TCRN Shock and Resuscitation Questions and Answers — Questions and Answers
Question 1: A 28-year-old male arrives after a motorcycle crash with a suspected high thoracic spinal cord injury. He is hypotensive (BP 80/40 mmHg), bradycardic (HR 48 bpm), and his skin is warm and dry. These findings are most characteristic of which type of shock?
- Cardiogenic shock
- Hemorrhagic shock
- Neurogenic shock (Correct answer)
- Spinal shock
Correct answer: Neurogenic shock
Neurogenic shock, a form of distributive shock, results from a loss of sympathetic tone following a significant spinal cord injury (typically above T6). This leads to unopposed parasympathetic stimulation, causing vasodilation (hypotension, warm/dry skin) and bradycardia. Hemorrhagic shock would present with tachycardia and cool, clammy skin. Cardiogenic shock involves pump failure. Spinal shock is a temporary loss of reflex function below the level of injury and is not a true circulatory shock state.
Question 2: A trauma patient is receiving a massive transfusion protocol (MTP). To mitigate the 'trauma triad of death,' which balanced ratio of blood products is most commonly recommended?
- 1 unit packed red blood cells (PRBCs) : 2 units fresh frozen plasma (FFP) : 1 unit platelets
- 2 units PRBCs : 1 unit FFP : 1 unit platelets
- 1 unit PRBCs : 1 unit FFP : 2 units platelets
- 1 unit PRBCs : 1 unit FFP : 1 unit platelets (Correct answer)
Correct answer: 1 unit PRBCs : 1 unit FFP : 1 unit platelets
Current evidence and massive transfusion protocols (MTPs) advocate for a balanced resuscitation approach to mimic whole blood and combat coagulopathy. The most widely accepted ratio is 1:1:1, consisting of one unit of packed red blood cells, one unit of fresh frozen plasma, and one unit of apheresis platelets (or a 6-pack of pooled platelets).
Question 3: The resuscitation strategy known as 'permissive hypotension' is employed in certain trauma patients with uncontrolled hemorrhage. For which of the following patient populations is this strategy generally contraindicated?
- Patients with penetrating abdominal trauma
- Patients with a suspected traumatic brain injury (TBI) (Correct answer)
- Patients with an unstable pelvic fracture
- Patients with extremity amputation and active bleeding
Correct answer: Patients with a suspected traumatic brain injury (TBI)
Permissive hypotension, or hypotensive resuscitation, aims to maintain a lower-than-normal blood pressure (e.g., SBP 80-90 mmHg) to prevent dislodging newly formed clots before hemorrhage is surgically controlled. However, this strategy is contraindicated in patients with traumatic brain injury (TBI) because maintaining adequate cerebral perfusion pressure (CPP) is critical to prevent secondary brain injury. In TBI, a higher systolic blood pressure is targeted.
Question 4: A severely injured trauma patient is developing the 'trauma triad of death.' Which of the following components is NOT part of this lethal triad?
- Hypothermia
- Acidosis
- Hypocalcemia (Correct answer)
- Coagulopathy
Correct answer: Hypocalcemia
The classic 'trauma triad of death' is a vicious cycle consisting of hypothermia, metabolic acidosis, and coagulopathy. Each component exacerbates the others, leading to a rapid physiological decline. While hypocalcemia is a critical concern in massive transfusion (often called the 'trauma diamond of death' when included), it is not part of the original triad.
Question 5: A patient arrives after a fall from height and is in hemorrhagic shock. The massive transfusion protocol (MTP) has been activated. In addition to blood products, which medication should be administered early to inhibit fibrinolysis and stabilize clot formation?
- Calcium gluconate
- Tranexamic acid (TXA) (Correct answer)
- Sodium bicarbonate
- Vasopressin
Correct answer: Tranexamic acid (TXA)
Tranexamic acid (TXA) is an antifibrinolytic agent that prevents the breakdown of blood clots. Studies have shown that its administration within three hours of injury in bleeding trauma patients reduces mortality. It is a key adjunct in damage control resuscitation. Calcium is given to treat hypocalcemia from citrate in blood products, bicarbonate treats severe acidosis, and vasopressors are used for refractory hypotension, but TXA specifically targets clot stability.
Question 6: Which of the following is the primary goal of damage control resuscitation (DCR) in a patient with exsanguinating hemorrhage?
- To normalize all vital signs and laboratory values to pre-injury levels in the emergency department.
- To rapidly transport the patient to the operating room for definitive surgical hemorrhage control.
- To restore physiologic stability and correct coagulopathy before surgical intervention. (Correct answer)
- To aggressively infuse crystalloid fluids to achieve a systolic blood pressure greater than 120 mmHg.
Correct answer: To restore physiologic stability and correct coagulopathy before surgical intervention.
Damage control resuscitation (DCR) is a strategy that prioritizes restoring physiologic stability to prevent or reverse the trauma triad of death, allowing the patient to survive until definitive surgical repair can be performed. Key components include permissive hypotension, hemostatic resuscitation with blood products over crystalloids, and prevention of hypothermia and acidosis. The goal is not to normalize all parameters immediately, but to stabilize the patient enough to tolerate surgery.
TCRN Shock and Resuscitation Questions and Answers
A 28-year-old male arrives after a motorcycle crash with a suspected high thoracic spinal cord injury.
He is hypotensive (BP 80/40 mmHg), bradycardic (HR 48 bpm), and his skin is warm and dry.
These findings are most characteristic of which type of shock?