NREMT Paramedic Level Quiz: Allergic Reactions Anaphylaxis And Immunologic Emergencies

What this quiz covers

This quiz focuses on Allergic Reactions Anaphylaxis And Immunologic Emergencies, giving you a quick way to practice the rules, question types, and explanations that matter most for NREMT Paramedic Level.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. 0.3 mg IM epinephrine (1 mg/mL) with airway-focused monitoring (correct answer)
2. Diphenhydramine 25–50 mg IV/IM as the sole initial medication
3. Normal saline bolus only, then reassess for rash resolution
4. Nebulized albuterol only, then contact medical control for further orders

Explanation: This question tests paramedic-level understanding of allergic reactions and anaphylaxis, focusing on treatment escalation with worsening symptoms (NREMT standard). Anaphylaxis is a severe, life-threatening allergic reaction that requires rapid identification and treatment with epinephrine. In this scenario, worsening urticaria and hoarseness suggest progression to anaphylaxis with airway involvement. The correct answer involves prompt IM epinephrine administration with airway monitoring. A common distractor might involve antihistamines alone, which is incorrect for systemic symptoms. Teaching strategies include training paramedics to quickly identify signs of anaphylaxis and recognize progression cues. Encourage familiarity with protocols and emphasize the importance of continuous patient monitoring after intervention.

Question 2

1. Exact time and dose of the new medication and any prior reactions (correct answer)
2. Whether the patient has eaten spicy foods in the last 24 hours
3. Family history of asthma during childhood
4. Last dental visit and recent fluoride exposure

Explanation: This question tests paramedic-level understanding of allergic reactions and anaphylaxis, focusing on history-taking and assessment (NREMT standard). Anaphylaxis is a severe, life-threatening allergic reaction that requires rapid identification and treatment with epinephrine. In this scenario, the patient's urticaria and abdominal pain after a new antibiotic suggest a possible allergic reaction, making details about the medication crucial. The correct answer involves gathering information on the timing, dose, and prior reactions to guide treatment decisions. A common distractor might involve unrelated history like diet or family asthma, which is incorrect as it does not directly inform the allergic response. Teaching strategies include training paramedics to quickly identify signs of anaphylaxis and practice targeted questioning. Encourage familiarity with protocols and emphasize the importance of continuous patient monitoring after intervention.

Question 3

1. Keep suction and BVM ready, position for comfort, and prepare advanced airway backup (correct answer)
2. Force the patient supine to maximize venous return regardless of breathing comfort
3. Avoid any airway equipment to reduce agitation and delay reassessment
4. Attempt blind nasotracheal intubation as the first airway intervention

Explanation: This question tests paramedic-level understanding of allergic reactions and anaphylaxis, focusing on airway management during transport (NREMT standard). Anaphylaxis is a severe, life-threatening allergic reaction that requires rapid identification and treatment with epinephrine. In this scenario, anxiety and hoarseness indicate potential airway issues without full obstruction. The correct answer involves preparing equipment and positioning for comfort. A common distractor might involve forcing supine position, which is incorrect if it worsens breathing. Teaching strategies include training paramedics to quickly identify signs of anaphylaxis and adapt airway plans. Encourage familiarity with protocols and emphasize the importance of continuous patient monitoring after intervention.

Question 4

1. Encourage oral fluids and ambulation to improve blood pressure naturally
2. Wait for hospital arrival because repeat dosing is never indicated prehospital
3. Administer antihistamine only and discontinue oxygen to reduce tachycardia
4. Reassess airway and perfusion and give repeat IM epinephrine per protocol (correct answer)

Explanation: This question tests paramedic-level understanding of allergic reactions and anaphylaxis, focusing on managing recurrence (NREMT standard). Anaphylaxis is a severe, life-threatening allergic reaction that requires rapid identification and treatment with epinephrine. In this scenario, symptom recurrence after initial dose indicates need for repeat treatment. The correct answer involves reassessing and administering repeat epinephrine per protocol. A common distractor might involve waiting for hospital, which is incorrect for biphasic reactions. Teaching strategies include training paramedics to quickly identify signs of anaphylaxis and handle recurrences. Encourage familiarity with protocols and emphasize the importance of continuous patient monitoring after intervention.

Question 5

1. Norepinephrine infusion to provide potent alpha-adrenergic effects.
2. Glucagon 1-2 mg IV to bypass the beta-adrenergic receptor site. (correct answer)
3. Dopamine infusion titrated to maintain a systolic blood pressure of 90 mmHg.
4. Push-dose phenylephrine to rapidly increase systemic vascular resistance.

Explanation: Patients on beta-blockers may have an attenuated or refractory response to epinephrine. Glucagon has positive inotropic and chronotropic effects that are not mediated by beta-adrenergic receptors. It can therefore be effective in treating refractory hypotension in anaphylaxis in this specific patient population. While other vasopressors might be used, glucagon is the classic and most appropriate next choice for a patient on beta-blockers.

Question 6

1. Administer a second dose of epinephrine 0.18 mg IM via syringe. (correct answer)
2. Administer 2.5 mg of albuterol via nebulizer as a primary intervention.
3. Establish IV access and administer 18 mg of diphenhydramine.
4. Contact medical control to request an order for IV corticosteroids.

Explanation: The patient has signs of systemic reaction involving two body systems (skin and respiratory), which constitutes anaphylaxis. The first-line treatment is epinephrine. The initial dose from the auto-injector has not resolved his respiratory symptoms. The correct pediatric dose for epinephrine 1:1,000 is 0.01 mg/kg, which for this 18 kg patient is 0.18 mg. Administering a second, correctly calculated dose is the priority. Albuterol is an important adjunct for wheezing but does not address the systemic inflammatory cascade. Antihistamines and steroids are secondary treatments and should not delay repeat epinephrine administration.

Question 7

1. Administer 1 gram of calcium chloride IV over 60 seconds.
2. Initiate an epinephrine infusion at 2-10 mcg/min, titrated to effect. (correct answer)
3. Administer 2 grams of magnesium sulfate IV over 10 minutes.
4. Give an additional 1.0 mg of epinephrine 1:10,000 via rapid IV push.

Explanation: This patient is in profound, refractory anaphylactic shock. After IM epinephrine and fluids have failed, the next step is intravenous vasopressor support. An epinephrine infusion is the preferred agent, allowing for careful titration to achieve a target blood pressure (e.g., SBP > 90 mmHg). A rapid IV push of 1.0 mg epinephrine (as used in cardiac arrest) would be dangerously excessive and likely cause lethal arrhythmias. Calcium and magnesium do not have a primary role in treating anaphylactic shock.

Question 8

1. The deltoid muscle of the upper arm.
2. The subcutaneous tissue of the abdomen.
3. The vastus lateralis muscle of the anterolateral thigh. (correct answer)
4. The gluteus medius muscle of the buttock.

Explanation: The anterolateral thigh (vastus lateralis muscle) is the recommended site for IM epinephrine administration in anaphylaxis. This large, well-vascularized muscle provides more rapid and reliable drug absorption compared to the deltoid or gluteal muscles. Subcutaneous injection has been shown to result in slower absorption and lower peak plasma concentrations, which is undesirable in a life-threatening emergency.

Question 9

1. Administer a 500 mL bolus of normal saline.
2. Increase the epinephrine infusion rate. (correct answer)
3. Administer 1 mg of glucagon IV push.
4. Administer hydrocortisone 100 mg IV.

Explanation: The patient is on a titratable vasopressor infusion for hemodynamic support post-anaphylaxis. A sudden drop in blood pressure indicates that the current dose is insufficient to overcome the vasodilation. The most direct and immediate action is to titrate the infusion upward to increase the vasopressor effect and restore blood pressure. While a fluid bolus may also be helpful, adjusting the primary vasoactive medication is the priority. Glucagon is for beta-blocker associated resistance, and steroids have no immediate effect on blood pressure.

Question 10

1. Botulism poisoning
2. Ciguatera fish poisoning
3. Norovirus outbreak
4. Scombroid poisoning (correct answer)

Explanation: Scombroid poisoning results from the ingestion of fish (like tuna, mackerel, mahi-mahi) with high levels of histamine, produced by bacteria in improperly stored fish. The symptoms are nearly identical to an IgE-mediated allergic reaction because the underlying chemical mediator (histamine) is the same. The key diagnostic clue is often multiple people becoming ill after eating the same meal. While treatment is similar (antihistamines, supportive care), it's important to differentiate it from a true allergy.

Question 11

1. The resolution of the patient's urticaria.
2. The patient's level of anxiety.
3. The patient's respiratory effort and blood pressure. (correct answer)
4. The development of medication side effects like tremors.

Explanation: The primary goals of epinephrine in anaphylaxis are to maintain a patent airway, support breathing, and ensure adequate circulation. Therefore, the most critical parameters to monitor are those that reflect these life-sustaining functions: respiratory effort (rate, quality, presence of stridor/wheezing) and blood pressure. A recurrence of wheezing, stridor, or a drop in blood pressure would indicate the need for a repeat dose. While urticaria and anxiety are part of the clinical picture, they are not as critical to life as respiratory and circulatory status.

Question 12

1. Leukotrienes
2. Prostaglandins
3. Histamine (correct answer)
4. Bradykinin

Explanation: During an IgE-mediated allergic reaction, the primary preformed mediator released from mast cell granules is histamine. Histamine is responsible for the classic, immediate signs of anaphylaxis: vasodilation, increased capillary permeability (leading to edema and hypotension), and smooth muscle contraction (leading to bronchospasm). Leukotrienes and prostaglandins are newly synthesized mediators that contribute to the inflammatory response but act later. Bradykinin is the primary mediator in ACE-inhibitor angioedema, not IgE-mediated anaphylaxis.

Question 13

1. The severe wheezing and tripoding posture.
2. The failure to respond to albuterol therapy.
3. The tachycardia and tachypnea.
4. The lip swelling and generalized pruritus. (correct answer)

Explanation: Severe wheezing, albuterol resistance, tachycardia, and tachypnea can all be present in a severe asthma attack. The key features that point specifically to anaphylaxis are the signs of multi-system involvement beyond the respiratory tract. Lip swelling (angioedema) and generalized pruritus (itching) indicate involvement of the skin and mucous membranes, which, in conjunction with respiratory compromise, defines anaphylaxis and mandates treatment with epinephrine, not just bronchodilators.

Question 14

1. Epinephrine 0.5 mg IM
2. Epinephrine 1 mg 1:10,000 IV/IO (correct answer)
3. Diphenhydramine 50 mg IV/IO
4. Sodium bicarbonate 1 mEq/kg IV/IO

Explanation: This patient is in cardiac arrest, which is likely secondary to anaphylaxis (PEA). The standard ACLS algorithm for PEA arrest should be followed. The appropriate initial medication in any non-shockable cardiac arrest is epinephrine 1 mg of 1:10,000 solution via the IV or IO route, repeated every 3-5 minutes. While the arrest was caused by anaphylaxis, the priority is resuscitation from cardiac arrest, which uses the cardiac arrest dose and route of epinephrine, not the anaphylaxis dose/route. The IM route is ineffective in a patient without circulation.

Question 15

1. An anaphylactic reaction, which is IgE-mediated and requires prior sensitization.
2. A cytotoxic reaction, involving IgG antibodies binding to cell surface antigens.
3. An anaphylactoid reaction, which is not IgE-mediated but causes direct mast cell degranulation. (correct answer)
4. A delayed hypersensitivity reaction, mediated by T-cells and occurring 24-48 hours later.

Explanation: A reaction on first exposure that mimics anaphylaxis is termed an anaphylactoid, or non-IgE-mediated, reaction. Certain substances, like radiocontrast media, can directly trigger mast cells and basophils to release their mediators without involving the IgE antibody mechanism that requires prior sensitization. Although the pathophysiology is different, the clinical presentation and management are identical to true anaphylaxis.

Question 16

1. The administered corticosteroids can cause rebound hypertension that requires monitoring.
2. A biphasic reaction can occur, causing symptoms to return hours after they have resolved. (correct answer)
3. The IV catheter must be removed by a nurse to prevent infection and air embolism.
4. She may have developed a permanent and more severe allergy that requires inpatient testing.

Explanation: A significant percentage of patients with anaphylaxis (up to 20%) experience a biphasic reaction, where symptoms recur 1 to 72 hours after the initial reaction resolves, without any re-exposure to the allergen. This is the most compelling medical reason for transport and observation in an emergency department, as the recurrent symptoms can be as severe or worse than the initial presentation. The other options are either incorrect or not the primary justification for transport.

Question 17

1. Administer 50 mg of diphenhydramine IV and prepare for rapid transport.
2. Prepare and administer a second dose of intramuscular epinephrine. (correct answer)
3. Administer 125 mg of methylprednisolone IV to reduce inflammation.
4. Initiate a 500 mL normal saline fluid bolus and reassess vital signs.

Explanation: The patient is in decompensated anaphylactic shock with a threatened airway, and the first-line treatment is epinephrine. When the initial IM dose is ineffective, it should be repeated every 5-15 minutes. While antihistamines, corticosteroids, and IV fluids are all important adjuncts, none replaces the critical, life-saving effects of epinephrine in reversing bronchoconstriction, vasoconstricting peripheral vessels, and reducing capillary permeability. Given the worsening stridor and persistent hypotension, a second dose of epinephrine is the priority.

Question 18

1. Vasovagal syncope; place the patient supine and administer IV fluids.
2. Anaphylaxis; administer intramuscular epinephrine 1:1,000. (correct answer)
3. Sepsis; administer a broad-spectrum antibiotic and rapid fluid bolus.
4. Acute gastroenteritis; administer an antiemetic and provide IV hydration.

Explanation: Anaphylaxis is a clinical diagnosis and can present without cutaneous signs in up to 20% of cases. The presence of hypotension and GI symptoms after exposure to a known allergen (a new antibiotic) strongly suggests anaphylaxis. The feeling of 'impending doom' is also a classic sign. The priority intervention is intramuscular epinephrine to reverse the systemic effects of histamine release. The other options fail to account for the acute, allergen-related onset and life-threatening hypotension.

Question 19

1. IgE-mediated histamine release; treatment should focus on epinephrine and diphenhydramine.
2. Bradykinin-mediated cascade; the condition may be resistant to standard anaphylaxis therapies. (correct answer)
3. Direct mast cell degranulation; treatment requires aggressive IV fluid resuscitation.
4. Type IV delayed hypersensitivity; symptoms will resolve with corticosteroid administration.

Explanation: ACE inhibitor-induced angioedema is caused by the accumulation of bradykinin, not histamine release. This is critical because treatments targeting histamine (antihistamines) or its effects (epinephrine) are often ineffective. While airway management remains the priority, the paramedic must recognize that the underlying cause is different and the patient may not respond to the standard anaphylaxis algorithm, requiring early notification to the receiving facility.

Question 20

1. Administer IM epinephrine because of respiratory system involvement. (correct answer)
2. Administer IV diphenhydramine since the oral dose has not taken effect.
3. Administer nebulized albuterol to address the shortness of breath.
4. Monitor the patient and transport, as the oral medication will soon take effect.

Explanation: Anaphylaxis is defined by the involvement of two or more body systems (in this case, skin and respiratory) after exposure to a likely allergen. The presence of shortness of breath, regardless of how mild, requires immediate treatment with epinephrine. Oral antihistamines have a slow onset and are insufficient to manage a systemic reaction with respiratory compromise. Epinephrine is the first-line, life-saving intervention. Albuterol is an adjunct, and observation alone is inappropriate.