Chapters 3-10 All Questions Flashcards

Question

41. You are preparing to transport a twenty-year-old female, twenty-four weeks gestation, G3, P1, AB 1. The mother is being placed in lateral recumbent position to prevent which of the following? A. Decrease uterine contractions B. Supine hypotensive syndrome C. Hypertension D. Relieve bladder distention

Answer 1

41. B: Aortocaval compression syndrome is compression of the abdominal aorta and inferior vena cava by the gravid uterus when a pregnant woman lies in the supine position. It is a frequent cause of low maternal blood pressure (hypotension).Aortocaval compression is thought to be the cause of supine hypotensive syndrome. Supine hypotensive syndrome is characterized by pallor, bradycardia, sweating, nausea, hypotension, and dizziness and occurs when a pregnant woman lies on her back and resolves when she is turned on her side or by displacement of uterus.

Answer 2

A. DBP − PCWP

Answer 3

6. D: The four stages of the childbirth process are based on changes in the uterus and cervix as labor progresses. The first stage of labor begins at the onset of labor and ends when the cervix is 100% effaced and completely dilated to 10 centimeters. This is the longest stage of labor and can last 12-17 hours. The second stage begins when the cervix is completely effaced and dilated and ends with the birth of the baby, lasting about 1-2 hours. The third stage begins with the birth of the baby and ends with the delivery of the placenta. This is the shortest stage of labor, lasting 15-20 minutes. The fourth stage begins with delivery of the placenta and ends 1-2 hours after delivery.

Answer 4

17. D: In an adult, a normal count is about 150,000-400,000 (150-450) platelets per microliter of blood. If platelet levels fall below 20,000 per microliter, massive bleeding may occur and is considered a life-threatening risk.

Answer 5

48. B: Findings related to identification of esophageal atresia include inability to pass an oral gastric tube to the stomach, excessive oral secretions, and feeding intolerance. Management of these infants during transport should include the following: intermittent suction of the upper esophageal pouch, elevation of the head of the bed to prevent gastric reflux, and intravenous fluid therapy for fluids and glucose.

Answer 6

1. B: Signs and symptoms of uterine rupture include severe, sudden, continual abdominal pain and signs of hypovolemic shock. Contractions may cease or may increase in intensity and frequency. Shoulder (referred pain known as Kehr’s sign) or chest pain as a result of the collection of blood under the diaphragm, generalized tenderness with rebound, an abdominal mass with fetal parts easily felt, or vaginal bleeding is likely when the rupture occurs in the lower uterine segment. Most bleeding is intra-abdominal and the abdomen may be distended.

Answer 7

12. D: To release intrapleural pressure (tension pneumothorax), a large-bore needle should be placed into the pleural space. The second intercostal space, midclavicular approach is generally preferred. An alternate site approach is the fourth or fifth intercostal anterior midaxillary line. The anterior site is used to avoid the internal mammary vessels.

Answer 8

23. A: Acute respiratory failure (ARF) exists when breathing fails in its ability to maintain arterial blood gases within a normal range. By definition, ARF is present when the blood gases demonstrate a pO2 \< 60 mmHg (hypoxic respiratory failure) and a pCO2 \> 50 mmHg (ventilatory respiratory failure), which is usually accompanied by fall in the pH \< 7.3.

Answer 9

35. B: Falls from heights greater than 15-20 feet are associated with severe injuries. Three predictable injuries are seen with falls. The forces involved are deceleration and compression. The first injury, calcaneus fractures, is caused by compression of the feet on impact. Second, as the energy dissipates after impact and the top of the body pushes down toward the point of impact, compression fractures to T12-L1 are seen. Finally, as the body moves forward and the patient puts both arms out to complete the fall, bilateral wrist fractures occur. It is important to estimate the distance fallen and what the patient landed on. A soft-landing surface (dirt or sand) will absorb much more energy than a hard surface, such as concrete.

Answer 10

29. B: The Babinski’s sign can indicate upper motor neuron lesion constituting damage to the corticospinal tract (central nervous system). A normal Babinski’s reflex is plantar flexor (toes curl in “claw”) and an abnormal reflex is plantar extensor (toes fan out). In infants, the primitive reflexes are still present and will show an extensor reflex response. This happens because the corticospinal pathways that run from the brain down the spinal cord are not fully myelinated at this age, so the reflex is not inhibited by the cerebral cortex. The extensor response disappears and gives way to the flexor response around 12-24 months of age.

Answer 11

36. C: An elevated anion gap is associated with metabolic acidosis. Refer to the table in question 1 for review of causes for elevated anion gap.

Answer 12

B: Normal adult urinary output ranges from 30-50 mL/hour. Pediatric range is from 1-2 mL/kg/hour.

Answer 13

12. C: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is considered a complication of severe preeclampsia. HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of preeclampsia. Both conditions usually occur during the later stages of pregnancy or sometimes after childbirth. A platelet count lower than 100,000/mm−3 is characteristic of HELLP syndrome. Complications of PIH include eclampsia, placental abruption, pulmonary edema, DIC, hemolytic anemia, thrombocytopenia, preterm delivery, prematurity, IUGR, and HELLP. The only effective treatment is prompt delivery of the baby. Several medications have been investigated for the treatment of HELLP syndrome, but evidence is conflicting as to whether magnesium sulfate decreases the risk of seizures and progress to eclampsia. The DIC is treated with fresh, frozen plasma to replenish the coagulation proteins, and the anemia may require blood transfusion. In mild cases, corticosteroids and antihypertensives (labetalol, hydralazine, nifedipine) may be sufficient. Intravenous fluids are generally required.

Answer 14

4. D: The uniform should fit to allow 0.25 in. (1/4 in.) of air space between the suit and undergarments.

Answer 15

D: BNP is a blood test used to measure the amount of BNP hormone in the blood. BNP is produced by the heart and shows how well the heart is functioning. Normally, only a low amount of BNP is found in the heart. But if the heart has to work harder for a longer period of time, such as in heart failure, the heart releases more BNP, increasing the blood level of BNP. Lab findings— normal BNP level: 0-99 picograms per milliliter (pg/mL); Abnormal BNP level: 100 pg/mL or greater is indicative that heart failure may be present.

Answer 16

45. B: The best treatment for hydrocephalus is the placement of an extracranial shunt from the ventricles to an outside absorptive surface such as ventriculoperitoneal, ventriculoatrial, or ventriculopleural. Shunts usually consist of three parts: a. Proximal end that is radiopaque and is placed into the ventricle. This end has multiple small perforations. b. Valve—this allows for unidirectional flow. Can adjust various opening pressures. Usually has a reservoir that allows for checking shunt pressure and sampling CSF. c. Distal end that is placed into the peritoneum or another absorptive surface by tracking the tubing subcutaneously.

Answer 17

26. B: Tidal volume (Vt) is calculated in milliliters per kilogram. Traditionally 10-15 mL/kg was used but has been shown to cause barotrauma, or injury to the lung by overextension, so 6-8 mL/kg is now common practice in ICU for adults and older children. For infants and younger children without existing lung disease—a TV of 4-8 mL/kg to be delivered at a rate of 30-35 breaths/minute.

Answer 18

18. B: Loss of sympathetic tone below the level of the injury results in loss of autoregulation, a decrease in vascular tone, and inability of the heart to increase its intrinisic rate. The classic picture of neurogenic shock presents with the absence of tachycardia.

Answer 19

27. D: The pH is normal, HCO3 is low (acidosis), and the pCO2 is low (alkalosis). When both HCO3 and pCO2 are turned in opposite directions, the etiology is usually metabolic. The primary mechanism is a metabolic acidosis that has been fully compensated by respiratory alkalosis, making the pH within normal range.

Answer 20

21. A: Hydralazine (Apresoline) acts by relaxing arterioles and decreasing vasospasm, and as a result, it reduces blood pressure and stimulates cardiac output. Hydralazine is recommended when the diastolic blood pressure is 100 mmHg or greater. Two milligrams administered intravenously every five minutes until the diastolic blood pressure ranges between 90-100 mmHg.

Answer 21

32. D: Tocolytics are medicines that attempt to stop labor. The typical dosage of Terbutaline (brethine) is 0.25 mg subcutaneously every twenty minutes to three hours. The drug is discontinued if the maternal heart rate exceeds 120 beats/minute. Terbutaline is contraindicated if the mother has cardiac dysrhythmia. The principal maternal adverse effects are hyperglycemia, cardiac dysrhythmias, myocardial ischemia, pulmonary edema, hypotension, and tachycardia. The infrequent fetal and newborn adverse effects are fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, and myocardial ischemia. Because of the risk of hyperinsulinemia, newborns may develop hypoglycemia.

Answer 22

10. B: Linear stellate is a skull fracture with multiple linear fractures radiating from the site of impact. A growing skull fracture (GSF) also known as a craniocerebral erosion or leptomeningeal cyst due to the usual development of a cystic mass filled with cerebral spinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children below three years of age. There are four major types of skull fractures: linear, compressed, distatic, and basilar.

Answer 23

48. A: Early signs and symptoms of a tension pneumothorax can be characterized by increased work of breathing, tachycardia, pulsus paradoxus, narrowing pulse pressure, and breath’s sounds diminished on the affected side. Late signs and symptoms of decompensated obstructive shock include cyanosis, hypoxemia hypotension, bradycardia, and confusion. The affected side of the chest may be hyper-expanded and show decreased movement, with increased movement on the other side. The breath sounds may be diminished or absent on the affected side, as air in the pleural space dampens sound and percussion of the chest may sound hyperresonant (higher pitched). In very severe cases, the respiratory rate falls sharply, which may result in further shock and coma. Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Particular clinical signs may also be less useful in the recognition of tension pneumothorax, such as the deviation of the trachea away from the affected side and the presence of increased jugular venous pressure.

Answer 24

4. B: Variable decelerations can occur at any time during a contraction. The shape may also vary and is frequently V-shaped or W-shaped. Cord compression is responsible for these decelerations, which have a very characteristic appearance; frequently a short acceleration is observed, followed by a rapid deceleration for some seconds, then a rapid rise and a short acceleration before there is a return to the fetal heart rate (FHR) baseline. There are two keys in to interpreting FHR tracings: one is to focus on assessment of variability and second is to accurately identify the type of deceleration.

Answer 25

39. B: Romazicon has the possibility of causing severe adverse effects including seizures, adverse cardiac effects, and death. In the majority of cases, there is no indication for the use of flumazenil in the management of benzodiazepine overdose as the risks generally outweigh any potential benefit of administration. Additionally, if full airway protection has been achieved, a good outcome is expected and therefore, flumazenil administration is unlikely to be required.

Answer 26

33. C: The ABG interpretation of a pH 7.52, pCO2 27 and HCO3 24 is a noncompensated respiratory alkalosis, which is present is early salicylate poisoning. The metabolic changes eventually lead to renal depletion of fluids and electrolytes, hypoglycemia, hypokalemia, and a mixed presentation of respiratory and metabolic alkalosis coupled with metabolic acidosis, which may provoke cardiac dysrhythmias, acute pulmonary edema, renal failure or neurological injury. The clinical presentation of salicylate poisoning can also include gastrointestinal bleeding and an unexplained elevated anion gap (metabolic acidosis). Salicylate levels are obtained four to six hours after ingestion. Earlier samples may be unreliable because the pharmacokinetics is not stable before that time. The most important information in assessing severity, however is the patient’s clinical condition.

Answer 27

35. A: Preparation for endotracheal intubation is the most overlooked but often the most important part of the procedure. Being properly prepared for problems that may arise can often prevent life-threatening complications during intubation. Use of cuffed ET tubes is recommended for children over the age of eight years and adults. Use of uncuffed ET tubes is recommended for children under the age of eight years because the normal narrowing at the cricoid cartilage functions as the “natural cuff.” Alternative method is using the length-based Broselow tape. Remember that an intubated child is at risk for the displacement of the ETT, ETT plugging, pneumothorax, or an equipment failure (ventilator malfunction). Assume that any deterioration in the child’s status is an airway problem until that is ruled out as a cause. “DOPE” is a useful mnemonic to remember potential causes of airway or ventilation problems in intubated patients.

Answer 28

34. B: The most effective way to diagnose aceteminophen poisoning is by obtaining a blood acetominophen level. A drug nomogram developed in 1975, called the Rumack-Matthew nomogram, estimates the risk of toxicity based on the serum concentration of acetominophen at a given number of hours after ingestion. Use of a timed serum paracetamol level plotted on the nomogram appears to be the best marker, indicating the potential for liver injury. Acetominophen level drawn in the first four hours after ingestion may underestimate the amount in the system because acetominophen may still be in the process of being absorbed from the gastrointestinal tract. Therefore, a serum level taken before four hours is not recommended. The toxic dose of acetominophen is highly variable. In adults, single doses above 10 grams or 200 mg/kg of bodyweight, whichever is lower, have a reasonable likelihood of causing toxicity. In children acute doses above 200 mg/kg could potentially cause toxicity. Damage to the liver, or hepatotoxicity results not from Tylenol itself but from one of its metobolites, N-acetyl-p-benzoquinonemine (NAPQI). NAPQI depletes the liver’s natural antioxidant glutathione and directly damages cells in the liver, leading to liver failure. Treatment is aimed at removing the acetominophen from the body and replacing glutathione. Activated charcoal can be used to decrease absorption of acetominophen if the patient presents for treatment soon after the overdose; the antidote N-acetylcysteine (NAC) acts as a precursor for glutathione, helping the body regenerate enough to prevent damage to the liver. A liver transplant is often required if damage to the liver becomes severe.

Answer 29

39. C: Midazolam (versed) is classified as a benzodiazepine, schedule II controlled drug. It has potent anxiolytic, amnestic, hypnotic, anticonvulsant, skeletal muscle relaxant, and sedative properties. Major adverse effects include hypotension and respiratory depression and/or arrest. Flumazenil is a benzodiazepine antagonist that can be used to treat an overdose as well to reverse sedation. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 172). Xlibris. Kindle Edition.

Answer 30

3. C: A hyperstimulated uterus may have fewer than five contractions in ten minutes, but the interval between contractions is less than one minute. Another term used to describe long, strong contractions is “titanic.” An overdose of oxytocin may cause this type of uterine activity.

Answer 31

5. D: Respiratory alkalosis can be present initially as evidenced by an increase in respiratory rate in early shock as the body attempts to compensate for blood/volume loss in the compensatory stage. Other early signs of shock in the compensatory stage can include increase in heart rate, narrowing pulse pressure, and thirst.

Answer 32

11. C: A uniform sine wave pattern indicates fetal hypovolemia or anemia and may occur in cases of erythroblastosis fetalis, accidental tap of the umbilical cord during amniocentesis, fetomaternal transfusion, placental abruption, or another type of accident. Variability will be absent or minimal and accelerations are not seen. When this pattern is recognized, rapid delivery is usually recommended. A pseudosinusoidal or undulating pattern may be identified and can be associated to maternal drug administration of narcotics. The pseudo-sinusoidal FHR pattern appears very similar to the sinusoidal pattern; however, this pattern shows less regularity in the shape and amplitude of the variability waves. This type of pattern is benign and transient and can occur in the presence of narcotics. A saltatory FHR pattern is rapidly occurring couples of acceleration and deceleration causing relatively large oscillations of the baseline fetal heart rate. This pattern is usually caused by acute hypoxia or mechanical compression of the umbilical cord. It is considered a nonreassuring pattern, but it is not usually an indication for immediate delivery. A reassuring FHR pattern is the presence of fetal heart rate accelerations. This usually indicates there is no academia and is generally indicative of fetal well-being. In most cases, moderate variability is also reassuring but few studies exist to support this contention. When the fetal heart has absent or minimal variability without spontaneous accelerations and the fetal heart rate status does not change despite intervention, these findings are nonreassuring. A nonreassuring FHR pattern is the standard terminology to be used to describe threats to fetal well-being or indicators of fetal compromise. This term replaces such terms as fetal distress or fetal stress.

Answer 33

8. A: Histotoxic hypoxia is the inability of cells to take up or utilize oxygen from the bloodstream, despite physiologically normal delivery of oxygen to such cells and tissues. Histotoxic hypoxia results from tissue poisoning, such as that caused by alcohol, narcotics, cyanide (which acts by inhibiting cytochrome oxidase), and certain other poisons like hydrogen sulfide (byproduct of sewage and used in leather tanning). Hypemic hypoxia is where arterial oxygen pressure is normal, but total oxygen content of the blood is reduced, as from various types of anemia or from a loss of blood. Stagnant hypoxia occurs when conditions exist (cerebral ischemia, ischemic heart disease, intrauterine hypoxia) that result in reduced cardiac output, pooling of the blood within certain regions of the body, a decreased blood flow to the tissues, or restriction of blood.

Answer 34

A: Kussmual’s sign is a rise in venous pressure with inspiration (JVD), which can be indicative of (RVI) and cardiac tamponade.

Answer 35

44. B: Widespread pulmonary infiltrates that is ground glassy in appearance. ARDS results from a severe alteration in pulmonary vascular permeability, which leads to a change in the lung structure and function. The outstanding characteristic is hypoxemia refractory to oxygen therapy. ARDS is most commonly seen in patients with direct or indirect acute lung injury. Because ARDS is a complication of other illnesses or injuries, the transport team must also consider the pathophysiology of the underlying problem.

Answer 36

45. C: Absence of wheezing may indicate that the patient is not able to ventilate sufficiently to produce breath sounds. The problem with a patient presenting with asthma is a prolonged expiratory phase, which can cause air trapping. These patients are not able to exhale adequately. The physical examination can reveal different degrees of respiratory distress based on the severity of their condition. The transport team should consider the situation emergent if an asthma patient presents in respiratory distress without wheezing and has difficulty in speaking. Acute respiratory failure is defined as a pO2 50 mmHg.

Answer 37

21. D: A left shift causes an increase in the affinity, making the oxygen easier for the hemoglobin to pick up but harder to release. Refer to the table for review of causes.

Answer 38

43. C: Circumferential burns to the chest or extremities represent the more easily recognizable complications of burn care. Circumferential burns to the chest wall decrease chest wall compliance, creating respiratory insufficiency and hypoxia, especially in the pediatric patient. The treatment for this problem is an escharotomy, which allows the chest to expand fully for more efficient ventilation. Circumferential burns to the extremities or digits can be equally threatening to the circulatory stability of the affected limb, producing the “five Ps” that represent the signs and symptoms of an arterial injury: pain, pallor, pulselessness, paresthesias, and paralysis. Escharotomies ideally should be performed before transport of the patient and should be performed only under the direction of a medical physician.

Answer 39

B. Stop GI bleeding and evacuate bowel of blood Evacuation of gut-derived toxins (intestinal blood, bacteria) and administration of Lactulose (orally or as an enema) is one of the cornerstones of the treatment of hepatic encephalopathy.

Answer 40

17. B: The pCO2 is decreased and the pH is increased, indicating a respiratory alkalosis. The HCO3 is normal, indicating there is no compensation.

Answer 41

D: Hypothroidism occurs primarily in women, almost exclusively over the age of sixty, with 90% of the cases occurring in the winter months.

Answer 42

39. B: Clinical evaluation of brain death can be performed with the application of the oculovestibular reflex (cold-caloric exam). With head on bed at 30 degrees, instill 50 mL of iced water into ear canal. A normal response (presence of oculovestibular reflex) is tonic deviation of the eyes toward the irrigated ear.

Answer 43

17. A: Ethylene glycol poisoning is caused by the ingestion of ethylene glycol (the primary ingredient in both automotive antifreeze and hydraulic brake fluid). It is a toxic, colorless, odorless, and almost nonvolatile liquid with a sweet taste and is occasionally consumed by children for its sweetness. Following ingestion, the symptoms of poisoning follow a three-step progression starting with intoxication and vomiting, before causing metabolic acidosis, cardiovascular dysfunction, and finally acute kidney failure. Treatment consists of initially stabilizing the patient followed by the use of antidotes. The antidotes used are either ethanol or fomepizole (Antizol) administered by intravenous infusion. The antidotes work by blocking the enzyme responsible for metabolizing ethylene glycol and therefore halt the progression of poisoning. Hemodialysis is also used to help remove ethylene glycol and its metabolites from the blood.

Answer 44

50. A: Tricyclic antidepressants, (commonly called TCAs) have been prescribed since the 1950s for depression. Examples of TCAs are imipramine (Tofranil), amitriptyline (Elavil) and nortriptyline (Pamelor). Sinus tachycardia, the result of anticholinergic effects, often occurs with therapeutic doses of tricyclic antidepressants and has been a poor marker for serious toxicity. In a small study of patients with an acute overdose of tricyclic antidepressants, QRS prolongation, probably a manifestation of the quinidinelike effects of the drugs, was a better predictor of seizures and ventricular arrhythmias than was a serum drug level. Sodium loading may be the most important factor in the reversal of the symptoms of cyclic antidepressant toxicity. Prolonged QRS is most often the indication for serum alkalinization in TCA toxicity. Although beta-blockers were once contraindicated in CHF, as they have the potential to worsen the condition, studies in the late 1990s showed their positive effects on morbidity and mortality in CHF. Bisoprolol, carvedilol, and sustained-release metoprolol are specifically indicated as adjuncts to standard ACE inhibitor and diuretic therapy in CHF. Beta-blockers are primarily known for their reductive effect on heart rate, although this is not the only mechanism of action of importance in CHF. Beta-blockers, in addition to their sympatholytic B1 activity in the heart, influence the renin/angiotensin system at the kidneys. Beta-blockers cause a decrease in renin secretion, which, in turn, reduce the heart oxygen demand by lowering extracellular volume and increasing the oxygen-carrying capacity of blood. Beta-blockers’ sympatholytic activity reduce heart rate, thereby increasing the ejection fraction of the heart despite an initial reduction in ejection fraction. Glucagon has been used in the treatment of overdose. Glucagon has a positive inotropic action on the heart and decreases renal vascular resistance. It is, therefore, useful in patients with beta-blocker cardiotoxicity. Cardiac pacing should be reserved for patients unresponsive to pharmacological therapy. The most widespread clinical usage of calcium channel blockers is to decrease blood pressure in patients with hypertension, with particular efficacy in treating elderly patients. With a relatively low blood pressure, the afterload on the heart decreases; this decreases the amount of oxygen required by the heart. Calcium channel blockers, frequently, are used to control heart rate, prevent cerebral vasospasm, and reduce chest pain due to angina pectoris. Most calcium channel blockers decrease the force of contraction of the myocardium. Calcium channel blockers work by blocking voltage-gated calcium channels in cardiac muscle and blood vessels. This decreases intracellular calcium, leading to a reduction in muscle contraction. In the heart, a decrease in calcium available for each beat results in a decrease in cardiac contractility. It is because of the negative inotropic effects of most calcium channel blockers that they are avoided (or used with caution) in individuals with cardiomyopathy. Many calcium channel blockers also slow down the conduction of electrical activity within the heart by blocking the calcium channel during the plateau phase of the action potential of the heart. This results in a negative chronotropic effect, resulting in a lowering of the heart rate and the potential for heart block. The negative chronotropic effects of calcium channel blockers make them a commonly used class of agents in individuals with atrial fibrillation or flutter in whom control of the heart rate is an issue. Treatment of calcium channel blocker toxicity involves intravenous calcium, atropine, fluids, insulin, and inotropes. Insulin is required because, at high doses, calcium channel blockers block the effect of insulin.

Answer 45

26. B: The use of etomidate for continued sedation of critically ill patients has been associated with increased mortality, which is due to suppression of steroid synthesis (both glucocorticoids and mineralocorticoids) in the adrenal cortex, which sometimes leads to death due to an adrenal crisis. There is no evidence that a single induction dose of etomidate has any effect on morbidity or mortality.

Answer 46

8. C: Normal serum magnesium level ranges from 1.5-2.5. Therapeutic serum magnesium levels to prevent seizures range from approximately 4-8 mEq/L. When therapeutic levels are achieved, deep tendon reflexes will be depressed but not absent. Loss of deep tendon reflexes indicates a toxic level. Respiratory arrest and cardiac arrest are seen with high toxic levels \>15 mEq/L. While a patient is receiving intravenous magnesium sulfate, frequent assessment of deep tendon reflexes is essential. Respirations should also be closely monitored and the infusion stopped if less than twelve breaths per minute. Pulse oximetry should be used during transport. The antidote for magnesium sulfate toxicity is calcium gluconate. Calcium stimulates the release of acetylcholine, stimulating nerve transmission to the muscle. The recommended dosage of calcium gluconate is 1 gram of a 10% solution administered intravenously over at least three minutes. If administered too rapidly, bradycardia and dysrhythmias may occur.

Answer 47

36. A: Chemical burns differ from thermal burns in that the burning process continues until the agent is inactivated by reaction of tissues: neutralized or diluted with water. Dry chemicals, such as lime, should be brushed off before irrigation. Water and physiologic saline are fluids of choice for wound irrigation.

Answer 48

45. C: Many organophosphates are potent nerve agents, functioning by inhibiting the action of acetylcholinesterase (AChE) in nerve cells. They are one of the most common causes of poisoning worldwide, and are frequently intentionally used in suicides in agricultural areas. The effects of organophosphate poisoning are recalled using the mnemonic SLUDGE (salivation, lacrimation, urination, defecation, gastrointestinal motility, emesis). These side effects occur because of the excess acetylcholine that results from blocking acetylcholinesterase. In addition, bronchospasm, blurred vision, and bradycardia may result. Another mnemonic is DUMBBELSS, which stands for diarrhea, urination, miosis, bradycardia, bronchoconstriction, excitation (as of muscle in the form of fasciculations and CNS), lacrimation, salivation, and sweating.

Answer 49

B. Increased ammonia levels Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.

Answer 50

20. B: Decompression illness (DCI) describes a collection of symptoms arising from decompression of the body. DCI is caused by two different mechanisms, which result in overlapping sets of symptoms. The two mechanisms are the following: Decompression Sickness (DCS), which results from gas dissolved in body tissue under pressure, precipitating out of solution and forming bubbles on decompression. It typically afflicts scuba divers on poorly managed ascent from depth or aviators flying in inadequately pressurized aircraft. Arterial gas embolism (AGE), which is gas bubbles in the bloodstream. In the context of DCI these may form either as a result of precipitation of dissolved gas into the blood on depressurization, as for DCS above, or by gas entering the blood mechanically as a result of pulmonary barotrauma. Pulmonary barotrauma is a rupturing of the lungs by internal overpressurization caused by the expansion of air held in the lungs on depressurization such as a scuba diver ascending while holding the breath or the explosive decompression of an aircraft cabin or other working environment. Immediate treatment of DCS and AGE are to establish basic and advanced life-support measures, place the patient in left lateral decubitus position (Durante position) has been recommended to minimize further passage of air emboli to the brain and transport to the closest hyperbaric treatment facility for recompression. Patients should be transported in an aircraft with cabin pressurized to 1 ATA. If the aircraft cannot be pressurized to 1 ATA, such as a helicopter, it should be flown at the lowest and safest altitude possible, preferably below 1,000 feet above sea level.

Answer 51

20. C: Pneumothorax can trigger high-pressure alarms when resistance to ventilation is too high.

Answer 52

32. C: Dalton’s law of partial pressures states that the total pressure of a gas mixture is the sum of the individual or partial pressures of all the gases in the mixture.

Answer 53

47. A: During an actual flight emergency, flight team members are responsible for confirming with the pilot that an actual emergency crisis exists and assisting as necessary, shutting off the main oxygen supply, preparing patients by placing them flat and tightening the stretcher straps, and securing all equipment. As the final step in preparation, the flight team members should have their helmet visors in down position and get into the survival position by placing the arms across the chest, forming an “X” with the forearms, and grasping the shoulder harness, while placing the knees together and the feet approximately 6 in. apart.

Answer 54

43. B: Brown recluse spiders usually have a dark violin-shaped mark on their cephalothorax, just behind their eyes, resulting in the nicknames fiddleback spider, brown fiddler, or violin spider. Unlike most spiders, the brown recluse has six eyes arranged in three pairs, instead of the usual eight. The bite forms a necrotizing ulcer, “bull’s-eye” in appearance, that destroys soft tissue and may take months to heal, leaving deep scars. These bites usually become painful and itchy within 2-8 hours. Pain and other local effects worsen 12-36 hours after the bite, and the necrosis develops over the next few days. Over time, the wound may grow to as large as 25 cm (10 in.) in extreme cases. The damaged tissue becomes gangrenous and eventually sloughs away.

Answer 55

26. B: Lysergic acid diethylamide (LSD) is the most potent hallucinogen known. Phencyclidine (PCP), also known as angel dust and other street names, is a recreational, dissociative drug formerly used as an anesthetic agent, exhibiting hallucinogenic and neurotoxic effects. Patients may become hostile, beligerent, and destructive. A common neurologic sign of PCP intoxication is nystagmus. Extreme caution should be taken during transport; use of ear protection, sedation, and restraints may be necessary prior to transport. In extreme situations, sedation and neuromuscular blocking agents, with airway control, may be necessary to safely transport these patients.

Answer 56

23. D: A pneumothorax can lead to severe oxygen shortage and low blood pressure, progressing to cardiac arrest unless treated; this situation is termed as tension pneumothorax. Clinical presentation can include dyspnea, tachycardia, altered mentation, narrowing pulse pressure, pulsus paradoxus, jugular venous distension, hypotension, diminished/absent breath sounds on the affected side, shock, and cardiac arrest. Initial treatment of a tension pneumothorax is performing a needle thoracostomy, with definitive treatment to include placement of a chest tube. To release intrapleural pressure, a large-bore needle should be placed into the second intercostal space, two-finger breadths lateral to the sternal border on the affected side. The needle should then be placed superior to the rib margin to avoid the intercostal artery. The anterior site should be used for avoidance of the internal mammary vessels.

Answer 57

3. A: Salicylate toxicity initially manifests in an increased respiratory rate and hyperventilation. Blood gas analysis usually reflects respiratory alkalosis. Clinical manifestations of mild intoxication include headache, vertigo, tinnitus (ringing in the ears), mental confusion, sweating, and thirst. Severe intoxication produces similar symptoms combined with base/electrolyte imbalances. Patients are agitated, restless, and uncommunicative and may have seizures or become comatose. Noncardiac pulmonary edema is observed in severe poisoning, whereas bleeding diatheses are less common. Treatment involves gastric emptying, administration of oral-activated charcoal, and alkaline diuresis. The severely poisoned patient may require hemodialysis. Refer to the table for review of estimated dose ingested and toxic reaction.

Answer 58

34. B: Injuries associated with a side-impact motorcycle crash are related to the body parts crushed between the cycle and the second object. Most commonly seen injuries involve the leg and foot on the impact side. Open fracture of the femur, tibia/fibula, and malleolus are predictable. Motorcycle riders have learned the technique of laying down the bike and sliding off to the side before colliding with another object. Commonly seen are abrasions on the affected side.

Answer 59

9. D: Acute hemolytic reaction can occur within minutes of the transfusion. The most common immediate adverse reactions to transfusion are fever, chills, and urticaria. The most potentially significant reactions include acute and delayed hemolytic transfusion reactions and bacterial contamination of blood products. During the early stages of a reaction, it may be difficult to ascertain the cause. Citrate is the anticoagulant used in blood products. It is usually rapidly metabolized by the liver. Rapid administration of large quantities of stored blood may cause citrate toxicity, resulting in hypocalcaemia and hypomagnesemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion.

Answer 60

D. Gallbladder Right upper quadrant pain, may indicate gallbladder disease

Answer 61

17. A: Sinus tachycardia is the most common cardiac disturbance seen following TCA overdose. TCAs remain widely prescribed for depression and an increasing number of other indications, including anxiety disorders. TCA overdose is a significant cause of fatal drug poisoning. The severe morbidity and mortality associated with these drugs is well documented due to their cardiovascular and neurological toxicity. Additionally, it is a serious problem in the pediatric population due to their inherent toxicity and the availability of these in the home when prescribed for bed wetting and depression. An overdose on TCA is, especially, fatal as they are rapidly absorbed from GI tract in the alkaline conditions of the small intestines. As a result, toxicity often becomes apparent in the first hour after an overdose. However, symptoms may take several hours to appear if a mixed overdose has caused delayed gastric emptying. Many of the initial signs are those associated to the anticholinergic effects of TCAs such as dry mouth, blurred vision, urinary retention, constipation, dizziness, emesis, tachycardia, mydriasis (pupil dilation), fever, and flushing (skin redness). Treatment depends on severity of symptoms and can include the administration of IV fluids, and pressor agents (alpha-adrenergic agents are preferred). GI decontamination may be helpful within the first several hours postingestion because TCAs can slow gastric emptying through the anticholinergic activity. Activated charcoal reduces the absorption of TCAs. It may also be beneficial in cases of multi-substance ingestion. It should be administered only in patients who are able to protect the airway. If there is a metabolic acidosis and/or ECG changes present (prolonged QT interval, QRS widening), infusion of sodium bicarbonate is recommended. Physostigmine is not an antidote to cyclic antidepressant poisoning and should not be used on these patients. Commonly known TCAs, among others, are amitriptyline (Elavil, Tryptizol, Laroxyl); doxepin (Adapin, Sinequan); imipramine (Tofranil, Janimine, Praminil); nortriptyline (Pamelor, Aventyl). The toxic effects of tricyclics are results of the following four main pharmacologic properties: 1. Inhibition of norepinephrine and serotonin reuptake at nerve terminals 2. Anticholinergic action 3. Direct alpha-adrenergic blockade 4. Membrane-stabilizing effect on the myocardium by blocking the cardiac myocyte fast sodium channels

Answer 62

5. C: The integumentary system is the largest organ system that protects the body from damage, comprising the skin and its appendages (including hair, scales, feathers, and nails). The integumentary system has a variety of functions; it may serve as waterproof, cushion, and protect the deeper tissues, excrete wastes, regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans, the integumentary system also provides vitamin D synthesis.

Answer 63

16. A: The FIO2 can be increased and/or application of/or increasing PEEP can also provide acceptable oxygenation levels.

Answer 64

22. B: A ventilation/perfusion lung scan, also known as a V/Q lung scan, is a type of medical imaging that is used to evaluate the circulation of air and blood within the lungs. The ventilation portion of the exam assesses the ability of air to reach all sections of the lungs, and the perfusion portion evaluates how well blood circulates within the lungs. The test is commonly done to evaluate for the presence of blood clots or abnormal blood flow inside the lungs, such as a pulmonary embolism (PE).

Answer 65

31. A: Once in the water, the flight team can minimize heat loss by using the HELP. Flight crew members can achieve this position by bringing the knees up to the chest and putting the arms across the chest. The flotation device must be used with the HELP to stay afloat. The surviving flight team should huddle together to decrease heat loss. Protection against exposure, care of the raft, and signaling are the primary objectives in open-water survival.

Answer 66

22. D: Low serum sodium levels following traumatic brain injury (TBI) can lead to extracellular volume depletion and cerebral edema. These can all result in dangerous increases in ICP. Hypertonic saline can help avoid the negative effects of hyponatremia by increasing serum sodium levels in the acute phase of head trauma care (Johnson and Criddle, 2004; Suarez, 2004). Maintaining serum sodium levels of 145-155 mmol/L is likely to achieve this goal. Serum sodium levels should be maintained no higher than 155 mmol/L. Higher levels are dangerous. Patients with serum sodium levels higher than 160 mmol/L are at increased risk for treatment-related renal failure, pulmonary edema, and heart failure. If serum sodium levels remain above 160 mmol/L for more than 48 hours, the risk of these problems increases even more. Furthermore, if serum sodium levels climb beyond 160 mmol/L, patients are at risk for seizures. The target serum osmolarity is less than 320 mOsmol/L. At higher levels, patients are at increased risk for treatment-related renal failure (Qureshi and Suarez, 2000; Suarez, 2004).

Answer 67

2. B: Once the burning process has been stopped, the patient should be volume resuscitated according to the Parkland formula. This formula dictates the amount of Lactated Ringer’s solution or Hartmann’s solution to deliver in the first twenty-four hours after the time of injury. Half of this volume is given in the first eight hours with the remaining half to be administered in the subsequent sixteen hours. This formula excludes first-degree burns, so erythema (redness of the skin) alone is discounted.

Answer 68

C: Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction.

Answer 69

28. C: ARDS, also known as respiratory distress syndrome (RDS); lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma, which leads to impaired gas change, resulting in a severe oxygenation defect (hypoxemia). Their compliance is typically reduced, and their dead space increased. ARDS has gradually shifted to mean acute rather than adult. A less severe form is called acute lung injury (ALI).

Answer 70

3. A: Gay-Lussac’s law states that the pressure of a sample of gas at constant volume is directly proportional to its temperature. Simply, if a gas temperature decreases, then so does its pressure, if the mass and volume of the gas are held constant. The oxygen tank pressure (psi) changes are directly proportional to temperature is an example of this law.

Answer 71

1. D: Epinephrine (adrenaline) is a hormone and neurotransmitter. It increases heart rate (beta 1 and inotropic effect), contracts blood vessels (alpha property), dilates air passages (beta-2 property), and participates in the fight-or-flight response of the sympathetic nervous system. A pediatric dosage of 0.01 mg/kg (intravenous or intraosseous route) is recommended every 3-5 minutes as needed. Endotracheal tube route dosage is 0.1 mg/kg body weight (0.1 mL of a 1:1,000 solution). Adrenaline is used as a drug to treat cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac output. Its primary action initially is to increase peripheral resistance via alpha receptor-dependent vasoconstriction and secondly is to increase cardiac output via its binding to beta-receptors.

Answer 72

48. A: Meningitis is inflammation of the meninges, which are the protective coverings that are present over the brain and the spinal cord. This inflammation can be either bacterial or viral in nature. Some of the common symptoms that the patient presents with include headache and neck stiffness. This is a serious and possibly fatal condition, as the inflammation of the meninges can easily spread to the brain and the spinal cord, thus, causing life-threatening complications. One of the important bacterial meningitis precautions is to see to it that the patient wears a face mask at all times. This is of paramount importance because bacterial meningitis is contagious in nature, and it is a droplet infection. H. influenzae and N meningitis may be transmitted by droplets generated during coughing, sneezing, talking, or procedures, such as intubation and bronchoscopy. Droplet precautions should therefore be used whenever there is a clinical suspicion of infection with one of these pathogens. Traditional systems of isolation precautions have relied on an understanding of the mechanisms by which disease can be spread and have focused the use of protective barrier equipment, such as gloves, gowns, masks, and protective eyewear in order to interrupt transmission and to break the chain of infection.

Answer 73

37. C: VHF low-band FM (30-50 MHz); the VHF radio signal in this band follows the curvature of the earth and has the greatest range.

Answer 74

34. B: Elevated peak inspiratory pressures (PIP) can be managed by decreasing the flow rate and tidal volume initially. If necessary, increasing the respiratory rate can be done to correct an underlying respiratory acidosis.

Answer 75

16. C: Each program must have a policy that allows any crew member to refuse or abort a flight if they feel uncomfortable. The flight is aborted because the weather minimum of 800 foot ceiling and 1 mile visibility is less than the specified minimums recommended for local-night with the use of NVG of a 800 foot ceiling and 3 mile of visibility.

Answer 76

25. A: Boyle’s law describes the inversely proportional relationship between the absolute pressure and volume of a gas, if the temperature is kept constant within a closed system.

Answer 77

29. A: The FARs are rules prescribed by the FAA governing all aviation activities in the United States. Pilots need to be mindful that the “eight-hour bottle-to-throttle” rule is the absolute minimum. Some individuals may require a longer period between drinking and flying depending on the amount of alcohol consumed and their personal metabolism.

Answer 78

35. A: Once it is established that a duty exists, the second element is a breach of duty. Breach of duty may occur as a result of malfeasance (act of commission) or nonfeasance (act of omission). Administering the wrong medication would be malfeasance, whereas failure to follow a procedure would be nonfeasance.

Answer 79

39. C: A radio repeater is a combination of a radio receiver and a radio transmitter that receives a weak or low-level signal and retransmits it at a higher level or higher power, so that the signal can cover longer distances without degradation. A repeater system is a type of half duplex system that involves a base station “repeater” at an elevated site remote from the communications center. A repeater system receives a signal on one frequency and instantly retransmits it on a second frequency to the other radios in the system, extending the communication’s center’s range. The process is reversed when the repeater receives signals coming into the base station.

Answer 80

43. A: In 1988, the National Transportation Safety Board (NTSB) released the results of an investigation of fifty-nine EMS accidents that occurred between 1978 and 1986. The study concluded that weather-related (pushing the weather) accidents were the most common and most serious type of accident experienced by EMS helicopters. In comparison with the 1980s, the 1990s saw a 10% increase in weather-related accidents.

Answer 81

8. A: Persistent pulmonary hypertension of the newborn (PPHN) results in a right-to-left shunt at the ductus arteriosus or the foramen ovale, leading to hypoxemia in the presence of a structurally normal heart. Demonstration of right-to-left shunting at the ductus using preductal and postductal simultaneous arterial blood gas (ABG) levels is helpful in the diagnosis.

Answer 82

9. B: Apnea and hypoventilation are the most common side effects complicating transport with the use of PGE 1. The length of transport and the difficulty of placing an ETT during transport must be considered in the decision of whether to place an ETT before transport when prostaglandins are begun. Other side effects can include fever, vasodilation with flushing, and diarrhea. Uncommonly, the vasodilation may result in systemic hypotension requiring intervention.

Answer 83

10. A: In newborns, a medication such as indomethacin or ibuprofen can be given to accelerate closure of the PDA. These medications are given in the stomach and can constrict the muscle in the wall of the PDA and promote closure. These drugs do have side effects, however, such as kidney injury or bleeding, so not all infants can receive them. Because of the potential side effects, the infant must have lab values checked before medications can be given. If the lab values are not normal or if the medications do not work, surgery can be performed and the PDA tied off (ligated).

Answer 84

46. B: The infant who is hypoxic in room air but demonstrates a partial pressure of oxygen (pO2), greater than 150 in 100% oxygen is more likely to have pulmonary disease than heart disease with a fixed right-to-left shunt. Comparison of simultaneous ABGs demonstrating a PaO2 at least 10 mm higher from a preductal site versus a postductul site indicates right-to-left shunting of desaturated blood at the ductal level.

Answer 85

2. D: Mauriceau’s maneuver is a method of delivering the head in an assisted vaginal breech delivery in which the infant’s body is supported by the right forearm while traction is made upon the shoulders by the left hand. The fetal head is maintained in a flexed position by using the Mauriceau’s maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck. In the breech presentation, the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation. Certain factors can encourage a breech presentation. Prematurity is likely the chief cause. There are either three or four main categories of breech births, depending upon the source. Total breech extraction is where the fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head.

Answer 86

15. B: The commonly used terms Rh factor, Rh positive, and Rh negative refer to the D antigen only. Rho(D) immune globulin is a medicine solution of IgG anti-D (anti-RhD) antibodies used to prevent the immunological condition known as Rhesus disease (or hemolytic disease of newborn). The disease ranges from mild to severe. When the disease is mild, the fetus may have mild anemia with reticulocytosis. When the disease is moderate or severe, the fetus can have a more marked anemia and erythroblastosis (erythroblastosis fetalis). When the disease is very severe, it can cause morbus hemolyticus neonatorum, hydrops fetalis, or stillbirth. During any pregnancy, a small amount of the baby’s blood can enter the mother’s circulation. If the mother is Rh negative and the baby is Rh positive, the mother produces antibodies (including IgG) against the Rhesus D antigen on her baby’s red blood cells. During this and subsequent pregnancies, the IgG is able to pass through the placenta into the fetus and if the level of it is sufficient, it will cause destruction of Rhesus D positive fetal red blood cells, leading to the development of Rh disease. The medication has an FDA Pregnancy Category C. It is given by intramuscular injection as part of modern routine antenatal care at about twenty-eight weeks of pregnancy, and within seventy-two hours after childbirth. It is also given after antenatal pathological events that are likely to cause a fetomaternal hemorrhage.

Answer 87

38. C: Sinusoidal FHR pattern, which are excluded from the definition of variability are described as a smooth, sine wave-like pattern of regular frequency and amplitude.

Answer 88

39. B: Preeclampsia is a disease characterized by high blood pressure, swelling of the face and hands, and protein in the urine after the twentieth week of pregnancy. The most common symptom and hallmark of preeclampsia is high blood pressure. This may be the first or only symptom. Blood pressure may be only minimally elevated initially or can be dangerously high; symptoms may or may not be present. The blood pressure is considered to be elevated if the systolic pressure has increased by 30 mmHg or more, or if the diastolic pressure has increased by 15 mmHg or more, above the blood pressure obtained during the first trimester. Generally, a blood pressure of 140/90 mmHg or more is considered above the normal range.

Answer 89

45. B: The mean fetal heart rate is rounded to increments of five beats per minute during a ten-minute segment, excluding periodic/episodic changes, periods of marked variability or baseline segment that differ by more than twenty-five beats per minute. In any given ten-minute window, the minimum baseline duration must be at least two minutes. Otherwise, it is considered indeterminate. In these instances, review of the previous ten-minute segment should be the basis on which to determine the baseline. In determining the baseline rate, a minimum of a ten-minute period of monitoring is necessary for confirmation of the rate.

Answer 90

7. C: Rhabdomyolysis is a common condition which complicates a variety of genetic and acquired diseases. It is characterized by muscle cell necrosis and release of muscle cell components into the circulation, most notably creatinine phosphokinase (CPK), also known as creatinine kinase (CK) and myoglobin. Other muscle enzymes that can be elevated are SGOT, SGPT, and LDH. The primary mechanism through which muscle damage occurs in rhabdomyolysis is sarcoplasmic calcium overload, leading to activation of degradative enzymes. This may occur secondary to a number of processes, including ATP depletion and increased intracellular sodium concentration and direct sarcolemmal injury. The complications of rhabdomyolysis can be potentially life threatening and include cardiac arrest and myoglobinuric acute renal failure. Prompt action must be taken to prevent these complications in a patient with rhabdomyolysis, most importantly aggressive intravenous volume replacement. Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability and death. The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.

Answer 91

10. D: TCAs exert a quinidinelike cardiac action that depresses conduction velocity, prolonged QT interval, QRS interval widening, right bundle-branch block, and first-degree heart block are common findings. More than fifty medications, many of them common, can lengthen the Q-T interval in otherwise healthy people and cause a form of acquired long QT syndrome known as drug-induced long QT syndrome. Medications that can lengthen the Q-T interval and upset heart rhythm include certain antibiotics, antidepressants, antihistamines, diuretics, heart medications, cholesterol-lowering drugs, diabetes medications, as well as some antifungal and antipsychotic drugs. An easy way to assess for a prolonged QT interval is to measure the Q-T interval from the beginning of the QRS complex to the end of the T wave. If the length measures greater than 50% the width of an R-R interval, the Q-T interval is prolonged.

Answer 92

14. D: It is essential to maintain higher rates of urinary output because hemoglobinuria and myoglobinuria are common with electrical injuries. The fluid resuscitation must be based on actual urine flow. A minimum of 50-100 mL/hour of urine output must be maintained; however, in the presence of urinary hemochromagen, the fluid volume must sufficient quantity to maintain a minimum urine output of 100 mL/hr. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (pp. 279-280). Xlibris. Kindle Edition.

Answer 93

16. C: Hypothermia, defined as core body temperature

Answer 94

18. A: Cooling can be accomplished by first removing the patient from the hot environment. The transport team should remove the patient’s clothing and wet down the patient. Covering the patient with cool fluid and increasing the movement of air over the patient enhance heat loss by increasing the evaporative gradient. The transport team should open the windows of the ambulance or make use of the air circulation of helicopter rotors during transport to further increase air movement over the patient. Controversy surrounds the question of which method is ideal for cooling the patient with heatstroke. Several methods are considered to be of therapeutic benefit. Packing the patient in ice and immersing the body in cold water are historic methods of cooling. Other therapies involve the use of room-temperature water evaporated from the patient’s skin surface by circulating air from a fan. The field treatment measure of ice packs placed in areas of maximum heat transfer (neck, axillae, and inguinal areas) may also be continued with caution. Cooling measures are ceased when body core temperature reaches 39°C (102°F). Refractory hyperthermia will require move-invasive methods. Iced-water gastric lavage, iced peritoneal lavage, hemodialysis, and cardiopulmonary bypass have been used as end attempts in severely refractory hyperthermia.

Answer 95

25. A: Histotoxic hypoxia interferes with the utilization phase of respiration because of metabolic poisoning or dysfunction. Cyanide, sulfide, azide, and carbon monoxide all bind to cytochrome oxidase, thus competitively inhibiting the protein from functioning, which results in chemical asphyxiation of cells. Methanol [methylated spirits] is converted into formic acid, which also inhibits the same oxidase system.

Answer 96

30. C: Ethylene glycol is an organic compound widely used as an automotive antifreeze. In its pure form, it is an odorless, colorless, syrupy, sweet-tasting liquid. The major danger is due to its sweet taste. Because of that, children and animals are more inclined to consume large quantities of it than they are other poisons. The primary source of ethylene glycol in the environment is from run-off at airports where it is used in de-icing agents for runways and airplanes. Upon ingestion, ethylene glycol is oxidized to glycolic acid which is, in turn, oxidized to oxalic acid, which is toxic. This and its toxic byproducts first affect the central nervous system, then the heart, and finally the kidneys. Ingestion of sufficient amounts can be fatal if untreated. Serum blood levels guide treatment for ethylene glycol ingestion. Ethanol IV administration blocks the conversion of ethylene glycol to its toxic form. Fomepizol (Antizol) is an antidote for ethanol toxicity, which prevents the formation of toxic metabolites.

Answer 97

33. C: The main undesirable side effects of aspirin are gastrointestinal ulcers, stomach bleeding, and tinnitus, especially in higher doses. In children and adolescents, aspirin is no longer used to control flulike symptoms or the symptoms of chickenpox or other viral illnesses because of the risk of Reye’s syndrome. Aspirin overdose can be acute or chronic. In acute poisoning, a single large dose is taken; in chronic poisoning, higher than normal doses are taken over a period of time. Toxicity is managed with a number of potential treatments, including activated charcoal, intravenous dextrose, normal saline, sodium bicarbonate, and dialysis.

Answer 98

35. B: Flumazenil (also known as trade names Anexate, Lanexat, Mazicon, Romazicon) is a competitive benzodiazepine receptor antagonist that can be used as an antidote for benzodiazepine overdose. It reverses the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABA receptor. Flumazenil is very effective at reversing the CNS depression associated with benzodiazepines but is less effective at reversing respiratory depression. There are many complications that must be taken into consideration when used in the acute care setting. Its use, however, is controversial as it has numerous contraindications. It is contraindicated in patients who are on long-term benzodiazepines, those who have ingested a substance that lowers the seizure threshold, or in patients who have tachycardia, widened QRS complex, anticholinergic signs, or a history of seizures. Due to these contraindications and the possibility of it causing severe adverse effects, including seizures, adverse cardiac effects, and death, in the majority of cases, there is no indication for the use of flumazenil in the management of benzodiazepine overdose as the risks generally outweigh any potential benefit of administration. It also has no role in the management of unknown overdoses. Additionally, if full airway protection has been achieved, a good outcome is expected and therefore, flumazenil administration is unlikely to be required.

Answer 99

38. A: Excretion of the resulting ferrioxamine complex results in pink-red urine that is classically called “vin-rosé urine.”

Answer 100

41. B: The mainstays of medical therapy in organophosphate (OP) poisoning include Atropine, pralidoxime (2-PAM, Protopam), and benzodiazepines. Pralidoxime is a nucleophilic agent that reactivates the phosphorylated AChE by binding to the OP molecule. Used as an antidote to reverse muscle paralysis, resulting from OP AChE pesticide poisoning but is not effective once the OP compound has bound AChE irreversibly (aged). Current recommendation is administration within forty-eight hours of OP poisoning. Because it does not significantly relieve depression of respiratory center or decrease muscarinic effects of AChE poisoning, administer Atropine concomitantly to block these effects of OP poisoning. Signs of atropinization might occur earlier with addition of 2-PAM to treatment regimen. 2-PAM administration is not indicated for carbamate exposure since no aging occurs.

Answer 101

46. A: Hypoglycemic (insulin shock) symptoms and manifestations can be divided into those produced by the counter-regulatory hormones (epinephrine and glucagon) triggered by the falling glucose, and the neuroglycopenic effects produced by the reduced brain sugar.

Answer 102

48. C: Pralidoxime chloride (2-PAM, protopam) is a nucleophilic agent that reactivates the phosphorylated AChE by binding to the OP molecule.

Answer 103

1. B: Tracheobronchial injury (TBI) is damage to the tracheobronchial tree (the structure of airways involving the trachea and bronchi). It can result from blunt or penetrating neck or chest trauma, causing a tear in the trachea or bronchus, allowing air to enter the pleural space or mediastinum. These injuries are characterized by palpable subcutaneous emphysema (in the neck, face, and thorax), dyspnea, hemoptysis (coughing up blood), and absent breath sounds to the affected side. Hamman’s sign, which is a crunching sound auscultated to the anterior chest that is synchronized to the patient’s heart beat, may also be present. A pneumothorax that reaccumulates after needle decompression has been performed or chest tube has been placed, should heighten the suspicion for tracheobronchial injury. The airways may also be injured by inhaling harmful fumes or aspirating liquids or objects. Intubation with placement of the tube distal to the injury site should be accomplished (right mainstem intubation in most cases). These patients should be closely monitored for development of a tension pneumothorax during transport.

Answer 104

9. A: Blunt injury to the diaphragm, resulting in rupture or partial tear, occurs when a tremendous force is applied to the abdomen. Diaphragmatic tears can occur without herniation of bowel into the chest cavity. If an intestinal herniation into the pleural space does occur, intestinal strangulation may develop. The left diaphragm is injured more often than the right because the liver absorbs the impact of the force on the right side. If a right-sided tear has occurred, liver injury will probably accompany it. Spleen injuries often occur with left-sided diaphragmatic trauma. Specific treatment for a known or suspected diaphgramatic tear with possible herniation should focus on airway management, oxygenation, and ventilation because of the potentially decreased lung capacity.

Answer 105

11. C: Rhabdomyolysis is the rapid breakdown (lysis) of skeletal muscle (rhabdomyo) due to injury to muscle tissue. The muscle damage may be caused by physical (e.g., crush injury), chemical, or biological factors. The destruction of the muscle leads to the release of the breakdown products of damaged muscle cells into the bloodstream; some of these, such as myoglobin (a protein), are harmful to the kidney and may lead to acute kidney failure. Treatment is with intravenous fluids, and dialysis or hemofiltration, if necessary. Swelling of the damaged muscle occasionally leads to compartment syndrome, the compression by swollen muscle of surrounding tissues in the same fascial compartment (such as nerves and blood vessels), leading to damage or loss of function in the part of the body, supplied by these structures. Symptoms of this complication include, decreased blood supply, decrease in sensation, or pain in the affected limb. Release of the components of muscle tissue into the bloodstream, leads to disturbances in electrolytes, causing, nausea, vomiting, confusion, coma, and cardiac arrhythmias. Furthermore, damage to the kidneys may lead to dark (tea-colored) urine or a marked decrease (oliguria) or absence (anuria) of urine production, usually about 12-24 hours after the initial muscle damage. Finally, disruptions in blood clotting may lead to the development of a state called disseminated intravascular coagulation (DIC). The most reliable test in the diagnosis of rhabdomyolysis is the level of creatine kinase (CK) in the blood. CPK levels greater than 20,000 are ominous and are indicative of later DIC, acute kidney failure, and potentially dangerous hyperkalemia.

Answer 106

12. D: An automobile hit from behind rapidly accelerates, causing the car to move forward under the patient. Predictable injuries are to the back with T12-L1 being the common area of injury, femur fractures, tibia/fibula fractures, ankle fractures, cervical strain, and C2 fractures caused by hyperextension if the head restraint is not in the proper position.

Answer 107

18. B: Pericardial effusion (“fluid around the heart”) is an abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to an increased intrapericardial pressure, and this can negatively affect heart function. When there is a pericardial effusion, with enough pressure to adversely affect heart function, this is called cardiac tamponade. Normal levels of pericardial fluid are from 15 to 50 mL. The so-called “water-bottle heart” is a radiographic sign of pericardial effusion, in which the cardiopericardial silhouette is enlarged and assumes the shape of a flask or water bottle. Electrical alternans is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.

Answer 108

25. C: Injury to the spleen is the most common serious complication of abdominal injury, resulting from trauma. Kehr’s sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr’s sign in the left shoulder is considered a classical symptom of a ruptured spleen. It may result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury, or ectopic pregnancy. Kehr’s sign is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is due to the fact that the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.

Answer 109

28. C: Cerebral perfusion pressure, or CPP, is the net pressure gradient, causing blood flow to the brain (brain perfusion). It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic (having inadequate blood flow) and too much could raise ICP.

Answer 110

44. C: Shock is a clinical syndrome which results in a systemic imbalance between oxygen supply and demand. Inadequate blood flow to body organs and tissue causes life-threatening cellular dysfunction.

Answer 111

2. B: All neurologic emergencies can lead to coma. During patient assessment, it is useful to use a systematic approach in evaluating the comatose patient and establishing a baseline differential diagnosis. The Glasgow Coma Scale (GCS) is widely used to measure the severity of coma in patients and is therefore and indicator of prognosis.

Answer 112

23. B: Pneumocephalus is the presence of air or gas within the cranial cavity. It is usually associated with disruption of the skull: after head and facial trauma, tumors of the skull base, after neurosurgery, or with scuba diving (rare). The CT scan of patients with a tension pneumocephalus typically show air that compresses the frontal lobes of the brain, which results in a tented appearance of the brain in the skull known as the Mount Fuji sign. The name is derived from the resemblance of the brain to Mount Fuji in Japan, a volcano known for its symmetrical cone. The presenting symptoms of pneumocephalus vary widely, but headache is almost always present. Experience with diagnostic pneumocephalus has shown that the headache is not induced by the intracranial air alone but that the dura mater must be stretched for pain to occur. Nausea, vomiting, vertigo, nuchal rigidity, aphasia, dysphasia, hemiplegia, and obtundation have all been associated with pneumocephalus, yet all are nonspecific symptoms. Treatment options for pneumocephalus vary. In some cases, the condition resolves on its own with some watchful waiting, application of oxygen, and surgery if not resolving in a timely fashion.

Answer 113

28. A: Subarachnoid hemorrhage is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia mater surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury. Signs and symptoms can include a severe headache with a rapid onset (“thunderclap headache,” which is described as the worst ever), vomiting, neck stiffness (Brudzinski’s sign—severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.), confusion, or a lowered level of consciousness, and sometimes seizures (1 in 14 patients). Intracerebral hemorrhage is a subtype of intracranial hemorrhage, which occurs within the brain tissue and not outside of it. Most intracerebral hematomas are found the frontal and temporal lobes, usually very deep, and are associated with necrosis and hemorrhage. The clinical picture may vary from no neurologic defect to deep coma. Intracerebral bleeds are the second most common cause of stroke, accounting for 30-60% of hospital admissions for stroke. High blood pressure raises the risk of spontaneous intracerebral hemorrhage by two to six times. More common in adults than in children, intraparenchymal bleeds due to trauma are usually due to penetrating head trauma but can also be due to depressed skull fractures; some may experience intense headaches. They may also go in to a coma before the bleed is noticed. A hit in the head or a fracture in the skull may also cause this bleed, acceleration-deceleration trauma, rupture of an aneurysm or arteriovenous malformation (AVM), and bleeding within a tumor.

Answer 114

38. C: The absence of doll’s eye sign indicates injury to the midbrain or pons, involving cranial nerves III and VI. It typically accompanies coma caused by lesions of the cerebellum and brain stem. This sign usually can’t be relied upon in a conscious patient because he can control eye movements voluntarily. Absent doll’s eye sign is necessary for a diagnosis of brain death.

Answer 115

42. A: Epidural hematomas are usually caused by tears in arteries, resulting in a buildup of blood between the dura and the skull. The middle meningeal artery runs in a groove on the inside of the cranium beneath the pterion, which is vulnerable to injury at this point, where the skull is thin. A blow or fracture of the temporal bone is often the cause of a rupture of the middle meningeal artery, which may cause an epidural hematoma.

Answer 116

1. A: Metabolic and respiratory acidosis. The pCO2 is high, resulting in a respiratory acidosis, and the pH and HCO3 are low, resulting in a metabolic acidosis. Review

Answer 117

21. B: Vt (tidal volume) of 5-8 mL/kg is generally indicated, with the lowest values recommended in the presence of obstructive airway disease and ARDS. The goal is to adjust the TV so that plateau pressures are less than 35 cm H2O.

Answer 118

31. A: Neuromuscular blocking agents (NMBA) binds with cholinergic receptor sites of motor neurons preventing the neurotransmitter from relaying the signal. The interruption in this signal pathway is what causes paralysis. Succinylcholine (anectine) is classified as a noncompetitive depolarizing agent because it binds with the motor end-plate receptor site, causing a continuous depolarization to take place. It is this depolarization that causes the initial fasciculations (irregular muscle contractions produced by depolarization of the muscle membrane before complete cessation of muscle activity). As the acetycholinesterase enzyme breaks down the NMBA, there is a return of fasciculations.

Answer 119

D: Cushing’s syndrome.

Answer 120

37. A: The presence of the plantar extensor reflex (toes fan upward) in an adult patient can indicate damage to the nerve pathways connecting the spinal cord and brain. It is wrong to say that the Babinski’s reflex is positive or negative; it is present (plantar extensor reflex—toes fan upward which is bad) or absent (plantar flexor response—toes curl downward which is good).

Answer 121

29. D: Excess magnesium sulfate results in magnesium sulfate toxicity, which results in both respiratory depression and a loss of deep tendon reflexes (hyporeflexia). The kidneys are efficient at excreting excess magnesium and it is unlikely that the mineral will accumulate to toxic levels. A high intake of magnesium might impair absorption and use of calcium. Frequently monitor patients’ vital signs, oxygen saturation, deep tendon reflexes, and level of consciousness (also fetal heart rates and maternal uterine activity if the drug is used for preterm labor). Assess patients for signs of toxicity (e.g., visual changes, somnolence, flushing, muscle paralysis, respiratory depression, loss of patellar reflexes) or pulmonary edema. Calcium gluconate is the antidote for magnesium sulfate toxicity. Rapid intravenous injections of calcium gluconate may cause vasodilation, cardiac arrhythmias, decreased blood pressure, and bradycardia. Intramuscular injections may lead to local necrosis and abscess formation. Extravasation of calcium gluconate can lead to cellulitis.

Answer 122

C: The emergent treatment of choice is pericardiocentesis. A large bore needle is placed just to the left of the patient’s sub-xyphoid process and with negative pressure applied to the syringe, it is directed toward the left scapula (shoulder) while monitoring the ECG for the presence of ventricular ectopy. As little as 15-20 mL of blood to improve the patient’s condition.

Answer 123

22. C: Beck’s triad is a collection of three medical signs associated with acute cardiac tamponade, an emergency condition wherein fluid accumulates around the heart and impairs its ability to pump blood. The result is the triad of low arterial blood pressure, jugular venous distention (unless the patient is hypovolemic), and distant, muffled heart sounds. Pulsus paradoxus, a fall in the systolic blood pressure \>15 mmHg during normal inspiration and a narrowing pulse pressure may also be observed prior to hypotension.

Answer 124

6. A: The innermost part of the temporal lobe, the uncus, can be compressed so that it goes by the tentorium and places pressure on the brain. The uncus can compress the third cranial nerve, which can affect the parasympathetic input to the eye on the side of the affected nerve, causing the pupil on the affected side to dilate and fail to constrict in response to light as it should.

Answer 125

26. A: Henry’s law states that at a constant temperature, the amount of a given gas dissolved in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid. An everyday example of Henry’s law is given by carbonated soft drinks. Before the bottle or can is opened, the gas above the drink is almost pure carbon dioxide at a pressure slightly higher than atmospheric pressure. The drink itself contains dissolved carbon dioxide. When the bottle or can is opened, some of this gas escapes, giving the characteristic hiss (or “pop” in the case of a champagne bottle). Because the pressure above the liquid is now lower; some of the dissolved carbon dioxide comes out of solution as bubbles. If a glass of the drink is left in the open, the concentration of carbon dioxide in solution will come into equilibrium with the carbon dioxide in the air, and the drink will go “flat.”

Answer 126

50. B: Leopold’s Maneuvers are a common and systematic way to determine the position of a fetus inside the woman’s uterus. The maneuvers consist of four distinct actions, each helping to determine the position of the fetus. Refer to the table.

Answer 127

36. C: The umbilical vein remains patent and viable for cannulation until approximately one week after birth. The transport team must be able to identify the two thick-walled, constricted arteries (four o’clock and eight o’clock position) and the thinner-walled larger vein (twelve o’clock position).

Answer 128

12. A: The clinical presentation of Cushing’s triad is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is a sign of increased ICP, and it occurs as a result of the Cushing reflex. The normal average range for ICP is 0-10 mmHg.

Answer 129

30. A: Myasthenia gravis and renal failure are contraindications for the use of magnesium sulfate. The recommended dose is 4-6 grams intravenous bolus given slowly over 15-30 minutes, followed by a maintenance infusion drip of 1-5 grams/hour on an infusion pump (average infusion is 2 grams/hour).

Answer 130

6. D: The pH is normal and the HCO3 is high, indicating a metabolic alkalosis. The pCO2 is high, indicating compensatory response. Since the pH is normal, the patient is completely compensated.

Answer 131

42. C: Oral albuterol solutions are not indicated for patients who do not respond to aerosol therapy. Corticosteroids are not indicated for the treatment of bronchiolitis. Patients in severe distress, who are unresponsive to therapy, may require intubation and mechanical ventilation.

Answer 132

8. D: Ipsilateral pupil dilation on the affected side.

Answer 133

29. D: Nasal intubations should not be performed on children less than twelve years of age because the acute angle to the glottis makes this an extremely difficult procedure while maintaining neutral cervical spine position. Needle or surgical cricothyroidotomy (dependent on age) may be necessary for airway protection for patients who cannot be successfully intubated and who cannot be ventilated and oxygenated by any other means. Children with Glasgow coma scores (GCS) of 8 or less, children with ongoing seizure activity, or those with deteriorating neurologic status should be intubated so that adequate oxygenation and airway protection is assured. Hypoxia and hypotension are the leading causes of neurologic deterioration in the head-injured patient. Preservation of stable mean arterial pressure is important to provide adequate cerebral perfusion and oxygenation. Elevation of the backboard to thirty degrees unless precluded by other injuries may assist in decreasing intracranial pressure.

Answer 134

1. D: The intracranial contents have three components: cerebrospinal fluid (CSF), blood volume, and the brain. As mean systemic arterial pressure increases, cerebral arterial blood vessels constrict, preventing the increase in blood volume and flow that would normally occur. If the mean systemic arterial blood pressure decreases, the cerebral arteries dilate, increasing cerebral blood flow. A mean systolic arterial pressure of approximately 60-140 mmHg, cerebral blood flow may be maintained in a constant state.

Answer 135

6. C: Survival equipment (kit or bag) should be standard on every air medical aircraft. Specific service area, climate, type of aircraft, and time of year are considerations when survival gear is assembled. The survival gear should be assembled and stored in a manner that affords easy access.

Answer 136

37. C: The average recommended ET tube for an adult male airway is 8.0-9.0 mm (size refers to the internal diameter of the tube). The average adult female airway can accommodate a 7.0-8.0-mm tube. The balloon cuff pressure should be at minimal occluding volume of 5-10 mL. At pressures greater than 25 mmHg, mucosal ischemia begins to occur.

Answer 137

50. B: The middle cerebral artery (MCA) is one of the three major paired arteries that supplies blood to the cerebrum. The left and right MCAs rise from trifurcations of the internal carotid arteries and thus are connected to the anterior cerebral arteries and the posterior communicating arteries, which connect to the posterior cerebral arteries. The MCAs are not considered a part of the Circle of Willis. Occlusion/damage of the middle cerebral artery results in middle cerebral artery syndrome, potentially showing the following: paralysis (plegia) or weakness (paresis) of the contralateral face and arm (faciobrachial); sensory loss of the contralateral face and arm; damage to the dominant hemisphere (usually the left hemisphere since most individuals are right-handed) results in aphasia (Broca’s or Wernicke’s); large MCA infarcts often have deviation conjugée (a gaze preference toward the side of the lesion), especially during the acute period. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 215). Xlibris. Kindle Edition.

Answer 138

B: Aortic rupture with 90% of patients who die at the scene. Chest x-ray findings: widening mediastinum and loss of aortic knob shadow

Answer 139

27. C: Many organophosphates are potent nerve agents, functioning by inhibiting the enzyme action of acetylcholinesterase (AChE) in nerve cells. They are one of the most common causes of poisoning worldwide and are frequently intentionally used in suicides in agricultural areas. The effects of organophosphate poisoning are recalled using the mnemonic SLUDGE (salivation, lacrimation, urination, defecation, gastrointestinal motility, emesis). These side effects occur because of the excess acetylcholine (AcH) that results from blocking acetylcholinesterase (enzyme responsible for the breakdown of AcH). In addition, bronchospasm, blurred vision, and bradycardia may result. Treatment includes the administration of Atropine (drying effect) and the antidote is pralidoxime (2-pam). Pralidoxime reversibly binds to the enzyme acetylcholinesterase, competing with organophosphate binding. Since barbiturates are potentiated by the anticholinesterases, they should be used cautiously in the treatment of seizures; diazepam is the recommended drug of choice.

Answer 140

32. B: The administration of a defasiculation dose of a competitivenon depolarizing NMBA, such as vecuronium (Norcuron), can prevent fasciculations that occur when succinylcholine (Anectine) is administered. Administration of 10% of the initial NMBA dose is recommended to prevent this complication, especially in trauma patients who have sustained significant skeletal fractures for the purpose of preventing further injury at the fracture site/s.

Answer 141

40. C: In aviation, VMC is an aviation flight category in which VFR flight is permitted—that is, conditions in which pilots have sufficient visibility to fly the aircraft maintaining visual separation from terrain and other aircraft. They are the opposite of IMC. IMC, sometimes referred to as blind flying, is an aviation flight category that describes weather conditions that normally require pilots to fly primarily by reference to instruments, and therefore under IFR, rather than by outside visual references under VFR. Typically, this means flying in cloud, bad weather or at night. So the rule is, you may fly IFR in VMC, but you cannot fly VFR in IMC. It is important not to confuse IMC with IFR—“IMC” describes the actual weather conditions, while “IFR” describes the rules under which the aircraft is flying. Aircraft can (and often do) fly IFR in clear weather, for operational reasons, or when flying in airspace where flight under VFR is not permitted; indeed by far the majority of commercial flights are operated solely under IFR.

Answer 142

18. D: Night vision loss occurs at 5,000 feet, which is part of the first stage of hypoxia which is called the indifferent stage. Four stages of hypoxia need to be considered when examining its effect on human pathophysiology. The four stages are divided by altitude.

Answer 143

B. Pancreatitis Periumbilical bruising, may indicate pancreatitis or intra-abdominal bleeding

Answer 144

46. C: Since airway management is an essential life-saving measure, and endotracheal intubation is an important aspect of airway management; the initial education and training must include no less than five live (animal labs are also acceptable) cadaver or dynamic human patient simulator (HPS) experience specific to age groups in program’s scope of care and patient population. An experienced transport team member may show documentation that demonstrates this requirement has been previously met. Both crewmembers must be trained in airway management although license or state regulations may dictate who is allowed to intubate before and during transport.

Answer 145

A. Sugar Problem is usually higher levels of sugar (higher than DKA), high serum osmolarity, severe dehydration, lack of ketones, and acidosis. Patient with HHNK may also experience more severe and sudden neurologic changes than the patient with DKA.

Answer 146

42. D: Boyle’s law describes the inversely proportional relationship between the absolute pressure and volume of a gas, if the temperature is kept constant within a closed system.

Answer 147

47. B: 2 × 100 = 200; 200 × 70 = 14,000; half is administered in the first eight hours = 7,000 mL (is the lower end of the Consensus formula). Answer = 7,000-14,000 mL Consensus formula (Parkland and modified Brook formulas combined) [(2-4 mL × weight in kg) × % TBSA] = Total fluids in twenty-four hours with half of the total fluids calculated administered

Answer 148

46. D: Perfusion becomes inadequate because of decreased venous return to the heart as a result of the increased intrapleural pressure and shift of mediastinal structures. A narrowing pulse pressure is considered a compensatory response that can occur just prior to the patient becoming hypotensive. The diastolic blood pressure becomes closer to the systolic blood pressure in a narrowing pulse pressure, whereas, the systolic blood pressure increases in a widening pulse pressure as seen with Cushing’s triad (increased intracranial pressure[ICP]).

Answer 149

24. D: Using the formula 16 + age in years divided by 4 equals an ET tube size of 5.0.

Answer 150

9. A: Cyanosis has been determined to be an unreliable sign of hypoxia because the oxygen saturation must be below 75% in patients with normal hemoglobin before it is detectable. Hypotension and cyanosis are late signs of hypoxia. Providing adequate supplemental oxygen is the prime consideration in the treatment of hypoxia.

Answer 151

28. B: Newborns are susceptible to hypoglycemia because of immature glucose control mechanisms, decreased glucose stores, or both. A serum glucose of \< 40 mg/dL represents hypoglycemia in the newborn. Hypoglycemia may be treated with a slow intravenous bolus of 2-4 mL/kg of 10% dextrose followed by a maintenance infusion drip of 10% dextrose in water at a rate of 80 mL/kg/24 hour. Serum glucose levels should be checked every thirty minutes to one hour until it has been demonstrated that the amount of glucose provided is adequate to maintain normal serum glucose levels. The newborn weighing less than 1,000 g should receive 5% dextrose in water because of their intolerance of the higher glucose loads resulting in hyperglycemia. Hyperglycemia, blood glucose levels greater than 125 mg/dL, is most commonly seen in the newborn weighing less than 1,000 g or in newborns whose hypoglycemia as been overcorrected.

Answer 152

32. B MAP − ICP

Answer 153

47. A: Anterior cord syndrome is a type injury that usually results from hyperflexion and is characterized by variable loss of motor and sensory function below the level of injury. However, posterior column function is maintained. Clinically this person will present with a variable degree, perhaps even complete, of motor and sensory loss below the level of injury to the spinal cord, but the capacity to perceive light touch and position sense distal to the injury is maintained. Refer to the table in question 20 for review of spinal cord syndromes.

Answer 154

44. A: The female black widow’s bite is particularly harmful to humans because of their unusually large venom glands (males almost never bite humans). The black widow spider produces a protein venom that affects the victim’s nervous system. This neurotoxic protein is one of the most potent venoms secreted by an animal. Some people are slightly affected by the venom, but others may have a severe response. The first symptom is acute pain at the site of the bite, although there may only be a minimal local reaction. Symptoms usually start within twenty minutes to one hour after the bite. Local pain may be followed by localized or generalized severe muscle cramps, abdominal pain, weakness, and tremor. The southern black widows, as well as the closely related western and northern species, which were previously considered the same species, have a prominent red hourglass figure on the underside of their abdomen. A person bitten by a black widow spider, who has pain severe enough to seek treatment at an emergency department, will require narcotic pain relief. Muscle relaxants given by injection may also be of value. Although calcium gluconate given through an IV has long been advocated, it does not seem to produce much relief of symptoms.

Answer 155

34. A: Guillain-Barre syndrome is an acute inflammatory demyelinating polyneuropathy (AIDP), an autoimmune disorder affecting the peripheral nervous system, usually triggered by an acute infectious process. It is frequently severe and usually exhibits as an ascending paralysis noted by weakness in the legs that spreads to the upper limbs and the face, along with complete loss of deep tendon reflexes. With prompt treatment by plasmapheresis or intravenous immunoglobulins and supportive care, majority of patients will regain full functional capacity. Myasthenia gravis is an autoimmune neuromuscular disease, leading to fluctuating muscle weakness and fatiguability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction, inhibiting the stimulative effect of the neurotransmitter acetylcholine. Myasthenia is treated medically with cholinesterase inhibitors or immunosuppressants, and, in selected cases, thymectomy. Symptoms, which vary in type and severity, may include asymmetrical ptosis (a drooping of one or both eyelids), diplopia (double vision) due to weakness of the muscles that control eye movements, an unstable or waddling gait, weakness in arms, hands, fingers, legs, and neck, a change in facial expression, dysphagia (difficulty in swallowing), shortness of breath and dysarthria (impaired speech, often nasal due to weakness of the velar muscles). In myasthenic crisis a paralysis of the respiratory muscles occurs, necessitating assisted ventilation to sustain life. In patients whose respiratory muscles are already weak, crises may be triggered by infection, fever, an adverse reaction to medication, or emotional stress. Diagnostic testing is done by injecting the drug edrophonium chloride (Tensilon, Reversol) or neostigmine (Prostigmin) into a vein and watching for rapid improvement of strength, usually of eye muscles. In patients with myasthenia gravis, involving the eye muscles, Edrophonium Chloride will briefly relieve eye muscle weakness. Improvement in strength of speech may also be considered a positive test.

Answer 156

27. D: Boyle’s law (expansion or contraction of a gas) describes the inversely proportional relationship between the absolute pressure and volume of a gas, if the temperature is kept constant within a closed system. The air in the ETT cuff, for example, expands with altitude (ascent) and contracts during descent.

Answer 157

24. D: A Braxton Hicks contraction might get closer together but not consistently, or they may feel stronger but go away with activity and/or rest. These contractions were first described in 1872 by British gynecologist John Braxton Hicks. Sometimes these contractions are also called prelabor contractions or Hicks sign. Not everyone will notice or experience these contractions, and some pregnant mothers will have them frequently.

Answer 158

13. B: One of CAMTS’s standards is a recommendation for weather minimums. It seems that weather, particularly fog, which can impair pilot visualization, continues to be a cause of helicopter crashes. Flight programs need to establish weather minimums based on the terrain in which they operate and then adhere to them. The definition of weather minimums is the lowest (worst) visibility conditions under which an aircraft may legally be flown under (VFR). When visibility is less than specified minimums, an aircraft must fly under IFR or not at all. VFR “response” weather minimums must meet or exceed as outlined in FAA-A021.

Answer 159

23. A: The main goal of treatment is to treat shock and preserve kidney function. Initially this is done through the administration of generous amounts of intravenous fluids, usually saline. This will ensure sufficient circulating volume to deal with the muscle cell swelling (which typically commences when blood supply is restored) and to prevent the deposition of myoglobin in the kidneys. Amounts of six to twele liters over twenty-four hours are recommended. While many sources recommend mannitol, which acts by osmosis to ensure urine production and may prevent heme deposition in the kidney, there are no studies directly demonstrating its benefit. Similarly, the addition of bicarbonate to the fluids is intended to improve acidosis and thereby prevent cast formation in the kidneys, but there is limited evidence that it has benefits above saline alone. Furosemide, a loop diuretic, is often used to ensure sufficient urine production.

Answer 160

B: RVI because of the low PAWP. Review

Answer 161

14. C: Magnesium sulfate is not an antihypertensive agent. However, a transient drop in blood pressure after initiation of treatment is frequently seen and can be attributed to smooth muscle relaxation. Adverse reactions include flushing, diaphoresis, nausea, vomiting, and drowsiness. A decrease in FHR variability may be observed. The drug is primarily excreted in the urine; toxicity may develop rather rapidly in the patient with significantly impaired kidney function.

Answer 162

C: Pericarditis is an inflammation of the pericardium which can present with chest pain radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety.

Answer 163

49. A: The most serious manifestation of pressure-related injuries or barotraumas is AGE. AGE is a leading cause of death among scuba divers. Divers need to exhale continuously when ascending, or several things may occur, which can include air pushing through the lung tissues and enters the skin in the neck, air pushing through the lung tissues and into the spaces between the lungs causing a pneumothorax, and air forced from the lungs into blood vessels and carried to vital organs. The greatest changes in pressure and volume occur at shallower depths. Pulmonary overpressurization and alveolar rupture can occur during an ascent from a depth as shallow as four feet if compressed air is held in the lungs. Breath holding results in lung overexpansion and rupture of the alveoli. Manifestations of AGE usually begin during or in minutes of ascent. Recompression in a hyperbaric chamber is the only effective treatment for this diving emergency. The immediate treatment includes administration of 100% oxygen and placing the patient in a supine position. The head-down (Trendelenburg) position and the head-down left lateral decubitus position have been recommended to minimize further passage of air emboli to the brain.

Answer 164

31. B [(DBP × 2) + SBP] divided by 3

Answer 165

14. D: Rapid and shallow respirations are seen with a shock patient, which is due to sympathetic nervous system stimulation and acidosis.

Answer 166

34. C: Using the formula (age in years × 2) + 8 gives an approximate weight of 16 kg for a-year-old child.

Answer 167

43. D: BUN:creatinine ratio is usually \>20:1 in prerenal and postrenal azotemia, and

Answer 168

33. B: If a transport team suspects hypovolemia, the treatment would include careful transfusion with 10 mL/kg of an isotonic crystalloid solution such as normal saline or Ringer’s lactate solution.

Answer 169

Clutching of the chest, may be cardiac in origin

Answer 170

11. B: N-Acetylcysteine (NAC); trade name Mucomyst, Acetadote is FDA approved to reduce the extent of liver injury after acetaminophen overdose. The primary toxic effect of acetaminophen is hepatotoxicity caused by the formation of the toxic metabolite N-acetyl-p-benzoquinonimine. Acute ingestion of 200 mg/kg in children or 6.5 grams in adults of acetaminophen may cause hepatotoxicity. Chronic ingestion of acetaminophen often occurs in adults with ongoing pain syndromes or children with febrile illnesses and can also result in hepatoxicity if the recommended daily dose is exceeded. The decision to initiate antidotal therapy following acute ingestion is based on the serum acetaminophen concentration. The Rumack-Matthew nomogram compares the acetaminophen concentration with the time since ingestion to provide guidance on which patients should be considered for antidotal therapy. The nomogram cannot be used to evaluate chronic ingestions. Oral administration is often limited by nausea and vomiting, which results in delayed or ineffective administration of NAC. Intravenous administration of NAC results in 100% bioavailability. Adverse events associated with IV NAC administration include anaphylactoid type reactions such as flushing, urticaria, rash, hypotension, and bronchospasm. NAC can minimize liver toxicity associated with acetaminophen and should be administered within 8-10 hours of an acute exposure when possible.

Answer 171

48. D: Primary and receiving hospital helipad(s) must: be marked (with a painted “H” or similar landing designation); be identified by a strobelight or heliport beacon. A beacon may not be necessary when the location of the hospital can be readily determined by the light(s) on a prominent building or landmark near the helipad; have perimeter lighting for night operations; have a device to identify wind direction and velocity (i.e., windsock). The wind indicator should be located in an illuminated area or lighted for night operations; have at least two approach and takeoff paths, oriented to be 90-180 degrees apart; have adequate fire retardant chemicals readily available; have documented, ongoing safety programs for those personnel responsible for loading and unloading patients or working around the helicopter on the helipad; have evidence of adequate security—a minimum of one person to prevent bystanders from approaching the helicopter as it lands or lifts off, or perimeter security such as fencing, rooftop, etc. A means must exist to monitor the primary helipad if accessible to the public, that is, through direct visual monitoring or closed circuit TV; and have at least one clear final approach and takeoff area (FATO) according to the FAA Advisory Circular entitled Heliport Design Advisory Circular, AC 150/5390-2A which also includes: takeoff and landing area length and width, or diameter, should be 1.5 times the overall length of the helicopters that utilize the helipad; surface of the helipad should be clear of objects, including parked helicopters; and parking area should be provided if more than one helicopter at a time is to be accommodated.

Answer 172

14. A: Airband frequencies of 121.5 MHz and 243.0 MHz are internationally designated distress signal channels.

Answer 173

40. D: Cushing’s triad is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is a sign of increased ICP, and it occurs as a result of the Cushing reflex. Brain herniation, also known as cistern obliteration, is a deadly side effect of very high ICP that occurs when the brain shifts across structures within the skull. Brain herniation frequently presents with abnormal posturing a characteristic positioning of the limbs indicative of severe brain damage. These patients have a lowered level of consciousness, with Glasgow Coma Scores of three to five. One or both pupils may be dilated and fail to constrict in response to light. Vomiting can also occur due to compression of the vomiting center in the medulla oblongata. Routine hyperventilation is not longer recommended in the initial management of the patient with traumatic brain injury. The patient’s EtCO2 should be maintained between 35-45 mmHg. Mannitol may be used to treat increasing ICP manifested by deterioration in the patient’s neurologic status.

Answer 174

15. C: The current treatment of choice is the intravenous administration of dantrolene (Dantrium), the only known antidote, discontinuation of triggering agents, and supportive therapy directed at correcting hyperthermia, acidosis, and organ dysfunction. Dantrolene is a muscle relaxant that appears to work directly on the ryanodine receptor to prevent the release of calcium. Treatment must be instituted rapidly on clinical suspicion of the onset of malignant hyperthermia. Malignant hyperthermia (MH) is a rare life-threatening condition that is triggered by exposure to certain drugs used for general anesthesia (specifically all volatile anesthetics), nearly all gas anesthetics, and the neuromuscular blocking agent succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body’s capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly. Malignant hyperthermia develops during or after receiving a general anesthetic, and symptoms are generally identified by operating department staff. Characteristic signs are muscular rigidity, followed by a hypercatabolic state; with increased oxygen consumption, increased carbon dioxide production (hypercapnea, usually measured by capnography), tachycardia (fast heart rate), and an increase in body temperature (hyperthermia) at a rate of up to ~2°C per hour, temperatures up to 42°C (108°F) are not uncommon. Rhabdomyolysis (breakdown of muscle tissue) may develop as evidenced by red-brown discoloration of the urine and cardiological or neurological evidence of electrolyte disturbances.

Answer 175

4. C: Positive Brudzinski’s sign can indicate the presence of a subarachnoid hemorrhage as well as meningitis. Severe neck stiffness causes the patient’s hips and knees to flex when the neck is flexed.

Answer 176

6. C: Diffuse axonal injury occurs when the delicate axons of the brain are stretched and damaged as a result of rapid movement of the brain, involving mechanism of injury associated with acceleration and deceleration that occurs with high-speed motor vehicle accidents or ejection from a vehicle. This type of brain

Answer 177

39. A: Hydrofluoric acid (HF) is an extremely corrosive liquid and is a contact poison. Because of the ability of hydrofluoric acid to penetrate tissue, poisoning can occur readily through exposure of skin or eyes, or when inhaled or swallowed. Symptoms of exposure to hydrofluoric acid may not be immediately evident. HF interferes with nerve function, meaning that burns may not initially be painful. Once absorbed into blood through the skin, it reacts with blood calcium and may cause cardiac arrest. Formation of insoluble calcium fluoride is proposed as the etiology for both precipitous fall in serum calcium and the severe pain associated with tissue toxicity. In some cases, exposures can lead to hypocalcemia. Thus, hydrofluoric acid exposure is often treated with calcium gluconate, a source of Ca2+ that sequesters the fluoride ions. HF chemical burns can be treated with a water wash and 2.5% calcium gluconate gel or special rinsing solutions. However, because it is absorbed, medical treatment is necessary; rinsing off is not enough and in some cases, amputation may be necessary.

Answer 178

20. B: Central cord syndrome is the most common spinal cord injury (SCI) syndrome. This syndrome is unlike a complete lesion and causes loss of all sensation and movement below the level of the injury. Remember “you can dance, but you can’t clap.”

Answer 179

50. B: Multiple stressors have been identified that may be caused by transport. Type Definition or clinical manifestation Decreased partial pressure of oxygen Hypoxia stages and types, TUC Barometric pressure changes Barotitis media, barosinusitis, barodontalgia, and gastrointestinal changes Thermal changes Increase in altitude results in decrease in ambient pressure Decreased humidity Increase in altitude results in decrease in ambient pressure and therefore a decrease in humidity Noise Can impair the ability to perform patient assessment Vibration Can interfere with transport equipment Fatigue Is always a potential threat to safety Gravitational forces g-forces, ELT activates on impact beginning at 4g’s Additional stressors of flight Type Definition or clinical manifestation Spatial disorientation Inaccurate perception of position, attitude, and motion in relation to the center of the earth Flicker vertigo Can occur when exposed to lights that flicker at a rate of 4-20 cycles per second, which can cause nausea and vomiting. In severe cases, it can cause seizures and unconsciousness. Fuel vapors Jet fuel, diesel fuel, and gasoline fuel exposures can cause altered mental status, nauseas, and eye inflammation.

Answer 180

26. A: This test is based on the ability of amniotic fluid to form a fern pattern when air-dried on a glass slide; this phenomenon in part due to the fluid’s protein and sodium chloride content. A vaginal liquid pool specimen is obtained, allowed to dry completely in room air, and examined microscopically. A positive screen is depicted by the presence of fernlike patterns characteristic of amniotic fluid crystals.

Answer 181

11. E: All of the above are considered movements/stimulators that can increase ICP. The intubated patient who is restless or who resists ventilatory support is increasing their ICP, which can be extremely critical. Seizures that develop during transport should be promptly treated because they produce hypoxia and cause increased ICP. Intravenous administration of benzodiazepines is indicated for initial seizure management. Hypotension has been found to contribute to the mortality and morbidity of head-injured patients. The patient’s mean arterial pressure (MAP) should be maintained at more than 90 mmHg. Fluids and blood products should be administered to maintain blood pressure.

Answer 182

43. B: The opposite of mydriasis (dilated pupil) is constriction of the pupil and is referred to as miosis when less than or equal to two millimeters. This is a normal response to an increase in light but can also be associated with certain pathological conditions, microwave radiation exposure, and certain drugs, especially opioids.

Answer 183

B: Levophed (norepinephrine) indication is mainly used to treat patients in vasodilatory shock states such as septic and neurogenic shock. Levophed functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (beta-adrenergic action).

Answer 184

36. B: Boyle’s law describes the inversely proportional relationship between the absolute pressure and volume of a gas, if the temperature is kept constant within a closed system. Boyles law: Volume decreases and pressure increases; pressure increases and volume decreases. Charles’ law: Temperature decreases and volume decreases; temperature increases and volume increases. Gay-Lussac’s law: Pressure decreases and temperature decreases; pressure increases and temperature increases.

Answer 185

30. D: Sandostatin (octreotide) is a vasoactive peptide used in the management of upper gastrointestinal esophageal varices. The mechanism of action is believed to be a reduction of splanchnic blood flow. Treatment is primarily with endoscopic banding and IV octreotide.

Answer 186

16. C: Common initial symptoms for intestinal obstruction include bilious vomiting, abdominal distention, feeding intolerance, large quantities of gastric contents at delivery, absence of an anal opening, and lack of stooling in the first twenty-four hours. Presence of tenderness, metabolic acidosis, or decreasing platelets may indicate a bowel necrosis or peritonitis and should be treated as an urgent problem. Management includes decompression of the bowel with intermittent large-bore gastric suction, IV fluids, antibiotic therapy as indicated, and respiratory support. Severe abdominal distention may compromise respiratory status.

Answer 187

12. C: The antidote for an overdose with warfarin (Coumadin) is vitamin K. In severe cases, blood or plasma transfusions can be given to help reverse a Coumadin overdose. In all cases, the patient should be evaluated for bleeding (including less obvious internal bleeding) and appropriate measures should be taken to control the bleeding. Warfarin is prescribed to people with an increased tendency for thrombosis or as secondary prophylaxis in those individuals that have already formed a blood clot (thrombus). Warfarin treatment can help prevent formation of future blood clots and help reduce the risk of embolism. Heparin is generally used for anticoagulation for the following conditions: acute coronary syndrome (NSTEMI), atrial fibrillation, deep-vein thrombosis, pulmonary embolism, cardiopulmonary bypass for heart surgery, ECMO circuit for extracorporeal life support. Antidote dosage for heparin reversal is Protamine Sulfate 1 mg IV for every 100 IU of active heparin. In patients who are allergic to fish, it can cause significant histamine release, resulting in hypotension and bronchoconstriction, and also causes pulmonary hypertension. Infusion should be slow to minimize these side effects. In large doses, Protamine Sulfate itself has some anticoagulant effect. Lab value monitoring will include coagulation studies. The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. They are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. The reference range for prothrombin time is usually around 12-15 seconds; the normal range for the INR is 0.8-1.2. PT measures factors I, II, V, VII, and X. It is used in conjunction with the activated partial thromboplastin time (aPTT), which measures the intrinsic pathway.

Answer 188

3. C: The patient is presenting with signs and symptoms of neurogenic shock: tachypnea, normal heart rate, and hypotension. Hemodynamic parameters to indicate the presence of neurogenic shock would include a decreased SVR

Answer 189

29. A: Careful interpretation of the CVP is important! Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end-diastolic volume. The CVP should always be considered in conjunction with other cardiovascular parameters. Under normal circumstances, the right-sided heart pressures should indirectly reflect left-sided pressures, and the left-sided filling pressure may be an indicator of left ventricular function. Preload (end-diastolic volume) is the pressure stretching the ventricle of the heart at the beginning of systole after passive filling of the ventricle and subsequent atrial contraction. Afterload (end-systolic volume) is the ventricular pressure at the end of systole.

Answer 190

35. C: Infection has been recognized as a primary cause of preterm labor. Sources of infection may include urinary tract infection, pyelonephritis, vaginitis, chorioamnionitis, and viral infection.

Answer 191

C: Inferior wall MI presents with ST elevation in leads II, III, and aVF. Reciprocal changes are present in leads I, aVL, and V1-V4.

Answer 192

39. B: The principal indication for umbilical vein catheterization is to gain vascular access during emergency resuscitation. Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation. A 3.5 F catheter is used for preterm newborns, and a 5 F catheter is used for full-term newborns. In an emergency, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained to avoid injecting hyperosmolar fluids into the portal vessels and causing liver necrosis. This is approximately 4-5 cm in a full-term neonate. Umbilical vein catheters may be placed in the inferior vena cava above the level of the ductus venosus and below the level of the right atrium (10-12 cm). This acts as central venous access, allowing central venous pressure (CVP) monitoring, medication infusions, and the administration of hyperalimentation solutions. The position of the catheter must be confirmed radiographically. After proper placement of the umbilical line, intravenous fluids and medication may be administered to critically ill neonates.

Answer 193

7. B: Antero-septal MI as evidenced by ST elevation of \>2 mm in two more contiguous leads in V1-V4.

Answer 194

13. B: Methylergonovine (Methergine), 0.2 mg administered intramuscularly or intravenously, is recommended. Methylergonovine should be used cautiously in patients with PIH because of the pressor effects that may result in further elevated blood pressure. Methylergonovine is a blood vessel constrictor and smooth muscle agonist most commonly used to prevent or control excessive bleeding following childbirth and spontaneous or elective abortion. It also causes uterine contractions to aid in expulsion of retained products of conception after a missed abortion and to help deliver the placenta after childbirth. Side effects can include nausea, vomiting, diarrhea, cramping, dizziness, pulmonary hypertension, coronary artery vasoconstriction, and severe systemic hypertension (especially in patients with preeclampsia).

Answer 195

20. B: Treatment is aimed at maintaining adequate oxygenation, maintaining the infant in an alkalemic state through hyperventilation and the use of blood buffers, sedation or neuromuscular blockade, fluid boluses, and cardiotonic drugs. Maintenance of the systemic blood pressure discourages right-to-left shunting.

Answer 196

16. B: MAP = [(DBP × 2) + SBP] divided by 3.

Answer 197

49. C: Normal range HCO3 is 22-26.

Answer 198

49. D: Sodium nitroprusside is an antihypertensive agent used frequently in the critical care setting. Recently, the Food and Drug Administration (FDA) published a report that led to a labeling change, emphasizing the pharmacokinetics of nitroprusside with metabolism to highly toxic cyanide. Although evidence validates that cyanogenesis occurs with nitroprusside administration, prevention and treatment of cyanide poisoning is rarely instituted in clinical practice. Simultaneous infusion of thiosulfate with nitroprusside provides the sulfur donor necessary to prevent cyanide accumulation. Cyanide combines with thiosulfate to form the less toxic sodium thiocyanate, which is then excreted. A 10:1 ratio of nitroprusside to thiosulfate in the infusion eliminates the possibility of cyanide intoxication without altering the efficacy of nitroprusside.

Answer 199

20. C: Most ectopic pregnancies occur in the fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of five to eight weeks. Shoulder pain (Kehr’s sign) is caused by free blood tracking up the abdominal cavity and irritating the diaphragm and is an ominous sign.

Answer 200

1. C: Beta blockers must not be used in the treatment of cocaine, amphetamine, or other alpha adrenergic stimulant overdose. The blockade of only beta receptors increases hypertension and reduces coronary blood flow, left ventricular function, cardiac output, and tissue perfusion by means of leaving the alpha adrenergic system stimulation unopposed. The appropriate antihypertensive drugs to administer during hypertensive crisis, resulting from stimulant abuse are vasodilators like nitroglycerin, diuretics like furosemide and alpha blockers like phentolamine. Although benzodiazepines and NTG are first-line agents in drug-induced acute coronary syndromes, cocaine-induced vasoconstriction also is reversed by phentolamine. Therefore, AHA 2005 Guidelines recommends phentolamine as a second-line agent. Cocaine stimulates both the peripheral and central adrenergic nervous system. The drug is metabolized by the liver and excreted by the kidney. With excessive or prolonged use of cocaine, the drug can cause itching, tachycardia, hallucinations, and paranoid delusions. Overdoses cause tachyarrhythmias and a marked elevation of blood pressure. Toxicity results in seizures, followed by respiratory and circulatory depression of medullar origin. This may lead to death from respiratory failure, stroke, cerebral hemorrhage, or heart failure. Cocaine is also highly pyrogenic because the stimulation and increased muscular activity cause greater heat production. Heat loss is inhibited by the intense vasoconstriction. Cocaine-induced hyperthermia may cause muscle cell destruction and myoglobinuria, resulting in renal failure. These can be life-threatening, especially if the user has existing cardiac problems.

Answer 201

C: Trousseau’s sign is observed in patients with low calcium. This sign may be present before other manifestations of hypocalcemia such as hyperreflexia and tetany and is generally more sensitive than the Chvostek sign of hypocalcemia. https://www.youtube.com/watch?v=Ry5Rh3wO8Sw

Answer 202

11. C: Malignant hyperthermia is a rare life-threatening condition that is triggered by certain medications administered during general anesthesia (gas agents) and the neuromuscular blocking agent succinylcholine (anectine). Dantrolene sodium is classified as a muscle relaxant and is the only specific and effective treatment of malignant hyperthermia.

Answer 203

46. D: Uterine atony is the major cause of postpartum hemorrhage. Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage. Clinically, 75-80% of postpartum hemorrhages are due to uterine atony. Blood loss in excess of 500 mL after delivery is defined as postpartum hemorrhage (PPH). The blood loss frequently occurs in the first few hours after delivery but can occur more than twenty-four hours later.

Answer 204

3. B: The most common cause of respiratory distress in the preterm infant (born before 28-32 weeks of gestation) is respiratory distress syndrome (RDS), formerly known as hyaline membrane disease (HMD). This condition is primarily caused by a deficiency of surfactant. Surfactant decreases the surface tension in the alveolus during expiration, allowing the alveolus to maintain a functional residual capacity. The absence of surfactant results in poor lung compliance and atelectasis. Goal treatment for the use of exogenous surfactant is to increase pulmonary compliance, to prevent atelectasis at the end of expiration, and to facilitate recruitment of collapsed airways. The cornerstone of treatment of RDS is supplemental oxygen to maintain a PaO2 of 60-70 mmHg and an arterial saturation of 92-95%.

Answer 205

22. A: The most correct answer is ground transport; Boyle’s law. Pneumocephalus is the presence of air or gas within the cranial cavity. It is usually associated with disruption of the skull: after head and facial trauma, tumors of the skull base, after neurosurgery or otorhinolaryngology, and rarely, spontaneously. Pneumocephalus can occur in scuba diving, but is very rare in this context. Unpressurized aircraft is not recommended for this patient’s condition.

Answer 206

9. D: All of the above. The middle meningeal artery runs in a groove on the inside of the cranium beneath the pterion, which is vulnerable to injury at this point, where the skull is thin. A blow or fracture of the temporal bone is often the cause of a rupture of the middle meningeal artery, which may cause an epidural hematoma (occurs between the skull and the dura). There is often significant “mass effect” with compression of the ipslateral lateral ventricle and dilatation of the opposite lateral ventricle due to obstruction of the foramen of Monro. Emergency treatment requires decompression of the hematoma, usually by craniotomy.

Answer 207

25. C: The steeple sign is a sign on a frontal radiograph of tracheal narrowing and suggestive of the diagnosis of croup (laryngotracheobronchitis). Croup is the common term for a viral infection that affects the larynx but may extend into the trachea and bronchi. Patients generally present with a history of fever and coryza (acute inflammation of the mucous membrane of the nose, with discharge of mucus; a head cold). As the illness progresses inspiratory stridor may be present, as well as a characteristic “barking” cough. If the inflammation extends to the bronchi, rhonchi and wheezing may also be present. Care must be taken to rule out epiglottitis and retropharyngeal abscess because the presentations can be similar. Treatment is supportive and centers on treating dehydration and respiratory distress. Medications can include racemic epinephrine aerosols, dexamethasone, and prednisolone.

Answer 208

B: Etomidate (Amidate), which is classified as a sedative-hypnotic can block the adrenal gland’s production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure. This may cause abnormal salt and water balance, lowered blood pressure, and, ultimately, shock.

Answer 209

30. D: Seizure types are organized according to whether the source of the seizure within the brain is localized (partial or focal onset seizures) or distributed (generalized seizures). Partial seizures are further divided on the extent to which consciousness is affected (simple partial seizures and complex partial seizures). If consciousness is unaffected, then it is a simple partial seizure; otherwise, it is a complex partial seizure. A partial seizure may spread within the brain—a process known as secondary generalization. Generalized seizures are divided according to the effect on the body, but all involve loss of consciousness. These include absence, myoclonic, clonic, tonic, tonic-clonic, and atonic seizures. A mixed seizure is defined as the existence of both generalized and partial seizures in the same patient. Generalized epilepsy leading to status epilepticus is mostly seen in the acute state in one of the two situations: with generalized encephalopathy, including that immediately following trauma, and in patients who are known epileptics, who have reduced drug intake, and whose blood levels have fallen below therapeutic concentrations. Use a benzodiazepine as the first-line therapy. Seizure management requires a risk benefit analysis that balances the patient’s needs with the urgency of the situation. Lorazepam is the preferred first-line agent for seizure control due to its long-lasting anticonvulsant properties. Diazepam is equally effective but requires that a concomitant, long-acting antiseizure medication be administered, such as Dilantin. When the IV access is unavailable, alternate routes such as IM injections of Midazolam, rectal solutions of Diazepam, and IM Fosphenytoin should be considered; of the three, IM Midazolam is probably the fastest and easiest to use. Alternative agents that have been used to manage seizure activity include Phenobarbital, Lidocaine, etomidate, propofol, and Paraldehyde.

Answer 210

48. B: Late decelerations always indicate uteroplacental insufficiency; there is inadequate oxygen exchange in the placenta during a contraction. Uteroplacental insufficiency may result from pregnancy-induced hypertension (PIH), diabetes mellitus (DM), cardiovascular or kidney disease, chorioamnionitis, smoking, and a fetus that is past maturity. It may also result from decreased placental perfusion in placental abruption or previa, uterine hypertonus as a result of oxytocin stimulation, and hypotension. Signs of fetal decompensation include back-to-back decelerations, loss of variability, lack of spontaneous accelerations, tachycardia, and subtle decelerations. Standard interventions that may help to resolve the abnormal pattern (and that may also be warranted for some category II tracings) include supplemental oxygen to the mother, a change in maternal position, discontinuation of oxytocin, and resolution of maternal hypotension. In most situations, expeditious delivery is likely warranted if an abnormal pattern persists.

Answer 211

2. B: The normal inspiration-to-expiration (I:E) ratio to start is 1:2. This is reduced to 1:4 or greater in the presence of obstructive airway disease (asthma, COPD) in order to avoid air-trapping (breath stacking) and auto-PEEP or intrinsic PEEP (iPEEP).

Answer 212

24. D: MAP = [(75 × 2) + 150] divided by 3 = 100. CPP = 100-25 = 75 mmHg

Answer 213

10. B: Humidity is the concentration of water vapor in the air; as air cools, it loses its ability to hold moisture because temperature is inversely proportional to altitude; an increase in altitude produces a decrease in temperature and, therefore, a decrease in the amount of humidity. Increase in altitude = low temperature and low humidity.

Answer 214

47. D: Gastrochisis is a defect in the abdominal wall that has completed its development. The defect allows for protrusion of abdominal contents and is not covered by a membrane. Because the defect is normally very close to the umbilicus, it is frequently mistaken for an omphalocele. An omphalocele is an arrest of development of the abdominal wall, with the abdominal contents remaining externalized. The defect remains covered by a membrane in utero, although the sac may be broken during delivery.

Answer 215

32. B: Cranial nerve III, which is the oculomotor nerve, innervates five intrinsic eye muscles: levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique, which collectively perform most eye movements. It also sends parasympathetic efferents (via the ciliary ganglion) to the muscles controlling pupillary constriction and accommodation. The motor fibers originate in the oculomotor nuclei of the midbrain.

Answer 216

13. D: Thromboplastin is the combination of both phospholipids and tissue factor, both needed in the activation of the extrinsic pathway. However, partial thromboplastin is just phospholipids and not tissue factor. Tissue factor is not needed to activate the intrinsic pathway. Partial thromboplastin is used to measure the intrinsic pathway. This test is called the aPTT, or activated partial thromboplastin time.

Answer 217

B. Prinzmetal’s Can occur at rest, while sleeping, or after exercise

Answer 218

21. D: In children younger than 10 years of age, the narrowest portion of the trachea is at the cricoid process. The vocal cords are attached lower anteriorly and the tongue (especially in infants) is proportionately larger.

Answer 219

15. C: The objective assessment of the burn injury itself includes estimating the burn size and depth, associated inhalation injuries, and calculation of fluid resuscitation needs. The size of the burn wound is most frequently estimated by using the rule of nines method, which divides the body into multiples of 9%. A fairly accurate approximation can be made using the patient’s entire palm size to represent 1% of the total BSA and visualizing that palm over the burned area. BSA calculated: 9% entire face; 18% anterior torso; 9% complete left arm. Answer: 4 × 20 = 80; 80 × 36 = 2,880; ½ administered in the first 8 hours = 1,440 mL. Refer table to review the rule of nines.

Answer 220

49. B: Pulseless electrical activity (PEA), also known by the older term electromechanical dissociation or nonperfusing rhythm, refers to any heart rhythm observed on the ECG that should be producing a pulse, but is not. The most common cause of PEA is hypovolemia. The approach in treatment of PEA is to treat the underlying cause. These possible causes are remembered as the 6 Hs and the 6 Ts or by using the mneumonic PATCH4MD. Refer to the tables for review of causes for PEA. Where an underlying systemic cause cannot be determined rapidly enough, pulseless electrical activity should be treated as if the patient were in asystole. Treatment is intravenous delivery epinephrine (1:10,000) 1 mg every 3-5 minutes, and, if the underlying rhythm is bradycardia (

Answer 221

40. B: Alcohol and hypoglycemia are the two things that really do not go together. Sometimes people with hypoglycemia or “low blood sugar” are mistaken for drunks. This is because their reaction to sugar and alcohol can be very similar. The high sugar content of some alcoholic drinks alone can cause blood sugar to drop so fast that they appear intoxicated. This is because over consumption of sugar causes the pancreas to release insulin into the blood stream. Because insulin has a much longer half-life (the time of a substance to reduce itself by half) than sugar, the insulin will remain longer in the blood than the sugar. Wernicke-Korsakoff syndrome is a neurological condition, caused by an acute deficiency of the vitamin thiamine, often related to acute and chronic alcohol use. Symptoms include confusion, profound short-term memory loss, incoordination, and abnormalities of eye movement (gaze palsies). Excessive prolonged use of alcohol can damage the stomach lining (gastritis), esophagus (esophageal varices), liver (liver failure, cirrhosis), pancreas (pancreatitis), and heart (cardiomyopathy). Ethanol enhances cutaneous blood flow, which causes heat loss through vasodilation.

Answer 222

7. B: All pneumothoraces greater than 20% or any pneumothorax present in patients requiring positive pressure ventilation should be treated with tube thoracostomy prior to transport. Treatment consists of placement of an appropriate-sized chest tube to the fifth intercostal space, at the anterior midaxillary line of the affected side. An alternate site for chest tube placement is the second intercostal space at the midclavicular line of the affected hemothorax. The anterior approach (alternate site) is inappropriate if both air and fluid are suspected in the pleural space.

Answer 223

43. C: Determination of fundal height and marking the fundus can assist the transport team in recognition of concealed bleeding will be confirmed by noting an increase in the fundal height. Because of normal physiologic changes of pregnancy, early symptoms of hypovolemia may be masked.

Answer 224

44. D: Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure. It may also be due to a condition that results in decreased blood flow to the kidneys, such as CHF, shock, stress, recent MI, or severe burns, conditions that cause obstruction of urine flow or dehydration. BUN concentrations may be elevated when there is excessive protein breakdown (catabolism), significantly increased protein in the diet, or gastrointestinal bleeding (because of the proteins present in the blood).

Answer 225

7. B: MAP − ICP = CPP.

Answer 226

47. C: A FHR of more than 160 beats per minute for a period of ten minutes or longer is defined as fetal tachycardia. Fetal tachycardia is a response of increased sympathetic tone and is reflected by a compensatory mechanism to increase cardiac output in the presence of transient hypoxia. A decreased variability is generally associated with tachycardia. Factors that contribute to tachycardia include maternal fever, smoking, use of beta-sympathomimetic agents, fetal anemia, fetal hypovolemia, chorioamnionitis, and maternal hyperthyroidism. Whatever the mechanism of insult to the fetus, the plan of action when presented with possible fetal distress is intrauterine resuscitation. Refer to table in question no. 45 to review the “key” formula LOCK.

Answer 227

27. B: Diaphragmatic hernia is caused early in gestation when the pleuroperitoneal cavity fails to close. Abdominal contents migrate into the thoracic cavity, compressing developing lungs and causing pulmonary hyoplasia. Classic presentation by these infants includes early onset of respiratory distress with deterioration between the 1 and 5 minute APGAR scores in the delivery room. Clinical signs include dyspnea, unequal breath sounds, a shift in the PMI, and potentially scaphoid abdomen. The initial treatment efforts of preoperative stabilization are aimed at optimizing oxygenation, maintaining an adequate systemic blood pressure, and reducing the associated pulmonary hypertension. Because any distention of the bowel further compromises respiratory function, the transport team should insert a large-bore (10 Fr) orogastric tube and initiate suction. Positive-pressure ventilation with a face mask should be avoided. When ventilation is required, immediate endotracheal intubation should be performed.

Answer 228

13. B: Respiratory acidosis with complete compensation. The pCO2 is elevated, which is the primary disorder, and the compensatory response is the increased HCO3. The pH is normal, so there is complete compensation.

Answer 229

28. C: Time between each communication should not exceed 15 minutes while in flight unless a system of continuous automatic position tracking is utilized or 30 minutes on ground transport. Time between communications should not exceed 45 minutes while on the ground.

Answer 230

40. C: Ketamine (ketalar) is classified as an NMDA receptor antagonist with a wide range of effects that include analgesia, anesthesia, hallucinations, elevated blood pressure, and bronchodilation. Indications include use for pediatric anesthesia and asthmatics or patients with COPD. Ketamine has been useful in managing bronchospasm because it inhibits pro-inflammatory cytokines. The accumulation of pro-inflammatory cytokines causes beta-adrenergic receptor hypofunction.

Answer 231

9. D: Pregnancy-induced hypertension (PIH) refers to a group of hypertensive disorders that have their onset during pregnancy and resolve after pregnancy. Gestational hypertension develops after twenty weeks gestation without evidence of hypertension. Preeclampsia is characterized by hypertension, proteinuria, and edema. Eclampsia refers to the development of clonic and tonic seizures.

Answer 232

48. C: Normal range pH is 7.35-7.45.

Answer 233

21. A: The oxygen-hemoglobin dissociation curve illustrates the relationship between hemoglobin saturation and PaO2. This curve depicts the ability of hemoglobin to bind and release oxygen into the tissues. Various physiologic states change the relationship between hemoglobin saturation and PaO2.

Answer 234

2. C: Boyle’s law (expansion or contraction of a gas) describes the inversely proportional relationship between the absolute pressure and volume of a gas, if the temperature is kept constant within a closed system. The air in the ETT cuff, for example, expands with altitude (ascent) and contracts during descent. Boyle’s law is one of three gas laws that thoroughly describe the behavior of gases under varying temperatures, pressures, and volumes. The other two laws are Gay-Lussac’s law and Graham’s law. Graham’s law of effusion and diffusion states that the rates of movement of gases at the same temperature and pressure are inversely proportional to the square root of its molecular mass. Dalton’s law of partial pressures states that the total pressure of a gas mixture is the sum of the individual or partial pressures of all the gases in the mixture. Charles’s law, or the law of volumes, states that for an ideal gas at constant pressure, the volume is proportional to the absolute temperature, which describes how gases tend to expand when heated.

Answer 235

24. A: Newton’s laws of motion are three physical laws that form the basis for classical mechanics. They describe the relationship between the forces acting on a body and its motion due to those forces.

Answer 236

17. B: Oxygen concentration remains at 21% regardless of altitude. However, oxygen availability decreases with altitude because the oxygen molecules are farther apart, potentially resulting in hypoxia.

Answer 237

19. B: Normal range of K+ is 3.5-4.5. Some laboratories go as high as 5.5 for upper normal range.

Answer 238

5. C: Prostaglandins are normally used during transport when the patient’s condition is deteriorating, as indicated by the presence of metabolic acidosis, or when deterioration is anticipated before the completion of the transport. Prostaglandin E1 (PGE 1) is indicated for those heart defects that may be dependent on ductal patency for pulmonary blood flow. These heart defects include transposition without ventricular septal defect (VSD), pulmonary or tricuspid atresia, and critical pulmonary stenosis, including tetralogy of Fallot (TOF). Coarctation of the aorta and hypoplastic left heart syndrome may also require the use of PGE 1 for stabilization for transport. Keeping the patent ductus arteriosus (PDA) open using this medication allows stabilization of the newborn until more definitive treatment, usually surgical, can be carried out.

Answer 239

An indicator of brainstem dysfunction, the absence of the doll’s eye sign is detected by rapid, gentle turning of the patient’s head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 211). Xlibris. Kindle Edition.

Answer 240

18. D: Meconium is normally stored in the infant’s intestines until after birth, but sometimes (often in response to fetal distress) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur. The most obvious sign that meconium has been passed during or before labor is the greenish or yellowish appearance of the amniotic fluid. After birth, rapid or labored breathing, cyanosis, slow heartbeat, a barrel-shaped chest or low APGAR score are all signs of the syndrome. Inhalation can be confirmed by one or more tests such as using a stethoscope to listen for abnormal lung sounds (diffuse crackles and rhonchi), performing blood gas tests to confirm a severe loss of lung function, and using chest x-rays to look for patchy or streaked areas on the lungs. Infants who have inhaled meconium may develop RDS often requiring ventilatory support. Complications of meconium aspiration include pneumothorax and PPHN. When meconium staining of the amniotic fluid is present and the baby is born depressed, it is recommended by the newborn resuscitation guidelines that an individual trained in neonatal intubation use a laryngoscope and ETT to suction meconium from below the vocal cords. The APGAR score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. The resulting APGAR score ranges from zero to ten. The five criteria (Appearance, Pulse, Grimace, Activity, Respiration) are used as a mnemonic learning aid. The test is generally done at one and five minutes after birth, and may be repeated later if the score is and remains low. Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.

Answer 241

42. Brown-Séquard

Answer 242

43. A: Hyperinflation of the lungs, narrow elongated heart shadow, increased anterior-posterior diameter, and flattened hemidiaphragms are common findings on the chest radiography of a COPD patient. ARDS can present with widespread infilitrates, with a ground glassy appearance, pneumonia with lobar infiltrates and consolidation, and CHF with cardiomegaly and pulmonary congestion.

Answer 243

40. C: Mydriasis is an excessive dilation of the pupil due to disease, trauma, or the use of drugs. A mydriatic pupil will remain excessively large even in a bright environment and is sometimes referred to as “blown pupil.” Pupillary dilation (mydriasis) indicates unopposed sympathetic activity due to impaired parasympathetic axons. This may reflect compression or distortion of the oculomotor nerve (CN III) by either primary injury or herniation. Mydriasis also may be an effect of adrenergic stimuli, such as epinephrine, anticholinergics, cocaine, PCP, and drug withdrawal. The classic fixed and dilated “blown pupil” is a unilateral phenomenon that may occur when a rapidly expanding intracranial mass, including blood from a hemorrhage, is compressing cranial nerve III. It may also represent herniation of the uncus of the temporal lobe. The opposite, constriction of the pupil, is referred to as miosis.

Answer 244

24. D: Hypothermia causes the oxygen-hemoglobin dissociation curve to shift to the left. Remember everything that is low is left.

Answer 245

7. B: Uteroplacental insufficiency may result from pregnancy-induced hypertension (PIH), diabetes mellitus (DM), cardiovascular or kidney disease, chorioamnionitis, smoking, and a fetus that is past maturity. It may also result from decreased placental perfusion in placental abruption or previa, uterine hypertonus as a result of oxytocin stimulation and hypotension.

Answer 246

22. B: Hypoxia is a major cause of bradycardia in the pediatric patient, so bradycardia during any airway procedure should be treated promptly with assuring that the airway is open, oxygenation and ventilation. Placing the child in a “sniffing position,” with the midface placed superiorly and anteriorly, is the optimal alignment for airway protection. With traumatic injuries, care must be taken to maintain a neutral position of the cervical spine while opening the airway. Padding of the backboard under a child’s shoulders and posterior thorax will also aid in neutral alignment of the cervical spine.

Answer 247

23. A: The presence of moderate variability is strongly predictive of normal fetal acid-base status.

Answer 248

50. D: One of the first very obvious physiologic differences between children and adults is the variation of normal pediatric vital signs based on the age of the child. A thorough understanding of pediatric vital signs is imperative in being able to detect very subtle abnormalities in a child’s heart rate and RR. For example, a subtle tachycardia may be the only clue to the possibility of early hemorrhagic shock in a child who otherwise looks stable. A subtle tachypnea may be the earliest clue to possible intrathoracic injuries in a child with a normal room air oxygen saturation. Thus, anyone involved in the emergency care of children must be aware of normal vital signs based on a child’s age.

Answer 249

19. B: The fundal height is measured from the top of the pubic bone to the top of the uterus and is generally measured in centimeters. It’s a measurement, as you might suspect, that should increase as the pregnancy continues toward the estimated date of confinement (EDC). The fundal height can be out of sync with what’s expected for the gestational age due to abnormal conditions such as, oligohydramnios (too little fluid, taking away from the entire mass effect, leading to a smaller fundal height), hydramnios, polyhydramnios (too much fluid, indicating possibly genetic problems or anatomical problems with the baby), and abnormal position of the baby close to term. [image chart]

Answer 250

31. B: Blunt trauma is the cause of the majority of abdominal injuries in children. Abdominal examination can be extremely difficult in the pediatric population because fear from exam or pain from distracting injuries interferes with assessment. A high index of suspicion should always be maintained with patients suffering multisystem injury. The solid organs most commonly injured in the pediatric patient are the spleen and the liver. Disruption of the vascular supply to these organs can result in massive hemorrhage. Radiation of pain to the left shoulder (Kehr’s sign) can indicate splenic injuries.

Answer 251

Aggressive fluid replacement and the administration of vasopressin (Pitressin). Vasopressin increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in the regulation of water, glucose, and salts in the blood.

Answer 252

25. C: Preterm is defined at before the thirty-seventh week. Preterm labor does not always result in preterm delivery. Generally true labor contractions will get longer in length, closer in frequency, and stronger in intensity.

Answer 253

11. C: After a forced aircraft landing, the main danger is fire. If the pilot has become incapacitated, the throttle, fuel switch and master battery in sequence, should be turned off. The position of these switches varies with the aircraft, and the flight team must be familiar with the procedure for their specific aircraft.

Answer 254

B: (2 × DBP) + SBP divided by 3 = MAP. Normal MAP is 80-100 mmHg.

Answer 255

33. C: Elements that must be proved in a malpractice case are causation, injury, and damages. Negligence and malpractice are often incorrectly used as interchangeable terms. Negligence is a deviation from accepted standards of performance. Malpractice is based on a professional standard of care, as well as the professional statutes of the caregiver. Other elements included in a malpractice case are presence of duty, breach of duty, and forseeability.

Answer 256

12. A: Knowledge of the rule of threes when priorities are set will greatly increase the chances of survival in the outdoors. This rule states that the average person can survive three minutes without oxygen, three hours without shelter in extreme conditions, three days without water, and three weeks without food. Medical concerns and safety are important in accident, but once these are addressed, the rule of threes should guide priorities. With this rule in mind, the flight team’s immediate concerns after an accident should be creating or seeking shelter, building a fire, and making appropriate fire signals.

Answer 257

A: Acute renal insufficiency, also known as Addison’s disease. Hypotension is common: caution with etomidate administration, Symptoms: fatigue and weight loss.

Answer 258

27. D: The classic symptoms include transient loss of consciousness, recovery with a lucid interval during which the patient’s neurologic status returns to normal, and the secondary onset of headache and a decreasing level of consciousness. In children, bradycardia and early papilledema (optic disc swelling) may be the only warning signs. Epidural hematomas are usually caused by tears in arteries, resulting in a buildup of blood between the dura and the skull. The dura mater also covers the spine, so epidural bleeds may also occur in the spinal column. Often due to trauma, the condition is potentially deadly because the buildup of blood may increase pressure in the intracranial space and compress delicate brain tissue. Epidural hematoma commonly results from a blow to the side of the head. The pterion region which overlies the middle meningeal artery is relatively weak and prone to injury. Epidural hematomas are classified as acute or subacute. An acute epidural hematoma that is arterial in origin generally produces symptoms within a few hours. Subacute epidural hematomas are venous in origin and take a longer time to produce symptoms. These hematomas are associated with linear skull fractures in 90% of patients. Hemorrhages commonly result from acceleration-deceleration trauma and transverse forces (10% of epidural bleeds may be venous). Venous epidural bleeds are usually due to shearing injury from rotational or linear forces, caused when tissues of different densities slide over one another. Subdural hematoma is a collection of blood within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater enveloping the brain. Usually resulting from tears in veins that cross the subdural space, subdural hemorrhages may cause an increase in ICP, which can cause compression of and damage to delicate brain tissue. Subdural hematomas are classified as acute (within 24 hours), subacute (between 2-10 days), and chronic (after 2 weeks). Subdural hematomas are often life-threatening when acute, but chronic subdural hematomas are usually not deadly if treated. Elderly patients may have larger subdural hematomas, with slowly developing symptoms because they have larger potential subdural spaces as a result of cerebral atrophy. Subdural hematomas generally occur in children less than two years of age. Signs and symptoms include a bulging fontanelle and a large head (because of separation of the sutures) and retinal hemorrhages as a result of increased ICP.

Answer 259

14. D: The initial compensatory mechanism that the transport team should look for during the early stages of hemorrhagic shock is tachycardia. The other compensatory mechanism that occurs to maintain normal perfusion and blood pressure is an increase in the systemic vascular resistance, which is manifested clinically by mottled or cool extremities, weak or thready distal pulses, delayed capillary refill time, and a narrowed pulse pressure. Hypotension and bradycardia should always be recognized as ominous signs and aggressively treated in the pediatric patient. After ventilation and oxygenation has been addressed, fluid resuscitation should quickly follow. Resuscitation begins with a 20 mL/kg bolus of warmed Ringer’s lactate or normal saline. Because only approximately one-third of crystalloid infusions remain in the intravascular space, this bolus may need to repeated twice or thrice. If more than 40-60 mL/kg of crystalloid solution is required to restore adequate perfusion, blood replacement must then be considered. The administration of 10 mL/kg of type specific or O negative packed red blood cells (PRBCs) should be considered in the pediatric patient presenting with hypovolemic shock.

Answer 260

27. D: The fluid resuscitation must be based on actual urine flow. A minimum of 50-100 mL/hour of urine must be maintained. If blood-colored urine is present, then the fluid volume must be sufficient enough to maintain a minimum output of 100 mL/hr.

Answer 261

6. B: The consensus is that the patient should be rewarmed as quickly as possible because the myocardium is refractory to therapy below 30°C. There are three techniques for rewarming: passive external, active external, and active internal. Only passive external, active external, and limited forms of active internal rewarming measures can be initiated in the prehospital environment. Afterdrop is a dangerous phenomenon that can occur in the initial stages of passive and active external rewarming. Afterdrop is defined as a decline of 1-2°C in the core body temperature when cool blood from the extremities moves to the core. Any action that moves blood rapidly from the extremities to the heart can cause afterdrop and precipitate ventricular fibrillation. Active internal rewarming delivers heat to the body core, thereby avoiding the dangers of afterdrop. The heart, lungs, and brain are warmed first and in turn rewarm of the rest of the body.

Answer 262

13. C: End-organ perfusion will decrease with fluid or blood loss and will be reflected by oliguria or anuria. Maintenance of 1-2 mL/kg of urine output is the goal of circulatory support in the pediatric patient. Urinary output varies with age. After fluid resuscitation, maintenance fluids must be provided on a kilogram body weight basis. Prevention of hypothermia as a result of fluid resuscitation is imperative.

Answer 263

19. A: Autonomic dysreflexia (AD), also known as “autonomic hyperreflexia or hyperreflexia,” is a potentially life-threatening condition, which can be considered a medical emergency requiring immediate attention. AD occurs most often in spinal cord-injured individuals with spinal lesions above the T6 spinal cord level. Acute AD is a reaction of the autonomic (involuntary) nervous system to overstimulation. This condition is distinct and usually episodic, with the patient experiencing remarkably high blood pressure (often with systolic readings over 200 mmHg), intense headaches, profuse sweating, facial erythema (redness), flushing of the skin above the level of the lesion, goosebumps, nasal stuffiness, bradycardia, apprehension, anxiety, and a “feeling of doom.” An elevation of 40 mmHg over baseline systolic should be suspicious for dysreflexia. Catheterization of the bladder or relief of a blocked urinary catheter tube may resolve the problem. If the noxious precipitating trigger cannot be identified, drug treatment is needed to decrease elevated ICP until further studies can identify the cause.

Answer 264

49. A: Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated, while the opposing set is not, and an external stimulus, such as pain, causes the working set of muscles to contract. Posturing can be caused by conditions that lead to large increases in ICP. Such conditions include traumatic brain injury, stroke, intracranial hemorrhage, brain tumors, and encephalopathy. Posturing due to stroke usually only occurs on one side of the body and may also be referred to as spastic hemiplegia. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation. Refer to the table for review of abnormal posturing. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (pp. 214-215). Xlibris. Kindle Edition.

Answer 265

Diabetic ketoacidosis (DKA) is problem with insulin. Treatment goal for both are aimed at administering fluids, insulin, and correcting electrolyte imbalances to control the hyperglycemia and to prevent shock and other complications.

Answer 266

5. C: If ventricular fibrillation (VF) is detected, emergency personnel should deliver three shocks to determine fibrillation responsiveness. If VF persists after three shocks, further shocks should be avoided until after rewarming to above 30°C (86°F). CPR, rewarming, and rapid transport should immediately follow the three defibrillation attempts. If core temperature is below 30°C (86°F), successful defibrillation may not be possible until rewarming is accomplished. If the patient fails to respond to initial defibrillation attempts or initial drug therapy, subsequent defibrillations or additional boluses of medication should be avoided until the core temperature rises above 30°C (86°F).

Answer 267

37. D: A pediatric patient has only 80 mL of circulating volume/kg, so small amounts of fluid or blood loss can cause serious physiologic effects. The goal in supporting cardiac output in shock is the replacement of lost circulating volume.

Answer 268

42. C: Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it.

Answer 269

12. B: The primary goal of asthma management is reversal of hypoxemia as well as control of contributing inflammatory responses. Too much oxygen or mechanical force may result in lung injury. Insufficient oxygen or mechanical force will result in hypoxia and hypoventilation. The starting respiratory rate (RR) is in part age determined, commonly 30-50 in neonates, 25-30 in infants, 20 in children, and 10-15 in teenagers. The rate is also dependent on the disease process. For example, patients who have air trapping or hyperinflation disorders (such as asthma) need a longer expiratory phase and therefore, a slower rate. The inspiratory time (IT or I-time) is also age and rate dependent and will also need to be altered depending on the child’s disease. A guideline is 0.4-0.7 seconds for infants and 0.5-1 seconds for children and adults. Longer I-times increase mean airway pressure (MAP) (by prolonging the inspiratory cycle) and therefore usually improve oxygenation. In choosing a tidal volume (TV) or PIP, the most important tenant to remember is, in general, to use a volume or pressure that causes good visible chest rise and air entry on auscultation. For TV ventilation, the starting range is usually about 5-8 mL/kg. Adjusting the FIO2 will only affect the pO2 and oxygen saturation. Increasing the ventilator rate will increase the minute ventilation, so this decreases the pCO2 (and hence increases the pH). These are the two most basic changes that occur in ventilator management. One could also increase the minute ventilation (which would decrease the pCO2) by increasing the TV (on a volume ventilator) or the PIP (on a pressure ventilator). Also realize that any parameter change which increases the MAP will also increase the pO2. One could increase the MAP by increasing the positive end-expiratory pressure (PEEP), the IT, or the PIP. Increasing the TV on a volume ventilator, in essence, increases the PIP, so this also increases the MAP. In nonventilated patients, the glottis opens and closes during spontaneous respirations. Partial closure of the glottis provides a physiologic “PEEP” of 3-4 mmHg by preventing complete emptying of the airway. In patients with good oxygenation and little pulmonary disease, a PEEP of 3-5 mmHg is adequate. Higher PEEPs are necessary for the patient with pulmonary edema, pneumonia, or atelectasis. High PEEP may also be useful for the postoperative heart patient with surgical bleeding. Be aware that increasing PEEP increases MAP. Patients with high MAPs may require volume infusions to maintain venous return and cardiac output. Inotropic support may also be needed in patients requiring very high PEEP of \> 10 mmHg.

Answer 270

D: The administration of Atropine will not work with patients who have had a heart transplant because of denervation of the vagus nerve. Atropine works by blocking the vagus nerves, thereby increasing heart rate. Symptomatic bradycardia, second degree Type II block, high-grade AVB and CHB require placement of a pacemaker. Complications of pacing can include oversensing and failure to sense; failure to capture, myocardial penetration/perforation, and cardiac tamponade.

Answer 271

C. Consider sedation and synchronize cardiovert at 100 joules

Answer 272

30. C: The PIC is accountable for nonmedical aspects of the flight and has final authority in flight-related issues. It is imperative that the PIC establishes clear leadership and command authority and appropriately applies the use of authority based on the current situation. Flight team members are in a valuable position to observe the pilot and assist in making safe decisions. Flight crew members assist in flight-related duties as outlined by the PIC. Each program must have a policy that allows any crew member to refuse or abort a flight if they feel uncomfortable.

Answer 273

30. C: Newborn (34-38 weeks) (2,000-3,000 g) should be intubated with a 3.5 ET tube with an estimated tube depth at approximately 9 cm at the gums.

Answer 274

8. A: Pericardial effusion. Electrical alternans is an ECG alteration of the QRS complex amplitude or axis between heart beats. It is thought to be associated to changes in the ventricular axis due to fluid in the pericardium. Pericardial effusion can lead to cardiac tamponade.

Answer 275

33. B: The term macrosomia is used to describe a newborn with an excessive birth weight. It is seen more commonly when the mother has gestational diabetes mellitus (GDM) or diabetes mellitus (DM) without vasculopathy. Macrosomia, as defined by birth weight greater than 4,000-4,500 g (8 lb 13 oz to 9 lb 15 oz), occurs with higher frequency in prolonged pregnancies that continue beyond the expected delivery date. It has also been defined as greater than 90% for gestational age after correcting for neonatal sex and ethnicity. Based on these definitions, macrosomia affects 1-10% of all pregnancies. Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large fetus, or a combination of these factors.

Answer 276

50. A: Cyanide makes the cells of an organism unable to use oxygen, primarily through the inhibition of cytochrome oxidase. Inhalation of high concentrations of cyanide causes coma with seizures, apnea, and cardiac arrest, with death following in a matter of minutes. At lower doses, loss of consciousness may be preceded by general weakness, giddiness, headaches, vertigo, confusion, and perceived difficulty in breathing. A fatal dose for a patient can be as low as 1.5 mg/kg body weight. Blood cyanide concentrations may be measured as a means of confirming the diagnosis in hospitalized patients or to assist in the forensic investigation of a criminal poisoning. Cyanide toxicity can occur following ingestion of amygdalin (found in almonds and apricot kernels), prolonged administration of nitroprusside, and after exposure to gases produced by the combustion of synthetic materials. The United States standard cyanide antidote kit first uses a small inhaled dose of amyl nitrite, followed by intravenous sodium nitrite, followed by intravenous sodium thiosulfate. Hydroxocobalamin is newly approved in the US at doses from 2.5 to 10 mg per injection and is available in Cyanokit antidote kits. Hydroxocobalamin (OHCbl, or B12a) is a natural form of vitamin B12. Pharmaceutically, hydroxycobalamin is usually produced as a sterile injectable solution; it is used for treatment of the vitamin deficiency and also (because of its affinity for cyanide ion) as a treatment for cyanide poisoning. Hydroxocobalamin will bind circulating and cellular cyanide molecules to form cyanocobalamin, which is excreted in the urine.

Answer 277

40. C: The International Guidelines for Neonatal Resuscitation include recommendations for noninitiation or discontinuation of resuscitation, which include birth weight

Answer 278

14. B: Hamman’s sign is a crunching sound heard with auscultation and may be synchronized with the patient’s heart beat. This sign is associated with tracheobronchial injury.

Answer 279

C: Hypothyroidism Infection common cause; coarse hair, deep voice, thinning or loss of the outer third of the eyebrows (Queen Ann’s sign) Women \> 60 years; occurs in the winter months Fatigue, weight gain

Answer 280

37. D: Symptoms of ethylene glycol poisoning usually follow a three-step progression, although poisoned individuals will not always develop each stage. Other laboratory abnormalities may suggest poisoning, especially the presence of a metabolic acidosis, particularly if it is characterized by a large anion gap. Large anion gap acidosis is usually present during the initial stage of poisoning.

Answer 281

29. B: Muscle damage is evidenced by rhabdomyolysis. Elevated creatine phophokinase (CPK) values are a diagnostic hallmark of heatstroke because of the rhabdomyolytic process. The release of destructive lysosomal enzymes occurs as a result of extensive muscle damage, which can lead to ARDS, DIC, and ATN.

Answer 282

24. C: After the aircraft has come to a complete stop, the aircraft should be exited by normal means first, jettison doors only if necessary, and forcible means if required. Crew members should meet at a predesignated position (usually meeting at the nose of the aircraft, which is twelve o’clock position) a safe distance from the aircraft.

Answer 283

15. D: A blood product is any component of the blood, which is collected from a donor for use in a blood transfusion. Whole blood is uncommonly used in transfusion medicine at present; most blood products consist of specific processed components, such as red blood cells, blood plasma, or platelets. Type and crossmatch refers to the complex testing that is performed prior to a blood transfusion to determine if the donor’s blood is compatible with the blood of an intended recipient, or to identify matches for organ transplants. Crossmatching is usually performed only after other less complex tests have not excluded compatibility. Blood compatibility has many aspects and is determined not only by the blood types (O, A, B, AB), but also by blood factors (Rh, Kell, etc.). Albumin is a blood protein that is mainly produced in the liver and helps maintain volume of the blood by maintaining the oncotic pressure. Albumin IV is a plasma volume expander made from pooled human venous plasma, which does require type and crossmatching. Indications of Albumin IV include hypovolemia and hypoalbuminemia, which can be caused by burns, major injury, hemorrhage, pancreatitis, infection, liver failure, or liver cirrhosis.

Answer 284

B: The patient suspected of having a cardiac tamponade will exhibit signs and symptoms of decreased cardiac output such as, cool, clammy skin, altered mental sratus, tachycardia, pulsus paradoxus (a drop in systolic blood pressure \> 15 mmHg during normal inspiration), distant muffled heart tones, jugular venous distention, unless the patient is hypovolemic, hypotension, and electrical alternans.

Answer 285

13. D: The administration of beta-blockers or calcium channel blockers, which also reduce heart rate, are contraindicated in digitalis toxicity. Digoxin toxicity is a poisoning that occurs when excess doses of digoxin (digitalis) are consumed acutely or over an extended period of time. Digoxin toxicity is often divided into acute or chronic. The theraputic level for digoxin is 0.5-2.0 ng/mL. Low potassium levels predispose to digitoxicity and dysrhythmias. The classic dysrhythmia is a paroxysmal atrial tachycardia with block. Symptoms include fatigue, nausea, vomiting, changes in heart rate and rhythm, loss of appetite (anorexia), diarrhea, visual disturbances (yellow or green halos around objects), confusion, dizziness, nightmares, agitation, and/or depression. The primary treatment of digoxin toxicity is digoxin immune Digoxin (Digibind) should not be given if the apical heart rate is below 60 beats per minute. Other treatments that may be tried to treat life-threatening dysrhythmias until digoxin immune fab is acquired are Magnesium, phenytoin, and lidocaine. Atropine is also used in cases of bradydysrhythmias. In severe cases, hemodialysis may be required to reduce the levels of digoxin in the body.

Answer 286

8. A: Acute hemolytic reaction has the shortest onset and is considered a medical emergency. It results from rapid destruction (hemolysis) of the donor red blood cells by host antibodies, usually related to ABO blood group incompatibility—the most severe of which often involves group A red cells being given to a patient with group O type blood. Properdin then binds to complement, C3, in the donor blood, facilitating the reaction through the alternate pathway cascade. The most common cause is clerical error (i.e., the wrong unit of blood being given to the patient). The symptoms are fever and chills, sometimes with back pain and pink or red urine (hemoglobinuria). The major complication is that hemoglobin released by the destruction of red blood cells can cause acute renal failure. The most important step in treating a presumed transfusion reaction is to stop the transfusion immediately (saving the remaining blood and IV tubing for testing) and to provide supportive care to the patient. More specific treatments depend on the nature and presumed cause of the transfusion reaction.

Answer 287

15. A: Normal ICP range is 0-10 mmHg, but range can go as high as 15 mmHg.

Answer 288

41. B: Bronchiolitis is a lower respiratory tract infection (primarily viral), which is one of the more common causes of new-onset wheezing in children. Respiratory syncytial virus (RSV) is the causative agent in the majority of cases, but parainfluenza and Mycoplasma pneumoniae have also been isolated. Wheezing is the most common presenting complaint, often with an accompanying 2-5 days’ history of coryaz and cough. Most cases occur in the winter months, with the majority of infections in children below one year of age. Apnea in children younger than three months is also characteristic of RSV infections.

Answer 289

41. C: Henry’s law has two parts: part one states that as pressure increases, solubility of gases in liquids increases; and part two state that as temperature increases, solubility of gases in liquids decreases (colder liquids hold more gas than warmer liquids, as liquid warms up, the gas starts to come out of solution). When a diver goes underwater and subjects the body to increase pressure, the tissues are able to absorb more gases. The oxygen is used up by cellular processes, but the nitrogen is inert and just packs into the tissues. The deeper the diver goes and the longer he stays, the more nitrogen packs into the tissues. Together, Boyle’s and Henry’s laws explain why, as a diver descends while breathing compressed air: 1. Inhaled PO2 and PN2 increase. 2. The amount of nitrogen and oxygen entering the blood and tissues also increase. Henry’s and Dalton’s laws predict that, with descent, inhaled PO2 and PN2 will increase and cause an increased amount of nitrogen and oxygen to enter the blood and tissues. The opposite occurs on ascent: inhaled PO2 and PN2 decrease, and allow the excess nitrogen and oxygen to leave the blood and tissues. The problem begins when the diver ascends and reduces the pressure the body is under, making the nitrogen less soluble in the tissues. If the diver comes up too fast (releases the pressure to fast), the nitrogen comes out in the form of bubbles, just like soda (the bottle of carbonated soda before it is opened is under pressure, when the bottle is opened, you release the pressure and the carbon dioxide becomes less soluble and comes out of solution in the form of bubbles). In order to avoid DCS, “the bends” and to prevent the bubbles from being released from the tissues, the diver must ascend slowly enough that the pressure is released slow enough to allow the nitrogen to leave the tissues without forming bubbles.

Answer 290

44. B: Variable decelerations can occur at any time during a contraction. The shape may also vary and is frequently V-shaped or W-shaped. Cord compression is responsible for these decelerations, which have a very characteristic appearance; frequently a short acceleration is observed, followed by a rapid deceleration for some seconds. Then there is a rapid rise and a short acceleration before there is a return to the FHR baseline. Signs that the fetus is losing the ability to tolerate the stress of repeated cord compression or that the cord compression is becoming more severe include a deeper deceleration that last longer, a slow return to baseline, an “overshoot” increase in FHR baseline immediately after the deceleration, loss of shoulders, and decreased variability.

Answer 291

41. A: Application of positive end-expiratory pressure (PEEP). ARDS lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma. Their compliance is typically reduced, and their dead space is increased. Initiating ventilation of patients with ARDS with A/C ventilation at a tidal volume of 6 mL/kg, with a PEEP of 5 and initial ventilatory rate of 12, titrated up to maintain a pH \> 7.25. Target plateau pressure of

Answer 292

D. Nitroglycerin

Answer 293

C: Kernig’s and Brudzinski’s signs are physical examination results that are strongly suggestive of meningitis. A “stiff neck” is one of the general warning signs of meningitis, and these are some of the first steps to investigate such a finding.

Answer 294

4. C: The burn formulas are a guide only and infusions must be tailored to the urine output and central venous pressure. Inadequate fluid resuscitation causes renal failure and death, but over-resuscitation also causes morbidity and mortality. Consensus Formula (Parkland and modified Brook formulas combined) [(2-4 mL × weight in kg) × % TBSA] = Total fluids in twenty-four hours with half of the total fluids calculated administered in the first eight hours and the rest in the subsequent sixteen hours.

Answer 295

33. D: Cranial nerve VI, which is the accessory nerve (spinal accessory nerve), originates from neurons in the medulla and in the cervical spinal cord. It has a cranial root, which joins the vagus (cranial nerve X) nerve and sends motor fibers to the muscles of the larynx, and a spinal root, which sends motor fibers to the trapezius and the sternocleidomastoid muscles. Damage to the nerve produces weakness in head rotation and shoulder elevation.

Answer 296

44. C: Normal MAP is 80-100 mmHg.

Answer 297

27. D: Nitrazine paper is impregnated with an indicator dye Phenaphthazine. The color changes as pH changes, giving a broad range of colors from yellow through blue. It is used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac. While vaginal pH is normally acidic, a pH above 7.0 can indicate that the amniotic sac has ruptured (nitrazine paper will turn blue). More sensitive than litmus paper, nitrazine indicates pH in the range of 4.5 to 7.5. An elevated vaginal pH can also be associated with bacterial vaginosis.

Answer 298

22. C: Betamethasone (Celestone) is a steroid used to stimulate fetal lung maturation (prevention of ARDS) and to decrease the incidence and mortality from intracranial hemorrhage in premature infants. It is given to the pregnant mother as an injection into muscle tissue. The use of betamethasone can decrease the chance that the fetus will have respiratory distress syndrome when born. It is usually used if preterm delivery is a concern. Dexamethasone (Decadron) can also been used, which is very similar. Side effects may include sleeplessness and higher blood sugar levels for the mother and decreased fetal movement for the baby.

Answer 299

6. C: The proper endotracheal tube (ETT) size can be determined in several ways. It can be approximated by the size of the child’s little finger or nares.

Answer 300

D. Cardiogenic shock

Answer 301

1. C: Nitrogen, always present in body fluids, comes out of solution and forms bubbles if the pressure on the body drops sufficiently as it does during ascent into the higher altitudes. Overweight persons (bariobariatrauma) are more susceptible to evolved gas decompression sickness (DCS) as fatty tissue contains more nitrogen. Henry’s and Dalton’s laws predict that, as the diver descends, excess nitrogen will enter the blood and all body tissues. These laws also predict that, on ascent (as ambient pressure decreases) the extra nitrogen that accumulated will diffuse out of the tissues and into the circulation. DCS arises when excess nitrogen leaving tissue forms bubbles large enough to cause symptoms. Size of bubbles is important, since small bubbles can often be found in divers with no symptoms. DCS arises when the pressure gradient for nitrogen leaving the tissues is so great that large bubbles form, probably by coalescence of many smaller bubbles. Large bubbles within tissues and the circulation cause the symptoms and signs of DCS. Diving DCS: A diver ascends from a dive. Altitude DCS: An aircraft flies upward (ascent).

Answer 302

38. B: All EMS aircraft are required by the FAA to carry an ELT, which are designed to emit a radio signal when activated that will be received by satellites and relayed to rescue personnel. The radio signal does not pinpoint the position of the aircraft but gives rescuers a general area in which to begin search. The ELT is activated by an impace exceeding 4g’s (four times the force of gravity) and broadcasts on the universal distress channel 121.5. Flight team members should know the location of the ELT and ensure that it has been activated. If an impact does not automatically activate the ELT, it can be activated manually by use of the directions on the box.

Answer 303

Grey Turner’s sign refers to bruising of the flank areas. It can take up to twenty-four to forty-eight hours to appear, and it can predict a severe attack of acute pancreatitis. May also be accompanied by Cullen’s sign (periumbilical bruising) or Halstead’s sign (marbled abdomen), which then may be indicative of pancreatic necrosis with retroperitoneal or intra-abdominal bleeding.

Answer 304

28. B: Labetalol (Normodyne, Trandate) is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood pressure. It has a particular indication in the treatment of pregnancy-induced hypertension which is commonly associated with preeclampsia. It is also used to treat chronic hypertension of pheochromocytoma and hypertensive crisis. It works by blocking these adrenergic receptors, which decreases peripheral vascular resistance without significantly altering heart rate or cardiac output. The standard dosage when managing pregnancy-induced hypertension is 20 mg administered by intravenous push over two minutes and may be repeated as needed every ten minutes with 40-80 mg until the maximum dose of 300 mg has been administered.

Answer 305

32. D: Metoprolol is classified as a beta-blocker, which blocks the action of endogenous catecholamines (epinephrine and norepinephrine) in particular, on β-adrenergic receptors, part of the sympathetic nervous system, which mediates the “fight or flight” response. There are three known types of beta receptors, designated β1 (one heart), β2 (two lungs) and β3 receptors. β1-adrenergic receptors are located mainly in the heart and in the kidneys. β2-adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscle. β3-adrenergic receptors are located in fat cells. Some beta-blockers such as, labetalol and carvedilol, exhibit mixed antagonism of both β—and α1-adrenergic receptors, which provides additional arteriolar vasodilating action. Calcium channel blockers are a class of drugs and natural substances that disrupt the calcium (Ca2+) conduction of calcium channels.

Answer 306

30. D: BNP is an amino acid polypeptide released by the ventricles of the heart in response to excessive stretching of the heart muscle cells. BNP is a blood test used to help in the diagnosis of CHF and is typically higher in these patients. For patients with CHF, the BNP levels will generally be \>100 pg/mL. The synthetic version of BNP in medication form is Neseritide (natracor), which reduces systemic vascular resistance and cardiac output.

Answer 307

19. A: Mechanical ventilatory complications most commonly encountered in the emergency department and during transport include hypoxia, hypotension, high-pressure alarms, and low exhaled volume alarms.

Answer 308

42. B: Chronic obstructive pulmonary disease (COPD) can be considered a continuum with asthma on one end, chronic bronchitis in the middle, and emphysema on the opposite end. It is not unusual for emphysema and chronic bronchitis to coexist in varying degrees. Physical examination may reveal pursed-lip breathing, flaring nostrils, rhonchi and/or expiratory wheezes, hyperresonant to percussion, anterior-posterior diameter of the chest is increased (barrel-chest), and tachycardia. The patient’s mental status is an important component since this is the first sign showing that CO2 level has increased beyond the patient’s normal baseline level. Chronic bronchitis results in mucus-secreting cells of the bronchial walls hypersecreting copious amounts of sputum, which prevents airflow into the alveoli. The alveolar gas exchange is normal, but the alveoli are under-ventilated because of obstruction of airflow. Refer the following tables for review of diagnostic studies, pathophysiology, and management of the COPD patient.

Answer 309

A: Cardiac patients are usually not affected with altitude temperature changes.

Answer 310

36. C: Central Cord syndrome is a type of injury that usually results from hyperextension and is characterized by a disproportionally greater motor impairment of the upper than the lower extremities with variable sensory loss below the level of injury. Sacral sparing typically occurs. Two very important determinants of an incomplete, as opposed to a complete, lesion of the spinal cord are preservation of voluntary rectal sphincter tone and perianal sensation (“sacral sparing”). To check for voluntary rectal sphincter tone, insert a gloved finger in the rectum and request the patient, if cooperative, to squeeze down as if attempting to prevent movement of the bowels. If able to do so, there is substantial indication of an incomplete, as opposed to a complete, spinal cord injury, i.e., some spinal neural pathways are intact.

Answer 311

13. D: The patient is presenting with neurogenic shock. The SVR

Answer 312

46. B: Brown-Séquard syndrome is a type of injury that usually results from a penetrating injury which has damaged one side of the spinal cord and is characterized by motor loss on the same side and sensory loss on the opposite side of the injury. Spinal cord injury can be classified in two main forms: complete and incomplete. A complete injury is defined as one in which there is complete disruption of continuity of all spinal pathways at one or more levels of the spinal cord. The result is absent motor function, sensory and pressured (touch) sensation and position and vibratory perception to all body areas enervated by the spinal cord tissue below the level of disruption. Incomplete spinal cord injury can be defined as one in which there is a variable degree of loss of function secondary to partial disruption of the spinal cord (some pathways of neurological function are intact, some are disrupted either permanently or transiently).

Answer 313

31. D: A group of medicines extracted from foxglove plants are called “digitalin.” The use of digitalis purpurea extract containing cardiac glycosides for the treatment of heart conditions is used to increase cardiac contractility (positive inotrope) and as an antiarrhythmic agent to control the heart rate, particularly in atrial fibrillation. Digitalis is often prescribed for patients in atrial fibrillation, especially if they have been diagnosed with CHF. Digitalis works by inhibiting sodium-potassium ATPase. This results in an increased intracellular concentration of sodium, which in turn increases intracellular calcium by passively decreasing the action of the sodium-calcium exchanger in the sarcoplasmic reticulum. The increased intracellular calcium gives a positive inotropic effect. Digitalis poisoning can cause heart block and either bradycardia or tachycardia, depending on the dose and the condition of the patients heart. The classic drug of choice for VF (ventricular fibrillation) in the emergency setting, amiodarone, can worsen the dysrhythmia caused by digitalis; therefore, the second-choice drug lidocaine is more commonly used.

Answer 314

34. A: Air bubbles travel to the surface observing them may help crew members establish orientation; however, poor lighting conditions may prevent adequate visualization of bubbles. Crew members should gently use their arms to push themselves out of the aircraft and avoid kicking to prevent injury to crew members following behind. During surface descent the crew member should exhale slowly to prevent serious lung damage, should they attempt to hold their breath.

Answer 315

15. A: The pCO2 is

Answer 316

50. C: Diarrheal dehydration can cause metabolic acidosis, especially in the pediatric patient. Metabolic alkalosis can be caused by loss of hydrogen ions through the kidneys or GI tract. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCL). Renal losses (use of diuretics) of hydrogen ions occur when the distal delivery of sodium increases in the presence of excess aldosterone, resulting in reabsorption of sodium, leading to the secretion of hydrogen ions and potassium ions. The administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause metabolic alkalosis. Shifting of hydrogen ions into the intracellular space can also occur, which is mainly seen with hypokalemia.

Answer 317

5. B: Observance of a sterile cockpit is a regulation of the Federal Aviation Administration (FAA) (FAR 135.100) that prohibits nonessential communications between the medical crew and pilot during critical phases of flight. The critical phases of flight include all ground operations that involve taxi, takeoff, and landing and all other flight operations except cruise flight. The medical crew should be aware that there are certain times when they should refrain from speaking to the pilot unless absolutely imperative. These times include the following: during takeoff, during landing, during instrument approaches, and in dense air traffic areas.

Answer 318

49. A: Early decelerations are innocuous decelerations that begin very close to the beginning of the contraction, appear almost as a “mirror image” of the contraction, and end close to the end of the contraction. Head compression with vagus stimulation causes the deceleration.

Answer 319

37. B: Tracheobronchial injuries occur when blunt or penetrating trauma causes a tear in the trachea or bronchus, allowing air to enter the pleural space or mediastinum. These injuries are characterized by palpable subcutaneous emphysema in the neck, face, and thorax. Other clinical findings include dyspnea, hemoptysis (coughing up blood), and absent breath sounds on the affected side. Hamman’s sign is a crunching sound auscultated on the anterior chest wall and is synchronized to the patient’s heartbeat. A pneumothorax that reaccumulates after chest tube insertion and placement to water seal drainage and suction should heighten the transport team’s suspicion for tracheobronchial injuries. Treatment is intubation, with placement of the tube distal to the injury site, which most often can involve an intentional right mainstem intubation.

Answer 320

47. B: Normal range pCO2 is 35-45 mmHg.

Answer 321

44. B: Newton’s first law of motion states unless it is acted on by a force, a body at rest will remain at rest and a body in motion will move at a constant speed in a straight line. The remaining three are gas laws.

Answer 322

20. A: Graham’s law, also known as Graham’s law of effusion states that the rate at which gas molecules diffuse is inversely proportional to the square root of its density (same as the square root of its molecular weight). This means that gases will flow from a higher pressure or concentration to an area of lower pressure or concentration. Simple diffusion and gas exchange at the cellular level are examples of this gas law.

Answer 323

19. C: The PAIP becomes the road map for the communication center staff to initiate the necessary critical steps that enhance crew survival and limit the program’s liability. Priorities include verifying facts (crash location, etc.); dispatching rescue crews (civil air patrol, air medical, or ambulance response to the crash site); activating notification list according to the PAIP; and notifying security for crowd control at base of operations and/or hospitals. CAMTS recommends the following for time between each communication during flight and ground operations.

Answer 324

32. D: The thumbprint sign is a finding on a lateral C-spine radiograph that suggests the diagnosis of epiglottitis. The sign is caused by a thickened free edge of the epiglottis, which causes it to appear more radiopaque than normal, resembling the distal thumb. Epiglottitis is a rare but life-threatening bacterial infection of the epiglottitis and surrounding airway structures. Epiglottitis is second only to croup as a cause for infectious stridor. Clinical presentation includes symptoms that often occur rapidly causing caretakers to seek medical attention in twenty-four hours of the onset of initial symptoms, fever, stridor, labored respirations, and because of supraglottic edema, often present with drooling. They are often anxious and present in a classic tripod position (sitting forward with their arms supporting them with their jaws thrusted forward), which increased air entry. Endotracheal intubation should only be undertaken by staff capable of securing the airway, surgically if necessary.

Answer 325

33. C: Grey Turner’s sign refers to bruising of the flanks and can indicate retroperitoneal or intra-abdominal bleeding, which can take up to 24-48 hours to show up on assessment. It can be caused by acute pancreatitis, blunt abdominal trauma, ruptured abdominal aortic aneurysm, or ruptured/hemorrhagic ectopic pregnancy. It may be accompanied by Cullen’s sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus), which may then be indicative of pancreatic necrosis, with retroperitoneal or intra-abdominal bleeding. Murphy’s sign is useful for differentiating pain in the right upper quadrant. Typically, it is positive in cholecystitis (gallbladder disease). Kernig’s and Brudzinski’s signs when elicited can indicate meningitis. Kehr’s sign (referred shoulder pain) can be indicative of a spleen injury or ectopic pregnancy.

Answer 326

38. B: The administration of succinylcholine (Anectine) is contraindicated in patients with known and/or suspected hyperkalemia. The hyperkalemia associated with succinylcholine, which can approach or exceed life-threatening levels, is of greater consequence in patients who have a history of burns or massive muscle trauma 2 to 3 days prior, and patients may continue to be at risk for hyperkalemia for 2 to 3 months. The two absolute contraindications to use of succinylcholine are situations in which cricothyrotomy would be difficult or impossible to accomplish and the use of the medication by individuals who do not possess a thorough knowledge about the pharmacology of neuromuscular blocking agents, and they do not possess advanced airway skills or an alternative plan if they should encounter a failed airway.

Answer 327

20. B: Entire face 4.5%, left forearm 4.5%, right hand 1%, and anterior portion of the entire left leg 9% = BSA of 19%

Answer 328

18. B: Gravida indicates the total number of pregnancies a woman has had, regardless of whether they were carried to term. Para indicates the number of viable (\>20 weeks) births. Note: pregnancies consisting of multiples, such as twins or triplets, count as one birth.

Answer 329

26. B: Cushing’s triad is defined as a widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is sign of increased ICP, and it occurs as a result of the Cushing reflex. The body’s compensatory mechanism and response to decreased cardiac output is to stimulate the sympathetic nervous system. This will cause vasoconstriction and results in a rise in the diastolic pressure, causing a narrowed pulse pressure. A narrow pulse pressure, which is the difference between the systolic and the diastolic, is an early indication of shock. Look for hypovolemia or decreased cardiac output. A narrowing pulse pressure in shock is consistent with hypovolemic and cardiogenic causes. Septic shock will cause a widened pulse pressure. One way to differentiate shock in your patients is to look at the pulse pressure. A narrowing pulse pressure associated with hypovolemia would be hypovolemic. A narrowing pulse pressure associated with volume overload would be cardiogenic. A widening pulse pressure associated with hypovolemia would be septic. 27. D: The classic symptoms include

Answer 330

45. B: Four basic variables that affect gas volumetric relationships are temperature, pressure, volume, and the relative mass of gas or the number of molecules. Gas laws govern the body’s physiologic response to barometric pressure changes. When the transport team is taking care of the patient being transported by air, these changes become particularly important on ascent and descent.

Answer 331

45. D: 90 × 2 = 180 180 × 2 = 360 360 divided by 3 = 120 120-25 = 95 MAP-ICP = CPP

Answer 332

4. A: Subtle seizures are a type of seizure that is frequently overlooked by health-care providers. It may consist of repetitive mouth or tongue movement, bicycling movements, eye deviations, repetitive blinking, staring, or apnea. To treat neonatal seizures, it is important to attempt to identify the cause. The glucose level should be checked immediately, and if hypoglycemia is present (serum glucose

Answer 333

31. C: The facial nerve is the seventh (VII) of twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla, controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia. Patients may suffer from acute facial nerve paralysis, which is usually manifested by facial paralysis. Bell’s palsy is one type of idiopathic acute facial nerve paralysis, which is more accurately described as a multiple cranial nerve ganglionitis that involves the facial nerve, and most likely results from viral infection and also sometimes as a result of Lyme disease. Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly (inability to do so is called lagophthalmos), pursing the lips, and puffing out the cheeks, all test the facial nerve.

Answer 334

9. C: A pneumothorax with a persistent air leak or failure of a lung to re-expand after needle thorocostomy and/or chest tube has been placed should lead the transport team to suspect a tracheobronchial injury. A tension pneumothorax may be the first visible sign of the problem. Other signs/symptoms can include hemoptysis, respiratory distress, subcutaneous, and/or mediastinal emphysema. Tracheobronchial injuries occur most often from blunt trauma. Penetrating thoracic trauma is a less common cause. If tracheobronchial injury is suspected, immediate endotracheal intubation is performed with placement of the endotracheal tube below the level of the injury.

Answer 335

47. A: The primary mechanism of action of organophosphate pesticides is inhibition of carboxyl ester hydrolases, particularly acetylcholinesterase (AChE). AChE is an enzyme that degrades the neurotransmitter acetylcholine (ACh) into choline and acetic acid. ACh is found in the central and peripheral nervous system, neuromuscular junctions, and red blood cells (RBCs). Organophosphates inactivate AChE by phosphorylating the serine hydroxyl group located at the active site of AChE. The phosphorylation occurs by loss of an organophosphate leaving group and establishment of a covalent bond with AChE. Once AChE has been inactivated, ACh accumulates throughout the nervous system, resulting in overstimulation of muscarinic and nicotinic receptors. Clinical effects are manifested via activation of the autonomic and central nervous systems and at nicotinic receptors on skeletal muscle. Organophosphates can be absorbed cutaneously, ingested, inhaled, or injected. Although most patients rapidly become symptomatic, the onset and severity of symptoms depend on the specific compound, amount, route of exposure, and rate of metabolic degradation.

Answer 336

5. A: Spinal cord injury can lead to neurogenic shock. The patient is presenting with tachypnea, hypotension, and a normal heart rate but can also be present with bradydysrhythmias because of loss of sympathetic tone secondary to the spinal cord injury.

Answer 337

31. B: An ectopic pregnancy is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common complication. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of five to eight weeks. Shoulder pain (Kehr’s sign) is caused by free blood tracking up the abdominal cavity, irritating the diaphragm and is an ominous sign.

Answer 338

23. A: Flicker vertigo can occur when transport team members and patients are exposed to lights that flicker at a rate of 4-20 cycles per second. Flicker vertigo can cause nausea and vomiting. In severe cases, it can cause seizures and unconsciousness. Even though flicker vertigo is not a common condition, sunlight flickering through rotor blades can trigger seizure activity in persons with seizure disorders or neurologic disorders. This patient had been recently diagnosed as having a stroke. Other clues to consider that flicker vertigo was the cause of the seizure activity included; sunny afternoon and the seizure activity ceased when the rotor blades stopped and started again with start-up. Treatment can include covering the patient’s eyes to prevent flicker vertigo from occurring.

Answer 339

16. B: Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats (high, low, high). Also a wandering baseline may be seen. It is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.

Answer 340

49. C: A high clinical index of suspicion based on the mechanism of injury should always guide one’s assessment and management. The possibility of non-accidental trauma (i.e., child abuse) should always be considered under certain circumstances, which can include a discrepancy between the history that is presented by the caregivers and the actual physical examination findings; injuries that are incompatible with a infant’s neurodevelopmental capabilities; a delay in seeking medical advice or treatment for what appears to be a serious injury; findings of multiple injuries at various chronological stages; bites marks, cigarette burns or rope/cord marks; burns with sharply demarcated margins; genital or perianal trauma (including burns to these areas); multiple subdural hematomas; retinal hemorrhages; and rib fractures involving multiple ribs and/or at various chronological stages.

Answer 341

21. D: Cardiac tamponade also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium (the sac in which the heart is enclosed). If the fluid significantly elevates the pressure on the heart, it will prevent the heart’s ventricles from filling properly. This, in turn, leads to a low-stroke volume. The end result is ineffective pumping of blood, shock, and often death. Clinical presentation can include; tachycardia, bradycardia, Beck’s triad (muffled heart tones, hypotension, jugular venous distension), pulsus paradoxus, and the presence of electrical alternans on the ECG. Management of a cardiac tamponade in the prehospital setting includes rapid transport to the closest, most appropriate facility, intravenous fluids (this measure improves filling pressures and temporarily improves cardiac output) until pericardiocentesis can be performed. Landmark for performing a pericardiocentesis is the infrasternal angle or subcostal angle, into the apex of which the xiphoid process projects with the needle and syringe directed toward the left shoulder/scapula. A needle placed into the pericardial sac, with aspiration of as little as 15-20 mL of blood can improve the patient’s condition. Pericardial blood will generally not clot because it has been defibrinated by heart motion.

Answer 342

42. C: The diastolic blood pressure is a more reliable predictor of the disease process. The blood pressure should be taken with the pregnant patient in the left lateral recumbent position. Hypertension associated with PIH is labile and may change in the time it takes to retake the blood pressure. The patient should be monitored closely to rapidly identify preeclampsia and its life-threatening complications (HELLP syndrome and eclampsia). Drug treatment options are limited as many antihypertensives may negatively affect the fetus; methyldopa, hydralazine, and labetalol are most commonly used for severe pregnancy hypertension. The end goal treatment is to achieve a diastolic blood pressure of 90-100 mmHg. The fetus is at increased risk for a variety of life-threatening conditions, including pulmonary hypoplasia. There exist several hypertensive states of pregnancy: • Gestational hypertension = usually defined as a BP over 140/90 • Preeclampsia = gestational hypertension (BP \> 140/90), and proteinuria (\>300 mg of protein in a 24-hour urine sample). Severe preeclampsia involves a BP over 160/110 (with additional signs) • Eclampsia = seizures in a preeclamptic patient • HELLP syndrome = Hemolytic anemia, elevated liver enzymes and low platelet count • Acute fatty liver of pregnancy is sometimes included in the preeclamptic spectrum.

Answer 343

7. D: Pediatric tubes that are cuffless prevent subglottic stenosis and ulceration, and they range in size from 2.5-6.5 mm. Cuffless tubes are recommended in children younger than eight years of age because the cricoid cartilage is the narrowest portion of the trachea, and if the tube used is of proper size, it serves as a physiologic cuff. A tube that is too large will not pass through the cricoid cartilage. A tube that is too small will not provide total airway protection.

Answer 344

38. C: Urinary output is perhaps the most accurate method of evaluating the effectiveness of fluid replacement. Adult burn patients should have an hourly urine output of 30-50 mL/hr, and in the pediatric patient, it should be maintained at 1-2 mL/kg/hr/% BSA below 30 kg. Oliguria is an indication of inadequate fluid volume and should be easily corrected by increasing the rate of fluid administration. An osmotic diuretic, such as mannitol can be administered to avoid acute renal failure when fluid administration has been ineffective.

Answer 345

14. C: Normal cerebral perfusion pressure range is 70-90 mmHg.

Answer 346

19. D: Atmospheric pressure is the force per unit area exerted against a surface by the weight of air above that surface in the earth’s atmosphere. A column of air one square inch in cross-section, measured from sea level to the top of the atmosphere, would weigh approximately 14.7 lbs per square inch (psi) or 760 mmHg (torr), which is defined as 1 atmosphere of pressure (ATM). Because the density of water is uniform throughout, the proportional relationship of pressure and depth remains constant; pressure increases 1 ATM for every thirty-three-foot column of seawater. At the given depth underwater, the total pressure will be the sum of the barometric pressure exerted by the column of air above plus the hydrostatic pressure exerted by the column of water. This is the concept of absolute pressure or atmospheres absolute (ATA). Therefore, a scuba diver at a depth of thirty-three feet will experience an ambient pressure of 2 ATM absolute pressure, or 2 ATA (air column plus water column).

Answer 347

19. B: Reye’s syndrome is a potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing hypoglycemia. The exact cause is unknown, and while it has been associated with aspirin consumption by children with viral illness, it also occurs in the absence of aspirin use. The disease causes fatty liver with minimal inflammation and severe encephalopathy (with swelling of the brain). The liver may become slightly enlarged and firm, and there is a change in the appearance of the kidneys. Jaundice is not usually present. Early diagnosis is vital; while most children recover with supportive therapy, severe brain injury or death are potential complications. The ammonia test is primarily used to help investigate the cause of changes in behavior and consciousness. It may be ordered, along with other tests such as glucose, electrolytes, and kidney and liver function tests, to help diagnose the cause of a coma of unknown origin or to help support the diagnosis of Reye’s syndrome or hepatic encephalopathy caused by various liver diseases.

Answer 348

45. D: The care of viper envenomation should include wound cleansing, immobilization of the affected part (decreases the circulation of venom throughout the body), no use of compression techniques (including ice), and transport. Included in the coagulation studies should be fibrin split products and fibrinogen levels. Treatment can include fluids, administration of steroids, medications to decrease risk of anaphylaxis, and snake antivenin. If the patient exhibits signs of severe envenomation, such as edema that has progressed 30 cm in 1 hour of the bite, shock, kidney failure, pulmonary edema, bleeding, or paralysis, administration of antivenin should be started.

Answer 349

8. B: Hemothorax occurs when blood accumulates in the pleural space. When more than 1,500 mL of blood accumulates in the pleural space, a hemothorax is deemed massive. Clinical presentation can include dyspnea, chest pain, decreased or absent breath sounds over the affected side, and dullness to percussion of the affected hemothorax. Signs of shock, which would be related to the blood loss, may be evident. Advanced Trauma Life Support (ATLS) guidelines state the tube should be clamped after 1,000 mL of blood is removed in adult patients. Pediatric patients have a circulating volume of 80 mL/kg. The 1,000 mL in adults represents one fifth of the circulating volume, so a similar 20% loss in children may require thoracostomy tube clamping. It is important to remember that tube clamping is a temporizing measure until open thoracotomy can be performed.

Answer 350

28. A: One of the major organs that must be functional if heat is to be dissipated is the skin. The primary mechanism for heat dissipation is the evaporation of sweat. Vasodilation maximizes the cooling surface and greatly decreases peripheral vascular resistance.

Answer 351

23. B: Sepsis is by far the most common cause of distributive shock. Goals of early resuscitation in patients with sepsis include restoration of tissue perfusion, reversal of oxygen supply dependency, and normalization of cellular metabolism. When appropriate fluid administration fails to restore adequate tissue perfusion and arterial pressure, vasopressors are usually necessary to increase mean systemic pressure, cardiac output, and oxygen delivery. Norepinephrine (Levophed) improves systemic blood pressure and does not substantially worsen end-organ ischemia in most studies of crystalloid-resuscitated septic shock patients. Norepinephrine may be preferential to other catecholamine pressors as first-line therapy for septic shock. Dosing of norepinephrine in shock patients is normally in the range of 0.01-5 µg/kg/minute and titrated to improvements in blood pressure and tissue perfusion. If sepsis is suspected, antibiotic therapy should be anticipated and discussed with both the referring and receiving physician.

Answer 352

36. D: Eclampsia can occur befor labor, during labor, or early into the postpartum period. Headache, visual disturbances, epigastric pain, apprehension, anxiety, and hyperreflexia with clonus in a patient with severe preeclampsia are signs of impending eclampsia. Seizures are characterized by clonic and tonic activity and usually begin around the mouth in the form of facial twitching.

Answer 353

17. B: SVR

Answer 354

37. A: Absent and minimal variability may be precipitated by fetal hypoxia, administration of drugs to mother, smoking, extreme prematurity, and fetal sleep. The fetus will have frequent sleep periods ranging from 20-40 minutes. Marked variability of more than twenty-five beats per minute may be one of the earliest signs of hypoxia. The presence of moderate variability is strongly predictive of normal fetal acid-base status. Absent variability is an ominous finding, especially when it occurs in conjunction with late or variable declerations. Assessment of variability is an important part of interpreting a fetal heart rate (FHR) pattern. Baseline FHR is defined as fluctuations in the baseline of irregular amplitude and frequency. These fluctuations are quantified in terms of the amplitude of the peak-to-trough in beats per minute (BPM). Baseline FHR variability is determined on a ten-minute segment of the FHR strip. FHR variability is assigned to one of four possible categories: Baseline FHR variability Category Definition Absent No peak-to-trough changes in FHR detected Minimal Amplitude is \>0 and ≤5 BPM Moderate Amplitude is 6-25 BPM Marked Amplitude is \>25 BPM

Answer 355

3. C: Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated, while the opposing set is not, and an external stimulus, such as pain, causes the working set of muscles to contract. Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands clenched into fists, and the legs extended, and feet turned inward. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. A hallmark of decerebrate posturing is extended elbows. The arms and legs are extended and rotated internally. The patient is rigid, with the teeth clenched.

Answer 356

46. B: Cardiac tamponade, tension pneumothorax, massive pulmonary embolism, and aortic stenosis are classified as forms of obstructive shock. In these situations, the flow of blood is obstructed, which impedes circulation and can result in circulatory arrest.

Answer 357

7. B: Hypoxic hypoxia is also referred to as altitude hypoxia because its primary cause is exposure to low barometric pressure. It is a deficiency in alveolar oxygen exchange, which interferes with gas exchange in two phases of respiration: ventilation and diffusion. A reduction in PO2 in inspired air or the effective gas exchange area of the lung may cause oxygen deficiency. The result is an inadequate oxygen supply to the arterial blood, which in turn decreases the amount of oxygen available to the tissues. Decreased barometric pressure at high altitudes causes a reduction in the alveolar partial pressure of oxygen (PaO2). The blood oxygen saturation, which is 98% at sea level, is reduced to 87% at 10,000 feet and 60% at 22,000 feet. The most effective way to prevent physiologic problems is to provide an aircraft pressurization system so that occupants of the aircraft are never exposed to pressure outside the physiologic zone. In those cases in which ascent above the physiologic zone is required, protective oxygen equipment must be provided. Treatment of hypoxia is administration of 100% oxygen.

Answer 358

41. B: A basilar skull fracture (or basal skull fracture) is a fracture of the base of the skull, typically involving the temporal bone, occipital bone, sphenoid bone, and/or ethmoid bone. This type of fracture is rare, occurring as the only fracture in just 4% of severe head injury patients. Such fractures can cause tears in the membranes surrounding the brain, or meninges, with resultant leakage of the cerebrospinal fluid (CSF). The leaking fluid may accumulate in the middle ear space and dribble out through a perforated eardrum (CSF otorrhea) or into the nasopharynx via the eustachian tube, causing a salty taste. CSF may also drip from the nose (CSF rhinorrhea) in fractures of the anterior skull base, yielding a halo sign. Clinical signs include Battle’s sign, which is ecchymosis of the mastoid process of the temporal bone and Raccoon eyes is periorbital ecchymosis (“black eyes”).

Answer 359

15. D: TUC refers to the elapsed time from the point of exposure to an oxygen-deficient environment to the point at which deliberate function is lost. Rapid decompression, which occurs when a quick loss of cabin pressure occurs in a pressurized aircraft at high altitudes, dramatically reduces the time of useful consciousness. On decompression at altitudes above 33,000 feet, an immediate reversal of oxygen flow in the alveoli takes place, caused by higher PO2 within the pulmonary capillaries that depletes the blood’s oxygen reserve. The causes of hypoxia include high altitude, hypoventilation, and pathologic condition of the lung.

Answer 360

10. D: Cardiogenic shock with uncompensated respiratory acidosis and hypoxemia. The hypotension indicates cardiogenic shock secondary to pump failure, leading to left ventricular heart failure (vesicular rales and hypoxia). The pH is low and the pCO2 is high, resulting in respiratory acidosis. The HCO3 is normal, indicating that no compensatory response has occurred. Acute respiratory failure is defined as a pO2 50 mmHg. Normal pO2 is 80-100 mmHg.

Answer 361

24. D: The oxyhemoglobin dissociation curve describes the relation between the partial pressure of oxygen and the oxygen saturation. The effectiveness of hemoglobin-oxygen binding can be affected by several factors.

Answer 362

16. D: Frequency shows how far apart your contractions are.

Answer 363

36. C: The specific antidote for moderate to severe cases of iron poisoning is deferoxamine, a chelator that binds the ferric ion and forms a ferrioxamine complex, a water-soluble compound that is excreted in the urine (thereby reducing the iron load). Serious iron poisoning usually causes symptoms within six hours of the overdose. The symptoms of iron poisoning typically occur in five stages. In stage 1 (within 6 hours after the overdose), symptoms include vomiting, vomiting blood, diarrhea, abdominal pain, irritability, drowsiness, unconsciousness, and seizures. Deferoxamine mesylate, for injection, is an iron-chelating agent, available in vials for intramuscular, subcutaneous, and intravenous administration. Deferoxamine mesylate is contraindicated in patients with severe renal disease or anuria, since the drug and the iron chelate are excreted primarily by the kidney. Excretion of the resulting ferrioxamine complex results in pink-red urine that is classically called “vin-rosé urine.”

Answer 364

2. B: Bradydysrhythmia is a complication that frequently is associated with succinylcholine (Anectine) use, especially in the pediatric patient, but may also occur in adults. Pretreatment with atropine (0.02 mg/kg) is advised in children to prevent bradycardia, and pretreatment with lidocaine (1.5 mg/kg) in patients with suspected or known head injury has been shown to attenuate the rise in ICP associated with endotracheal initubation. Atropine is a tropane alkaloid extracted from deadly nightshade (Atropa belladonna), jimsonweed (Datura stramonium), mandrake (Mandragora officinarum), and other plants of the family Solanaceae. Atropine increases firing of the sinoatrial (SA) node and conduction through the atrioventricular (AV) node of the heart, opposes the actions of the vagus nerve, blocks acetylcholine receptor sites, and decreases bronchial secretions. It is classified as a parasympatholytic (lytic—blocks). It is usually not effective in second-degree heart block (Mobitz type 2) and in third-degree heart block with a low Purkinje or ventricular escape rhythm. Atropine is contraindicated in ischemia-induced conduction block (widened QRS), because the drug increases oxygen demand of the AV nodal tissue, thereby aggravating ischemia and the resulting heart block.

Answer 365

17. C: Duration shows how long your contractions last.