NREMT — EMT & Paramedic
NREMT Trauma Practice Questions (Bleeding, Shock & Injuries)
NREMT trauma items revolve around a single physiological story: perfusion. Bleeding control, shock recognition, chest injuries that break ventilation, and head injuries that raise intracranial pressure are all variations of 'find the threat to oxygen delivery and fix it in the right order.' The exam's favorite trick is hiding compensated shock behind normal-looking blood pressure.
Anchor points: the XABC hemorrhage-first hierarchy, the difference between compensated and decompensated shock, the handful of chest-injury patterns with specific field fixes, and the transport-decision logic that gets unstable patients to surgeons rather than treated exhaustively in a driveway.
Hemorrhage and shock: the perfusion story
Bleeding control ladder: direct pressure is first-line; for life-threatening extremity hemorrhage uncontrolled by pressure — or when pressure is impractical (multiple casualties, entrapment) — apply a tourniquet proximal to the wound, tighten until bleeding stops, note the time, and never loosen it in the field. Junctional/torso wounds get pressure and hemostatic dressings per protocol. Internal bleeding (mechanism + shock signs + rigid abdomen or unstable pelvis) has one field treatment: recognize it, keep the patient warm, and transport rapidly to surgical care.
Shock stages: compensated shock shows tachycardia, pale cool clammy skin, anxiety, delayed capillary refill, tachypnea — with a maintained blood pressure; decompensated shock adds hypotension and falling mentation, and it's late. The tested insight: in healthy adults (and dramatically in children), blood pressure is the last thing to fall — choosing 'normal BP, therefore stable' is the planted error. Field shock care: stop the bleeding, maintain oxygenation, keep them warm (hypothermia worsens coagulopathy), supine positioning, rapid transport, early ALS/trauma-center notification.
Patterned injuries with patterned answers
Chest: open chest wound → occlusive dressing (per current teaching, vented or taped per protocol; monitor for tension development and lift a corner if deterioration follows sealing). Suspected tension pneumothorax — escalating respiratory distress, absent unilateral breath sounds, hypotension, JVD, late tracheal deviation — needs rapid transport and ALS (needle decompression at the paramedic level per protocol). Flail segment → support ventilation as needed; positive pressure is the real splint. Head: suspected brain injury gets oxygenation (hypoxia kills injured brains), ventilation at normal rates (routine hyperventilation is wrong; reserved, per protocol, for active herniation signs), bleeding control without pressure on depressed skull segments, and rapid transport — with Cushing's triad (hypertension, bradycardia, irregular respirations) recognized as late ICP rise.
Burns and bones: stop the burning, remove jewelry, dry sterile coverings, keep the patient warm (large burns lose heat), rule-of-nines estimation, and airway vigilance with any facial burns, singed nasal hair, hoarseness, or enclosed-space fire — the airway can close hours later. Splinting logic: life before limb (splinting never precedes shock care); check distal circulation/sensation/motor before and after; align severely angulated long-bone fractures with gentle traction per protocol if pulseless; femur fractures with traction splints when indicated and no contraindicating pelvic/knee involvement; pelvis instability → binder per protocol and minimal handling.
Practice questions with answers & rationales
Q1. Direct pressure has not controlled arterial bleeding from a mid-thigh wound. What's the next step, and what's the common error?
Answer: Apply a tourniquet proximal to the wound (high and tight or 2–3 inches above per protocol, not over a joint), tighten until bleeding stops, record the time. The common errors the exam plants: 'elevate and use pressure points' (outdated as a substitute for a tourniquet), tightening only until 'it slows,' or loosening periodically — all wrong. A correctly applied tourniquet hurts; that's expected, not a reason to loosen.
Q2. A 24-year-old stabbing victim is anxious with HR 124, RR 24, pale clammy skin — BP 118/76. How sick is he?
Answer: Sick: this is compensated shock. Catecholamines are maintaining his pressure while perfusion is already failing (tachycardia, skin signs, anxiety are the evidence). He's a high-priority transport with bleeding control, warmth, oxygen as indicated, and trauma-center notification — before the BP falls, because when it does he's decompensating with little reserve. 'Normal BP = stable' is the exact trap this stem exists to spring.
Q3. You seal an open chest wound and minutes later the patient's distress worsens, with falling BP and diminished breath sounds on that side. What happened and what do you do?
Answer: A tension pneumothorax is developing — the seal converted an open pneumothorax into a one-way valve problem. Immediately lift/burp the occlusive dressing to release pressure; if no improvement, this patient needs paramedic-level needle decompression per protocol and the fastest transport you can produce. The exam loves this two-step: the right intervention can create the next problem, and you're tested on the rescue.
Q4. Head-injured patient, GCS dropping, BP 190/100, pulse 54, irregular breathing. Identify the pattern and the prehospital priorities.
Answer: Cushing's triad — hypertension, bradycardia, irregular respirations — signaling critically raised ICP/impending herniation. Priorities: airway and oxygenation (avoid hypoxia at all costs), ventilation at normal rates (hyperventilation only per protocol for active herniation), 30° head elevation if protocol allows and no shock/spinal contraindication, avoid hypotension, rapid transport to a neurosurgical-capable center with early notification. There is no field fix — recognition, oxygenation, and speed are the treatment.
Q5. Why is keeping a bleeding trauma patient warm a treatment rather than a comfort measure?
Answer: Hypothermia impairs clotting-factor function and platelet activity — part of the 'lethal triad' with acidosis and coagulopathy — so a cold trauma patient literally bleeds more. Strip wet clothing, cover with blankets, warm the compartment. The exam encodes this as 'maintaining body temperature' inside shock management; it's a why-question favorite at every certification level.
Q6. An adult has partial-thickness burns covering one entire arm and the anterior chest. Estimate the body surface area and name the field priorities.
Answer: Rule of nines: whole arm 9% + anterior chest (half the anterior torso, 9%) = roughly 18% BSA — a significant burn. Priorities: stop the burning, remove jewelry/non-adherent clothing, dry sterile dressings (large burns are not soaked — cooling large areas causes hypothermia), keep warm, monitor the airway aggressively if any facial/inhalation indicators, and transport per burn-center criteria. Estimating BSA and resisting the urge to irrigate big burns are both tested.
Q7. A motorcyclist has an obviously deformed, pulseless lower leg and signs of shock. Order your actions.
Answer: Shock care first: hemorrhage control, oxygenation, warmth, rapid transport decision — life before limb. The pulseless limb is the one splinting urgency that justifies action: align with gentle longitudinal traction per protocol to attempt pulse restoration, splint, recheck CSM, and document times. But it's done expeditiously en route or in parallel — never delaying transport of a shocky patient for elaborate splinting.
Common mistakes to avoid
- Underestimating compensated shock because the blood pressure is normal — especially in young adults and children.
- Loosening tourniquets, applying them over joints, or tightening only until bleeding 'slows.'
- Sealing an open chest wound and never reassessing for tension physiology.
- Routinely hyperventilating head injuries — normal ventilation rates unless protocol-directed for herniation.
- Soaking large burns in water (hypothermia) or smearing anything on them.
- Performing meticulous on-scene splinting/bandaging while a surgical patient's clock runs — the trauma answer is usually 'go.'