. Not just listening to breath sounds. Not just fogging in the tube.

Host 2: And during CPR, the AHA says waveform capnography can help you monitor CPR quality. If the E T C O two is low or dropping, reassess your compressions. And a sudden jump in E T C O two can be an early sign of return of spontaneous circulation.

Host 1: And a flat line on the waveform right after you intubate, assume the tube is out until proven otherwise.

Host 2: Number ten. Triage. Operations questions are where good clinical people lose easy points.

Host 1: In START triage, anyone who can walk goes green, minor. Then you check respirations. Not breathing after you reposition the airway, that's black, deceased or expectant. Breathing over thirty a minute, that's red, immediate.

Host 2: Then perfusion. A radial pulse that's absent or a cap refill over two seconds, red. Then mental status. Can't follow simple commands, red. If they pass all of that, they're yellow, delayed.

Host 1: The trap is that people want to stop and treat during triage. The only things you do in START are quick ones, like opening the airway and controlling major bleeding.

Host 2: Okay, quick recap. Stable versus unstable. BLS before ALS. Compensated shock. The right-sided MI. Beck's versus Cushing's. Acid-base. Hyperkalemia. Contraindications in the history. Capnography. And triage.

Host 1: And the theme through all of them is the same. Assess first, fix the basics, then advance. Read every vital sign and every line of history in that question.

Host 2: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 1: This is education, not medical direction. Follow your local protocols. Go crush that exam.