IBSC FP-C Exam Questions

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181.

Which of the following disorders may a patient experiencing thyroid storm be erroneously diagnosed with due to overlapping symptoms?

  • Psychosis

  • Neuroleptic malignant syndrome

  • Sepsis

  • Anxiety

Correct answer: Psychosis

When patients who experience thyroid storm, a severe, potentially life-threatening complication of hyperthyroidism (or thyrotoxicosis), present for emergency care, their symptoms are frequently mistaken for those of psychosis (or an acute mania), causing a delay in appropriate treatment. Many of the symptoms of thyroid storm are neurological in nature due to the intrinsic role the thyroid hormones play in supporting healthy nervous system function. Patients experiencing thyroid storm often present with symptoms of confusion, anxiety, agitation, talking incoherently, tremor or disorders of movement, among others. Non-neurological symptoms include hot, dry skin, complaints of palpitations, weight loss, exophthalmos, tachycardia or tachydysrhythmias, hyperthermia, and signs of heart failure.

Anxiety does not present with the severity of neurologic symptoms as thyroid storm. Sepsis and neuroleptic malignant syndrome may cause altered mental status, but the other signs and symptoms have minimal significant overlap.

182.

You are transporting a 68-year-old, 75 kg male COPD patient on BiPAP. The patient goes into respiratory failure and requires intubation and mechanical ventilation. BiPAP settings prior to intubation were the following:

  • IPAP: 18
  • EPAP: 8
  • Rate: 14
  • FiO2: .50

Which of the following initial ventilator settings are recommended?

  • Rate 12, PEEP 8 cm H20, FiO2 50%, Vt 525 mL

  • Rate 8, PEEP 5 cm H20, FiO2 50%, Vt 500 mL

  • Rate 14, PEEP 5 cm H20, FiO2 50%, Vt 550 mL

  • Rate 12, PEEP 10 cm H20, FiO2 50%, Vt 725 mL

Correct answer: Rate 12, PEEP 8 cm H20, FiO2 50%, Vt 525 mL

The Positive Expiratory End-Pressure (PEEP) should match the EPAP, and FiO2 should be the same as that received while on BiPAP. The recommended initial respiratory rate range is 10-20 breaths/min; for COPD patients, the recommended rate is 10-12 breaths/min, with extended expiratory time. Tidal Volume (Vt) should be set at 6-8 mL/kg of ideal body weight.

If the patient had evidence of ARDS, the PEEP could be initiated up to 10 cm H2O, and the Vt should be 4-6 mL/kg. However, there is no indication that the patient has ARDS.

183.

What change would you expect to see in coagulation studies for a patient having an acute ischemic stroke?

  • Elevated D-dimer

  • Elevated prothrombin time

  • Elevated aPTT

  • Elevated INR

Correct answer: Elevated D-dimer

D-dimer tests look at fibrin degradation and assess for clotting and hypercoagulability. D-dimer levels are often elevated in ischemic stroke.

Coagulation studies may be used in patients with neurologic emergencies to determine if coagulopathy is present. These tests consist of values for Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), International Normalized Ratio (INR), and D-dimer, among others. PT measures the health of the extrinsic clotting pathway. The aPTT looks at the intrinsic pathway. INR is a standard value for PT based on the international sensitivity index. All three would be elevated in patients who have a bleeding problem, such as in hemorrhagic stroke.

184.

What is the preferred method for first attempt at medication administration in patients with cardiac arrest?

  • Intravenous

  • Intraosseous

  • Endotracheal

  • Oral

Correct answer: Intravenous

It is reasonable for providers to first attempt establishing IV (intravenous) access for drug administration in cardiac arrest.

IO (intraosseous) access may be considered if attempts at IV access are unsuccessful or not feasible. ET (endotracheal) administration is not recommended during cardiac arrest as ET administration results in poor absorption of medication unless IV and IO access are not possible. 

185.

The BPAP settings of 12/5 cm H2O, RR 12, FiO2 of .3 would result in what pressure support?

  • 7 cm H2O

  • 17 cm H2O

  • 30 cm H2O

  • 5 cm H2O

Correct answer: 7 cm H2O

In Bi-level Positive Airway Pressure (BPAP), the Inspiratory Pressure (IPAP) and Expiratory Pressure (EPAP) are set with the IPAP higher than the EPAP, and denoted with the IPAP number over the EPAP (in this scenario, 12/5). The difference between the IPAP and EPAP is known as pressure support, calculated as IPAP - EPAP. Pressure support dictates tidal volume; higher pressure support means a higher tidal volume. This will allow for more carbon dioxide elimination. BPAP is also of benefit because it decreases the work of breathing during exhalation.

In this scenario, the calculation would be 12 - 5, resulting in a pressure support of 7 cm H2O.

186.

During chest compressions of a term parturient in cardiac arrest, at what rate should breaths be delivered by bag valve mask?

  • Cycles of 30 chest compressions:2 breaths

  • 12 breaths/minute

  •  20 breaths/minute

  • Cycles of 15 chest compressions:2 breaths

Correct answer: Cycles of 30 chest compressions:2 breaths

Per AHA 2020 ACLS guidelines, trained healthcare providers performing CPR for adults should use a 30:2 compression-to-rescue breath ratio. To ensure high-quality CPR is maintained, the AHA 202 ACLS guidelines recommend

  • Compressions should be at least 2 inches deep, making sure to allow for complete chest recoil.
  • Providers should switch roles every 2 minutes, or 10 cycles, with minimal interruption, to reduce rescuer fatigue and ensure high-quality compressions.

187.

You are transporting a 9-year-old male patient when he goes into respiratory arrest and requires intubation. You decide to use a 6.0 cuffed tube on the patient because of his size. Based on this, what size suction catheter should be used and how deep should the EndoTracheal Tube (ETT) be inserted?

  • 12fr suction, 18 cm insertion depth

  • 18fr suction, 12 cm insertion depth

  • 12fr suction, 24 cm insertion depth

  • 10fr suction, 18 cm insertion depth

Correct answer: 12fr suction, 18 cm insertion depth

The 2/3/4 Rule can be used to determine the diameter of the suction or nasogastric tube, insertion depth of the EndoTracheal Tube (ETT), and size of the chest tube in pediatric patients when the ETT size is known. The formulas are as follows:

  • 2 x ETT size = Size of the suction or nasogastric tube
  • 3 x ETT size = ETT insertion depth
  • 4 x ETT size = Size of chest tube

This patient has a 6.0 ETT tube. Therefore, the correct size of the suction catheter would be 2 x 6.0, or 12fr. The correct insertion depth for the ETT would be 3 x 6.0, or 18 cm.

188.

Which of the following statements regarding chemical injuries sustained as a result of exposure to an alkaline product is most accurate?

  • Tissue damage from contact with an alkaline product is more severe than that sustained from contact with an acidic product.

  • EMS providers should immediately neutralize the alkaline substance with the application of calcium gluconate.

  • Immediate medical transport of the burned individual should take precedence in chemical burn situations.

  • Tissue destruction is decreased as the specific neutralizing agent is applied to the chemical burn.

Correct answer: Tissue damage from contact with an alkaline product is more severe than that sustained from contact with an acidic product.

Chemical burns which result from contact with an alkaline substance can be among the most devastating of chemical burn injuries. Alkalis causes tissue destruction through the process of saponification — liquefication of the fatty acids of the cell membranes — resulting in liquefaction necrosis of the tissues. Acidic agents cause tissue destruction through coagulative necrosis—cell death as a result of ischemia or infarction. The EMS provider responding to the scene in which an alkaline product was used to cause chemical burns should, after ensuring the patient is stable and does not require immediate transport, delay transport temporarily to provide copious irrigation of the burn wounds using a low-pressure water source. Irrigation of chemical burns should take precedence over immediate transport, unless the patient's condition requires immediate transport or the copious irrigation can be managed within the transport vehicle. Use of neutralization agents typically worsens the extent of tissue destruction as exogenous heat is produced through the neutralization reaction. 

Calcium gluconate is the neutralization agent for hydrofluoric acid, which is used in glass etching and metal cleaning.

189.

You are the flight paramedic called for the emergent transfer of a 30-year-old who was the victim of an assault. The patient presented to the sending facility's ER with signs of shock. The sending RN states the patient is 36 weeks pregnant. Upon your initial assessment, while examining the abdomen, you note what appears to be fetal parts underneath the patient's skin. What do you suspect?

  • Uterine rupture

  • Diaphragmatic rupture

  • Ruptured liver

  • Placenta abruptio

Correct answer: Uterine rupture 

Uterine rupture occurs due to a traumatic or spontaneous disruption of the uterine wall. Risk factors for uterine rupture include a prior cesarean section, use of labor stimulants, trauma, history of prior uterine rupture, grand multiparity, and uterine distention. In a uterine rupture, fetal parts may extend through the uterine wall and into the abdominal cavity. Patients will present with severe sudden abdominal pain, hypovolemic shock, Kehr's sign, and palpation or visualization of fetal parts under the skin.

Diaphragmatic rupture would result in tachypnea from decreased tidal volume, and the auscultation of bowel sounds in the lung fields. Ruptured liver would not cause the presence of fetal parts to be felt. Placenta abruptio would result in painful bleeding from the vagina.

190.

What are signs and symptoms of Type 1 Decompression Sickness?

  • Painful joints, mottled skin, pruritus (itching)

  • Altered mental status, ascending paralysis, visual disturbances 

  • Hypertension, altered mental status, combative

  • Epistaxis, maxillary pain, renal failure

Correct answer: Painful joints, mottled skin, pruritus (itching)

Type 1 decompression sickness has signs and symptoms related to the skin and joints. Patients will present with itching, a sunburn-like rash, painful joints, and may feel like "ants are crawling on their skin." Type 2 decompression sickness is related to neurologic signs and symptoms. 

191.

 Which of the following CMP (Comprehensive Metabolic Profile) disturbances may result as a normal part of the aging process?

  • Elevated Blood Urea Nitrogen (BUN)

  • Elevated blood glucose

  • Elevated sodium

  • Elevated potassium

Correct answer: Elevated Blood Urea Nitrogen (BUN)

Elderly patients may experience elevations in the BUN as a normal part of the aging process. BUN provides a look at renal clearance, with BUN level being significantly higher in the elderly when compared to younger counterparts due to a decrease in renal function. While elevations in BUN may be indicative of true renal pathophysiology, in the elderly, BUN elevations should be evaluated in light of other laboratory studies.

Blood glucose, sodium, and potassium levels do not change as a result of normal aging. 

192.

A 34-year-old patient was shot in the chest by an assault rifle, and has a sucking chest wound. Which of the following injuries did they most likely sustain? 

  • Open pneumothorax

  • Tension pneumothorax

  • Hemothorax

  • Flail chest

Correct answer: Open pneumothorax

A sucking chest wound may be encountered in patients who have sustained trauma to the chest, particularly gunshot wounds or other penetrating trauma. The EMS provider may note the presence of bubbles of blood appearing over the site of a chest wound when the patient breathes out, or may hear the sound of air sucking in and out of the chest wound with the patient's breathing. While an open pneumothorax appears dramatic, it is less of a threat to the survival of the patient than is a tension pneumothorax, as the inspired air in a tension pneumothorax is unable to escape, increasing the thorax pressure, compromising both cardiac and pulmonary function. Historically, sucking chest wounds have been immediately treated with the placement of a 3-sided occlusive dressing to allow for venting of the defect. More recently, commercially manufactured medical plastic chest shields (occlusive dressings) have been used to treat open pneumothorax in hopes of preventing the development of a tension pneumothorax. Needle decompression should be considered if the patient's condition deteriorates.

A hemothorax does not present with a sucking chest wound, neither does a flail chest. Hemothorax occurs due to an accumulation of blood in the pleural space, while a flail chest is due to multiple breaks in contiguous ribs.

193.

Which of the following is incorrect regarding hyperventilation in patients with traumatic brain injury?

  • Target ETCO2 should be between 30-45 mmHg

  • Hyperventilation should be avoided in patients without signs of neurologic deterioration or impending brainstem herniation

  • Intubated patients should be mechanically ventilated to avoid fluctuations in ETCO2

  • An ETCO2 under 30 mmHg has been shown to worsen neurologic outcomes

Correct answer: Target ETCO2 should be between 30-45 mmHg

Providers should target an ETCO2 of 35 to 40 mmHg, and mechanical ventilation should be used as soon as possible to reduce the risk of ETCO2 fluctuations common with manual ventilation.

Hyperventilation is a common management strategy in patients with traumatic brain injury and was previously routinely used in this patient population. However, it is now recommended in patients only with signs of neurologic deterioration and impending brainstem herniation, including pupil dilation, asymmetric pupil reactivity, decorticate or decerebrate posturing, and evidence of traumatic brain injury on CT. An ETCO2  reading under 30 mmHg has been shown to worsen neurologic outcomes as it impedes cerebral pefusion, which can already be reduced by up to 50% in the first 24 hours of injury. Hyperventilation increases ETCO2 and decreases the risk of cerebral hypoperfusion.

194.

Your patient is in compensated metabolic acidosis. His ABGs indicate a pH of 7.41 and HCO3 of 22. What would you expect the compensated PaCO2 to be?

  • 48 mmHg

  • 52 mmHg

  • 26 mmHg

  • 35 mmHg

Correct answer: 48 mmHg

Winter's Formula is used to calculate expected PaCO2 in patients with metabolic acidosis. Winter's Formula states the following:

  • Expected PaCO2 = (1.5 x serum HCO3)+ 8 ± 2

To calculate for this patient, we would substitute 26 for the serum HCO3 as follows:

  • Expected PaCO2 = (1.5 x 26)+ 8 ± 2
  • Expected PaCO2 = 39 + 8 ± 2
  • Expected PaCO2 = 47 ± 2

Therefore, we would expect the PaCO2 for this patient to be between 45 and 49.

195.

You are working as a flight paramedic and are called to transport a ventilated patient to another facility. Upon arrival to the patient, you find the patient is on SIMV ventilator setting. Which of the following best describes the SIMV vent setting?

  • SIMV is a setting that allows spontaneous breathing by the patient. During the respiratory time interval, the ventilator will either deliver a breath or allow a breath triggered by the patient. If the patient triggers a breath, the ventilator will not provide support. If no breath is triggered, the ventilator will deliver a breath at the set rate and pressure or volume.

  • SIMV is a setting that does not allow a patient to take a spontaneous breath. All breaths are delivered by the ventilator. 

  • SIMV is a setting that allows the patient to trigger a breath. Every breath, whether triggered by the patient or the ventilator, receives a full set tidal volume. 

  • SIMV is a setting that delivers a breath to a targeted volume within a specified pressure.

Correct answer: SIMV is a setting that allows spontaneous breathing by the patient. During the respiratory time interval, the ventilator will either deliver a breath or allow a breath triggered by the patient. If the patient triggers a breath, the ventilator will not provide support. If no breath is triggered, the ventilator will deliver a breath at the set rate and pressure or volume.

This is the correct definition for SIMV (Synchronized Intermittent Mandatory Ventilation). 

A setting that does not allow a patient to take a spontaneous breath describes CMV (Continuous Mandatory Ventilation). AC is a setting that allows the patient to trigger a breath or a breath is trigger by the determined rate and a full tidal volume is delivered. A setting that delivers a breath to a targeted volume within a specified pressure is PRVC. 

196.

What is the primary difference between delayed and rapid sequence intubation?

  • In delayed sequence intubation, there is a delay between administration of the sedative and paralytic, while medications are administered back-to-back in rapid sequence intubation

  • In rapid sequence intubation, all medications are given at the same time in two different IV lines. In delayed sequence intubation, medications are given one right after the other in the same IV line.

  • In delayed sequence intubation, all medication is delayed to pre-oxygenate the patient. Rapid sequence intubation has no delay between oxygenation and medication administration.

  • Delayed sequence intubation occurs when passage of the tube is delayed due to provider inexperience

Correct answer: In delayed sequence intubation, there is a delay between administration of the sedative and paralytic, while medications are administered back-to-back in rapid sequence intubation

Endotracheal intubation can be performed in patients in one of two ways: Delayed Sequence Intubation (DSI) or Rapid Sequence Intubation (RSI). When using RSI, the sedative and paralytic are administered back-to-back to facilitate emergency endotracheal intubation. In DSI, the sedative is first administered, then there is a delay while the patient is oxygenated. The goal for this delay is to achieve hemodynamic stability, correct hypotension, and improve oxygenation. After goals for the delay are met, the paralytic is administered, and the patient is intubated. 

197.

Which of the following breathing techniques most accurately describes the use of tactical breathing?

  • Inhale for 4 seconds, hold the inhaled breath for 4 seconds, exhale for 4 seconds, then hold the exhalation for 4 seconds.

  • Inhale for 4 seconds, hold the inhaled breath for 7 seconds, then exhale for 8 seconds.

  • Breathe in slowly through the nose, then exhale slowly through pursed lips.

  • Inhale slowly for a count of 15, then exhale slowly for a count of 30.

Correct answer: Inhale for 4 seconds, hold the inhaled breath for 4 seconds, exhale for 4 seconds, then hold the exhalation for 4 seconds.

Tactical breathing is a breathing technique that was designed by the military for use in extremely stressful situations to try to help quickly de-escalate in stressful situations and be able to continue working. This breathing technique aids in lowering heart rate and stress levels, and can help in moderating the surge in sympathetic nervous system activity in direct response to stress.

The technique of inhaling for 4 seconds, holding the inhaled breath for 7 seconds, then exhaling for 8 seconds, is referred to as "relaxing breath" or the "4-7-8 breathing technique" and is used to help in falling asleep or decreasing anxiety.

Pursed lip breathing is useful for improving shortness of breath.

198.

What is a possible complication of using AC ventilator setting in the critical care transport environment?

  • Breath stacking and ventilator-induced lung injury can occur.

  • Reduced barotrauma

  • Underventilation

  • There is no risk of using AC in the critical care transport environment.

Correct answer: Breath stacking and ventilator-induced lung injury can occur.

Assist control mode is often the mode of choice in hospitals due to the minimal work required from the patient, allowing them to rest post-intubation. However, extra movement such as vibration from ground and air transport can cause auto triggering of a ventilator set in AC mode. This can result in breath stacking as well as air trapping and auto-PEEP, leading to barotrauma and ventilator-induced lung injury. The critical care paramedic should closely monitor patients who are on AC. Considerations may be made for lowering the trigger sensitivity to prevent auto triggering.

199.

Which of the following statements most accurately describes a commercial medical escort?

  • The transport of a stable patient on a commercial flight with attendance by an EMS provider. 

  • The transport of a patient using any commercial means of air travel.

  • The transport of a stable patient on a commercial flight with attendance by a full medical transport crew.

  • The transport of a critically ill or injured patient on a commercial flight with attendance of at least a registered nurse and a physician.

Correct answer: The transport of a stable patient on a commercial flight with attendance by an EMS provider. 

Depending upon the regulations and restrictions of a commercial airline or aircraft, both stable and critically injured patients may ultimately be transported by use of these means. Several terms exist to describe the transport of patients on commercial aircraft, including the term commercial medical escort. A commercial medical escort refers to the air transport of a stable patient on a commercial aircraft with only one medical attendant present. Medical attendants may be registered nurses, physicians, EMTs, or EMT paramedics. 

Other medical assist transports may involve the commercial air transport of a critically ill or injured patient with attendance by a full or partial air medical transport crew, however they would not be described as commercial medical escorts.

200.

During air medical transport of a preeclamptic patient who is being maintained on a magnesium sulfate infusion, the patient exhibits changes in her level of consciousness, depressed respiratory drive, and loss of her Deep Tendon Reflexes (DTRs). Which of the following medications should be administered? 

  • 1 gram of 10% calcium gluconate

  • 0.25 mg of terbutaline

  • 30 mg of nifedipine

  • 12 mg of betamethasone

Correct answer: 1 gram of 10% calcium gluconate

Magnesium sulfate is administered to preeclamptic pregnant patients to prevent the development of seizures. Therapeutic serum magnesium levels should be maintained between 4 to 8 mEq/L with regular checking of the serum magnesium, and the Deep Tendon Reflexes (DTRs) should be checked hourly for the duration of the magnesium therapy. Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium and calcium maintain an inversely correlated relationship; if magnesium levels rise, calcium levels fall, and vice versa. With serum magnesium at a toxic level, the administration of calcium gluconate serves to drive magnesium levels down, and with it, the toxic side effects seen with elevated levels. A 1-gram dose of 10% calcium gluconate should be administered intravenously over approximately 3 minutes; a second dose of 1 gram, or a second titrated dose, may be needed to produce a therapeutic effect.

Terbutaline and nifedipine are both tocolytics used to suppress uterine activity (labor contractions). Betamethasone is administered to promote fetal lung maturity in the likely event of preterm delivery.