General Principles
Members accompanying a patient in transport should receive a safety briefing that includes
seatbelt regulations.
function of medical equipment.
signed and witnessed consent.
both medical team members.
seatbelt regulations.
Comments: A safety briefing should be provided by the pilot (air) or driver (ground). The safety briefing should include the use of seatbelts, egress procedures, fire extinguishers, flotation devices, use of cell phones and portable computers, smoking/tobacco products, sterile cockpit, and emergency procedures. While consent is important to obtain in appropriate situations, it is not part of the safety briefing. Similarly, medical equipment and team member configuration is not relevant to a safety briefing. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 581
Early treatment of a trauma patient in prerenal failure includes
a low-dose dopamine (Intropin) infusion.
administration of furosemide (Lasix).
restricting IV fluid.
administration of a fluid bolus.
administration of a fluid bolus.
Comments: The first step in managing shock due to trauma is to administer a balanced salt solution (Normosol, Lactated Ringers Solution) followed by blood products. End points/targets of resuscitation include a MAP > 65 mm Hg, urine output of 1 mL/kg/h or more, and a decreasing serum lactate and creatinine. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 204
The flight crew is on scene for a 911 EMS request. The basic life support unit on scene leads the nurse to a tall, 19-year-old male who has sudden shortness of breath and decreased breath sounds on the left side. Vital signs are as follows:
BP 134/70 mmHg
HR 134 beats/min
RR 30 breaths/min
T (oral) 94.4°F (36.9°C)
O2 Sat 80% on room air.
The NEXT procedure the nurse should prepare for is:
rapid sequence intubation.
oxygen administration at 4L/min via nasal cannula.
intravenous access.
needle decompression.
needle decompression.
Comments: This patient is having a spontaneous pneumothorax. Tall, thin, adolescent males are most at risk. Because of the patient’s oxygen saturation, needle decompression should be the first action to correct the issue. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 356
The flight crew arrives at the referring facility to transport a marathon runner who collapsed at the finish line. The patient is agitated, hot to touch, dry, and is breathing rapidly. The priority interventions for this patient are:
High flow nasal cannula and IV fluid administration
Verbal redirection and airway management
Rapid cooling and ECG monitoring
Passive cooling and expediting transport
Rapid cooling and ECG monitoring
Comments: Patients who are experiencing heat stroke need to be rapidly cooled and ECG monitoring should be initiated to monitor for arrhythmias related to electrolyte imbalances. Passive cooling is not enough for a patient experiencing heat stroke. Agitation due to extreme oxygen consumption demands of the hyperthermic patient will not be resolved with verbal redirection. While airway management, high flow oxygen, and IV fluids are indicated, the most important intervention is rapid cooling. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 404
The flight nurse is responding to a critical access hospital for a 1 year-old child with cough, fever and nasal congestion. Vital signs are stable and the patient is being prepared for transport. Labs are as follows:
Hematocrit: 43%
Hemoglobin: 15 g/dL
WBC: 21 x 1000/mm3
Platelets 275 ×103/μL
Lactic Acid: 4.0 mmol/L
The flight nurse's next PRIORITY should be to:
transport as soon as possible
administer an antibiotic
administer IV fluid bolus
apply humified oxygen
administer an antibiotic
Comments: The child is septic and the most important action would be to start antibiotics. Any delay could cause an increase in mortality. IV fluids are important however the vitals are stable so can be deferred. If the child requires oxygen, then humified would be preferred. The child should be stabilized before transporting. _____Reference: Sheehy's Manual of Emergency Care, 7th Edition (2013), p. 228
The flight crew is called to transport a patient with acute respiratory distress syndrome. When placed on a ventilator, the patient will be managed with lower
respiratory rates and higher pressures.
tidal volumes and higher respiratory rates.
PEEP and higher oxygen levels.
PEEP and higher expiratory times.
tidal volumes and higher respiratory rates.
Comments: ARDS is characterized by poor lung compliance, where lower tidal volumes will be better achieved than higher tidal volumes. The use of higher respiratory rates will counteract the lower tidal volume by maintaining a consistent minute ventilation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 194
The flight team has been called to bedside to perform a rapid sequence intubation. The patient is post motor vehicle collision with head trauma and in spinal immobilization. Vital signs are:
BP 110/60 mmHg
HR 118 beats/min
RR 12 breaths/min
O2 saturation 87% (non rebreather mask at 15L/min)
Glasgow Coma Scale: 7 (e2, v2, m3)
What is a PRIORITY intervention in performing this procedure?
Positioning
Pre-oxygenation
Placing nasal capnography
Pain management
Pre-oxygenation
Comments: All of these options should be considered in preparation for rapid sequence intubation (RSI), however, prevention of worsening hypoxia should be the primary concern before performing the procedure. Highest priority should be resuscitation before intubation. Patients who are to have invasive airway management procedures performed on them should have optimal pre-oxygenation before the procedure begins and should have passive oxygenation throughout the procedure. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 159
The nurse is called to transport a patient with a SCUBA diving related injury. The patient requires transport to a decompression chamber. The nurse recognizes that the flight plan should include:
Administration of calcium channel blockers
Maintaining a low FiO2 level
Pick the most direct routing over the mountains
Flying at the lowest altitude possible
Flying at the lowest altitude possible
Comments: The patient with a dive injury should be kept at as close to sea level as possible to avoid further injury. The nitrogen dissolved in the tissue will form bubbles in the patient's blood, possibly causing an embolism the further above sea level the patient goes. The patient should be provided with a high percentage of oxygen to breathe as well. If in doubt contact the DAN (Diver Alert Network) emergency line for help with dive injury care. The definitive treatment is a hyperbaric chamber as soon as possible. _____Reference: Rosen's Emergency Medicine: Concepts & Clinical Practice, 9th Edition (2018), p. 1797
Initial management of a patient suspected of having an air embolus would include
positioning the patient in the aircraft with the head forward.
providing 100% O2 through a nonrebreathing mask.
administration of corticosteroids.
infusing a crystalloid bolus.
providing 100% O2 through a nonrebreathing mask.
Comments: Initial management would include providing 100% O2 through a nonrebreathing mask. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 358
The flight crew is preparing to transfer a patient with morbid obesity. The flight nurse knows that transporting the patient in a semi-Fowler's position is advantageous because it:
increases cardiac preload.
decreases the work of breathing.
facilitates cerebral perfusion.
improves patient comfort.
decreases the work of breathing.
Comments: Transporting a bariatric patient with their head elevated reduces the effort needed to initiate a breath and decreases work of breathing. Elevating the head of the bed does not increase preload or facilitate cerebral perfusion in the morbidly obese. While patient comfort may be affected, the main physiological benefit is the decreased work of breathing. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 139
An awake, alert, and oriented patient is en route in an interfacility transfer. The transport is normal until the patient becomes disoriented with nausea and dry heaves. Another member of the transport team also reports nausea. The MOST likely source of the nausea is
temperature change in the ambulance.
spatial disorientation.
flicker vertigo.
exposure to fuel vapors.
exposure to fuel vapors.
Comments: The most likely source is fuel vapor exposure. Ground and air transport can cause nausea if patients or crew members are exposed to fuel vapors. While the other options may cause nausea, since multiple individuals are experiencing nausea simultaneously it is most likely a result of fuel vapor exposure. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 42
The flight crew is transporting a patient receiving blood products via a mass transfusion protocol. The patient begins to exhibit carpopedal spasms while collecting a noninvasive blood pressure measurement. The MOST appropriate action for the flight crew is to administer:
levetiracetam (Keppra)
calcium chloride
lorazepam (Ativan)
sodium bicarbonate
calcium chloride
Comments: Hypocalcemia is a concern with massive transfusion due to the preservative citrate added to banked blood. The citrate binds with serum calcium leading to hypocalcemia. Signs and symptoms of hypocalcemia include cardiac dysrhythmias, muscle tremors, seizures, Chvostek and Trousseau signs. _____Reference: Trauma Nursing Core Course, 8th ed., p. 81
The flight team is called to transport a patient that recently had alteplase (Activase) administered. On arrival, the patient is noted to be lying in the fetal position and snoring respirations are heard. The patient will not open their eyes to any stimuli but does say the word “no” continuously. The patient is now flexing both arms towards their chest; lower extremities are also noting a similar assessment. The flight nurse documents the patient’s Glasgow Coma Score as:
E1, V2, M4 = 7
E1, V4, M1 = 6
E1, V3, M2 = 6
E1, V3, M3 = 7
E1, V3, M3 = 7
Comments: The patient has a GCS of 7 [E1, V3, M3]. Eyes: closed no response for a score of 1 Verbal: “No” is being repeated, indicating Inappropriate words. Motor: Abnormal flexion to the upper and lower extremities. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 238
The nurse arrives on scene after request of an ambulance. The patient is laying on the stretcher and there are no obvious signs of trauma. The EMS provider states the patient has shortness of breath, hemoptysis and the following vital signs:
BP: 155/67 mmHg
HR: 125 beats/min
RR: 35 breaths/min
SPO2: 88% on 4L nasal canula
The nurse suspects the patient has:
Hemothorax
Pneumothorax
Pulmonary embolism
Pulmonary hypertension
Pulmonary embolism
Comments: The patient is likely suffering from a pulmonary embolism. The classic vital signs include tachycardia, hypoxia, and tachypnea. Hemoptysis, shortness of breath and a cough are also symptoms to watch out for. It is unlikely to be a hemothorax without trauma and pneumothorax would not cause hemoptysis. Pulmonary hypertension is also unlikely based on the presentation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.357
The flight team is called to transport a 6-month-old child diagnosed with febrile seizures. Upon arrival, hospital staff states the child has lost IV access and two additional attempts have been made to initiate access, which have been unsuccessful.
Vital signs:
BP: 68/40 mmHg
HR: 178 beats/min
RR: 36 breaths/min
T(rectal):103F (39.4C)
O2 Sat: 93% (room air)
The NEXT appropriate step is:
Attempt a third intravenous access
Obtain central access
Transport without intravenous access
Initiate intraosseous access
Initiate intraosseous access
Comments: This child is presenting with shock, elevated HR and low BP. It is pertinent to obtain access on this child to initiate fluid resuscitation. Intraosseous access can be obtained quickly, and fluid resuscitation can be started without further delay. The other three options would delay fluid administration and therefore could be harmful to the patient outcome. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 295
The flight team arrives on scene for a patient with decreased respiratory effort. The crew elects to initiate bag mask ventilation. They note an immediate decrease in systolic blood pressure. The flight nurse recognizes that this is likely due to:
lack of positive end expiratory pressure and an ineffective mask seal
decreased preload caused by increased intrathoracic pressure
cardiac tamponade due to blunt chest trauma
fluid overload secondary to aggressive resuscitation
decreased preload caused by increased intrathoracic pressure
Comments: An abrupt decrease in blood pressure following the initiation of positive pressure ventilation suggests that increased intrathoracic pressure is decreasing preload. There is no mention of fluid overload in the history and that would increase preload. There is no mention of chest trauma in the history. Use of positive end expiratory pressure would further decrease preload, however, it is not applicable in this scenario. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.205
The flight team is transporting a patient with a subarachnoid hemorrhage to a tertiary facility for neurosurgical consult. Management priorities during transport include:
Administering osmotic diuretics if the patient develops a newly fixed and dilated pupil
Routine hyperventilation to maintain ETCO2 20-25
Systolic blood pressure goal of 70-80 mmHg
Administering Rocuronium if the patient requires rapid sequence intubation
Administering osmotic diuretics if the patient develops a newly fixed and dilated pupil
Comments: Osmotic diuretics (hypertonic saline and Mannitol) are indicated to manage acute neurologic changes due to suspected increasing intracranial pressure, such as a newly dilated pupil, new onset hemiparesis, or a new loss of consciousness. Hyperventilation causes cerebral vasoconstriction, which decreases cerebral perfusion. Hypotension worsens cerebral perfusion. Long-acting paralytics mask seizure activity for an extended period. _____Reference: Advanced Trauma Life Support Student Course Manual, 10th Ed (2018), p. 119-122
A farmer was trapped beneath a wheel while performing maintenance on their tractor. They were extricated and found to have an open fracture of their left femur, pelvic instability, crepitus to the left lateral ribs, and bruising to the left flank. Two units of packed red blood cells have already been transfused. Vital signs are:
BP 62/20 mmHg
HR 140 beats/min
RR 40 breaths/min
SpO2 86% (15L nonrebreathing mask)
Glasgow Coma Scale 14 (E3, V5, M6)
The flight team’s NEXT intervention is to administer:
Norephinephrine (Levophed)
Tranexamic acid (TXA)
2 liters of isotonic crystalloids
Sublimaze (Fentanyl)
Tranexamic acid (TXA)
Comments: This patient has multiple potential sources of internal bleeding, including the femur, pelvis, and abdominal organs (especially the spleen). Tranexamic acid is an antifibrinolytic that works to prevent the breakdown of clots, which would help promote clotting and reduce their bleeding. Excessive IV fluids would contribute to their coagulopathy by diluting their blood. Using vasopressors to elevate the blood pressure could contribute to blood loss by potentially breaking up new, fragile clots that are forming. Opiate pain medications could cause further hypotension, exacerbating cellular hypoxia and metabolic acidosis. _____Reference: Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients; http://dx.doi.org/10.3109/10903127.2016.1142628
The flight team is called to transport a trauma patient from an outlying hospital to a level 1 center. The flight team is delayed 4 hours due to weather. During the report, the sending nurse reports 950ml of bloody chest tube drainage over the last 4 hours. The vitals are:
HR: 115 beats/min
BP: 100/70 mmHg
RR: 26 breaths/min
SPO2: 96% on 15 LPM via NRB
The nurse's PRIORITY action should be to administer:
balanced transfusion
norepinephrine (Levophed)
isotonic fluid bolus
TXA (tranexamic acid)
balanced transfusion
Comments: The output of greater than 200ml/hr indicates the patient is continuing to bleed into their chest cavity. This patient will need surgical intervention, but should receive blood products to replace the blood lost. TXA should only be administered within 3 hours of injury. Levophed is not recommended when volume replacement is still necessary. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.252
A pediatric near-drowning victim is unresponsive and cyanotic with a pulse of 60 beats/min. The patient is being ventilated via an ET tube. The flight nurse's FIRST action is to
assess ET tube placement.
add positive end-expiratory pressure to the resuscitator bag.
manually override the pop-off valve.
administer 1 mg of atropine via the endotracheal tube.
assess ET tube placement.
Comments: The flight nurse's first action is to assess ET tube placement. Administering 1 mg of atropine is incorrect because bradycardia is hypoxia related. Adding PEEP to the resuscitator bag or manually overriding the pop-off valve will not improve the heart rate if the tube is not in the correct location. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 518
What information would lead the transport team to suspect a biological agent exposure?
clusters of patients in the same location with the same symptoms
multiple outbreaks of same illness with different onset times
multiple patients with dissimilar complaints
appearance of a disease during its peak season
clusters of patients in the same location with the same symptoms
Comments: Initially small clusters of patients in a similar geographical area, experiencing similar characteristic symptoms, should cause agencies to suspect biological agent exposure as the source patient comes into contact with other individuals and the infection spreads. It is essential to identify this phase early on, before spread occurs at longer distances from the source patient location. _____Reference: Emergency Nursing Core Curriculum, 7th Ed. (2018), p. 623-627
Which of the following is the MOST appropriate intervention to prevent and protect the patient from and to reduce the risk for pulmonary barotrauma from mechanical ventilation?
Decrease the expiration time.
Increase the fraction of inspired oxygen.
Attempt to lower the plateau pressure.
Initiate permissive hypocapnia strategies.
Attempt to lower the plateau pressure.
Comments: Attempting to lower the plateau pressure is the most appropriate intervention. Maintaining a plateau pressure less than or equal to 35 cm H2O is desired. The other interventions are not the most appropriate interventions. Initiating permissive hypocapnia strategies would mean increasing the tidal volume or the respiratory rate. Both actions may further the barotrauma. Decreasing expiration time is not appropriate, because decreasing the inspiration time will increase the peak inspiratory pressure. Increasing the fraction of inspired oxygen will have no effect on barotrauma. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 191
The flight crew responds to an interfacility transfer of a patient who suffered a reported gun shot wound to the right anterior chest at the 5th intercostal space, resulting in a massive hemothorax. The sending facility reports all uncrossed blood products have been exhausted, and the patient remains in hemorrhagic shock. The sending physician requests the flight crew to auto-transfuse blood collected from the chest drainage system. The nurse questions this order due to:
Risk of gastric contents in the collected blood
Increased risk of hypothermia
Blood being in the chest drainage system for one hour
High levels of coagulation factors
Risk of gastric contents in the collected blood
Comments: Penetrating trauma below the 4th intercostal space increases the risk for gastric contamination. Wounds older than 3 hours are contraindicated. Auto-transfused blood is warmer than room temperature and has decreased risk of hypothermia. Auto-transfused blood has lower levels of coagulation factors than donor blood and may require additional platelets or cryoprecipitate. _____Reference: Trauma Nursing Core Course, 9th ed. (2024), p.99, 156
The flight team is transporting a 70kg patient in cardiogenic shock who is mechanically ventilated on multiple high-dose vasopressors and inotropes. Mean arterial pressure is 57 mmHg. Oxygen saturations are consistently 100%. Arterial blood gas results are:
pH 7.39
pCO2 40 mmHg
pO2 238 mmHg
HCO3 24 mmol/L
Base excess +2 mmol/L
Ventilator settings are:
Assist Control Mode
Respiratory Rate 20
FiO2 50%
Tidal Volume 450ml
PEEP 18 cm H2O
What adjustment should the transport team consider?
Increase inotropic support
Decrease PEEP
Decrease Tidal Volume
Increase FiO2
Decrease PEEP
Comments: PEEP has the potential to increase intrathoracic pressure. In this scenario, the ABG is normal. Oxygen saturations are 100%. Ventilator settings are noted. PEEP is high at +18. The team should consider decreasing the PEEP as this should also decrease intrathoracic pressure, which in turn should help increase venous return and preload, resulting in a higher blood pressure/mean arterial pressure. Sustained high PEEP levels may potentially cause ventilator induced lung injury. Decreasing PEEP vs increasing vasopressor and/or inotropic support is warranted more in this instance due to the PEEP of +18 being too high in this situation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p.193
A transport nurse is assessing a child who has pneumococcal pneumonia and is being mechanically ventilated. The patient's ventilator settings and arterial blood gas results are as follows:
Rate 16 breaths/min
VT 200 mL
FiO2 35%
PEEP 5 cm H2O
Oxygen saturation 96%
pH 7.25
PaCO2 60 mm Hg
PaO2 80 mm Hg
HCO3 25 mEq/L
Which of the following ventilator adjustments should the nurse consider making?
Increase the rate to 20.
Decrease the VT to 180 mL.
Increase the FiO2 to 50%.
Increase PEEP to 8 cm H2O.
Increase the rate to 20.
Comments: Increasing the ventilator rate/frequency will result in more CO2 being exhaled, ultimately lowering the PaCO2 (which is elevated) and raising the pH to a more normal level. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 192-193