IBSC FP-C Exam Questions

Correct answer: Cerebral atrophy may contribute to the delay in subdural hematoma symptom development in the elderly population.

Both the elderly and infants (and young children) are at an increased risk for the development of a subdural hematoma due to the fragility of the intracranial vessels. But while symptoms of subdural hematoma may develop quite rapidly in an infant and as a result of comparatively small hemorrhage, the elderly individual who sustains a larger subdural hematoma may demonstrate a delay in symptom manifestation due to cerebral atrophy. Cerebral atrophy lends itself to a gradual increase in the subdural space, allowing for greater blood loss into this area before symptoms become apparent. Infants who sustain subdural hematoma (often through shaken baby syndrome) will also often sustain retinal hemorrhaging and may succumb to a shock-like state as a result of large amounts of intracranial bleeding.

Correct answer: Shaken Baby Syndrome

Shaken Baby Syndrome is a common type of non-accidental trauma in pediatric patients. While it can happen in any child, the most common victims are those born prematurely and those with multiple underlying medical conditions. These children will present with a triad of injuries that includes retinal hemorrhage, subdural hematoma, and encephalopathy. These patients may also present with suspicious bruising to their chest and back from being held tightly while being shaken. Some degree of bruising may be normal in children who are moving on their own on bony prominences, but bruising to soft or fatty tissue is not normal.

While hypoglycemia and accidental toxic ingestion may cause altered mental status in pediatric patients, neither would cause retinal hemorrhaging or bruises.

Correct answer: An R wave in V₅ or V₆ > 35 mm

Several ECG criteria are used to diagnose Left Ventricular Hypertrophy (LVH). The more criteria that are present, the more likely that the patient has LVH. These criteria include:

• Any precordial lead of 45mm or higher
• An R wave in Lead aVL of 11mm or more
• An R wave in Lead I of 12 mm or more
• An R wave in lead aVF of 20 mm or more

Additionally, if the sum of the tallest R wave in V₅ or V₆ and the deepest S wave in V₁ or V₂ is 35 mm or more, LVH is likely. 

Correct answer: Dalton's Law

Dalton’s Law = The pressure of a gas mixture is equal to the sum of the partial pressures of the gases in the mixture. Dalton's law illustrates that increasing altitude results in a proportional decrease in the partial pressure of the gas found in the atmosphere. Partial pressure decreases as a direct result of the decrease in barometric pressure as altitude increases.

Boyle’s Law = The volume of a gas is inversely proportional to pressure (as long as the temp is constant).

Henry’s Law = The amount of a gas dissolved in solution is directly proportional to the pressure of the gas over the solution.

Gay-Lussac’s Law= The pressure of a gas is directly related to temperature.

Correct answer: An increase in secretions

Suctioning is a critical step in the management of a patient with airway compromise or who has excessive secretions or debris in the airway. An increase in secretions, however, is not typically a complication of suctioning. 

Proper suctioning can eliminate the need for endotracheal intubation and restore airway patency while reducing the risk of aspiration. However, suctioning is not without potential complications. Improper technique or poorly applied suction can cause hypoxemia, cardiac arrhythmia, mechanical trauma, infection, or increased intracranial pressure. Suctioning may also be unable to clear the obstruction due to dried crusting or mucus plugs. 

Correct answer: Administer blood products

Due to the mechanism of injury in combination with this patient's signs and symptoms, they are likely suffering from hypovolemic shock due to internal bleeding. The altered mental status, weak and rapid pulse, and hypotension indicate this patient is progressing into stage 3 and will likely require a blood transfusion. 

While shock treatment typically calls for up to three 20 ml/kg boluses, blood products can often by preceded by 40 ml/kg of crystalloids prior to administration. Additionally, repeated administration of IV crystalloids can precipitate coagulopathy in severely injured children. Ultimately, early administration of blood products is needed in children with severe volume loss due to trauma. 

Inotropes may improve this patient's blood pressure but will not assist in correcting the fluid loss. TXA may stop internal bleeding, but this patient has an immediate need for fluid replacement. TXA may be considered as a second line of treatment in this scenario. 

Correct answer: Morphine

The severe, persistent, unrelenting pain experienced by almost all patients who present with acute pancreatitis, chronic pancreatitis, or acute and chronic pancreatitis, is one of the hallmarks of pancreatitis and remains difficult to adequately treat. First-line treatment of the pain associated with pancreatitis involves the administration of Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) such as indomethacin or diclofenac, as well as ketamine and meperidine. These medications do not have any effect on the sphincter of Oddi, while the administration of morphine may cause spasms of the sphincter, causing a worsening of the pain as well as obstruction to bile flow. That being said, there are times when morphine is used in the treatment of pancreatic pain, but it is not considered a first-line agent for treatment of this type of pain.

Correct answer: Helicobacter pylori (H. pylori)

Acute hemorrhagic events may occur as a result of perforations of peptic or duodenal ulcers, causing significant morbidity and mortality for the patient. Upper gastrointestinal (GI) bleeding occurs in up to 50% of cases of peptic or duodenal ulcers; treatment modalities include the placement of gastric tubes such as Linton or Minnesota tubes, the administration of medications, endoscopy, thermal therapy, injection of medications (such as epinephrine) to control the bleeding, or surgery if these less invasive treatment methods are ineffective. Peptic ulcers may be caused by NSAID use, alcohol use/abuse, tobacco usage, as a result of stress, or from gastritis. H. pylori is the most common cause of peptic ulcers, and is typically treated with a combination of two antibiotics and a gastric acid lowering agent. NSAID use is the second most common.

Correct answer: 2 to 4 L/min

At times, members of the air medical transport crew may be called upon to aid in transporting a patient via a commercial airline carrier. This type of medical air transport is referred to as commercial medical escort and may involve one member of the air medical transport crew serving as escort to a medically stable patient, or it may involve the entire crew (or several members of the crew) stabilizing a critically ill patient and escorting them to their destination by use of a commercial airline. Commercial airlines are equipped to deliver oxygen to their passengers, most often at a rate of only 2 to 4 L/min. 

If the patient requires oxygen at a higher flow rate, or requires the delivery of 100% oxygen, oxygen tanks should be obtained at least 24 hours in advance of the travel, and ideally, several days prior to the planned travel. 

Correct answer: Ruptured spleen

The injuries sustained during a side impact collision are somewhat dependent upon whether or not the occupants of the vehicle were restrained by seat belts. Typically, side impact collisions cause lateral injuries to the occupants of the vehicle who are seated on the same side as the impact. These injuries include rib and clavicle fractures and femur and lower leg fractures. Ruptured spleen often results in side impact collisions due to both the presence of rib fractures, as well as from direct compression to the abdomen from seatbelts. If the occupants of the vehicle were not restrained, further injury then may result from being pushed to the opposite side of the vehicle.

Concussions and dislocated hips often occur in head-on collisions. T12-L1 fractures are often seen in rear-end collisions.

Correct answer: Alkalosis

Altered mental status is a common finding in patients with a neurologic deficit. The causes of altered mental status can be summarized with the mnemonic AEIOU-TIPS, detailed below:

• Acidosis (not alkalosis): Metabolic acidosis due to many potential underlying conditions
• Epilepsy: Seizures or a post-ictal period
• Insulin: Hyperglycemia, hypoglycemia
• Overdose: Toxic ingestion of drugs or alcohol
• Uremia: Accumulation of uremic toxins in the brain
• Trauma: Head trauma, increased intracranial pressure, and concussions
• Infection: Sepsis, urinary tract infections, etc.
• Psychosis: Acute and chronic behavioral disorders
• Seizures: Seizures with no known history and post-ictal periods

Correct answer: The patient was not properly pre-oxygenated before suctioning

Suctioning is perhaps one of the most critical basic level skills providers can use to eliminate respiratory compromise. Suction can clear debris, vomitus, blood, and other secretions from an otherwise patent airway. Suction catheters can be large bore and rigid for larger debris or small bore and flexible for suctioning of the nasopharynx and lower airways. Care should be taken when suctioning to pre-oxygenate the patient to ensure suctioning does not cause hemodynamic instability and hypoxemia. Suction attempts must also last no longer than 10 seconds for the same reason. Patients should also receive oxygen during suction attempts if possible and should be oxygenated and, if necessary, ventilated between attempts.

While apnea may be the cause of this patient's drop in oxygen saturation levels, it is more likely that the suctioning is causing hypoxemia since the drop corresponds with performance of that procedure. A drop in oxygen saturation should not be considered normal during suction and should be quickly addressed.

Correct answer: Newton's Third Law 

Newton's three Laws of Motion can be used to explain the physics of many common trauma situations, and also the physical injuries sustained by the individuals involved in the trauma. During a motor vehicle accident, Newton's First Law of Motion comes into play when the vehicle crashes: "A body in motion remains in motion in a straight line unless acted upon by an outside force." Both the vehicle and the occupants of the vehicle remained in motion until some force acted against them; in the case of the vehicle, the tree, and in the case of the driver of the vehicle, the seatbelt. The passenger of the vehicle, who was not wearing a seatbelt, continued in forward motion until the force of the ground stopped his motion. The driver was not ejected from the vehicle as a result of Newton's Third Law of Motion: "For every action, there is an equal and opposite reaction." In this case, both the airbag and the seatbelt exert its own force back onto the driver, causing a deceleration of the driver's forward motion. 

Newton's Second Law of Motion states, "Acceleration is dependent on the mass of the object and the force of the object." This law can be used to discuss the rate at which the passenger was ejected from the vehicle.

Newton's Fourth Law is his law of gravitation, not motion.

Correct answer: Hyponatremia

Seizures in pediatric patients can be caused by a variety of things, including fevers, hypoglycemia, and idiopathic causes. One cause of seizures in patients six months of age and younger is hyponatremia. These patients have significant differences in renal physiology to adult patients and cannot tolerate excess free water due to a higher percentage of body water compared to adult patients. One possible cause of excess free water in infants is diluted baby formula. Parents may dilute formula to make it last longer due to shortages, budget constraints, or other reasons. Anytime a patient under the age of six months is seizing, questions should be asked regarding formula concentration to rule out hyponatermia as the cause.

This patient is afebrile with no history of illness, so febrile seizures are not likely the cause. Blood sugar should be checked before ruling out hypoglycemia entirely, but hyponatremia is more likely the cause due to the diluted formula. Idiopathy is always a potential cause of seizures, but treatable causes should be considered first. 

Correct answer: Decrease the RPM and give IV fluids

The medical air transport crew who flies missions transporting patients on ECMO needs to receive regular simulation training on the management of catastrophic events which may occur to patients while on ECMO. The greatest risk to patients on ECMO is bleeding due to the need to maintain the patient on anticoagulants while on the machine. Other, less frequent catastrophic risks include massive air embolism and complete loss of pump function. Hemolysis, pulmonary edema and left ventricular distention, limb ischemia, circuit rupture, and complete pump failure can also occur. "Chugging" or "chatter" presents as visible and rhythmic movement or vibration in the venous line and is indicative of insufficient flow. Flow is influenced by the relationship between preload, afterload, and RPM. When "chugging" is noted, RPM should be reduced in order to stabilize the flow, and IV fluids given to replace intravascular volume and increase preload.

In the event of cardiac arrest, ACLS should be initiated. The ECMO is the form of ventilator; in the event of ECMO circuit failure, the crew may need to begin providing ventilation using bag-valve-mask ventilation. Critical care providers may need to isolate patients from the circuit in cases when repair is needed. Patients would not need to be removed from the circuit in this scenario.

Correct answer: Ensure the patient has a patent airway

The initial priority in patient management follows the ABCs (airway, breathing, circulation). A patient who is drowsy and minimally responsive may have a compromised airway, and maintaining a patent airway is crucial. The paramedic must first ensure that the airway is clear and adequately managed to prevent respiratory failure or further deterioration.

Flumazenil is a reversal agent for benzodiazepine overdoses, but its use is controversial due to the risk of inducing seizures, particularly in chronic benzodiazepine users or those with mixed overdoses.

Naloxone (Narcan) is used for opioid overdoses, not benzodiazepines, and would not be effective in this scenario.

Gastric lavage is no longer commonly recommended due to the risks involved and is generally reserved for specific cases of life-threatening ingestion within an hour of the overdose.

Correct answer: Patients with hypertension can maintain adequate perfusion in a shock state.

Patients can experience a shock state as a result of any number of different insults, including hypovolemia, vasomotor dysfunction, sepsis, anaphylaxis, or acute spinal cord injury (among others), but overall, the effect of shock is the same. The physical signs, including changes in vital signs, exhibited by a patient in shock are a reflection of the compensation attempts of the body, as well as a result of hypoxia. If the shock state is not treated rapidly, hypotension will ensue, indicating a failure of the body's compensatory mechanisms; this is typically referred to as "uncompensated shock." 

In patients with an underlying history of hypertension, the development of a hypotensive state may be ignored or missed. It may be assumed that adequate perfusion is being maintained due to what appears to be normal systemic blood pressures. However, this may not be the case as patients with a history of hypertension have chronically higher than normal systemic blood pressures. Often, hypertensive patients in a shock state are ultimately grossly underperfused as a result of decreases in arterial blood pressure, due to their already dysfunctional blood pressure state.

Correct answer: Toxic alcohol ingestion 

Fomepizole is used for the ingestion of methanol or ethylene glycol. These alcohols are toxic to the body and lead to severe anion gap acidosis. Fomepizole prevents the metabolites of these alcohols from forming. 

Malignant hyperthermia is treated with dantrolene. Delirium tremens is treated with benzodiazepines. Excited delirium is treated with ketamine or benzodiazepines. 

Correct answer: Large T-wave inversion in the anterior leads

Patients with increased intracranial pressure will present with a variety of symptoms, including posturing, pupillary changes, altered mental status, and more. A 12-lead may show ST depression but more commonly will show large T-wave inversion in the anterior leads.

ST segment elevation is seen in ST elevation myocardial infarction among other conditions. Peaked QRS complexes are a significant finding for hyperkalemia. 

Correct answer: Assisted ventilation synchronized with the patient's breathing

Synchronized Intermittent Mandatory Ventilation (SIMV) is a type of volume control mode of ventilation. With this mode, the ventilator will deliver a mandatory (set) number of breaths at a set pressure synchronized with the patient's breathing (spontaneous respirations).