IBSC FP-C Exam Questions

Correct answer: Pedestrian accident

Waddell's triad is a cluster of findings with sole association with pediatric pedestrians who are struck by a motor vehicle while walking. In Waddell's triad, a femoral fracture is seen as a result of the initial impact of the child's body with the bumper of the vehicle. After striking the bumper, the pediatric pedestrian typically then catapults upward onto the hood of the vehicle, resulting in internal thoracoabdominal injuries. The child is then thrown from the hood of the vehicle, most often striking his or her head on the ground, resulting in traumatic brain injury or injury to the cervical spine.

Correct answer: Concussion

When adults fall from heights averaging 15 feet or less, as when falling from the roof of an average single-story home, they are most likely to land in the same direction of their fall. The roofer in this scenario was noted to have slipped and fallen feet-first from the roof of a single-story home, so he is most likely to have sustained fractures to his feet (calcaneus fractures), a Colles fracture (fracture of the distal radius) due to extending his arms in an attempt to stop his fall, and a compression fracture of his thoracolumbar spine as a result of landing on his feet. Had the roofer's fall been from a height greater than 15 to 20 feet, his injuries would most likely have been the same, as adults who fall from heights greater than 15 to 20 feet are more likely to land on their feet. On the other hand, had the roofer slipped and fallen off the roof head first in the scenario from the 15-foot height, he would have most likely sustained a concussion or other, far more serious, head injuries.

Correct answer: Subdural hematoma

Subdural hematomas are caused by a sudden acceleration-deceleration injury to the brain and damage to the dural bridging veins, resulting in blood entering the potential space between the arachnoid and the dura. On CT, acute subdural hematomas are hyperdense (white), crescent-shaped lesions that cross suture lines.  

Subdural hematomas have traditionally been classified as acute, subacute, or chronic based on the length of time from the onset of active hemorrhage. Acute symptoms typically develop within 14 days of the injury, and are termed chronic subdural hematoma after 2 weeks. There is no specific clinical presentation associated with subdural hematoma. Acute cases typically present immediately after significant trauma, and the patient is frequently unconscious. Chronic subdural hematomas are more common in elderly or alcoholic patients, may result in vague complaints or mental status changes, and there may be no recall of injury.

Epidural hematomas have a lenticular shape on CT. Subarachnoid hemorrhages will present with starfish signs. Intracerebral hemorrhage appears as readily identifiable white shapes within the brain on CT.

Correct answer: Anion gap 

The anion gap measures the difference between the negatively charged and positively charged electrolytes. The most common causes of metabolic acidosis can be remembered using the MUDPILES pneumonic:

• Methanol
• Uremia or kidney failure
• Diabetic ketoacidosis
• Propylene glycol
• Infection, inborn errors of metabolism
• Lactic acidosis
• Ethanol
• Salicylates

Corrected sodium is only used in calculations for DKA or hyperglycemia acidosis. Base excess is defined as the amount of acid required to restore blood to its normal pH at a PaCO₂ of 40 mmHg. The base excess increases in metabolic alkalosis and decreases in metabolic acidosis. 

Correct answer: Administration of dexamethasone, IV fluids, broad-spectrum antibiotics

Based on this patient's signs and symptoms, they are likely suffering from bacterial meningitis. Bacterial meningitis is a life-threatening emergency that affects about 1.2 million individuals worldwide each year. 

The classic presentation of fever, stiff neck, and altered mental status is commonly seen in patients with bacterial meningitis, but their absence does not exclude meningitis. Approximately 50% of patients present with these symptoms. Other symptoms may include headache, photophobia, seizures, Brudzinski's and/or Kernig's sign, and focal neurologic defects. Brudzinski's sign is flexion of hips and knees in response to passive neck flexion, and Kernig's sign is contraction of the hamstrings in response to knee extension while the hip is flexed. 

After addressing airway, breathing, and circulation status, immediately initiate IV fluid resuscitation and dexamethasone. Dexamethasone has been shown to decrease the risk of mortality and neurologic complications. Broad-spectrum antibiotics should be started if a lumbar puncture has not been completed to identify a definitive diagnosis. Ideally, the lumbar puncture should be performed and specific antibiotic therapy should be started, but if lumbar puncture is delayed, antibiotics should not be withheld. Blood cultures can also be used to determine diagnosis.

Correct answer: Shouting for help

There are several efficient means of signaling for help to would-be rescuers in the event of an emergency landing of a medical air transport aircraft. Crew members may elect to use personal cell phones to access the local 911 dispatch system or may be able to utilize any portable radios carried by the aircraft. Fire may be made both to provide warmth and to use to signal; natural materials such as green leaves or green wood, or synthetic materials such as rubber or plastics from the aircraft may be added to the fire to create smoke for smoke signals during daylight hours. Any flashlights, strobe lights, or flares carried by the crew or present on the aircraft should be used to signal, and should be used when aircraft or other rescue vehicles can be heard, even if they cannot be seen. Signal mirrors should also be used when aircrafts can be heard, even if not visible, and any brightly colored clothing can be waved or laid out for possible air rescuers. Dyes can be placed in the water in the event of water landings, or in the snow during wintertime to improve visibility to rescuers, and other ground-to-air signals such as using debris on the ground to spell out "SOS," or a letter "X" should be made. Whistles are also considered an efficient means of signaling.

Shouting for help is not considered an efficient means of signaling for help.

Correct answer: Graham’s Law

Graham’s Law states that the rate of diffusion of a gas through a liquid medium is directly related to the solubility of the gas and inversely proportional to the square root of its density. This means that lower molecular weight molecules will diffuse faster through a membrane. 

Boyle‘s Law relates gas pressure to volume. Dalton’s Law tells us the pressure of a gas is the sum total of all partial pressures. Henry’s Law describes gas diffusion into a liquid. 

Correct answer: The patient's SpO₂ falls precipitously during the first intubation attempt

If a patient's SpO₂ falls precipitously during the first intubation attempt, then the failed airway algorithm should be used, not the difficult airway algorithm. 

Failure to predict a difficult airway has been identified as the leading cause of preventable airway failure. An airway may be deemed difficult based on anatomic or physiological considerations. Anatomically, the patient can be assessed using the LEMONS or HEAVEN mnemonics and other factors such as weight, pregnancy, false teeth, and facial abnormalities. Physiologically, a patient may have a failure to maintain oxygenation or require additional treatment or resuscitation.

Correct answer: Cardiac tamponade

Pulsus paradoxus is defined as a fall of systolic blood pressure of 10 to 15 mmHg during the inspiratory phase. Pulsus paradoxus can be observed in cardiac tamponade and significant hypovolemia.

Pericarditis presents with global ST-segment elevation, chest pain, and low voltage in all leads. Tension pneumothorax will result in difficulty breathing, decreased breath sounds, and jugular vein distention. Pulmonary embolism presents with shortness of breath, chest pain, and hemoptysis. None of these conditions present with pulsus paradoxus.

Correct answer: Aortic insufficiency/disease 

While the critical care provider is not likely to be included in the decision to place or placement of IABP, understanding of the indications and contraindications can be useful. IABP therapy is beneficial in many conditions that result in heart failure by reducing workload of the heart, improving coronary and systemic blood flow, and balancing oxygen demand and supply. Myocardial infarction, cardiogenic shock, and post CABG (Coronary Artery Bypass Graft) can all be indications for the use of an IABP (Intra Aortic Balloon Pump). Disease of the aorta is a contraindication to having an IABP placed. Other contraindications include abdominal or aortic aneurysm, severe peripheral vascular disease, and severe calcific aortic or iliac arterial disease.

Correct answer: Troponin I

Troponin I is highly specific to cardiac muscle in myocardial infarction. Troponin levels will begin to rise four hours after infarct starts with peak levels at 8 to 12 hours. Troponin levels will return to normal 5 to 7 days after the cardiac event.

Myoglobin is released into circulation with any damage to muscle tissue, including myocardial necrosis. Because skeletal muscle contains myoglobin, this measurement is quite nonspecific for myocardial infarction. Creatine Kinase (CKMB) and Lactate Dehydrongenase (LDH) are found in multiple body systems and are not specific to cardiac muscle. 

Correct answer: Neurogenic shock

Neurogenic shock, a type of distributive shock, results in vasomotor dysfunction as a result of spinal cord injury. Loss of sympathetic nervous system tone ensues with the loss of spinal cord transmission, resulting in a loss of vascular tone below the level of the spinal injury. Patients in neurogenic shock will often present with cool, moist, pale skin (often consistent with other types of shock, such as hypovolemic or cardiogenic shock) above the level of spinal injury, while the skin below the level of spinal injury is warm, dry, and sometimes flushed (as is seen in septic and anaphylactoid shock). 

Correct answer: Invasive Continuous Positive Airway Pressure (CPAP) ventilation is most commonly used during medical air transport.

Conflict exists as to which ventilator mode is best for use during air medical transport. Due to the unique complications posed by air transport, including aircraft vibration, the need to more frequently move the patient, and recent changes in air transport industry standards, air medical transport programs ultimately often choose the mode of ventilation based on program member preference or at the recommendation of experts. Many believe that AC ventilation is superior, particularly when used in patients during the acute phase of illness, as it provides optimal support for the patient. Others feel that the use of SIMV is advantageous, particularly as current air transport standards call for the withholding of any long-acting paralytic drugs, maintaining the patient on the ventilator solely through the use of sedatives and pain medications. 

CPAP is not frequently used during air medical transport, as it is not appropriate for use in acutely ill, or critically ill patients.

Correct answer: Acute subdural hematoma

Subdural hematoma, which is a collection of blood located between the arachnoid and dura maters typically as a result of trauma to the head, is classified as acute, subacute, and chronic. The classification is made based on the timing of when signs and symptoms of the intracranial hemorrhage become apparent. Acute subdural hematoma symptoms present within 24 hours of the initial head trauma and have the highest association with death and disability. The Glasgow Coma Scale (GCS), used to aid in determining the level of neurologic injury, can be used to score patients with subdural hematoma; a GCS score of less than 8 has an associated mortality rate of 50% to 90%. The high mortality rates associated with subdural hematoma are due to both the severity of the injuries associated with the development of the hematoma, as well as with the rapid, significant increase in Intracranial Pressure (ICP) experienced with subdural hematoma.

Symptoms of a subacute subdural hematoma manifest within 2 to 10 days of the initial injury, and symptoms of chronic subdural hematoma do not manifest until at least 2 weeks after the injury. The epidural hematoma can be described as being lenticular in shape.

Correct answer: Position all patients with a pad behind the shoulders

The likelihood of successful endotracheal intubation can be significantly improved through the application of the "6 P's for Success."

• Preparation: Make sure all the necessary equipment is in working order and present.
• Preoxygenate: Administer oxygen via nasal cannula at a rate of 10 to 15 L/minute for 3 to 5 minutes prior to attempting intubation.
• Position: Ramp patients to 30^o and ensure the ear and sternal notch are at the same level, pad the shoulders of pediatric patients.
• Pre-treatmant and paralysis: Provide sedation, analgesia, and paralysis after confirming medication doses with your partner.
• Placement with proof: Confirm correct endotracheal tube placement visually or through the use of capnography or radiography.
• Post-intubation management: Maintain oxygenation, sedation, and pain control; place an NG or OG tube, and apply the ventilator.

All patients do not need shoulder padding, only pediatric patients due to their larger occiput.

Correct answer: Nitroprusside

Dobutamine, dopamine, and norepinephrine may be used in cardiogenic shock patients, depending on the underlying etiology. Nitroprusside reduces afterload and can increase stroke volume, making it useful for patients in cardiogenic shock who are not hypotensive.

Correct answer: 12,000 mg; 60 mg/mL

N-Acetylcysteine (NAC) (Mucomyst, Acetadote) should be administered to treat acetaminophen poisoning if serum acetaminophen levels are toxic at 4 hours following ingestion, or 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 by IV. When administered orally, the loading dose should be administered at 140 mg/kg; a dose of 150 mg/kg is administered when IV administration is used. The IV loading dose should be mixed in a 200 mL bag of 5% dextrose and administered over 60 minutes. The initial administration is followed by 2 more doses of NAC, these via continuous infusion, administered over 4 hours and then 16 hours respectively. Patients should receive a total of 300 mg/kg of NAC administered over the 3 divided doses.

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 x 80 kg = 12,000 mg

We next need to calculate the concentration of the solution. According to the information presented in the scenario, the 12,000 mg dose will be mixed in a 200 mL bag of 5% dextrose. We calculate concentration through use of the following formula: 

total dose/volume = concentration

12,000 mg/200 mL = concentration

60 mg/mL is the concentration of the NAC solution that was mixed.

Correct answer: All crew members should be trained in response to ground vehicle accidents.

In order to be prepared in case of a ground vehicle transport, all programs should have response plans in place for both aircraft and ground vehicle accidents.

Both the patient and all crew members riding in the front of the ground transport vehicle are required to remain buckled in their seat belts at all times while the vehicle is in motion. If possible, crew members in the patient compartment should also remain buckled in their seat belts, but may need to remove their seat belts and move around the compartment in the provision of patient care.

Correct answer: Between the T2-T4 vertebrae, 5 +/- 2 cm above the carina

Chest x-ray is considered to be the gold standard for confirmation of proper EndoTracheal Tube (ETT) placement. When viewing the ETT on a chest x-ray, the anterior-posterior view should be used. The tube should be visible with the end of the tube between the T2-T4 vertebrae or 5 +/- 2 cm above the carina. 

Correct answer: Communicate a patient's wishes for medical care during emergency situations

Medical Orders for Scope or Treatment, also known as a MOST or MOLST form, communicates to providers in emergency situations what medical interventions the patient wishes to have performed on them. These forms are not the same as a Do Not Resuscitate or end of life request but often accompany these forms. This legal document can inform EMS if a patient wishes to be intubated, have chest compressions performed, or comfort care only, among other wishes. These forms are filled out by the patient and their physician and should be kept current with the patient's medical condition. The appearance and title of the form may differ between locations but all function similarly. 

A MOST or MOLST form is not for the purpose of communicating with family and is not used for debrief after a call.