IBSC FP-C Exam Questions

Correct answer: Air Medical Resource Management (AMRM)

Within both commercial aviation and military aviation (specifically the U.S. Air Force), a process referred to as Crew Resource Management (CRM) exists to reduce the risk of aviation error and stress by involving all members of the flight crew in mission planning and safety and decision-making regarding the proposed flight.

Within medical air transport, an identical process has been adopted and is referred to as Air Medical Resource Management (AMRM). All members of the air transport crew, including the pilot and the clinical team members, meet to discuss all potential assignments, and all members have an equal say in accepting or declining an assignment based on the available information. This process was adopted after several severe accidents occurred during which solely the pilot was allowed to decide on whether to proceed with the assignment. The AMRM requires the entire crew to use good communication and problem-solving skills, as well as teamwork, when evaluating all the components of a potential assignment.

Correct answer: Rising glucose levels cause osmotic diuresis.

The severe hyperglycemic state of Diabetic Ketoacidosis (DKA) causes significant fluid losses to create a fluid volume deficit, often in the range of 6 liters. As blood glucose levels rise, the kidneys are unable to continue to absorb the glucose, as the levels exceed the threshold, causing rising levels of glucose to then be excreted in the urine. Osmotic diuresis develops, in which water loss then increases due to elevated urine glucose levels. It is this process that causes patients to experience polydipsia (increased thirst) and polyuria (increased urination). The cycle of rising glucose and increasing fluid loss is worsened by the hyperosmolar state, as fluid is a necessary component of decreasing blood glucose. The administration of fluid resuscitation can result in a drop in blood glucose by 20 mg/dL to 50 mg/dL per hour without the additional administration of insulin.

Correct answer: 6

The equation for ETT (Endotracheal Tube) in pediatric patients is (16+ age in years) / 4. This patient is 9 years old. We would calculate ETT size as follows:

16+9 =25

25 / 4 = 6.25

We would round this patient's ETT size down to 6.

Correct answer: Septic shock

The patient experiencing septic shock is most likely to undergo significant shifts in the white blood cell (WBC) count as a result of the overwhelming infection. Most often, WBC count will rise in the early stages of sepsis as the body attempts to fight off the infection. If sepsis progresses and the patient moves into a state of septic shock, leukopenia (WBC < 4,000) may develop as a result of destruction of WBCs at a more rapid rate than the production of new WBCs.

Anaphylactic shock is caused by a release of histamine due to allergen exposure or an anaphylactoid reaction. Neurogenic shock occurs when there is a loss of sympathetic tone due to spinal cord or brain trauma, or a pharmacologic agent. Cardiogenic shock is caused by failure of the heart to pump effectively. None of these will have a significant effect on white blood cell count.

Correct answer: Electromagnetic interference may present an issue when using personal NiPPV devices on an aircraft

Noninvasive Positive Airway Pressure, or NiPPV, is becoming more common in home and acute care settings in the hospital. When patients have their own personal NiPPV devices, aviation protocols regarding electromagnetic interference must be considered and followed. 

While the use of NiPPV during transport has not been clearly studied, it is becoming more likely that critical care transport crews will have patients on NiPPV ventilators. Regardless of how well patients may be responding to NiPPV ventilation in hospital, transferring to the transport ventilator often presents a problem for these patients. Transport ventilators are not as readily able to maintain the necessary inspiratory flow rates, leading to increased work of breathing and intubation. The necessity for high flow rates and fast battery depletion presents a challenge for transport crews with limited space and patients who now require extra oxygen and batteries as well as alternative power sources.

Correct answer: 1 liter to 2 liters

Isolated skeletal orthopedic injuries and fractures, while not typically considered an emergency, can result in the development of life-threatening complications due to the potential for significant blood loss and hemorrhage as a result of the injury. In addition, if adjacent organs or soft tissues are also injured in the trauma, the potential for significant injury, disability, and death goes up exponentially. Isolated skeletal fracture carries with it the risk of hemorrhage due to the vascular nature of the bone itself, as well as the potential for damage to the nearby vessels. 

Rib fractures can result in up to 125 mLs of blood loss, fractures of the forearm bones (radius and ulna) can result in a blood loss between 250 mLs to 500 mLs, bleeding from a humerus fracture can range between 500 mLs to 750 mLs, an isolated single femur fracture can result in a blood loss between 1 liter to 2 liters, and a pelvic fracture typically results in blood loss greater than 1 liter. EMS providers responding to the scene of isolated skeletal fractures should be prepared to both assess for and manage signs of potential hemorrhage and prevent the development of hemorrhagic shock, in addition to managing the orthopedic injury.

Correct answer: Pneumocephalus

A depressed skull fracture, especially if the dura mater was torn and the sinuses are involved, can introduce air into the intracerebral space. Once the pneumocephalus is under tension, symptoms will start to develop. 

Patients with skull fractures that are open or depressed, involve a sinus, or are associated with pneumocephalus should be given antibiotics. A skull fracture that is depressed by more than the thickness of the skull usually requires operative repair. The flight medic will need to instruct the pilot to fly at a lower altitude to ensure there is no air expansion.

Correct answer: The hypoxic stage

The pathologic progression of hypoxia is divided into four stages: the indifferent stage, the compensatory stage, the disturbance stage, and the critical stage. 

During the indifferent stage, patients typically retain the reasoning ability but may exhibit a slight increase in both heart rate and breathing. This stage may begin at sea level, and progress to an altitude of 10,000 feet. Changes in night vision may occur at 5,000 feet.

The compensatory stage may occur between 10,000 to 15,000 feet, and individuals typically experience significant increases in heart rate and breathing (as the body attempts to protect against hypoxia), and slowing of judgment may occur.

Between 15,000 and 20,000 feet, the disturbance stage of hypoxia occurs. Individuals typically exhibit slurred speech and significant impairments in judgment, making the individual appear drunk.

The final stage of hypoxia is the critical stage, which takes place between 20,000 to 30,000 feet. Individuals in the final stage of hypoxia are at extreme risk of death.

Correct answer: Orbital blowout fracture

Orbital blowout fractures most commonly occur due to blunt force trauma to the eye. A serious complication of an orbital blowout fracture is the presence of an entrapped inferior rectus muscle, which can be identified by the absence of consensual movement when the patient is asked to look up. The muscle (or other orbital material, such as orbital fat) becomes entrapped in the fractured area when the traumatic blow to the orbital region causes a sudden, massive increase in the intraorbital pressure, pushing the orbital material into the fractured area. When the increase in orbital pressure is released (withdrawing of the closed fist), the sudden decrease in pressure results in the inferior rectus muscle becoming pinched or entrapped within the orbital rim fracture. Patients with entrapped inferior rectus muscle may also complain of double vision. The presence of an entrapped inferior rectus muscle constitutes a surgical emergency.

Pneumocephalus occurs when air enters the cranium through a fracture. Le Fort fractures involve the maxilla and are categorized based on location and extent of the fracture. Subdural hematomas occur when blood collects between the arachnoid mater and the dura. None of these would be expected to cause a change in eye movement as seen in this patient. 

Correct answer: Henry’s Law

Henry’s Law explains that increased pressure increases the solubility of a gas. When pressure is suddenly decreased, as when a diver surfaces too fast, the gas solubility also decreases and comes out of the blood into the tissues. 

Boyle’s Law describes gas volume changing in relation to gas pressure. Fick’s Law describes that increasing the PaO₂ will increase oxygenation. Charles’ Law relates gas temperature to its volume.

Correct answer: Administer a mineralocorticoid steroid

The standard components of care for patients experiencing septic shock include the administration of intravenous fluids to establish euvolemia, the administration of vasopressor medications to obtain and maintain a MAP (Mean Arterial Pressure) of ≥ 65 mm Hg, and the administration of the most appropriate antimicrobial agent to treat the infectious process which contributed to the development of sepsis. Norepinephrine is most frequently used to maintain the MAP; if the administration of one vasopressor agent does not adequately support MAP, the addition of a second-line vasopressor, such as vasopressin, may be warranted. 

In patients who require the administration of two vasopressor agents, the additional administration of a mineralocorticoid steroid is recommended and has been found to be beneficial.

Correct answer: IBW= 75.3 kg; V_t= 377

The current protocol for treating ARDS comes from the NIH NHLBI ARDSnet Protocol which was specifically developed in an attempt to more effectively treat the complicated course of ARDS. The ARDSnet Protocol uses a sex-based Ideal Body Weight (IBW) formula to determine the appropriate V_t delivery range for the patient. IBW is calculated for patients by use of the following formulas:

• Male patients IBW = 50 + 2.3 [height in inches - 60]
• Female patients IBW = 45.5 + 2.3 [height in inches - 60]

The patient in our scenario had a height of 71 inches and was male.  Inserting this number into our formula we calculate the following:

• Male patient IBW = 50 + 2.3 [71 - 60]
• IBW = 50 + 2.3 [11]
• IBW = 50 +25.3
• IBW = 75.3 kg 

The ARDSnet Protocol recommends the delivery of a low V_t,, typically delivered between 4 mLs to 8 mLs per IBW. In this scenario, we assumed a V_t delivery rate of 5 mLs/IBW.

So we then multiply 5 mLs x the PBW of 75.3 kg, to get a recommended V_t of 376.5, which we then round to 377.

Correct answer: pH = 7.14, CO2 = 62 mm Hg, PaO2 = 59 mm Hg

Respiratory Failure (RF) is diagnosed when the patient loses the ability to ventilate adequately or to provide sufficient oxygen to the blood and systemic organs. RF is defined as: PO₂ < 60 mm Hg. It is frequently accompanied by ventilatory failure (CO₂ > 50 mm hg). Urgent resuscitation of the patient requires airway control, ventilatory management, and stabilization of the circulation while providing treatment for the underlying cause.

Correct answer: The 4th or 5th intercostal anterior axillary space on the affected side

Treatment of a spontaneous pneumothorax is dependent upon the degree of severity of the pneumothorax and the patient's related symptoms. Some patients may be asymptomatic or have very mild symptoms, which allows for a period of hospitalized observation and fairly rapid return to home, while other patients may be extremely symptomatic and require intervention. Typically, for a pneumothorax in which less than 20% of the lung is involved, no invasive treatment is necessary; patients may still require a period of bed rest and the administration of supplemental oxygen to aid in recovery. 

When invasive treatment is indicated, a needle decompression is often the best choice, with the needle typically inserted at the second intercostal space on the affected side. In patients who are obese, the preferred site for needle decompression is the 4th or 5th intercostal anterior axillary space on the affected side. Some studies have shown that the anterior site is preferred and results in better outcomes than the anterior site. Always follow local protocols.  

Correct answer: 3 fingers in the mouth opening, 3 fingers of mandible length, 2 fingers from hyoid bone to thyroid notch

When assessing a patient for a difficult airway, the LEMONS mnemonic can be used. The E in LEMONS stands for Evaluate 3-3-2. This evaluation is done using the provider's fingers with the first 3 presenting an ideal mouth opening of three fingers wide or more. The second 3 indicates that the length of the mandible from the tip of the chin to the hyoid bone should be three fingerbreadths or more. The 2 is for two fingerbreadths from the hyoid bone to the thyroid notch. 

Correct answer: Initiate chest compressions 

Resuscitation of a neonate is required in up to 10% of deliveries of term or late-term deliveries. Initial resuscitation efforts should include stimulation of the infant through vigorous drying of the head and body, followed quickly by suctioning of the mouth and nares (in that order) if the infant's condition does not improve spontaneously. If suctioning of the mouth and nares does not result in the desired spontaneous respiration and improvement in the neonatal condition, then Positive-Pressure Ventilation (PPV) should be administered for 30 seconds at a rate of 40 to 60 breaths per minute, followed by assessment of the heart rate. If the heart rate is less than 60 beats per minute despite effective PPV, then chest compressions should be initiated with a compression-to-breath ratio of 3:1. Chest compressions should be delivered by use of the thumbs-encircling-hands technique, which is the currently recommended method. Resuscitation efforts should be temporarily stopped after 60 seconds to reevaluate; if the heart rate is above 60 beats/minute, chest compressions can be stopped at that time, but if the heart rate remains below 60, epinephrine should be administered.

If the medical transport team is unable to deliver effective PPV, a laryngeal mask airway device may be inserted to improve ventilation.

Correct answer: Wearing NVGs improves safety by multiplying light up to 5,000 times.

The use of Night Vision Goggles (NVGs) by Helicopter Emergency Medical Service (HEMS) crews has increased rapidly in the last few years after many years of usage by military pilots. NVGs work through the use of an electronic system that amplifies available light by up to 10,000 times, lending itself to significant improvements in night transport safety. However, there is some added weight to the flight helmet as well as a decrease in depth perception and peripheral vision.

The use of rotating strobe-type lights on the ground at Landing Zones (LZ) during taking off and landing should be minimized, and lights should never be shined directly at the aircraft during night transport missions, and overhead lighting of LZs is not advisable, as it tends to erode the perimeter lighting used to mark off the LZ. It is most common for both the pilot and members of the medical team to wear NVGs during night transport missions.

Correct answer: No access to a specialized maternal-fetal transport team

While not all pregnant patients requiring transport truly need a specialized maternal-fetal transport team in order to be safely transported, general transport teams should be required to participate in regular/annual specialty training in the high-risk obstetrical care and transport of pregnant patients. Team members should also receive training in neonatal resuscitation. 

Certain situations should preclude the transport team from agreeing to transport a pregnant patient. These include: the inability to stabilize the patient's condition, such as during third-trimester bleeding; the imminent delivery of the fetus, particularly if the transport vehicle interior does not allow the medical team members to have direct access to both patients; concern of fetal well-being or poor fetal status; lack of experience, or no team members trained in care and transport of pregnant patients; and poor weather conditions that may delay or prolong transport of the patient. While care by a specialized maternal-fetal transport team is ideal, lack of access to one is not a contraindication to the transfer of pregnant patients.

Correct answer: Assure VE of 4-8 L/min and keep Pplat 25-30 mmHg

Use caution in exceeding 8ml/kg of Ideal Body Weight (IBW) for tidal volume settings. Higher amounts may cause Ventilator Induced Lung Injury (VILI). If the patient is receiving adequate tidal volumes, the Plataea Pressure (Pplat) should be 25-30 mmHg. Adjust the respiratory rate (F) to achieve a minute ventilation (VE) of 4-8 L/min and reassess every 15 minutes for improvement. While SpO₂ and EtCO₂ levels are important parameters to consider for ventilated patients, they may not reflect VILI as promptly as Plat.

Correct answer: 92% to 98%

The 2020 Post-Cardiac Arrest Care Algorithm was updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension; as such, changes include a target SpO₂ of 92% to 98%.