DHA Emergency Medical Services 2 — Questions and Answers
Question 1: A 25-year-old male is brought to the ED after a road traffic accident. He is unresponsive, BP 70/40 mmHg, HR 130 bpm, and has absent breath sounds on the right side with tracheal deviation to the left. What is the immediate management?
- Chest X-ray to confirm diagnosis
- Immediate needle thoracostomy in the right 2nd intercostal space, midclavicular line (Correct answer)
- Insertion of bilateral chest drains
- IV fluid resuscitation with 2L normal saline
Correct answer: Immediate needle thoracostomy in the right 2nd intercostal space, midclavicular line
This is a tension pneumothorax — a life-threatening emergency requiring immediate needle decompression. Tracheal deviation away from the affected side, absent breath sounds, and hemodynamic instability are classic signs. Do not wait for imaging.
Tension pneumothorax: air enters pleural space and cannot escape, shifting mediastinum and compressing the heart. Classic triad: absent breath sounds, hypotension, tracheal deviation (away from tension side). Treatment: immediate needle thoracostomy (14G needle, 2nd ICS, MCL) as temporizing measure, followed by definitive chest drain (5th ICS, mid-axillary line). Never delay for CXR in hemodynamically unstable patients.
Question 2: An adult patient in cardiac arrest is receiving CPR. After the second defibrillation shock, which medication should be administered next according to ACLS guidelines?
- Atropine 1mg IV
- Amiodarone 300mg IV bolus
- Epinephrine 1mg IV every 3–5 minutes (Correct answer)
- Calcium gluconate 1g IV
Correct answer: Epinephrine 1mg IV every 3–5 minutes
Per ACLS guidelines, epinephrine 1mg IV should be given as soon as possible during cardiac arrest. For shockable rhythms (VF/pVT), epinephrine is given after the second shock. It is repeated every 3–5 minutes throughout resuscitation.
In ACLS: for VF/pVT, defibrillate as soon as available. Epinephrine 1mg IV/IO is given every 3–5 minutes throughout. Amiodarone 300mg IV is given after the 3rd shock for refractory VF/pVT (lidocaine is an alternative). Epinephrine's alpha-adrenergic effects increase coronary perfusion pressure during CPR, improving ROSC rates.
Question 3: A 60-year-old male presents with sudden onset severe headache described as 'the worst headache of my life.' Neurological exam is normal. CT head is negative. What is the next most important step?
- MRI brain with contrast
- Lumbar puncture (Correct answer)
- Prescribe analgesics and discharge
- CT angiography of cerebral vessels
Correct answer: Lumbar puncture
A 'thunderclap' headache with normal CT requires lumbar puncture to rule out subarachnoid hemorrhage (SAH). CT misses ~2–5% of SAH (especially early presentations). LP looks for xanthochromia (yellow discoloration of CSF), which indicates prior bleeding.
SAH workup: CT head (sensitivity ~98% within 6 hours of onset, decreases thereafter). If CT negative and clinical suspicion remains, LP is mandatory — xanthochromia (from hemoglobin breakdown products) is diagnostic and detectable 2–4 hours after bleed, lasting up to 2 weeks. CT angiography is done to identify the aneurysm once SAH is confirmed. DHA exams frequently test this two-step diagnostic approach.
Question 4: In the ED, a patient presents with anaphylaxis with urticaria, angioedema, and bronchospasm after a bee sting. What is the first-line treatment?
- IV hydrocortisone 200mg
- IV diphenhydramine 50mg
- IM epinephrine 0.3–0.5mg (1:1000) in the outer thigh (Correct answer)
- Nebulized salbutamol
Correct answer: IM epinephrine 0.3–0.5mg (1:1000) in the outer thigh
IM epinephrine (0.3–0.5mg of 1:1000 concentration) in the anterolateral thigh is the first-line and most critical treatment for anaphylaxis. It reverses bronchospasm, hypotension, and angioedema. All other treatments are adjuncts.
Anaphylaxis management: IM epinephrine (1:1000, 0.3mg adults, 0.01mg/kg children) anterolateral thigh — fastest absorption compared to deltoid or lateral thigh. Adjuncts: antihistamines (H1+H2), corticosteroids (reduce biphasic reactions), bronchodilators. Patient should be observed for 4–6 hours due to biphasic anaphylaxis risk. Prescribe epinephrine auto-injector on discharge. Corticosteroids are NOT first-line.
Question 5: A patient presents with heat stroke: core temperature 41.5°C, confusion, and hot dry skin after outdoor work in Dubai summer. What is the most effective cooling method?
- Oral rehydration with cold fluids
- Ice water immersion or aggressive evaporative cooling (Correct answer)
- Antipyretic medications (paracetamol/ibuprofen)
- IV normal saline at room temperature
Correct answer: Ice water immersion or aggressive evaporative cooling
Classic heat stroke is a medical emergency requiring rapid core cooling. Ice water immersion achieves the fastest cooling rate (0.2°C/min). Evaporative cooling (wetting skin + fanning) is also effective. Target core temperature <39°C within 30 minutes. Antipyretics are ineffective as heat stroke is not fever — it is thermoregulatory failure.
Heat stroke in Dubai (classic and exertional) is a critical DHA exam topic. Exertional heat stroke (EHS) in outdoor workers is common in UAE. Management: remove from heat, ice water immersion (most effective), cold IV fluids, cool mist + fanning. Avoid antipyretics (ineffective). Monitor for rhabdomyolysis (CK, urine myoglobin), AKI, DIC, hepatic failure. UAE labor law mandates midday work ban (12:30–3:00 PM) June–September.
Question 6: A trauma patient arrives in the ED with open fracture of the right femur, BP 85/50, HR 145, and active bleeding. In the initial management, what is the correct order of priorities per ATLS?
- Control bleeding first, then airway management
- Airway → Breathing → Circulation → Disability → Exposure (Correct answer)
- Fluid resuscitation, then splinting the femur
- Immediate surgical consultation before any intervention
Correct answer: Airway → Breathing → Circulation → Disability → Exposure
ATLS follows the ABCDE primary survey: Airway (with cervical spine control), Breathing, Circulation (hemorrhage control), Disability (neuro), Exposure. Even with visible external bleeding, airway takes priority. Direct pressure on wounds can occur simultaneously with airway assessment.
ATLS ABCDE: A — Airway with C-spine control; B — Breathing and ventilation; C — Circulation with hemorrhage control (direct pressure, tourniquet); D — Disability (GCS, pupils); E — Exposure/environment. For femur fractures: traction splint reduces blood loss (femur can hold 1–1.5L). Permissive hypotension (target SBP 80–90) in penetrating trauma; normal BP in TBI. DHA exam tests ATLS principles extensively.
DHA Emergency Medical Services 2
A 25-year-old male is brought to the ED after a road traffic accident.
He is unresponsive, BP 70/40 mmHg, HR 130 bpm, and has absent breath sounds on the right side with tracheal deviation to the left.
What is the immediate management?