General Principles
In a helicopter safety and landing zone (LZ) presentation to a local EMS service, which of the following is the MOST important instruction for EMS personnel?
Utilize ambulance lights to highlight the LZ.
Approach only from the loading side of the helicopter.
Ensure LZ is at least 200' x 200'.
Proceed toward the aircraft only when directed by the pilot.
Proceed toward the aircraft only when directed by the pilot.
Comments: The EMS scene call environment is one of the most potentially hazardous aspects of air medical operations. Safety is of paramount importance and situational awareness must be maintained when working around an aircraft. Ground personnel should only be allowed to approach the aircraft when directed to do so by the pilot or a flight crew member. The pilot in command of the aircraft must be able to see personnel approaching. Mitigating the hazard from air medical operations on ground personnel is the most important instruction. The LZ can be a minimum of 100' x 100'. While some situations may require lighting the landing zone, the MOST important instruction for EMS personnel should be to approach only when directed. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 105-106
The flight team is transporting a patient with 40% second degree, high voltage electrical burns. The patient weighs 85 kg. According to the recommended American Burn Resuscitation guidelines, initial fluid resuscitation over 8 hours should be:
13.6L
6.8L
4.0L
8.0L
6.8L
Comments: Patients suffering from high voltage electrical burns need to be resuscitated using the fluid calculation of 4ml x kg x % burn. The first half of the resuscitation should occur over 8 hours, with the second half of the resuscitation occurring in the following 16 hours. An isotonic fluid is recommended, with lactated ringer's being the recommended choice. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 281
A patient who leaped from a third story window and landed on his feet presents with bilateral lower extremity fractures. What other injury is MOST likely in this patient?
acetabular fractures
wrist fractures
pelvic fracture
lumbar fractures
lumbar fractures
Comments: Lumbar and also thoracic spinal column fractures should always be ruled out in falls or axial loading injuries. Kinetic energy produced by the person's body traveling through space and a sudden deceleration of the body against an immovable object/surface is concentrated in an area of the thoracic or lumbar spine. This axial loading causes the vertebral structures to fracture and subluxate/move. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 246-247
A patient receiving mechanical ventilation is noted to have an increased respiratory rate after engine start. The flight team knows the PRIORITY intervention is
administer sedation.
abort the start up.
reposition the patient.
restrain the patient.
administer sedation.
Comments: When the engine starts up, the patient experiences vibration, a normal flight stressor. The patient might require more sedation with the increased sensory input. It is not necessary to restrain the patient or abort the startup unless the patient is a danger to themselves or the crew. Repositioning is not indicated in this situation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 37
The transport team is preparing a pediatric trauma patient for a 45-minute fixed-wing flight to a tertiary care hospital. The patient's mother has requested that she be allowed to accompany her child on the flight. Which of the following is the MOST important factor that the transport team must consider when evaluating the request?
The aircraft does not have another passenger seat available.
The mother states she has a history of motion sickness.
The weather for the flight is predicted to be marginal.
The mother appears to be extremely anxious.
The aircraft does not have another passenger seat available.
Comments: Safety for the entire team is the primary factor on which to base the decision regarding family members accompanying patients on transports. If the aircraft does not have a passenger seat with a seat belt for the mother, she may not accompany the patient in the aircraft. A history of motion sickness is a valid concern when evaluating family members' requests to accompany patients on transports, but it is not the highest priority. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 581
Which of the following is a goal of Crew Resource Management (CRM)?
Provide a way for the team leader to direct the decision-making process.
Promote teamwork based on open communication between team members.
Identify ways to divide tasks so each team member has time to rest.
Train individuals to rely on their own experiences when planning missions.
Promote teamwork based on open communication between team members.
Comments: Team communication or lack thereof was identified as a contributor to aircraft accidents in the 1970’s. CRM was designed to mitigate that threat. All other answers are components of CRM, but are not the goals. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 70
Upon initial assessment of a patient that was struck by lightning, the patient is unresponsive with diminished breath sounds on the right side. Needle decompression is performed with improvement. The cause of pneumothorax is related to:
Electrical current passing through the chest.
Blunt force trauma from being knocked to the ground by lightning strike.
Third degree burns to the chest wall.
Increased chest pressure related to muscle damage from compartment syndrome.
Blunt force trauma from being knocked to the ground by lightning strike.
Comments: Lightning strikes have voltage exposures as high as 1 billion volts. As a result of such high voltage, victims are commonly found with blunt force trauma related to being thrown. Electrical current passing through the chest will cause dysrhythmias, increased pressure from abdominal compartment syndrome will not manifest right away. While patients may sustain third degree burns from a lightning strike, this is not directly related to development of a pneumothorax. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 279
The flight team arrives on the highway for a trauma patient who was unrestrained in a motor vehicle collision. Vitals are as follows:
BP 80/30 mmHg
HR 130 beats/min
RR 30 breaths/min
O2 sat: 88% (nonrebreathing mask)
The patient has jugular vein distention, equal and clear lung sounds, and no obvious penetrating wounds. The team should recognize that the patient may require
an infusion of 2 units of packed red blood cells.
a pericardiocentesis.
needle chest decompression.
rapid sequence intubation.
a pericardiocentesis.
Comments: The patient has a cardiac tamponade and needs a pericardiocentesis. The patient might also need packed red blood cells (PRBCs) and intubation, but that is not the priority. There is no indication for chest decompression. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 210
Upon reaching altitude, the endotracheal cuff pressure reads 32 cm of H20. Which of the following actions, if any, is required?
Replace the endotracheal tube.
Deflate the cuff slightly.
No intervention is required.
Inflate the cuff slightly.
Deflate the cuff slightly.
Comments: Deflating the cuff slightly is correct because the recommended ETT cuff pressure is 20-30 cm H20 . Higher pressures may cause complications such as mucosal damage and tracheal ischemia. Replacing the end of the endotracheal tube is incorrect because there is no indication that the ETT is not functioning properly. Inflating the cuff slightly is incorrect because the current cuff pressure already exceeds what is recommended. No intervention is incorrect because the current cuff pressure exceeds what is recommended. Therefore, the cuff should be deflated slightly to avoid complications. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 165
The flight team notes that noise from the aircraft has caused a 70-year-old patient who is being mechanically ventilated to become agitated. Which of the following should the team administer for further sedation?
rocuronium (Esmeron)
ketamine (Ketalar)
lorazepam (Ativan)
midazolam (Versed)
ketamine (Ketalar)
Comments: Elderly patients can have paradoxical excitation with benzodiazepines and caution should be used. A paralytic is not indicated in this situation. Ketamine can provide a safer alternative for sedation. _____Reference: Sheehy's Manual of Emergency Care, 7th Edition (2013), p. 584
The flight crew is transporting a patient with a femur facture via interfacility transfer. The flight nurse received report from the nurse that the patient was treated with two doses of IV narcotics and one dose IV benzodiazepines, which are documented appropriately on the MAR. The patient is alert and oriented, reporting pain at 10 out 10 and is adamant that no pain medications have been administered. The flight team should treat the assessed pain level and:
Assess the patient for a history of substance abuse
Report the flight crews' concerns of possible diversion to the hospital supervisor
Confront the nurse for the ineffective pain control
Explain to the patient that long bone fractures are painful and distracting which contributed to missing the administration
Report the flight crews' concerns of possible diversion to the hospital supervisor
Comments: Per the Joint Commission, "Appropriate response for staff can be summarized as 'see something, say something.' At the institutional level, appropriate responses include establishing a just culture in which reporting drug diversion is encouraged, assessing harm to patients, consulting with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies." _____Reference: https://www.jointcommission.org/-/media/tjc/newsletters/quick_safety_drug_diversion_final2pdf.pdf
The flight team is receiving a victim of a lightning strike from a Basic Life Support unit. The patient is breathing and has a rapid pulse. Which immediate life threat should the flight team be MOST concerned for?
Third degree burn
Internal bleeding
Hyperkalemia
Lethal arrhythmia
Lethal arrhythmia
Comments: The immediate life threats from lightening strikes are lethal dysthymias and/or respiratory arrest. Hyperkalemia may manifest within 8 hours of injury. Third degree burns and internal bleeding are life threatening injuries, however a lethal arrhythmia will cause death if not treated immediately. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 280
Which of the following BEST describes the result of sympathetic dysfunction in a patient who has a spinal cord injury?
vasodilation
areflexia
hyperreflexia
spastic paralysis
vasodilation
Comments: Vasodilation best describes this result. Vasodilation is the result of interruption of sympathetic outflow below the level of the injury and loss of auto regulation. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 243
The flight team is called to the scene of an industrial accident where a worker was electrocuted by a live wire. The electrolyte imbalance that would cause the MOST concern is
magnesium.
potassium.
calcium.
sodium.
potassium.
Comments: Electrical burns pose a risk to kidney function because they are associated with rhabdomyolysis and elevated myoglobin levels. Without adequate kidney function, potassium levels will increase and pose a threat to cardiac regularity. _____Reference: Critical Care Nursing: Diagnosis & Management, 8th Ed. (2018), p. 850
When administering medications to the geriatric patient population, the flight team understands that:
The patient is less sensitive to medication, so larger doses should be administered.
The patient has increased kidney function, so smaller doses should be administered.
The patient has less fat reserves, so larger doses should be administered.
The patient's liver function is lower, so lower doses should be administered.
The patient's liver function is lower, so lower doses should be administered.
Comments: The older adult generally has lower function of end organs and increased fat reserves. Medications should be given carefully as they will not be metabolized as quickly as in the younger adult population. _____Reference: Critical Care Nursing: Diagnosis & Management, 8th Ed. (2018), p. 1005
Which of the following actions by a transport nurse BEST supports a family's grieving process?
Repeat any essential information.
Avoid answering specific medical questions.
Remain quiet and refrain from displaying emotions.
Share a recent experience involving another grieving family.
Repeat any essential information.
Comments: Repeating any essential information falls under the "U" of the NURSE mnemonic and stands for "understanding" and best supports a family's grieving process. Nurses need to understand the needs of the family as they progress through the stages of grief. The family may not be ready to receive all the information they have to process immediately after the death of a loved one. The astute nurse will recognize this and be willing to repeat any essential information as many times as necessary. Although remaining quiet and refraining from showing emotion may be warranted and beneficial in the acute setting of loss to allow the family time to grieve, it does not work beyond the acute loss to help to progress the family to the next stage of grief. Communicating with the family and showing sympathy without using cliche is an integral part of the NURSE mnemonic. Avoiding answering specific medical questions does not build trust between the nurse and the grieving family. This does not allow for open communication to help progress the family to the next stage of grief. Sharing a recent experience is not the best answer. Grief affects each individual differently and a nurse cannot presume to know what an individual or a family is going through even if they have experienced something similar. Comparing one grieving family to another should be avoided not only for this reason, but also because of HIPPA Laws. _____Reference: Rosen's Emergency Medicine: Concepts & Clinical Practice, 9th Edition (2018), p. e95-e96
The flight team is called to an accident scene where a patient has been trapped under a fallen tree for several hours and has a crushed leg. IV access has been established. As the patient is extracted, the team should prepare to administer
fentanyl (Duragesic).
magnesium chloride.
calcium gluconate.
normal saline.
calcium gluconate.
Comments: Crush injuries can cause a large release of potassium. Calcium gluconate is used to neutralize the effects of hyperkalemia. Fentanyl can be given after or before for pain control but is not the priority. Normal saline can be given for volume replacement but is again not the priority. Magnesium chloride would not be a correct choice for this patient. _____Reference: Sheehy's Emergency Nursing: Principles and Practice, 7th Edition (2019), p. 199
The flight team is called to transport a patient following a motor vehicle collision. The patient presents with sharp left shoulder pain, decreased right-sided breath sounds, and bowel sounds in the right lung base. The flight team knows this patient is most likely suffering from which injury?
Diaphragm rupture
Splenic rupture
Large intestine rupture
Liver rupture
Diaphragm rupture
Comments: Patients with rupture of the large intestine often present with diminished or absent bowel sounds. Patients with a rupture of the spleen or liver may be profoundly hypotensive and could have positive Kehr's sign from blood within the peritoneal cavity. The distinguishing factor from all of these options, however, is the presence of bowel sounds in the right lung base, signifying that the diaphragm has ruptured and the bowel has navigated upward into the thoracic cavity. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 256
A 49-year-old patient complains of chest pain during transport. The 12 lead ECG reveals ST elevation in all 12 leads. The flight team suspects this is a STEMI imposter due to
hyperkalemia.
digoxin toxicity.
left bundle branch block.
pericarditis.
pericarditis.
Comments: The hallmark of acute pericarditis is widespread ST-segment elevation. A right bundle branch block will result in ST elevation in V1, and hyperkalemia will present with peaked T waves. Digoxin toxicity can lead to a number of dysrhythmias but not widespread ST elevation. _____Reference: Ismail T. F. (2020). Acute pericarditis: Update on diagnosis and management. Clinical medicine (London, England), 20(1), 48–51. https://doi.org/10.7861/clinmed.cme.20.1.4
When postpartum hemorrhage is identified, the transport team should immediately
perform bimanual uterine compression.
place the patient in the Trendelenburg position.
massage the fundus.
administer magnesium sulfate.
massage the fundus.
Comments: The transport team should immediately massage the fundus. Fundal massage in the setting of postpartum hemorrhage causes the uterine muscles to contract and this greatly decreases bleeding. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 445
Treatment for acute decompression illness includes which of the following?
rapid descent
positive pressure ventilation
climb back to an acceptable altitude
250 mg acetazolamide (Diamox) slow IV push
rapid descent
Comments: Rapid descent along with 100% oxygen is the initial treatment for acute decompression illness. 250 mg acetazolamide (Diamox) slow IV push is the treatment for acute mountain sickness. It is not a treatment for acute decompression illness. Climbing back to an acceptable altitude is used for barodontalgia or ear block and not acute decompression illness. Positive pressure ventilation would not have any effect on the cause of acute decompression illness. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 41
A transport team is transporting an adult patient with type 1 diabetes mellitus who presents to the emergency department with a one day history of polydipsia, polyuria, vomiting, and generalized weakness. Laboratory results are as follows:
serum sodium 128 mEq/L
serum potassium 3.2 mEq/L
serum chloride 94 mEq/L
serum glucose 550 mg/dL
serum calcium 8.8 mg/dL
blood urea nitrogen (BUN) 40 mg/dL
creatinine level 1.3 mg/dL
CO2 14 mEq/L
The flight team should prepare to administer which medication FIRST?
potassium chloride
calcium chloride
regular insulin
sodium bicarbonate
potassium chloride
Comments: Potassium chloride should be administered first. Potassium Chloride: Low serum potassium occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. The potassium level must be 3.3 mEq or greater before insulin therapy is initiated. The potassium level must be checked frequently as insulin drives potassium into the cell, and serum potassium can drop precipitously. Potassium chloride is administered as soon as the serum potassium level drops below normal. Frequent potassium verification is required while the patient is receiving fluid resuscitation and insulin therapy. Regular Insulin: If serum potassium is greater than 3.3 mEq, then regular insulin is initiated IV at a rate of 0.1 unit/kg/h (in conjunction with a normal saline fluid bolus) to achieve a 50-70 mg/dL decline in glucose level per hour. The insulin drip is titrated each hour to achieve/maintain this rate of glucose level decline. When the glucose level is at 200 mg/dL, the insulin drip is decreased to 0.05-0.1 units/kg/h. Sodium Bicarbonate: Adequate IVF hydration and insulin replacement usually corrects the acidosis related to DKA. Administration of sodium bicarbonate is no longer routine therapy except for severely acidotic patients with a pH less than 7.0. Calcium Chloride: Calcium chloride is not indicated in the initial treatment of DKA. _____Reference: Critical Care Nursing: Diagnosis & Management, 8th Ed. (2018), p. 735-740
A patient with an unstable pelvis was found 6 hours after falling down a ravine and is being evacuated from the scene via helicopter. They were placed on oxygen at 6 L/min via nasal cannula and have the following vital signs:
BP 80/45 mm Hg
HR 98 beats/min
RR 32 breaths/min
02 Sat 100%
ETCO2 22 mm Hg
The flight team recognizes this patient is MOST likely suffering from:
neurogenic shock.
permissive hypotension.
anaerobic metabolism.
pulmonary contusion
anaerobic metabolism.
Comments: The low ETCO2 value coupled with vital signs consistent with shock are indicative of a patient in anaerobic metabolism. Neurogenic shock is incorrect because in neurogenic shock bradycardia would be expected. Permissive hypotension is incorrect because there is no indication of an intentional choice to not resuscitate the patient. Pulmonary contusion is incorrect because with a pulmonary contusion it is unlikely the oxygen saturation would be 100% on 6 L. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 198-203
The flight crew is called to transport a patient who fell from approximately 20 feet. The patient was diagnosed with a subdural hematoma with a 5 mm shift. The patient is intubated and has the following ventilator settings and vital signs:
Mode: SIMV
FiO2 50%
TV 350 mL
RR 14 breaths/min
PEEP 7
BP 195/90 mmHg
HR 43 beats/min
O2 sat 95%
ETCO2: 46 mm Hg
The flight nurse’s IMMEDIATE intervention should be to change the:
PEEP to 10 cm.
respiratory rate to 20 breaths/min.
FiO2 to 100%.
tidal volume to 300 mL.
respiratory rate to 20 breaths/min.
Comments: Cushing’s triad is indicative of increased intracranial pressure. Increasing the respiratory rate will decrease ETCO2, which can help decreased intracranial pressure until definitive treatment can be achieved. Changing the PEEP to 10 cm, tidal volume to 300 mL or the FiO2 to 100% will not help decrease intracranial pressure. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 194
An infant with dehydration and sepsis is being transported for admission to the ICU. Which of the following findings would indicate the need for further fluid resuscitation?
tachycardia
flat fontanelle
urine output of 2 mL/kg/hr
apneic episodes
tachycardia
Comments: Tachycardia is an early sign of hypovolemia. Infants can only increase cardiac output by increasing heart rate. They cannot increase stroke volume. A flat fontanelle is incorrect because in a dehydrated infant the fontanelle would be sunken rather than flat. A flat fontanelle is a normal finding. A urine output here is incorrect because a urine output of 2 mL/kg/hr indicates normal fluid volume status. Apneic episodes are incorrect because apneic episodes are not an indication of volume depletion. _____Reference: ASTNA Patient Transport: Principles and Practice, 5th Ed. (2018), p. 524