Hemorrhage Control and Traumatic Shock - NREMT Paramedic Level

1. Where should an extremity tourniquet be placed relative to the bleeding site?

   High and tight or $2$–$3$ inches proximal; never over a joint. Proper placement ensures effective arterial compression without risking joint damage or ineffective control.

2. What is the correct initial fluid choice for hemorrhagic shock when blood products are unavailable?

   Balanced isotonic crystalloid in limited volumes (avoid large boluses). Limited crystalloids support perfusion without causing hemodilution or clot disruption in hypovolemic states.

3. Which bleeding control method is preferred for junctional hemorrhage (groin or axilla)?

   Direct pressure with hemostatic gauze and wound packing. Junctional areas require packing to compress vessels directly, as tourniquets are ineffective there.

4. What is the correct technique for wound packing with hemostatic gauze?

   Pack to the bleeding source and hold firm pressure for $3$ minutes. Packing fills the wound cavity to apply targeted pressure and promote clotting at the source.

5. Which action is correct if bleeding continues after one tourniquet is fully tightened?

   Apply a second tourniquet proximal to the first. A second device addresses potential slippage or inadequate compression from the initial tourniquet.

6. Identify the interpretation: HR $120$, SBP $90$. What is the shock index value?

   Shock index $= \frac{120}{90} \approx 1.3$. Elevated values above 1 indicate possible occult shock, prompting closer monitoring and intervention.

7. What must you do immediately after applying a tourniquet in the field?

   Document the application time and keep the tourniquet visible. Documentation and visibility facilitate timely reassessment and prevent complications like compartment syndrome in definitive care.

8. What is the correct management for an open chest wound (sucking chest wound)?

   Apply a vented chest seal; reassess for tension pneumothorax. Vented seals allow air escape to prevent tension pneumothorax while sealing the wound to maintain negative intrathoracic pressure.

9. What endpoint confirms adequate tourniquet tightness in hemorrhage control?

   Bleeding stops and distal pulse is absent (if previously present). These indicators confirm sufficient occlusion of blood flow to prevent further hemorrhage.

10. Which condition is a contraindication to permissive hypotension in trauma resuscitation?

    Suspected traumatic brain injury requiring adequate cerebral perfusion. TBI requires higher pressures to maintain cerebral perfusion pressure and prevent secondary injury.

11. Which classic early vital sign change is most consistent with developing hemorrhagic shock?

    Tachycardia. Compensatory mechanisms in early shock increase heart rate to maintain cardiac output despite reduced stroke volume.

12. Which finding is a late sign of hemorrhagic shock and decompensation?

    Hypotension. Blood pressure drops only after compensatory mechanisms fail, indicating advanced hypovolemia.

13. What is the immediate priority sequence for traumatic shock care after scene safety?

    Control hemorrhage, support airway/ventilation, then rapid transport. Addressing life threats in this order stabilizes the patient for transport to definitive care.

14. Which intervention is appropriate for suspected internal hemorrhage in trauma?

    Rapid transport, permissive hypotension when indicated, and hemorrhage control. These measures minimize ongoing blood loss and support perfusion without over-resuscitation that could disrupt clots.

15. Which skin finding most strongly suggests traumatic shock from hypoperfusion?

    Cool, pale, diaphoretic skin. Vasoconstriction in shock diverts blood to vital organs, resulting in peripheral hypoperfusion signs.

16. Which immediate intervention is first-line for life-threatening external extremity bleeding?

    Apply direct pressure with a dressing; add hemostatic gauze if needed. Direct pressure is the initial method to control external bleeding by promoting clot formation, with hemostatic agents added for enhanced coagulation in severe cases.

17. Which mental status change is concerning for poor perfusion in traumatic shock?

    Altered mental status (anxiety, confusion, decreased responsiveness). Hypoperfusion affects cerebral function, progressing from sympathetic stimulation to decreased responsiveness.

18. What is the correct next step if direct pressure fails to control severe extremity hemorrhage?

    Apply a tourniquet proximal to the wound and tighten until bleeding stops. Tourniquets provide mechanical occlusion of arterial flow when direct pressure is insufficient for life-threatening extremity hemorrhage.

19. What is the trauma triad of death that must be prevented during hemorrhagic shock?

    Hypothermia, acidosis, and coagulopathy. This lethal combination impairs clotting and perfusion, worsening outcomes if not interrupted early.

20. What is the definition of hemorrhagic shock in trauma patients?

    Inadequate tissue perfusion due to acute blood volume loss. This condition arises from hypovolemia leading to insufficient oxygen delivery to tissues.

21. Which temperature management action is essential to reduce trauma mortality in shock?

    Prevent hypothermia: cover patient and warm the environment/fluids. Maintaining normothermia prevents exacerbation of coagulopathy and metabolic acidosis in trauma patients.

22. What is the correct management for an open neck wound with suspected air entry?

    Apply an occlusive dressing and monitor for respiratory compromise. Occlusive dressings prevent air embolism while monitoring ensures early detection of complications like airway obstruction.

23. Which blood pressure target best reflects permissive hypotension for uncontrolled hemorrhage without TBI?

    Maintain SBP about $80$–$90$ mmHg (or just enough for radial pulse/mentation). Permissive hypotension avoids disrupting fragile clots while ensuring minimal perfusion to vital organs.

24. Which blood product strategy is preferred for severe traumatic hemorrhage when available?

    Early balanced transfusion (packed RBCs, plasma, and platelets). Balanced ratios mimic whole blood to correct coagulopathy and improve oxygen-carrying capacity effectively.

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