The second half of resuscitation: recognizing which shock state you are treating, and keeping blood, pressors and circulatory support running on a stretcher with few hands, few pump channels and finite power.
Shock management (both outlines): hypovolemic, obstructive, distributive and cardiogenic.
Mechanical circulatory support: named under cardiovascular conditions on both outlines; the CTRN also lists IABP, Impella, VAD and ECMO among advanced interventions.
Moving a patient on circulatory support
How these devices work and how they are managed in the unit is taught on CMC therapeutic interventions. In transport the questions turn practical.
Intra-aortic balloon pump: after each move of the patient, recheck the left radial pulse and the urine output. A balloon that slides toward the arch can block the left subclavian artery; one that sits low can compromise the renal arteries. Vibration and electrical noise can corrupt the ECG trigger, so know how your console switches to a pressure trigger.
Left ventricular assist device: a continuous-flow pump often leaves no palpable pulse, so blood pressure comes from a Doppler reading taken as the mean pressure. The 2017 AHA scientific statement on resuscitation with mechanical circulatory support advises chest compressions for an unresponsive patient whose mean pressure is below 50 mmHg or ETCO2 below 20 mmHg.
15 perfusion questions
0 of 15 attempted · 0 correct · 0 missed
Perfusion and shock
The transport nurse reassesses a patient with septic shock after 2 L of balanced crystalloid and norepinephrine at 8 mcg/min. Which finding BEST indicates improving tissue perfusion?
Answer and why, all 4 options
A rising CVP shows that fluid was given, not that tissues are better perfused; it is a poor perfusion target.
A heart rate that falls after an antipyretic reflects less fever, not better perfusion.
Capillary refill that shortens from 5 to 2 seconds shows that peripheral perfusion is actually improving.
A higher BP after a vasopressor increase shows pressure, not flow; vasoconstriction can raise BP while perfusion stays poor.
Item 564271
Perfusion and shock
A patient in septic shock with DKA is receiving norepinephrine, vasopressin, insulin, fentanyl and maintenance lactated Ringer's. The transport team has three pump channels, and the sending physician agrees to stop the maintenance fluid. Which remaining infusion is MOST appropriate to convert to intermittent IV doses?
Answer and why, all 4 options
Fentanyl can be given as intermittent IV doses titrated to pain, freeing a channel without risking hemodynamic or metabolic swings.
Norepinephrine has a half-life of minutes, so intermittent doses would cause wide swings in BP in a patient in septic shock.
Vasopressin is a continuous adjunct in septic shock; intermittent dosing would leave gaps in support.
An insulin bolus regimen in DKA causes unpredictable glucose and potassium swings; DKA needs a continuous infusion.
Item 1882727
Perfusion and shock
A transport program is updating its cardiac arrest protocol to AHA 2025. In which situation is a mechanical chest compression device MOST appropriate?
Answer and why, all 4 options
In a moving aircraft the crew must stay belted, and manual compressions are poor and unsafe, so a mechanical device keeps CPR going.
Short resuscitations are where good manual CPR works well; the device is meant for prolonged CPR or CPR in motion.
Mechanical devices are built for adult chest sizes and are not used in young children.
Routine use in adult arrests is not recommended because mechanical CPR has not beaten good manual CPR in outcomes.
Item 565934
Perfusion and shock
The transport team is asked to move a patient in refractory cardiac arrest to an ECPR center 20 minutes away. Which feature MOST strongly supports this patient as an ECPR candidate?
Answer and why, all 4 options
Metastatic cancer on hospice makes ECPR inappropriate; it offers no realistic recovery.
Unwitnessed asystole means long no-flow time and a nonshockable rhythm, both predicting poor outcome.
A low-flow time of 110 minutes is far beyond the window in which ECPR improves survival.
A witnessed arrest with a shockable rhythm and immediate bystander CPR gives short no-flow time, the profile that benefits from ECPR.
Item 565942
Perfusion and shock
Two days after hip surgery, a patient awaiting transfer becomes acutely short of breath and arrests. Rhythm is PEA. A bedside echo before the arrest showed a dilated right ventricle. Which intervention is MOST appropriate in addition to CPR?
Answer and why, all 4 options
Needle decompression treats tension pneumothorax; a dilated RV after hip surgery points to PE.
Arrest from suspected massive PE with a dilated RV is an indication for a fibrinolytic, with compressions continued long enough (60–90 minutes) for it to work.
A large fluid bolus overloads a failing right ventricle and worsens septal shift.
Dobutamine is not a cardiac arrest drug and does not clear the clot obstructing the pulmonary circulation.
Item 565951
Perfusion and shock
A patient with ongoing intra-abdominal hemorrhage is being flown in a helicopter with a cabin temperature of 12 °C (54 °F). Core temperature is 35.1 °C (95.2 °F). Which intervention BEST addresses this flight stressor?
Answer and why, all 4 options
Wet clothing speeds heat loss throughout the flight, so it is removed at once.
Active warming and warmed fluids and blood counter the cold cabin, protecting clotting, which hypothermia slows.
Loosening the binder releases pelvic stabilization and increases bleeding; it does nothing for temperature.
Cold fluids deepen hypothermia and worsen coagulopathy in a bleeding patient.
Item 1882659
Perfusion and shock
An intubated patient with intra-abdominal hypertension and dilated bowel is flown in an unpressurized helicopter to 5,000 ft. Which change should the flight nurse anticipate during the climb?
Answer and why, all 4 options
Higher abdominal pressure compresses the vena cava and reduces venous return.
An expanding abdomen pushes up the diaphragm and lowers chest wall compliance.
Bladder pressure rises as gas in the dilated bowel expands with altitude.
By Boyle's law the bowel gas expands on the climb, raising abdominal pressure, which raises peak airway pressure and lowers cardiac output.
Item 1882757
Perfusion and shock
En route with a patient who has a penetrating abdominal wound, BP 74/40 mmHg, HR 134 beats/min and no head injury, the aircraft carries 2 units of PRBCs and lactated Ringer's, but no plasma. Which resuscitation plan is MOST appropriate?
Answer and why, all 4 options
Pushing to an SBP of 120 mmHg before surgical control raises bleeding and can dislodge clot.
Following each unit with a liter of LR dilutes clotting factors and red cells, the dilutional coagulopathy that crystalloid causes.
With only PRBCs on board, warmed blood with a permissive SBP of 80–90 mmHg limits clot disruption until surgery in penetrating injury without head injury.
Crystalloid first delays oxygen-carrying blood and dilutes clotting factors before the PRBCs arrive.
Item 1882897
Perfusion and shock
A 15 kg child in septic shock remains hypotensive after 40 mL/kg of isotonic crystalloid given in 10–20 mL/kg aliquots with reassessment. Epinephrine is ordered at 0.1 mcg/kg/min, and the syringe contains 10 mcg/mL. At which rate should the pump be set?
Answer and why, all 4 options
0.9 mL/h results from a decimal error; it gives a tenth of the ordered dose.
90 mL/h forgets to divide by the concentration and gives a tenfold overdose.
1.5 mL/h confuses mcg/min with mL/h and gives a sixth of the dose.
Item 1882908
Perfusion and shock
A 5 kg infant in shock is ordered an epinephrine infusion at 5 mcg/min, copied from an adult protocol. The correct pediatric dose is 0.1 mcg/kg/min. How does the ordered dose compare with the correct dose?
Answer and why, all 4 options
A 100-fold error would require 50 mcg/min; the order is ten times the correct dose.
The correct dose is 0.1 × 5 = 0.5 mcg/min, so 5 mcg/min is ten times too much.
The adult fixed dose does not fit a 5-kg infant; weight-based dosing gives 0.5 mcg/min.
A 2-fold error would be 1 mcg/min; 5 mcg/min is ten times the correct dose.
Item 1882912
Perfusion and shock
A 4 kg infant with abdominal trauma from suspected abuse remains in shock (HR 190 beats/min, capillary refill 5 seconds, weak pulses) after one 10 mL/kg crystalloid aliquot. PRBCs are available on the aircraft. Which intervention is MOST appropriate next?
Answer and why, all 4 options
In hemorrhagic shock after one crystalloid aliquot, PRBCs at 10–20 mL/kg (40–80 mL here) replace both volume and oxygen-carrying capacity.
60 mL/kg of crystalloid in a bleeding infant dilutes blood and clotting factors without carrying oxygen.
Epinephrine without volume squeezes an empty circulation; hemorrhagic shock needs blood.
Waiting for a hemoglobin value ignores that hemoglobin lags behind acute blood loss.
Item 1882914
Perfusion and shock
An 80-kg patient with septic shock has 70 mL of urine in the catheter bag after a 2.5-hour transport. Which calculation and interpretation are correct?
Answer and why, all 4 options
0.88 mL/kg/h results from dividing by 1 hour and ignoring the transport time.
0.44 mL/kg/h results from dividing by 2 hours instead of 2.5.
0.35 mL/kg/h is correctly calculated, but it is below the 0.5 mL/kg/h target.
70 mL ÷ 80 kg ÷ 2.5 h = 0.35 mL/kg/h, which is below the 0.5 mL/kg/h target.
Item 1882946
Perfusion and shock
The transport nurse is evaluating four patients who need RSI before transport. Which pre-intubation finding MOST strongly predicts post-intubation hypotension?
Answer and why, all 4 options
A shock index above about 0.9 marks hidden shock; induction drugs and positive pressure then remove sympathetic tone and venous return, so BP falls.
A Mallampati class III view predicts a difficult airway, not hypotension.
A GCS of 7 is an indication for intubation, not a predictor of hemodynamic collapse after induction.
An SpO2 of 94% on a nonrebreather predicts desaturation during apnea, not circulatory collapse.
Item 564206
Perfusion and shock
A 68-year-old with GI bleeding has a hemoglobin of 6.8 g/dL, an SaO2 of 94% on room air and a cardiac output of 4.2 L/min. The team plans to transfuse 2 units of PRBCs during transport. If each unit raises hemoglobin by about 1 g/dL and SaO2 and cardiac output stay the same, by about what percent will oxygen delivery increase? (DO2 = 1.34 × Hgb × SaO2 × CO × 10)
Answer and why, all 4 options
38% assumes SaO2 also rises to 100%, which the question rules out.
23% divides the 2 g/dL rise by the new hemoglobin of 8.8 instead of the starting value of 6.8.
With SaO2 and cardiac output fixed, DO2 rises in proportion to hemoglobin: 8.8 ÷ 6.8 = 1.29, a 29% increase.
15% counts only one unit (7.8 ÷ 6.8); the plan is two units.
Item 1941681
Perfusion and shock
A septic patient has norepinephrine running through the only IV, a 20-gauge in the forearm. Before loading, the flight nurse needs to give fentanyl IV push. Which approach is MOST appropriate?
Answer and why, all 4 options
Flushing the line delivers a sudden bolus of the norepinephrine in the tubing, causing a BP spike or arrhythmia.
Muscle perfusion is poor in shock, so IM absorption is slow and unpredictable.
A push through the pressor line flushes the norepinephrine sitting in the tubing into the patient as a bolus, so pushes go through separate access.
Stopping a pressor, even briefly, drops the BP of a patient who depends on it.
Item 9730047
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Where resuscitation answers go wrong
Waiting for a central line. The 2021 Surviving Sepsis Campaign guidelines for adults suggest starting vasopressors through a peripheral vein rather than delaying them until central access is in place.
Escalating one pressor without end. The same guidelines make norepinephrine the first-line agent, set an initial mean arterial pressure target of 65 mmHg, and suggest adding vasopressin rather than raising norepinephrine further, usually once it reaches 0.25–0.5 µg/kg/min.
Giving volume to a wet, cold heart. Cool extremities with congestion point to cardiogenic shock, where more fluid deepens pulmonary edema; perfusion comes from inotropes, pressors or mechanical support.
Treating trauma resuscitation here. Massive transfusion, tranexamic acid and permissive hypotension are taught on TCRN continuum of care; this page uses them mostly where the aircraft changes the answer.
Yes. Both outlines name mechanical circulatory support under cardiovascular conditions, and the CTRN also lists IABP, Impella, VAD and ECMO among advanced interventions. This page covers the transport angle; device physiology is on the CMC pages.
Which shock states are tested?
All four on both exams: hypovolemic, obstructive, distributive and cardiogenic.