# NEED HELP! scenario question



## leyvabre (Aug 21, 2015)

Hey everyone, I'm new to this site and EMT class as well. I need some clarification on the following scenario:
25 year old man found unresponsive in the forest by two hikers. He's lying on the ground supine with a liquor bottle nearby. Temp outside is 30F and he's in a tshirt and jeans. After establishing unresponsive what should your next step in patient management be?
A. C spine
B. Open airway
C. Check pulse
D. Measure core body temp

My instructor told me when I'm doubt, follow the sheet. Since the patient is unresponsive, and a cervical injury is unknown would the answer be to take c spine precautions since it is also first on the sheet? Would it be airway because airway is always priority? Would it be pulse because he could possibly be in cardiac arrest? Feedback is much appreciated and any tips on how to better determine treatment in questions like this would be amazing as well. Thank you!


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## EMT11KDL (Aug 21, 2015)

Testing- C-spine would be first.  

Now real life, I would consider c-spine and I would do this by limiting the movement of the patient neck and back, and once I kneel next to the patient I will check to make sure he is unresponsive while also checking for a pulse and visualizing the chest for movement. When you are doing your assessment on a patient you will learn how to check multiple things at once and it just takes practice and time to find how to preform an assessment that works for you.


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## leyvabre (Aug 21, 2015)

Okay one more question. Is it c-spine because he is unresponsive and a spinal injury is unknown? Because all patients in cardiac arrest are unresponsive and on the skill sheet for CPR c spine isn't even a consideration. That's where my confusion is coming from and it's driving me insane.


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## teedubbyaw (Aug 21, 2015)

Stupid question.


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## Fleury14 (Aug 21, 2015)

Given that exact question I'd check the pulse first.


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## DesertMedic66 (Aug 21, 2015)

Just saying that c-spine precautions are going to do squat if your patient doesn't have a pulse...


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## Gurby (Aug 21, 2015)

Check for a pulse.  The answer is absolutely *not* test C-spine.  That's ridiculous.  

What does "follow the sheet" mean?  What sheet is he talking about?  He definitely doesn't mean just pick the first answer, and if he does mean that then you should just ignore him from here on out.

Airway is not always priority.  In an unresponsive patient, ABC gets switched around to CAB.  Circulating blood to the brain is more important than moving air in and out, so we need to make sure they have a pulse before we do anything else.


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## Akulahawk (Aug 22, 2015)

leyvabre said:


> Hey everyone, I'm new to this site and EMT class as well. I need some clarification on the following scenario:
> 25 year old man found unresponsive in the forest by two hikers. He's lying on the ground supine with a liquor bottle nearby. Temp outside is 30F and he's in a tshirt and jeans. After establishing unresponsive what should your next step in patient management be?
> A. C spine
> B. Open airway
> ...


I would say that the question is relatively stupid. The question is aimed at the lay rescuer, not the EMT. As such, the correct answer would probably be to check circulation first. As we know, recently CPR was changed to CAB instead of ABC for the unresponsive patient. If the patient does not have a pulse, then the fact that the neck is broken is kind of moot. And the assessment of such is beyond the skill of the typical lay rescuer.


In real life, what I probably would do if both hikers were EMT or better trained, I probably would start with immediate C-spine control and airway management along with checking for a pulse. Real world is very different from the test, because the test requires more linear thinking and real world is more parallel tasks put together.

Given the level of the question, I'd choose answer C.


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## SeeNoMore (Aug 22, 2015)

So one thing to consider : the question seems to assume you have established the patient is unresponsive. Presumably this means you have already made some provision for possible cervical injuries (like not kicking him in the head as you rush over to help?). If that is the case you would check a pulse next. I don't know if that's the direction the question is meant to take you. Generally C-Spine precautions are the first thing you do after scene safety / BSI for EMT testing.


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## EBMEMT (Aug 22, 2015)

That is a lousy test question, which is unfortunately very common.

Key words: "After establishing unresponsive" and "next step".   In this type of test question, this is critical as it tells you where on the sheet you are.   You don't want to pick the first step, you want to pick the next step.     In this case, it means that if you are following your sheet, you are on step 2 of  the primary assessment.   "Consider c-spine" is part of the scene size up which is done before checking for responsiveness.    So, your next steps would be:

Determine Chief Complaint/Apparent Life threats
Assess airway
Initiate appropriate O2 therapy/appropriate adjunct
insure adequate ventillation
Assess/control major bleeding if present
Assess pulse
Assess skin/color/temperature
Technically, the  three remaining answers could come under apparent life threats.  But apparent life threats is more of a visual/cognitive than a hands on step and the testers also may forget that it is part of chief complaint step.

"measure core body temp" sounds like a destructive test a coroner would do.   Or something an EMT would ballpark.  Some of the thermometers you might have on an ambulance won't read below 94degrees.   In any event, you might assess the temp but you definitely wouldn't measure it until after ABC.

Cardiac comes before airway if it is a cardiac patient but that has not been established that this is a cardiac patient.   Also, that is for Action, not assessment:   Chest compressions before rescue breathing, not assess circulation before assessing breathing.  

In this case, though, AHA would seem to agree:
AHA 2010 CPR guidelines as implemented by NREMT exam:  1) unresponsive, 2) check breathing, 3) check pulse, 4) break ribs (compressions) 5) rescue breathing
Under our local protocols, we would also check for signs of irreversible death like decapitation, rigor mortis, and lividity before starting CPR.

Open the airway with a jaw thrust (possible c-spine compromise due to possible ground level fall) and assess airway/breathing.   Answer B.


And, no, in these types of questions and most real life situations, the two hikers aren't EMT trained.   They found the patient and called 911.   You responded.


 Also, if your instructions are to follow the sheet, then the order on the medical assessment sheet (at least in my state) is ABC.    Please note, however, that following the sheet can potentially get you in trouble when you get to the NREMT test, though it is expected by the practice questions in a certain textbook.   And ABC vs CAB is one area to watch out for.   NREMT has been updated for the 2010 AHA guidelines; your textbook and quiz questions maybe sporadically.


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## RedAirplane (Aug 22, 2015)

I would check the pulse. 

ABC/CAB are the only things more important the Cspine. (Per the way the EMT textbook tends to explain things.)


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## SeeNoMore (Aug 22, 2015)

I'm trying to remember EMT tests, but I feel like C Spine is usually the first choice. Wouldn't you consider the need for c spine precautions before choosing a method of opening the airway for example? Maybe I'm just not remmebering very well.


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## Gurby (Aug 22, 2015)

SeeNoMore said:


> I'm trying to remember EMT tests, but I feel like C Spine is usually the first choice. Wouldn't you consider the need for c spine precautions before choosing a method of opening the airway for example? Maybe I'm just not remmebering very well.



Both on EMT tests and in real life, checking for a pulse is a higher priority than taking C spine precautions.

If there is possibility of trauma, you open the airway with a jaw thrust instead of head-tilt-chin-lift.


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## AcadianExplorer1910 (Aug 22, 2015)

leyvabre said:


> Hey everyone, I'm new to this site and EMT class as well. I need some clarification on the following scenario:
> 25 year old man found unresponsive in the forest by two hikers. He's lying on the ground supine with a liquor bottle nearby. Temp outside is 30F and he's in a tshirt and jeans. After establishing unresponsive what should your next step in patient management be?
> A. C spine
> B. Open airway
> ...


good question I'm thinking about it too. i think the most important thing is the next thing you do, so i would say Check pulse is the next step. I'm gonna go further and explain what i think about other choices: the fact that he is lying supine might indicate he has a c spine injury so stabilize it then make sure he has no obstruction of the airway then measure core body temp to make sure that he is not hypothermic which in late stages could be hard to detect especially when you get to the scene and no one knows how long he has been there, if he is hypothermic use emergency blanket (foil blanket preferred because it keeps internal temp stabile and traps body heat (hopefully there is still some heat in the pt's body)


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## EMT11KDL (Aug 22, 2015)

For testing you need to verbalize C-spine precautions, this is a critical fail, so if you do not do it and you open the airway with head tilt you are a NO GO. That is why c spine precautions, if everyone remembers when they test and for us who proctor test it is said before you touch the patient


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## AcadianExplorer1910 (Aug 22, 2015)

oh ok i got it thanks


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## Jim37F (Aug 22, 2015)

I would answer C: Check pulse.

I remember in my EMT class practice assessments you would do BSI and assess PENMAN first (Personal/Partner/Patient safety in that order, Environmental hazards, Number of patients, Mechanism of injury/nature of illness, Additional resources needed, and Need for spinal immobilization/extrication) while walking up to the patient forming your general impression (Big sick/Little sick) AND then you make first contact with the patient. If you suspect spinal, your partner holds C-Spine while you assess for responsiveness using AVPU.

So this is where the scenario places you, you can eliminate A because that's already been done, and you can eliminate D because even if that's in your scope in your location, I don't believe it's in the NREMT national scope....it sure doesn't come until after ABC/CAB.

So your answer is either B or C, and really then becomes of test on when to use CAB vs ABC. I was taught if the patient is responsive to A, V, or P in AVPU, you continue down ABC...

BUT if the patient is U (Unresponsive to verbal and painful stimuli) which in this scenario this patient IS, then you go CAB and check their pulse prior to opening the airway ...hence the answer is C. (Once you check the pulse, if they have one, then you continue down the rest of AB etc like normal, its only if they didn't have a pulse you start CPR).


Now that's all for testing purposes^ In the real world you'll find yourself merging bots and pieces and going in different order as you focus on the pertinents to the patients actual presentation/complaint. You should be able to complete the entire primary assessment from general impression to the ABC's on most patients in less time than it takes to describe an individual step.


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## Gurby (Aug 22, 2015)

EMT11KDL said:


> For testing you need to verbalize C-spine precautions, this is a critical fail, so if you do not do it and you open the airway with head tilt you are a NO GO. That is why c spine precautions, if everyone remembers when they test and for us who proctor test it is said before you touch the patient



For the practical exam yes:
Scene safety, BSI
Direct my partner to stabilize C-spine
Determine responsiveness, etc.

For a written test, check pulse is probably the answer they are looking for.


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## JeffT (Aug 23, 2015)

check pulse FOR A LONG TIME.  At that temp pulse may be one per minute according to the textbook... so it's a trick question... you usually do cpr on someone with no pulse after 10 second check, but in frigid cold, it's another story according to the text books.


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## chaz90 (Aug 23, 2015)

JeffT said:


> check pulse FOR A LONG TIME.  At that temp pulse may be one per minute according to the textbook... so it's a trick question... you usually do cpr on someone with no pulse after 10 second check, but in frigid cold, it's another story according to the text books.


If someone's heart is theoretically beating once or twice a minute due to extreme cold, is that really enough to count as a "pulse"? It's clearly not producing any kind of reasonable blood pressure or perfusing the brain or other organs. If someone is pulseless after a quick 5 second pulse check, they're buying themselves CPR.


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## DesertMedic66 (Aug 23, 2015)

JeffT said:


> check pulse FOR A LONG TIME.  At that temp pulse may be one per minute according to the textbook... so it's a trick question... you usually do cpr on someone with no pulse after 10 second check, but in frigid cold, it's another story according to the text books.


A pulse of 1 per minute or even 10 per minute is no where near enough to sustain life. If you don't feel a pulse after 5-10 seconds you need to start compressions and get the blood moving.

Edit: or what Chaz said


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## Flying (Aug 23, 2015)

JeffT said:


> check pulse FOR A LONG TIME.  At that temp pulse may be one per minute according to the textbook... so it's a trick question... you usually do cpr on someone with no pulse after 10 second check, but in frigid cold, it's another story according to the text books.


You're in the cold. You find someone with a pulse rate of 5-10 per minute. You start the CPR you should've done half a minute ago.

^^What they said.^^


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## AcadianExplorer1910 (Aug 23, 2015)

Gurby said:


> For the practical exam yes:
> Scene safety, BSI
> Direct my partner to stabilize C-spine
> Determine responsiveness, etc.
> ...


i probably should have said that instead of my long response to the original forum info. nicely said Gurby


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## Ewok Jerky (Aug 24, 2015)

Check pulse.


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## RobertAlfanoNJEMT (Sep 3, 2015)

leyvabre said:


> Hey everyone, I'm new to this site and EMT class as well. I need some clarification on the following scenario:
> 25 year old man found unresponsive in the forest by two hikers. He's lying on the ground supine with a liquor bottle nearby. Temp outside is 30F and he's in a tshirt and jeans. After establishing unresponsive what should your next step in patient management be?
> A. C spine
> B. Open airway
> ...


Check pulse.. If there is no pulse it becomes a CPR situation and c-spine consideration is no longer a priority


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## EOPFD (Oct 16, 2015)

ABC'S and take it from there. Like they said above multitasking is key.


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## TimRaven (Nov 3, 2015)

How do you measure core temp anyway as EMT?  
I have never seen any BLS unit can do esophageal measurement.


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## TimRaven (Nov 3, 2015)

DesertMedic66 said:


> A pulse of 1 per minute or even 10 per minute is no where near enough to sustain life. If you don't feel a pulse after 5-10 seconds you need to start compressions and get the blood moving.
> 
> Edit: or what Chaz said



I have to disagree with that.
A severely hypothermic patient could have very slow and weak but sustainable pulse(due to low metabolism). 
Starting CPR too early could make it into a VF and kills them. 

It is actually specific mentioned in WEMT course that both pulse and respiration have to be checked for full one minute by the clock on severe hypothermia before decision of CPR.(Dr. Gordon G. Giesbrecht)
http://www.wemjournal.org/article/S1080-6032(14)00326-3/fulltext#s0420


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## Underoath87 (Nov 3, 2015)

TimRaven said:


> I have to disagree with that.
> A severely hypothermic patient could have very slow and weak but sustainable pulse(due to low metabolism).
> Starting CPR too early could make it into a VF and kills them.
> 
> ...



*"Indication for cardiopulmonary resuscitation*
_CPR is only indicated in cardiac arrest. CPR is contraindicated if there are signs of life. In a hypothermic patient in the out-of-hospital setting, signs of life may be very difficult to detect. Heart rate can be very slow and pulses can be faint and hard to palpate. The traditional method of checking a pulse by trying to feel the pulse with a finger placed over the presumed location of an artery is limited by cold. Cold fingers have decreased sensitivity to tactile stimuli. Breathing can be very slow and shallow, but may be detectible in the absence of palpable pulses. If cardiac monitoring is not available, the diagnosis of cardiac arrest can be difficult.
_
*Recommendation*
_Rescuers should make every effort to move the patient to a warm setting, such as a ground or air ambulance or a medical facility where cardiac monitoring is available to guide resuscitation and to start rewarming (1C).

Before starting CPR, feel for a carotid pulse for 1 minute. If there is no detectible pulse after 1 minute, start CPR, including rescue breathing (1C)."_

They recommend checking a carotid pulse for 1 minute because the cold environment makes it difficult to palpate a pulse.  Nowhere does it say that 5 or 10 BPM is acceptable.  If it's actually that low, they aren't perfusing and will need CPR, regardless of their decreased metabolism.


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## TimRaven (Nov 3, 2015)

Dr. Gordon Giesbrecht (who is a subject expert and wrote above guideline) clearly states even heart rate of 4/min is a contraindication of CPR on severe hypothermic patient during his lecture in 2009. He also condemns common "15 sec look and feel" practice in this situation.

http://remote.wms.org:8083/Overview_Of_Hypothermia/Player.html
(at 42 minutes, or slide 41, unfortunately I don't know if the link works for non-member.)


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