General Principles
The MOST accurate way to ensure endotracheal tube placement in the field is
tube depth.
pulse oximetry.
ETCO2 monitoring.
using an esophageal aspirate device.
ETCO2 monitoring.
Comments: ETCO2 monitoring is the most accurate and is the standard of care to ensure endotracheal tube placement is correct. The other options can verify tube placement, but are not the most accurate. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 176
The nurse arrives to a rural hospital to transport a patient who has been involved in a motor vehicle collision. Upon arrival, the patient is awake, and complains of abdominal pain and left shoulder pain. Vitals signs are:
BP: 85/48 mmHg
HR: 118 beats/min
RR: 26 breaths/min
O2 Sat: 100% (15L non-rebreather mask)
Pain: 8/10
Initial resuscitation of this patient should begin with:
Sublimaze (Fentanyl)
Tranexamic acid (TXA)
Normal saline
Packed red blood cells
Packed red blood cells
Comments: This patient is presenting with Kehr's sign, which is indicative of splenic injury and blood in the peritoneal cavity. They are hypotensive and tachycardic. Initial resuscitation should begin with blood administration, followed by platelets, plasma, and cryoprecipitate if available. While the pain may need to be addressed, replacing lost blood products takes priority. TXA should be initiated after blood product resuscitation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 205
The flight team has been called to the scene of a single vehicle rollover. The patient has a palpable skull deformity. The patient also has extensive soft tissue injury and open fracture to the left forearm, which is wrapped in blood-soaked dressings. Current vital signs are:
HR 136 beats/min
BP 72/50 mmHg
RR 34 breaths/min
SpO2 88% (15L nonrebreathing mask)
Glasgow Coma Scale 7 (E2, V2, M3)
The flight nurse's FIRST priority intervention is:
Transfuse packed red blood cells
Apply a tourniquet
Administer tranexamic acid (TXA)
Perform drug-assisted intubation
Apply a tourniquet
Comments: Although all four interventions are warranted, reprioritizing to control uncontrolled external hemorrhage is the highest priority in the Circulation, Airway, Breathing, Circulation, Disability algorithm. A properly applied tourniquet will stop the external hemorrhage and allow the flight team to proceed with managing the patient’s airway, breathing, and circulation abnormalities, which will therefore minimize any secondary brain injury from a traumatic brain injury. _____Reference: Trauma Nursing Core Course, 9th ed. (2024), p. 42
A patient with a history of hypertension taking ACE inhibitors reports mild chest pain during transport. The ECG shows tented T waves, a wide QRS, and a prolonged PR interval. The nurse should prepare to FIRST administer
calcium gluconate.
insulin and dextrose.
potassium chloride.
sodium bicarbonate.
calcium gluconate.
Comments: Potassium chloride is not indicated, as ECG demonstrates peaked T waves consistent with hyperkalemia. All other treatments are appropriate in the setting of hyperkalemia; however, calcium gluconate should be given first to stabilize the myocardial membrane. After calcium gluconate is administered, efforts should be made to reduce potassium levels, which sodium bicarbonate and insulin/glucose will do transiently. _____Reference: Emergency Nursing Core Curriculum, 7th Ed. (2018), p. 271
A 330-lb (150-kg) patient is being transported. Upon initiation of mechanical ventilation, the high-pressure alarm sounds. Peak inspiratory pressure is 45 cm H2O, plateau pressure is 36 mm Hg, I:E ratio is 1:2.3 and oxygen saturation is 92%. The ventilator is on the following settings:
Mode Assist control
Rate 16 breaths/min
Tidal volume 900 mL
FiO2 60%
PEEP 5 cm H2O
Which of the following ventilator settings should be decreased?
PEEP
inspiratory time
tidal volume
rate
tidal volume
Comments: Decreasing tidal volume will decrease the peak inspiratory pressure. The rate does not affect peak and plateau pressure unless it is at a high enough rate to cause breath stacking. A PEEP of 5 cm H2O will not cause a significant increase in plateau pressure. There is no indication to decrease the inspiratory time for this patient. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 183-186
The flight crew arrives at the bedside of an intubated, 80kg adult with asthma exacerbation. When you review their vent settings, you note that they are receiving a tidal volume of 800ml and have peak airway pressures of 30 cm H2O. The nurse should decrease the tidal volume to 480 ml to prevent what?
Ventilator acquired pneumonia
Ventilator induced lung injury
Pneumothorax
Atelectasis
Ventilator induced lung injury
Comments: Patients with status asthmaticus are prone to ventilator induced lung injury due to high transpulmonary pressures and high tidal volumes. Atelectasis is usually caused by under inflation of the lungs. Ventilator acquired pneumonia is a complication of mechanical ventilation but is not generally associated with tidal volumes or associated with the acute need for ventilator adjustments. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 239
The nurse is transporting a patient with a lower gastrointestinal bleed who is alert but anxious. The patient has cool, clammy skin with significant pallor of the mucous membranes. The patient received one liter of normal saline by local EMS upon arrival to the ED. Vital signs are as follows:
BP 78/42 mm Hg
HR 132 beats/min
RR 32 breaths/min
Temp 97.0º F (36.1 Cº)
What is the highest priority intervention for this patient?
initiation of packed red blood cells
rapid sequence intubation
nasogastric tube insertion
initiation of vasopressors
initiation of packed red blood cells
Comments: The highest priority intervention is the initiation of packed red blood cells. The patient is presenting with fluid refractory hypovolemic shock and the highest priority is to restore the oxygen-carrying capacity of the blood. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 368
The flight team is transporting a 10-year-old, 30kg patient who was involved in a dirt bike accident. The helmeted patient was ejected from the motorcycle, thrown approximately 15 feet, and hit a tree. The patient was found altered, with bruising to the abdomen, and a palpable deformity to the left femur. The patient has since been intubated, ventilated, and spinal motion restriction has been provided. The patient has a rapid, weak central pulse and mottled, cold, moist skin. The NEXT priority intervention is:
Isotonic crystalloids 10mL/kg
Tranexamic acid 5mg/kg
Norepinephrine 0.05-2mcg/kg/min
Packed red blood cells 10mL/kg
Packed red blood cells 10mL/kg
Comments: This patient is symptomatic for shock. Based on mechanism of injury, this patient is suspected of having intrabdominal bleeding and a left femur fracture (which is also a source of blood loss). If available, the flight team can infuse packed red blood cells immediately. Isotonic crystalloids boluses are an option, but the appropriate dose would be 20mL/kg IV/IO. Norepinephrine is not indicated as this patient is presumed to be in hemorrhagic shock, which vasopressors are not a first line intervention for. Tranexamic acid is seldom used in pediatric cases and dosing is recommended at 15mg/kg when it is administered. _____Reference: Trauma Nursing Core Course, 9th ed. (2024), p. 278; https://pubmed.ncbi.nlm.nih.gov/30893114/
The flight nurse is called to an ICU to transport a ventilated patient 24 hours after a major chest trauma. The patient has high pressure alarms with worsening oxygenation and increased peak inspiratory pressures. Pink, frothy sputum sputum is noted. The nurse suspects the primary cause to be:
Pneumonia
Mucus plug
Pulmonary contusion
Acute Respiratory Distress Syndrome
Pulmonary contusion
Comments: Pulmonary contusion occurs after blunt chest trauma and usually is delayed from time of injury. The patient's often have high peak inspiratory pressures, hemoptysis, and hypoxia. This would be unlikely to be ARDS 24 hours after injury. Pneumonia would be a concern later in the hospital stay. A mucus plug would not cause pink sputum. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.255
The transport team is transporting a 2-year-old child who has a suspected bacterial infection. The child is responsive to painful stimuli, and has mottled skin. The patient's vital signs are as follows:
BP 60/30 mm Hg
HR 180 beats/min
RR 10 breaths/min
T 94.1ºF (34.5ºC)
Which of the following interventions would be the highest priority
Administer adenosine 0.1 mg/kg.
Initiate a normal saline bolus of 20 mL/kg.
Administer broad spectrum of antibiotics.
Perform synchronized cardioversion.
Initiate a normal saline bolus of 20 mL/kg.
Comments: Initiating a normal saline bolus of 20 mL/kg is correct because this patient is in uncompensated septic shock. Restoring an adequate circulating volume is the highest priority. Administering adenosine and performing synchronized cardioversion is incorrect because the heart rate is due to profound shock, not SVT. Administering a broad spectrum of antibiotics is incorrect because resuscitation to correct the fluid deficit comes before antibiotic administration. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 551
While completing a secondary physical exam on a patient with frostbite to their feet, the flight nurse notices that the skin on the patients' feet is red and has developed clear blisters. What stage of frostbite does this patient have?
First-degree
Fourth-degree
Second-degree
Third-degree
Second-degree
Comments: Second-degree frostbite produces blistering or peeling of the skin and is characterized by hyperemia and vesicle or bleb formation. First-degree frostbite appears as hyperemia and edema but there is no blister formation. Third and fourth degree frostbite is indicated by hemorrhagic blisters on the digits (3rd degree) and carpals or tarsals (4th degree). _____Reference: Burn Nursing: Injury Prevention to Rehabilitation and Aftercare, 1st Ed. (2023), p.502
The flight crew is called to transport a patient with aortic dissection. Current vital signs are:
HR 52 beats/min
BP 135/70 mmHg
RR 18 breaths/min
SPO2 100% (2L nasal cannula)
The MOST appropriate medication to initiate for this patient is:
nicardipine (Cardene)
fentanyl (Sublimaze)
esmolol (Brevibloc)
epinephrine (Adrenalin)
nicardipine (Cardene)
Comments: The most important management for patient's with aortic injury is blood pressure management, with a goal of 90-120mmHg. Nicardipine will decrease blood pressure without affecting heart rate. Esmolol is contraindicated for this patient due to low heart rate. Epinephrine will increase blood pressure. Fentanyl is important for pain control, but will not affect blood pressure effectively for this patient. _____Reference: Sheehy's Emergency Nursing: Principles and Practice, 7th Edition (2019), p. 247
The flight nurse is transporting a patient from the scene of an accident where the patient states he hit his head on the window and briefly lost consciousness. Upon loading into the aircraft, the patient again loses consciousness. Vital signs are as follows:
BP 180/110 mm Hg
HR 40 beats/min
RR 10 breaths/min
O2 Sat 98% (2L via nasal cannula)
The flight nurse suspects the patient has:
a subdural hematoma.
an epidural hematoma.
a subarachnoid hemorrhage.
an intraparenchymal hemorrhage.
an epidural hematoma.
Comments: Epidural hematomas classically present with brief periods of lucidness with sudden changes in responsiveness. The other injuries are more commonly associated with continuously worsening symptomology. _____References: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 233
A nurse is transporting a patient with an intra-aortic balloon pump (IABP) catheter in the right femoral artery. The left arm becomes cool, mottled, and pulseless. The MOST likely cause for the clinical change is
catheter whip.
pump failure.
balloon rupture.
catheter migration.
catheter migration.
Comments: The most likely cause for this clinical change is catheter migration. The catheter has most likely migrated to occlude the left subclavian artery which has caused the left arm to become cool, mottled, and pulseless. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 330
The flight nurse is transporting a 6-year-old child from a youth football game after sustaining a tackle from another child. The patient's mother states "he got the wind knocked out of him." Vital signs:
BP 85/50 mmHg
HR 120 beats/min
RR 26 breaths/min
SPO2 93% on room air
The nurse suspects:
Splenic rupture
Pneumothorax
Pulmonary contusion
Cardiac contusion
Pulmonary contusion
Comments: Because of the incomplete calcification of the pediatric skeleton, the bones are more pliable and therefore may not result in fracture after injury. This does not mean that the underlying structures may not still be affected by the injury. Hypotension may present with pneumothorax and splenic rupture, however this patient is normotensive for their age (70+2x age). Cardiac contusion is likely to cause arrhythmia, not necessarily tachycardia. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.516
The flight team is requested to transport a patient with an ischemic stroke directly to an interventional neuroradiology suite. Report to the crew includes right-sided deficits that remained after full dose thrombolysis was administered; GCS 15. Upon arrival, the patient is found in a fetal position with vomit present. Snoring respirations are noted. The patient is now flexing both arms and legs towards their chest. Based on this finding, the flight nurse should:
Notify the interventional neuroradiology team and transport as planned.
Cancel the transport and reschedule when the patient stabilizes.
Notify the accepting physician prior to transfer.
Transport as planned and provide airway protection
Notify the accepting physician prior to transfer.
Comments: The accepting interventional neuroradiologist needs to be advised prior to departure from the sending facility. The treatment plan for this patient will change. Hemorrhagic conversion after IV thrombolysis can be a severe, life-threatening situation. Neurosurgical consultation, airway protection, additional CT scans and correction of coagulopathy will be assessed for and treated. Based off of this finding, the transport destination of the patient could potentially change. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 287-297
Oxygen saturation is 86% with high flow oxygen via nonrebreathing mask on a patient with pulmonary contusions from blunt chest trauma. The next intervention should be
positive pressure ventilation.
fluid resuscitation.
administration of an opiate.
nasotracheal suctioning.
positive pressure ventilation.
Comments: Positive pressure ventilation, either noninvasive or invasive, is indicated to improve oxygenation in a pulmonary contused patient. Fluids will not improve oxygenation and neither will pain medication or suctioning of the nonintubated patient be likely to improve the patient's hypoxia. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 250
The flight crew is called to transport a patient from a rural care facility that was involved in a motor vehicle collision and sustained a Chance fracture. During transport, the nurse should anticipate performing frequent assessments of:
Glasgow Coma Scale.
upper extremity pulses.
depth of respirations.
abdominal pain.
abdominal pain.
Comments: A lumbar distraction fracture (Chance fracture) is often associated with intestinal injuries. To assess for intestinal injury, the nurse should frequently assess the patient's abdominal pain. Glasgow Coma Scale, upper extremity pulses, and depth of respirations would not be reliable exams to evaluate for intestinal injuries associated with Chance fractures. ______Reference: Trauma Nursing: From Resuscitation Through Rehabilitation, 5th Ed. (2019), p. 461
Which of the following signs are an indication for sodium bicarbonate administration in a tricyclic antidepressant ingestion?
a QRS complex greater than 100 milliseconds
hypotension refractory to IV fluid boluses
protracted vomiting
pH 7.42, PCO2 25 mm Hg, HCO3- 28 mEq/L, PaO2 220 mm Hg
a QRS complex greater than 100 milliseconds
Comments: Prolonged QRS is most often the indication for serum alkalinization in TCA toxicity. However, about 88% of the poison control directors in the United States use a QRS of 100 milliseconds or greater as the cut-off for intravenous sodium bicarbonate. Arterial blood gasses of pH 7.42, PCO2 25 mm Hg, HCO3- 28 mEq/L, PaO2 220 mm Hg do not warrant sodium bicarbonate administration. For hypotension refractory to intravenous saline, vasopressors with alpha-agonist effect (e.g., Neo-Synephrine, norepinephrine) may be used. Protracted vomiting is not an indication for sodium bicarbonate. _____Reference: Rosen's Emergency Medicine: Concepts & Clinical Practice, 9th Edition (2018), p. 1869-1870
The flight nurse responds to a high speed motor vehicle collision on the highway. The patient is an 80-year-old male presenting with bruising on the abdomen and upper chest consistent with a seat belt outline. The patient's vital signs are:
BP: 100/50 mmHg
HR: 63 beats/min
RR: 14 breaths/min
SPO2: 95% (room air)
The PRIORITY historical question is:
Have you had a tetanus shot in the past ten years?
Have you had any recent surgeries?
Do you take any medications?
When did you last eat?
Do you take any medications?
Comments: The elderly patient often takes medications that can cause abnormal presentations of shock. Medications can often interfere with vital signs, masking abnormalities in the presence of trauma. _____Reference: Sheehy's Emergency Nursing: Principles and Practice, 7th Edition (2019), p. 549
The goal of intra-aortic balloon pump counter pulsation therapy is to
decrease afterload and decrease left ventricle filling pressures.
increase afterload and increase left ventricle filling pressures.
increase afterload and decrease left ventricle filling pressures.
decrease afterload and increase left ventricle filling pressures.
decrease afterload and decrease left ventricle filling pressures.
Comments: The balloon inflates during ventricular diastole, increasing intra-aortic pressure and blood flow to the coronary arteries. The balloon deflates just prior to ventricular systole, decreasing intra-aortic pressure. This pressure decrease reduces the resistance to left ventricular ejection, or afterload and decreases left ventricle filling pressures. Afterload and left ventricle pressures would increase if the intra-aortic balloon pump timing was incorrect and showed late deflation, which then causes an increase in the workload and oxygen consumption of the heart. _____Reference: AACN Essentials of Critical Care Nursing, 3rd Ed. (2014), p. 497
The flight nurse arrives on scene of an interfacility transfer for altered mental status of a 70 year-old. The hospital reports the following lab work:
RBC: 5.16×106/μL
Hemoglobin: 13.8g/dL
Hematocrit: 44.1%
WBC: 19.6x thousand/mm3
Platelet: 149×103/μL
The patient is pale and clammy and has a GCS of 14. The nurses NEXT action should be to:
Obtain a chest X-ray
Intubate the patient
Initiate an isotonic fluid bolus
Place the patient on a non-rebreather
Initiate an isotonic fluid bolus
Comments: This patient is likely in septic shock, either from pneumonia or a UTI. While the patient might need oxygen or a chest x-ray, fluids are the priority. This patient does not need intubation based on the information provided. _____Reference: Sheehy's Emergency Nursing: Principles and Practice, 7th Edition (2019), p. 580
The flight crew has been called to transport a trauma patient with a radiology report of "widened mediastinum with blunted aortic notch". Vital signs are:
BP: 110/78 mmHg
HR: 95 beats/min
RR: 22 breaths/min
SpO2: 94% (4L nasal canula)
The nurse anticipates the following action will be required:
vasopressor administration.
beta blocker administration.
right mainstem intubation.
needle decompression.
beta blocker administration.
Comments: A widened mediastinum can result from an aortic dissection or traumatic aortic rupture. Treatment of an aortic dissection includes administration of beta blockers (e.g. Esmolol). A needle decompression is indicated for tension pneumothorax. Right mainstem intubation may be indicated in cases of tracheobronchial disruption. Vasopressor administration could worsen the aortic dissection by increasing arterial pressure. _____Reference: Advanced Trauma Life Support Student Course Manual, 10th Ed (2018), p. 76
A patient with chronic obstructive pulmonary disease presented to a community emergency room after a ground level fall. The patient was intubated for airway protection and a subdural hematoma was identified. Mechanical ventilator settings are:
Assist Control/Volume Control
RR 10 breaths/min
Tidal volume 580 mL
PEEP 10 cm H2O
FiO2 50%
While preparing the patient for transport to a tertiary facility, the flight nurse notices elevated Peak Inspiratory Pressure (PIP) of 40 cm H2O, Plateau Pressure of 35 cm H2O, and asynchronous breathing. Vital signs are stable. The nurse should:
Manually ventilate the patient
Perform needle decompression
Increase the respiratory rate to 20 breaths/min
Decrease the PEEP to 5 cm H2O
Decrease the PEEP to 5 cm H2O
Comments: Chronic Obstructive Pulmonary Disease is a form of obstructive lung disease in which patients have difficulty fully exhaling, leading to air trapping and elevated airway pressures. Decreasing the PEEP decreases lung overinflation, reducing airway pressures. Respiratory rates of 8-16 breaths/min allow more time to exhale between breaths, reducing air trapping; increasing the respiratory rate would have only exacerbated the problem. Needle decompression is not immediately indicated as the patient is not showing other signs or symptoms of tension pneumothorax. Bag-mask ventilation could potentially worsen the patient’s condition due to the potential for excessive minute ventilation and lung hyperinflation with overzealous bag-mask technique. _____Reference: Pilbeam’s Mechanical Ventilation, 6th Edition (2015), p. 106-107
The flight crew is called to transport a child from a motor vehicle collision. The child was restrained with a lap belt in a booster seat. The child is irritable, and has positioned themselves in the fetal position. The nurse knows this is MOST likely indicative of injury to the:
Pelvis
Abdomen
Chest
Head
Abdomen
Comments: In a conscious child, flexion of the legs in toward the abdomen is indicative of intra-abdominal injury. Injury to the pelvis would result in more pain with flexion of lower extremities. Head injury may result in posturing, but should be noted in all limbs, rather than just lower extremities. Intra-thoracic injury within the chest would not result in posturing behaviors. _____Reference: Trauma Nursing: From Resuscitation Through Rehabilitation, 5th Ed. (2019), p.691