Your patient has taken a significant overdose of nortriptyline (Pamelor). You would expect which of the following?
A. behavior similar to a cocaine overdose
(5/76) Your DIC patient would most likely demonstrate;
D. high fibrin split product (FSP) levels
Your focus when treating the DIC patient should be; (5/77)
D. correcting underlying pathology
(5/77) Your patient's H&H was 7 & 20. You have administered two units of packed red blood cells (PRBC's). You can reasonably assume his H&H should increase to;
A. 9 & 26
(5/78) The ABO antigens, which dictate blood type, are found;
C. on red blood cells (RBC's)
(5/79) You have administered 5 units of PRBC's in rapid succession during a trauma resuscitation. You should be considering;
A. citrate toxicity
(5/80) What is the corrective action for citrate toxicity post rapid admin of 5 units of PRBC's?
C. calcium administration
(3/1) Semilunar valves include;
B. Aortic
(3/2) The patient's 12-lead ECG is demonstrating an inferoposterior wall AMI. The most likely site of the lesion is;
C. proximal to mid PDĄ
(3/3) In ~90% of the population, the RCA is the primary blood supply to;
B. left inferior wall & right ventricle
(3/4) The first cardio-specific enzyme to elevate is;
A. CK-MB
(3/5) The ECG finding that signals transmural ischemia is;
D. ST elevation
(3/6) "Lateral leads" on the 12-Lead ECG are;
D. none of the selections
(3/7) Your patient reports a prior history of CAD with chest pain reliably relieved by sublingual NTG. He has recently had recurring episodes of spontaneous chest pain in the morning upon waking. His condition may be described as
A. Mixed angina
(3/8) Nitroglycerine's primary role in treating the AMI patient is:
D. decreasing preload
(3/9) Your patient takes verapamil daily. You should use caution administering which of the following;
B. all selections
Verapamil is a cardioselective CCB. Both Diltiazem & Nifedipine are CCBs wh/ could result in CCB OD.
Metoprolol is a BB & could result in a complete blockade of primary mechanisms involved in stimulating the heart when taken with a CCB.
(3/10) Integrelin® is;
B. a glycoprotein IIb/IIIa inhibitor
(3/11) An absolute contraindication to thrombolytics would be;
B. CVA (11 months prior)
(3/12) Your patient is being transported with a PTCA sheath in the left femoral artery. Complications you should anticipate include;
D. LCA dissection
(3/13) The patient's pacemaker is pacing constantly regardless of the patients intrinsic rhythm. This pacemaker failure would be described as;
C. failure to sense
(3/14) Your patient is exhibiting a diastolic murmur at the level of the mid-clavicular 5th intercostal on the left chest field. The most likely condition associated with this is;
B. mitral stenosis
the valve between the left atrium and the left ventricle of the heart, consisting of two tapered cusps
(3/15) Which of the following murmurs would be heard only during diastole?
D. mitral stenosis
(3/16) Which of the following murmurs would be heard only during systole?
B. ventricular septal defect
(3/17) Your patient is exhibiting a systolic murmur at the level of the second intercostal at the right border of the manubrium. The most likely condition associated with this
is;
D. IHSS
(idiopathic hypertrophic subaortic stenosis)
(3/18) Your patient is experiencing a systolic failure. A typical cause of this could be;
B. dilated cardiomyopathy
(3/19) Your patient has been diagnosed with a DeBakey Type II aortic aneurysm. Complications include;
D. all of the selections
(3/20) Your patient is experiencing a left ventricular diastolic failure. Treatment would include;
A. preload increase with fluid bolus
(3/21) Your patient is demonstrating 1mm of ST elevation in leads III & AVF. Which of the following therapies could prove hazardous;
C. nitroglycerine administration
(3/22) Your patient is 6 months status post heart transplant. He has had difficulties with organ rejection throughout the course of his recovery. You're now transporting him for chest pain. He demonstrates the following vital signs; HR 42, BP 72/30, RR 30, SpO2 85% and states he "can't breath". Which of the following therapies will not be helpful;
C. atropine
(3/23) The pressure bag on your arterial line set-up should be;
A. monitored for drop in pressure while descending
(3/24) The transducer can;
A. all of the selections
(phlebostatic axis is located at the 4th intercostal, mid-axillary line)
(3/25) An arterial line demonstrates a dicrotic notch. The dicroti notch may represent;
A. all of the selections
(3/26) Slurring of the dicrotic notch would suggest;
A. aortic valve disease
(3/27) The correct chain of events in normal physiology are;
B. renal pressure drops >> angiotensin I formed >> aldosterone released
(3/28) ACE inhibitors interfere with;
D. angiotensin I conversion to angiotensin II
(3/29) Your 64 year old male patient presents complaining of chest pain and shortness of breath exhibiting the following vital signs; HR 98, BP 72/28, RR 28, SpO2 92%, Temp 38°C. 12-lead ECG demonstrates acute anterolateral wall AMI. Therapy already in progress includes ASA administration, supplemental O2 via NC at 6pm, IV access with NS at TKO. Sublingual NTG was administered X 1 by first responders, nothing further. Select the best treatment from the choices below;
D. Initiate dopamine, then dobutamine infusions, consider intubation
(3/30) Which of the following is not a 'normal' value?
A. RVP 15-25mmHg
(3/31) The PA pressure line waveform is exhibiting an obvious anacrotic notch with large sharp waveform deflections. The likely location of the catheter tip is;
C. RV
Anacrotic notch is on the ascending side (L) of the waveforms peak.
Represents the "Atrial Kick" - provides 22%-33% of CO. (importance of correcting Afib in PTs status post heart bypass "Fresh Heart"
(3/32) During transport it is your assessment that the PA catheter tip has moved to the RV. From the options below, you should;
C. withdraw the catheter with the balloon down until a CVP waveform is seen
(5) Methemoglobinemia
Blood disorder in which an abnormal amount of methemoglobin is produced. Hemoglobin is the protein in red blood cells (RBCs) that carries and distributes oxygen to the body. Methemoglobin is a form of hemoglobin.
With methemoglobinemia, the hemoglobin can carry oxygen, but is not able to release it effectively to body tissues.
(3) Right Coronary Artery (RCA) supplies blood to;
the posterior wall (90% of population) and the Posterior Descending Artery (PDA)
The Posterior Descending Artery (PDA) supplies blood to the inferior aspects of the heart
(3/34) During transport the patient's PA waveform has changed morphology to a low amplitude "rolling" waveform. The most likely cause of this change is;
B. inadvertent migration of the catheter to a wedge position
(3/35) PA catheters are typically designed for the distal balloon to be inflated with;
B. no more than 1.5ml air
(3/36) Inadvertent 'wedging' of the PA catheter is a common problem;
D. (i) & (ii)
(3/37) Which of the following will not contribute to over damping of a transduced pressure line?
A. descending to a lower altitude
(3/38) Your patient has experienced an acute left anteroseptal AMI. Which of the following is not commonly associated with this pathology?
A. AV nodal ischemia
(3/39) When assessing transduced pressure line readings, you should always take measurements;
B. (i) & (ii)
(3/40) When performing a fast flush test of a peripheral arterial line you note six obvious "bounces" of slowly decreasing amplitude after the flush. The arterial line's dynamics would be described as;
C. 'under-damped'
(3/41) A contraindication to the use of an IABP would be;
C. all of the selections
(3/42) The tip of the intra-aortic balloon is typically;
B. 2-4cm below the apex of the aortic arch
(3/43) While caring for a patient with an IABP in place you note rust colored flakes in the IABP balloon supply tubing. This would indicate;
D. IABP balloon failureHelium source contamination or leak
(3/44) The IABP works on the basis of;
B. (i) & (ii)
(3/45) The IABP may be used successfully;
A. status post PTCA in patient's with multi-vessel disease
(3/46) When timing the IABP, place the device in;
D. 1:2 assist mode
(3/47) When transporting the IABP patient, it is not essential to carefully monitor which of the following;
C. CVP waveform
(3/48) In the event of an IABP mechanical failure, you should;
D. cycle the balloon once every 30 minutes manually
(3/49) The IABP timing strip demonstrates
A. early inflation
(3/50) The IABP timing strip demonstrates
B. late inflation
(3/51) The IABP timing strip should be corrected by;
B. adjusting the deflation time later
(3) Good timing IABP timing strip.
(3/52) The ECG below is demonstrating;
C. anteroseptal wall AMI
This ECG shows distinctive ST elevation patterns in V1, V2, V3 & V4 clearly identifying an anteroseptal wall AMI. There appears to be slight ST elevation in leads I and aVL as well. This would suggest probable lateral wall AMI involvement or 'extension' as well.
(3/53) The location of an infarct in a anteroseptal wall AMI is most likely located at;
B. proximal LAD
The best choice is the proximal LAD. The LAD provides the majority of flow to the anterior wall, anterior 2/3s of the septal wall and the diagonal branch of the LAD feed portions of the anterolateral wall. An argument could be easily made that this may be an occlusion of the left main or LCA, however that option is not offered as an answer oprtion.
(3/54) Complications associated with a anteroseptal wall AMI include;
C. mitral papillary rupture
An anterior wall AMI may precipitate mitral valve papillary muscle failure or rupture. Acute flash edema will result as the incompetent mitral valve allows high pressure from the L ventricle to preferentially flow backwards into the pulmonary circulation.
(3) Right Coronary Artery (RCA)
1. Supplies the R ventricle and in most of the population the SA Node (60%)
2. Supplies PDA (85%)
Bradycardia due to SA Node involvement
(Inferior MI)
(3) Posterior Descending Artery (PDA)
1. Branch off of the RCA in most of the population (85%)
2. Inferior wall
3. Ventricular septum
4. Papillary muscles ("heart-strings")
(3) Left Coronary Artery (LCA or "Left Main Artery" or "Widow Maker"
1. Supplies LAD
2. Supplies LCX
(basically the entire left heart)
(3) Left Anterior Descending (LAD)
1. Anterior L Ventricle
2. Anterior septum
(Anterior MI/Septal MI/Anteroseptal MI)
(3) Left Circumflex (LCX) or "Circumflex Artery"
1. Lateral L Ventricle
2. Posterior L Ventricle (45% of population)
(Lateral MI/Posterior MI)
(3) Lateral Leads Vessel & Treatment
LCX / MONA
(3) Inferior Leads Vessel & Treatment
RCA / 2L Fluids
(3) Septal Leads Vessel & Treatment
LAD / MONA
(3) Anterior Leads Vessel & Treatment
LAD / MONA
(PHI1 6) Drug of choice for treating a GI bleed is?
B. Sandostatin
(PHI1 9) You are transporting a 30 YOM involved in a MCA from an outerlying facility. The 70 kg patient is on a ventilator with FIO2 1.0, Vt 500, Rate 16, PIP 22 and Peep 5. The ABG results are pH 7.01, pCO2 68, HCO2 12, base deficit – 8, pO2 280. Interpretation of the blood gas reveals?
D. mixed disturbance
(PHI1 14) Beta-blockers are contraindicated with?
B. Cocaine overdose
(PHI1 28) A neonate who is experiencing repetitive motions of a bicycling type action with lip-smacking is presenting with what type of seizure?
A. Subtle
(PHI1 31) The patient is a breech presentation and delivery appears to be halted upon delivery of the head. The appropriate action would be to?
A. Perform Mauriceau’s maneuver
(PHI1 33) Which patient is not affected with altitude temperature changes?
D. Cardiac patient
(PHI1 38) Your 18 YOF patient was ejected during an MVA. She is currently awake and oriented x 3 however she is slow to respond. BP 70/42, HR 68, RR 26, Sats 94%, Temp 98.8 and a CVP of 3. Your patient is exhibiting?
A. A spinal cord injury
(PHI1 43) Your patient is experiencing a subarachnoid hemorrhage. He will likely demonstrate?
A. positive Brudzinki's sign
(PHI1 50) You are transporting a 12 YOM weighing 60 kg with diagnosis of status asthmaticus on a ventilator. EtCO2 is 56. Ventilator settings are at Vt 450, FIO2 1.0, Rate 16, I:E 1:2, Peep 5, PIP 48. How will manage this patient?
A. Increase I:E ratio
(PHI1 60) Late decelerations may indicate?
D. Uterine placental insufficiency
(PHI1 66) The clotting cascade can be triggered through an extrinsic pathway. The triggering mechanism is the release of?
D. tissue thromboplastin
(PHI1 70) You would expect the patient’s HR to ________ for each degree above 37 degrees centigrade?
D. Increase 20 BPM
(PHI1 72) The fetus of a pre-eclamptic mother during labor will commonly experience:
D. Late decelerations
(PHI1 75) The patient’s peripheral A-line is showing a very sharp waveform with readings that appear exaggerated. This may be due to:
B. Catheter whip
(PHI1 80) Inadvertent migration of the IAB may cause which of the following, EXCEPT:
D. Loss of flow to the carotid vein
(PHI1 83) A common primary complication of PGE1 administration is:
A. Apnea
(PHI1 87) Your patient’s ABG’s are: pH 7.49, pCO2 61, HCO3 34. You should correct the pH by:
D. Analyze electrolytes and replace deficiency
(PHI1 89) Which of the following is the most potentially harmful timing error?
C. Late deflation
(PHI1 99) You are managing a 4 YOM presenting lethargic with nystagmus. You note he has depressed DTR’s and has a profound anion-gap. The patient should be managed with which of the following?
C. IV ethanol drip
(PHI1 108) Your patient has a chief complaint of dyspnea and weakness with the following vitals: BP 72/64, HR 112, RR 28, SpO2 88%, Temp 99.1 He is on 6 L/min of oxygen via NC. The ECG shows ST with frequent PVC’s. Physical exam reveals profound vesicular rales and bronchial wheezing. Your most likely diagnosis is:
D. Cardiogenic shock
(PHI1 112) Needle thoracostomy should be performed where:
D. 5th intercostal space anterior mid-axillary line
(PHI1 113) A patient presenting with Beck’s triad is most likely experiencing:
A. Cardiac tamponade
(PHI1 117) The patient received a skull fx that appears to have a central focal point with multiple fx’s outwards. This skull fx would be described as:
B. Diastatic
(PHI1 119) The fetus’s variability is:
C. All of the selections
(PHI1 128) A common problem seen with hepatic encephalopathy is?
A. Ammonia toxicity
(PHI1 131) When managing a patient with an electrical injury, you should maintain a urine output of:
B. 100 ml/hr
(PHI1 134) Your patient presents with following parameters: CVP 20, CI 1.1, PA S/D 8/4, wedge 3 and SVR 1800. What is your diagnosis?
A. RVMI
Classic picture of neurogenic shock presents with:
C. absence of tachycardia
High pressure alarms can be caused by all of the following, EXCEPT:
A. hypovolemia
Phenytoin can be administered to a patient having recurrent seizures. The dose of 18 mg/kg IV given at a rate of 50 mg/minute can cause which of the following?
C. SVT and ventricular dysrhythmias
A sign of hyperventilation and hypocalcemia is:
D. Trousseau's
Your patient presents upper body obesity with thin arms and legs. He has a founded face "buffalo hump" and is complaining fatigue. He is hypertensive and hyperglycemic. He is hypertensive and hyperglycemic. He most likely experiencing which condition?
D. Cushing's syndrome
You are transporting a 60 y/o male with a h/o complaining of severe chest pain and mid-scapular pain. He is short of breath and is hypertensive in the upper extremities. You auscultate a harsh systolic murmur. Your diagnosis of this patient is?
A. Aortic rupture
After administering fluid resuscitation, performing vigorous fundal massage and giving Oxytocin your patient continues with post-partum hemorrhage. Which drug would be indicated to decrease blood loss?
C. Methergine
When administering a defasciculating neuromuscular blockade, the dose recommended is:
B. 10% normal RSI dosage of NMBA
Digitalis toxicity is easily exacerbated by:
C. Electrolyte abnormalities
(FB 2) A patient is suffering from right heart failure. What hemodynamic changes would NOT be expected?
B. Decreased central venous pressure (CVP)
CVP +, PAP-, PCWP -, SVR +
(FB 14) A massive hemothorax in an adult is defined as a rapid accumulation of more than how much blood
D. 1,500 mL
(FB 16) Which medication below would be the most beneficial for a patient suffering from a heatstroke event
A. Cimetidine
Cimetidine is an H2 blocker primarily used to treat ulcers. In the hyperthermic patient, it is used to prevent ulcer formation due to the stress response. During a stress response, the body increases glucose production by releasing cortisol. The release of cortisol leads to a reduction of prostaglandin (PGE) production which slows GI mucous synthesis.
(FB 17) In a patient with a diaphragmatic injury, what organ would also have a high suspicion of injury along with this?
A. 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.
(FB 18) While flying at cruising altitudes, Boyle’s law causes difficulty in controlling the rate of IV fluid drips. What is the most appropriate action to manage this?
B. Place the IV fluids on a pressure bag
IV fluid drips can be challenging to maintain because of Boyle's law and the ever-changing altitude and pressures. The best option in flight is to place fluids on a pressure bag and then titrate the drip rate under pressure. This pressure will overcome any volume increases associated with altitude differences and Boyle’s law.
(FB 22) A patient is experiencing left ventricular diastolic failure. What is the focus of first-line therapy?
B. 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.
(FB 23) A patient experiencing an aplastic sickle cell crisis typically presents with pallor, tachycardia, weakness, and fatigue as well as:
A. Facial rash
The patient experiencing an aplastic sickle cell-crisis usually presents with increased pallor, weakness, and fatigue in addition to tachycardia and a facial rash/facial erythema. Given the destruction of the red-blood-cell, all of the answer choices are physiologically inaccurate in this condition.
(FB 24) A patient sustained commotio cordis after being hit in the chest with a baseball. This condition occurs as a result of which of the following?
B. Fatal dysrhythmia
Commotio cordis (an often lethal disruption of heart rhythm) is caused by sudden blunt force trauma that is non-penetrating to the chest, specifically the precordial area, during the vulnerable state of ventricular repolarization, causing a fatal ventricular dysrhythmia and sudden cardiac death.
(FB 27) When obtaining a pulmonary capillary wedge pressure (PCWP) on a cardiac patient, there is a large "V" wave present on the waveform. After confirming correct placement of the pulmonary artery (PA) catheter and ensuring that the balloon is not ruptured, what condition is suspected?
C. Mitral valve regurgitation
When wedging the PA catheter, a measurement of the left atrial pressure is obtained. Seeing a "V" on the waveform while performing the wedge, indicates left atrial filling against a closed mitral valve and thus shows mitral valve disease/regurgitation. Please recall that wedging a catheter is no longer routinely performed and this is unlikely to be encountered but is essential to know and understand for testing purposes.
(FB 28) An 8-year-old has an orbital wall and floor fracture which can be associated with which of the following findings?
B. Entrapment of extraocular muscles
Entrapment of extraocular muscles can occur with orbital wall/floor fractures, which can result in restricted gaze, double vision, ecchymosis, and ptosis.
(FB 34) HELLP syndrome is characterized by what?
D. 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.
(FB 35) You have an 80-kilogram patient diagnosed with metabolic acidosis who is intubated, sedated, and currently paralyzed with long-acting medications. Prior to intubation, the patient's initial respiratory rate was 34 breaths per minute with a corresponding EtCO2 of 22 mmHg. What would be the most appropriate ventilator settings for this patient?
A. SIMV 32, Vt 400, FiO2 1.0, PEEP 5
With metabolic acidosis, always allow the patient to compensate. If the patient is paralyzed, then match their respiratory rate and EtCO2 reading to that which it was before intubation; to continue blowing off excess acid (CO2). Removing excess acid will help prevent the pH from decreasing and prevent a potential lethal acidemia. Remember - for every 10 mmHg of change in PaCO2, there will be an inverse change in pH by 0.08.
(FB 39) Spinal cord injuries that cause respiratory and diaphragmatic paralysis would be at what level?
A. Above the level of C3
The phrenic nerve controls the diaphragm and our ability to breathe. The left and right phrenic nerve innervates at the level of C3-C5. Spinal cord injuries above the level of the third vertebra can disrupt nerve impulses that travel from the brain to the phrenic nerves. This disruption can cause paralysis of the diaphragm and the need for advanced airway management and mechanical ventilation.
(FB 46) In volume controlled ventilation, it is most appropriate to monitor ________________?
C. PIP, Pplat, and static compliance
Airway pressures are the most important parameter to monitor in volume controlled ventilated patients. PIP, Pplat and static compliance are indicators of alveolar health, barotrauma, and overall lung health.
(FB 48) Which of the following is not a treatment strategy when dealing with rhabdomyolysis and myoglobinuria?
B. Vasopressin administration
All of the above answers are correct except for vasopressin. 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.
(FB 53) Which of the following congenital disorders results in a right-to-left shunt?
B. Tetralogy of Fallot (TOF)
Tetralogy of Fallot is a right-to-left shunt allowing blood to flow from the right heart to the left heart. Tetralogy of Fallot results in four defects including pulmonary stenosis, overriding aorta, right ventricular hypertrophy, and ventricular septal defect.
(FB 58) The team is on the scene of a motor vehicle collision (MVC), where an 8-year-old patient is fully immobilized with apparent difficulty breathing. Assessment reveals circumoral cyanosis, diminished breath sounds throughout, and shallow chest expansion. SpO2 is 89% on a non-rebreather. Due to the patient’s poor respiratory status, the decision is made to perform rapid sequence intubation (RSI) and continue fluid resuscitation. The patient is placed on the mechanical ventilator, and after approximately 10 minutes, they are demonstrating an increasing PIP, decreasing chest expansion, and decreasing pulse oximetry. The most appropriate action is to:
A. Check the Pplat and if > 30 mmHg perform immediate chest decompression
In this scenario, the mechanism and initial assessment should alert to a high index of suspicion that this patient has a probable pneumothorax, and it is likely to progress to a tension pneumothorax. Taking the patient off the ventilator and bagging the patient is not going to solve the underlying problem. It is a late sign to have BVM compliance diminish to the point of identifying a tension pneumothorax. The Pplat is going to be the most sensitive indicator of impending problems at the alveolar level and helps identify that the simple pneumothorax is now a tension pneumothorax. Immediate chest decompression on the affected side or bilaterally is warranted. A tension pneumothorax is life-threatening and needs immediate action by the clinician.
(FB 62) A police cadet suddenly collapsed secondary to heat exhaustion while training at the academy. A diagnosis of acute renal failure was made. What is the most likely classification for this renal failure?
A. Intra-renal - tubular
Pre-renal failure is secondary to decreased renal perfusion from a source above the level of the kidneys. Post-renal failure occurs secondary to an obstruction below the level of the kidneys. This patient is suffering from rhabdomyolysis secondary to the intense exertion. This intra-rental failure is an example of a tubular etiology. As myoglobin releases from the breakdown of muscle, it can precipitate in the kidneys leading to renal tubular obstruction and tubular injury. Vascular causes of intra-renal failure would include situations associated with artery obstruction, malignant hypertension, DIC, transplant rejection, etc.
(FB 70) Which of the following maneuvers may be used to help deliver an infant with shoulder dystocia?
D. McRobert's maneuver
Shoulder dystocia occurs after the delivery of the head when the anterior shoulder cannot pass below the pubic symphysis and requires manipulation. This is an OB emergency, and fetal demise can occur if the infant is not delivered, due to cord compression within the birth canal. McRobert's maneuver involves flexing the mother's legs tightly to her abdomen (knee to chest position), which causes the pelvis to widen and flattens the lumbar spine.
(FB 74) In a salicylate overdose, the primary acid-base disturbance is __________ followed by __________?
B. Respiratory alkalosis; metabolic acidosis
Salicylate (aspirin) is acetylsalicylic acid, which causes stimulation of the respiratory center in the brain leading to hyperventilation and respiratory alkalosis. It then leads to a state of metabolic acidosis as hydrogen ions are exchanged for potassium and potassium is then lost in the urine.
(FB 76) A multi-trauma patient undergoes fluid resuscitation with three liters of normal saline and five units of unwarmed packed red blood cells. They remain unconscious, intubated and ventilated with 100% oxygen. They have received sedation and remain immobilized on a backboard. Which of the following secondary complications should be of concern?
C. Hypothermia due to unwarmed blood
The infusion of unwarmed or inadequately warmed intravenous (IV) fluids and cold blood may contribute to the many adverse consequences associated with hypothermia. These can include: cardiac arrhythmia, hemostasis abnormalities from impaired platelet function and slowed enzymatic reactions in the coagulation cascade, peripheral vasoconstriction, dehydration, decreased oxygen delivery to tissues, which impairs oxidative killing of bacteria by neutrophils and reduces the deposition of collagen during wound healing, increased red cell release of potassium, metabolic acidosis, and citrate toxicity (with blood component transfusion).
(FB 81) When monitoring invasive intracranial pressure lines, the transducer should be leveled where?
B. Foramen of Monro
The transducer should be leveled at the point of the patient's face which corresponds to the Foramen of Monro. This location is the outer canthus of the eye. As with any other invasive transducer, the biggest thing to remember is that it must always be leveled, so pick a mark and stick with it!
(FB 83) Blood loss (per liter) should be replaced with crystalloid solutions (per liter) at what ratio?
B. 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.
(FB 84) Which of the following is associated with a poor prognosis in a patient with severe acute respiratory distress syndrome (ARDS)?
C. Significantly elevated lactate
A significant elevation in lactate indicates multi-system involvement and is an indication of a stress response, with some physicians still using lactate as an indication of illness severity. An elevated fever and leukocytosis indicate a possible infection but not necessarily an indicator of a worsened prognosis.
(FB 92) A child aspirated a coin, and their left lung is hyperinflated. Where is the coin?
B. Alveoli
If there is asymmetry within the lung fields, the object has to be past the carina. Alveoli are microscopic, so the best answer is bronchus.
(FB 94) A 3-year-old patient’s current ABGs are: pH 7.30, PaCO2 24, PaO2 62, HCO3- 16. What is your interpretation?
D. Partially compensated metabolic acidosis
This ABG is a partially compensated metabolic acidosis due to the PaCO2 being lower than normal with metabolic involvement. The patient is attempting to blow off the acid.
(FB 99) What is the pitot tube on an aircraft used for?
A. Pressure measurement
The pitot tube on any aircraft is used to determine airspeed and altitude. The pitot tube has two holes that are used for measurement. One hole is located at the front of the tube and placed in the airstream. This hole measures stagnation pressure. The second hole is located on the side and measures static pressure. The difference between the two pressures is the dynamic pressure, which is used to determine airspeed and altitude.
(FB 100) A patient who sustained extensive electrical burns is being transferred. Upon entering the room, there is brown urine noted in the foley bag, and myoglobinuria on the urinalysis. To prevent the development of acute tubular necrosis and further renal failure, what is the anticipated treatment?
D. Lactated Ringer's, sodium bicarbonate, and mannitol
Electrical burns will cause destruction of the muscles, leading to the release of myoglobin. The myoglobin will deposit in the kidneys and appear in the urine. This can cause acute tubular necrosis and further renal failure if not treated appropriately. The goal of treatment is to flush the myoglobin out, with the use of IV fluids, usually LR, and a diuretic, which is most often mannitol. The urine should be kept alkaline, with the use of bicarbonate, to increase excretion of the myoglobin.
(FB 103) You are transferring a patient who recently underwent a left lower lobectomy. When auscultating lung sounds you notice diminished breath sounds in the right posterior lobe. What is the suspected cause of this?
A. Atelectasis
The most common cause would be atelectasis, which is common after surgery and especially in smokers. This patient needs deep breaths and use of incentive spirometry to improve ventilation and prevent pneumonia from occurring.
(FB 105) Cushing's triad consists of which of the following?
B. Increased systolic blood pressure, bradycardia, and change in respiratory status
Cushing's triad is an ominous sign and not often seen in the early management of our patients. It is a sign of increasing ICP and occurs due to the Cushing reflex. If left untreated, it can lead to herniation and death.
(FB 113) Identify the underlying problem based on the following parameters: CVP 1, CI 1.6, PA S/D 12/8, PCWP 5, SVR 300
B. 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.
(FB 116) With a diagnosis of diabetes insipidus (DI), what lab findings would be anticipated?
C. Polyuria, increased serum osmolality, hypernatremia, and low urine specific gravity
DI occurs secondary to a decline in antidiuretic hormone (ADH) levels. This decline leads to a state of polyuria because the body has no ADH to tell it to reabsorb water and sodium. With polyuria, the body has more free water loss in comparison to sodium, so it results in a state of hypernatremia. Also, the serum osmolality increases because there are more electrolytes in the serum than water (dehydration). The specific gravity of the urine decreases because the urine contains more free water than electrolytes. The low urine specific gravity will cause the urine to be clear in color.
(FB 117) Upon review of a patient's labs, their potassium level is noted to be 3.1 mEq/L. When looking at their ECG, what would be expected?
D. U waves
Hypokalemia can result in ECG changes including, inverted T waves, ST segment depression, and prominent U waves.
(FB 118) 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?
B. 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.
(FB 122) The most common congenital heart defect in neonates is which of the following?
C. Ventricular septal defect (VSD)
VSD is one of the most common congenital heart defects and occurs when there is a hole in the septum between the left and right ventricles.
(FB 124) The team is transporting a 5-day-old neonate. On arrival, the report states that the baby is suffering from Tetralogy of Fallot (TOF). What is the long-term treatment to correct this heart defect?
D. Catheterize and dilate the pulmonary artery (PA) and patch the ventricular septal defect (VSD)
Patients that suffer from Tetralogy of Fallot have multiple issues. Most often, they suffer from a VSD, stenotic pulmonic valve, RV hypertrophy, and a pulmonary artery outflow obstruction. Patency of the ductus arteriosus is essential short-term and accomplished with the administration of prostaglandin (PGE1). Administration of oxygen needs to be minimal. While PGE1 administration is essential short-term, the question is in regards to the long-term treatment of this defect. Long-term treatment is dilation of the pulmonary artery to alleviate the PA outflow obstruction and surgical repair of the VSD.
(FB 125) Which tube would be most affected by altitude changes based on Boyle’s law?
C. Blakemore tube
The Blakemore tube has a standard volume of 250 mL. Based on Boyle’s law calculation [(P1 x V1) / P2] (P1 = initial starting ATM, V1 = starting volume, P2 = ATM at highest flight altitude), the increase would be more significant with the Blakemore tube in comparison to the other answer choices.
