Airway + Ventilation
8-12%of exam
Cardiology + Resuscitation
10-14%of exam
Trauma
6-10%of exam
Medical + OB/GYN
24-28%of exam
EMS Operations
8-12%of exam
Clinical Judgment
34-38%of exam
Quick Facts
- Exam
- NREMT Paramedic
- Format
- CAT
- Items
- 110-150
- Unscored
- 20 items
- Time
- 3.5 hr
- Pass
- 950/1500
- Fee
- $175
- Provider
- Pearson VUE
Intubation vs Oxygenation
Intubation
- Tube placement
- Skill task
- May fail
Oxygenation
- Patient survival
- BVM acceptable
- Always priority
Tube vs oxygen
Airway Picker
- No gag reflex→OPA(Basic adjunct)
- Gag present→NPA(Avoid facial trauma)
- Poor ventilation→BVM(Two-person seal)
- Failed intubation→SGA(Rescue airway)
- Need definitive airway→ETT(Confirm EtCO2)
- Cannot oxygenate→Cric(Surgical airway)
- Rising EtCO2→Increase ventilation
- Falling SpO2→Reoxygenate
Airway Tools
- OPA
- No gag reflex
- NPA
- Gag present
- BVM
- Ventilate manually
- SGA
- Rescue airway
- ETT
- Definitive airway
- Cric
- Cannot intubate
- Suction
- Clear obstruction
Ventilation
- EtCO2
- Ventilation marker
- Low EtCO2
- Poor perfusion
- High EtCO2
- Hypoventilation
- Plateau high
- Barotrauma risk
- FiO2
- Oxygen fraction
- PEEP
- Alveoli open
- Vt
- Breath volume
Defib vs Cardiovert
Defibrillate
- Pulseless rhythm
- Unsynchronized
- VF/pVT
Cardiovert
- Pulse present
- Synchronized
- Unstable tachy
No pulse vs pulse
Rhythm Picker
- VF or pulseless VT→Defibrillation
- PEA/asystole→CPR + epinephrine
- Unstable tachycardia→Synchronized shock
- Stable regular SVT→Adenosine
- Unstable bradycardia→Atropine/pacing
- Inferior STEMI→Check V4R
- Posterior signs→Check V7-V9
- Post-ROSC hypotension→Perfusion support
ECG Leads
- II III aVF
- Inferior wall
- V1-V4
- Anterior wall
- I aVL V5 V6
- Lateral wall
- V7-V9
- Posterior wall
- V4R
- Right ventricle
- ST elevation
- Injury pattern
- ST depression
- Ischemia/reciprocal
ACLS Actions
- VF/pVT
- Defibrillate
- PEA
- CPR + causes
- Asystole
- CPR + epi
- Unstable tachy
- Cardiovert
- Stable SVT
- Vagal/adenosine
- Brady unstable
- Atropine/pacing
- Post-arrest
- Oxygen/perfusion
Cardiac Drugs
- Epinephrine
- Vasopressor
- Amiodarone
- Refractory VF/pVT
- Adenosine
- Regular narrow SVT
- Atropine
- Symptomatic brady
- Nitro
- Chest pain preload
- Aspirin
- ACS platelet block
- Dopamine
- Pressure support
MARCH
Massive bleed before airway
Massive bleedAirwayRespirationCirculationHypothermia
Trauma vs Medical
Trauma
- Mechanism matters
- Bleeding first
- Rapid transport
Medical
- History matters
- Differentials first
- Trend vitals
Mechanism vs history
Trauma Priorities
- MARCH
- Trauma sequence
- Massive bleed
- Control first
- Airway
- Protect patency
- Respiration
- Fix chest
- Circulation
- Perfuse organs
- Head injury
- Avoid hypoxia
- Hypothermia
- Prevent coagulopathy
Chest Trauma
- Tension pneumo
- Decompress now
- Open pneumo
- Occlusive dressing
- Flail chest
- Ventilatory support
- Tamponade
- Obstructive shock
- Hemothorax
- Blood in chest
- Contusion
- Delayed hypoxia
- Crush
- Hyperkalemia risk
APGAR
Appearance, pulse, grimace, activity, respiration
AppearancePulseGrimaceActivityRespiration
DKA vs HHS
DKA
- Ketones
- Acidosis
- Often type 1
HHS
- Extreme glucose
- Dehydration
- Minimal ketones
Ketones vs osmoles
Medical Cues
- DKA
- Ketone acidosis
- HHS
- Hyperosmolar dehydration
- Sepsis
- Infection + shock
- Stroke
- Time critical
- Anaphylaxis
- Epinephrine first
- Opioid
- Respiratory depression
- Adrenal crisis
- Low sodium/high potassium
Previa vs Abruption
Previa
- Painless bleeding
- Placenta low
- Soft uterus
Abruption
- Painful bleeding
- Placenta separates
- Rigid uterus
Painless vs painful
OB Emergencies
- Previa
- Painless bleeding
- Abruption
- Painful bleeding
- Eclampsia
- Seizure pregnancy
- Shoulder dystocia
- McRoberts first
- PPH
- Uterine atony
- Cord prolapse
- Relieve pressure
- Neonate
- Ventilation priority
START RPM
Respiration, perfusion, mental status
RespirationPerfusionMental status
START vs JumpSTART
START
- Adult triage
- RPM checks
- Walking wounded
JumpSTART
- Pediatric triage
- Rescue breaths
- Age adjusted
Adult vs pediatric
EMS Operations
- Scene safety
- First priority
- BSI
- Standard precautions
- ICS
- Unified command
- Operations
- Tactical work
- Triage
- Sort patients
- PCR
- Legal record
- Refusal
- Capacity documented
Clinical Judgment
Recognize, analyze, prioritize, act, evaluate
CuesHypothesesSolutionsActionEvaluation
Judgment Picker
- Many symptoms→Recognize cues
- Cues conflict→Analyze cues
- Several diagnoses→Prioritize hypotheses
- Plan needed→Generate solutions
- Time critical→Take action
- Treatment given→Evaluate response
- Team confused→Communicate clearly
- Scene complex→Lead roles
Exam Facts
- CAT
- Adaptive difficulty
- Minimum
- 110 items
- Maximum
- 150 items
- Pretest
- 20 unscored
- Clock
- 3.5 hours
- Scale
- 100-1500
- Passing
- 950 point
CJ Steps
- Communicate
- Share key facts
- Lead
- Direct team
- Recognize cues
- Notice signals
- Analyze cues
- Interpret meaning
- Prioritize
- Rank hypotheses
- Generate
- List solutions
- Take action
- Treat now
- Evaluate
- Reassess effect
Common Traps
Pulse vs no pulse
Pulse gets synchronized ≠ No pulse gets defib
Tube vs patient
Tube is method ≠ Oxygenation is goal
Previa vs abruption
Previa painless ≠ Abruption painful
DKA vs HHS
DKA has ketones ≠ HHS has osmoles
Shock in kids
Tachycardia early ≠ Hypotension late
Pretest items
Cannot identify ≠ Answer all seriously
Last Minute
- 1.Clinical Judgment is highest
- 2.Answer every item
- 3.Pediatric care is integrated
- 4.Confirm ETT with EtCO2
- 5.Unstable tachy gets synchronized shock
- 6.VF/pVT gets defib
- 7.Massive bleeding comes first
- 8.Scene safety comes first
- 9.Previa painless; abruption painful
- 10.Reassess after every treatment
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