TNCC - Trauma Nurse Core Curriculum Special Populations in Trauma Questions and Answers 1 — Questions and Answers
Question 1: A 25-year-old male is brought in by police after being found wandering in the street, smelling strongly of alcohol. He has a GCS of 13 (E4, V4, M5) and a laceration on his forehead. He is uncooperative with the cervical collar. What is the most appropriate approach to assessing this patient's altered mental status?
- Rule out a traumatic brain injury before attributing altered mental status to intoxication. (Correct answer)
- Defer the neurological exam until the patient is clinically sober.
- Assume the altered mental status is solely due to alcohol intoxication.
- Administer a reversal agent for alcohol to facilitate the exam.
Correct answer: Rule out a traumatic brain injury before attributing altered mental status to intoxication.
In trauma care, any altered mental status must be presumed to be from a traumatic brain injury until proven otherwise. While alcohol intoxication can cause altered mental status, it can also mask the signs and symptoms of a serious head injury. A thorough neurological assessment, including imaging if indicated, is required.
Question 2: An 82-year-old male on a beta-blocker for hypertension fell down a flight of stairs. His initial blood pressure is 110/70 mmHg, and his heart rate is 78 bpm. He has a fractured femur. Which of the following is the most accurate interpretation of this patient's vital signs?
- The patient's blood pressure indicates he is hemodynamically stable.
- The patient is likely in compensated shock, and the beta-blocker is masking tachycardia. (Correct answer)
- The vital signs are within normal limits and not concerning.
- The heart rate is low due to a potential cervical spine injury.
Correct answer: The patient is likely in compensated shock, and the beta-blocker is masking tachycardia.
Geriatric patients often have a blunted physiological response to trauma, and pre-existing conditions like hypertension mean a blood pressure of 110/70 mmHg may represent relative hypotension. Beta-blockers prevent the expected tachycardic response to hypovolemia. A 'normal' heart rate and blood pressure in this context can be misleading and may represent occult hypoperfusion or compensated shock.
Question 3: When calculating the initial fluid bolus for a 4-year-old child weighing 18 kg who is showing signs of hypovolemic shock, which of the following is the most appropriate dose and fluid type?
- 500 mL of 0.9% Normal Saline.
- 180 mL of D5W.
- 360 mL of Lactated Ringer's. (Correct answer)
- 100 mL of 5% Albumin.
Correct answer: 360 mL of Lactated Ringer's.
The standard initial fluid bolus for pediatric trauma patients in shock is 20 mL/kg of an isotonic crystalloid, such as Lactated Ringer's or 0.9% Normal Saline. For an 18 kg child, this calculates to 18 kg * 20 mL/kg = 360 mL. Dextrose-containing solutions are avoided for initial resuscitation unless hypoglycemia is confirmed.
Question 4: A 32-week pregnant patient arrives after a motor vehicle collision. Her blood pressure is 90/60 mmHg and her heart rate is 115 bpm. She is secured to a backboard. In addition to standard resuscitation measures, which intervention is a priority for this patient to improve maternal hemodynamics?
- Administer a tocolytic agent to prevent preterm labor.
- Prepare for an immediate emergency Cesarean section.
- Place the patient in a reverse Trendelenburg position.
- Place a wedge under the right hip to achieve left uterine displacement. (Correct answer)
Correct answer: Place a wedge under the right hip to achieve left uterine displacement.
In a pregnant patient beyond 20 weeks of gestation, the gravid uterus can compress the inferior vena cava when she is supine, causing supine hypotensive syndrome. This reduces venous return to the heart and can decrease cardiac output significantly. Manually displacing the uterus to the left or tilting the patient/backboard relieves this compression, which can immediately improve cardiac output and blood pressure.
Question 5: Which of the following represents a primary challenge when performing the initial airway assessment and management on a bariatric trauma patient?
- Reduced pharyngeal soft tissue and a smaller tongue.
- Difficulty achieving optimal positioning and a higher risk of rapid desaturation. (Correct answer)
- Decreased likelihood of underlying obstructive sleep apnea.
- Lower risk of rapid oxygen desaturation during apnea.
Correct answer: Difficulty achieving optimal positioning and a higher risk of rapid desaturation.
Bariatric patients present significant airway challenges due to factors like a short, thick neck, increased pharyngeal soft tissue, and a larger tongue. They have a reduced functional residual capacity (FRC), which leads to very rapid oxygen desaturation during apneic periods, such as during intubation attempts. Achieving the 'sniffing' position can be difficult, often requiring a 'ramped' or head-elevated position to align the airway axes.
Question 6: A 78-year-old female presents after a fall, complaining of right-sided chest pain. An x-ray reveals fractures of the 7th and 8th ribs. Her oxygen saturation is 95% on room air, and her respiratory rate is 22 breaths/min with shallow breaths. What is the primary focus of management for this geriatric patient?
- Immediate surgical fixation of the rib fractures.
- Application of a chest binder to splint the fractures.
- Aggressive intravenous fluid resuscitation.
- Adequate pain management to promote effective ventilation. (Correct answer)
Correct answer: Adequate pain management to promote effective ventilation.
In geriatric patients, rib fractures carry a high risk of mortality and morbidity, primarily due to respiratory complications like pneumonia and atelectasis. These complications arise from shallow breathing (splinting) due to pain. Therefore, aggressive and effective pain control is the cornerstone of management to allow for deep breathing, coughing, and adequate lung expansion, thereby preventing these complications.
TNCC - Trauma Nurse Core Curriculum Special Populations in Trauma Questions and Answers 1
A 25-year-old male is brought in by police after being found wandering in the street, smelling strongly of alcohol.
He has a GCS of 13 (E4, V4, M5) and a laceration on his forehead.
He is uncooperative with the cervical collar.
What is the most appropriate approach to assessing this patient's altered mental status?