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EMT / Paramedic Interview & Exam Preparation Guide

For Apollo, CMC Vellore, Kavery & Multi-Speciality Hospitals

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PART 1 - INTERVIEW QUESTIONS & ANSWERS

Section A: Personal / HR Questions

"I am a certified Emergency Medical Technician with [X years] of experience in pre-hospital and in-hospital emergency care. I am trained in BLS, airway management, IV cannulation, patient triage, and transport. I am applying to [Apollo/CMC/Kavery] because of its reputation for high-quality emergency care and my desire to contribute to a professional, high-volume emergency department."

Mention the hospital's reputation - Apollo for tertiary care, CMC Vellore for academic excellence, Kavery for cardiac/neuroscience specialisation. Show you've researched them.

"I remain calm under pressure, communicate clearly with the team, and I have strong hands-on skills in BLS, airway management, and patient stabilisation."

"I follow the START/SALT triage protocol - assess patients systematically, prioritize by acuity, delegate tasks clearly, and communicate with the team throughout without letting emotion override clinical judgment."

"I aim to complete my ACLS and Trauma Nurse/Paramedic certifications, take on a senior paramedic or emergency response coordinator role, and eventually contribute to training junior paramedics."

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Section B: Situational / Scenario-Based Questions

Ensure scene safety -> Check responsiveness (tap shoulders, shout) -> Call for help/activate EMS -> Check pulse (carotid, max 10 seconds) -> No pulse: begin CPR at 30:2 ratio, 100-120 compressions/min, depth 5-6 cm -> Attach AED as soon as available -> Shock if shockable rhythm (VF/pulseless VT) -> Resume CPR immediately after shock -> Continue until ROSC, ALS team arrives, or patient declared.

Follow ABCDE approach:

• A - Airway (patent? obstruction? c-spine control)
• B - Breathing (bilateral chest rise, SpO2, tension pneumothorax signs?)
• C - Circulation (pulse, BP, active hemorrhage control, IV access, fluids)
• D - Disability (GCS, pupils, neuro status)
• E - Exposure (fully expose patient, look for all injuries, prevent hypothermia)

Position patient upright (tripod if needed) -> High-flow O2 via non-rebreather mask (15 L/min) -> Pulse oximetry, vital signs -> Assess for cause: wheeze (asthma/COPD), stridor (upper obstruction), crackles (pulmonary edema) -> Prepare for BVM ventilation if deteriorating -> Notify team for advanced airway if SpO2 <90% despite O2.

• Remove allergen if possible
• Epinephrine (Adrenaline) 0.3-0.5 mg IM (1:1000) into outer thigh - this is the FIRST-LINE drug
• Lay patient flat, elevate legs
• O2 high flow
• IV access, fluid bolus (NS 500 mL-1L)
• Antihistamine (chlorpheniramine) + steroid (hydrocortisone) - secondary drugs
• Monitor for biphasic reaction

15:2 compression-to-ventilation ratio for infants and children with 2 rescuers. For a single rescuer, 30:2 is used. Rate: 100-120 compressions/minute.

GCS ≤8 = intubation threshold. Prepare for rapid sequence intubation (RSI):

• Pre-oxygenate with 100% O2 for 3-5 minutes
• Assemble equipment: laryngoscope, ETT (appropriate size), suction, BVM, ETCO2
• Sedative + paralytic (e.g., ketamine/etomidate + succinylcholine)
• Intubate, confirm with ETCO2 waveform capnography, chest rise, auscultation
• Secure tube, CXR confirmation

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Section C: Technical Questions

• S - Signs & Symptoms
• A - Allergies
• M - Medications
• P - Past medical/surgical history
• L - Last oral intake
• E - Events leading to the emergency

30:2 (30 chest compressions followed by 2 ventilations) for both 1-rescuer and 2-rescuer adult CPR. Once an advanced airway is placed (ETT/supraglottic), ventilate at 10 breaths/minute without interrupting compressions.

• Monophasic defibrillator: 360 joules for VF/pulseless VT
• Biphasic defibrillator: 120-200 joules (as per manufacturer; typically 200J)
• AED: device selects energy automatically
• Internal defibrillation (open chest): 10 joules

1 mg IV/IO every 3-5 minutes (1:10,000 solution for IV use). Epinephrine improves ROSC and short-term survival in cardiac arrest.

• 4 Hs: Hypoxia, Hypovolemia, Hypo/Hyperkalemia (electrolytes), Hypothermia
• 4 Ts: Tension pneumothorax, Tamponade (cardiac), Toxins (drugs/poisons), Thrombosis (PE/MI)

Quick neurological assessment:

• A - Alert
• V - Responds to Voice
• P - Responds to Pain
• U - Unresponsive

• Primary: Waveform end-tidal CO2 (ETCO2) - gold standard
• Secondary: Bilateral chest rise, bilateral breath sounds, absence of gurgling over epigastrium
• Chest X-ray for final confirmation (ETT tip should be 2-3 cm above carina)
• SpO2 improvement

First line: Crystalloids - Normal Saline (0.9% NaCl) or Lactated Ringer's. Bolus: 500 mL-1L in adults (reassess after each bolus). In hemorrhagic shock: blood products (O-negative PRBCs) as early as possible; avoid over-resuscitation with crystalloids.

Component	Score
Eye opening (spontaneous/to voice/pain/none)	4/3/2/1
Verbal response (oriented/confused/words/sounds/none)	5/4/3/2/1
Motor response (obeys/localizes/withdraws/flexion/extension/none)	6/5/4/3/2/1

• Total: 3-15. Normal = 15. Intubation threshold = ≤8. Severe TBI = ≤8.

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PART 2 - WRITTEN EXAM PREPARATION (MCQ Topics)

High-Frequency Topics for Hospital EMT Exams (Apollo/CMC/Kavery)

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PART 3 - HOSPITAL-SPECIFIC TIPS

Apollo Hospitals

• Focus on ACLS protocols, cardiac emergencies (MI, arrhythmias), code blue procedures
• Know Apollo's 5-step patient safety protocol
• They test infection control, hand hygiene (WHO 5 moments)
• Ask about experience with cardiac monitoring, 12-lead ECG interpretation basics

CMC Vellore

• Strong academic institution - expect theory-based written exam
• Know drug mechanisms, not just doses
• They value communication skills and ethical patient handling
• May ask about tropical diseases (dengue, leptospirosis, malaria) management in emergency setting
• Expect questions on academic protocols and evidence-based practice

Kavery Hospital

• Cardiac and neuroscience specialty - know stroke codes, STEMI protocols, post-cardiac surgery monitoring
• Know tPA indications for stroke (onset <4.5 hrs, BP <185/110, no hemorrhage on CT)
• Familiarity with ICU monitoring equipment is valued

General Multi-Speciality Hospital

• Be ready for questions on ALL areas: pediatric emergencies, obstetric emergencies, toxicology
• Know poison management: paracetamol overdose (NAC), organophosphate (atropine + pralidoxime), opioid (naloxone), benzodiazepine (flumazenil)
• Know hospital codes: Code Blue (cardiac arrest), Code Red (fire), Code Pink (infant abduction)

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PART 4 - COMMONLY ASKED BEHAVIOURAL QUESTIONS

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PART 5 - QUICK REVISION FLASHCARDS

• Oxygen delivery: Nasal cannula 1-6 L (24-44%), Simple mask 6-10 L (35-60%), Non-rebreather 15 L (60-90%), BVM with O2 100%
• Normal saline osmolarity: 308 mOsm/L
• Shock BP threshold (adult): Systolic <90 mmHg or MAP <65 mmHg
• Pediatric CPR depth: 1/3 of chest AP diameter (approx. 4 cm infant, 5 cm child)
• ROSC signs: Palpable pulse, BP returns, spontaneous breathing, purposeful movements
• Amiodarone: 300 mg IV for refractory VF/VT (second dose 150 mg)
• Atropine: 0.5 mg IV for symptomatic bradycardia (max 3 mg total)
• Morphine: 2-4 mg IV titrated for acute chest pain (use cautiously)
• Adenosine: 6 mg rapid IV push for SVT (second dose 12 mg)
• Needle decompression: 2nd intercostal space, midclavicular line for tension pneumothorax

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Additional Preparation Resources

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1. Carry your BLS/ACLS/EMT certificates to the interview
2. Dress in formal attire (hospitals value professional appearance)
3. Know the specific hospital's department structure and specialty focus
4. Practice hands-on skills before the interview (CPR demonstration is sometimes asked)
5. Review the latest AHA 2020 CPR Guidelines (still current for most Indian hospital exams)
6. For CMC Vellore: expect a longer written test with case-based reasoning
7. For Apollo: code blue simulation/scenario may be part of the selection process

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EMT / PARAMEDIC - 10-DAY COMPLETE INTERVIEW PREP

Apollo | CMC Vellore | Kavery | Multi-Speciality Hospitals

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DAY 1 - BASIC LIFE SUPPORT (BLS) & CPR

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Q1. What is BLS? What are the steps of BLS for an adult?

1. Ensure scene safety - Look for hazards (fire, electricity, traffic) before approaching
2. Check responsiveness - Tap shoulders firmly, shout "Are you okay?"
3. Call for help - Shout for someone to call emergency services; if alone, call yourself; ask bystander to get AED
4. Check breathing and pulse simultaneously - Look for chest rise; feel carotid pulse for no more than 10 seconds
5. No pulse + no normal breathing - Begin CPR immediately
6. Chest compressions:
   • Place heel of one hand on center of chest (lower half of sternum)
   • Place second hand on top, fingers interlaced
   • Keep arms straight, compress at least 5 cm (2 inches) but not more than 6 cm
   • Rate: 100-120 compressions per minute
   • Allow full chest recoil after each compression - do not lean on chest
7. Ventilations:
   • Give 2 breaths after every 30 compressions (30:2 ratio)
   • Each breath should take 1 second; visible chest rise
   • If unable/unwilling to give breaths: hands-only CPR is acceptable for bystanders
8. Attach AED as soon as it arrives - Turn on, follow voice prompts
9. Continue CPR until: ROSC (return of spontaneous circulation), ALS team takes over, or patient is declared

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Q2. What is the CPR ratio for adults, children, and infants?

• Once advanced airway is placed (ETT): give 1 breath every 6 seconds (10/min) without stopping compressions

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Q3. What is the compression depth for adults, children, and infants?

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Q4. How do you use an AED?

1. Turn on the AED (open lid or press power button)
2. Attach pads: one below right collarbone, one on left side below armpit
3. AED analyzes rhythm - do NOT touch patient during analysis
4. If shockable rhythm (VF or pulseless VT): AED announces "Shock advised" - ensure everyone is clear, press shock button
5. Immediately resume CPR for 2 minutes after shock
6. AED will re-analyze after 2 minutes - repeat if advised

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Q5. What is the "chain of survival"?

• Early recognition and call for help
• Early CPR
• Early defibrillation
• Early advanced care (ALS)
• Post-resuscitation care

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DAY 2 - AIRWAY MANAGEMENT

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Q6. What are the steps to assess and manage an airway?

• Look - Chest rise, use of accessory muscles, cyanosis, foreign body
• Listen - Stridor (upper obstruction), gurgling (secretions), wheeze (lower), silence (complete obstruction)
• Feel - Air movement at mouth and nose

• Head tilt-chin lift - For non-trauma patients
• Jaw thrust - For trauma patients (suspected cervical spine injury) - this is the SAFEST maneuver

• OPA (Oropharyngeal Airway / Guedel Airway): Used in unconscious patients with no gag reflex. Size = distance from corner of mouth to earlobe. Insert inverted then rotate 180 degrees (adults)
• NPA (Nasopharyngeal Airway): Can be used in semiconscious patients. Contraindicated in basal skull fracture. Lubricate before inserting

• Use E-C clamp technique to seal mask
• Give one breath over 1 second; see chest rise
• Two-person technique preferred (one holds mask, one squeezes bag)

• ETT (Endotracheal Tube) - Gold standard for definitive airway
• Supraglottic airways: LMA (Laryngeal Mask Airway), i-gel - used when intubation not possible

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Q7. When do you intubate a patient?

• GCS ≤8 (cannot protect own airway)
• Respiratory failure (SpO2 <90% despite high-flow O2)
• Anticipated airway loss (facial burns, angioedema, epiglottitis)
• Need for deep sedation/paralysis
• Prevention of aspiration in unconscious patient

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Q8. How do you confirm ETT placement?

• Waveform capnography (ETCO2) - GOLD STANDARD - consistent CO2 waveform confirms tracheal placement
• Bilateral equal breath sounds on auscultation
• Absence of sounds over epigastrium (stomach)
• Visible bilateral chest rise

• Chest X-ray (ETT tip should be 2-3 cm above carina, at level of aortic knob)
• Improving SpO2

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Q9. What is RSI (Rapid Sequence Intubation)?

1. Preparation - Equipment ready (laryngoscope, ETT sizes, suction, BVM, drugs drawn up)
2. Preoxygenation - 100% O2 for 3-5 minutes; BVM if inadequate
3. Pretreatment - Atropine (pediatrics, to prevent bradycardia); lidocaine (head injury, to blunt ICP rise)
4. Paralysis with induction - Give sedative + neuromuscular blocker simultaneously
5. Protection - Sellick's maneuver (cricoid pressure) - now controversial
6. Placement - Intubate, confirm with ETCO2
7. Post-intubation management - Secure tube, ventilate, sedation

• Etomidate 0.3 mg/kg IV + Succinylcholine 1.5 mg/kg IV (most common)
• Ketamine 1-2 mg/kg IV + Succinylcholine (hemodynamically unstable patients)
• If succinylcholine contraindicated (hyperkalemia, burns >48h): use Rocuronium 1.2 mg/kg IV

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Q10. What is the difference between stridor and wheeze?

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DAY 3 - CARDIAC EMERGENCIES & ECG BASICS

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Q11. What are the 4 cardiac arrest rhythms? Which are shockable?

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Q12. What are the defibrillation energy settings?

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Q13. What is the ACLS algorithm for cardiac arrest?

1. Start CPR - push hard and fast
2. Defibrillate (shock)
3. Resume CPR immediately x 2 min
4. Epinephrine 1 mg IV/IO every 3-5 min
5. After 3rd shock: Amiodarone 300 mg IV (2nd dose: 150 mg)
6. Reassess rhythm every 2 minutes
7. Treat reversible causes (4H4T)

1. Start CPR - push hard and fast
2. Epinephrine 1 mg IV/IO every 3-5 min
3. Treat reversible causes (4H4T)
4. Reassess rhythm every 2 minutes

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Q14. What are the 4Hs and 4Ts (reversible causes of cardiac arrest)?

• Hypovolemia - give fluids/blood
• Hypoxia - ensure adequate oxygenation
• Hypo/Hyperkalemia (and other electrolytes) - correct electrolytes
• Hypothermia - warm the patient

• Tension pneumothorax - needle decompression
• Tamponade (cardiac) - pericardiocentesis
• Toxins/drugs - specific antidotes
• Thrombosis (PE or MI) - thrombolysis/PCI

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Q15. What are the signs of STEMI on ECG?

• ST elevation > 1mm in 2 or more contiguous limb leads, OR > 2mm in contiguous chest leads
• New LBBB (Left Bundle Branch Block) - treat as STEMI equivalent
• Q waves (pathological) = old infarct

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Q16. What is the MONA protocol for acute MI?

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Q17. What are common arrhythmias and their first-line treatment?

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DAY 4 - TRAUMA MANAGEMENT (ATLS/PHTLS)

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Q18. What is the primary survey in trauma? (CABCDE)

• Apply direct pressure or tourniquet for life-threatening external bleeding FIRST
• Tourniquet: apply 5-7 cm above wound; note time of application

• Open airway using jaw thrust (NOT head tilt in trauma)
• Apply cervical collar if mechanism of injury suggests spinal injury
• Remove foreign bodies, suction blood/secretions
• Intubate if airway compromised

• Expose chest; count respiratory rate; check SpO2
• Check for: tension pneumothorax, open chest wound, flail chest, massive hemothorax
• Give high-flow O2

• Check pulse quality (radial = SP >80; femoral = SP >70; carotid = SP >60)
• Control external bleeding
• Establish 2 large-bore IV lines (14-16G); draw bloods
• Fluid resuscitation (NS or LR bolus 1L); blood if hemorrhagic shock

• GCS; AVPU; pupils (size, reactivity, equality)
• Blood glucose

• Remove ALL clothing to look for ALL injuries
• Log-roll to check back and spine
• Cover with warm blanket to prevent hypothermia

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Q19. What are the classes of hemorrhagic shock?

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Q20. What is tension pneumothorax? How do you treat it?

• Severe respiratory distress
• Absent breath sounds on one side
• Tracheal deviation to OPPOSITE side (late sign)
• Hypotension
• Distended neck veins (JVD)
• Tachycardia

• Needle thoracostomy (decompression): Insert 14-16G cannula into 2nd intercostal space, midclavicular line (or 4th/5th ICS, anterior axillary line). Hiss of air confirms diagnosis.
• Follow with formal chest drain (intercostal tube) insertion: 5th ICS, midaxillary line

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Q21. What is the FAST exam in trauma?

• Pericardial - around heart (cardiac tamponade)
• Right upper quadrant (Morrison's pouch) - liver/kidney
• Left upper quadrant (Splenorenal space) - spleen/kidney
• Pelvic (Pouch of Douglas/Rectovesical) - free pelvic fluid

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DAY 5 - SHOCK MANAGEMENT

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Q22. What is shock? What are the types?

• Cause: Blood loss (hemorrhage), fluid loss (dehydration, burns, vomiting)
• Signs: Tachycardia, hypotension, cool clammy skin, decreased urine output
• Treatment: Stop bleeding; IV fluids (crystalloids then blood products)

• Septic shock: Infection -> vasodilation -> hypotension. BP <90 despite fluids; Norepinephrine is vasopressor of choice. Cultures + antibiotics within 1 hour
• Anaphylactic shock: Allergen -> massive histamine release. IM Epinephrine 0.3-0.5 mg FIRST LINE; fluids; antihistamines; steroids
• Neurogenic shock: Spinal cord injury -> loss of sympathetic tone. Bradycardia + hypotension (no tachycardia). Atropine + vasopressors

• Cause: Pump failure (massive MI, severe heart failure, myocarditis)
• Signs: Hypotension, tachycardia, pulmonary edema (wet and cold)
• Treatment: Identify and treat cause; inotropes (dobutamine); IABP if needed; PPCI for MI

• Cause: Physical obstruction to blood flow
• Tension pneumothorax: needle decompression
• Cardiac tamponade: pericardiocentesis
• Massive PE: thrombolysis (alteplase)

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Q23. How do you differentiate cardiogenic from septic shock?

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DAY 6 - NEUROLOGICAL EMERGENCIES

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Q24. What is GCS and how do you score it?

• Total range: 3 (worst) to 15 (normal)
• Mild TBI: 13-15 | Moderate TBI: 9-12 | Severe TBI: 3-8
• Intubation threshold: GCS ≤8

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Q25. What is the FAST test for stroke?

• Balance (sudden loss of balance)
• Eyes (sudden vision loss or double vision)

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Q26. What is the treatment for ischemic stroke?

1. ABC assessment; O2 if SpO2 <94%
2. IV access; blood glucose (hypoglycemia mimics stroke - check!)
3. Urgent non-contrast CT brain (to exclude hemorrhage)
4. 12-lead ECG

• Ischemic stroke confirmed on CT (no bleed)
• Onset of symptoms within 4.5 hours
• Age >18
• BP <185/110 mmHg (control BP first if needed)
• No contraindications (recent surgery, active bleeding, anticoagulants, prior stroke <3 months)
• Dose: 0.9 mg/kg IV (max 90 mg); 10% as bolus, rest over 60 min

• Large vessel occlusion (MCA, basilar)
• Up to 24 hours from onset (selected patients)

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Q27. What is status epilepticus? How do you manage it?

• 0-5 min: Position patient (lateral), protect from injury, O2, suction, IV access, check BGL
• 5-20 min (1st line): IV/IM Benzodiazepine - Lorazepam 0.1 mg/kg IV (or Diazepam 0.15 mg/kg IV or Midazolam 0.2 mg/kg IM)
• 20-40 min (2nd line): IV Phenytoin 20 mg/kg (or Levetiracetam 60 mg/kg, or Valproate 40 mg/kg)
• 40-60 min (refractory): Intubation + IV Phenobarbital or Propofol/Midazolam infusion
• Treat underlying cause: hypoglycemia (D50), hyponatremia, infection, toxins

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DAY 7 - TOXICOLOGY & ANTIDOTES

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Q28. What are the key antidotes every EMT must know?

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Q29. What are the signs of organophosphate poisoning? (DUMBBELS)

• D - Diarrhea
• U - Urination (incontinence)
• M - Miosis (pinpoint pupils)
• B - Bradycardia
• B - Bronchospasm/Bronchorrhea (wheezing, wet secretions)
• E - Emesis (vomiting)
• L - Lacrimation (excessive tearing)
• S - Salivation (excessive drooling)

1. Remove from exposure; decontaminate (remove clothes, wash skin)
2. Airway management (suction secretions heavily)
3. Atropine 2-4 mg IV every 5-10 min until secretions dry (endpoint = dry secretions, NOT pupils)
4. Pralidoxime (2-PAM) 1-2g IV over 15-30 min (within 24-48 hours of exposure)

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Q30. What are the signs of opioid overdose? How do you treat it?

• Pinpoint pupils (miosis)
• Respiratory depression (slow, shallow breathing)
• Decreased consciousness (sedation/coma)

1. Airway - open, suction; BVM if not breathing
2. O2 high flow
3. Naloxone (Narcan) 0.4-2 mg IV/IM/intranasal - repeat every 2-3 minutes
4. Watch for re-sedation (naloxone has shorter half-life than most opioids) - may need infusion or repeat doses
5. Transport to hospital

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DAY 8 - PEDIATRIC & OBSTETRIC EMERGENCIES

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Q31. What are normal vital signs for different age groups?

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Q32. How do you manage febrile seizures in a child?

1. Safety - protect child, lateral position
2. Airway management - suction, O2
3. Time the seizure
4. If seizure >5 min: Diazepam 0.5 mg/kg rectal / 0.1-0.2 mg/kg IV or Midazolam 0.1 mg/kg IM/buccal
5. Treat fever: paracetamol/ibuprofen, tepid sponging
6. Investigate cause of fever; LP if first seizure in infant <12 months

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Q33. What are obstetric emergencies an EMT must know?

• Seizures in a pregnant woman (>20 weeks) with pre-eclampsia (hypertension + proteinuria)
• Treatment: MgSO4 4g IV loading dose over 15 min, then 1-2g/hr infusion; control BP (labetalol/hydralazine); deliver the baby

• Blood loss >500 mL after vaginal delivery or >1000 mL after C-section
• 4 Ts of causes: Tone (atony), Tissue (retained placenta), Trauma (lacerations), Thrombin (coagulopathy)
• Treatment: Uterine massage, Oxytocin 10 IU IM immediately after delivery, bimanual compression, fluids

• Head delivered but shoulders are stuck (anterior shoulder behind pubic symphysis)
• HELPERR mnemonic: Help, Episiotomy, Legs (McRoberts maneuver - flex hips), Pressure (suprapubic pressure), Enter (rotational maneuvers), Remove posterior arm, Roll to all-fours

• Umbilical cord comes out before baby - emergency!
• Do NOT push cord back; elevate presenting part; knee-chest position; immediate C-section

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DAY 9 - MEDICAL EMERGENCIES (QUICK MCQ FACTS)

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Q34. What are the signs and treatment of pulmonary embolism (PE)?

• Sudden onset dyspnea (most common symptom)
• Pleuritic chest pain
• Hemoptysis
• Tachycardia, hypotension (massive PE)
• Raised JVP
• ECG: Sinus tachycardia (most common); S1Q3T3 pattern; new RBBB

• O2, IV access, monitor
• Anticoagulation: Heparin (LMWH or unfractionated heparin) immediately
• Massive PE with cardiac arrest/hemodynamic instability: Thrombolysis (Alteplase 100 mg IV over 2 hours)
• Surgical embolectomy if thrombolysis fails

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Q35. How do you manage a diabetic emergency?

• Conscious patient: 15g fast-acting carbohydrates orally (sugar water, glucose tablets)
• Unconscious/cannot swallow: 50 mL of 50% Dextrose IV (D50W) OR Glucagon 1mg IM
• Recheck BGL after 15 min; give complex carbs after recovery

• Signs: Hyperglycemia (>250 mg/dL), Kussmaul breathing, fruity breath, nausea, dehydration, BGL >250 + ketones + acidosis (pH <7.3)
• Treatment: IV fluids (NS 1L/hr first); insulin infusion; potassium replacement; monitor electrolytes

• BGL >600 mg/dL, no significant ketosis; severe dehydration
• Treatment: Aggressive IV fluids; slow correction

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Q36. What is the management of acute severe asthma?

• Cannot speak full sentences
• SpO2 <92%
• Silent chest (no air entry)
• Cyanosis
• Exhaustion, altered consciousness

1. Sit patient upright
2. High-flow O2 (target SpO2 94-98%)
3. Salbutamol (Albuterol) MDI with spacer OR nebulizer 2.5-5 mg - repeat every 20 min
4. Ipratropium bromide 0.5 mg nebulized with salbutamol
5. Oral/IV Prednisolone 40-50 mg (or hydrocortisone 200 mg IV)
6. MgSO4 2g IV over 20 min (for severe/life-threatening)
7. Prepare for intubation if deteriorating (most dangerous - will crash after intubation)

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Q37. What is the difference between cardiac tamponade and tension pneumothorax?

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DAY 10 - HOSPITAL CODES, INFECTION CONTROL & FINAL REVISION

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Q38. What are hospital emergency codes?

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Q39. What are the WHO 5 Moments of Hand Hygiene?

1. Before touching a patient
2. Before a clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings

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Q40. What are universal precautions in emergency care?

• Wear gloves for any contact with blood, body fluids, or mucous membranes
• Wear mask + eye protection for risk of splashing
• Wear gown for heavy contamination risk
• Never recap needles by hand (needle-stick prevention)
• Dispose sharps in puncture-proof containers
• Report all needle-stick injuries immediately

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Q41. What is the SBAR communication tool?

• S - Situation: "This is [name], I am calling about patient [name] in Bed [X]"
• B - Background: Age, diagnosis, relevant history
• A - Assessment: "I think the problem is..." with vital signs
• R - Recommendation: "I need you to come urgently / order X medication / check the patient"

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Q42. What is documentation in emergency care and why is it important?

• Document in real time or as soon as possible
• Include: time of events, vital signs, interventions, drugs given (dose, route, time), patient response
• Use objective language ("Patient GCS 8" not "Patient was unresponsive")
• Medicolegal document - never erase; strike through errors with single line and initial
• MIST handover: Mechanism, Injuries, Signs/vitals, Treatment given

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FINAL 10-DAY STUDY SCHEDULE

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TOP 20 MCQ REVISION FACTS (Read daily)

1. CPR rate: 100-120/min | Depth (adult): 5-6 cm
2. Adult CPR ratio: 30:2 | Child 2-rescuer: 15:2
3. Defibrillation (monophasic): 360 J | Biphasic: 200 J
4. Epinephrine in cardiac arrest: 1 mg IV every 3-5 min
5. Amiodarone for refractory VF/VT: 300 mg IV (2nd dose: 150 mg)
6. Adenosine for SVT: 6 mg IV rapid push (2nd dose: 12 mg)
7. Atropine for bradycardia: 0.5 mg IV (max 3 mg)
8. GCS intubation threshold: ≤8
9. Stroke tPA window: 4.5 hours from symptom onset
10. Anaphylaxis first-line drug: Epinephrine IM 0.3-0.5 mg (1:1000)
11. Organophosphate antidote: Atropine + Pralidoxime
12. Paracetamol antidote: N-Acetylcysteine
13. Opioid antidote: Naloxone 0.4-2 mg
14. Tension PTX: needle at 2nd ICS, MCL
15. MONA = Morphine, Oxygen, Nitrates, Aspirin (for MI)
16. Normal SpO2: 95-100% | Give O2 if <94%
17. Normal adult HR: 60-100 | RR: 12-20 | BP: 90-120/60-80
18. Status epilepticus: first drug = Lorazepam or Diazepam IV
19. PPH treatment: Oxytocin 10 IU IM
20. Eclampsia treatment: MgSO4 4g IV loading dose

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SAMPLE ANSWER TEMPLATE FOR SCENARIO QUESTIONS

1. Scene safety - Is it safe to approach?
2. Call for help - Activate team/emergency response
3. Primary assessment - ABCDE or CABCDE
4. Identify the problem - Name the condition
5. Immediate interventions - In order of priority
6. Monitoring - Vital signs, SpO2, ECG, ETCO2
7. Drugs - Drug name, dose, route, timing
8. Reassessment - Did patient respond? What next?
9. Handover/documentation - SBAR or MIST

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Sources: Tintinalli's Emergency Medicine | Rosen's Emergency Medicine | Miller's Anesthesia | Goodman & Gilman's Pharmacology | The Washington Manual of Medical Therapeutics | Current Surgical Therapy | Lippincott's Pharmacology | AHA 2020 CPR Guidelines

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DAY 2 - AIRWAY MANAGEMENT (COMPLETE)

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Q1. What are the types of airway adjuncts and how do you use them?

OPA - Oropharyngeal Airway (Guedel Airway)

• Unconscious patient with NO gag reflex
• To maintain airway during BVM ventilation

• Conscious or semi-conscious patient (stimulates gag reflex - causes vomiting and aspiration)
• Intact gag reflex

• Measure from corner of mouth to earlobe OR center of mouth to angle of jaw
• Sizes: 000 (neonate) to 5 (large adult)
• Wrong size = worsens obstruction. Too small pushes tongue back. Too large stimulates larynx.

1. Select correct size
2. Open mouth (cross-finger or jaw-thrust technique)
3. Insert OPA upside down (curved tip pointing UP toward palate)
4. Advance until resistance felt at hard-soft palate junction
5. Rotate 180 degrees so curve follows tongue
6. Ensure flange rests on lips

• Insert with tongue depressor directly (curved tip pointing DOWN) - do NOT rotate, risk of trauma

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NPA - Nasopharyngeal Airway (Nasal Trumpet)

• Patients who are semiconscious (intact gag reflex) - better tolerated than OPA
• Trismus (clenched teeth - jaw cannot open)
• Seizure patients (teeth clenched)

• Suspected basal skull fracture (risk of entering cranial vault) - signs: raccoon eyes, Battle's sign, CSF from nose/ears
• Severe nasal trauma or obstruction
• Anticoagulation (relative - risk of epistaxis)

• Length: nostril to earlobe
• Diameter: matches patient's little finger OR largest that fits comfortably

1. Lubricate generously with water-based gel
2. Insert into the right nostril (bevel toward septum) - left nostril if right blocked
3. Advance gently along the floor of the nasal passage (not upward!)
4. If resistance: do NOT force; try other nostril or smaller size
5. Correctly placed: tip in oropharynx behind tongue

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Q2. Explain the BVM technique in detail.

• Self-inflating bag (450 mL pediatric / 1600 mL adult)
• One-way valve
• Mask (transparent, cushioned, sizes 0-5)
• Oxygen reservoir bag attached = delivers close to 100% O2

• C = Thumb and index finger form a C, pressing mask firmly onto face (apex over nose bridge, base between lower lip and chin)
• E = Remaining 3 fingers form an E, hooking under mandible (lower jaw) to perform jaw thrust
• Other hand squeezes bag
• Give 1 breath every 5-6 seconds (10-12/min) for adults
• Each breath: 1 second; visible chest rise; do NOT over-ventilate

• Person 1: Both hands on mask using two-thumb E-C or thenar eminence technique = better seal
• Person 2: Squeezes bag
• Far superior seal, reduces air leaks

• Adults: squeeze enough to see chest rise (~500-600 mL)
• Do NOT give excessive volumes - causes gastric insufflation and aspiration

• Without reservoir: ~40-60% O2
• With reservoir bag at 15 L/min flow: ~90-100% O2

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Q3. What is the difference between LMA, i-gel, and ETT?

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Q4. What is a surgical airway and when is it needed?

Needle Cricothyrotomy:

• Insert 14G or 16G IV cannula through cricothyroid membrane (between thyroid and cricoid cartilage)
• Aspirate air to confirm tracheal placement
• Attach O2 tubing (jet ventilation)
• Provides temporary oxygenation (15-45 minutes maximum)
• Allows oxygenation but NOT adequate ventilation (CO2 builds up)

Surgical Cricothyrotomy:

• Identify cricothyroid membrane (landmark: notch below thyroid cartilage)
• Make horizontal stab incision through skin and membrane
• Insert tracheostomy tube or small ETT (size 6.0)
• Inflate cuff, confirm with ETCO2
• This IS a definitive (though temporary) airway

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Q5. What are the signs of a difficult airway? (LEMON assessment)

• L - Look externally: beard, short neck, obesity, facial burns, trauma, small mouth
• E - Evaluate 3-3-2 rule:
  • 3 fingers between upper and lower teeth (mouth opening)
  • 3 fingers between hyoid bone and chin
  • 2 fingers between notch of thyroid cartilage and floor of mouth
• M - Mallampati score: Open mouth, protrude tongue, look for uvula/palate visibility
  • Class I (all visible) = easy; Class IV (nothing visible) = very difficult
• O - Obstruction: foreign body, hematoma, epiglottitis, abscess
• N - Neck mobility: limited (c-spine injury, ankylosing spondylitis, cervical collar)

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Q6. What oxygen delivery devices are there and what FiO2 do they deliver?

• In COPD: target SpO2 88-92% (risk of hypercapnic respiratory failure with high O2) - use Venturi mask
• In all other emergencies: target SpO2 94-98%
• In CO poisoning, anaphylaxis, cardiac arrest: always use 100% O2 / NRM first

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DAY 3 - CARDIAC EMERGENCIES & ECG (EXTENDED)

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Q7. How do you read a 12-lead ECG systematically?

Step 1 - Rate

• Count large squares between two R waves: divide into 300
  • 1 box = 300, 2 boxes = 150, 3 boxes = 100, 4 boxes = 75, 5 boxes = 60
• Normal: 60-100 bpm

Step 2 - Rhythm

• Regular or irregular?
• P before every QRS? QRS after every P?
• Regular = sinus rhythm
• Irregularly irregular (no pattern) = Atrial Fibrillation
• Regular irregular (pattern to it) = 2nd degree AV block

Step 3 - Axis

• Normal axis: leads I and aVF both positive (upright QRS)
• Left axis deviation: lead I positive, aVF negative (LAD)
• Right axis deviation: lead I negative, aVF positive (RAD)

Step 4 - P wave

• Present? Upright in II? PR interval 0.12-0.20 sec (3-5 small boxes)
• Prolonged PR = 1st degree AV block
• Absent P waves = AF or junctional rhythm

Step 5 - QRS complex

• Duration: <0.12 sec (3 small boxes) = normal
• Wide QRS (>0.12) = LBBB, RBBB, hyperkalemia, ventricular rhythm
• Pathological Q wave: >0.04 sec wide and >25% of R wave height = old MI

Step 6 - ST segment

• ST elevation (STEMI or pericarditis)
• ST depression (ischemia, NSTEMI, digoxin)
• Measure J-point (where S wave meets ST segment)

Step 7 - T wave

• Normal: upright in I, II, V3-V6; inverted in aVR
• Tall peaked T waves = hyperkalemia (first ECG sign)
• Inverted T waves = ischemia, PE, RBBB
• Flat/biphasic T waves = hypokalemia

Step 8 - QTc interval

• Normal: <440ms (men), <460ms (women)
• Prolonged QTc = risk of Torsades de Pointes
• Causes: medications (amiodarone, haloperidol), hypokalemia, hypomagnesemia

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Q8. Explain common arrhythmias with their ECG features and management.

1. Sinus Tachycardia

• ECG: Normal P-QRS-T; rate >100 bpm
• Cause: Pain, fever, anxiety, anemia, PE, hypovolemia
• Treatment: Treat the underlying cause (NOT the rhythm itself)

2. Atrial Fibrillation (AF)

• ECG: No P waves; irregularly irregular QRS; fibrillatory baseline
• Symptoms: Palpitations, breathlessness, dizziness, stroke risk
• Treatment:
  • Rate control: Metoprolol or Diltiazem IV
  • Rhythm control (if <48 hrs onset): Electrical cardioversion (synchronized) or Amiodarone
  • Anticoagulation: Warfarin/NOACs to prevent stroke (CHA2DS2-VASc score)
  • Unstable AF (BP <90, altered consciousness): immediate synchronized cardioversion

3. SVT - Supraventricular Tachycardia

• ECG: Narrow QRS; rate 150-250; P waves may be buried in QRS
• Treatment (stable):
  • Step 1: Vagal maneuvers (Valsalva, carotid massage)
  • Step 2: Adenosine 6 mg rapid IV push (flush immediately with 20 mL NS)
  • If no response after 1-2 min: Adenosine 12 mg IV (can repeat once)
  • Step 3: Verapamil or Diltiazem IV
• Treatment (unstable): Synchronized cardioversion 50-100J

4. Ventricular Tachycardia (VT) with pulse

• ECG: Wide QRS (>0.12 sec); rate >100; regular; AV dissociation
• Treatment (stable):
  • Amiodarone 150 mg IV over 10 minutes, then 1 mg/min infusion
  • OR Lidocaine 1-1.5 mg/kg IV
• Treatment (unstable): Synchronized cardioversion 100J (biphasic)
• Pulseless VT: = cardiac arrest - immediate defibrillation

5. Complete Heart Block (3rd Degree AV Block)

• ECG: P waves and QRS completely dissociated (no relationship); both regular but independent
• Symptoms: Severe bradycardia, syncope (Stokes-Adams attacks), hypotension
• Treatment: Atropine; Transcutaneous pacing immediately; definitive = permanent pacemaker

6. 1st Degree AV Block

• ECG: PR interval prolonged (>0.20 sec); every P followed by QRS
• Usually benign - no treatment needed; monitor

7. 2nd Degree AV Block - Mobitz Type I (Wenckebach)

• ECG: Progressively lengthening PR interval until a P wave is NOT followed by QRS; then cycle repeats
• Usually benign; may need pacing if symptomatic

8. 2nd Degree AV Block - Mobitz Type II

• ECG: PR interval constant; some P waves suddenly not followed by QRS (2:1, 3:1 ratio)
• Dangerous - can progress to complete heart block
• Treatment: Pacemaker

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Q9. What is the full STEMI management protocol?

Immediate Assessment (within 10 minutes of arrival):

1. 12-lead ECG (door-to-ECG within 10 minutes)
2. IV access x2; bloods: Troponin, CK-MB, FBC, U&E, coagulation
3. O2 if SpO2 <94%
4. Continuous monitoring (BP, ECG, SpO2)

Immediate Drugs (MONA + P2Y12):

• Aspirin 300 mg chewable (unless contraindicated)
• P2Y12 inhibitor: Ticagrelor 180 mg OR Clopidogrel 300-600 mg
• Heparin (LMWH or UFH)
• Nitrates (GTN) if BP >90 systolic (NOT in right ventricular MI - causes severe hypotension)
• Morphine 2-4 mg IV for pain (use cautiously)

Reperfusion Decision:

• Primary PCI (angioplasty) - if cathlab available within 90 minutes of first medical contact - GOLD STANDARD
• Thrombolysis - if PCI not available within 120 minutes from diagnosis:
  • Streptokinase 1.5 million units IV over 60 min, OR
  • Alteplase (tPA) 15 mg bolus + 0.75 mg/kg over 30 min + 0.5 mg/kg over 60 min

Contraindications to Thrombolysis:

• Absolute: Prior intracranial hemorrhage, current stroke, aortic dissection, active bleeding, recent head/facial trauma
• Relative: Severe uncontrolled hypertension (>180/110), recent major surgery (<3 weeks), pregnancy, oral anticoagulants

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DAY 4 - TRAUMA MANAGEMENT (EXTENDED)

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Q10. What is the PHTLS (Pre-Hospital Trauma Life Support) approach?

1. Scene safety and mechanism of injury (MOI)
   • What happened? (MVC, fall height, penetrating vs blunt)
   • High energy = high index of suspicion for serious injury
   • Consider spinal injury if: fall >3x patient height, high-speed MVC, diving accident, axial loading
2. Primary survey with simultaneous treatment (not sequential)
   • In the field: C-A-B-C-D-E performed rapidly (2-3 min goal)
3. Scoop and run vs stay and play:
   • Critical trauma patient: LOAD AND GO - stabilize basics only; get to hospital fast (goal <10 min on scene for penetrating trauma)
   • Only minor injuries: may take time on scene to fully treat
4. Spinal Motion Restriction (SMR):
   • Full SMR: C-collar + long spine board/vacuum mattress
   • Indications: Altered mental status + trauma, spine pain/tenderness, neurological deficits, high-energy mechanism
   • In conscious, alert, sober patients with no spine pain and normal motor/sensory = can clear clinically (NEXUS criteria)

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Q11. What are the NEXUS criteria for clearing cervical spine without X-ray?

1. No midline cervical tenderness (press along posterior spinous processes - no pain)
2. No focal neurological deficit
3. Normal alertness (GCS 15, no drugs/alcohol)
4. No intoxication
5. No painful distracting injury (e.g., no femur fracture causing distraction)

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Q12. What are the types of head injuries an EMT must know?

1. Concussion (Mild TBI - GCS 13-15):

• Temporary loss of consciousness or confusion after head injury
• Headache, nausea, amnesia
• No structural damage on CT
• Rest and observation

2. Epidural Hematoma:

• Lucid interval followed by rapid deterioration = CLASSIC presentation
• Cause: Temporal bone fracture + middle meningeal artery rupture
• CT: Biconvex (lens-shaped) hyperdense lesion
• Crosses midline: NO | Crosses suture lines: NO
• Treatment: Emergency craniotomy

3. Subdural Hematoma:

• Acute: Bridging vein rupture; rapid deterioration; crescent-shaped bleed on CT
• Chronic: Elderly patients on anticoagulants; weeks after minor fall; headache, confusion
• CT: Crescent-shaped (concave) lesion
• Crosses suture lines: YES
• Treatment: Craniotomy or burr holes

4. Subarachnoid Hemorrhage (SAH):

• "Worst headache of my life" - sudden onset thunderclap headache
• Cause: Ruptured cerebral aneurysm
• CT: Star-shaped blood in subarachnoid space
• Treatment: Neurosurgery; nimodipine (prevents vasospasm)

5. Intracerebral Hemorrhage:

• Bleeding within brain tissue; hypertension most common cause
• Altered consciousness, focal deficits
• CT: Hyperdense lesion within brain parenchyma

• Protect airway (intubate if GCS ≤8)
• Maintain SpO2 >94% and ETCO2 35-40 mmHg (avoid hypoxia AND hypocapnia)
• Maintain MAP ≥80 mmHg (cerebral perfusion pressure)
• Do NOT give excessive fluids
• Head of bed 30 degrees
• Urgent CT head

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Q13. What is the management of burns?

Classification:

Rule of Nines (adult BSA estimation):

• Head and neck: 9%
• Each arm: 9% (total 18%)
• Chest: 9% | Abdomen: 9% (Anterior trunk = 18%)
• Upper back: 9% | Lower back: 9% (Posterior trunk = 18%)
• Each thigh: 9% | Each lower leg: 9% (each leg = 18%; total = 36%)
• Genitalia: 1%
• Lund-Browder chart is more accurate for children (head larger)

Parkland Formula (fluid resuscitation for burns >20% BSA):

4 mL x Weight (kg) x %BSA burned = total IV fluid (Lactated Ringer's) in first 24 hours

• Give half in first 8 hours from time of burn (not from hospital arrival)
• Give remaining half over next 16 hours

Initial EMT management:

1. Stop burning (remove clothing, cool with room temperature water 10-20 min - NOT ice)
2. Airway priority: singed eyebrows/nasal hair, hoarseness, carbonaceous sputum = airway burn = intubate EARLY
3. IV access x2; fluid resuscitation (Parkland formula)
4. Pain management (IV morphine/ketamine)
5. Cover with clean dry dressing; keep warm
6. Catheter (urine output target: 0.5-1 mL/kg/hr adults; 1 mL/kg/hr children)

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DAY 5 - SHOCK MANAGEMENT (EXTENDED)

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Q14. What is the Surviving Sepsis Campaign bundle for septic shock?

• Life-threatening organ dysfunction due to dysregulated host response to infection
• Septic shock = sepsis + vasopressor needed to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L despite adequate fluid resuscitation

1. Measure lactate (repeat if >2 mmol/L)
2. Blood cultures x2 (before antibiotics - peripheral + central line)
3. Broad-spectrum antibiotics IV within 1 hour (do NOT delay for cultures)
4. IV Crystalloid 30 mL/kg for hypotension or lactate ≥4 mmol/L
5. Norepinephrine if hypotensive during or after fluid resuscitation

• 1st line: Norepinephrine (balanced alpha + beta; prevents tachycardia)
• 2nd line: Vasopressin 0.01-0.03 units/min (to reduce norepinephrine dose)
• Dobutamine if cardiac dysfunction (low cardiac output component)
• Goal: MAP ≥65 mmHg, urine output ≥0.5 mL/kg/hr, normalizing lactate

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Q15. What is cardiac tamponade and how is it treated?

Pathophysiology:

Signs - Beck's Triad:

1. Hypotension (low BP)
2. Raised JVP (distended neck veins - elevated CVP)
3. Muffled heart sounds (fluid dampens sounds)

• Pulsus paradoxus: BP drops >10 mmHg during inspiration (classic for tamponade)
• Tachycardia
• Electrical alternans on ECG (alternating QRS height)

Causes:

• Penetrating chest trauma (stab wound) - most common in young trauma patients
• Post-cardiac surgery
• Malignancy (slow-filling)
• Pericarditis, TB, uraemia

Treatment:

• Pericardiocentesis - needle aspiration
  • Patient sitting up at 45 degrees
  • Insert needle at subxiphoid angle, aim toward left shoulder at 45 degrees
  • Even 10-15 mL removal dramatically improves cardiac output
  • Ideally ultrasound-guided
• Definitive: Surgical pericardial window or pericardiotomy in theatre

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Q16. What is massive transfusion protocol (MTP)?

1. Permissive hypotension: Target systolic BP 80-90 mmHg (NOT 120) in penetrating trauma until surgical hemorrhage control - prevents "popping the clot"
2. Balanced resuscitation: Ratio of pRBC : FFP : Platelets = 1:1:1
3. Avoid crystalloid - dilutes clotting factors and worsens coagulopathy
4. Tranexamic acid (TXA): Give within 3 hours of injury - 1g IV over 10 min + 1g over 8 hours
5. Correct the "lethal triad": Hypothermia + Acidosis + Coagulopathy

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DAY 6 - NEUROLOGICAL EMERGENCIES (EXTENDED)

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Q17. What are the types of strokes and how do you differentiate them?

• Hemorrhagic stroke looks IDENTICAL clinically to ischemic stroke
• tPA in a hemorrhagic stroke = catastrophic - massively worsens the bleed
• CT scan immediately differentiates: blood appears WHITE on non-contrast CT

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Q18. What is increased intracranial pressure (ICP) and how do you manage it?

1. Hypertension (rising BP - body trying to perfuse brain)
2. Bradycardia (reflex)
3. Irregular respirations (Cheyne-Stokes)

1. Head of bed 30-45 degrees
2. Avoid hyponatremia - may use hypertonic saline
3. Mannitol 0.25-1 g/kg IV (osmotic diuretic - draws water out of brain)
4. Controlled hyperventilation (ETCO2 30-35 mmHg) - temporary bridge only (causes cerebral vasoconstriction)
5. Avoid hypotension (maintain MAP ≥80 mmHg for cerebral perfusion)
6. Surgical decompression (decompressive craniectomy) for refractory cases

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Q19. What is spinal cord injury and what is neurogenic shock?

• C3-C5: Diaphragm (C3,4,5 keeps the diaphragm alive) - above this level = cannot breathe
• C5-C6: Biceps, wrist extension
• C7: Triceps, wrist flexion
• T1-T12: Intercostals, abdominal muscles
• L1-L2: Hip flexors
• L3-L4: Quadriceps, knee extension
• L4-L5: Ankle dorsiflexion (foot drop if injured)
• S2-S4: Bladder, bowel, erectile function

• Loss of sympathetic tone below lesion
• Result: Vasodilation + bradycardia
• UNIQUE FEATURE: Bradycardia with hypotension (all other shocks have tachycardia)
• Warm, dry, flushed skin (vasodilated)
• Treatment: Atropine for bradycardia; Vasopressors (norepinephrine/phenylephrine) for hypotension; careful fluids (risk of pulmonary edema)
• Maintain spinal immobilization

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Q20. What is meningitis and how do you recognise it?

1. Fever
2. Neck stiffness (nuchal rigidity)
3. Photophobia (sensitivity to light)

• Kernig's sign: Cannot extend knee when hip flexed at 90 degrees (pain)
• Brudzinski's sign: Passive neck flexion causes involuntary hip and knee flexion
• Purpuric/petechial rash (non-blanching) = meningococcal disease - EMERGENCY
• Altered consciousness, seizures

1. Immediate assessment and IV access
2. Do NOT delay antibiotics for CT scan or LP if patient deteriorating
3. IV Benzylpenicillin (if pre-hospital, in UK: 1.2g for adults before hospital transfer)
4. In hospital: Ceftriaxone 2g IV + Dexamethasone 0.15 mg/kg IV
5. Isolation precautions (droplet)

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DAY 7 - TOXICOLOGY (EXTENDED)

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Q21. What are the major toxidromes (poisoning syndromes)?

1. Cholinergic Toxidrome (too much acetylcholine)

• Causes: Organophosphates, carbamates, nerve agents, pilocarpine
• DUMBBELS: Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm/Bronchorrhea, Emesis, Lacrimation, Salivation
• Nicotinic effects: Muscle fasciculations, weakness, paralysis (can't breathe)
• Treatment: Atropine (large doses) + Pralidoxime

2. Anticholinergic Toxidrome (blocked acetylcholine)

• Causes: Atropine, antihistamines, TCA antidepressants, jimsonweed
• Mnemonic: "Hot as a hare, Blind as a bat, Dry as a bone, Red as a beet, Mad as a hatter"
  • Hyperthermia, Mydriasis (dilated pupils), Dry skin/mouth, Flushing, Confusion/hallucinations
  • Tachycardia, urinary retention, decreased bowel sounds
• Treatment: Physostigmine (specific antidote); supportive care; benzodiazepines for agitation

3. Opioid Toxidrome (too much opioid)

• Causes: Morphine, heroin, codeine, fentanyl, tramadol
• Classic triad: Miosis (pinpoint pupils) + Respiratory depression + Decreased consciousness
• Treatment: Naloxone 0.4-2 mg IV/IM/IN; repeat every 2-3 min

4. Sympathomimetic Toxidrome (too much adrenaline)

• Causes: Cocaine, amphetamines, MDMA (ecstasy), caffeine overdose
• Signs: Mydriasis (dilated pupils), tachycardia, hypertension, hyperthermia, diaphoresis, agitation
• Treatment: Benzodiazepines (calm hyperadrenergic state); cooling; avoid beta-blockers (causes unopposed alpha = worse hypertension)

5. Sedative-Hypnotic Toxidrome

• Causes: Benzodiazepines, barbiturates, alcohol
• Signs: CNS depression, respiratory depression, slurred speech, ataxia; NORMAL pupils
• Treatment: Airway support; flumazenil for benzodiazepines (use with caution)

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Q22. What is the management of paracetamol (acetaminophen) overdose?

• Normal dose: paracetamol conjugated safely in liver
• Overdose: NAPQI (toxic metabolite) accumulates, depletes glutathione, causes liver necrosis
• Critical period: 72-96 hours after ingestion = maximum liver damage

• 0-24 hr: Nausea, vomiting, malaise (may appear well)
• 24-72 hr: Right upper quadrant pain, rising LFTs
• 72-96 hr: Liver failure, jaundice, coagulopathy, encephalopathy

• 96 hr: Recovery OR death from liver failure

1. If <1-2 hours: Activated charcoal 50g orally (absorbs paracetamol in gut)
2. N-Acetylcysteine (NAC) = definitive antidote:
   • Replenishes glutathione stores
   • IV regime: 150 mg/kg in 200 mL 5% Dextrose over 60 min → 50 mg/kg over 4 hours → 100 mg/kg over 16 hours
   • Start within 8 hours for maximum benefit (still give up to 24 hours)
3. Monitor LFTs, INR, creatinine, blood glucose
4. Liver transplant assessment if fulminant liver failure develops

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Q23. What is carbon monoxide (CO) poisoning?

1. Remove from exposure; scene safety
2. 100% O2 via non-rebreather mask - reduces COHb half-life from 5 hours to 90 minutes
3. Hyperbaric oxygen (HBO) if: COHb >25%, unconscious, cardiac arrhythmias, neurological signs, pregnancy - reduces half-life to 20-30 min
4. Supportive care; ECG monitoring (CO causes arrhythmias)

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DAY 8 - PAEDIATRIC & OBSTETRIC EMERGENCIES (EXTENDED)

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Q24. What are the key differences in paediatric emergency assessment?

1. Appearance (TICLS):
   • Tone: Is child active, limp, or floppy?
   • Interactiveness: Engaged, curious, or unresponsive?
   • Consolability: Can parent comfort them?
   • Look/Gaze: Direct eye contact or glazed?
   • Speech/Cry: Strong cry or weak/absent?
2. Work of Breathing:
   • Nasal flaring, grunting, retractions (subcostal, intercostal, sternal)
   • Head bobbing (severe respiratory distress in infants)
   • Audible sounds: stridor, wheeze, grunting
3. Circulation (skin color):
   • Pallor (anemia, shock), cyanosis (hypoxia), mottling (impaired perfusion), flushing

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Q25. How do you manage croup vs epiglottitis?

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Q26. What is the Paediatric Early Warning Score (PEWS)?

• Behaviour (normal/sleeping/irritable/lethargic/confused)
• Cardiovascular (colour/capillary refill/HR)
• Respiratory (RR/work of breathing/SpO2)

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Q27. What are the neonatal emergencies an EMT must recognise?

Neonatal Resuscitation:

• At birth: Dry, stimulate, assess tone, breathing, HR
• HR <100 + not breathing adequately → BVM ventilation with air (21% O2) at 40-60 breaths/min
• HR <60 despite 30 sec effective ventilation → start CPR: 3:1 ratio (3 compressions : 1 breath), rate 120 events/min
• Vascular access: umbilical vein catheter

Hypoglycaemia in neonate:

• Blood glucose <2.6 mmol/L in neonate = emergency
• Treatment: 2 mL/kg 10% Dextrose IV

Respiratory Distress Syndrome (RDS):

• Premature baby (lungs not mature, lack surfactant)
• Signs: grunting, nasal flaring, subcostal retractions, cyanosis
• Treatment: surfactant replacement therapy, CPAP

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Q28. Obstetric emergencies - full details

Pre-eclampsia vs Eclampsia:

• Loading dose: 4g IV in 100 mL NS over 10-15 min
• Maintenance: 1g/hr IV infusion
• Toxicity signs (in order): Loss of DTRs → Respiratory depression → Cardiac arrest
• Antidote for MgSO4 toxicity: Calcium gluconate 10 mL of 10% IV
• Therapeutic level: 2-3.5 mmol/L
• Check: patellar reflexes, urine output, respiratory rate before each dose

HELLP Syndrome (severe pre-eclampsia variant):

• Hemolysis + Elevated Liver enzymes + Low Platelets
• Treatment: Urgent delivery; transfuse if platelets <20,000

Ectopic Pregnancy:

• Fertilised egg implants outside uterus (usually fallopian tube)
• Risk factors: PID, previous ectopic, IUD
• Signs: Amenorrhoea + lower abdominal pain + vaginal bleeding
• Can rupture → massive intraperitoneal hemorrhage → shock
• Positive pregnancy test + hemodynamic instability = ruptured ectopic until proven otherwise
• Treatment: Emergency surgery (salpingectomy)

Placenta Praevia vs Placental Abruption:

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DAY 9 - MEDICAL EMERGENCIES (EXTENDED)

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Q29. What is acute pulmonary oedema and how do you manage it?

• Severe breathlessness (orthopnoea - cannot lie flat)
• Pink frothy sputum
• Bilateral crackles (basal, moving upward as severity worsens)
• SpO2 dropping despite O2
• Tachycardia; raised JVP; gallop rhythm (S3)

• Alveolar oedema (bat wing opacification)
• B-lines / Kerley B lines (interstitial oedema)
• Cardiomegaly
• Diversion (upper lobe blood diversion)
• Effusions (pleural)

1. Sit patient upright
2. High-flow O2 (target SpO2 94-98%)
3. CPAP (Continuous Positive Airway Pressure) - if available; improves gas exchange significantly
4. IV Furosemide (Frusemide) 40-80 mg IV (diuresis - removes fluid)
5. GTN (Glyceryl Trinitrate) sublingual/infusion (vasodilation - reduces preload/afterload; only if BP >90)
6. Morphine 2.5-5 mg IV (reduces anxiety and venodilation - use cautiously)
7. Treat underlying cause: AF (rate control), MI (reperfusion), hypertensive crisis (antihypertensives)
8. Intubation if respiratory failure despite CPAP

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Q30. What is COPD exacerbation and how do you manage it?

• Barrel chest, pursed lip breathing, use of accessory muscles
• Prolonged expiratory phase, wheeze
• Cyanosis, confusion (hypercapnia)
• SpO2 low but may be chronically low

1. Controlled O2: target SpO2 88-92% (NOT 100% - hypercapnic drive)
   • Use Venturi mask 24-28% first; titrate up slowly
2. Nebulized Salbutamol 2.5-5 mg + Ipratropium 0.5 mg (bronchodilators)
3. Oral Prednisolone 30-40 mg (or hydrocortisone 200 mg IV if cannot swallow)
4. Antibiotics if purulent sputum/signs of infection (amoxicillin or doxycycline)
5. NIV (BiPAP) for hypercapnic respiratory failure (pH <7.35 + PaCO2 >6 kPa)
6. Intubation only if NIV fails (high mortality in COPD)

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Q31. What is acute kidney injury (AKI) and what are the causes?

1. Treat underlying cause
2. Stop nephrotoxins (NSAIDs, aminoglycosides, contrast)
3. Fluid challenge for pre-renal AKI (500 mL crystalloid bolus)
4. Monitor electrolytes - especially hyperkalemia (cardiac arrhythmias)
5. Strict fluid balance and urine output measurement
6. Dialysis if: severe hyperkalemia, metabolic acidosis, pulmonary edema, uremia

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Q32. How do you manage hyperkalemia?

1. Peaked (tall, tented) T waves - FIRST sign
2. Prolonged PR interval
3. Widening QRS
4. Sine wave pattern
5. VF/Asystole

1. Calcium gluconate 10 mL 10% IV over 2-5 min (stabilizes cardiac membrane - FIRST LINE; works in 1-3 min; does NOT reduce K+)
2. Insulin 10 units + 50 mL 50% Dextrose IV (shifts K+ into cells; works in 15-30 min)
3. Salbutamol 10-20 mg nebulized (shifts K+ into cells; adjunct)
4. Sodium bicarbonate (if metabolic acidosis)
5. Calcium resonium (oral/PR) or Patiromer (binds K+ in gut - slow)
6. Dialysis for severe/refractory hyperkalemia

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DAY 10 - HOSPITAL PROTOCOLS, COMMUNICATION & FINAL EXAM PREP

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Q33. What is the hospital emergency response for Code Blue?

1. Person who finds patient: Calls "Code Blue" to switchboard (or presses emergency button), starts CPR
2. Code Blue team responds within 3 minutes (typically: senior doctor, anaesthetist, nurse, runner)
3. Role allocation on arrival:
   • Team leader: Most senior clinician; directs team; rhythm analysis decisions
   • Compressor: CPR (rotated every 2 min to prevent fatigue)
   • Airway person: BVM → intubation
   • IV/IO access + drug administration
   • Recorder: Documents time of events, drugs, rhythm changes
   • Runner: Gets drugs, equipment
4. DNAR (Do Not Attempt Resuscitation): Always check before starting resuscitation; valid DNAR order overrides team response
5. Post-resuscitation care (ROSC):
   • Target SpO2 94-98%; ETCO2 35-40 mmHg
   • Target MAP ≥65 mmHg; avoid hypotension
   • 12-lead ECG (check for STEMI → PCI)
   • Targeted Temperature Management (TTM): 32-36°C for 24 hours if still unconscious
   • Urgent CT brain if cause unclear

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Q34. What are medication safety practices in emergency settings?

1. Right Patient (check ID band + ask name + DOB)
2. Right Drug (read label twice)
3. Right Dose (calculate correctly; double-check with colleague for high-risk drugs)
4. Right Route (IV, IM, oral, nebulized)
5. Right Time (give at correct interval)

• Insulin (type + dose)
• Concentrated electrolytes (KCl, NaCl 3%, MgSO4)
• Opioids
• Anticoagulants (heparin, warfarin)
• Neuromuscular blockers (succinylcholine, rocuronium)
• Concentrated adrenaline (1:1000 vs 1:10,000)

• Give a verbal order without read-back confirmation
• Pre-draw and label multiple syringes without immediately using them
• Give any drug without checking allergy status first

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Q35. What are infection prevention and control (IPC) fundamentals?

Standard Precautions (apply to ALL patients):

• Hand hygiene (5 moments)
• PPE: Gloves, apron, mask, eye protection (based on risk)
• Safe sharps disposal
• Safe handling of body fluids
• Environmental cleaning

Transmission-Based Precautions:

N95 vs surgical mask:

• Surgical mask: Protects OTHERS from the wearer (large droplets only)
• N95/FFP2/FFP3: Protects the WEARER from airborne particles (TB, aerosol-generating procedures)

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Q36. What are the key documentation principles in emergency care?

MIST Handover (used for trauma/emergency handover):

• M - Mechanism of injury
• I - Injuries identified (and suspected)
• S - Signs and vital signs (initial and current)
• T - Treatment given (drugs, fluids, interventions) and time given

Legal documentation rules:

• Write legibly in BLACK ink
• Date, time, sign every entry
• Never use correction fluid/Tipp-Ex - strike through with single line and initial
• Record: Time of events, vital signs, assessments, interventions, responses, discussions with relatives
• Document any refusal of treatment (patient must sign)
• Document DNAR discussions

Electronic records:

• Every login is auditable - never use another person's login
• Document immediately or within the same shift

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Q37. What are common interview MCQ scenario questions with answers?

Scenario 1:

• Call for help
• Deliver shock: 200J biphasic (or 360J monophasic)
• Immediately resume CPR for 2 min post-shock
• Continue ACLS algorithm

Scenario 2:

• Airway first: BVM ventilation with 100% O2
• IV/IM Naloxone 0.4-2 mg immediately
• Repeat every 2-3 minutes if no response (up to 10 mg total)
• Watch for re-sedation - observe for minimum 4 hours after last naloxone dose

Scenario 3:

• Airway, left lateral tilt, O2
• Diazepam 10 mg IV if actively seizing
• MgSO4 4g IV over 15 min (loading dose) + 1g/hr infusion
• Labetalol 20 mg IV or Nifedipine orally for BP
• Urgent obstetric review for delivery

Scenario 4:

• Do NOT give thrombolysis (catastrophic)
• Urgent CT aortogram
• Urgent cardiothoracic surgery review
• Control BP: IV Labetalol or Esmolol (target systolic 100-120 mmHg)

Scenario 5:

• In COPD: chronically high CO2; respiratory drive is hypoxic (not hypercapnic)
• High-flow O2 suppresses this drive → respiratory arrest
• Titrate O2 slowly; prepare for NIV (BiPAP) if hypercapnic

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Q38. What are the most likely written exam MCQ topics for Apollo/CMC/Kavery?

Guaranteed Topics (appear in almost every hospital exam):

1. CPR ratios and compression depths
2. Defibrillation energy settings and shockable vs non-shockable rhythms
3. ACLS drugs (epinephrine dose, amiodarone dose)
4. 4H 4T reversible causes
5. Anaphylaxis management (epinephrine dose, route, concentration)
6. GCS scoring and intubation threshold
7. Oxygen delivery devices and FiO2
8. Types of shock and differentiating features
9. Triage (START system - Red/Yellow/Green/Black)
10. ECG rhythm recognition (AF, VT, VF, SVT, Complete heart block)
11. STEMI location on ECG (leads)
12. Stroke FAST assessment and tPA criteria
13. Organophosphate poisoning signs (DUMBBELS) and antidotes
14. Burns: Rule of Nines and Parkland formula
15. Needle decompression site (tension pneumothorax)
16. WHO 5 moments of hand hygiene
17. Hospital emergency codes (Code Blue, Red, Pink, etc.)
18. Normal vital signs by age group
19. Pediatric CPR differences
20. MgSO4 for eclampsia - dose and toxicity signs

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COMPLETE RAPID REVISION CARD

Cut this out and read every morning:

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Sources used: Tintinalli's Emergency Medicine | Rosen's Emergency Medicine | Miller's Anesthesia | Roberts and Hedges' Clinical Procedures in Emergency Medicine | The Washington Manual of Medical Therapeutics | Sabiston Textbook of Surgery | Goldman-Cecil Medicine | Lippincott's Pharmacology | Goodman & Gilman's Pharmacology | AHA 2020 Guidelines

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