Epinephrine and Initial Management Practice Questions

25 multiple-choice questions on Epinephrine and initial management for paramedic and EMT students, from Chapter 26 (Immunologic Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Your partner draws up 0.3 mL from a prefilled 0.1 mg/mL epinephrine syringe to give IM for anaphylaxis. The problem is that this:

   1. A. Gives one-tenth of the intended dose
   2. B. Gives ten times the intended dose
   3. C. Is correct but belongs in the deltoid
   4. D. Is correct but must be given IV
   Show answer

   Answer: A. Gives one-tenth of the intended dose

   IM epinephrine for anaphylaxis uses the 1 mg/mL concentration, so 0.3 mL equals 0.3 mg. The same volume of the 0.1 mg/mL cardiac concentration delivers only 0.03 mg, an ineffective dose. The fix is the right concentration, not a different route or site.

2. A patient improves after IM epinephrine, but 15 minutes later the wheezing and low BP return. The most likely reason is that:

   1. A. The first dose went into the wrong leg
   2. B. The effect of one dose is short-lived
   3. C. Epinephrine has caused a new allergy
   4. D. The dose was absorbed too slowly
   Show answer

   Answer: B. The effect of one dose is short-lived

   A single IM dose acts for a relatively short time, while mast-cell mediators can keep coming. Returning symptoms call for a repeat dose. Either thigh works, epinephrine does not cause allergy, and IM thigh absorption is fast.

3. A patient in anaphylaxis has bilateral above-knee amputations. The best alternative site for IM epinephrine is the:

   1. A. Deltoid muscle
   2. B. Abdominal fat
   3. C. Upper gluteal fat
   4. D. Forearm skin
   Show answer

   Answer: A. Deltoid muscle

   When the anterolateral thigh cannot be used, the deltoid is the usual alternate IM site. Injecting into fat or skin gives subcutaneous absorption, which is slower and less reliable. Do not delay the dose to obtain IV access.

4. A 12-kg toddler is in anaphylaxis. The only auto-injector available is a 0.15-mg device. You should:

   1. A. Wait until a dose can be drawn by weight
   2. B. Give half the device into each thigh
   3. C. Give oral diphenhydramine instead
   4. D. Give the 0.15-mg device without delay
   Show answer

   Answer: D. Give the 0.15-mg device without delay

   For a 12-kg child the ideal dose is about 0.12 mg, but delaying epinephrine is more dangerous than the small overdose from a 0.15-mg device. The American Academy of Pediatrics advises using it rather than waiting. Auto-injectors cannot be split, and antihistamines do not treat anaphylaxis.

5. A patient in profound anaphylactic shock has had three IM epinephrine doses with little effect. One reason IM doses may fail is:

   1. A. The thigh muscle destroys epinephrine
   2. B. Antihistamines are blocking epinephrine
   3. C. Poor muscle blood flow slows absorption
   4. D. IM epinephrine works mainly on the skin
   Show answer

   Answer: C. Poor muscle blood flow slows absorption

   In severe shock, blood is shunted away from muscle, so drug from an IM injection reaches the circulation slowly. That is why refractory shock calls for IV epinephrine by infusion, along with fluids, per protocol. Antihistamines do not block epinephrine.

6. A patient used her nasal epinephrine spray 10 minutes ago, and her wheezing and hives are worse. You should:

   1. A. Wait 30 minutes for the spray to work
   2. B. Give oral diphenhydramine instead
   3. C. Repeat the spray in 1 hour
   4. D. Give IM epinephrine per protocol
   Show answer

   Answer: D. Give IM epinephrine per protocol

   Needle-free nasal epinephrine is absorbed through the nasal lining. If symptoms persist or worsen after 5 minutes, another dose is needed, and EMS gives IM epinephrine per protocol. Waiting or substituting an antihistamine delays the only drug that reverses anaphylaxis.

7. A bystander has tied a tight band above a bee sting on a patient's forearm to 'slow the venom.' You should:

   1. A. Leave it until you reach the hospital
   2. B. Remove the band; it does not help
   3. C. Loosen it so one finger fits under it
   4. D. Move it closer to the sting
   Show answer

   Answer: B. Remove the band; it does not help

   Constricting bands are not recommended for insect stings. Most bee venom is delivered within about a minute, and a band neither stops an allergic reaction nor helps the limb. Remove it and treat the patient's symptoms. Loosening the band or moving it still leaves a useless constriction on the arm.

8. A woman stung on the finger has swelling spreading over her hand. She is wearing two rings on that hand. You should:

   1. A. Take the rings off right away
   2. B. Leave them on as a splint
   3. C. Remove them after swelling peaks
   4. D. Tape them in place
   Show answer

   Answer: A. Take the rings off right away

   Swelling can make rings impossible to remove and can cut off blood flow to the finger. Take them off early, using soap or lubricant if needed. Waiting until swelling peaks may mean the rings must be cut off.

9. A man stung on the forearm has swelling 12 cm across around the sting, no other symptoms, and normal vital signs. Appropriate care is to:

   1. A. Give IM epinephrine right away
   2. B. Apply heat packs to draw out the venom
   3. C. Cool, elevate, and watch for spread
   4. D. Lance the swelling to drain venom
   Show answer

   Answer: C. Cool, elevate, and watch for spread

   A large local reaction causes swelling around the sting that may peak over a day or two, without systemic signs. Care is a cold pack, elevation, and an antihistamine for itching per protocol, with monitoring for systemic signs. Epinephrine is for systemic reactions.

10. An adult in anaphylactic shock remains hypotensive after two IM doses of epinephrine, and two IV attempts have failed. The next step is to:

    1. A. Keep trying IV access in the feet
    2. B. Give a third dose under the tongue
    3. C. Stop fluids until an IV is in place
    4. D. Place an IO for fluids and drugs
    Show answer

    Answer: D. Place an IO for fluids and drugs

    When IV access fails in a patient who needs fluids and possibly an epinephrine infusion, intraosseous access is fast and reliable. IM doses can continue meanwhile. Sublingual epinephrine is not a standard route, and fluids should not be held.

11. Expected side effects of IM epinephrine include:

    1. A. Bradycardia, sedation, and drowsiness
    2. B. Hypotension, flushing, and warmth
    3. C. Tachycardia, tremor, and anxiety
    4. D. Hypoglycemia, sweating, and hunger
    Show answer

    Answer: C. Tachycardia, tremor, and anxiety

    These effects are expected and short-lived.

12. The position for a hypotensive anaphylaxis patient without respiratory distress is:

    1. A. Sitting fully upright
    2. B. Supine with legs elevated
    3. C. Semi-Fowler at 45 degrees
    4. D. Prone
    Show answer

    Answer: B. Supine with legs elevated

    Sudden upright positioning can cause fatal cardiovascular collapse in anaphylactic shock.

13. A patient in anaphylaxis with severe dyspnea but adequate BP should be placed:

    1. A. Position of comfort, often sitting up
    2. B. Flat on the back with the legs level
    3. C. Prone with the head turned to one side
    4. D. In Trendelenburg with the head down
    Show answer

    Answer: A. Position of comfort, often sitting up

    Breathing is easier sitting up. Lay the patient flat if hypotension develops.

14. Fluid resuscitation for anaphylactic shock in adults typically starts with:

    1. A. 50 mL of D5W
    2. B. 100 mL of normal saline
    3. C. 1 to 2 L of crystalloid
    4. D. IV fluids held until arrival
    Show answer

    Answer: C. 1 to 2 L of crystalloid

    Large fluid shifts require aggressive replacement. Children receive 20 mL/kg boluses.

15. Oxygen should be given to anaphylaxis patients who:

    1. A. Have only localized itching at a site
    2. B. Have respiratory distress or low SpO2
    3. C. Have only mild hives on the arms
    4. D. Have nasal congestion with sneezing
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    Answer: B. Have respiratory distress or low SpO2

    Use high-flow oxygen for patients with airway or breathing compromise.

16. When should you consider early advanced airway management in anaphylaxis?

    1. A. When hives first appear
    2. B. After the patient has arrived at the hospital
    3. C. After cardiac arrest occurs
    4. D. With progressing stridor or voice change
    Show answer

    Answer: D. With progressing stridor or voice change

    Airway edema can worsen quickly and make intubation impossible later.

17. Intubating a patient with severe laryngeal edema may require:

    1. A. A smaller tube and a surgical backup
    2. B. A larger tube than usual for the patient
    3. C. Blind nasal intubation without backup
    4. D. No special preparation beyond suction
    Show answer

    Answer: A. A smaller tube and a surgical backup

    Have a surgical airway kit ready in case intubation fails.

18. Removing the stinger after a honeybee sting should be done:

    1. A. Slowly, using fine-tip tweezers
    2. B. Quickly, by any method
    3. C. After about an hour has passed
    4. D. At the hospital, not in the field
    Show answer

    Answer: B. Quickly, by any method

    Speed matters more than technique, since venom continues to be injected.

19. A mother says she gave her son his auto-injector, but the device in her hand is labeled 'trainer' and has no needle. The child is wheezing. You should:

    1. A. Wait 15 minutes for the dose to act
    2. B. Give a half dose to avoid an overdose
    3. C. Give oral diphenhydramine and observe
    4. D. Give epinephrine now; none was given
    Show answer

    Answer: D. Give epinephrine now; none was given

    Trainer devices look like real auto-injectors but contain no drug or needle. Mix-ups happen, so assume no epinephrine was given and treat the anaphylaxis now with a full weight-based dose. Show the parents how to tell the devices apart.

20. A patient's own epinephrine auto-injector should be:

    1. A. Ignored in favor of IV access
    2. B. Saved for the hospital
    3. C. Used if indicated, per protocol
    4. D. Left for the patient to give himself
    Show answer

    Answer: C. Used if indicated, per protocol

    Auto-injectors deliver a fixed dose quickly. Assist the patient per protocol.

21. After two IM doses of epinephrine, a diabetic patient's glucose reads 268 mg/dL, up from 140 before treatment. The most likely cause is:

    1. A. Epinephrine raising blood glucose
    2. B. Diabetic ketoacidosis developing quickly
    3. C. A faulty or miscalibrated glucose meter
    4. D. An allergic reaction to his insulin
    Show answer

    Answer: A. Epinephrine raising blood glucose

    Epinephrine stimulates glycogen breakdown and glucose release from the liver, so a temporary rise is expected. Recheck later. DKA does not develop within minutes, and nothing points to the meter or to insulin allergy.

22. Why should IM epinephrine be given before IV access in anaphylaxis?

    1. A. IV access is rarely useful in shock
    2. B. IM epinephrine has fewer side effects
    3. C. Delays in epinephrine increase deaths
    4. D. IV epinephrine is outside paramedic scope
    Show answer

    Answer: C. Delays in epinephrine increase deaths

    Delayed epinephrine is the main factor in fatal anaphylaxis.

23. A patient in anaphylaxis improves after epinephrine but remains wheezy. The next step is:

    1. A. IV furosemide
    2. B. Nebulized albuterol
    3. C. Oral diphenhydramine
    4. D. Nebulized normal saline
    Show answer

    Answer: B. Nebulized albuterol

    Albuterol treats residual bronchospasm but does not replace epinephrine. Furosemide treats fluid overload, not bronchospasm. Diphenhydramine helps itching and hives but does not open the airways, and saline mist has no bronchodilator effect.

24. A patient taking propranolol receives IM epinephrine for anaphylaxis. Her BP rises to 210/120 and her heart rate falls to 48. This happens because:

    1. A. The epinephrine was a ten-fold overdose
    2. B. The allergen has reached the heart
    3. C. Propranolol has caused a new allergy
    4. D. Alpha effects are left unopposed
    Show answer

    Answer: D. Alpha effects are left unopposed

    Nonselective beta blockers block epinephrine's beta-2 vasodilating and beta-1 cardiac effects, leaving its alpha vasoconstriction unopposed. The BP can spike, with a reflex slowing of the heart. These patients still need treatment for anaphylaxis, with close monitoring.

25. After a correctly given IM epinephrine dose, improvement in wheezing and BP is usually seen within:

    1. A. A few minutes
    2. B. About 30 to 60 minutes
    3. C. 2 to 4 hours
    4. D. The next day
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    Answer: A. A few minutes

    IM epinephrine in the thigh reaches peak blood levels within about 10 minutes, and many patients improve within minutes. If there is no improvement after 5 to 15 minutes, repeat the dose. Waiting an hour for an effect would let shock progress.