BCEN CFRN CTRN Exam Questions

Correct answer: Sodium bicarbonate 

Sodium bicarbonate is given to neutralize TCA overdose. 

Narcan is used for opiate overdose, benzodiazepines are used for sympathomimetics overdose, and Mucomyst is given for acetaminophen overdose.

Correct answer: The 5th intercostal space on the midaxillary line

Massive hemothorax should be treated the same as tension pneumothorax with decompression of the affected lung through needle decompression. A large-bore, 14 or 16 gauge 2-inch needle should be placed on the affected side, in any of the following anatomic sites:

• The 2nd intercostal space on the midclavicular line
• The 4th intercostal space on the midaxillary line, or
• the 5th intercostal space on the midaxillary line

The hemorrhaged blood should be measured and replaced if possible during transport with the administration of packed red blood cells. A chest tube also should be placed to allow for continued reinflation of the lung and drainage of any further bleeding. Pulmonary edema may result from reexpansion of the affected lung in rare cases as a result of rapid emptying of the hemorrhaged blood from the chest. If the chest tube drainage is greater than 200 mLs over 4 to 5 hours, the chest tube should be clamped temporarily to prevent the too-rapid emptying of the chest contents and subsequent development of pulmonary edema.

Correct answer: Mass casualty incident

The management system responsible for the establishment of power of command at incident/accident scenes is referred to as the Incident Command System (ICS). This system functions through the use of a common set of terminology designed to improve communication, manages the emergency response during both major and minor incidents across their assigned geographical region(s), all of which facilitates seamless transition during incidents/accidents. 

An example of the common language used by ICS is that of a "mass casualty incident." Neither the number of victims involved in an incident nor the actual size of the incident actually defines what makes an incident a "mass casualty incident," so much as does the actual location where the incident occurred, such as in a more rural area, and the associated resources available for response in that area.

The term "command function" refers to the need for one individual, or a group of individuals, to maintain authority during an incident.

Correct answer: Stable angina

Acute coronary syndrome (ACS) is a cardiac condition typically brought on by acute coronary artery occlusion, often from clot formation, spasm of a coronary blood vessel, or rupture of an atherosclerotic plaque in the arteries of the heart. There are 3 manifestations of ACS: unstable angina, acute NSTEMI, and acute STEMI. Unstable angina represents the least serious of the ACS manifestations, but all may ultimately cause sudden cardiac death.

Correct answer: Acute pancreatitis

Cullen's sign, or an acute development of ecchymosis in the subcutaneous tissue of the periumbilical region, may result from a ruptured ectopic pregnancy, abdominal aorta rupture, or acute pancreatitis due to hemorrhaging of the pancreas. 

Patients with acute pancreatitis often complain of severe upper left quadrant pain which is exacerbated when the patient moves into a recumbent position, or severe pain to the epigastric region. Vasodilation of the pancreatic vasculature or leaking of the pancreatic capillary bed may contribute to a sequestration of up to 6 liters of fluid in the retroperitoneal area. Medical transport teams will need to ensure aggressive fluid resuscitation to these patients to overcome the hypovolemia that results from the fluid sequestration. In addition, oxygenation, hemodynamic stability, and pain management, are all critical components of transporting these patients.

Correct answer: Lifeguard status

Lifeguard status may be requested by medical air transport pilots in an attempt to obtain priority in landing due to critical or urgent medical incidents affecting their patients (or ill or injured crew members). The request to be granted lifeguard status should not be requested cavalierly, but should be requested only during urgent medical crises such as full cardiac arrest or a rapidly deteriorating condition. When lifeguard status is granted, all other aircraft are required to hold, delaying takeoff and landings at the cost of potentially thousands of dollars, in order to allow the aircraft which has received lifeguard status to expeditiously complete their urgent takeoff or landing.

Correct answer: Succinylcholine causes an increase in intraocular pressure (IOP) less than the increase in IOP associated with crying

For many years, the use of succinylcholine in patients who have sustained eye injuries, particularly open globe injuries, has been contraindicated due to the concerns of increased intraocular pressure (IOP). And while succinylcholine does cause an increase in IOP, this increase in pressure is less than the increase in IOP associated with crying, rubbing of the eyes, or even forceful blinking, and has not been found to contribute to the expulsion of the vitreous humor in open globe injuries, hence its use during RSI for patients who have sustained eye injury is not contraindicated by the available evidence.

Correct answer: 2 to 4 L/min

At times, members of the medical air transport crew may be called upon to aid in transporting a patient via a commercial airline carrier. This type of medical air transport is referred to as commercial medical escort and may involve one member of the medical air transport crew serving as escort to a medically stable patient, or it may involve the entire crew (or several members of the crew) stabilizing a critically ill patient and escorting them to their destination by use of a commercial airline. Commercial airlines are equipped to deliver oxygen to their passengers, most often at a rate of only 2 to 4 L/min. 

If the patient requires oxygen at a higher flow rate, or requires the delivery of 100% oxygen, oxygen tanks should be obtained at least 24 hours in advance of the travel, and ideally, several days prior to the planned travel.

Correct answer: Subarachnoid hemorrhage

Patients with a subarachnoid hemorrhage (SAH) who are conscious at the time of receiving emergency medical care often report their current symptom as "the worst headache of my life." SAH may result in response to head trauma, or may be spontaneous; spontaneous SAH is more common in females under the age of 55, and has an association with nicotine smoking, alcoholism, and hypertension. As many as 10% of patients who experience SAH report having been bending over, lifting heavy objects, or engaging in other strenuous activity when their symptoms manifested. Nearly 25% of patients who experience SAH will die within 24 hours regardless of having sought out medical intervention. SAH survival rates, ironically, are higher for those individuals who experience SAH as a result of trauma versus spontaneous SAH.

Correct answer: Abruptio placenta

Anytime a pregnant patient suffers blunt trauma (such as in a car wreck), the critical care provider should suspect placenta abruption, especially when the patient complains of pain and there is bleeding. Not all cases of abruptio placenta result in bleeding, but the CFRN/CTRN should still suspect the condition, given the mechanism of injury. 

Placenta previa results in painless bright red bleeding from the vagina. Eclampsia is marked as seizures of the pregnant woman. While the mechanism of injury could result in hypovolemic shock, the main focus should be on the emergent condition of the possibility of placenta abruption, given the signs and symptoms.

Correct answer: The balloon has ruptured

While the use of intraaortic balloon pumps (IABP) has gone down in recent years, medical air transport of a patient with an IABP continues with frequency. These patients are often critically ill, having experienced cardiogenic shock as a result of myocardial infarction (MI) with (most frequently) left- or right-sided heart failure, endocarditis, or an underlying heart defect such as hypoplastic left heart. The IABP serves to increase cardiac perfusion and carbon dioxide while, at the same time, decreasing the workload of the heart. And while medical air transport crews are typically well-trained in the care of, and transport of, patients requiring IABP, these devices are not without risk to the patient.

In addition to the cardiac pathology that may occur to patients who have an IABP, including the development of ventricular fibrillation or pulseless ventricular tachycardia among other cardiac emergencies, the pump itself may experience complications which jeopardize the health and well-being of the patient. Power failure of the pump, running out of helium for the balloon, dislodgement of the catheter, oozing from the insertion site, occlusion of the catheter, and rupture of the balloon or balloon tubing are all potential complications of IABP placement. In the instance of balloon rupture, the medical air crew will most likely observe the presence of brown- or rust-colored flakes inside the tubing, indicating the presence of clotted red blood cells. Other signs of balloon rupture include the presence of frank blood in the tubing or a loss of gas alarm.

Correct answer: Administer 20 mg IV push, repeating the dose every 10 minutes to a maximum dosage of 300 mg

There are several first-line antihypertensive agents which may be utilized in the treatment of preeclampsia. Methyldopa, hydralazine, nifedipine, and labetalol are all considered first-line agents and safe for use during pregnancy. Labetalol is frequently utilized for both its selective beta-blocking effects (it is both an alpha- and beta-blocking drug), causing a decrease in the systemic vascular resistance without altering the cardiac output, and its ability to decrease the cerebral perfusion pressure, lowering the risk of seizures in preeclampsia. Labetalol should be administered using a standard dose of 20 mg delivered via IV push over 2 minutes; this dose may be repeated every 10 minutes until a maximum dosage of 300 mg has been administered. Subsequent dosing with labetalol at higher dosing levels frequently results in profound hypotension with slow return to a normal baseline level.

Correct answer: A 68-year-old type II diabetic who takes an oral hypoglycemic agent and a diuretic for blood pressure management 

Hyperglycemic hyperosmolar non-ketosis (HHNK), which is also known as hyperosmolar hyperglycemic state (HHS), is a condition of extremely elevated blood glucose (greater than 600 mg/dL, and often as high as 1,000 mg/dL), and occurs as a complication of type II diabetes. It is often precipitated by an infection or illness, or even a stroke or myocardial infarction. In contrast to patients who experience diabetic ketoacidosis (DKA), patients who experience HHNK do not have elevated ketones or metabolic acidosis as a result of the significantly elevated blood glucose levels (and hence no fruity odor to the breath or presence of Kussmaul's respirations), but may present with symptoms similar to those of DKA: abdominal pain, decreased appetite, polydipsia, polyuria, headaches, blurred vision, and confusion. Like DKA, as HHNK progresses, patients experience dehydration as a result of osmotic diuresis, and hypotension, tachycardia, and cardiac dysrhythmias may result. If left untreated, patients may experience seizures, coma, or even death. 

HHNK most commonly occurs in type II diabetic patients who are over the age of 50, are using oral agents to control their blood glucose, and who are taking other medications, often a diuretic, worsening the HHNK.

Correct answer: Anemia

The kidney is responsible for the production of erythropoietin, which acts on the bone marrow to increase the production of red blood cells (RBCs). Iron, folic acid, and vitamin B12 are also needed for RBC production. 

A patient in renal failure is most likely to suffer from anemia because of the reduced production of the hormone erythropoietin.  

Correct answer: Hyperglycemia

The elevated maternal glucose levels experienced in women with gestational diabetes, particularly during the third trimester of pregnancy, cause the pancreas of the growing fetus to increase its production and secretion of insulin, due to the fact that while maternal glucose crosses the placenta, maternal insulin does not. Once the infant has been born, its exposure to the elevated maternal glucose levels immediately ceases, while the infant's pancreatic production of insulin remains elevated for the next several days. As a result, these infants are likely to experience significant hypoglycemia, particularly in the 1 to 2 hours following birth, as this is the time of blood glucose nadir in all infants, then exacerbated by the excess insulin production (hyperinsulinemia) that had been necessary for life prior to delivery. In addition, these infants also often experience low levels of calcium and magnesium in the first few postpartum days.

Correct answer: Streptococcus pneumoniae

Pneumonia is an infection of the lower respiratory tract and is usually caused by inhalation of aerosols containing pathogenic microorganisms or by aspiration of oropharyngeal flora. S pneumoniae is the most common etiology identified in CAP when identification is obtained. 

The incidences of the other organisms differ throughout different regions of the country and vary significantly when nosocomial infections are considered. 

Correct answer: 30 minutes 

TUC refers to the elapsed time from the point of exposure to an oxygen-deficient environment to the point at which deliberate function is lost. With the loss of effective flight performance, an individual can no longer take the proper corrective or protective action. Thus, for air medical personnel, the emphasis is on prevention. At an altitude of 18,000 feet (and lower), TUC is approximately 30 minutes. 

At an altitude of 25,000 feet in a nonpressurized aircraft, TUC is only 3-5 minutes. 

Correct answer: Hypokalemia

The aggressive fluid resuscitation necessary for treating diabetic ketoacidosis (DKA) almost always results in the development of several electrolyte disturbances. As the patient's fluid volume increases and their state of metabolic acidosis is improved, serum potassium levels fall; the administration of insulin to correct the gross hyperglycemia also contributes to a state of hypokalemia. It may be necessary to temporarily cease the insulin infusion to allow for correction of a significant hypokalemic state; once the potassium level has reached at least 3.5 mEq/L, the insulin can be restarted and potassium replacement should continue through the addition of this electrolyte to the patient's intravenous fluid and/or through oral administration of potassium when the patient is able to tolerate oral administration.

Hypomagnesemia and hyperchloremia also typically result from treating DKA.

Correct answer: A nasogastric tube (NGT)

Patients with known esophageal varices are at increased risk of varice rupture and subsequently, severe bleeding or hemorrhage. These patients may have associated coagulopathies if the varices are a result of liver disease, making risk of hemorrhage even greater. Esophageal balloon tamponade devices, such as a Sengstaken-Blakemore tube, are often used in an attempt to prevent varice rupture, and should be placed after the patient has been intubated. Gastric suction equipment needs to be readily available when using these devices, and the medical crew must have a method of managing what may be copious gastric secretions. NGTs should not be used in patients with esophageal rupture, as insertion of the tube may penetrate a varice, causing rupture, and potentially death from massive hemorrhage. A football helmet placed on the head of the patient with a Sengstaken-Blakemore tube can be extremely helpful in helping to maintain the correct position of these traction-dependent devices during air transport.

Correct answer: Deep partial-thickness burn injury

Superficial or first-degree burns involve only the epidermis skin layer, and may be painful, red and warm, area turns white when touched, no blisters, moist.

Partial thickness or second degree burns involve the epidermis and some portion of the dermis. Depending on the how much of the dermis is affected, the burn is further broken down into superficial or deep; superficial partial thickness burns are usually painful, red, moist, with blisters, hair still intact, while deep partial thickness burns may or may not be painful (nerve endings destroyed), may be moist or dry (sweat glands destroyed), and any hair is usually gone.

Full thickness or third degree burns are the most severe burn and involve all layers of skin – epidermis and dermis. Nerve endings, small blood vessels, hair follicles, sweat glands are all destroyed; subcutaneous fat tissue, muscle and bone may also be involved in very severe burns. Full thickness burns are painless with no sensation to touch, skin is pearly white or charred, dry, and may appear leathery.