NREMT Paramedic Level Quiz: Allergic Reactions Anaphylaxis And Immunologic Emergencies
20 questions · exam conditions
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Allergic Reactions Anaphylaxis And Immunologic EmergenciesQuestion 1 of 20

Patient on beta-blocker has anaphylaxis; epinephrine is ineffective. Next drug?

Glucagon 1-5 mg IV
Atropine 0.5 mg IV
Epinephrine 0.3 mg IV
Dopamine 5 mcg/kg/min
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NREMT Paramedic Level Quiz

NREMT Paramedic Level Quiz: Allergic Reactions Anaphylaxis And Immunologic Emergencies

Practice Allergic Reactions Anaphylaxis And Immunologic Emergencies in NREMT Paramedic Level with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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.

All questions

Question 1

Patient on beta-blocker has anaphylaxis; epinephrine is ineffective. Next drug?

  1. Glucagon 1-5 mg IV (correct answer)
  2. Atropine 0.5 mg IV
  3. Epinephrine 0.3 mg IV
  4. Dopamine 5 mcg/kg/min
Explanation: Beta-blockade blocks epinephrine's effects, so glucagon is next because it increases cAMP through a non-beta-receptor pathway, restoring myocardial contractility and reversing refractory shock. Repeating epinephrine IV is tempting but fails while beta receptors are blocked. Atropine treats bradycardia but does not counteract anaphylaxis.

Question 2

20 kg child, anaphylaxis, no IV. IM epinephrine 1:1000 dose?

  1. 0.2 mg = 0.2 mL (correct answer)
  2. 0.2 mg = 2.0 mL
  3. 0.5 mg = 0.5 mL
  4. 1.0 mg = 1.0 mL
Explanation: For anaphylaxis, IM epinephrine 1:1000 is given at 0.01 mg/kg. A 20 kg child needs 20 x 0.01 = 0.2 mg. Since 1:1000 means 1 mg/mL, that is 0.2 mL. The tempting wrong answer is 0.2 mg = 2.0 mL, which mistakenly uses the 1:10,000 IV concentration instead of 1:1000 IM.

Question 3

Anaphylaxis with hypotension; patient has known CAD. Epinephrine?

  1. Give diphenhydramine instead
  2. Hold epinephrine until ECG
  3. Give IM epinephrine right away (correct answer)
  4. Wait for IV fluid bolus first
Explanation: In anaphylaxis with hypotension, epinephrine is first-line regardless of CAD; IM epinephrine treats vasodilation and bronchospasm, and the cardiovascular risk is far lower than the risk of delayed treatment. Holding it for an ECG or waiting for IV fluids lets shock worsen. Diphenhydramine is only adjunctive and won't fix hypotension. The dangerous temptation is to wait because of the CAD history; don't - give IM epinephrine now.

Question 4

First exposure to IV contrast causes urticaria and wheezing. Mechanism?

  1. IgE-mediated degranulation
  2. Direct mast cell activation (correct answer)
  3. Cytotoxic antibody binding
  4. Immune complex deposition
Explanation: First exposure rules out prior sensitization, so IgE-mediated degranulation cannot be the cause. IV contrast directly triggers mast cells to degranulate, releasing histamine and producing urticaria and wheezing. The tempting wrong answer is IgE-mediated degranulation, but it requires prior exposure to form IgE antibodies.

Question 5

After a new medication, urticaria worsens and voice becomes hoarse; what is the primary treatment for anaphylaxis here?

  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 6

New antibiotic started; hours later urticaria and crampy abdominal pain occur—what additional information is most helpful?

  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 7

Bee sting: patient anxious, hoarse voice, drooling absent; how should airway be managed during transport?

  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 8

Bee sting: after first epinephrine dose, symptoms recur 10 minutes later; based on symptoms, what action first?

  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 9

You are treating a 66-year-old female for anaphylaxis after she ate shrimp. She has a history of hypertension treated with metoprolol. You have administered two doses of IM epinephrine and initiated an IV fluid bolus, but her blood pressure remains 76/40 mmHg. She is conscious but lethargic.

Given her history and persistent hypotension refractory to epinephrine, which medication should be considered?

  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 10

A 5-year-old boy weighing 18 kg is stung by a bee. He develops hives over his chest and has mild expiratory wheezing. His parents administered his prescribed epinephrine auto-injector (0.15 mg) five minutes prior to your arrival. He is anxious but alert, with RR 28/min and SpO2 95%.

The child's wheezing has not improved. What is the most appropriate next step?

  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 11

A 50-year-old male is in anaphylactic shock with a blood pressure of 60/30 mmHg and is unresponsive to two IM epinephrine injections and 1 liter of IV fluids. His airway is patent, and he is being ventilated with a BVM.

Which of the following interventions is most appropriate for this patient's refractory shock state?

  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 12

You are treating a patient with known severe allergies who is hypotensive and wheezing. You elect to administer epinephrine 1:1,000 via the intramuscular route.

Which injection site provides the most reliable and rapid absorption of epinephrine?

  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 13

A patient had an anaphylactic reaction to a medication administered in the hospital. The patient is now being transferred to the ICU by your crew. They are intubated, sedated, and have an epinephrine infusion running at 5 mcg/min. The patient's blood pressure is 94/60 mmHg.

During transport, the patient's blood pressure suddenly drops to 70/40 mmHg. The IV line is patent and the infusion pump is working correctly. What is the most appropriate immediate action?

  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 14

Several people at a banquet who ate tuna steak develop flushing, headache, palpitations, and urticaria within 30 minutes. One person also feels short of breath. Anaphylaxis is suspected.

Which alternative diagnosis should the paramedic strongly consider, which presents similarly to an allergic reaction but is caused by bacterially-generated histamine in spoiled fish?

  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 15

A paramedic administers 0.4 mg of epinephrine IM to an adult patient in anaphylactic shock. The patient's initial response is good, with an increase in blood pressure and improved work of breathing.

Which parameter is the most crucial to monitor continuously to assess for the patient's potential need for a second dose of epinephrine?

  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 16

In the pathophysiology of anaphylaxis, the binding of an allergen to IgE antibodies on the surface of mast cells and basophils triggers the immediate release of preformed mediators. Which of the following is the most significant preformed mediator responsible for the initial, acute symptoms?

  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 17

A 22-year-old asthmatic patient is having a severe asthma attack after exercising outdoors. He has used his albuterol inhaler multiple times with no relief. He is audibly wheezing, has a RR of 32, and is speaking in 1-2 word sentences. Upon further questioning, he also mentions his lips feel swollen and he feels itchy all over.

The presence of which signs or symptoms most clearly differentiates this presentation as anaphylaxis rather than a simple asthma exacerbation?

  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 18

A 19-year-old male is found unresponsive after being stung by multiple bees. He is apneic and pulseless. CPR is in progress by first responders. An AED has advised no shock.

In addition to high-quality CPR and airway management, what is the most appropriate initial medication and route for this patient?

  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 19

A patient experiences a severe, immediate reaction to an IV contrast agent during a CT scan, on their first known exposure to the substance. This reaction includes hypotension and bronchospasm. This type of reaction is best classified as:

  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 20

You have successfully treated a 30-year-old patient for a severe anaphylactic reaction to peanuts. After IM epinephrine, IV fluids, diphenhydramine, and methylprednisolone, her vital signs have normalized and all symptoms have resolved. She feels fine and is requesting to sign a refusal of transport.

What is the most critical piece of information to convey to the patient to justify the need for transport to a hospital?

  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.