test 1 FB

Question 1

A patient is demonstrating a sudden elevated PIP with an elevated Pplat. The most likely cause is?

Pulmonary hypertension
Asthma
Acute respiratory distress syndrome (ARDS)
Tension pneumothorax

Answer 1

Tension pneumothorax

An elevated PIP with an increased Pplat is a direct indication of lower airway involvement and alveolar health. Think tension pneumothorax and treat accordingly.

Question 2

What is the normal range for a pulmonary capillary wedge pressure (PCWP)?

Answer 2

The normal range for PCWP is 8-12 mmHg. PCWP is a direct reflection of left atrial preload as well as left ventricular end diastolic pressure.

Question 3

A 14-year-old patient is currently being treated for diabetic ketoacidosis (DKA). There is a noted decrease in mental status with associated lethargy, and their Glasgow coma scale (GCS) score is now 7, dropping from the previous 14. The neurological changes would most likely indicate which situation?

Acute ischemic stroke
Cerebral edema
Hyponatremia
Diabetes insipidus

Answer 3

The sudden neurological changes is a sign that the glucose has dropped too quickly, and cerebral edema has manifested secondary to this.

Question 4

Two criteria for determining respiratory failure

Answer 4

a PaCO2 > 50 and associated hypoxia with the PaO2 < 60.

Question 5

A 4-year-old with a past medical history of asthma is in respiratory distress and appearing anxious. Current vitals: BP 80/32, HR 130, RR 38. Crackles are auscultated throughout the lungs. The patient is placed on the monitor, and sinus tachycardia is noted. Upon review of current arterial blood gas results, you would anticipate which of the following findings?

Decreased pH, increased PaCO2, normal PaO2
Increased pH, decreased PaCO2, normal PaO2
Decreased pH, increased PaCO2, decreased PaO2
Increased pH, decreased PaCO2, decreased PaO2

Answer 5

Decreased pH, increased PaCO2, normal PaO2

This patient is presenting with an acute respiratory obstructive process. This presentation and management are about optimizing the patient’s ability to exhale. The ABGs would most often show an uncompensated respiratory acidosis, with a normal or elevated PaO2. The patient will become hypoxic if their minute ventilation (VE) becomes deficient, and gas exchange is decreased.

Question 6

You are caring for a pediatric burn patient weighing 20kg with second- and third-degree burns involving 45% total burn surface area (TBSA). The injury occurred two hours previously, and the referring facility administered 300 mL of LR thus far. Using the consensus formula, what would the fluid resuscitation amount be for the first 8 hours, taking into account volume already administered?

1,050 mL; 175 mL/hr
1,350 mL; 169 mL/hr
1,400 mL; 180 mL/hr
1,800 mL; 200 mL/hr

Answer 6

1,050 mL; 175 mL/hr

The consensus formula is the new standard in burn fluid resuscitation management, with ranges from 2-4 mL/kg. The range is based on the following: 2 mL/kg – adults, 3 mL/kg – pediatrics, and 4 mL/kg – electrical burns. This question involves a pediatric patient and is determined as: 3 mL/kg x TBSA = volume/24 hours (3 x 20 x 45 = 2,700 mL/24 hours). Administer half of the total fluids during the first eight hours post-burn. The question also says to take into account the volume already administered. Therefore, 1,350mL should be administered in the first eight hours and the patient has already received 300 mL, so 1,050 mL is left to administer over the next six hours (it has been two hours since the injury).

Question 7

Which of the following conditions would put a patient at the LEAST amount of risk for acute respiratory distress syndrome (ARDS)?

Myocardial infarction
Sepsis
Inhalation of smoke
Chest injury

Answer 7

Myocardial infarction

Sepsis is the most common indirect lung injury that leads to the development of ARDS, secondary to the release of inflammatory cytokines and the breakdown of the alveolar-capillary membrane. Inhalation of harmful substances, such as smoke or chemical fumes, severe pneumonia, and head or chest injury, can also lead to the development of ARDS.

Question 8

A patient has left systolic failure and a cardiac index (CI) of 1.3. Which medication would improve contractility?

Dopamine
Vasopressin
Epinephrine
Dobutamine

Answer 8

Dobutamine has primary inotropic effects and will optimize left systolic function. This is coupled with the medications ability to reduce SVR, which in turn reduces the outflow pressure that the left ventricle has to contract against.

Question 9

In a patient experiencing status asthmaticus, all of the following are expected findings EXCEPT for?

Hypocapnia
Dehydration
Respiratory acidosis
Decreased cardiac output

Answer 9

Hypocapnia

You would expect to see hypercapnia in these individuals, along with respiratory acidosis from the eventual hypoventilation caused by respiratory muscle fatigue. Dehydration occurs secondary to insensible water loss from the respiratory tract during tachypnea. Decreased cardiac output occurs as the venous return to the right ventricle is reduced from the elevated intrathoracic pressures.

Question 10

Indications for intubation of the asthmatic patient include which of the following?

Vital capacity above the level of the tidal volume
pH >7.2
PaO2 < 80 mmHg
pCO2 >55 mmHg

Answer 10

pCO2 >55 mmHg

One indication used in determining if an asthmatic patient needs to be intubated is ventilatory failure. A PaCO2 >50 mmHg is an indication of this. These patients have extreme fatigue and cannot blow off the excess CO2 that has accumulated. Often, these patients will not have a decrease in their oxygenation status. If they do suffer from a decreased oxygenation status, it is most often associated with poor minute ventilation and a lack of moving air. Once the ventilatory failure is corrected, then the oxygenation status will recover quickly.

Question 11

What is the most common cyanotic congenital heart defect in the neonate population?

Patent ductus arteriosus (PDA)
Ventricular septal defect (VSD)
Aortic stenosis
Tetralogy of Fallot (TOF)

Answer 11

Tetrology of Fallot is the most common cyanotic heart defect and is often called “blue baby syndrome.” “Tet babies” suffer from four different heart defects, which include: pulmonary stenosis, overriding aorta, right ventricular hypertrophy, and ventricular septal defect. These babies will be dependent on ductal flow and need to have prostaglandin administration to maintain patency of the ductus arteriosus.

Question 12

The hallmark indicator of rhabdomyolysis in a hyperthermic patient is?

Increased blood urea nitrogen (BUN)
Altered mental status
Hyperthermia
Elevated creatine kinase (CK)

Answer 12

Elevated creatine kinase (CK)

The earliest lab value that identifies muscle damage and the release of myoglobin is the CK level. Creatine kinase is an enzyme that is present in all muscles of the body and is a catalyst in the energy conversion process. CK used in the body are of two types – for the muscles and the brain.

Question 13

All of the following contribute to poor variability EXCEPT:

Fetal hypoxia
Extreme prematurity
Nuchal cord
Smoking by the mother

Answer 13

Nuchal cord

With any neonate suffering from poor variability, always think about anything that causes hypoxia or prematurity.

Question 14

An 80-kilogram patient diagnosed with an acute myocardial infarction is now suffering from aspiration pneumonia. Vital signs: BP 110/60, HR 110, R 16/assisted. Dopamine is infusing at 10 mcg/kg/min. Current ventilator settings are: SIMV 20, PC 22, Vte 462, (f) 26, PEEP 3 and FiO2 0.6. Current ABG: pH 7.34, PaCO2 50, HCO3- 19, PaO2 50, and SpO2 90%. What would your next treatment priority be?

Give a fluid bolus of 250 mL of Lactated Ringer’s
Increase the FiO2 and PEEP to 5 cmH2O
Wean the dopamine to 7.5 mcg/kg/min
Continue transporting with no additional interventions

Answer 14

This patient is suffering from a low PaO2 and lower than the desired SpO2. All other ventilator settings are appropriate. By increasing the FiO2 and PEEP, oxygenation increases the quickest. Adjusting the rate and tidal volume are ventilation maneuvers and do not change the oxygenation.

Question 15

The patient’s pulmonary artery (PA) catheter is exhibiting a large defined waveform with an obvious notch on the left side of the waveform. The distal tip is most likely located in the:

Right atrium (RA)
Pulmonary artery (PA)
Pulmonary capillary wedge position
Right ventricle (RV)

Answer 15

Right ventricle (RV)

When transferring a patient with a PA catheter, always verify placement and be diligent about monitoring the waveforms. A change in shape from a PA waveform to a waveform exhibiting a large notch on the left side of the waveform means that the catheter has migrated back into the right ventricle. This is very important to identify quickly and treat. Treatment includes pulling the catheter back into the right atrium. Never advance it forward.

Question 16

A patient has a past medical history of hypertension, hypertriglyceridemia, coronary artery disease, and diabetes mellitus and is complaining of chest pain. Current vitals are: BP 152/90, HR 82, and RR 22. Upon auscultation, there is a noted split S2 on expiration and single S2 on inspiration. A 12-lead ECG is obtained and it has a normal P wave with each QRS complex, and a PR interval measuring 0.2 seconds. The QRS complexes measure 0.14 seconds and are positive in leads V5 and V6, and negative in V1. What do these findings indicate?

Second degree heart block - type I
Left bundle branch block
Right bundle branch block
Unstable ventricular tachycardia

Answer 16

Left bundle branch block

A LBBB will cause widened QRS complexes greater than 0.12 seconds and a positive R wave in leads V5 and V6. It will also cause a negative QS wave in V1. A LBBB will also cause a paradoxical splitting of S2, which causes the split on expiration but not on inspiration. It is considered paradoxical because it is opposite of a normal split S2, which is split on inspiration but not on expiration.

Question 17

Dalton’s law demonstrates that the concentration of O2 at 18,000 feet mean sea level (MSL) is 21%. If the atmospheric pressure at 18,000 feet MSL is 380 torr, what would the partial pressure of oxygen be at that altitude?

14 torr
34 torr
45 torr
79 torr

Answer 17

79 torr

Dalton’s law (or Dalton’s gang) essentially states that as altitude increases, the concentration of O2 remains the same. However, because of the decreased atmospheric pressure at altitude, the partial pressure (PaO2) of oxygen decreases as altitude increases. For example, a ziplock bag is filled with oxygen molecules. At sea level, the oxygen molecules would have a greater pressure exerted against them (760 torr). Whereas at 18,000 feet MSL, the same concentration of oxygen molecules would only have 380 torr of pressure exerted against them; thus lowering the partial pressure of oxygen. The PaO2 at sea level is 159 torr. However, the PaO2 would only be 79 torr at 18,000 feet. See the example below.

At sea level: 760 torr x 0.21 = PaO2 of 159

18,000 feet MSL: 380 torr x 0.21 = PaO2 of 79

Question 18

Approximately 15 minutes out from the receiving facility, a severely hypothermic patient becomes pulseless and apneic. Current esophageal temperature probe reads 28°C. Cardiac medications should be withheld until the core temperature reaches what degree?

32°C
30°C
34°C
28°C

Answer 18

30°C

With core temperatures below 30ºC, the medication pharmacodynamics and mechanism of action will not work, thus causing the medication to build up within the system. This is why all medications and defibrillation are withheld until the core temperature reaches 30°C.

Question 19

You are transferring a patient that was involved in a head-on collision. They are currently on a non-rebreather at 15 L/min but are demonstrating signs of hypoxia. Current vitals: BP 100/70, HR 139, RR 28 (shallow and rapid). Assessment reveals a GCS of 10; skin is pale, dry and warm. The patient’s current hemoglobin and hematocrit are 7 and 19 with a current urine output of 0.5 mL/kg/hr for the past three hours. What type of shock is this patient experiencing?

Stagnant hypoxia
Hypemic hypoxia
Hypoxic hypoxia
Histotoxic hypoxia

Answer 19

Hypemic hypoxia

When identifying potential types of shock in trauma patients, always consider hemorrhage and potential secondary problems associated with losing significant amounts of blood. Hemoglobin concentrations are essential for oxygen carrying capacity and should be monitored closely. The patient can become hypoxic quickly, and anaerobic metabolism will ensue.

Question 20

The team is caring for a five-year-old, 20-kilogram victim of a motor vehicle accident. The patient’s blood pressure was 64/43 mmHg and received a 400 mL bolus of IV fluid. The next blood pressure obtained is 72/50 mmHg. The best action is to:

Administer the remaining 600 mL of the 1L bag of IV fluid
Notify the receiving facility of the ETA
Provide the patient with low flow oxygen and monitor for hypoxia
Administer another 400 mL bolus of IV fluid

Answer 20

Administer another 400 mL bolus of IV fluid

In this scenario, it is important for the flight team to recognize that this patient requires an additional fluid bolus. The target MAP for a five-year-old patient is at least 60 mmHg with a systolic blood pressure target minimum of [70 + 2(age)]. In this case, the target minimum systolic blood pressure would be 80 mmHg.

Question 21

The primary problem with disseminated intravascular coagulation (DIC) is?

Deactivation of thrombin
Clotting
Platelet function failure
Bleeding

Answer 21

Clotting

DIC occurs from overstimulation of the clotting cascade resulting in clots being formed in the body’s small blood vessels. These clots lead to loss of blood flow past that point leading to ischemia and eventual organ failure. Although these patients are at increased risk of bleeding due to the excessive clotting using up all the body’s platelets and clotting factors, the primary problem is with clotting.

Question 22

When administering high concentrations of oxygen to alleviate hypoxic hypoxia, which component of which gas law is being altered?

Partial pressure; Boyle’s law
Partial pressure; Charles’s law
Solubility; Graham’s law
Solubility; Henry’s law

Answer 22

Solubility; Henry’s law

Giving high concentrations of O2 is affecting Henry’s law and the solubility of gaseous diffusion. Graham’s law affects the active process of diffusion, which is moving molecules from a higher concentration to a lower concentration. Henry’s law affects the pressure of the gas over the solution, which translates to overall solubility of the gas in the solution.

Question 23

Your patient is suspected of having toxic shock syndrome (TSS). Which of the following symptoms would you anticipate?

Hypothermia
Cardiac arrhythmias
Hypertension
Skin rash

Answer 23

Skin rash

The pathophysiology of TSS is related to septic shock. It is typically characterized by fever, hypotension, and skin rash.

Question 24

Which type of fire extinguisher is used inside the aircraft in the air medical environment?

CO2
Halon
Foam
Water

Answer 24

Halon

Halon fire extinguishers are rated for class “A” (common combustibles), “B” (flammable liquids), and “C” (electrical fires). Halon is the best for an enclosed space because it does not consume all available oxygen as a CO2 extinguisher does. Both Halon and CO2 extinguishers are considered “clean agents” and will not leave a residue, thus being the best for electronics, computers, or other devices that could be damaged with water or foam.

Question 25

You are transporting an intoxicated patient who was involved in a motor vehicle collision and sustained a closed femur fracture. Which types of hypoxia-related problems may occur in flight?

Hypoxic, hypemic
Histotoxic, hypemic
Stagnant, hypemic
Hypoxic, stagnant

Answer 25

Histotoxic, hypemic

Histotoxic hypoxia occurs when metabolic disorders or poisoning of the cytochrome oxidase enzyme system results in a cell’s inability to use molecular oxygen. Specific causes of histotoxic hypoxia include respiratory enzyme poisoning or degradation and the intake of carbon monoxide, cyanide, or alcohol. The hypemic hypoxia is due to the blood loss from the femur fracture.

Question 26

The transport team is taking care of a 32-week post-conceptual age neonate with hyaline membrane disease. The patient is currently being ventilated on high-frequency oscillatory ventilation. The ventilator settings have been established as amplitude 25 cmH20, frequency 8 Hertz (Hz), mean airway pressure 8 cmH20, 40% FiO2. After your assessment, you note that the chest oscillation has diminished. What is the next best action?

Increase the amplitude
Increase the frequency level
Increase the mean airway pressure
Increase the FiO2

Answer 26

Increase the amplitude

When high-frequency ventilation (HFV) is being applied to a patient, it can be difficult to assess the lungs as with an average patient continually. Assessment is guided by visually inspecting for the adequacy of what is called “chest wiggle.” When applying HFV, the frequency will either increase or decrease ventilation. A lower frequency will increase ventilation and increase the amplitude, thus causing an increase in the flow of gas.

Question 27

Identify the underlying problem based on the following parameters:

CVP 2, PCWP 7, CI 1.5, SVR 1800

Cardiogenic shock
Septic shock
Hypovolemic shock
Neurogenic shock

Answer 27

Hypovolemic shock

Anytime the CVP is low, always think preload issues. The cardiac index is also low with an associated high SVR which indicates a volume or hypovolemic issue.

Question 28

Which medication is recommended for sedation of a patient in an obstructive shock state secondary to pulmonary hypertension?

Ketamine
Etomidate
Fentanyl
Versed

Answer 28

Ketamine

Ketamine has bronchodilating properties and is useful in treating patients that may have underlying respiratory problems. Using IV ketamine results in a dissociative state without significant respiratory depression. Bronchodilation begins within minutes of administering ketamine and lasts approximately 20-30 minutes after cessation of the medication. Additionally, ketamine has great analgesic effects along with sedative effects and is very good with patients that have hemodynamic instability.

Question 29

HELLP syndrome is characterized by what?

Hemolysis, elevated liver enzymes, and low platelets
Hypertension, elevated lipase, and low protein
Hypertension, elevated liver enzymes, and low platelets
Hemolysis, elevated lipase, and low protein

Answer 29

Hemolysis, elevated liver enzymes, and low platelets

HELLP syndrome is a life-threatening OB complication. It can occur during the later stages of pregnancy or even after childbirth. It includes hemolysis, elevated liver enzymes, and low platelet count. Delivery of the fetus is the cornerstone of therapy in most situations.

Question 30

Common causes of an elevated pulmonary artery pressure include all of the following except?

Right ventricular failure
Mitral valve regurgitation
Left ventricular failure
Mitral valve stenosis

Answer 30

Right ventricular failure

Elevated PA pressures are a direct indication of afterload (left atrial and left ventricular end-diastolic pressures). Mitral valve regurgitation, mitral valve stenosis and left ventricular failure are all primary aspects of afterload and left ventricular function.

Question 31

The team is caring for a 36-week pregnant patient who experienced an eight-foot fall, landing on the right side. Due to physiologic changes during pregnancy, this patient will present with:

Signs of shock may be delayed
Signs of shock will be minimal
Signs of shock immediately after the fall
Signs of shock 24-48 hours after the fall

Answer 31

Signs of shock may be delayed

It is important to remember that due to physiologic changes related to pregnancy, signs of shock may be delayed. This delay is due to the persistently elevated heart rate and increased blood volumes in the pregnant patient.

Question 32

The flight team is transporting a pediatric patient in respiratory distress via fixed-wing aircraft. Their work of breathing has increased as they transition to level flight. According to Boyle’s law, what intervention might improve their respiratory status?

Nasogastric tube placement
Needle decompression
Nasal cannula @ 4 L/min
Intubation

Answer 32

Nasogastric tube placement

NG/OG tube placement is warranted and indicated. As altitude increases, any volume will expand. The increase in respiratory rate and work of breathing is most likely from the volume expansion in the abdomen that is compressing on the diagram and lungs.

Question 33

Blood loss (per liter) should be replaced with crystalloid solutions (per liter) at what ratio?

1:1
1:2
1:3
1:4

Answer 33

1:3

When you administer a crystalloid solution, only 1/4 – 1/3 of that solution makes it into the intravascular space. Therefore, for every liter of blood loss, 3 liters of a crystalloid would have to be given to account for that loss.

Question 34

A 32-week premature neonate is experiencing respiratory distress. Which drug may be administered in preparation for transport?

D10
Surfactant
Prostaglandin
Antibiotics

Answer 34

Surfactant

The amount of surfactant is minimal in premature neonates, especially if born before 35-weeks gestation. The surfactant is required to keep the lungs inflated and keep the alveoli open. Without sufficient surfactant, alveolar collapse, atelectasis, and respiratory distress will ensue.

Question 35

Identify the underlying problem based on the following parameters:

CVP 1
CI 1.6
PA S/D 12/8
PCWP 5
SVR 300
Neurogenic shock
Hypovolemic shock
Left systolic dysfunction
Septic shock

Answer 35

Septic shock

The preload is low as indicated by the CVP of only 1. Next, look at the cardiac output that is indicated by a low CI of 1.6. Next, the PA S/D is low as well. Remember, the PA pressure is looking at the left end diastolic pressure. This pressure shows that the left ventricle is not able to sufficiently provide enough stroke volume. Also, the PCWP is low as well and matches the low PA pressures. Last, the SVR is only 300. No constriction and no compensation is occurring. Hint…sepsis or septic shock is the only thing that will show low hemodynamic numbers in all categories. A diagnosis of septic shock is correct.

Question 36

Calculate the cerebral perfusion pressure (CPP) with the following findings: BP 150/75, HR 140, RR 28, SpO2 100%, CVP 2, ICP 25.

125
65
95
75

Answer 36

75

CPP = MAP – ICP

MAP = [(2 x DBP) + SBP] / 3

MAP = [(2 x 75) + 150] / 3 = 100

CPP = 100 – 25 = 75

Question 37

When attempting to “wedge” a pulmonary artery (PA) catheter, how much air should be placed into the balloon?

Fill the balloon with exactly 2.5 mL, but no more
Fill the balloon with exactly 2 mL
Fill the balloon with exactly 0.5 mL
Fill the balloon with up to 1.5 mL, but no more

Answer 37

Fill the balloon with up to 1.5 mL, but no more

When attempting to wedge the PA catheter, always remember to use the syringe that came with the PA catheter and only fill the balloon with the amount needed to achieve the wedge position, up to 1.5 mL. Never exceed 1.5 mL. Although the test may refer to wedging the PA catheter, this is no longer performed in practice. Standard practice now is to calculate the PCWP off the pulmonary artery diastolic pressure by subtracting 2-4 mmHg from this pressure.

Question 38

The flight crew’s shift just began and they received in briefing that they have marginal visual flight rules (VFR) weather. Approximately two hours later, they are toned for a scene flight. They are given a distance and heading of 20 miles and 280 degrees. The pilot says that the current weather conditions are 800’ and 1 mile. What is the best response?

Decline the flight because this is lower than the FAA local VFR weather minimums
Ask the pilot what they think and go along with what ever he/she wants
Advise the pilot to launch and “see what it looks like”
Accept the flight as this is the current FAA local VFR weather minimums

Answer 38

Decline the flight because this is lower than the FAA local VFR weather minimums

The local daytime FAA weather minimums for non-mountainous areas is 800′ and 2 miles. Although this is the minimum, most pilots will have higher minimums and would not take a flight at even 800′ and 2 miles.

Question 39

The transport team provider has arrived to transfer a patient with a confirmed hemorrhagic stroke. During pupillary assessment the clinical provider notices bilateral eyelid retraction. What is this assessment finding called?

Kehr’s Sign
Collier’s Sign
Cullen’s
Kernig’s Sign

Answer 39

Collier’s Sign

Collier’s sign is well known as unilateral or bilateral eyelid retraction due to midbrain lesions. This is often secondary to cerebral infarction, stroke, tumors, MS, thyroid disorder, and encephalitis to name a few.

Question 40

A 72kg patient presents with second- and third-degree burns to their face, anterior torso and complete left arm. How much fluid should the patient receive in the first 8 hours using the Parkland formula?

5,184 mL
9,072 mL
4,536 mL
2,268 mL

Answer 40

4,536 mL

This is a two-part question as the TBSA involved has to be calculated first followed by the amount of fluid needed for resuscitation. The face equals 4.5%, anterior torso accounts for 18%, and left arm 9% giving a total TBSA of 31.5%. The Parkland formula states: 4mL/kg x TBSA = volume/24 hours. 4mL x 72kg x 31.5 = 9,072 mL over the first 24 hours. Administer half of the total fluid during the first eight hours post-burn which would equal 4,536 mL. Next, administer a quarter of the total fluid during the second eight hours post-burn. Finally, administer a quarter of the total fluid during the third eight hours post-burn.

Question 41

Your patient is the victim of a near-drowning incident that occurred earlier today. They presented to the ED complaining of increasing shortness of breath. Upon assessment, they were found to be breathing at a rate of 42/min and crackles were auscultated in bilateral lower lobes as well as wheezing throughout the lungs. They were immediately placed on a non-rebreather (NRB), and ABGs obtained. Initial ABGs showed the following: pH 7.32, PaCO2 48 mmHg, PaO2 46 mmHg, and HCO3- 20 mEq/L. What is the next best action?

Administer albuterol/atrovent via nebulizer
Maintain high flow oxygen via NRB at 15 L/min
Assist with ventilation via a bag-valve-mask (BVM) at 15 L/min
Intubation and mechanical ventilation

Answer 41

Intubation and mechanical ventilation

The patient is suffering from a mixed disturbance with associated hypoxemia. The patient needs to be evaluated for intubation and mechanical ventilation based on the near-drowning incident. Before the decision to intubate the clinician needs to apply the NRB mask at 15 L/min (which the patient already has on) as a bridge to higher-level airway care. Further care would consist of possible CPAP or NiPPV and potential intubation. Since positive pressure choices are not available, the best option would be intubation.

Question 42

A 48-week post-conceptual age infant with a respiratory syncytial virus (RSV) is being transported. This infant is at increased risk of which of the following?

Bradycardia
Apnea
Tachypnea
Tachycardia

Answer 42

Apnea

In infants that are 48-weeks post-conceptual age (8 weeks old) with RSV, apnea is a significant risk factor and should be monitored closely. Prophylactic intubation is not necessary. Just be ready and have your equipment/medications available.

Question 43

What is the recommended insertion site for a chest tube?

3-4th intercostal space mid-clavicular
4-5th intercostal space anterior-axillary
5-6th intercostal space mid-axillary
4-5th intercostal space mid-clavicular

Answer 43

4-5th intercostal space anterior-axillary

Correct placement for chest tube insertion is between the 4th-5th ICS mid- to anterior axillary. This is an important landmark. Lower than the 5th ICS increases the risk of liver or spleen injuries and displacement.

Question 44

A patient is ordered to have constant nasogastric tube suctioning. Based on this, what acid-base derangement is expected?

Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
Metabolic acidosis

Answer 44

Metabolic alkalosis

Continuous gastric suctioning leads to metabolic alkalosis. Metabolic alkalosis is a primary increase in sodium bicarbonate (HCO3–) concentration. Metabolic alkalosis occurs because of a loss of H+ ions from the body (in this case due to gastric suctioning) or an increase in HCO3–. In its purest form, it manifests as an alkalemia (pH >7.40). As a compensatory mechanism, metabolic alkalosis leads to alveolar hypoventilation with a rise in arterial carbon dioxide tension (PaCO2), which diminishes the change in pH that would otherwise occur.

Question 45

A pediatric patient has sustained a pelvic fracture. What is the most likely secondary complication associated with this?

Retroperitoneal hemorrhage
Bladder injury
Intestinal perforation
Renal artery laceration

Answer 45

Retroperitoneal hemorrhage

The pelvis has many vessels that can become lacerated. Massive hemorrhage can lead to significant volume loss in a matter of minutes. Vertical shear pelvic fractures will cause the most significant potential secondary vascular injuries.

Question 46

Barodentalgia will most likely be exacerbated by ________?

Descent
Ascent
Level flight
Turbulent flight

Answer 46

Ascent

Barodentalgia will worsen on the ascent phase of flight. During ascent, a dull or severe pain will be experienced. The differences in pain will depend on whether it is a recent dental filling (severe pain) or an abscess (dull ache). Boyle’s law best explains this phenomenon.

Question 47

Which of the following is not a treatment strategy when dealing with rhabdomyolysis and myoglobinuria?

Mannitol administration
Sodium bicarbonate administration
Fluid resuscitation
Vasopressin administration

Answer 47

Vasopressin administration

Mannitol is utilized as a diuretic in attempts to “flush” the kidneys as well as fluid resuscitation with IV fluids. Sodium bicarbonate is utilized to alkalinize the urine to promote excretion of myoglobin. Vasopressin would do just the opposite and cause water retention and further damage, as it acts as a synthetic anti-diuretic hormone.

Question 48

Which of the following medications contains both nonselective beta-adrenergic and alpha1-adrenergic blocking effects?

Carvedilol (Coreg)
Nebivolol (Bystolic)
Propranolol (Inderal)
Metoprolol (Lopressor)

Answer 48

Carvedilol (Coreg)

Carvedilol contains nonselective beta-adrenergic and alpha1-adrenergic blocking effects and is often used for patients with congestive heart failure, hypertension, and left ventricular dysfunction. Metoprolol and nebivolol are cardioselective and do not block alpha receptors. Propranolol is non-cardioselective but does not block alpha receptors.

Question 49

The purpose of a trachea hook during a surgical cricothyroidotomy is to:

Grasp the outer rings of the trachea and pull laterally
Support the epiglottis during a crash airway
Stabilize the trachea anteriorly
Pull any blood clots out of the trachea

Answer 49

Stabilize the trachea anteriorly

The purpose of a tracheal hook during a surgical airway procedure is to stabilize the trachea towards the patient’s anterior neck. Additionally, it can be used to support and retract the thyroid cartilage out of the surgical airway window.

Question 50

In a patient with a diaphragmatic injury, what organ would also have a high suspicion of injury along with this?

Gallbladder
Liver
Stomach
Kidney

Answer 50

liver

The most likely organ injured with a confirmed diaphragmatic injury would be the liver. Remember the liver sits right below the diaphragm and against the right lung in the right upper quadrant. Its size is larger in comparison to other organs, with it being the size of a football and weighing 3-4 pounds on average.

Question 51

You and your partner respond to a 10-year-old that fell at school. On arrival, the patient has an altered level of consciousness. EMS states that they had a brief loss of consciousness and a period of lucidness before the current decline in GCS. This presentation most often presents with what type of head trauma?

Epidural bleed
Intraventricular bleed
Subdural bleed
Diffuse axonal injury

Answer 51

Epidural bleed

This type of question is commonly found on advanced certification exams. Remember, epidural bleeds will have a period of initial unconsciousness followed by a period of lucidness and then go unresponsive. Often, the last phase of unresponsiveness will lead to airway difficulties, clenched teeth, and increased ICP.

Question 52

The sequela of sepsis can lead to multi-organ dysfunction. Which of the following organs is involved first?

Brain
Liver
Lungs
Heart

Answer 52

Lungs

Respiratory failure is common usually in the first 72 hours, followed by hepatic failure and then renal failure.

Question 53

A patient sustained significant trauma after a motor vehicle collision. They were initially unresponsive and demonstrated increasing respiratory difficulty and were intubated. Before intubation, their BP was 116/70 and HR 98. They respond to painful stimuli with decorticate posturing on the right side. Reassessment after intubation shows a BP of 170/52 and HR 60. What do you suspect?

Cushing’s response
Brown-Sequard syndrome
Horner’s syndrome
Neurogenic shock

Answer 53

Cushing’s response

Cushing’s response is a nervous system response that is associated with an increase in intracranial pressure (ICP). The increase in ICP results in the Cushing’s triad of increased blood pressure with a widened pulse pressure, irregular breathing, and a reduction in the heart rate. This may indicate impending brain herniation. Horner’s syndrome is caused by damage to the sympathetic nerves on one side and produces ptosis, miosis, and anhydrosis on the affected side. Brown-Sequard syndrome is seen after an incomplete spinal cord lesion and demonstrated by ipsilateral upper motor neuron paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensation. Neurogenic shock results in low blood pressure and occasionally lower heart rate caused by disruption of the autonomic pathways within the spinal cord.

Question 54

A patient was exposed to a substance that is inhibiting ATP production by blocking the electron transport chain in their mitochondria. What antidote management would best suit this patient?

Physostigmine
Oxygen
Atropine and 2PAM
Sodium nitrite/amyl nitrate and sodium thiosulfate

Answer 54

Sodium nitrite/amyl nitrate and sodium thiosulfate

Cyanide binds to cytochrome c oxidase in the electron transport chain, thus inhibiting oxygen conversion to water and stopping ATP synthesis. As a result, the chain can no longer produce ATP, which quickly leads to both CNS and cardiac insults. As ATP production ceases, this causes the patient to move from an aerobic state to an anaerobic state. Administering a cyanide antidote is essential. Hydroxocobalamin (Cyanokit) is now considered first-line therapy as it is ordinarily well-tolerated by patients. However, if unavailable, sodium nitrite or amyl nitrite and sodium thiosulfate are still utilized and recommended.

Question 55

Federal aviation administration (FAA) guidelines state that an aeromedical program may only fly?

Visual flight rules (VFR) in visual meteorological conditions (VMC)
Visual meteorological conditions (VMC) in visual flight rules (VFR)
Instrument flight rules (IFR) in visual meteorological conditions (VMC)
Instrument flight rules (IFR) in visual flight rules (VFR)

Answer 55

Visual flight rules (VFR) in visual meteorological conditions (VMC)

Always remember VFR = VMC. IFR requires a filed flight plan and an IFR equipped aircraft that includes auto-pilot, dual engines, IFR trained pilot, GPS approach, and a certified landing zone or airport.

Question 56

You are transporting an 80-kilogram patient who is being mechanically ventilated. Current SpO2 is 89%. The patient is currently chemically paralyzed, and lung sounds are noted to be diminished bilaterally in the lower lobes. Current ventilator settings are: SIMV 14, Vt 450, FiO2 0.8, PEEP 4, I:E 1:2. Manipulating which setting would be MOST beneficial to increase the patient’s SpO2?

(f)
Vt
PEEP
I:E ratio

Answer 56

PEEP

When attempting to increase oxygenation in hypoxic patients, always increase FiO2 first and PEEP second. With the answers available, increasing PEEP would be the best choice.

Question 57

What is the most common cause for a patient to file a complaint against the transport team?

Ineffective communication
Poor outcomes
Medical bill received for services
Medication errors

Answer 57

Ineffective communication

Many problems or potential liability situations can be avoided if effective communication is the focus. Patients are in a position that is scary and unknown to them, and it is the flight crew’s job to explain what is happening and the treatment they are providing. Poor communication will always lead to conflict.

Question 58

You are preparing to intubate a patient who has sustained an extensive burn. Before administering succinylcholine, it is essential to establish the time of injury. Use of this agent in patients with burns greater than 12 hours old can cause severe electrolyte disturbances including?

Hyperkalemia
Hypercalcemia
Hypernatremia
Hypermagnesemia

Answer 58

Hyperkalemia

Administration of succinylcholine results in leakage of potassium from membrane depolarization. In the post-burn patient, administration of succinylcholine can lead to an exaggerated hyperkalemic response and potential lethal arrhythmias. Always consider another form of paralysis, like Rocuronium.

Question 59

The four elements required to prove negligence include ________, breach, causation, and damages.

Neglect
Injury
Tort
Duty

Answer 59

Duty

The first element that must be present is a legal duty of care from the defendant. Next, it will be determined whether the defendant breached this duty by doing, or not doing something, that a reasonably prudent individual would do under similar circumstances. Causation requires that the defendant’s negligence caused injury or harm. Last, damages require that there is an ability to compensate for the injury or harm that occurred.

Question 60

A 6-year-old patient treated for diabetic ketoacidosis (DKA) is showing signs of deterioration. Which of the following assessment findings would confirm this suspicion?

Urine pH less than 5.8
An increase in bicarbonate from 22 mEq/L to 25 mEq/L
Potassium levels decreasing from 6.3 mEq/L to 5.2 mEq/L
Deep tendon reflexes (DTRs) decreasing from +2 to +1

Answer 60

Deep tendon reflexes (DTRs) decreasing from +2 to +1

A decrease in DTRs indicates a drop in the pH and worsening metabolic acidosis. A urine pH of less than 6 shows that the kidneys are excreting acid. An increase in bicarb suggests improvement in the current acidotic state, and potassium levels are expected to slightly decrease as acidosis is corrected and potassium is shifted back into the intracellular space. This decrease to 5.2 mEq/L is not worrisome at this time as it is still on the higher side of normal.

Question 61

Treatment for pregnancy-induced hypertension (PIH) may include all of the following EXCEPT:

Magnesium sulfate
Labetalol
Brethine
Hydralazine

Answer 61

Brethine

Brethine is used for pre-term labor only and is a smooth muscle relaxant. It is used to slow the contractions of the uterus based on its mechanism of action. The other choices can be used for the treatment of PIH with hydralazine being the first choice.

Question 62

When applying pressure support (PS) in a neonate on SIMV, what is the stopping point for allowing the patient to take a spontaneous breath?

Spontaneous breaths > 25% of the controlled set Vt
Spontaneous breaths > 33% of the controlled set Vt
Spontaneous breaths > 50% of the controlled set Vt
Spontaneous breaths > 75% of the controlled set Vt

Answer 62

Spontaneous breaths > 75% of the controlled set Vt

Using SIMV has become a standard mode of ventilation when dealing with patients that are ventilator dependent. Research has shown that assist control causes respiratory muscle atrophy and severely hinders patients weaning off the ventilator. SIMV is now used around the country for a primary mode because it always allows the patient the ability to take a spontaneous breath. With the addition of pressure support (PS), the patient can take an augmented breath, and it reduces the work of breathing by reducing overall dead space. The objective is to allow patient induced respiratory effort without causing muscle fatigue. This respiratory effort helps eliminate dead space that is currently in the ETT and ventilator circuit. Those spontaneous breaths should be monitored and should not be allowed to exceed 75% of the set Vt. If Vt is set at 400 mL, the patient’s spontaneous breath should not exceed 300 mL. If this happens, treat the patient with analgesic medication and sedation, turn the trigger setting higher, or turn the PS down by 1 cmH2O. Changing the PS by 1 cmH2O increases or decreases the spontaneous tidal volume by 75-150 mL.

Question 63

A neonate who is experiencing repetitive motion of a bicycling type action with lip-smacking is presenting with what type of seizure?

Clonic
Tonic
Subtle
Myoclonic

Answer 63

Subtle

Subtle seizures consist of repetitive mouth/tongue movements, bicycling, eye deviation and rapid blinking.

Question 64

A patient is having complications with postpartum hemorrhage. Vigorous fundal massage has been attempted without improvement in bleeding. What should be considered next?

Administration of packed red blood cells (PRBCs)
Continued vigorous fundal massage
Administration of Methergine 0.2mg
Administration of oxytocin 20-40 units

Answer 64

Administration of oxytocin 20-40 units

Oxytocin (Pitocin) should be the first drug of choice followed by Methergine to try to stop postpartum hemorrhage. PRBCs or FFP may be required for fluid resuscitation but getting the bleeding to stop is of top priority at the moment.

Question 65

All of the following are triggers for sickle cell crisis except?

Altitude changes
Poor fluid intake
Cold weather
Stress

Answer 65

Altitude changes

All the choices except for changes in altitude are potential triggers of sickle cell crisis. The key for these patients is to keep them hydrated, oxygenated, and pain-free.

Question 66

The transport team received a 450-pound patient with a current Vt of 925 mL and decreased SpO2. What would the next best action be?

Increase Vt
Decrease Vt
Increase inspiratory pressure (Pinsp)
Increase PEEP

Answer 66

Increase PEEP

This question can be tough. The first thing to start with is what would this patient’s ideal body weight be? This question does not provide height, but common sense tells us that patients do not have an ideal body weight of 220 kg. From there, what can we fix? We know that the SpO2 is low and increasing the PEEP would increase oxygenation and reduce alveolar shunt. Increasing PEEP is the best answer despite knowing Vt is also high.

Question 67

A patient is experiencing left ventricular diastolic failure. What is the focus of first-line therapy?

Decreasing preload
Increasing afterload
Increasing preload
Augmentation of left ventricular clearing

Answer 67

Augmentation of left ventricular clearing

Augmentation of the left ventricle revolves around allowing the ventricle to fill appropriately. Often, treatment of hypertension with ACE-inhibitors and beta blockers, are first-line treatments, along with digoxin for inotropic augmentation and contractility.

Question 68

Identify the underlying problem based on the following hemodynamic parameters:

CVP 2, PCWP 4, CI 1.8, SVR 400

Neurogenic shock
Hypovolemic shock
Septic shock
Anaphylactic shock

Answer 68

Septic shock

All hemodynamic parameters are low. The only presentation that would show these parameters is septic shock. Always start with the CVP and work from right to left. The CVP is low, which indicates volume. Next, look at the CI. It is also low indicating that CO is diminished. The PCWP is the next value. It is also low and will often follow what the CVP is (the only exception is right heart failure). Last, the SVR is also low indicating that the patient cannot compensate any longer and needs vasopressor augmentation.