TCRN TCRN Special Patient Populations 3 — Questions and Answers
Question 1: A 78-year-old patient fell from standing height and is in the trauma bay. Which of the following vital sign parameters is MOST misleading when assessing shock in elderly trauma patients?
- Respiratory rate
- Heart rate due to chronotropic medications (Correct answer)
- Oxygen saturation
- Temperature
Correct answer: Heart rate due to chronotropic medications
Elderly patients on beta-blockers or with pacemakers may not mount a tachycardic response to hemorrhage, making heart rate unreliable as a shock indicator.
Question 2: An 82-year-old patient sustains rib fractures 4-8 on the right side after a fall. What complication is of greatest concern and should drive early aggressive management?
- Tension pneumothorax
- Pneumonia and respiratory failure (Correct answer)
- Hemothorax requiring chest tube
- Pericardial effusion
Correct answer: Pneumonia and respiratory failure
Elderly patients with multiple rib fractures have high risk for pneumonia and respiratory failure due to decreased respiratory reserve and splinting from pain.
Question 3: A 75-year-old patient is on warfarin for atrial fibrillation and presents after a ground-level fall with a head CT showing subdural hematoma. What is the priority reversal agent?
- Vitamin K alone (IV)
- Fresh frozen plasma alone
- 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K (Correct answer)
- Protamine sulfate
Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K
4F-PCC provides immediate factor replacement for rapid reversal of warfarin, while concurrent vitamin K sustains reversal; FFP is slower and volume-intensive.
Question 4: An elderly trauma patient is alert and oriented but develops confusion 36 hours after admission. Which condition should be suspected first?
- Stroke from paradoxical embolism
- Hospital-acquired delirium (ICU delirium) (Correct answer)
- Opiate overdose from pain medications
- Hypertensive encephalopathy
Correct answer: Hospital-acquired delirium (ICU delirium)
Post-traumatic delirium is extremely common in hospitalized elderly patients and is associated with worse outcomes; it should be the initial diagnostic consideration.
Question 5: Which radiographic finding is unique to elderly osteoporotic patients after blunt thoracic trauma and often missed on initial evaluation?
- Sternal fracture
- Anterior wedge compression fractures of thoracic vertebrae (Correct answer)
- Clavicle fractures
- First rib fracture
Correct answer: Anterior wedge compression fractures of thoracic vertebrae
Osteoporotic thoracic vertebrae are prone to anterior wedge compression fractures from minor mechanisms, which can be subtle on plain films and missed without CT.
Question 6: An 80-year-old patient with hypertension has a pre-hospital systolic BP of 110 mmHg. How should the trauma nurse interpret this in context of this patient's baseline?
- Normal and requires no intervention
- Hypotensive relative to baseline, indicating early shock (Correct answer)
- Acceptable since over 100 mmHg
- Hypertensive crisis requiring antihypertensives
Correct answer: Hypotensive relative to baseline, indicating early shock
Chronic hypertension shifts the autoregulatory curve; a systolic of 110 in a patient whose baseline is 160-180 mmHg represents relative hypotension and organ hypoperfusion.
Question 7: Which factor most significantly increases 30-day mortality in geriatric trauma patients compared to younger adults with identical injury severity scores?
- Higher baseline pain sensitivity
- Reduced physiologic reserve and inability to compensate (Correct answer)
- Increased hospital-acquired infection rate only
- Slower medication metabolism
Correct answer: Reduced physiologic reserve and inability to compensate
Reduced physiologic reserve means elderly patients cannot mount compensatory responses to injury, leading to earlier decompensation and higher mortality at equivalent ISS.
TCRN TCRN Special Patient Populations 3
A 78-year-old patient fell from standing height and is in the trauma bay.
Which of the following vital sign parameters is MOST misleading when assessing shock in elderly trauma patients?