CFRN Neurological Trauma Management 2 — Questions and Answers
Question 1: A flight patient with severe TBI has a GCS of 6 and a BP of 90/60 mmHg. What is the primary hemodynamic goal during transport?
- Maintain SBP ≥ 90 mmHg to prevent secondary brain injury (Correct answer)
- Target SBP 70-80 mmHg to reduce cerebral edema
- Allow permissive hypotension to limit hemorrhage
- Prioritize MAP > 110 mmHg at all times
Correct answer: Maintain SBP ≥ 90 mmHg to prevent secondary brain injury
Hypotension (SBP < 90 mmHg) in TBI significantly worsens outcomes by reducing cerebral perfusion pressure and causing secondary brain injury.
Question 2: During air transport, a TBI patient develops Cushing's triad. Which combination correctly identifies this reflex?
- Hypertension, bradycardia, and irregular respirations (Correct answer)
- Hypotension, tachycardia, and shallow breathing
- Hypertension, tachycardia, and apnea
- Hypotension, bradycardia, and Cheyne-Stokes respirations
Correct answer: Hypertension, bradycardia, and irregular respirations
Cushing's triad—hypertension, bradycardia, and irregular respirations—is a late sign of severely elevated ICP and impending herniation.
Question 3: A patient with a basilar skull fracture is exhibiting CSF rhinorrhea. What intervention is contraindicated?
- Nasogastric tube insertion (Correct answer)
- Cervical spine immobilization
- IV fluid resuscitation
- Continuous SpO2 monitoring
Correct answer: Nasogastric tube insertion
Nasogastric tube insertion is contraindicated in basilar skull fracture due to risk of the tube entering the cranial vault through the fractured cribriform plate.
Question 4: Which pupillary finding is most consistent with uncal herniation in a TBI patient?
- Unilateral fixed and dilated pupil ipsilateral to the lesion (Correct answer)
- Bilateral pinpoint pupils
- Bilateral dilated reactive pupils
- Unilateral constricted pupil contralateral to the lesion
Correct answer: Unilateral fixed and dilated pupil ipsilateral to the lesion
Uncal herniation compresses CN III on the ipsilateral side, causing a fixed, dilated pupil on the same side as the expanding lesion.
Question 5: A patient with a spinal cord injury at C4 is being transported. What immediate respiratory concern should the flight nurse anticipate?
- Loss of diaphragmatic function requiring ventilatory support (Correct answer)
- Intact respiratory drive but impaired intercostal muscles
- Paradoxical breathing with preserved SpO2
- Hyperventilation due to loss of inhibitory pathways
Correct answer: Loss of diaphragmatic function requiring ventilatory support
C4 and above injuries disrupt phrenic nerve function (C3-C5), eliminating diaphragm control and requiring immediate ventilatory support.
Question 6: During transport, a TBI patient's EtCO2 reads 28 mmHg. What is the appropriate action?
- Reduce ventilation rate to target EtCO2 of 35-45 mmHg (Correct answer)
- Maintain current ventilation as mild hyperventilation is therapeutic
- Increase ventilation to further reduce ICP
- Administer sodium bicarbonate to correct acidosis
Correct answer: Reduce ventilation rate to target EtCO2 of 35-45 mmHg
EtCO2 of 28 mmHg represents excessive hyperventilation causing cerebral vasoconstriction; target 35-45 mmHg unless herniation is imminent.
Question 7: A flight nurse is managing a patient with a penetrating brain injury. Which action is most appropriate regarding the impaled object?
- Stabilize the object in place and do not remove it (Correct answer)
- Remove the object immediately to assess the wound depth
- Apply firm pressure around the object to control hemorrhage
- Cut the object flush with the skull to facilitate transport
Correct answer: Stabilize the object in place and do not remove it
Impaled objects should be stabilized in place, as removal can cause massive hemorrhage and worsen brain injury; removal occurs in the OR.
CFRN Neurological Trauma Management 2
A flight patient with severe TBI has a GCS of 6 and a BP of 90/60 mmHg.
What is the primary hemodynamic goal during transport?