NREMT - National Registry of Emergency Medical Technicians Neurological Emergencies & Stroke Care 1 — Questions and Answers
Question 1: A 62-year-old patient describes the sudden onset of 'the worst headache of my life,' with a stiff neck and sensitivity to light. This presentation is most suspicious for:
- Ischemic stroke affecting the frontal lobe
- Subarachnoid hemorrhage from a ruptured aneurysm (Correct answer)
- Hypertensive encephalopathy
- Complex migraine with aura
Correct answer: Subarachnoid hemorrhage from a ruptured aneurysm
A sudden, severe 'thunderclap' headache — especially with nuchal rigidity and photophobia — is the hallmark presentation of subarachnoid hemorrhage. Ischemic stroke rarely causes headache of this severity, and migraine is a diagnosis of exclusion in this context.
Question 2: When transporting a conscious, hemodynamically stable stroke patient without respiratory distress, the most appropriate position is:
- Supine with legs elevated 12 inches
- Semi-Fowler's with the head elevated 15–30 degrees (Correct answer)
- Trendelenburg to maximize cerebral perfusion
- Recovery position on the paralyzed side
Correct answer: Semi-Fowler's with the head elevated 15–30 degrees
A slight head elevation (15–30 degrees) in a conscious stroke patient helps reduce intracranial pressure while maintaining adequate cerebral perfusion pressure. Trendelenburg and leg elevation can worsen intracranial hypertension.
Question 3: During an active generalized tonic-clonic seizure, the EMT's MOST important intervention is:
- Inserting a bite block between the patient's teeth to protect the airway
- Firmly restraining the patient's limbs to prevent musculoskeletal injury
- Protecting the patient's head and maintaining airway patency (Correct answer)
- Immediately administering high-flow oxygen via non-rebreather mask
Correct answer: Protecting the patient's head and maintaining airway patency
During an active seizure the priority is preventing injury — especially head trauma — and keeping the airway clear. Nothing should be placed in the patient's mouth, and limb restraint risks injury to both patient and rescuer. Oxygen can be applied when feasible but is secondary to safety.
Question 4: A patient's blood pressure is 210/118 mmHg, heart rate is 44 bpm, and respirations are irregular. The patient is unresponsive with unequal pupils. These findings together are most consistent with:
- Severe hypoglycemic crisis
- Increasing intracranial pressure (Cushing's triad) (Correct answer)
- Anaphylactic shock with neurological involvement
- Hypovolemic shock with compensatory response
Correct answer: Increasing intracranial pressure (Cushing's triad)
Cushing's triad — hypertension, bradycardia, and irregular respirations — is a late, ominous sign of rising intracranial pressure causing brainstem herniation. Unequal pupils further confirm herniation. This is a true emergency requiring immediate transport.
Question 5: A patient tells you they experienced left-arm weakness and slurred speech that completely resolved on its own about 20 minutes ago. The patient now feels fine and refuses transport. The EMT's best course of action is to:
- Allow refusal since symptoms have fully resolved and document accordingly
- Encourage transport urgently, explaining that a TIA significantly raises the short-term risk of stroke (Correct answer)
- Monitor the patient on scene for another 30 minutes to confirm symptoms do not return
- Contact medical control only if symptoms recur within the hour
Correct answer: Encourage transport urgently, explaining that a TIA significantly raises the short-term risk of stroke
A transient ischemic attack (TIA) is a neurological emergency even when symptoms resolve completely. The risk of a subsequent — potentially disabling — stroke is highest in the hours to days following a TIA. Patients must be strongly encouraged to accept transport for urgent evaluation.
Question 6: Using the AVPU scale, how would you classify a patient who moans and withdraws only when you apply a sternal rub, but does not respond to your voice?
- Alert
- Verbal
- Pain (Correct answer)
- Unresponsive
Correct answer: Pain
The AVPU scale classifies level of consciousness as: Alert (spontaneously aware), Verbal (responds to voice commands), Pain (responds only to painful stimuli), and Unresponsive (no reaction). A patient who requires a painful stimulus to elicit any response is classified as 'P' — Pain.
NREMT - National Registry of Emergency Medical Technicians Neurological Emergencies & Stroke Care 1
A 62-year-old patient describes the sudden onset of 'the worst headache of my life,' with a stiff neck and sensitivity to light.
This presentation is most suspicious for: