IBSC FP-C Exam Questions

Correct answer: Stop the transfusion of blood

The signs of rash, tachycardia, and hypotension all point to anaphylactic reaction. When this occurs during blood transfusion, the provider must stop the transfusion and treat the anaphylactic shock. Epinephrine, steroids, and Benadryl may be considered after stopping the transfusion to treat the symptoms. Definitive care for the anaphylactic reaction in this case is to stop the transfusion.

Administering more pain medication would be contraindicated in this scenario due to hypotension and would not treat the cause. While a rapid fluid bolus may briefly help the hypotension, the main cause of the symptoms is a transfusion reaction and the blood transfusion must be stopped. 

Correct answer: Twenty to 30% of coral snake bites are dry bites in which no venom is injected into the other organism.

Coral snakes are the only venomous member of the Elapidae snake family that is native to the United States (US). Coral snakes can be found in the southwestern and gulf coast states, and the Carolinas. Envenomation by a coral snake causes neurotoxicity, in contrast to envenomation by a member of the pit viper family, which primarily causes localized tissue damage and coagulopathy. Individuals who are bitten by coral snakes typically experience symptoms of drowsiness, euphoria, weakness, nausea and vomiting, muscle tremors (fasciculations), dysphagia, excessive salivation, weakness of the eye muscles, hypotension, and cardiopulmonary failure. Up to 50% of bites from coral snakes are dry bites, in which no venom is injected into the bitten individual; these dry bites likely occur at such a high rate due to a lack of the typical fangs seen in pit vipers. Instead, coral snakes have shortened teeth-like fang structures, which are less effective in delivering a venomous bite. Twenty to 30% of bites from pit vipers are considered dry bites.

Immediate treatment of a coral snake bite should be with application of a compress at the site of the bite to slow systemic absorption of the injected venom. Coral snake antivenin, if available, should be administered to the bitten individual. This antivenin (antivenom) is no longer manufactured and is no longer readily available in the US. While a new antivenin is being tested for manufacture, the several states with the most dangerous endemic coral snake species have been allocated a very limited supply of the remaining antivenin for use when truly needed.

Correct answer: In the right ventricle

Leadless pacemakers are small, self-contained pacemaker units that contain both pacing and sensing leads in the unit. They are implanted directly into the right ventricle with no need for chest incisions or a pocket in the skin; implantation occurs via a femoral vein transcatheter approach. Leadless pacemakers have single-chamber ventricular pacing capability. Other benefits include MRI compatibility, a 10 to 15-year battery life, and the ability to be easily turned off and replaced when necessary with the potential for retrieval.

Correct answer: Decompression sickness

Patients who are being transported by air may experience adverse effects specifically related to the method of transportation. Vibration from any source, including the aircraft or the atmosphere, difficulty in regular changing of the patient's position, and decompression sickness, are all complications directly related to air transport, and all may result in cutaneous changes. The friction which results from vibration may affect the skin, as may the inability to adequately reposition the patient. And while sepsis may cause a petechial rash, in this scenario, only decompression sickness may result in the development of a diffuse, sunburn-like rash. Other cutaneous symptoms of decompression sickness include a sensation of insects crawling on the skin, mottling of the skin, and pruritus. Flicker vertigo occurs in rotor wing aircraft, and is caused by the flickering of sunlight by the rotor blades. 

Correct answer: Volume: A preset tidal volume is delivered by the ventilator. After the set volume is given, the exhalation phase begins. Volumes are consistent with every breath. 

Pressure: A preset inspiratory pressure is given by the ventilator. Once the pressure is achieved, the exhalation phase begins. Volumes can change from breath to breath. 

Volume and pressure are both settings that can be set by the critical care flight paramedic. When controlling volume, each breath delivered will be at the chosen volume (i.e., 450 mL). The pressure between each breath can change due to lung compliance and if the equipment is in working order. It is imperative that the flight paramedic monitor pressures when delivering set volumes to prevent high pressures from causing lung injury. If the flight paramedic elects to use pressure delivery mode, the ventilator will deliver each breath up to a certain preset pressure (i.e., 30 cm H₂O). Once the pressure has been delivered, the exhalation phase begins. In this setting, the volume of air delivered will vary and therefore, minute volume must be monitored to ensure the patient is adequately ventilated. 

Correct answer: Size = (16 + age in years)/4

There are a number of ways to select the correct ETT size in pediatric patients. For children over two years of age, there are three formulas that can be used:

1. ETT size = (16 + age in years)/4
2. Uncuffed ETT size (mmID) = (age in years/4) + 4
3. Cuffed ETT size (mmID) = (age in years/4) + 3

A quick and reliable method is matching the outside diameter of the ETT to the child's fifth (little) finger or nares; for patients up to 36 kg, the ACS/ATLS recommends use of a length-based resuscitation guide, such as a Broselow Tape. 

 Correct answer: Part 135

Federal Aviation Regulations (FARs) governing the requirements for flight operations in the face of weather are located in Part 135. Part 135 describes in straightforward language the required weather minimums for safe operations using either Visual Flight Rules (VFRs) or Instrument Flight Rules (IFRs). Limitations are imposed during unfavorable weather, and the pilot, and medical air transport crew members, are mandated to comply with these limitations.

Part 91.155 discusses basic weather minimums at specific altitudes which must be met in order for all aircraft to fly using VFR.

Part 91.605 addresses the weight and balance limits of aircraft.

Part 91 flight regulations are general regulations and rules for all civil aircraft. 

Correct answer: Vibration

The most common stressors of air transport include medications, supplements, nicotine, alcohol, fatigue, vibrations, and flicker vertigo. Vibrations in rotor-wing transport can affect the whole body and can cause symptoms of motion sickness, hyperventilation, headache, and a decrease in vision as well as pain in the legs, buttocks, and back, indicating exacerbation of spinal disorders. 

Flicker vertigo typically causes spatial disorientation due to confusion of the vestibular system. Alcohol consumption and fatigue may impair crew members but will not typically directly cause insult to the spine. 

Correct answer: Active external rewarming strategies include the application of heat packs.

Hypothermia is defined as having a core temperature of 35^o Celsius or below. EMS providers must take great care when handling and transporting the patient, as these basic interventions can worsen the hypothermia through mobilization of cold blood in a metabolic state of acidosis, ultimately resulting in cardiac arrhythmias or cardiac arrest. It is not uncommon for a hypothermic patient to arrive to the receiving hospital with a core temperature lower than what it was initially upon discovery in the field. Rewarming should be initiated during transport through the use of both external and internal warming strategies.

Passive external rewarming strategies include the removal of wet clothing and drying of the skin, increasing the ambient temperature of the transport vehicle, applying blankets, administering warmed IV fluids, and administration of heated humidified oxygen.

Active external rewarming strategies include applying heated packs, the use of a radiant heat warmer, or the use of a forced warm air device. Active external rewarming strategies often result in worsening of the hypothermia, hypotension as a result of shock due to rewarming, ventricular fibrillation, or asystole. Care must be taken to rewarm the extremities after the trunk.

Active internal rewarming strategies include the continuation of administration of warmed IV fluids and warmed, humidified oxygen, as well as more invasive methods of rewarming, including the administration of warmed fluids into the stomach via gastric lavage, or administration of warmed fluids into the pleural space, the bladder, or peritoneum. ECMO may also be utilized to aid in rewarming.

Correct answer: Hypocalcemia

Hypocalcemia, which is indicated by a serum calcium level of less than 8.2 mEq/L, may be caused by a number of medical and surgical factors and can result in depressed myocardial contractility and hypotension. The presence of hypocacemia can be assessed through elicitation of either Trousseau's sign or Chvostek sign. To elicit Trousseau's sign, a blood pressure cuff is applied and when inflated, tetany of the forearm muscles ensues. Chvostek's sign is elicited by tapping on the facial nerve (immediately in front of the ear) and watching for the development of facial spasms.

CVA may result in the development of decorticate posturing. Meningitis may result in the development of decerebrate posturing. Hypomagnesemia may co-exist with hypocalcemia and should be assessed through the obtaining of laboratory studies. None of these result in Trousseau's sign.

Correct answer: Fat embolism 

Fat embolism is a complication of large bone, pelvic, and rib fractures that may occur twelve to 72 hours after injury. Signs and symptoms of fat embolism include respiratory failure, shock, and elevated serum lipase levels. Patients may also have a low SpO₂ despite adequate FiO₂.

Pneumothorax and hemothorax would result in decreased breath sounds on one side of the lungs. Cardiac tamponade would result in muffled heart sounds and jugular vein distention.

Correct answer: A fall greater than 15 feet

Adults tend to land on their feet in falls greater than 15 feet. This causes calcaneus (heel) fractures and spinal compression fractures typically seen in the T12-L1 region. Patients usually fall forward after landing on the ground and reach out their hands, causing the wrist fractures. When an adult patient falls less then 15 feet, they tend to land as they fell. This can cause a wider variety of possible injuries. 

Head-on motorcycle collisions cause fractures to the femurs, tibias, and fibulas as well as chest and abdominal injuries, and trauma to the head and neck. Side impact collisions cause crush injuries between the rider and the object that has impacted them. This leads to injuries with the foot and leg only on the involved side.

Correct answer: Every 3-5 minutes

If the power fails while transporting a patient on an IABP, the flight crew must manually pump the balloon every three to five minutes to prevent blood from clotting in the balloon.

Correct answer: Wait to attempt exiting the aircraft until it is upside down.

The type of aircraft involved in an emergency water landing or crash in water determines what steps the crew members should take in escaping from the aircraft. Helicopters will almost always sink, or capsize, after impact with water; an emergency escape should not be attempted until crew members can see that the rotors have stopped spinning and the helicopter has turned completely upside down.

Attempts should not be made until the cabin of the aircraft has almost completely filled with water, at which time crew members should release their seat belt buckles. Once the buckle is released, crew members will float, and if unsure of their position in the water, should attempt to visualize released air bubbles in the water to help determine their way to the surface. No attempts to kick or swim away from the aircraft should be made, as this is more likely to result in a crew member becoming entangled within the aircraft or accidentally injuring another crew member. Crew members should instead pull themselves through and out of the aircraft.

Correct answer: Cuffed pediatric tubes may be used safely with a cuff manometer or by auscultation of air leak.

Recent studies have determined that the pediatric airway is not as narrow as previously believed. Previous information which suggested significant narrowness of the pediatric airway led providers to primarily provide endotracheal intubation through use of an uncuffed ETT. PALS guidelines advocate the use of either cuffed or uncuffed pediatric ETT, specifically recommending use of cuffed ETTs in situations when high airway pressures are required for effective ventilation, as in asthma or acute respiratory distress.  

Pediatric ETT cuff pressures can be safely managed either through the use of a manometer device or through auscultation for air leak around the tube.

Correct answer: Assume the crash position with knees together, feet 8 inches apart and placed under the seat.

The design of all aircraft continues to evolve and change in an attempt to improve survival during aircraft crashes. Landing gear, fuel systems, and aircraft seat design are all aspects of the aircraft that have undergone significant improvements in recent years to ensure these systems specifically are more capable of withstanding the massive forces experienced during a crash. Aircraft seats are now designed to both absorb the energy of a crash and decrease the G forces experienced by the individuals occupying the seats. This being said, aircraft seats will break apart with a crash landing, and all passengers of the aircraft should ensure that when they assume the crash position, their legs are not positioned under the seats and 6 inches apart.

Correct pre-crash sequence includes the following:

• Make sure to follow sterile cockpit.
• Assist the pilot per their direction.
• Tighten your helmet strap, pull your visor down, tighten seat belts, and assume the crash position.
• Position the patient with their head down and arms crossed, tighten patient seatbelts.
• Secure all equipment, shut off oxygen and inverter.
• Assist the pilot in looking for appropriate landing sites.
• If directed by the pilot, start emergency communication.

Correct answer: Adequate bilateral breath sounds and chest expansion plus detection of ETCO2 with waveform capnography

In a low-powered clinical trial and a number of observational studies, waveform capnography was observed to be 100% specific for confirming endotracheal tube position during cardiac arrest. Although sensitivity of waveform capnography decreases after a prolonged cardiac arrest, and waveform capnography for the assessment of the placement of other advanced airways (e.g., Combitube, laryngeal mask airway) has not been studied, it is the recommended method of ensuring adequate ETT (endotracheal tube) placement in the field.

Correct answer: External laryngeal manipulation

The current standard of practice, when airway manipulation is required to assist in bringing the airway into view for the individual attempting endotracheal intubation, is the application of external laryngeal manipulation. While the intubator herself may be able to provide the laryngeal manipulation by use of her free hand, it is advantageous to have an assistant apply the external laryngeal manipulation. Typically with this method, the intubator places the laryngoscope, bringing the vocal cords into view, and then asks the assistant to place external pressure on the thyroid cartilage, using either a lateral or direct approach. This helps to "push" the glottis into more full view of the intubator.

The Sellick's maneuver, while considered a form of external laryngeal manipulation, is no longer routinely recommended. There has been no evidence found either in favor or against this maneuver. The SALAD technique is used to clear highly contaminated airways during intubation.

Correct answer: Calling the patient "it" after finding out they are transgender

Diversity and cultural considerations must be made during every patient transport. Critical care providers will encounter a variety of patients from all cultural and ethnic backgrounds, races, genders, sexual orientations, ages, and more. Providers must be sensitive to the cultural and diversity differences between them and their patients to provide the best care. The best and easiest way to do this is to ask patients about their personal and cultural preferences. Ask patients what gender they identify with and respect their choice of name and pronouns, including not referring to a patient as "it." 

Ask about cultural preferences that may impact treatment. For example, some religions do not allow for blood transfusions, and some cultures may have a wariness of Western medicine that requires extra explanation about what you are doing.

Correct answer: Learning about the patient populations and their special healthcare needs that providers may respond to most frequently

Critical care providers may be called to care for patients from a variety of cultural and ethnic backgrounds. The phrase cultural competence is used to describe the act of care providers learning about and becoming familiar with the patient populations they may be called to treat to learn about their unique healthcare needs and preferences. This does not mean imposing your beliefs on others and caring for them based on what you think is right, but instead learning about them to provide treatment that they will accept. Patients should not be forced to accept care they do not believe in, and providers must be understanding of patients refusing medical care on the basis of cultural and religious beliefs.