AIR METHODS Pre-Hire Exam: COMPLETE
Simulated Assessment - Flight Crew & Medical
Role Candidate Preparation
DOMAIN 1: CRITICAL CARE & TRAUMA MEDICINE (Questions 1-25)
Q1. During transport of a ventilated patient with a suspected tension pneumothorax
following a stab wound, you note a rapid rise in peak airway pressures, hypotension, and
unilateral diminished breath sounds. In the confined helicopter cabin, your most
immediate and appropriate intervention is:
A. Increase PEEP to improve oxygenation
B. Prepare for needle decompression at the 4th intercostal space, mid-axillary line
C. Perform needle decompression at the 2nd intercostal space, mid-clavicular line
D. Request an immediate divert to the nearest hospital for chest tube placement
Correct Answer: C
Primary Principle: Life-threatening conditions requiring immediate intervention are
managed in the aircraft. Tension pneumothorax is a "treat now" pathology.
Scenario Deconstruction: Classic signs of tension pneumothorax in a ventilated patient.
This is a progressive, immediately life-threatening condition.
Optimal Action Rationale: Needle decompression is the standard pre-hospital/transport
intervention for tension pneumothorax. The 2nd ICS, MCL is the landmark specified in
most air medical and trauma protocols for needle thoracostomy. Doing it in the aircraft
addresses the immediate threat.
,Risk of Distractors: A (increasing PEEP) would worsen the pneumothorax. B uses the
correct procedure but the wrong landmark (4th ICS, MAL is often for chest tube
insertion, not initial needle decompression). D (diverting) delays critical intervention,
risking cardiac arrest.
Q2. You are managing a traumatic brain injury patient with a Glasgow Coma Scale
(GCS) of 8. The patient is intubated and mechanically ventilated. At cruise altitude, the
end-tidal CO₂ (EtCO₂) reading drops from 35 mmHg to 25 mmHg despite no changes to
ventilator settings. Your most appropriate response is:
A. Increase the respiratory rate to compensate for altitude
B. Recognize this as expected physiologic change due to reduced barometric pressure
and adjust ventilation targets accordingly
C. Administer sodium bicarbonate
D. Sedate the patient more deeply to reduce metabolic demand
Correct Answer: B
Primary Principle: Altitude physiology and gas laws. As altitude increases, barometric
pressure decreases, affecting gas partial pressures and ventilator measurements.
Scenario Deconstruction: The Boyle's Law effect on ventilator pressure transducers and
the actual alveolar gas exchange changes at altitude cause EtCO₂ to read lower than
actual PaCO₂. The patient may actually be normocarbic or hypocarbic.
Optimal Action Rationale: Understanding that EtCO₂ values decrease at altitude is
critical. The target EtCO₂ for TBI patients (typically 35-40 mmHg at sea level) must be
adjusted downward at altitude to maintain actual PaCO₂ in the target range. The clinical
goal is eucapnia, not a specific EtCO₂ number.
Risk of Distractors: Increasing rate (A) would cause iatrogenic hypocapnia, worsening
cerebral vasoconstriction and ischemia. Bicarbonate (C) is inappropriate for respiratory
alkalosis. Deepening sedation (D) doesn't address the ventilation issue.
,Q3. During a scene flight for a pediatric trauma patient, you establish IV access and
begin fluid resuscitation. The patient weighs 20 kg and shows signs of compensated
shock. According to pediatric trauma protocols and air medical considerations, your
fluid bolus should be:
A. 200 mL of normal saline, given rapidly
B. 400 mL of warmed normal saline, given in aliquots with reassessment
C. 600 mL of lactated Ringer's, given as a continuous infusion
D. 100 mL of 3% saline for suspected head injury
Correct Answer: B
Primary Principle: Pediatric fluid resuscitation is weight-based (20 mL/kg) with
emphasis on warmed fluids and reassessment in the flight environment.
Scenario Deconstruction: 20 kg × 20 mL/kg = 400 mL. This is the standard pediatric
bolus for shock. The flight environment introduces hypothermia risk from cold fluids
and altitude.
Optimal Action Rationale: Warming fluids is critical in air medical transport (cold stress
from altitude and cabin environment). Giving in aliquots (e.g., 200 mL, then reassess)
prevents fluid overload while treating shock. Reassessment guides further therapy.
Risk of Distractors: 200 mL (A) is insufficient for shock. Continuous infusion (C) is
inappropriate for bolus therapy; LR is acceptable but the volume and method are wrong.
Hypertonic saline (D) is for suspected herniation with specific signs, not general shock.
Q4. You are transporting a patient with a suspected cervical spine injury who was
intubated at the scene. Mid-flight, you notice the endotracheal tube (ETT) pilot balloon is
fully inflated and tense. The patient is on 100% FiO₂ with stable oxygen saturation. Your
immediate concern and action should be:
A. No concern; this indicates a good seal
, B. The cuff is overinflated due to altitude-related gas expansion; aspirate air to maintain
appropriate cuff pressure
C. The patient has a bronchospasm; administer albuterol
D. Extubate and reintubate with a fresh tube
Correct Answer: B
Primary Principle: Boyle's Law: Gas expands as atmospheric pressure decreases with
altitude. Trapped gases (ETT cuffs, pneumothoraces, air in stomach) expand at altitude.
Scenario Deconstruction: At sea level, the cuff was appropriately inflated. At cruise
altitude (e.g., 5,000-10,000 feet), the gas in the cuff expands, increasing pressure
against the tracheal wall. This risks tracheal ischemia, necrosis, and potential rupture.
Optimal Action Rationale: Monitoring and adjusting cuff pressure is essential. Many air
medical programs use saline-filled cuffs to avoid this issue, or carefully aspirate air to
maintain <30 cm H₂O pressure.
Risk of Distractors: A (ignoring) risks tracheal damage. Bronchospasm (C) wouldn't
affect the pilot balloon. Extubation (D) is unnecessary and dangerous in a patient with
cervical spine precautions.
Q5. You are transporting a patient in cardiogenic shock on a norepinephrine drip. At
altitude, the patient's blood pressure begins to drop. You check the IV pump and the
line. Your first assessment should be to:
A. Increase the drip rate on the pump
B. Check for positional changes in the aircraft affecting drip chamber fluid level and
tubing
C. Draw blood to check a lactate level
D. Switch to a new bag of norepinephrine
Correct Answer: B
Simulated Assessment - Flight Crew & Medical
Role Candidate Preparation
DOMAIN 1: CRITICAL CARE & TRAUMA MEDICINE (Questions 1-25)
Q1. During transport of a ventilated patient with a suspected tension pneumothorax
following a stab wound, you note a rapid rise in peak airway pressures, hypotension, and
unilateral diminished breath sounds. In the confined helicopter cabin, your most
immediate and appropriate intervention is:
A. Increase PEEP to improve oxygenation
B. Prepare for needle decompression at the 4th intercostal space, mid-axillary line
C. Perform needle decompression at the 2nd intercostal space, mid-clavicular line
D. Request an immediate divert to the nearest hospital for chest tube placement
Correct Answer: C
Primary Principle: Life-threatening conditions requiring immediate intervention are
managed in the aircraft. Tension pneumothorax is a "treat now" pathology.
Scenario Deconstruction: Classic signs of tension pneumothorax in a ventilated patient.
This is a progressive, immediately life-threatening condition.
Optimal Action Rationale: Needle decompression is the standard pre-hospital/transport
intervention for tension pneumothorax. The 2nd ICS, MCL is the landmark specified in
most air medical and trauma protocols for needle thoracostomy. Doing it in the aircraft
addresses the immediate threat.
,Risk of Distractors: A (increasing PEEP) would worsen the pneumothorax. B uses the
correct procedure but the wrong landmark (4th ICS, MAL is often for chest tube
insertion, not initial needle decompression). D (diverting) delays critical intervention,
risking cardiac arrest.
Q2. You are managing a traumatic brain injury patient with a Glasgow Coma Scale
(GCS) of 8. The patient is intubated and mechanically ventilated. At cruise altitude, the
end-tidal CO₂ (EtCO₂) reading drops from 35 mmHg to 25 mmHg despite no changes to
ventilator settings. Your most appropriate response is:
A. Increase the respiratory rate to compensate for altitude
B. Recognize this as expected physiologic change due to reduced barometric pressure
and adjust ventilation targets accordingly
C. Administer sodium bicarbonate
D. Sedate the patient more deeply to reduce metabolic demand
Correct Answer: B
Primary Principle: Altitude physiology and gas laws. As altitude increases, barometric
pressure decreases, affecting gas partial pressures and ventilator measurements.
Scenario Deconstruction: The Boyle's Law effect on ventilator pressure transducers and
the actual alveolar gas exchange changes at altitude cause EtCO₂ to read lower than
actual PaCO₂. The patient may actually be normocarbic or hypocarbic.
Optimal Action Rationale: Understanding that EtCO₂ values decrease at altitude is
critical. The target EtCO₂ for TBI patients (typically 35-40 mmHg at sea level) must be
adjusted downward at altitude to maintain actual PaCO₂ in the target range. The clinical
goal is eucapnia, not a specific EtCO₂ number.
Risk of Distractors: Increasing rate (A) would cause iatrogenic hypocapnia, worsening
cerebral vasoconstriction and ischemia. Bicarbonate (C) is inappropriate for respiratory
alkalosis. Deepening sedation (D) doesn't address the ventilation issue.
,Q3. During a scene flight for a pediatric trauma patient, you establish IV access and
begin fluid resuscitation. The patient weighs 20 kg and shows signs of compensated
shock. According to pediatric trauma protocols and air medical considerations, your
fluid bolus should be:
A. 200 mL of normal saline, given rapidly
B. 400 mL of warmed normal saline, given in aliquots with reassessment
C. 600 mL of lactated Ringer's, given as a continuous infusion
D. 100 mL of 3% saline for suspected head injury
Correct Answer: B
Primary Principle: Pediatric fluid resuscitation is weight-based (20 mL/kg) with
emphasis on warmed fluids and reassessment in the flight environment.
Scenario Deconstruction: 20 kg × 20 mL/kg = 400 mL. This is the standard pediatric
bolus for shock. The flight environment introduces hypothermia risk from cold fluids
and altitude.
Optimal Action Rationale: Warming fluids is critical in air medical transport (cold stress
from altitude and cabin environment). Giving in aliquots (e.g., 200 mL, then reassess)
prevents fluid overload while treating shock. Reassessment guides further therapy.
Risk of Distractors: 200 mL (A) is insufficient for shock. Continuous infusion (C) is
inappropriate for bolus therapy; LR is acceptable but the volume and method are wrong.
Hypertonic saline (D) is for suspected herniation with specific signs, not general shock.
Q4. You are transporting a patient with a suspected cervical spine injury who was
intubated at the scene. Mid-flight, you notice the endotracheal tube (ETT) pilot balloon is
fully inflated and tense. The patient is on 100% FiO₂ with stable oxygen saturation. Your
immediate concern and action should be:
A. No concern; this indicates a good seal
, B. The cuff is overinflated due to altitude-related gas expansion; aspirate air to maintain
appropriate cuff pressure
C. The patient has a bronchospasm; administer albuterol
D. Extubate and reintubate with a fresh tube
Correct Answer: B
Primary Principle: Boyle's Law: Gas expands as atmospheric pressure decreases with
altitude. Trapped gases (ETT cuffs, pneumothoraces, air in stomach) expand at altitude.
Scenario Deconstruction: At sea level, the cuff was appropriately inflated. At cruise
altitude (e.g., 5,000-10,000 feet), the gas in the cuff expands, increasing pressure
against the tracheal wall. This risks tracheal ischemia, necrosis, and potential rupture.
Optimal Action Rationale: Monitoring and adjusting cuff pressure is essential. Many air
medical programs use saline-filled cuffs to avoid this issue, or carefully aspirate air to
maintain <30 cm H₂O pressure.
Risk of Distractors: A (ignoring) risks tracheal damage. Bronchospasm (C) wouldn't
affect the pilot balloon. Extubation (D) is unnecessary and dangerous in a patient with
cervical spine precautions.
Q5. You are transporting a patient in cardiogenic shock on a norepinephrine drip. At
altitude, the patient's blood pressure begins to drop. You check the IV pump and the
line. Your first assessment should be to:
A. Increase the drip rate on the pump
B. Check for positional changes in the aircraft affecting drip chamber fluid level and
tubing
C. Draw blood to check a lactate level
D. Switch to a new bag of norepinephrine
Correct Answer: B
