IBSC FP-C Exam Questions

Correct answer: Deflate the balloon.

The routine use of pulmonary artery catheters (PAC), such as Swann-Ganz catheters, has decreased in the last few years; however, the medical flight crew may still encounter these devices with some frequency, particularly in patients who have experienced cardiogenic shock, Acute Respiratory Distress Syndrome (ARDS), or other complicated pathology or injury. PACs have several lumens which are utilized for administration of IV fluids or medications, assessment of the patient's fluid volume status, and to assess cardiac output. An additional port, the balloon inflation port, is used to obtain Pulmonary Artery Wedge Pressure (PAWP) readings, by slowly inflating the balloon with 1.25 mLs to  1.5 mLs of air until the pulmonary artery waveform changes to a PAWP reading. 

During air medical transport, the balloon should be deflated due to the concern of overinflation of the balloon as a result of Boyle's Law gas changes, potentially resulting in balloon rupture or inadvertent wedging of the balloon distally in the pulmonary artery. Care should be taken to check the balloon has been deflated before leaving the receiving facility to avoid this. 

The balloon should only be inflated to obtain Pulmonary Artery Wedge Pressure (PAWP), and not for more than two or four respiratory cycles. For this reason, adding or removing small volumes of air is not necessary.

Correct answer: 10 years old and under

The decision to take the necessary steps to establish a patent airway by use of cricothyrotomy is not one that is made lightly, but it may be the decision that saves a life. Cricothyrotomy, the process of opening the airway at the level of the cricoid and thyroid cartilages, may be performed as a surgical procedure, or by use of a needle inserted between the two cartilages. Both the surgical method and needle method may be utilized in emergency situations in adults who have sustained severe facial trauma or who have other upper airway complications, but in the pediatric population, the individual responsible for establishing an airway must consider several physiological factors before deciding which method of cricothyrotomy to use. The cricothyroid membrane is much smaller in children than it is in adults, making it more difficult to safely perform a surgical cricothyrotomy. Additionally, the larynx is more tapered in the pediatric population, again, making safe surgical cricothyrotomy more challenging. 

As a general rule of thumb, recommendations are that surgical cricothyrotomy be performed only on children over the age of 10 years, and that needle cricothyrotomy be performed on children 10 years old and under. 

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. In volume mode of ventilation, check the plateau pressure (Pplat) if PIP suddenly increases. An increase in both PIP and Pplat is highly indicative of a tension pneumothorax. 

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 flight paramedic 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 it is impossible to auscultate during flight in rotor wing aircraft.

Correct answer: Epidural hematoma

The classic signs of epidural hematoma include an initial Loss of Consciousness (LOC) followed by a lucid interval. The patient then develops a headache and again loses consciousness. Increasing Intracranial Pressure (ICP) causes the pupil on the same side as the injury to dilate due to compression of the third cranial nerve. 

Subarachnoid hematoma's classic symptom is a headache the patient describes as "the worst headache of my life." Cerebral contusions occur after traumatic brain injury and do not typically cause loss of consciousness after the initial injury. Subdural hematomas present with a single deterioration in level of consciousness. None of these will cause the initial LOC with a lucid period, then return to LOC that this patient has presented with. 

Correct answer: Bruises in various stages of healing on the legs on a 14-month-old

Bruises are expected on the legs, especially when patients are learning to walk. 

Abuse and neglect of pediatric patients is not as uncommon of an occurrence as it should be. Care providers must be ready and able to identify and report these cases as well as keep their patients safe. Abuse is "improper or excessive action that injures or otherwise harms a child or infant." Neglect is "intentional or unintentional withholding of needed care and support." Abuse can be psychological, sexual, or physical and typically is identifiable by burns, certain fractures, bruises in atypical locations such as the upper back. Patients who are victims of abuse may appear unkempt or malnourished or may appear passive to their environment if under the age of six and aggressive if over the age of six. Behavior should be assessed with looking for neglect.

Correct answer: Controlled Mandatory Ventilation (CMV)

In this setting, all breaths are triggered, limited, and cycled by the ventilator. The patient has no control to initiate their own breaths, and spontaneous triggering is ignored by the ventilator. This setting is used for sedated and paralyzed patients.

Assist-Control ventilation allows the patient to breathe faster than the set rate, and supports patient-triggered ventilation. Synchronized Intermittent Mandatory Ventilation will allow spontaneous respiration, but does not provide ventilatory support to them. In pressure support ventilation, all breaths are triggered by the patient and supported by the ventilator.

Correct answer: Validation and discovery of knowledge that will guide improvements in healthcare practice

The use of research in critical care medicine is a fairly new concept but is critical to the growth of the field. The primary goal of research is to validate existing knowledge while discovering new knowledge so that both can be used to guide healthcare practices and ensure the highest quality of care is being provided. It utilizes systematic review to validate, refine, develop, and expand on clinical knowledge. 

Services that utilize evidence-based medicine and research as the basis for their practice are never stagnant but instead use the research to grow and develop their care plans. Research should not be used as a means for validating employee discipline but to educate and prevent errors from occurring. 

Correct answer: Atropine dose 1 mg and dopamine dose 5-20 mcg/kg per minute

The Adult Bradycardia Algorithm of the 2020 AHA ACLS Guidelines includes the following updates to medication dosages:

• Atropine dose changed from 0.5 mg to 1 mg
• Dopamine dose changed from 2-20 mcg/kg per minute to 5-20 mcg/kg per minute

Correct answer: Seizure activity

The subtle signs of seizure activity may easily be overlooked by the adults responsible for providing care to the infant, as lip smacking and tongue thrusting may be mistaken for early signs of hunger, and fluttering or deviation of the eyes may simply be overlooked. Due to the immaturity of the central nervous system, it is not common for infants to experience the more typical tonic-clonic seizure activity demonstrated by older children or adults. Other subtle signs of seizure activity in the newborn include staring, bicycling movements of the extremities, and apnea.

Correct answer: Bacterial endocarditis

The number one cause of bacterial endocarditis is IV drug abuse; other risk factors for bacterial endocarditis include dialysis, a history of rheumatic heart disease, artificial heart valves, and individuals who are immunocompromised (among other causes). New-onset heart murmurs often herald bacterial endocarditis in conjunction with a sudden onset of infection. Patients may also present with physical findings such as Osler nodes (painful red fingertips) and/or Janeway lesions (red lesions located on the palms and soles). 

Patients with secondary syphilis may present with macules and papules on the trunk, face, and extremities, or with large, partially ulcerated nodules. Patients with AIDS may present with cutaneous lesions of Kaposi's sarcoma. Patients experiencing severe malnutrition may present with various cutaneous findings (rashes, ulcerations, etc.), as well as significant cardiac changes.

Correct answer: Adynamic ileus

In patients that have suffered severe burns, the risk of an adynamic ileus should be considered. The severe fluid depletion in burns causes adynamic ileus, also known as paralytic ileus. A gastric tube should be placed to empty stomach contents, especially if flying at higher altitudes. 

None of the other listed conditions are associated with burns.

Correct answer: Uterine placental insufficiency

Late decelerations are indicative of uterine placental insufficiency, which is associated with Pregnancy Induced Hypertension (PIH), diabetic mothers, smokers, late deliveries, or pre-eclampsia. This is concerning, and the underlying condition needs to be treated. 

Correct answer: IV lines may only be placed in non-burned areas.

Patients who sustain burns begin to lose fluid immediately as a result of capillary fluid leakage due to increased permeability. Extensive plasma leakage from the capillaries can continue for up to three days following the burn, during which time rigorous control of fluid resuscitation should be maintained to prevent the development of hypovolemic shock. Patients should neither be under-resuscitated nor over-resuscitated, and several IV fluid resuscitation formulas specific to burn patients are in use to aid in preventing this. 

Depending upon the extent and severity of the burns, IV access may be difficult to obtain, particularly in the several hours following the initial injury as third-spacing of fluid occurs. The EMS provider who responds to the scene of a burn accident should make attempts to establish two large-bore IVs which are then sutured in place, placing the IV catheters through the burned tissue if no other acceptable IV insertion sites exist. When placing the IVs, blood samples should be obtained to send for studies upon arrival to the facility.

Correct answer: Dalton’s Law

Dalton’s Equation is Total Pressure = P₁+P₂+P₃. This means that the total pressure is equal to the sum of all partial pressures in a mixture. As altitude increases, the partial pressure of oxygen decreases, thus increasing the need for supplemental oxygen. Remember “Dalton’s Gang.“ The total pressure is a sum of partial pressures like a gang is a sum of its members. 

Boyle’s law deals with expansion of gas at changing pressures. Henry’s law defines the ability of a gas to go into or out of a solution. Fick’s law describes how a gas moves across a membrane-based upon its thickness.

Correct answer: The provider in charge of EMS holds a training on pediatric medication administration after a provider accidentally underdoses a child on Ondansetron

The correct answer involves training and support for a provider who miscalculated a medication dose.

Just culture is defined as "a system of shared accountability in which all contributing factors to accidents or sentinel events are considered." It involves identifying behaviors and maintaining accountability without assigning blame. The goal is to anticipate human error and plan for it without punishing providers for their mistakes. A Just Culture involves recognition, support, training, and discipline as needed to address human error.

Assigning blame is not part of a just culture, nor is undue discipline. While discipline is a part of Just Culture, punishment without alteration and improvement of systems is not. 

Correct answer: ETI has an advantage over BVM ventilation in pediatric patients

Managing and stablizing the airway is the first step in the treatment of the majority of pediatric patients. Failure to control the airway can lead to hypoxia, respiratory failure, and cardiac arrest. There are multiple interventions that can be done to maintain airway patency, ranging from basic to advanced life support techniques. Patients should be positioned by placing them in the sniffing or neutral position, depending on spinal motion restriction. A jaw thrust, oropharyngeal airway, and suctioning can also be used. The best airway in a pediatric patient is one that can be ventilated or oxygenated, so bag-valve-mask ventilations should never be overlooked in favor of EndoTracheal Intubation (ETI). Studies have shown that BVM ventilation may be just as effective and safer than intubation when transport times are short or during out-of-hospital resuscitation. 

When considering more advanced airway techniques, the appropriate technique must be selected based on the patient's age. Surgical cricothyrotomy should not be performed on children under 10; instead, needle cricothyrotomy should be used. Nasal intubation should not be done on patients under 12 due to the acute angle of the glotties. When necessary, rapid sequence intubation is supported by the National Association of EMS Physicians and other recognized medical organizations. Care should be taken to ensure drug dosing is appropriate for the patient's weight and that the patient's heart rate and oxygen saturation levels are closely monitored for deterioration. 

Correct answer: Administration of packed red blood cells, plasma, and platelets for resuscitation, limiting infusion of crystalloid fluids

Damage control resuscitation is a concept for treating victims of hemorrhagic shock which came into existence through an extension of what is known as damage control surgery. It involves the administration of a carefully controlled ratio of blood products, including packed red blood cells, plasma, and platelets (1:1:1) early during resuscitation, oftentimes even at the scene of the trauma, while limiting the administration of crystalloid fluids.

All of the other options in this scenario are considered part of damage control surgery, which should follow the administration of damage control resuscitation. The overall goal of all the damage control interventions is to bring about cessation of bleeding and provide hemodynamic stability for 1 to 2 days prior to definitive repair of injury.

Correct answer: Medical air transport helicopter landing zone was established too far from the accident scene

When participating in a medical rescue or transport at the scene of an incident, the risk of the rescue and/or transport crews being involved in a secondary incident (accident) is high. All personnel who respond to on-scene incidents need to be thoroughly trained in management of an accident scene, not only to ensure the victims are safely cared for, but also to keep the members of the rescue and transport crews safe. 

A lack of appropriate training, being distracted by details at the scene (lack of awareness of the situation), a failure to ensure traffic has been diverted appropriately to provide an ample buffer in which to work, poor use of lighting at the accident scene, incorrect usage of rescue or safety equipment, or positioning the medical air transport helicopter landing zone too close to the scene of the accident are all common potential causes of secondary incidents.

Correct answer: Cover the wound with an occlusive dressing.

Upon finding a sucking chest wound, the flight paramedic should cover the wound with an occlusive dressing to prevent air from entering the pleural cavity. Most often, this is achieved by placing the gloved hand over the wound, then applying a commercial chest seal. 

Covering the wound falls under the breathing portion of the initial ABC assessment and supersedes circulatory intervention. While chest tube placement is the definitive treatment for pneumothorax, it is not the appropriate intervention to perform when doing the initial assessment. Needle decompression is only indicated if the patient has the wound covered and shows signs of developing a tension pneumothorax. Bag-valve mask ventilation is only indicated in the initial assessment if the patient is having a change in respiratory rate or quality which is not the case with this patient. 

Correct answer: Choanal atresia

Choanal atresia is one of the most common congenital upper airway anomalies that may be encountered in pediatric airway compromise. In choanal atresia, there is stenosis of the posterior nostrils which may cause full or partial obstruction of breathing. This is particularly problematic in the neonates, as they are considered to be obligate nose breathers, and will quickly develop respiratory distress if their ability to breathe through the nose is obstructed. Children with syndromes such as Trisomy 18 and 21, Apert, and Crouzon have high associations with choanal atresia, as does CHARGE association. If not corrected shortly after birth, these children will require emergency placement of an oral airway to maintain their airway. Cases of bilateral choanal atresia are typically discovered at birth when the neonate rapidly develops respiratory distress due to inability to breathe.

An omega-shaped epiglottis is seen in laryngomalacia and may cause inspiratory stridor. Pierre Robin is a group of developmental abnormalities that can lead to airway obstruction, including a small chin and posterior positioning of the tongue. While all of these may be seen in neonates, choanal atresia is the most commonly found.