CFRN Specialized Trauma Care 5 — Questions and Answers
Question 1: A flight nurse responds to a scene where a patient fell 30 feet from scaffolding and is found supine with paradoxical chest wall movement of the right chest. What injury pattern does this represent and what is the immediate treatment?
- Open pneumothorax — apply a three-sided occlusive dressing
- Flail chest — provide positive pressure ventilation and consider intubation (Correct answer)
- Simple rib fractures — apply circumferential chest wrap for stabilization
- Hemothorax — needle decompression at the second intercostal space
Correct answer: Flail chest — provide positive pressure ventilation and consider intubation
Paradoxical chest wall movement indicates flail chest (≥3 consecutive ribs fractured in ≥2 places); treatment focuses on positive pressure ventilation to restore normal chest mechanics and intubation for severe respiratory compromise.
Question 2: A patient with a high-velocity gunshot wound to the abdomen is hemodynamically unstable with a distended, rigid abdomen. In the context of damage-control surgery principles, what is the flight nurse's primary goal during transport?
- Achieve full physiologic normalization before surgical intervention
- Minimize transport time and maintain the patient viable for damage-control surgery (Correct answer)
- Perform peritoneal lavage to assess for hollow viscus injury
- Administer broad-spectrum antibiotics and prepare for definitive repair
Correct answer: Minimize transport time and maintain the patient viable for damage-control surgery
Damage-control resuscitation aims to minimize the lethal triad (hypothermia, acidosis, coagulopathy) while expediting transport so surgeons can perform abbreviated hemorrhage control rather than awaiting full physiologic optimization.
Question 3: During transport of a patient with a severe traumatic brain injury, the flight nurse notes Cushing's triad. Which set of findings correctly identifies Cushing's triad?
- Tachycardia, hypotension, and irregular respirations
- Hypertension, bradycardia, and irregular respirations (Correct answer)
- Hypertension, tachycardia, and Cheyne-Stokes breathing
- Bradycardia, hypotension, and apneustic breathing
Correct answer: Hypertension, bradycardia, and irregular respirations
Cushing's triad (hypertension, bradycardia, and irregular respirations) is a late, ominous sign of severely increased intracranial pressure and impending brainstem herniation.
Question 4: A flight nurse is assessing a patient from a high-speed MVC who complains of mid-sternal chest pain and has a new right bundle branch block on ECG. What injury should be strongly suspected?
- Traumatic aortic dissection
- Myocardial contusion (Correct answer)
- Tension pneumothorax
- Pericardial tamponade
Correct answer: Myocardial contusion
Myocardial contusion from blunt chest trauma can cause dysrhythmias, conduction abnormalities such as RBBB, ST changes, and reduced cardiac output, and must be monitored closely during transport.
Question 5: A trauma patient is intubated and mechanically ventilated during transport. Peak airway pressures rise from 28 to 52 cmH2O suddenly. Breath sounds are absent on the left, trachea is midline, and BP drops to 75/45. What is the most likely diagnosis and next intervention?
- Right mainstem intubation — withdraw ETT 2-3 cm and reassess
- Left tension pneumothorax — perform needle decompression at left 2nd ICS MCL (Correct answer)
- Mucus plug obstruction — suction the ETT and increase FiO2
- ETT displacement into the esophagus — remove and bag-valve-mask ventilate
Correct answer: Left tension pneumothorax — perform needle decompression at left 2nd ICS MCL
Sudden increase in peak airway pressures with absent unilateral breath sounds, hemodynamic instability, and ventilated patient strongly indicates tension pneumothorax, requiring immediate needle decompression.
Question 6: A 45-year-old male involved in a blast injury from an improvised explosive device presents with tympanic membrane rupture, respiratory distress with hemoptysis, and abdominal pain. These findings are consistent with which phase of blast injury?
- Quaternary blast injury from structural collapse
- Primary blast injury from overpressure wave damage to air-filled structures (Correct answer)
- Secondary blast injury from fragmentation projectiles
- Tertiary blast injury from patient displacement
Correct answer: Primary blast injury from overpressure wave damage to air-filled structures
Primary blast injury is caused by the overpressure wave directly affecting air-filled organs such as the tympanic membranes, lungs (blast lung), and gastrointestinal tract.
Question 7: A flight nurse is assessing a trauma patient with an obvious open book pelvic fracture. The patient has a Foley catheter in place and 50 mL of gross blood is seen in the drainage bag. What does this finding most likely indicate?
- Bladder contusion from blunt impact
- Urethral or bladder injury requiring urologic evaluation (Correct answer)
- Normal finding in pelvic fracture patients due to retroperitoneal hematoma pressure
- Renal laceration with hematuria draining through the ureter
Correct answer: Urethral or bladder injury requiring urologic evaluation
Gross hematuria in a patient with a pelvic fracture strongly suggests associated urethral or bladder injury, which must be evaluated urologically; a Foley catheter should not have been placed if urethral injury was suspected.
CFRN Specialized Trauma Care 5
A flight nurse responds to a scene where a patient fell 30 feet from scaffolding and is found supine with paradoxical chest wall movement of the right chest.
What injury pattern does this represent and what is the immediate treatment?