CFRN - Certified Flight Registered Nurse Neurological Trauma Management Questions and Answers — Questions and Answers
Question 1: A 25-year-old male involved in a high-speed motorcycle collision is being transported by air. The patient is intubated and has a GCS of 6T. During transport, the CFRN notes the following changes in vital signs: blood pressure increases from 130/80 to 180/90 mmHg, heart rate drops from 85 to 50 bpm, and respirations become irregular. These findings are most indicative of:
- Neurogenic shock
- Hypovolemic shock
- Spinal shock
- Cushing's triad (Correct answer)
Correct answer: Cushing's triad
Cushing's triad is a physiological response to increased intracranial pressure (ICP) and imminent brain herniation. It consists of hypertension (specifically, a widening pulse pressure), bradycardia, and irregular respirations. [23, 20] Neurogenic shock is characterized by hypotension and bradycardia. [5, 18] Hypovolemic shock presents with hypotension and tachycardia. Spinal shock involves the temporary loss of reflex function below the level of a spinal cord injury.
Question 2: A patient with a traumatic brain injury has a blood pressure of 110/70 mmHg and an intracranial pressure (ICP) of 20 mmHg. What is the patient's Cerebral Perfusion Pressure (CPP), and is it adequate?
- CPP is 63 mmHg, which is borderline adequate. (Correct answer)
- CPP is 90 mmHg, which is adequate.
- CPP is 43 mmHg, which is inadequate.
- CPP is 70 mmHg, which is adequate.
Correct answer: CPP is 63 mmHg, which is borderline adequate.
To calculate CPP, first find the Mean Arterial Pressure (MAP). MAP = [(2 x Diastolic) + Systolic] / 3. In this case, MAP = [(2 x 70) + 110] / 3 = (140 + 110) / 3 = 250 / 3 = 83.3 mmHg. Next, use the formula CPP = MAP - ICP. CPP = 83.3 - 20 = 63.3 mmHg. A normal CPP is generally considered to be between 60-80 mmHg. [13, 8] A CPP of 63.3 mmHg is at the low end of the normal range and is considered borderline adequate, requiring close monitoring.
Question 3: During the transport of a patient with a known C5 spinal cord injury, the patient suddenly develops a pounding headache, profuse sweating above the level of the injury, and severe hypertension with a blood pressure of 210/110 mmHg. Which of the following is the MOST appropriate initial action by the flight nurse?
- Administer a fluid bolus to treat potential shock.
- Lay the patient flat to improve cerebral perfusion.
- Administer an antihypertensive agent immediately.
- Sit the patient upright and check for bladder distention. (Correct answer)
Correct answer: Sit the patient upright and check for bladder distention.
The patient is exhibiting classic signs of autonomic dysreflexia, a medical emergency common in patients with spinal cord injuries at T6 or above. It is triggered by a noxious stimulus below the level of injury, most commonly a distended bladder or bowel. [3, 6] The initial and most critical action is to sit the patient upright to help lower blood pressure via orthostatic hypotension and then immediately search for and remove the offending stimulus, starting with checking the urinary catheter for kinks or blockage. [12, 33] Administering fluids or laying the patient flat would worsen the hypertension. Antihypertensives are used if initial measures fail.
Question 4: A flight nurse is managing an intubated patient with a severe traumatic brain injury. To mitigate secondary brain injury, which of the following physiological parameters is the MOST critical to maintain?
- Normocapnia (EtCO2 35-45 mmHg)
- Normotension (Systolic BP > 90-110 mmHg, depending on guidelines) (Correct answer)
- Normoglycemia (Blood glucose 80-180 mg/dL)
- Normothermia (Temperature 36.5-37.5°C)
Correct answer: Normotension (Systolic BP > 90-110 mmHg, depending on guidelines)
While all listed parameters are important in preventing secondary brain injury, hypotension is the single most critical factor to avoid. A single episode of hypotension (Systolic BP < 90 mmHg) can significantly increase morbidity and mortality in TBI patients by reducing cerebral perfusion pressure and causing ischemia. [2, 35] Therefore, maintaining adequate blood pressure is the highest priority. Hypoxia is equally critical, but not listed as an answer choice. The other parameters (normocapnia, normoglycemia, normothermia) are also goals of care but avoiding hypotension takes precedence.
Question 5: A trauma patient with a suspected high thoracic spinal cord injury presents with a blood pressure of 80/40 mmHg, a heart rate of 52 bpm, and warm, dry skin. This clinical picture is most consistent with which type of shock?
- Cardiogenic shock
- Hypovolemic shock
- Septic shock
- Neurogenic shock (Correct answer)
Correct answer: Neurogenic shock
Neurogenic shock, a form of distributive shock, results from the loss of sympathetic tone following a spinal cord injury (typically above T6). This leads to massive vasodilation and a decreased heart rate (bradycardia) due to unopposed vagal stimulation. The combination of hypotension and bradycardia, along with warm, dry skin from peripheral vasodilation, is the classic presentation. [5, 29, 18] Other forms of shock are typically associated with tachycardia as a compensatory mechanism.
Question 6: Which of the following interventions is a primary strategy for acutely lowering dangerously high intracranial pressure (ICP) in a patient with a traumatic brain injury during transport?
- Administering a bolus of 3% hypertonic saline. (Correct answer)
- Inducing deep sedation with a barbiturate coma.
- Applying a cooling blanket to achieve therapeutic hypothermia.
- Administering prophylactic antibiotics.
Correct answer: Administering a bolus of 3% hypertonic saline.
Osmotic therapy is a first-line intervention to acutely reduce ICP. 3% hypertonic saline creates an osmotic gradient, drawing water out of the brain parenchyma and into the intravascular space, thereby reducing cerebral edema and lowering ICP. [19, 28] While deep sedation and therapeutic hypothermia can be used to manage ICP, they are typically not the primary, immediate interventions used in the transport environment for an acute spike. Prophylactic antibiotics do not affect ICP.
CFRN - Certified Flight Registered Nurse Neurological Trauma Management Questions and Answers
A 25-year-old male involved in a high-speed motorcycle collision is being transported by air.
The patient is intubated and has a GCS of 6T.
During transport, the CFRN notes the following changes in vital signs: blood pressure increases from 130/80 to 180/90 mmHg, heart rate drops from 85 to 50 bpm, and respirations become irregular.
These findings are most indicative of: