CFRN - Certified Flight Registered Nurse Specialized Trauma Care Questions and Answers — Questions and Answers
Question 1: A patient involved in a high-speed motor vehicle collision is found to be hypotensive and tachycardic, with a grossly unstable pelvis on examination. After addressing the airway and breathing, which of the following is the most critical initial intervention?
- Rapid infusion of two liters of isotonic crystalloid.
- Application of a commercial pelvic binder or improvised sheet. (Correct answer)
- Immediate log roll to assess for spinal injuries.
- Bilateral needle decompression for suspected tension pneumothorax.
Correct answer: Application of a commercial pelvic binder or improvised sheet.
In a hemodynamically unstable patient with a suspected open-book pelvic fracture, the immediate priority after ABCs is to control the hemorrhage. Applying a pelvic binder reduces the volume of the pelvic ring, which provides stability and tamponades the significant venous and cancellous bone bleeding that is the primary source of blood loss. While fluid resuscitation is necessary, it is secondary to hemorrhage control; adding volume without controlling the bleeding is ineffective.
Question 2: A flight nurse is preparing for the extrication of a patient who has been trapped under a concrete slab for approximately 5 hours. Which life-threatening metabolic derangement should the nurse be most prepared to treat immediately upon the release of the crushing force?
- Hypocalcemia
- Hypernatremia
- Hyperkalemia (Correct answer)
- Metabolic alkalosis
Correct answer: Hyperkalemia
Crush syndrome results from prolonged muscle compression, leading to rhabdomyolysis. When the pressure is released, reperfusion washes out toxic byproducts from the damaged muscle cells into the systemic circulation. The most immediate life-threatening substance released is potassium. The resulting acute hyperkalemia can cause fatal cardiac dysrhythmias, including ventricular fibrillation and asystole.
Question 3: A patient involved in a severe deceleration injury has a widened mediastinum on a pre-hospital chest x-ray. The patient's blood pressure is 165/95 mmHg and heart rate is 115 bpm. For the suspected traumatic aortic injury, what is the primary management goal during air transport?
- Aggressive fluid resuscitation to maintain a MAP greater than 85 mmHg.
- Titrating anti-impulse therapy to reduce heart rate and blood pressure. (Correct answer)
- Administering tranexamic acid (TXA) to prevent further bleeding.
- Maintaining permissive hypotension with a target systolic BP of 90 mmHg without heart rate control.
Correct answer: Titrating anti-impulse therapy to reduce heart rate and blood pressure.
The primary goal in managing a suspected or confirmed traumatic aortic injury is to reduce aortic wall shear stress to prevent propagation or rupture of the dissection. This is achieved through 'anti-impulse therapy,' which involves carefully titrating medications (typically a beta-blocker first, followed by a vasodilator) to lower both the heart rate (to < 100 bpm) and blood pressure (SBP < 120 mmHg). Aggressive fluid resuscitation would increase pressure and shear stress, worsening the injury.
Question 4: A patient has a large abdominal stab wound with a significant portion of the small bowel eviscerated. Which of the following describes the most appropriate field management for the exposed organs?
- Cover the bowel with a dry sterile dressing to absorb any contaminants.
- Gently attempt to reduce the bowel back into the abdominal cavity.
- Apply a bulky dressing to exert direct pressure on the organs to control bleeding.
- Cover the organs with a moist, sterile saline dressing and then an occlusive layer. (Correct answer)
Correct answer: Cover the organs with a moist, sterile saline dressing and then an occlusive layer.
The proper management of an abdominal evisceration is to protect the exposed organs from further injury, contamination, and dehydration. This is best accomplished by covering the organs with a sterile dressing moistened with saline, and then applying an occlusive layer (like plastic wrap or a sterile bag) over the top to prevent heat and moisture loss. The bowel should never be pushed back into the abdomen in the field, and dry dressings can adhere to and damage the serosa.
Question 5: A patient with blunt chest trauma is noted to have paradoxical chest wall motion, tachypnea, and significant hypoxemia. While the mechanics of the flail segment are dramatic, what is the primary cause of the patient's hypoxemia?
- Pain from the fractures causing splinting and atelectasis.
- The underlying pulmonary contusion beneath the fractured segment. (Correct answer)
- Rebreathing of dead-space gas between the lungs (Pendelluft effect).
- Inability to generate sufficient negative intrathoracic pressure.
Correct answer: The underlying pulmonary contusion beneath the fractured segment.
While pain, splinting, and altered chest wall mechanics contribute to respiratory insufficiency, the most significant cause of hypoxemia in a patient with a flail chest is the underlying pulmonary contusion. The contusion involves bleeding and edema in the lung parenchyma, leading to a severe ventilation/perfusion (V/Q) mismatch and shunting, which is the primary driver of hypoxemia. The Pendelluft theory is now considered to be of minimal clinical significance.
Question 6: An 80 kg patient has full-thickness burns to his entire back (18%) and entire chest (18%). The injury occurred 1 hour prior to the flight crew's arrival, and the transport will last 6 hours. Using the Parkland formula (4 mL x kg x %TBSA), how much Lactated Ringer's should be administered during the 6-hour flight?
- 5760 mL
- 2880 mL
- 4320 mL (Correct answer)
- 720 mL
Correct answer: 4320 mL
First, calculate the Total Body Surface Area (TBSA): Entire back (18%) + Entire chest (18%) = 36% TBSA. Next, calculate the total fluid needed for the first 24 hours: 4 mL x 80 kg x 36% TBSA = 11,520 mL. Half of this total (5,760 mL) must be given in the first 8 hours from the time of injury. To find the hourly rate for this period, divide the 8-hour volume by 8: 5,760 mL / 8 hours = 720 mL/hr. Since the transport is 6 hours long, the total volume to be infused during the flight is: 720 mL/hr * 6 hours = 4320 mL.
CFRN - Certified Flight Registered Nurse Specialized Trauma Care Questions and Answers
A patient involved in a high-speed motor vehicle collision is found to be hypotensive and tachycardic, with a grossly unstable pelvis on examination.
After addressing the airway and breathing, which of the following is the most critical initial intervention?