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NREMT Paramedic practice
Ten original, source-verified NREMT Paramedic questions with full answers and rationale below, free to read, no account required.
Question 1
A paramedic is preparing to perform rapid sequence intubation on an adult patient with a large total body surface area thermal burn and a rapidly deteriorating airway. Which rapid sequence intubation medication is contraindicated in this patient because it can precipitate life-threatening hyperkalemia?
Why: Succinylcholine is a depolarizing neuromuscular blocker that opens extrajunctional acetylcholine receptors on burned or otherwise injured muscle, releasing intracellular potassium into the circulation and risking life-threatening hyperkalemia and dysrhythmia. Etomidate is a sedative-hypnotic induction agent, not a paralytic, and does not act at the neuromuscular junction, so it carries no such risk. Midazolam and fentanyl are sedative and analgesic premedications used during rapid sequence intubation; neither affects potassium handling at the muscle membrane. Because burn injury predisposes patients to this exaggerated potassium release, a nondepolarizing agent is the safer paralytic choice. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2040. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Pharmacologic Intervention Minimum Psychomotor Skill Set table).
Question 2
A paramedic must select a sedative-hypnotic induction agent for rapid sequence intubation of a trauma patient who has borderline hypotension and signs of increased intracranial pressure. Which agent is most appropriate because it has minimal effect on heart rate, blood pressure, and intracranial pressure?
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Start free →Why: Etomidate is a non-opioid, nonbarbiturate hypnotic-sedative with a rapid onset and short duration that produces little change in pulse rate, blood pressure, or intracranial pressure, making it well suited for induction in a patient who is hemodynamically borderline or has elevated intracranial pressure. Midazolam and diazepam are benzodiazepines that can worsen hypotension and often require larger doses to achieve adequate relaxation for intubation, which increases risk in an unstable patient. Alfentanil is an opioid used for analgesia and sedation, not as a primary induction agent, and can itself cause hypotension and respiratory depression. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2037. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Pharmacologic Intervention Minimum Psychomotor Skill Set table).
Question 3
A paramedic is preparing to perform rapid sequence intubation on an adult patient in hemorrhagic shock with a systolic blood pressure of 78 mmHg who requires immediate airway control. Which induction agent's sympathomimetic effect makes it a hemodynamically favorable choice for this hypotensive patient?
Why: Ketamine is a dissociative anesthetic that produces a sympathomimetic effect, tending to preserve or increase heart rate and blood pressure, which makes it a hemodynamically stable induction choice for a hypotensive patient who needs emergent airway control. Midazolam and diazepam are benzodiazepine sedative-hypnotics that can add further hypotension and respiratory depression, worsening an already unstable patient. Pancuronium is a nondepolarizing neuromuscular blocking agent, not a sedative, and giving a paralytic without first sedating the patient would leave the patient paralyzed while fully aware. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2036. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Pharmacologic Intervention Minimum Psychomotor Skill Set table).
Question 4
A paramedic cannot ventilate or intubate a 6-year-old child by any other means and is considering an emergency surgical airway. Why is needle cricothyrotomy with translaryngeal catheter ventilation preferred over surgical cricothyrotomy in this patient?
Why: In children younger than about 8 years, the larynx is too small to safely accept a tube of adequate diameter through a surgical cricothyrotomy incision without risking damage to the developing laryngeal structures, so needle cricothyrotomy with translaryngeal catheter ventilation is the safer temporizing option. Surgical cricothyrotomy does not require cervical spine manipulation at all, which is actually one of its advantages, so that is not the reason for avoiding it here. Every child has a cricothyroid membrane from birth; it is simply proportionally smaller than an adult's. Esophageal injury is a possible complication of either technique if performed incorrectly, not an inherent, unavoidable outcome of surgical cricothyrotomy. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2073. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Airway and Breathing Minimum Psychomotor Skill Set table).
Question 5
A paramedic is about to perform a needle cricothyrotomy with translaryngeal catheter ventilation on a patient who cannot be intubated or ventilated by conventional means. Which finding would make this technique contraindicated?
Why: Needle cricothyrotomy delivers oxygen under high pressure through a small catheter, but exhalation occurs passively back up through the glottic opening; if the airway is completely obstructed above the insertion site, exhaled gas has no way to escape, causing progressive air trapping, hypercapnia, and barotrauma. Massive maxillofacial trauma, uncontrolled oropharyngeal bleeding, and inability to open the mouth are all situations that make conventional airway management impossible and are indications for cricothyrotomy, not contraindications to it. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2083. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Airway and Breathing Minimum Psychomotor Skill Set table).
Question 6
While using the LEMON mnemonic to predict a difficult airway, a paramedic applies the 3-3-2 rule. Which finding on this assessment suggests a potentially difficult intubation?
Why: The 3-3-2 rule evaluates mouth opening (ideally at least three fingerbreadths), mandible length from chin to hyoid bone (ideally at least three fingerbreadths), and the hyoid-to-thyroid-notch distance (ideally at least two fingerbreadths); a hyoid-to-thyroid-notch distance under two fingerbreadths leaves too little room to displace the tongue and epiglottis during laryngoscopy and predicts a difficult airway. A mouth opening or mandible length of four fingerbreadths both meet or exceed the minimum thresholds and are reassuring, not concerning, findings. Full neck range of motion is likewise a favorable finding under the 'Neck mobility' component of LEMON, not a predictor of difficulty. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 1973. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Airway and Breathing Minimum Psychomotor Skill Set table).
Question 7
A paramedic wants to use the Mallampati classification to help predict the difficulty of intubating a patient who is unresponsive after a witnessed seizure. Why is this classification of limited value for this particular patient?
Why: The Mallampati classification depends on visualizing the oropharyngeal structures in a seated, cooperative patient who can fully open the mouth on command, so it cannot be validly performed on an unresponsive patient who cannot follow instructions. It is used for patients of any age who can cooperate, not exclusively pediatric patients. It is a predictive screening tool, not a substitute for actually performing laryngoscopy, and it evaluates visible oropharyngeal structures, not neck mobility, which is a separate component of the broader LEMON assessment. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 1975. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Airway and Breathing Minimum Psychomotor Skill Set table).
Question 8
During direct laryngoscopy, a paramedic cannot visualize the vocal cords. An assistant applies backward, upward, and rightward pressure to the lower third of the thyroid cartilage to improve the view. What is this technique called?
Why: The BURP maneuver, or external laryngeal manipulation, applies backward, upward, and rightward pressure on the thyroid cartilage to bring the glottic opening into better view during laryngoscopy. The Sellick maneuver refers to cricoid pressure historically used to occlude the esophagus and reduce aspiration risk, a different technique with a different purpose. 'Bimanual laryngoscopy' describes the intubator performing this manipulation before an assistant takes over the pressure, but the pressure technique itself is specifically named the BURP maneuver. The jaw-thrust maneuver is a basic airway-opening technique unrelated to improving a laryngoscopic view during intubation. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 1996. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Airway and Breathing Minimum Psychomotor Skill Set table).
Question 9
A paramedic is monitoring waveform capnography on a patient in severe respiratory distress and notes a gradually upsloping (rather than abruptly rising) phase II, giving the waveform a 'shark fin' appearance. What does this waveform most strongly suggest?
Why: A shark fin waveform shows a gradual, sloped rise during exhalation rather than a sharp upstroke, which occurs when narrowed, bronchospastic airways slow and prolong gas emptying from the alveoli, classically seen in asthma or COPD exacerbations. Esophageal intubation typically produces a flat or absent capnography waveform because there is no exhaled carbon dioxide from the lungs, not a shark fin pattern. Hyperventilation lowers the ETCO2 baseline but preserves a normal waveform shape, and cardiac arrest with no perfusion produces a very low or absent ETCO2 reading rather than this characteristic sloped morphology. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 1876. Cross-reference: National Model EMS Clinical Guidelines, Version 3.0 (March 2022), PDF p. 184.
Question 10
A paramedic is choosing between succinylcholine and rocuronium for rapid sequence intubation. Why should rocuronium and other nondepolarizing paralytics not be given before the airway has been secured?
Why: Nondepolarizing agents such as rocuronium, vecuronium, and pancuronium have a much longer duration of action than succinylcholine, so if the airway cannot be secured after giving one of these drugs, the crew must be prepared to support ventilation for 30 to 60 minutes or longer rather than the brief window succinylcholine allows. Rocuronium's onset is actually comparable to succinylcholine's, so a slow onset is not the concern. Bradycardia from neuromuscular blockade is associated with succinylcholine's depolarizing mechanism, not with nondepolarizing agents. Nondepolarizing paralytics are always given after adequate sedation as part of standard rapid sequence intubation, not withheld from combination with sedatives. Nancy Caroline's Emergency Care in the Streets (AAOS/Jones & Bartlett Learning, 9th Edition), Airway Management, p. 2041. Cross-reference: Advanced Emergency Care and Transportation of the Sick and Injured, AEMT primary textbook (edition as cataloged in project library), PDF p. 34 (Pharmacologic Intervention Minimum Psychomotor Skill Set table).