IBSC FP-C Exam Questions

Correct answer: The spleen

Splenic injuries are the most common result of blunt (25%) and penetrating (7%) trauma. Patients who have sustained traumatic injury to the spleen may or may not present with symptoms (40% of patients are asymptomatic). Patients may also present with Kehr's sign (referred shoulder pain due to diaphragmatic irritation), or signs of hemorrhagic shock. 

The liver is the second most commonly injured organ in blunt trauma. The pancreas and small intestine are infrequently injured, with only 3% of all abdominal trauma resulting in injury to these organs.

Correct answer: More than 20 mLs

The pericardium is a fibrous sac which encloses the heart and consists of two layers, the visceral layer and the parietal layer. Pericardial fluid is contained between the two layers and provides lubrication for the heart as it contracts. The pericardium may become inflamed, as in pericarditis, or it may accumulate an unusually large amount of fluid between the two layers; this is referred to as pericardial effusion. Normally, 10 to 20 mLs of fluid is located in the pericardium; volume in excess of this number is considered to be an effusion, and may gradually occur over time, or acutely in response to illness, injury, or even surgery.

Correct answer: 10,000-15,000 ft

The four stages of hypoxia are:

• The indifferent stage 0 – 10,000 ft. 
• The compensatory stage 10,000 – 15,000 ft. 
• The disturbance stage 15,000 – 20,000 ft.
• The critical stage 20,000 – 30,000 ft.

Correct answer: Subarachnoid hemorrhage

Xanthochromia is blood-tinged cerebrospinal fluid as seen on lumbar puncture. It is considered to be one of the diagnostic criteria for SubArachnoid Hemorrhage (SAH), along with a starfish pattern on CT. These patients require careful blood pressure control to keep systolic blood pressure below 140 mmHg as well as treatment of cerebral vasospasm. 

Subdural and epidural hematomas will not cause xanthochromia. Basilar skull fracture may present with blood-tinged CSF. However, this would more likely be seen coming from the nose or ears as opposed to during lumbar puncture.

Correct answer: Digoxin

Digoxin is used as a treatment for heart failure and atrial arrhythmias. Toxicity presents with cardiac or noncardiac symptoms. Cardiac symptoms include braydysrhythmias and hyperkalemia. Noncardiac symptoms include nausea, vomiting, fatigue, anorexia, insomnia, drowsiness, hallucinations, and yellow-green halos in the visual fields. Treatment includes digoxin-specific antibody fragments, supportive care, and correction of hyperkalemia. 

The most likely signs and symptoms to be expected with carvedilol, a beta blocker, overdose are respiratory distress, bradycardia, and hypotension. Signs and symptoms of amitriptyline, a tricyclic antidepressant, overdose include abnormally low blood pressure, confusion, convulsions, dilated pupils and other eye problems, disturbed concentration, drowsiness, hallucinations, impaired heart function, rapid or irregular heartbeat, reduced body temperature, stupor, and unresponsiveness or coma. Alpralozam, a benzodiazepine, presents with drowsiness, coma, and other nonspecific symptoms in an overdose. 

Correct answer: Epidural hematoma

An accumulation of blood between the skull and the dura results in an epidural hematoma. Blunt trauma to the temporal or temporoparietal area with an associated skull fracture and middle meningeal arterial disruption is the primary mechanism of injury. Occasionally, trauma to the parieto-occipital region or the posterior fossa causes tears of the venous sinuses with epidural hematomas. The classic history of an epidural hematoma involves significant blunt head trauma with loss of consciousness, followed by a lucid period and subsequent loss of consciousness. This clinical presentation occurs in a minority of cases.

Subdural hematoma is caused by sudden acceleration-deceleration of brain parenchyma with subsequent tearing of the bridging dural veins. This results in hematoma formation between the dura mater and the arachnoid. Subdural hematoma tends to collect more slowly than epidural hematoma because of its venous origin.

Diffuse axonal injury is the disruption of axonal fibers in the white matter and brainstem. Shearing forces on the neurons generated by sudden deceleration cause diffuse axonal injury. The condition is seen after blunt trauma, such as from a motor vehicle crash. In infants, shaken baby syndrome is a well-described cause.

Traumatic subarachnoid hemorrhage results from the disruption of the parenchyma and subarachnoid vessels and presents with blood in the cerebrospinal fluid. Patients with isolated traumatic subarachnoid hemorrhage may present with headache, photophobia, and meningeal signs. Traumatic subarachnoid hemorrhage is the most common CT abnormality in patients with moderate to severe TBI (Traumatic Brain Injury).

Correct answer: Absence seizure

Seizures can be described based on the presentation of the patient during the seizure. The appearance of the seizure can help to understand how much of the brain is being affected. While all seizures are treated the same, understanding that not all seizures appear as convulsions can be crucial in identifying a seizing patient and providing appropriate treatment.

Absence seizures occur when a patient has a sudden and abrupt altered mental status. There is an interruption of the current activity, and the patient will likely have a blank stare. 

Atonic seizures present with a brief lapse in muscle tone, usually lasting less than fifteen seconds. A myoclonic seizure looks like brief, involuntary twitching in a single muscle or group of muscles. Simple partial seizures are experienced when the patient retains consciousness but describes an unusual feeling or sensation. The patient can remember everything that occurs during a simple partial seizure. 

Correct answer: Complete 1,000 hours as Pilot in Command (PIC) to qualify to fly

The Commission on Accreditation of Medical Transport Services (CAMTS) has established safety initiatives detailing qualifications necessary for both fixed-wing aircraft pilots and rotary wing (helicopter) pilots. In order to qualify to fly as a HEMS pilot, the pilot must:

• have completed 2,000 hours of total flight time, 1,200 of which must have been in piloting of helicopters,
• have completed 1,000 hours as the PIC, 100 hours of which must have taken place during night flights,
• be instrument rated for flying in instrument meteorological conditions (IFR in IMC),
• obtain Airline Transport Pilot (ATP) certification within 5 years of qualifying as a HEMS pilot, and
• have completed an air orientation of his/her area (5 hours total, 2 of which must be at night) prior to being allowed to accept any solo mission.

Correct answer: Administer surfactant

Persistent Pulmonary Hypertension of the Newborn (PPHN) is a syndrome in which the expected transition from fetal circulation to neonatal circulation fails to occur, resulting in right-to-left shunting of blood at the foramen ovale or the ductus arteriosus. This, in turn, results in significant pulmonary hypertension and hypoxemia. PPHN almost always occurs in term or near-term neonates who have experienced severe asphyxia or meconium aspiration syndrome, are septic at birth, or who have a congenital diaphragmatic hernia. However, idiopathic cases have been known to occur.

PPHN treatment aims to maintain adequate oxygenation while waiting for pulmonary vascular resistance to decrease. Oxygen is often adequate initially, as it functions as a potent vasodilator. If the neonate is unable to maintain adequate oxygenation with the delivery of the 100% oxygen concentration, nitric oxide should be administered, as this also serves to decrease pulmonary vascular pressure, usually more than what oxygen can when delivered singly. Sedation and neuromuscular blockade paralysis may also be considered to reduce oxygen consumption and pulmonary vascular resistance. High-frequency ventilation (oscillator, jet ventilator) should be used when possible if it is known the infant has parenchymal lung disease.

Surfactants are not routinely used to treat PPHN unless the cause of the PPHN is known (in this scenario, it was idiopathic), such as meconium aspiration syndrome, parenchymal lung disease, pneumonia, or sepsis.

Correct answer: Morbid obesity

Critical care providers may be called to transport patients with tracheostomy tubes in place. These devices can present many challenges to providers. While uncommon dislodgement of the device is a possibility, factors that increase the risk of dislodgement include morbid obesity, neck edema, excessive coughing, a poorly fitted tracheostomy tube, patients pulling at the tube, tension in the ventilator circuit, and loose ties.

Improper ventilator settings, loose ventilator tubing, and tension in tracheostomy tube ties are not factors that increase the risk of dislodgement in a tracheostomy device.

Correct answer: Intubation and mechanical ventilation 

Patients suffering from TBR require rapid intubation and mechanical ventilation to address the critical airway and breathing issues. 

Blunt force trauma to the chest can cause TracheoBronchial Rupture (TBR) in pediatric patients, an injury in which there is a rupture of the trachea or bronchi between the cricoid cartilage and the carina. While this is rare, it is a life-threatening emergency, and many of these patients die before reaching the hospital. TBR can cause pneumothorax, pneumomediastinum, and subcutaneous emphysema. The presentation of this injury can be vague and inconsistent, making it difficult to identify in the field. Chest x-ray and bronchoscopy are considered to be the best diagnostic tools for this injury. Signs and symptoms of TBR include dyspnea, hemoptysis, coughing, palpable subcutaneous emphysema, and absent breath sounds on one side of the chest. Hamman's crunch may be heard when auscultating lung sounds, distinguished by a crunch or rasping sound synchronized with the patient's heartbeat. 

Patients suffering from TBR require rapid intubation and mechanical ventilation to address the critical airway and breathing issues. Needle decompression should also be done to relieve pneumothorax. A chest tube can be placed once the airway is secured. IV access and resuscitation to restore hemodynamic stability should be done after the airway is addressed. Spinal immobilization is a later priority if necessary prior to moving the patient. 

Correct answer: Meningitis

Brudzinski's sign is tested in patients suspected of having meningitis. During this test, the patient's neck is flexed with the chin toward the chest. A positive finding would be noted if the patient's legs lift and knees bend when their neck is flexed. Meningitis is inflammation of the meninges caused by bacteria, viruses, fungi, or parasites. The disease moves through the nervous system through the cerebrospinal fluid, causing neck stiffness, photophobia, and headache. Patients may also present with a positive Kernig's sign, seen when the legs cannot be straightened when the hip is flexed to 90^o. Providers must be sure to wear gloves, gowns, and a mask when treating patients suspected of having meningitis. Treatment is based on the underlying cause.

Central cord injury presents with weakness in the upper extremities greater than the lower. Hypertensive crisis may present with headache, vomiting, and visual changes but will not show Brudzinski's sign. Herpes simplex enchepalitis also presents with a headache but can also show fever, seizures, and focal neurologic defect. Brudzinski's sign is also not seen in herpes simplex encephalitis. 

Correct answer: 5th intercostal space, mid-axillary, over the rib

Correct sites for needle decompression include the 2nd or 3rd intercostal space on the midclavicular line, and the 4th or 5th intercostal space on the mid-axillary line. The needle must always be placed over the rib to avoid the nerve, artery, vein bundle that lies beneath each rib.

The 4th or 5th intercostal space, mid-clavicular is too low and could cause cardiac damage if performed on the left side.

Correct answer: Heliox

In patients with acute, severe asthma exacerbation refractory to appropriate and adequate treatment interventions, including the administration of SABA (Short-Acting Beta-Agonists) medications and ipratropium via continuous nebulizer, the use of high-flow oxygen delivery, and intravenous corticosteroid administration, heliox should be administered. Heliox is a gas mixture consisting of helium and oxygen which can be administered to pediatric patients experiencing increased airway resistance, such as during acute asthma exacerbation, in an attempt to reduce the resistance within the airways, and hence the work of breathing. Its density is less than that of air. It is administered via a high-flow face mask (fit must be snug), often bringing about dramatic improvements in the patient's condition. Heliox can be used as the driving gas within nebulizer treatments, typically with the delivery rate set at 8 to 10 L/minute.

The patient in this scenario has already received more than one dose of intravenous corticosteroid without improvement; the stepwise asthma management plan recommends the use of an additional, adjunct treatment option at this point of care. Bag-valve-mask ventilation would not be effective alone in improving this patient's condition.

Intubation is a last resort in asthma patients as it is shown to increase mortality and should only be used if the following criteria are met:

1. The patient's level of consciousness decreases.
2. The patient demonstrates progressive exhaustion from breathing.
3. There is an absence of breath sounds or wheezing does not improve with appropriate interventions.
4. pH is 7.2 or less.
5. PCO₂ is > 55 mm Hg.
6. PO₂ is < 60 mm Hg even with high-flow oxygen in place.
7. The patient's vital capacity decreases to the level of the tidal volume.

Correct answer: Administer atropine

Ketamine is an analgesic drug utilized during Rapid Sequence Intubation (RSI) due to its hypnotic, analgesic, and amnesiatic properties. Ketamine is a first-choice drug in intubation of asthmatic patients due to its ability to bronchodilate. However, ketamine can also increase airway secretions, evidence in patients by laryngospasm. If increased secretions are noted post-intubation, atropine or scopolamine should be given.

Suctioning may clear secretions but will not address the underlying cause, and discontinuation of ketamine is not necessary if secretions are properly addressed. Flumazenil is a reversal agent for benzodiazepines and would have no effect here. Ipratropium bromide may help with e secretions but will not address the underlying cause.

Correct answer: Position the patient supine and displace the uterus manually to the left

The presence of a prolapsed umbilical cord is a medical emergency requiring immediate intervention to preserve the life of the fetus. A prolapsed cord may occur for a number of reasons, including Premature Rupture of Membranes (PROM), polyhydramnios, longer than normal cord, multiparity, multiple gestation pregnancy, maternal age ≥ 35, history of recent amniotomy, no engagement of fetal part, male sex of the fetus, or any of several obstetric procedures including attempts to change the fetal position or strategies to produce cervical ripening and dilation. 

Umbilical Cord Prolapse (UCP) may appear as a frank presentation of the cord, visible on the perineum or protruding from the vagina, or it may be occult, presenting alongside the fetal presenting part and obscured. And, while in some instances, the fetus does not show any evidence of distress with UCP, in the vast majority of instances of UCP (nearly 70%), the fetus experiences some degree of asphyxia which is evidenced by fetal bradycardia and recurrent variable decelerations on the EFM. Transport providers should reposition the maternal patient in an attempt to relieve pressure from the presenting part on the umbilical cord. The pregnant female may be positioned in steep Trendelenburg, in an exaggerated Sims position with the maternal head down, or in knee-chest position. If necessary, a member of the medical transport crew may be required to place two (sterile) gloved fingers into the cervical opening in an attempt to further buffer the prolapsed UC from uterine contraction pressure.

Manually displacing the uterus to the left with the pregnant patient lying supine is used when the patient is showing signs of inferior vena cava syndrome.

Correct answer: To occlude the descending aorta and stop internal bleeding 

REBOA (Resuscitative Endovascular Balloon Occlusion) stops internal, non-compressible, hemorrhage by occluding the descending aorta, not the inferior vena cava. This procedure has been utilized in the London Air Ambulance services but is not used prehospital in the United States.

REBOA does not support IABP placement and is not used in conjunction with IABP. REBOA does not open occluded arteries.

Correct answer: Ketamine 1-2 mg/kg/hr 

Ensuring adequate sedation for a patient post intubation is essential. Ketamine is the only answer choice that has analgesic properties and is a sedative.  

Etomidate is used as an induction agent for its quick onset; however, the medication’s half-life is very short, making it less than ideal to maintain sedation. Also, Etomidate has no analgesic properties. While the patient may be unresponsive, they are still able to experience pain and discomfort. Succinylcholine and Rocuronium are both Neuromuscular Blocking Agents (NMBA) and have no analgesic or anesthetic properties. In fact, there have been reported instances when patients are administered only NMBA and recall every part of the intubation procedure.

Correct answer: Pertussis

Pertussis, or whooping cough, is a highly contagious, vaccine-preventable disease caused by the Bordatella pertussis bacteria. It is most frequently spread to children by their parents and siblings through infected aerosolized respiratory droplets. Pertusis can cause significant morbidity and mortality, especially in infants under six months of age. Parents should be asked if they are vaccinated against pertussis if it is suspected. Pertussis most commonly presents with paroxysmal coughing fits, inspiratory whooping stridor, and posttussive emesis. In the initial stage, called the catarrheal stage, patients will present with a cough, coryza, and will be either afebrile or have a low grade fever. Infants in this stage may have severe complications, including failure to thrive, seizure, apnea, respiratory failure, and death. This stage lasts one to two weeks before the paroxysmal stage begins. In this stage, coughing fits are long and distinctive with little to no inspiratory effort between coughs. Children may gag or struggle to breathe. This stage lasts two to eight weeks, with the cough getting worse the first two weeks, remaining the same for the following two, then decreasing. When the cough subsides, the patient is in the convalescent stage, which may last weeks to months.

Children suspected of pertussis infection must be treated with antibiotics. Preventive treatment should be offered to all family and care providers who come in contact with the patient. Children under six months of age may require hospitalization due to the possibility of severe complications. 

Asthma, croup, and epiglottitis do not present with the classic whooping cough seen in pertussis. 

Correct answer: Murphy's eye can be seen in the upright position.

When possible, correct ETT placement should be confirmed through the use of a chest X-ray. The distal tip of the ETT should be positioned at a depth of 4 to 5 cm above the carina, at the level between the second and fourth thoracic vertebrae. Correct placement can quickly be confirmed by visualization of Murphy's eye, the vent hole located on the side of the ETT, at the junction of the clavicle bones.