Pre-hospital analgesia, sedation and RSI: DipIMC practice questions
PHEM curriculum unit 2.6 · Theme 2: Providing Pre-hospital Emergency Medical Care
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit 2.6, Provide analgesia, procedural sedation and anaesthesia in the pre-hospital environment.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 30 questions on this unit.
Question 1 · Environmental & Analgesia · Easy
Which of the following is a contraindication to methoxyflurane (Penthrox)?
AAge over 65 years with no renal history
BClinically significant renal impairment
CSuspected pneumothorax after chest trauma
DDecompression illness after a recent dive
EAsthma controlled on a salbutamol inhaler
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Answer: B
Clinically significant renal impairment
The UK Summary of Product Characteristics (SPC) for Penthrox (section 4.3) lists clinically significant renal impairment as a contraindication: methoxyflurane is nephrotoxic at high doses. Other licensed contraindications include hypersensitivity to methoxyflurane or any fluorinated anaesthetic, known or genetic susceptibility to malignant hyperthermia, previous liver damage after methoxyflurane or halogenated anaesthesia, altered consciousness from any cause including head injury, clinically evident cardiovascular instability and clinically evident respiratory depression. Older age is a caution, not a contraindication: the SPC says to use it with caution in the elderly. Pneumothorax and decompression illness are contraindications to Entonox, because nitrous oxide diffuses into and expands gas-filled spaces; they are not contraindications to methoxyflurane. Asthma is not listed. The SPC limits use to no more than 6 ml in a single day. Know the divergence: the Oxford Handbook (2021) lists renal risk factors only as a caution, so the licence, not the textbook, is the source for this key.
Ch. 4 Formulary · Methoxyflurane: cautions · p. 320“Elderly (risk of hypotension), risk factors for hepatic impairments, risk factors for renal impairment”
Ch. 5 Airway, analgesia and anaesthesia · Analgesia: inhalation · p. 357“contraindicated in patients with air in the cranial vault, pneumothorax, and bowel obstruction”
Which condition contraindicates the use of Entonox?
AClinically significant renal impairment
BChest injury with suspected pneumothorax
CEstablished labour at 39 weeks' gestation
DMyocardial infarction three months earlier
EKnown allergy to morphine and to codeine
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Answer: B
Chest injury with suspected pneumothorax
Nitrous oxide diffuses into closed gas-filled spaces and expands them. JRCALC therefore lists chest injury with a clinically suspected pneumothorax among the contraindications to Entonox, alongside air embolism, severe head injury with impaired consciousness (possible intracranial air), decompression sickness (treat anyone who has dived in the previous 24 hours as at risk), violently disturbed psychiatric patients, severe bullous emphysema, an intraocular gas injection within the last eight weeks and abdominal pain with gross distension. The Oxford Handbook uses a 48-hour diving window, so name the source if asked. Entonox is indicated for labour pain. Clinically significant renal impairment is a contraindication to methoxyflurane, not to Entonox. A previous myocardial infarction does not contraindicate it, and an allergy to opioids is irrelevant to a gas that contains none.
Ch. 4 Formulary · Nitrous oxide/oxygen 50:50 (Entonox®): contraindications · p. 328“These conditions include pneumothorax (so contraindicated in significant chest injury”
Ch. 4 Formulary · Nitrous oxide/oxygen 50:50 (Entonox®): contraindications · p. 328“so contraindicated in patients who have been diving within the last 48 hours”
ABC of Prehospital Emergency Medicinep. 52Ch. 10 Prehospital Analgesia and Sedation · Nitrous oxide: oxygen (50/50 mix): Entonox®“This is dangerous in pneumothorax, intracranial air after head injury and decompression sickness.”
A 9-month-old baby has pulled a cup of freshly made tea over her forearm and chest. She is screaming inconsolably despite cooling of the burn, her weight is not known, and cannulation has not been attempted. Following JRCALC, which analgesic is most appropriate?
AMorphine sulfate 2 mg oral solution
BMorphine sulfate 1 mg intramuscularly
CFentanyl 15 micrograms intranasally
DFentanyl 200 micrograms by lozenge
EFentanyl 10 micrograms intranasally
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Answer: E
Fentanyl 10 micrograms intranasally
JRCALC contraindicates morphine in children under 1 year, and the Page for Age charts show morphine by every route (intravenous or intraosseous, oral and intramuscular) as not applicable until 12 months, so neither morphine option can be given to a 9-month-old. Intranasal fentanyl, by contrast, appears on the Page for Age charts from the first month of life. On the 9-month Page for Age chart it is 10 micrograms (1 ml of a diluted 10 micrograms in 1 ml solution, divided between the nostrils), with a repeat of 5 micrograms after 10 minutes. 15 micrograms is the dose on the 12-month chart, where the undiluted 100 micrograms in 2 ml preparation is used; picking the neighbouring chart overdoses her by half again. The fentanyl lozenge only becomes available at 6 years. If her actual weight is known, JRCALC says to dose by weight rather than age, and its medicines overview stresses an independent double check for children under 12, which matters here because the dose must be diluted. ABC of Prehospital Emergency Medicine is clear that analgesia is mandatory for children of all ages who are in pain.
JRCALC Clinical Guidelines — Page for Age, 6 yearsJRCALC / AACE·Quick reference table“6 YEARS (P0120) — Fentanyl lozenge oral row”
JRCALC Clinical Guidelines — Medicines overviewJRCALC / AACE·Safety aspects: six rights and double checks“Medicines overview (D0010) — section 2, Double checks”
ABC of Prehospital Emergency Medicinep. 163Ch. 29 Care of Special Groups: The Paediatric Patient · Management of paediatric trauma emergencies: analgesia“Analgesia is mandatory for children of all ages who are in pain.”