IBSC FP-C Exam Questions

Correct answer: Atropine

Rapid Sequence Intubation, or RSI, is used to rapidly secure the airway in emergency settings. Pediatric patients may require RSI due to an increased risk of aspiration; airway obstruction; inadequate oxygenation or ventilation; respiratory distress, failure, or arrest; the need for high PEEP or mechanical ventilatory support; or as a route for administering medications prior to IV access is obtained. When intubating pediatric patients, atropine should be given first to block vagal response and prevent bradycardia during intubation attempts. 

Other medications can be given in the typical order with sedation and pain medication given first, then paralytics. 

Correct answer: Anaphylactic reaction to amniotic fluid and fetal cells

Amniotic fluid embolism has received a new nomenclature, due to what is now believed to be the etiology of this deadly pregnancy-related process. Anaphylactoid syndrome of pregnancy (or anaphylaxis syndrome of pregnancy) is believed to occur as a result of maternal anaphylactoid reaction to the presence of amniotic fluid and fetal cells within the maternal circulation as a result of labor and delivery. It is suspected that amniotic fluid and fetal cells enter the maternal circulation through the following three most likely routes: microscopic lacerations to the endocervical veins and to the lower uterine segment (occurring during cervical dilation), the placental attachment site (after delivery of the placenta), and the uterine veins (as a result of trauma). Disseminated Intravascular Coagulation (DIC) can be expected to occur in conjunction with anaphylaxis; the etiology of the DIC is unclear. Amniotic fluid embolism is much more likely to occur when there have been interventions during the labor, particularly the use of uterine stimulant medications to augment or induce labor, surgical delivery methods, or when uterine rupture occurs. Other risk factors include fetal demise, meconium in the amniotic fluid, placental abruption, large fetus, and precipitous delivery (among others).

It was previously believed that amniotic fluid embolism was caused by obstruction of the pulmonary vasculature due to amniotic fluid, fetal cells, or lanugo hairs but this is no longer the case. Disseminated Intravascular Coagulation (DIC) can be an expected complication of amniotic fluid embolism, but it is not due to an obstruction in pulmonary vasculature and is a separate condition from amniotic fluid embolism.

Correct answer: EMS should delay insertion of intravenous catheters until an anesthesiologist can establish a secure airway.

Epiglottitis is a rare but deadly bacterial infection which affects the epiglottis, primarily in children between the ages of two and six years. The regular administration of the Haemophilus influenzae type b vaccine (Hib) has resulted in a significant decline in epiglottitis cases. Children with epiglottitis typically appear acutely ill and have a toxic appearance, and their caregivers typically report a rapid onset of symptoms of high fever, sore throat, inability to swallow their own secretions, and noisy breathing. During emergency medical transport, the child should be kept as calm and quiet as possible to prevent worsening of the edema of the epiglottis, supporting an upright, classic tripod position if at all possible during transport. 

EMS should not plan to insert any intravascular access or administer any other invasive procedures until either an anesthesiologist or ear/nose/throat doctor can secure an airway in the patient. Should the patient's condition worsen during transport, needle cricothyroidotomy should be completed (surgical cricothyroidotomy is not indicated in pediatric patients under the age of 10 to 12 years), and tracheotomy should be considered if a skilled provider is present.

Correct answer: 9,000 mg

N-Acetylcysteine (NAC) (Mucomyst, Acetadote) should be administered to treat acetaminophen poisoning if serum acetaminophen levels are toxic at 4 hours following ingestion, if the medical transport team is unable to obtain serum levels and 8 hours or more have passed since the ingestion, or it is suspected the patient has ingested a toxic amount of acetaminophen. NAC may be administered orally or IV; when administered orally, the loading dose should be administered at 140 mg/kg, and at 150 mg/kg when IV administration is used. 

Using the information presented in our scenario, and the knowledge of IV loading dose to be administered at 150 mg/kg, the patient in this scenario should receive a loading dose of:

150 mg/kg x 60 kg = 9,000 mg

Correct answer: Increase respiratory rate to 35

Patients with ARDS represent a unique challenge when managing the ventilator. These patients require low tidal volumes paired with high levels of PEEP and FiO₂  to stay properly oxygenated. As with any ventilated patient, arterial blood gases will be the most accurate tool to use when adjusting ventilator settings. Per the ARDSnet NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol, an ARDS patient should have a target pH of 7.30-7.45 during ventilation. A patient with a pH under 7.15 requires an increase in ventilatory rate to a maximum of 35. If the pH remains under 7.15, then tidal volume should be increased step-wise in 1 ml/kg increments. Sodium bicarbonate may also be considered.

Decreasing the respiratory rate would have the opposite necessary effect on the patient, and increasing PEEP would serve to improve oxygenation but not pH. 

Correct answer: Loss of the patellar reflex

Preeclampsia is a disease process of pregnancy that affects multiple organ systems and typically presents with findings of hypertension and proteinuria after 20 weeks gestation. Left untreated, preeclampsia may progress to eclampsia, in which the pregnant woman experiences seizures as a result of grossly elevated blood pressure. Typically, hypertension in preeclampsia is treated with the administration of labetalol and/or hydralazine; seizure prophylaxis is provided through the administration of magnesium sulfate. Magnesium sulfate has the potential to cause toxicity, ultimately leading to pulmonary edema and death. For this reason, it is critical that the deep tendon reflexes (DTRs) be assessed every hour while magnesium sulfate is being infused. A not uncommon finding is loss of patellar reflex with preservation of biceps reflex, which may not indicate acute toxicity but does indicate increased serum magnesium levels.

Later signs of severe magnesium toxicity include loss of all the DTRs, a decrease in respiratory rate below 12 with poor respiratory effort, and changes in the level of maternal consciousness.

Correct answer: Obtaining measurement data at the same time

Research is being used more frequently in critical care medicine to support evidence-based treatments and advancements. With research comes many new terms critical care providers should be familiar with to appropriately review research materials. One of those terms is concurrent validity, which refers to the practice of obtaining all measurements at the same, or concurrent, times. 

External validity is analyzing how the results of research can be applied to outside samples and to what extent they will apply. Face validity is determining whether the instruments appear to be measuring what they should be measuring. Predictive validity is determining if measurements from one area of study or instrument are used to predict another area of study or instrument reading.

Correct answer: Afterload

Afterload is the resistance the ventricles of the heart must overcome to eject blood. Poiseuille's Law explains the determinants of afterload including vascular dilation, blood viscosity, outflow obstructions, and vascular tone. Obstructions, polycythemia, and vasoconstriction increase afterload, while vasodilation reduces afterload. More afterload is required for adequate left ventricular ejection in dilated cardiomyopathies. 

Frank-Starling law demonstrates the relationship between cardiac output and preload. Blood pressure is calculated by multiplying cardiac output and stroke volume.

Correct answer: 100 ft x 100 ft

Generally, 100 ft x 100 ft is a large enough minimum landing zone for these options. While a 75 ft x 75 ft landing zone is acceptable in daytime conditions, a 50 ft x 50 ft would be too small. Therefore, the most appropriate answer is 100 ft x 100 ft. 

Correct answer: No presence of intracranial hemorrhage

The neonate with PPHN who does not improve with standard invasive measures used to treat the disorder, including the administration of 100% oxygen using mechanical ventilation, the administration of nitric oxide, inotropes to support adequate peripheral perfusion and oxygenation, high-frequency ventilation including jet ventilator or oscillator, administration of surfactant (when appropriate), and the correction of acidosis or alkalosis, should be considered for cardiopulmonary support using ECMO. Since the purpose of ECMO is to support the neonate until the pulmonary and cardiac dysfunction is improved, the use of ECMO requires that the infant meet the severity of illness criteria, which is determined through calculation of the oxygen index (OI). The OI is calculated through use of the following formula:

Oxygenation Index = (FiO₂  * Mean Airway Pressure * 100)/PaO₂

If the severity of illness criteria is met, the clinicians must determine if the neonate meets further criteria used to determine patients selected for ECMO: 

• The birth weight must have been > 2000 grams
• Gestational age over 34 weeks
• No uncontrolled bleeding
• No major intracranial bleeding
• Neonate has been sustained on mechanical ventilation for at least 10 to 14 days
• No uncorrectable congenital heart disease
• No lethal congenital anomalies
• No irreversible brain damage

Correct answer: 103

To calculate the cerebral perfusion pressure, use the equation CPP = MAP - ICP. You would have to first calculate the MAP by using the equation MAP =  DBP + 1/3(SBP-DBP) or (2 x  DBP) + (SBP / 3). We would calculate this patient's CPP as follows:

MAP = 90 + 1/3(182-90)

MAP = 121

CPP = 121 - 18

CPP = 103

Normal CPP should be 70-90 mmHg. 

Correct answer: Increase PEEP when a low tidal volume strategy is necessary

Cyclic atelectasis occurs when the alveoli open during inspiration, then collapse during expiration. This causes the release of cytokines and contributes to the development of both local and systemic inflammatory reactions, compounding lung injury and leading to atelectasis trauma. While tidal volume holds a critical role in alveolar recruitment, in some patient populations, a low tidal volume strategy must be used. When this is the case, PEEP should be increased to maintain alveolar recruitment when the patient exhales. 

Correct answer: decreased blood viscosity

Studies have shown that up to 50% of trauma patients experience hypothermia either due to the environment or the treatment provided. Prolonged extrication times, loss of blood and thermoregulation, exposure of the patient, and administration of non-warmed fluids can all contribute to hypothermia. Care should be taken to quickly cover exposed patients with blankets, warm fluids and oxygen before administration, and increase the temperature in the patient compartment when caring for a trauma patient, even on warm days.

Effects of hypothermia on trauma patients include:

• Cardiac depression
• Peripheral vasoconstriction
• Blunted responses to catecholamines and medications
• Increased blood viscosity
• Metabolic acidosis
• Reduced platelet function
• Impaired tissue oxygen delivery

Correct answer: Cardiac tamponade

Beck’s Triad consists of Jugular Venous Distention (JVD), muffled heart tones, and narrowed pulse pressures. As fluid accumulates around the heart, the preload is reduced, causing decreased cardiac output. This causes a backup of blood into the venous system and is seen as JVD. Sound is dampened when traveling through a liquid medium and therefore, the sound of the closure of AV, aortic, and pulmonic valves is harder to auscultate. 

A pulmonary embolism would not produce muffled heart sounds. Hypovolemic shock would not show JVD because of low blood volume. Increased intracranial pressure would not show any of the signs of Beck’s Triad.

Correct answer: Electrocardiogram (ECG) changes seen in patients with PE include right axis deviation.

A pulmonary embolism is by definition an occlusion of the pulmonary artery, or one of its branches, which occurs as a result of thrombus formation, tumor, air, or fat. The patient with a Pulmonary Embolism (PE) may present with a variety of symptoms, including being asymptomatic, and symptoms often mimic those of other cardiac or pulmonary pathology. Possibly signs and symptoms include chest pain, cough, wheezing, tachypnea or tachycardia, orthopnea, jugular venous distention, lightheadedness, or hemoptysis (among other symptoms). Patients with these symptoms should be noted and then evaluated in light of the patient's history (including any recent travel, the use of oral contraceptive agents, or any coagulopathies), laboratory studies (such as ABG's, D-dimer, BNP, etc.), and radiographic studies such as a simple chest radiograph, a V/Q scan, or a computed tomographic pulmonary angiography. 

Examination findings include ECG changes such as right axis deviation, nonspecific ST segment and T wave changes, and SI QIII TIII patterning. Auscultation of the cardiac sounds may reveal an accentuated S2 or the presence of S3 heart sound. 

PE is often fatal.

Correct answer: 4.5 mLs

Preterm infants frequently experience Respiratory Distress Syndrome (RDS) as a result of a deficiency of surfactant due to preterm birth. Surfactant serves to prevent collapsing of the alveoli at the end of expiration by decreasing the surface tension of the air-water interface. Intrinsic surfactant production begins approximately between weeks 24 and 28 of pregnancy, so that by the time the fetus reaches 35 weeks of gestation, adequate surfactant should be present to provide stable respiratory status.

For infants born prior to 34 weeks, surfactant is typically administered via endotracheal tube. Surfactant is administered at a dose of 3 mL per kg of birth weight. The infant in this scenario weighs 1500 grams, which can be transposed to a weight of 1.5 kilograms (1,000 grams per kilogram). A simple calculation will yield the needed surfactant dosage.  

3 mL x 1.5 kg = 4.5 mLs of surfactant

Correct answer: Applied research

Applied research looks at finding solutions to existing problems. This makes the results of applied research uniquely suited for immediate use in clinical practice.

Research is often classified based on the methodology and the purpose behind the research. Quantitative research looks at numerical data, while qualitative research considers subjective data. The goal of basic research is to expand knowledge in general.

Correct answer: Croup

A steeple sign on an anterior poster radiograph of a pediatric patient is one of the hallmark signs of croup due to the narrowing of the upper airway and glottic space. 

Patients with epiglottitis will have a thumb-print sign visible on their radiograph when viewed laterally due to the inflammation of the epiglottis. Bronchiolitis will not present with changes in the head and neck radiograph, as it is a disease of the lower airway. A foreign body airway obstruction may be visible in a radiograph, however this will be due to the obstruction showing up on the radiograph, not from anatomical changes. 

Correct answer: A glucocorticoid such as dexamethasone

Croup describes acute upper airway viral infection. In typical cases, viral croup presents in children six months to five years of age in the fall and early winter, as symptoms of an upper respiratory tract illness, followed by a barking cough and stridor, in the absence of fever. Patients with mild disease may have stridor when agitated. As the obstruction worsens, stridor may occur at rest, accompanied in severe cases by retractions, air hunger, and cyanosis. On examination, the presence of cough and the absence of drooling favor the diagnosis of viral croup over epiglottitis.

Glucocorticoids, specifically dexamethasone, are the preferred treatment for croup. Children that are vomiting or cannot take oral steroids can be given nebulized budesonide. Moderate to severe croup can be treated with nebulized epinephrine. Endotracheal intubation is only indicated in the most severe of cases.

Oxygen should be administered to patients with oxygen desaturation.

Correct answer: Brown Sequard lesion

Brown Sequard lesion (also referred to as Brown-Sequard syndrome) results from damage sustained to one side of the spinal cord only. This condition most often occurs as a result of spinal cord lesions or tumors, with traumatic events such as stabbing or shooting also contributing to the incidence of Brown Sequard lesion. Patients with Brown Sequard lesion will experience loss of motor function to the side of the body on which the trauma occurred, as well as loss of touch, proprioception, and vibration to the ipsilateral side. Loss of pain and temperature sensation is noted on the contralateral side. 

Complete cord transection results in complete loss of motor and sensory function. Central cord injury presents with worsened motor and sensory impairment in the upper limbs compared to the lower. Anterior cord syndrome results in loss of pain and temperature sensation as well as paraplegia below the injury site.