BCEN CFRN CTRN Exam Questions

Correct answer: Third stage

The recommended maximum total daily dose of acetaminophen is 3900 milligrams of regular strength 325-milligram (in adults) or 3000 milligrams when using the extra strength 500-milligram preparation. Acetaminophen use by adults should not exceed 10 consecutive days unless directed by their physician. The recommended dose for children is 10 to 15 milligrams/kg every 4 to 6 hours as needed, with a maximum daily dose of 75 milligrams/kg or five doses in a 24-hour period.

Normal pathways for acetaminophen metabolism are saturated in overdose, and a larger proportion is oxidized by the CYP450 system into a reactive metabolite, N-acetyl-p-benzoquinoneimine (NAPQI). NAPQI is detoxified by hepatic glutathione to a compound able to be eliminated renally. However, glutathione levels decrease to < 30% of normal in the setting of overdose, and NAPQI binds to hepatic macromolecules, resulting in a centrilobular hepatic necrosis. Observed hepatocyte damage typically progresses with cell lysis on the second day after an acute toxic exposure, releasing hepatic enzymes (such as transaminases) and NAPQI-hepatic protein polymers transfer into the circulation, corresponding to the development of overt clinical toxicity.

Clinical presentation of acetaminophen poisoning is sometimes divided into four stages. Stage 1 is the first 24 hours following exposure in which patients may be asymptomatic or have minimal and nonspecific clinical effects, such as anorexia, nausea, vomiting, and malaise. Stage 2 occurs from days 2 to 3, when clinical findings seen from stage 1 improve, but  signs of hepatotoxicity (e.g., RUQ pain or tenderness) and elevated serum transaminases may be present. Most patients with mild to moderate hepatotoxicity recover without long-term consequence. However, in stage 3 (days 3 to 4), some patients will progress to fulminant hepatic failure. Stage 3  findings characteristically include metabolic acidosis, coagulopathy, renal failure, encephalopathy, and recurrent GI symptoms. Stage 4 describes patients who survive the complications of Stage 3 and begin to recover over the next two weeks, with complete resolution of hepatic ­dysfunction in survivors after 1 to 3 months.

Correct answer: Dobutamine 

Advanced cardiac life support (ACLS) guidelines are used as the standard of practice for resuscitation of the patient in cardiac arrest by most transport programs. Team members are expected to have current verification of ACLS skills through the American Heart Association (AHA) to participate in patient care within the transport environment. 

Transport teams must maintain a state of perpetual readiness for emergencies such as cardiac arrest. Preparation includes ensuring the proper functioning of resuscitation equipment and an adequate oxygen supply that is readily available. ACLS drugs should be well labeled, not expired, and ready for quick administration. The drugs most commonly used during resuscitation include epinephrine, lidocaine, and amiodarone.

Dobutamine has not been clinically shown to improve cardiopulmonary arrest outcomes. 

Correct answer: The ELT can be activated manually or automatically

The Federal Aviation Administration (FAA) requires all EMS aircraft to have an emergency locator transmitter (ELT) on board in the incident of aircraft crash. Each crew member, including the members of the medical air transport crew, should know the position of the ELT(s) and should be instructed on how to activate the ELT manually if it is not automatically activated by the crash. ELTs should automatically activate in response to a crash that exceeds 4 G forces, but this should be confirmed by a crew member, not just assumed. 

Distress signals are broadcast over frequencies 121.5 MHz and 406 MHz; distress frequency 121.5 MHz is no longer monitored by the COSPAS-SARSAT (an international humanitarian search and rescue organization) search and rescue satellite system. 

Correct answer: Adenosine

Adenosine is used to treat SVT that does not respond to vagal maneuvers. 

Amiodarone is used to treat ventricular tachycardia, as is Lidocaine. Atropine treats bradycardia and is an antidote for organophosphate poisonings. 

Correct answer: A mean pulmonary arterial pressure (mPAP) of 25 mm Hg or greater

Pulmonary hypertension (PH), an increase in the blood pressure of the vessels which carry blood from the heart to the lungs, may occur as a result of another pre-existing disease or condition or other insult, or it may be a primary disorder of the pulmonary vessels. PH is diagnosed through the use of catheterization of the right side of the heart, during which direct pressure of the pulmonary arteries and right ventricle is measured. A mean pulmonary arterial pressure (mPAP) of 25 mm Hg or greater is diagnostic for PH. Normal pulmonary arterial systolic pressure is between 15 mm Hg to 30 mm Hg, while normal diastolic pressure ranges from 4 mm Hg to 12 mm Hg. A mPAP between 21 mm Hg to 24 mm Hg is considered by many to be within a borderline range, which currently is of uncertain clinical significance. 

PH is categorized into 5 groups (this classification system is used internationally), and includes:

Group 1: caused by narrowing of the pulmonary vessels, adding stress to the right side of the heart, and eventually develops in to right-sided heart failure. May be caused by inherited factors, induced by drugs or toxins, or occur as a result of connective tissue disorders.

Group 2: characterized by involvement of the left ventricle and disease of the valves. 

Group 3: characterized by narrowing of the pulmonary arteries as a result of chronic lung disease and hypoxia.

Group 4: characterized by chronic thromboembolism which causes constricting of the pulmonary vessels.

Group 5: may be cause by hematologic, systemic, and metabolic disorders.

Correct answer: The only requirement for airtight earplugs during flight operations is to ensure the plugs are in place during descent. 

Earplugs must fit tightly to offer the maximum allowable attenuation; however, they must be removed before descent because pressure changes that result from decreased altitude tend to pull the plugs inward toward the tympanic membrane. 

The other choices are accurate when considering the effects of noise on the transport environment. 

Correct answer: Rhythm originating in the SA node

Sinus tachycardia is recognized on ECG with a normal upright P wave preceding every QRS complex (P:QRS ratio of 1:1). The PR interval and QRS configuration are normal (there is no prolonged pause), the rhythm is regular, the heart rate is increased (can be as high as 250 bpm, overlapping with rates of supraventricular tachycardia [SVT] in neonates), and the pacemaker is coming from the SA node and not elsewhere in the atria.

Sinus tachycardia is generally the result of an underlying condition and is rarely a primary cardiac arrhythmia. Most commonly, treating the underlying cause will resolve this condition. The heart rate is increased but regular in sinus tachycardia. If there is an inverted P wave noted on ECG, this generally indicates an ectopic atrial rhythm not originating in the SA node (i.e., a non-sinus origin of the P waves).

Correct answer: Activated charcoal

Acetaminophen poisoning should be considered when doses of more than 150 mg/kg are ingested, as this is considered to be a toxic level. Activated charcoal should be administered if the known ingestion occured within a few hours (under 4 hours). 

By four hours following the ingestion, a serum acetaminophen level should be obtained, and if the level is toxic at that time, or if the level is unable to be obtained by 8 hours following the ingestion, N-acetylcysteine (NAC) (Mucomyst) should be administered either by oral or IV route. Administration of NAC after 24 hours have passed since ingestion does not offer adequate benefit to make its administration worthwhile.

Glutathione is a naturally occurring antioxidant stored in the liver which helps to neutralize the metabolites of acetaminophen. The administration of NAC takes the place of glutathione.

Flumazenil is the antidote for benzodiazepine toxicity.

Correct answer: The use of specialty care pediatric transport teams has been found to improve pediatric outcomes

Recent studies have found that when a region has access to a specialized pediatric transport team, both pediatric and neonatal outcomes are significantly improved when these teams are called in for emergency transport. In areas where these speciality teams are not available, transport programs require medical team members to undergo additional specialty training in the care and transport of the pediatric population in order to support better outcomes. 

In areas where there are speciality pediatric transport teams, transport of the pediatric patient who is critically ill or who has a complex medical history or injury should be undertaken by these individuals, even if other transport programs operate in a vicinity somewhat closer to the patient, while the first-responding medical transport team provides the necessary interventions until this team arrives.

Correct answer: Within 60 seconds

The seasoned medical transport provider should be proficient enough in completing trauma patient assessments so as to be able to complete the full secondary assessment within 60 seconds. 

The secondary assessment should be completed in an orderly, systematic fashion, and should include a general visual inspection of the patient to determine additional injuries and extent of main life-threatening injury, auscultation of heart, lung, and bowel sounds, palpation of the extremities, and a collection of patient historical data. The mnemonic AMPLE can be used to aid in data collection, and stands for Allergy, Medication, Previous medical history or illness/pregnancy, Last meal, and Events/Environment related to the injury. Once the secondary assessment has been completed, any non-threatening injuries or findings should be attended to.

Correct answer: Myocardial infarction with left ventricular failure

Cardiogenic shock results from insult or injury to the cardiac muscle (heart), damaging it enough to prevent it from effectively circulating blood. It is considered to be a hypoperfusion state brought about by cardiac failure. Cardiogenic shock most commonly results from myocardial infarction (MI) with left ventricular failure, with MI with right ventricular failure causing 5% of cases of cardiogenic shock. 

Other causes of cardiogenic shock include: endocarditis, structural cardiomyopathies, myocarditis, valve failures, rupture of the ventricular wall or papillary muscle, and blunt or penetrating injuries to the heart.

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: Long-acting in duration so the patient can be comfortably transported 

If pain medications are used for analgesia in the transport setting, they should be:

• rapid in onset 
• short in duration
• easy to administer
• able to be administered by multiple routes
• easy to store (especially in different environments)

The intravenous (IV) route is the quickest method of administration and has a rapid onset. 

Correct answer: (Na⁺) - (Cl^- + HCO₃-)

Determination of the anion gap can be used to assess for metabolic acidosis and is often referred to as the "poor man's ABG." Normal anion gap is 12 (+/-4), with a worsening acidosis being indicated by a larger number. Evaluation of the anion gap is particularly helpful in instances when there is suspicion for toxicity or poisoning; several mnemonics have been devised to aid in remembering potentially toxic agents that may contribute to anion gap acidosis. An example of one of the mnemonics is shown below.

"MUDPILES"

M: Methanol

U: Uremia

D: Diabetic ketoacidosis

P: Propylene glycol

I: Isoniazid or iron

L: Lactate

E: Ethylene glycol

S: Salicylates

Correct answer: Diaphragmatic hernia

In patients that have suffered blunt trauma, such as in a car accident, the force generated can cause the diaphragm to tear and abdominal contents to enter the pleural space. This can be confirmed by the presence of bowel sounds while listening to the lungs. The bowels in the pleural space cause the lungs to not fully expand and, therefore, breath sounds are shallow and the patient is tachypneic. A scaphoid abdomen has a sunken-in appearance or is bowl-like. 

None of the other answer choices would produce these findings in a patient.

Correct answer: Arsenic

Determination of the anion gap can be used to identify anion gap acidosis, a metabolic acidosis. The anion gap is determined by factoring together sodium, chloride, and bicarbonate levels by use of a formula ([Na⁺] - [Cl^- + HCO₃-] = Anion Gap); the greater the number, the worse the metabolic acidosis.

Two mnemonic devices, "MUDPILES" and "GOLDMARK," have been created to help the provider remember potential causes of anion gap acidosis, which may be caused by exposure to toxic poisoning.

M: Methanol (alcohol)                                                                       G: Glycols (ethylene glycol and propylene glycol)   

U: Uremia                                                                                           O: Oxyproline (acetaminophen metabolite)

D: Diabetic ketoacidosis                                                                   L: L-Lactate

P: Propylene glycol (agent used in benzodiazepines)                 D: D-Lactate (acetaminophen, agent used in phenobarbital)

I: Isoniazid or iron                                                                               M: Methanol (alcohol)

L: Lactate                                                                                            A: Aspirin

E: Ethylene glycol (antifreeze)                                                          R: Renal Failure

S: Salicylates                                                                                       K: Ketoacidosis (diabetic, alcoholism)

Correct answer: Gastroschisis should be treated like an abdominal evisceration

Both gastroschisis and omphalocele abdominal wall defects require similar treatment and interventions in the initial period following delivery of the infant. Infants with these defects are at risk of infection, hypothermia, significant fluid volume losses, hypoglycemia, and impairments to perfusion of the small intestine, and require emergency care. The abdominal wall defects should be covered with moist saline gauze (warm if possible) and then covered with plastic to prevent desiccation of the exposed abdominal contents, or if possible, the infant should be placed in a bowel bag (a sterile plastic bag) to protect the exposed abdominal contents. Infants with these defects should be kept NPO, and infants with gastroschisis should have an orogastric tube placed as soon as possible after delivery to decompress the stomach. 

Omphalocele should be treated like an abdominal evisceration.

Correct answer: Three weeks without water

The average person can survive 3 minutes without oxygen (unconsciousness) or in icy water, 3 hours in a harsh environment (extreme heat or cold), 3 days without drinkable water, and 3 weeks without food. 

Once safety and immediate medical concerns have been addressed, the rule of threes should guide priority setting. The immediate priorities should be finding or creating shelter, building a fire, taking steps to maintain hydration, and signaling by whatever means possible. 

Correct answer: Administer intravenous fluids

Thyroid storm, a potential complication of hyperthyroidism or thyrotoxicosis, can be life-threatening if not immediately and aggressively treated. The combination of fluid losses from hyperthermia and an increase in gastric motility which causes nausea, vomiting, and diarrhea, can all rapidly lead to significant dehydration, which then causes cardiovascular instability, including tachydysrhythmias, atrial fibrillation, and heart failure. The first step in treating the patient with thyroid storm is the aggressive administration of IV fluids, followed by the administration of antipyretics (acetaminophen is preferred), beta blockers, and steroids. 

Beta blockers are used to treat the arrhythmias that result from the grossly elevated thyroid levels, while steroids (typically dexamethasone) are administered to prevent adrenal insufficiency and to inhibit the conversion of T4 into T3. Thyroid hormone levels should be reduced through the use of propylthiouracil or methimazole; iodine may also be administered. Long-term management of hyperthyroid may involve thyroid ablation.

Correct answer: 70 mm Hg

CPP = MAP - ICP; this value reflects the actual pressure of blood perfusing the brain. In critically ill neurologic patients, CPP is an even more important number to track than ICP and must be maintained within narrow limits. Too little pressure could cause brain tissue to become ischemic, and too much could raise ICP. 

A CPP greater than or equal to 70 mm Hg ensures adequate cerebral perfusion.