BCEN CFRN CTRN Exam Questions

Correct answer: Kidney 

These assessment findings are consistent with a renal injury. Hematuria is a marker for renal injury after blunt trauma. Because renal injuries are not usually immediately life-threatening, the transport team should give supportive care and identify the patient's risk for kidney injury when other life-threatening injuries are absent. At the receiving center, surgery may be indicated for major kidney injuries, urethral tears, or renal vascular damage. Many of these injuries, however, are managed without surgical intervention. 

Splenic injury leads to left shoulder pain, while patients with hepatic injury experience right shoulder pain. Abdominal pain, nausea, vomiting, and elevated serum amylase are associated with pancreatic injury. 

Correct answer: Initiate transcutaneous pacing (TCP)

Complete heart block is characterized by separate and independent atrial and ventricular activity. Either sinus or ectopic atrial pacemakers control the atria, and a pacemaker that is distal to the AV block controls the ventricles. The ECG shows QRS complexes and completely dissociated P waves. 

Immediate treatment for symptomatic third-degree AV block (i.e., shortness of breath, chest pain, hypotension) involves the use of TCP or a transvenous pacemaker, if available. Pharmacologic therapy can include atropine at 0.5 to 1.0 mg (although normally ineffective unless the QRS is narrow) or the initiation of a vasopressor infusion using either dopamine or epinephrine. Ultimately, these patients will require transvenous pacing. 

If the patient does not respond to the first dose of atropine, the next step should be to initiate TCP. Versed may be given if necessary for sedation and comfort; lidocaine is not indicated for complete heart block. 

Correct answer: Sudden increase in PIP

A sudden increase in PIP means that there is more resistance to the ventilator. This can be caused by a tension pneumothorax and should be further investigated to determine if this is the cause. Remembering the DOPE acronym for Dislodgement, Obstruction, Pneumothorax, Equipment failure will help in troubleshooting ventilator alarms. 

A decrease in PIP means there is loss of pressure in the system somewhere, possible dislodgment of the ET tube. Jugular vein distinction and tracheal deviation are classic signs of pneumothorax; however, these are very late signs. The CFRN/CTRN needs to know the signs and symptoms of a disease process early in its progression, not later. Muffled heart tones are signs of cardiac tamponade, not pneumothorax and, also, it is impossible to auscultate during flight in rotor wing aircraft.

Correct answer: COBRA

HIPAA was enacted to protect patient privacy. EMTALA is a law contained within the COBRA act. Affordable care act is the new health care insurance also known as Obamacare.

Correct answer: Mallampati I

The Mallampati score is used to grade or classify the patient's airway in reference to ease or difficulty of endotracheal intubation. Individuals with a Mallampati score of I often are tall and have a long, thin neck, while individuals with a Mallampati score of IV often have a neck that is short, fat, or muscular. 

When examining the oral cavity of an individual with a Mallampati score of I, the examiner can easily visualize the soft palate, the uvula, and both the anterior and posterior tonsillar pillars. Patients with a Mallampati I score are typically easy to intubate.

A Mallampati score of II indicates that while the soft palate and uvula were visible during the examination, view of the tonsillar pillars was obscured by the tongue. Patients with a Mallampati II score also are typically easy to intubate.

A Mallampati score of III indicates that when examining the oral cavity, only the soft palate and base of the uvula were able to be visualized. Patients with a Mallampati III score may present moderate difficulty during intubation.

A Mallampati score of IV indicates that during examination of the oral cavity, only the soft palate was visible, both the uvula and anterior and posterior tonsillar pillars were fully hidden from view by the tongue. It can be quite difficult to establish an airway in these individuals.

Correct answer: Labetalol

If the patient is a candidate for rtPA therapy, the target arterial blood pressures are systolic blood pressure ≤ 185 mm Hg and diastolic blood pressure ≤ 110 mm Hg.

Labetalol is the recommended emergency antihypertensive for hemorrhagic and acute ischemic stroke by the AHA. However, early aggressive b-blockade may be hazardous in hemodynamically unstable patients.  

Options for emergency antihypertensives in stroke patients:

Labetalol, 10 milligrams IV followed by infusion at 2–8 milligrams/min.

or

Nicardipine infusion, 5 milligrams/h, titrate up by 2.5 milligrams/h at 5- to 15-min intervals; maximum dose 15 milligrams/h.

or

Clevidipine infusion, 1–2 milligrams/h, titrate up by doubling dose every 2–5 min; maximum dose 21 milligrams/h.

Correct answer: History and mechanism of injury 

The use of critical thinking skills to determine whether to intervene in managing a patient's airway is a vital component in airway management. Along with education and technical skills, this will prevent procedural and physical complications when a transport team is managing a patient's airway in the transport environment.

The history, mechanism of injury, and progression of illness may provide subjective and objective data to assist the transport team in determining the best course of action, but they are not one of the four broad categories associated with assessing and managing an airway.

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: Midazolam 10 mg IM

Status epilepticus is clinically defined as abnormally prolonged or repetitive seizures, and presents in several forms: 

(1) convulsive status epilepticus consisting of repeated generalized tonic-clonic seizures with persistent postictal depression of neurologic function between seizures; 

(2) nonconvulsive status epilepticus, a persistent change in behavior or mental processes with continuous epileptiform EEG but without major motor signs; and 

(3) focal status epilepticus, with or without altered awareness. 

Convulsive status epilepticus, defined as more than 30 minutes of either continuous seizure activity or two or more sequential seizures without full recovery of consciousness between them, is a life-threatening emergency that requires immediate treatment. Persistent seizure activity is believed to cause permanent neuronal injury. Since the majority of seizures terminate spontaneously within 2 to 3 minutes, it is generally accepted that treatment should be begun when seizure duration reaches 5 minutes for generalized tonic-clonic seizures and 10 minutes for focal seizures. 

Initial treatment recommendation is a benzodiazepine, either intravenous lorazepam or diazepam, although intramuscular midazolam may be preferred if it reduces the time to receipt of the dose. In the prehospital setting, rectal diazepam, intranasal midazolam, or buccal midazolam are all acceptable alternative first treatments if first-line options are not available. 

Refractory status epilepticus is treated with anesthetic doses of pentobarbital, propofol, midazolam, or thiopental.

Correct answer: Bradycardia with desaturation

Pediatric patients are at risk for rapid deterioration during intubation with increased risk of bradycardia with desaturation with prolonged attempts. Because of anatomical differences based on size and age, airway management  in pediatric patients requires specialized equipment.

Correct answer: Atropine

The 2015 ACLS guidelines for the pharmacologic treatment of acute sinus bradycardia recommends the intravenous (IV) administration of atropine at a dose of 0.5 mg, which can be repeated every 3 to 5 minutes, to a maximum dosage of 3 mg. If atropine is not effective at re-establishing a life-sustaining rhythm, the medical air crew should prepare to apply transcutaneous pacing (TCP) as a temporary measure, and will need to medicate the patient appropriately for this external measure due to the discomfort it typically causes.

Dopamine may be used as a second-line treatment for sinus bradycardia, as may epinephrine. Adenosine is used to treat narrow complex SVT. Magnesium sulfate is used to treat torsades de pointes.

Correct answer: Pulseless ventricular tachycardia

According to 2015 ACLS treatment guidelines, amiodarone, procainamide, and sotalol, are all recommended as first-line agents in the treatment of pulseless ventricular tachycardia (pulseless V-tach) that is resistant to defibrillation. Lidocaine may also be used an an alternative, if the patient is stable.

Torsades de pointes is treated by the administration of magnesium sulfate. Asystole is treated by the administration of epinephrine. Narrow complex SVT is treated by the administration of adenosine.

Correct answer: Administration of tranexamic acid

The use of tranexamic acid (Lysteda) for heavily menstruating women or women who are experiencing obstetrical hemorrhage is well-established, as is its use in major orthopedic surgeries such as knee and hip arthroplasties. This clotting promoting drug slows down the breakdown of blood clots, preventing, or at least reducing, the risk of major hemorrhage, and thereby decreasing the rate at which patients require administration of blood products. The product appears to provide the most benefit when administered within 3 hours of injury (trauma), and may be the most reasonable treatment option for those who provide resuscitative care in the prehospital environment to patients experiencing hemorrhagic shock.

Correct answer: Oral administration of ethanol

Both ethylene glycol ingestion and methanol ingestion are treated with the administration of fomepizole. Fomepizole is an alcohol dehydrogenase inhibitor drug which is administered as an intravenous infusion, blocking the formation of toxic metabolites. It may be administered alone to treat toxic alcohol ingestion, or may be used in conjunction with hemodialysis to more rapidly detoxify the patient. If fomepizole is unavailable, the medical transport team may initiate oral or intravenous dosing of ethanol as an alternative. 

Pralidoxime is used to treat organophosphate poisoning. 

Physostigmine is used to treat anticholinergic poisoning.

Glucagon is used to treat poisoning from beta blockers or calcium channel blockers; it is administered via intravenous route.

Correct answer: Medical flight crew members should remain in contact with their own pilot via radio contact

During some instances of accident site rescue, multiple medical air transport aircraft may be present. The crews of each respective aircraft are expected to demonstrate professional behavior through strong communication and respect for each aircraft and crew member. Crew members must remain in contact with their own pilot through the use of radio communication, and should also be in contact with the pilot and/or crew of the other respective aircraft by relaying messages through their own pilot, by the use of hand signals, or by direct radio contact with the pilot or crew members of the other aircraft. 

Medical flight crew members may only approach or pass under the rotor disk of another aircraft after they have obtained permission from that pilot. Medical flight crew members typically work together in loading rescued patients into their own aircraft.

Correct answer: Volume-controlled pressure-variable ventilation

Just as there are several types of ventilators that may be chosen for use during medical air transport missions, so there are several modes of ventilation that may also be used. The use of a volume-controlled mode during medical air transport is appropriate, given that the patient will experience pulmonary changes as a result of the effects of Boyle's Law (at a constant temperature, the volume of a gas varies inversely with the pressure)—as the air mission ascends and reaches altitude, the volume of gas inside the patient's lungs will expand. 

To counter the effects of Boyle's Law and protect the patient from potential barotrauma, the medical air crew should decrease the tidal volume being delivered and instead, increase the breaths per minute being delivered.

Correct answer: Early defibrillation

Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with non-shockable rhythms. Reducing interruption of compressions is a key component of high-quality CPR.

Advanced airways when necessary should take no longer than 10 seconds to insert. Prompt initiation of targeted temperature management (TTM) is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome. TTM between 32°C and 36°C for at least 24 hours is recommended for all cardiac rhythms in both out-of-hospital and in-hospital cardiac arrest.

Correct answer: Gum chewing 

During flight ascent, air in the middle ear cavity expands but normally vents into the throat through the eustachian tube when a pressure differential of approximately 15 mm Hg has been reached. A mild fullness may be felt but resolves as equalization occurs. 

On a descent, however, the eustachian tube remains closed unless actively opened by muscle action or high positive pressure in the nasopharynx. If the tube does not open regularly during descent, a pressure differential may develop, causing pain and requiring equalization of pressure in the middle ear. This can be accomplished through the following techniques: 

• Valsalva's maneuver
• Yawning
• Swallowing
• Moving the lower jaw
• Topical administration of vasoconstrictors
• Use of a bag-valve mask

Gum chewing is not recommended because it causes swallowing of air, leading to gastric distention and discomfort. 

Correct answer: Stating no more than two ideas at a time

Each team member must have the skills and sensitivity to transmit information in an increasingly clear, bold, and concise manner as the team faces challenges and hazards. Steps to ensure an effective message include the following:

• Stating one idea at a time
• Stating things simply 
• Encourage feedback
• Repeat and explain as required 

Correct answer: Snow

In the event of an emergency landing or crash of a medical air transport aircraft in a wilderness location, after assessing survivors for injuries and providing for medical stabilization, priority should be placed on obtaining water for drinking. Acceptable sources of water include dew found on plant leaves or other surfaces, running water sources such as streams or rivers, standing surface water such as puddles, or condensation that collects on surfaces such as the aircraft windshield. All water should be purified prior to drinking either by the use of purification tablets included in survival kits or by boiling or filtering of the water. 

Snow should not be ingested to provide water, as this can cause heat loss and contribute to hypothermia; instead, it should be melted over fire or in the sun to bring the water temperature up to a more temperate level.