BCEN CFRN CTRN Exam Questions

Correct answer: Stuporous

Changes in the level of consciousness (LOC) are the best indicators of change in the intracranial pressure (ICP), and can be best described by use of several terms used to indicate either a conscious or unconscious state. A conscious state can be described by use of the terms alert, lethargic, and obtunded, while patients in an unconscious state can be described as being stuporous or comatose. An alert patient can respond to his environment, including intervention from the medical transport provider, but may be confused, have slurred speech, and have noted motor deficits. The lethargic patient may appear to the medical transport provider to be asleep or drowsy, but can easily be awakened and should be able to respond somewhat appropriately to the transport provider. Patients who are described as being obtunded also appear sleepy or asleep, but are difficult to rouse and has difficulty responding verbally to the medical provider, and may appear to fall back to sleep even while being actively engaged with by the transport team, necessitating the repeating of questions and instructions several times in an attempt to awaken and engage the patient. 

Further worsening of the LOC brings the patient into a state of unconsciousness. Stuporous patients may be in a light or deep state of stupor, with patients in states of light stupor moaning in response to pain or muttering one syllable words, typically curses. These patients may be observed to move all their extremities (if able) in response to pain, and while unable to communicate verbally, they maintain the rudimentary ability to respond to a localized site of pain/injury. Patients experiencing deep states of stupor are unable to protect themselves against pain, and do not appear to respond to localized sites of painful stimuli. A fully comatose patient may exhibit decerebrate or decorticate posturing, or may be completely flaccid and unresponsive.

Correct answer: Aortic dissection

Marfan’s syndrome is a disorder of the connective tissue where connective tissue degenerates. A common place for this to occur is the elastic fibers of the aortic media. This breakdown allows for a dissection to occur. This information, along with history of hypertension and differing blood pressures in each arm, leads us to believe aortic dissection is the cause of the patient's symptoms. 

Correct answer: Jefferson's fracture

Of all the different types of motor vehicle accidents (MVAs) involving passenger cars, the rollover accident causes the most unpredictable of the injuries sustained by occupants of vehicles involved in MVAs. The tumbling and multiple-impacts that occur during a rollover accident often contribute to passengers of these MVAs sustaining multi-system injuries. Spinal injuries may be incurred during these accidents; Jefferson's fracture, a burst fracture of the C1 vertebra, may occur in MVAs in which the vehicle both rolled over and the roof was crushed downward. 

A hangman's fracture, which is a cervical spine fracture involving the 2nd cervical vertebra, often occurs in rear-impact collisions. A chance fracture, which is a cervical spine fracture involving the T12-L1 vertebra, also often occurs during rear-impact collisions.

A greenstick fracture is a fracture typically of a young, soft bone (as in a developing child) in which the bone bends and incompletely fractures, and also may occur in vertebral burst fractures of the lumbar spine. This type of fracture is not necessarily associated with MVA collisions, but may occur.

Correct answer: Pulling the woman's knees to her chest and applying suprapubic pressure

Shoulder dystocia is more likely in infants that are large. The key to delivery of the infant with suspected shoulder dystocia is to manipulate the pelvis in such a way that the pelvis is widened. This is accomplished by using the McRoberts maneuver, where the woman's knees are brought up to the shoulders. Another provider then supplies suprapubic pressure to moves the infant's arm past the pelvis. 

Placing a mother on her left side is used to relieve pressure off the inferior vena cava. Placing the woman on all fours or ”bearing down” does not accomplish widening the pelvis.

Correct answer: Assume the HELP posture

If involved in an open-water landing while part of a medical air transport mission, all survivors should attempt to reach the shore. If this is not possible due to extreme far distance from shore or in the case of injured parties whose injuries prevent them from attempting to swim to shore, the next best step is for survivors to assume the HELP position in an attempt to try to prevent the development of hypothermia. HELP stands for heat escape-lessening posture and involves placing oneself in the fetal position with knees tucked up against the chest and arms crossed over the chest. A flotation device must be worn when using the HELP position. 

Flight helmets should be worn when in the water, as they provide a degree of insulation, and can aid in being spotted by rescuers. Survivors should then huddle together to, again, decrease development of hypothermia, and should signal to would-be rescuers. In addition, any life rafts should be carefully maintained.

Correct answer: Decreased antidiuretic hormone (ADH) levels 

DI is caused by inadequate or impaired secretion of ADH or impaired or insufficient renal response to ADH and is treated with ADH replacement with desmopressin acetate (DDAVP). Urine osmolality is low and serum sodium is high in DI due to a decrease in both urine concentrating ability and water conservation, resulting in excessive diuresis. 

DI does not affect blood glucose levels. 

Correct answer: International transport requires the use of redundant medical systems

In years past, medical air transport was limited primarily to domestic transport only, but in recent years, the need for international medical air transport has grown, making the need to fully comprehend the logistics of international air transport important for the medical crew. Commercial airline aircraft may not be utilized for the transport of medical patients depending upon transport restrictions; consequently, many air transport programs have extended their services to now include international transport. Due to the potential limitations of medical equipment, staff, pharmaceuticals, and other supplies in other countries, it is necessary for international transport aircraft to utilize redundant medical systems and equipment to ensure safe transport of their patients.

Correct answer: Assume the crash position with knees together, feet 6 feet 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.

Correct answer: Comprised of 9 cartilages and moved by 9 muscles

A solid knowledge of basic anatomy of the head and neck is necessary for successful intubation completion. The larynx, which is also referred to as the voice box, is a boxlike structure which houses the vocal cords, and is comprised of 9 cartilages (3 single and 6 paired) which are attached by membranes and ligaments. Its movement is controlled by 9 muscles. At the top, the larynx is attached to the hyoid bone, and is continuous with the trachea. 

The thyroid cartilage is described as a fusion of two curving cartilage plates.

Correct answer: Routine administration is not indicated during cardiac arrest

During cardiac arrest, disturbances in the control of calcium movement in myocardium result in elevations in cytosolic calcium and disturbances in myocardial function, similar to those that occur with calcium overload. Administration of calcium and the subsequent elevation in serum calcium concentrations under these conditions may have further detrimental effects on the heart and vascular smooth muscle. 

Two observational studies examining the administration of calcium during cardiac arrest demonstrated worse survival and ROSC with calcium administration. While there are special circumstances in which calcium administration is used, such as hypocalcemia, calcium channel blocker overdose, hypermagnesemia, and hyperkalemia, the routine use of calcium in cardiac arrest is not recommended.

Correct answer: The I-gel

Supraglottic airway (SGA) devices, also often referred to interchangeably as laryngeal mask airway (LMA) devices, first came into use in the 1980s in the United Kingdom. The LMA, which is a type of SGA, is reusable, has an inflatable cuff, comes in sizes from neonate to adult, and provides an excellent alternative to endotracheal tube placement when this cannot be achieved, and is now also considered to be a first-line airway management strategy. The Combitube device and the King airway are both considered to be retroglottic devices (the tube is passed behind the larynx and the glottis, into the esophagus, with two balloon cuffs used to seal off the opening of the larynx), as opposed to supraglottic devices. 

Only the I-gel, a type of SGA, does not use an inflatable cuffed- or balloon system for sealing off the esophagus and pharynx. Instead, the I-gel is manufactured using a medical-grade thermoplastic polymer with a gel-like texture with a design intended to be snugly fit into the perilaryngeal structures.

Correct answer: Ruptured tubing

The brown flakes in the tubing are clotted red blood cells. If the provider sees brown or rust-like flakes in the tubing, the tubing should be clamped off immediately to prevent any helium from entering the bloodstream. The tubing will have to be removed by a physician.  

Correct answer: Basilar skull fracture

Basilar skull fractures are the most serious type of skull fracture, involving a break in the bone at the base of the skull. Signs and symptoms associated with basilar skull fractures include cerebrospinal fluid leak, mastoid ecchymosis (Battle's sign), periorbital ecchymoses (raccoon eyes), hemotympanum, vertigo, decreased hearing or deafness, and seventh nerve palsy. Periorbital and mastoid ecchymoses develop gradually over hours after an injury. Basilar skull fractures commonly involve the petrous portion of the temporal bone, the external auditory canal, and/or the tympanic membrane. They are associated with dural tearing, which often leads to otorrhea or rhinorrhea. Basilar skull fractures may occur anywhere along the skull base, from the cribriform plate through the occipital condyles. Do not place a nasogastric tube through the nares if cribriform plate fracture is suspected; this can lead to direct intracranial injury.

Linear skull fractures are the most common type of skull fracture, in which there is a break in the bone, but the bone does not move.

Depressed skull fractures may or may not have a cut in the scalp with this type of fracture, in which part of the skull is sunken in from the trauma. Depressed skull fractures may require surgery, depending on the severity, to help correct the deformity.

Diastatic skull fractures occur along the suture lines in the skull (areas between the bones in the head that fuse during childhood), identified by widening of the normal suture lines. Newborns and older infants are more likely to get these types of fractures, and may be indicative of abuse.

Correct answer: Hydralazine (IM) and magnesium sulfate infusion

The definition of preeclampsia has been refined as the presence of de novo hypertension (> 140 mm Hg systolic or > 90 mm Hg diastolic) after 20 weeks of gestation combined with proteinuria or other maternal organ dysfunction (renal, liver, neurologic). In the absence of proteinuria, thrombocytopenia, liver dysfunction, renal insufficiency, pulmonary edema, and cerebral dysfunction are criteria for preeclampsia. Preeclampsia is associated with intrauterine growth retardation, premature labor, low birth weight, abruptio placentae, and future risk of maternal cardiovascular disease.

Headache, scintillating scotomata or other visual changes, abdominal pain, vaginal bleeding, and decreased fetal movement require immediate reevaluation. Treat severe preeclampsia (blood pressure > 160 mm Hg) with antihypertensive agent (Labetalol, Hydralazine) and IV magnesium sulfate.

Labetalol produces less hypotension and reflex tachycardia than hydralazine, though higher doses cause neonatal hypoglycemia, and long-term use is associated with fetal growth restriction. Hydralazine can lead to maternal hypotension and fetal distress, and requires waiting 20 minutes for a response between IV doses.

Caution is advised against use of Nitroprusside during pregnancy, as there is a risk of fetal bradycardia. While there is no known risk of teratogenicity, there is a risk of cyanide toxicity and fetal death (based on animal data at 25 mcg/kg/min)

Oxytocin generates uterine muscle contraction and is used for labor induction, postpartum hemorrhage, or as an adjunct to abortion.

Correct answer: 93%

If a patient is in respiratory distress, and you cannot seem to get the patient's oxygen saturation above 93% with supplemental oxygen alone, consider the use of positive pressure using one of the following techniques: 

• CPAP
• BiPAP
• Bag-valve device 

If positive pressure is used, there should be at least 5 cm H₂O of positive end-expiratory pressure in the system for any positive-pressure device. 

Correct answer: Interventions to improve the effectiveness of mask ventilation 

The MR. SOPA mnemonic describes interventions to improve the effectiveness of mask ventilation:

• M: Mask is tightly applied to the face
• R: Reposition the head into the "sniffing" orientation
• S: Suction the nares and the pharynx
• O: Open the mouth
• P: Pressure of PPV can be increased to a maximum of 40 cm H₂O
• A: Alternate airway plan and consideration 

The ROMAN mnemonic identifies patients who are at risk for being difficult to ventilate with a BMV device. The mnemonic HEAVEN can help illuminate the choice between video and DL. The Mallampati score describes the ability to see structures in the oropharynx with airway classes from I (easy intubation) to IV (difficult intubation). 

Correct answer: Examine the child's throat

This child has signs and symptoms indicative of acute epiglottitis, which include the acute onset of a high fever, a sore throat, dysphagia, drooling, respiratory distress, dysphonia, and stridor (if near-complete airway obstruction is present). This is a life-threatening medical emergency in which an acute bacterial infection causes the epiglottis to swell and obstruct the airway. You should not examine the child's throat without emergency airway equipment and high-level personnel available for immediate difficult intubation.

Assessing the throat or putting anything into the child's mouth (culturing the throat, taking an oral temperature, using a tongue depressor, etc) could cause a spasm, further blocking the airway. The other answer choices are appropriate interventions to perform during an assessment of the child.

Correct answer: Generalized  

Generalized tonic-clonic seizures are the most familiar and dramatic of the generalized seizures. In a typical attack, the patient suddenly becomes rigid (tonic phase), trunk and extremities are extended, and the patient falls to the ground. As the tonic phase subsides, there are increasing coarse movements that evolve into a symmetric, rhythmic (clonic) jerking of the trunk and extremities. Patients are often apneic during this period and may be cyanotic. They often urinate and may vomit. As the attack ends, the patient is left flaccid and unconscious, often with deep, rapid breathing. Typical attacks last from 60 to 90 seconds. Consciousness returns gradually, and postictal confusion, myalgias, and fatigue may persist for several hours.

Correct answer: Cardiac ablation

WPW Syndrome is a cardiac conduction disorder which causes ECG changes through the development of an accessory electrical pathway, essentially allowing electrical conduction directly from the atria to the ventricles, bypassing the AV node. Classic ECG changes in WPW syndrome are a shortened PR interval accompanied by the presence of delta waves, often described as a "slurring" of the leading edge of the QRS complex. Patients with WPW syndrome tend to be young at time of diagnosis (pre-adolescent or early 20's), and experience symptoms of tachycardia.

The best treatment for WPW syndrome is surgical cardiac ablation to destroy the accessory electrical pathway responsible for the conduction alterations. Vagal maneuvers may be used to try to slow the rate of tachycardia, but are not curative nor considered to be treatment for the syndrome. If patients with WPW develop atrial fibrillation (A-fib), as many do, the A-fib should be treated by the administration of drugs such as procainamide or amiodarone. Use of calcium channel blockers, such as verapamil, is contraindicated in WPW with A-fib, as they may contribute to the development of ventricular fibrillation.

Correct answer: Hypocalcemia

Hypocalcemia, which is indicated by a serum calcium level of less than 8.5 mEq/L, may be caused by a number of factors, including: acute pancreatitis, chronic renal failure, osteomalacia, hypoparathyroidism, malabsorption syndromes, or vitamin deficiency. The presence of hypocalcemia can be assessed for through elicitation of either Trousseau sign or Chvostek sign. To elicit Trousseau sign, a blood pressure cuff is applied and when inflated, tetany of the forearm muscles ensues. Chvostek 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 for through the obtaining of laboratory studies.