IBSC FP-C Exam Questions

Correct answer: PCO₂ > 40 mmHg

Patients experiencing a severe asthma exacerbation may require intubation when other interventions are not relieving symptoms. The severity of acute asthma exacerbation can be determined through multiple methods. Patients with a long history of asthma will be able to communicate the severity of this episode compared to previous exacerbations, and will be able to answer questions regarding prior Intensive Care Unit (ICU) admission for asthma exacerbation. Diagnostic tests such as spirometric measurements, peak expiratory flow rate, and Arterial Blood Gases (ABG) can also be used to determine severity. 

There are seven indications for intubation and mechanical ventilation in patients with asthma. They are:

• Decreased level of consciousness
• Progressive exhaustion
• Absent breath sounds or severe wheezing refractory to therapy
• pH 7.2
• PCO₂ > 55 mmHg
• PO₂ < 60 mmHg despite administration of high-flow oxygen
• Vital capacity decreasing to equal tidal volume

Asthma patients who require intubation have a sharp increase in mortality rate, so all other therapies should be exhausted before intubation is attempted. 

Correct answer: Transposition of the great vessels

Transposition of the great vessels is a congenital heart defect resulting in mixed blood flow in the neonate. It is characterized by the aorta receiving blood from the right ventricle, and the pulmonary artery leaving the left ventricle. This defect often presents with a patent foramen ovale and ventricular septal defect. These patients are considered ductal-dependent because they rely on Patency of the Ductus Arteriosus (PDA) in order to survive. Prostaglandin E1 is administered in order to maintain this patency. 

Not all congenital heart disease conditions cause the neonate to remain dependent upon a PDA for survival, but defects such as transposition of the great vessels, pulmonary atresia, tricuspid atresia, coarctation of the aorta, hypoplastic left heart syndrome, among others, do. Infants who have tetralogy of Fallot with pulmonary atresia will benefit from the administration of a prostaglandin E1 infusion.

Correct answer: Electrical alternans

Electrical alternans is an increase/decrease in QRS voltage in every other beat. This is caused by the motion of the heart “swinging” in the pericardial sac when it is full of fluid. 

Global ST elevation is seen in pericarditis. Osborne waves are seen in hypothermic patients. Slurring of R waves is seen in WPW syndrome due to accessory pathways.

Correct answer: Unsynchronized cardioversion  

Electrical energy can terminate an abnormal rhythm but, if inappropriately delivered, it may also induce ventricular fibrillation. This can happen if the electric shock is delivered during the relative refractory period of the cardiac electrical cycle. Movement artifacts or loose leads may resemble ventricular fibrillation and result in an inappropriate shock.

Synchronizing the defibrillator ensures that the shock is delivered at the QRS complex. If the shock is delivered during the T wide-complex, it risks the development of wide-complex polymorphic tachycardia, also known as "torsades des points."

Insufficient adenosine and over-sedation would not cause this patient's condition to deteriorate into ventricular fibrillation. Insufficient doses of adenosine would not allow for conversion from narrow complex tachycardia to a more normal rhythm. Over-sedation may depress the respiratory drive and cause the provider to need to assist the patient with ventilations. While cardiac arrest could cause the deterioration, in this scenario it is much more likely that the cardioversion was not properly synchronized than that the patient went into cardiac arrest at the same time cardioversion occurred.

Correct answer: Normal variability 

A variability in heart rate of 6-25 bpm from baseline is normal and assures providers that the fetus is adjusting to changes in uterine blood flow. 

Cord compression would show decelerations. Uterine insufficiency would present as late decelerations. The need for emergent C-Section would present as a sinusoidal waveform. 

Correct answer: Parkland formula

Fluid resuscitation in management of burns is a critical part of ensuring optimal circulation; however, the risks of both under-resuscitating or over-resuscitating these patients are great, necessitating careful calculation and administration of intravenous (IV) fluid replacement. Several formulas are in use for determining the fluid resuscitation needs of a specific burn patient, with the most commonly used formulas being the Parkland formula and the Modified Brooke (or simply, Brooke) formula. The Parkland formula recommends IV fluid replacement for both pediatric and adult burn patients at a rate of 4 mL/kg/percentage of the BSA, with administration of the first half of the total volume taking place within the first eight hours from the time of the burn. The remainder of the fluid is recommended to be administered over the subsequent 16-hour time period. 

The Modified Brooke formula recommends IV fluid replacement at a rate of 2 mL/kg/percentage of BSA, again, with the first half of the total volume being infused in the first eight hours following the burn injury, and the remainder of the fluid being administered over the following 16 hours.

Correct answer: Pericardiocentesis

Patients experiencing these signs, also known as Beck’s triad, are suffering from cardiac tamponade. The treatment of cardiac tamponade is pericardiocentesis, where a needle is inserted into the pericardium, the sac that surrounds the heart, draining off excess fluid. This fluid is usually blood in the case of trauma patients. 

Needle decompression and chest tube placement are used to treat pneumothorax. IV infusion of a positive chronotropic medication such as epinephrine would not benefit this patient.

Correct answer: Expiratory plateau 

The CO₂ readings during capnography are taken at the peak plateau of the waveform called the expiratory plateau. This measurement communicates the peak CO₂ level in exhaled air. While readings are taken during the other stages of the waveform, the displayed number is measured during the expiratory plateau. 

End-tidal waveform capngraphy is considered standard of care in the monitoring of intubated patients. A device is attached to the endotracheal tube that electronically measures and displays an end-tidal waveform as well as an end-tidal CO₂ reading. The waveform and number value allow for close monitoring of ventilation and can give valuable information about patient condition and the endotracheal tube itself.

Inhalation is seen on the downstroke of the waveform, and exhalation on the upstroke. Inspiratory plateau is not a term used when describing a capnography waveform.

Correct answer: An increase in volume

Charles' law states that at a constant pressure, the volume of a gas is directly proportional to the absolute temperature of the gas. This is expressed by the equation V₁ / T₁ = V₂ / T₂. 

Gay-Lussac's law deals with pressure and temperature and states that pressure and temperature are directly proportional. There are no gas laws that relate solubility and temperature.

Correct answer: Basilar skull fracture

Battle sign describes the ecchymosis seen in patients who have head injuries with fractures to the posterior aspect of the skull base. The pooling of blood around the eyes (raccoon eyes) is most commonly associated with fractures of the anterior cranial fossa. These findings may not be immediately present, potentially taking hours to days to develop. If bilateral, this finding is highly predictive of a basilar skull fracture. Patients may also present with cerebrospinal fluid leaking from the nasal cavity or external auditory canal. This leakage is evidence of a tear in the dura mater, exposing the patient to an increased risk for infection in the meninges or brain tissue.

Skull fractures are usually categorized by location (basilar vs. skull convexity), pattern (linear, depressed, or comminuted), and whether they are open or closed. A diastatic fracture occurs along a suture line, causing a widening or separation. Orbital fractures cause vision disturbances and eye movement difficulty. 

Correct answer: QRS greater than 0.12 seconds

The normal range for QRS is 0.08 to 0.12 seconds. QRS segments that are greater than 0.12 seconds are considered bundle branch blocks. 

A PR segment of greater than 0.20 seconds is a first degree AV block. A PR interval that is less than 0.20 seconds is normal.

Correct answer: 8 - E2, V2, M4

The Glasgow Coma Scale (GCS) is used to assess a patient's mental status and severity of neurologic impairment. Three areas are considered when assessing a GCS score: eye-opening, verbal response, and motor response. The lowest possible score is a 3, indicating an unconscious patient who does not speak or respond to any stimuli. The highest score is 15, indicating an alert and oriented patient who responds to commands. The GCS score is best used as part of a wider assessment due to the limitations in patients with facial trauma, those on a ventilator, or those with lesions that are causing progressive hemiparesis.

GCS is scored as follows:

Eye-opening 

1.  Never
2. To painful stimuli
3. To verbal stimuli
4. Spontaneously

Verbal response

1. None
2. Unintelligible sounds
3. Inappropriate words
4. Confused
5. Oriented

Motor response

1. None
2. Decerebrate posturing
3. Decorticate posturing
4. Withdraws from pain
5. Localizes pain
6. Obeys commands

This patient scores an 8 with 2 points for eye opening, 2 for verbal response, and 4 for motor response. He opens his eyes to painful stimuli and speaks in unintelligible sounds. When painful stimuli are applied, the patient pulls away, meaning he is localizing pain.

Correct answer: 2 mL/kg D50

Hypoglycemia in pediatric patients is considered to be a blood glucose level of under 60 mg/dl. Mild hypoglycemia is typically treated with oral glucose in the form of glucose paste, juice, or other fluids that contain glucose. Once the child becomes symptomatic, then IV glucose is administered. IV dextrose administration guidelines for pediatric patients are as follows:

• Neonates: 2 mL/kg D10
• Infants and toddlers: 2 mL/kg D25
• Children: 2 mL/kg D50

A 12-year-old would be considered a child, and would therefore receive 2 mL/kg D50 if hypoglycemic.

Correct answer: Leave the IABP in 1:1 counterpulsation.

If the patient develops a rapid heart rate > 200, leave the IABP (Intra-Aortic Balloon Pump) in 1:1 counterpulsation.

For a patient with an IABP who goes into cardiopulmonary arrest/asystole or pulseless electrical activity, the flight crew should initiate ACLS guidelines, and change the IABP to pressure mode during compressions. If the IABP experiences power failure, attach 60-mL syringe to the proximal stopcock and inflate the IABP catheter once every 3-5 minutes to prevent clot formation on the catheter. 

Correct answer: III, IV, VI

The normal patient can move the eye through the six cardinal positions of gaze, and the eye movements are controlled by the six extraocular muscles attached to each eye. Extraocular muscles are innervated by cranial nerves III, IV, and VI. Cranial nerve IV controls the superior oblique muscle, cranial nerve VI controls the lateral rectus muscle, and all other extraocular muscles are controlled by cranial nerve III. Extraocular movement due to lesions or general problems in the nerves or muscles of the eye.

Cranial nerve II (optic nerve) is sensory and does not affect movement of the eye.

Correct answer: The use of "renal-dose" dopamine has been found to cause harm.

The use of "renal-dose" dopamine, while considered to be the standard of care for many years in critical care medicine, is no longer routinely used or recommended in patients experiencing shock. Dopamine doses under 3 mcg/kg/minute defined renal dosing, and were thought to provide renal protection. 

Clinical trials have not supported this idea and have, in fact, demonstrated possible harm from the use of renal-dose dopamine.

Correct answer: Class III

Hypovolemic shock occurs as a result of a significant decrease in the circulating intravascular volume. This may be due to dehydration, or in the case of the patient in this scenario, due to hemorrhagic blood loss. Hypovolemic/hemorrhagic shock has been divided into four classes of shock to aid in recognition in the degree of both Estimated Blood Loss (EBL) and disability, specifically neurologic disability. 

Shock class can be determined by estimation of the amount of blood loss, as well as by assessment of physiologic parameters, both of which are inextricably linked to each other. Shock classes are defined as follows:

• Class I shock: EBL < 750 mLs, with minimal (or no) change noted in BP, HR, or RR. 
• Class II shock: EBL 750-1500 mLs, the HR is > 100, RR is elevated between 20-30 breaths/minute, and the patient typically appears anxious. BP remains within normal range.
• Class III shock: EBL 1500-2000 mLs, the HR is > 120, RR is between 30-40 breaths/minute, and the patient may appear confused. BP is now decreased.
• Class IV shock: EBL > 2000 mLs, the HR > 140, RR is > 35, BP remains decreased, and the patient is lethargic or unresponsive.

Correct answer: Ionized calcium

Ionized calcium, also referred to as free calcium, is the calcium in the body that is not already bound to a protein. This extracellular calcium is necessary for the body in maintaining homeostasis. In the instance of massive blood loss, when it is necessary to administer blood transfusion at the rate of greater than 10 to 20 units in 24 hours, the amount of citrate (added to units of blood as a preservative) that is also ultimately administered is too much to be rapidly metabolized, leading to citrate toxicity, and hence, hypocalcemia in the form of low ionized calcium. Concurrently, a state of hypomagnesemia may also result from the same pathway.

Potassium levels may be unusually high (hyperkalemia) as a direct result of massive blood transfusion. Chloride and white blood cell count should not be decreased by the administration of blood products.

Correct answer: Lithium ion battery

The best ventilator is only as good as its battery when it comes to air medical transport. Many air medical transport programs operate in large geographical areas, or are frequently required to fly missions over many hours, making a dependable ventilator battery a necessity. Ventilators may be equipped with lithium ion batteries, lead-acid batteries (similar to those used in vehicles), nickel-cadmium batteries, or nickel metal hydride batteries. Lithium ion batteries, while the most expensive of the battery types are best for use during air medical transport missions due to their lightweight, slow loss of charge (during storage), and no memory effect (which can ultimately cause rechargeable batteries to lose their ability to be charged).

Correct answer: With the use of three cross straps and a shoulder harness

The Commission for Accreditation of Medical Transport Systems (CAMTS) is responsible for patient safety standards which must be maintained during medical air transport. Regardless of patient position in the aircraft, the patient must be secured by the use of three cross straps—positioned at the chest, hips, and knees. In addition, when patients are positioned head forward in the aircraft, a shoulder harness must also be fastened.

Pediatric patients will need to be secured using a specifically sized device used to secure smaller individuals and, if an infant is to be transported using a car seat, the seat must be one that is approved by the Federal Aviation Administration (FAA) and have an FAA approval sticker already in place.