FP-C - Flight Paramedic-Certification Complex Trauma and Burns Questions and Answers — Questions and Answers
Question 1: A 45-year-old male involved in a house fire has full-thickness circumferential burns to his entire right arm and anterior chest. He is intubated for suspected inhalation injury. During transport, you note increasing ventilator peak pressures, decreasing SpO2, and absent radial pulse on the right side with a weak carotid pulse. What is the most critical intervention?
- Increase the IV fluid resuscitation rate.
- Perform a needle decompression of the chest.
- Immediately perform a chest and arm escharotomy. (Correct answer)
- Administer a fluid bolus and vasopressors.
Correct answer: Immediately perform a chest and arm escharotomy.
The patient's signs and symptoms—rising peak airway pressures, hypoxia, and loss of distal pulse in the circumferentially burned arm—are classic indicators of compartment syndrome secondary to a constricting eschar. An escharotomy of the chest is urgently needed to allow for adequate ventilation, and an escharotomy of the arm is required to restore circulation. While fluid resuscitation is crucial, it will not resolve the mechanical constriction. There are no signs of a tension pneumothorax, making needle decompression inappropriate. Vasopressors and fluid boluses will not restore perfusion if the underlying problem is a physical constriction.
Question 2: You are transporting a 70 kg patient with 40% TBSA deep partial-thickness burns sustained 2 hours ago. The patient also has a closed femur fracture and is hypotensive. According to standard burn resuscitation principles, which fluid management strategy is most appropriate?
- Initiate a rapid 2L bolus of normal saline to treat traumatic hypotension first.
- Start fluid resuscitation using the Parkland formula (4 mL/kg/%TBSA) and titrate to a urine output of 30-50 mL/hr.
- Administer crystalloids based on the Parkland formula but anticipate higher fluid requirements due to the concurrent trauma. (Correct answer)
- Use the Modified Brooke formula (2 mL/kg/%TBSA) to avoid fluid overload in a trauma patient.
Correct answer: Administer crystalloids based on the Parkland formula but anticipate higher fluid requirements due to the concurrent trauma.
Patients with combined burn and trauma injuries often require more fluid than predicted by standard burn formulas alone. The initial approach should be guided by the Parkland formula, but the flight paramedic must anticipate the need for additional volume due to the femur fracture and associated blood loss. While boluses may be needed for profound hypotension from trauma, the primary burn resuscitation should be a steady, titrated infusion. Simply using a standard formula without considering the traumatic injury may lead to under-resuscitation. The Modified Brooke formula might be insufficient in this complex trauma scenario.
Question 3: Which of the following is the most definitive clinical sign indicating the need for early endotracheal intubation in a patient rescued from an enclosed space fire?
- Singed nasal hairs and facial burns.
- Carbonaceous sputum.
- Progressive hoarseness and stridor. (Correct answer)
- SpO2 of 92% on a non-rebreather mask.
Correct answer: Progressive hoarseness and stridor.
Progressive hoarseness and stridor are ominous signs of significant upper airway edema and impending airway obstruction. This finding warrants immediate and definitive airway management. While singed nasal hairs, facial burns, and carbonaceous sputum are all indicators of potential inhalation injury, they do not, in isolation, mandate intubation and can be managed with close observation. A slightly low SpO2 can be due to various factors and can often be corrected with high-flow oxygen, but stridor indicates a critical airway narrowing that is unlikely to resolve without intervention.
Question 4: A 100 kg adult male has 30% TBSA full-thickness burns. Using the Parkland formula (4 mL/kg/%TBSA), what is the correct IV fluid rate (Lactated Ringer's) for the first 8 hours, calculated from the time of the burn?
- 1000 mL/hr
- 750 mL/hr (Correct answer)
- 1500 mL/hr
- 500 mL/hr
Correct answer: 750 mL/hr
The Parkland formula is calculated as: 4 mL x body weight (kg) x %TBSA. In this case: 4 mL x 100 kg x 30% = 12,000 mL over 24 hours. Half of this total volume (6,000 mL) must be administered in the first 8 hours from the time of injury. Therefore, the hourly rate for the first 8 hours is 6,000 mL / 8 hours = 750 mL/hr.
Question 5: During the transport of a patient with extensive burns and associated trauma, which of the following is the primary goal of fluid resuscitation?
- To normalize the patient's blood pressure to 120/80 mmHg.
- To maintain end-organ perfusion, evidenced by adequate urine output. (Correct answer)
- To replace the total calculated fluid deficit within 12 hours.
- To decrease the hematocrit to below 40%.
Correct answer: To maintain end-organ perfusion, evidenced by adequate urine output.
The primary goal of fluid resuscitation in burn and trauma patients is to maintain adequate end-organ perfusion without causing complications from fluid overload. The single best clinical indicator of adequate resuscitation is urine output (typically targeted at 0.5-1 mL/kg/hr for adults). While blood pressure is monitored, aiming for a specific number like 120/80 mmHg is not the primary goal; permissive hypotension may be acceptable in trauma, and mean arterial pressure (MAP) is often a better target. The fluid deficit is replaced over 24 hours, not 12. Hematocrit is not a primary endpoint for titrating fluid therapy.
Question 6: A flight paramedic is managing a patient with circumferential full-thickness burns to the left leg. Which assessment finding is the EARLIEST and most reliable indicator of developing compartment syndrome requiring a potential escharotomy?
- Loss of palpable dorsalis pedis pulse.
- Cool, pale skin on the distal extremity.
- Pain disproportionate to the injury, described as deep and throbbing. (Correct answer)
- Slow capillary refill (>3 seconds) in the toes.
Correct answer: Pain disproportionate to the injury, described as deep and throbbing.
Severe, deep, and throbbing pain that is out of proportion to the visible injury is the earliest and most sensitive sign of compartment syndrome. The other signs, such as pulselessness, pallor, and delayed capillary refill, are later and more ominous findings that indicate significant vascular compromise has already occurred. Intervention should be considered before the loss of pulses, as irreversible ischemic injury may have already started by that point.
FP-C - Flight Paramedic-Certification Complex Trauma and Burns Questions and Answers
A 45-year-old male involved in a house fire has full-thickness circumferential burns to his entire right arm and anterior chest.
He is intubated for suspected inhalation injury.
During transport, you note increasing ventilator peak pressures, decreasing SpO2, and absent radial pulse on the right side with a weak carotid pulse.
What is the most critical intervention?