Managing Hemorrhagic Shock: Permissive Hypotension, Blood, and TXA Practice Questions

25 multiple-choice questions on Managing hemorrhagic shock: permissive hypotension, blood, and TXA for paramedic and EMT students, from Chapter 31 (Bleeding). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 30-year-old has a stab wound to the abdomen and no head injury. His radial pulse is absent. If you give fluid, you should titrate it to a systolic pressure of about:

   1. A. 50 to 60 mmHg
   2. B. 80 to 90 mmHg
   3. C. 110 to 120 mmHg
   4. D. 130 to 140 mmHg
   Show answer

   Answer: B. 80 to 90 mmHg

   Targeting a SBP of about 80 to 90 mmHg, or a palpable radial pulse and improved mentation, maintains vital organ perfusion while limiting bleeding. Pushing pressure to normal before surgery risks dislodging clots.

2. The main reason for permissive hypotension in uncontrolled bleeding is that higher pressures:

   1. A. Can dislodge clots and increase bleeding
   2. B. Cause pulmonary edema in young patients
   3. C. Damage the kidneys through overperfusion injury
   4. D. Prevent the heart from filling normally
   Show answer

   Answer: A. Can dislodge clots and increase bleeding

   Raising blood pressure before bleeding is surgically controlled can blow off fragile clots ('pop the clot') while the fluid used dilutes clotting factors. Pulmonary edema can occur with large volumes, but it is not the main reason.

3. A 35-year-old has a gunshot wound to the abdomen and a severe head injury with a GCS of 7. The systolic blood pressure goal is at least:

   1. A. 70 mmHg
   2. B. 80 mmHg
   3. C. 110 mmHg
   4. D. 90 mmHg
   Show answer

   Answer: C. 110 mmHg

   Hypotension sharply increases mortality in traumatic brain injury, so permissive hypotension is not used. Brain Trauma Foundation guidance targets a SBP of at least 110 mmHg in adults aged 15 to 49; the 80 to 90 mmHg target applies only without head injury.

4. Your service has no blood products, and a stab victim is hypotensive. Crystalloid should be given:

   1. A. In small boluses titrated to radial pulse and mentation
   2. B. Wide open until the blood pressure is normal
   3. C. At only a keep-vein-open rate regardless of vital signs
   4. D. In 2-L boluses repeated until the pulse slows
   Show answer

   Answer: A. In small boluses titrated to radial pulse and mentation

   Small boluses titrated to a radial pulse or mentation support perfusion without heavily diluting clotting factors. Large-volume crystalloid aimed at a normal pressure worsens coagulopathy, hypothermia, and bleeding.

5. For a hemorrhaging patient on a cold night, fluids and blood given in the ambulance should be:

   1. A. Given cold to slow down the bleeding
   2. B. Warmed with a fluid warmer if available
   3. C. Given only after reaching the hospital
   4. D. Run as fast as possible to raise the BP
   Show answer

   Answer: B. Warmed with a fluid warmer if available

   Cold fluids and refrigerated blood lower core temperature, and hypothermia impairs clotting and worsens bleeding (part of the lethal triad). Warm them with an inline or portable warmer when available, and keep the patient covered. Cold fluids do not slow bleeding, and fluids should be titrated to a radial pulse or SBP target, not run wide open.

6. TCCC lists which as the preferred resuscitation fluid for hemorrhagic shock?

   1. A. Lactated Ringer's solution
   2. B. Hydroxyethyl starch solution (Hextend)
   3. C. Packed red cells alone
   4. D. Cold-stored low-titer O whole blood
   Show answer

   Answer: D. Cold-stored low-titer O whole blood

   Whole blood restores oxygen-carrying capacity, clotting factors, and platelets in one product. Red cells alone do not replace clotting factors, and Hextend was removed from TCCC recommendations.

7. Whole blood used in prehospital programs is low-titer group O because:

   1. A. Group O red cells carry more oxygen
   2. B. Low-titer blood stays usable for a year
   3. C. It has few anti-A and anti-B antibodies
   4. D. Group O blood contains no platelets
   Show answer

   Answer: C. It has few anti-A and anti-B antibodies

   Group O red cells lack A and B antigens, and choosing donors with low anti-A and anti-B titers limits hemolysis of the recipient's cells when the blood type is unknown. Whole blood does contain platelets, which is part of its value.

8. The main concern when giving Rh-positive blood to a female of childbearing age is:

   1. A. An immediate anaphylactic reaction
   2. B. Hemolytic disease in a future pregnancy
   3. C. Higher risk of transfusion infection
   4. D. Reduced platelet function in the recipient
   Show answer

   Answer: B. Hemolytic disease in a future pregnancy

   An Rh-negative woman exposed to Rh-positive cells may make anti-D antibodies that later attack an Rh-positive fetus. Programs weigh this small risk against the much larger risk of death from hemorrhage.

9. TCCC recommends calcium with the first unit of blood because:

   1. A. Stored blood is too high in potassium
   2. B. Calcium neutralizes donor antibodies
   3. C. Stored blood contains no electrolytes
   4. D. Citrate in stored blood binds calcium
   Show answer

   Answer: D. Citrate in stored blood binds calcium

   Citrate anticoagulant binds ionized calcium, and hypocalcemia impairs clotting and cardiac contractility. Hyperkalemia from stored blood is real, but it is not the reason calcium is routinely given.

10. You have just started the first unit of whole blood for a patient in hemorrhagic shock. Per TCCC, you should also give:

    1. A. 30 mL of 10% calcium gluconate
    2. B. 3 mL of 10% calcium gluconate
    3. C. 10 mL of 10% magnesium sulfate
    4. D. 50 mL of 8.4% sodium bicarbonate
    Show answer

    Answer: A. 30 mL of 10% calcium gluconate

    TCCC calls for 1 g of calcium, given as 30 mL of 10% calcium gluconate or 10 mL of 10% calcium chloride. A 3-mL dose is a tenth of that, and bicarbonate does not correct citrate-induced hypocalcemia.

11. Your partner prepares to give 1 g of TXA as a rapid IV push to a bleeding patient. You should point out that a rapid push can cause:

    1. A. Hyperkalemia
    2. B. Hypoglycemia
    3. C. Clot breakdown
    4. D. Hypotension
    Show answer

    Answer: D. Hypotension

    TXA given too quickly can cause hypotension, so it is given slowly: 1 g over about 10 minutes (or by slow push per TCCC). TXA is antifibrinolytic and blocks rather than causes clot breakdown, and it does not cause hyperkalemia or hypoglycemia; seizures are a known risk at high doses.

12. A 20-kg child with a severe leg injury is in hemorrhagic shock 1 hour after injury, and your protocol allows TXA for children. The usual dose is about:

    1. A. 15 mg/kg, about 300 mg IV
    2. B. 1 g IV, the same as an adult
    3. C. 2 g IV by rapid IV push
    4. D. 5 mg/kg, about 100 mg IV
    Show answer

    Answer: A. 15 mg/kg, about 300 mg IV

    Pediatric trauma protocols that allow TXA commonly use 15 mg/kg (maximum 1 g) given over about 10 minutes, which is 300 mg for a 20-kg child. A full adult 1-g or 2-g dose would be several times too much for this child, and 5 mg/kg is well below the usual dose.

13. The TCCC dose of TXA for a casualty in or at risk of hemorrhagic shock is:

    1. A. 500 mg IM in the thigh
    2. B. 2 g IV or IO by slow push
    3. C. 1 g orally every 8 hours
    4. D. 10 g IV over 1 hour
    Show answer

    Answer: B. 2 g IV or IO by slow push

    TCCC recommends a single 2-g dose by slow IV or IO push as soon as possible within 3 hours. Many EMS systems instead use the CRASH-2 regimen of 1 g over 10 minutes followed by 1 g over 8 hours; either is acceptable depending on protocol. IM and oral routes are not used for hemorrhagic shock.

14. In the CRASH-2 regimen, TXA is given as:

    1. A. 2 g over 1 minute, then 2 g over 1 hour
    2. B. 1 g over 8 hours, then 1 g over 10 minutes
    3. C. 1 g over 10 minutes, then 1 g over 8 hours
    4. D. 500 mg IV push, repeated every 30 minutes
    Show answer

    Answer: C. 1 g over 10 minutes, then 1 g over 8 hours

    A 1-g loading dose over 10 minutes is followed by a 1-g infusion over 8 hours. Pushed too rapidly, TXA can cause hypotension, which is why the load is not given as a fast push.

15. A trauma patient injured 40 minutes ago has HR 124 and SBP 86 mmHg and meets your protocol's criteria for TXA. Which statement about giving it is correct?

    1. A. It removes the need for any other bleeding control
    2. B. It should not delay transport or bleeding control
    3. C. It should be given only after hospital arrival
    4. D. It works best when given after 3 hours
    Show answer

    Answer: B. It should not delay transport or bleeding control

    The ACS COT, ACEP, and NAEMSP joint statement says prehospital TXA may reduce mortality in injured patients with hemorrhagic shock when given within 3 hours and after lifesaving interventions, but it must never delay hemorrhage control or transport. TXA stabilizes clots; it cannot stop arterial bleeding by itself.

16. Which intervention best addresses the lethal triad at the scene for a bleeding patient on a warm summer day?

    1. A. Leaving him exposed to stay cool
    2. B. Giving 2 L of room-temperature saline quickly
    3. C. Covering the patient to prevent heat loss
    4. D. Applying cold packs to the wound
    Show answer

    Answer: C. Covering the patient to prevent heat loss

    Trauma patients lose heat even in warm weather from exposure, blood loss, and fluids, and hypothermia worsens coagulopathy. Large amounts of room-temperature fluid cool the patient further.

17. Trauma-related clotting begins to fail noticeably when core temperature falls below about:

    1. A. 38 °C (100.4 °F)
    2. B. 37 °C (98.6 °F)
    3. C. 30 °C (86 °F)
    4. D. 35 °C (95 °F)
    Show answer

    Answer: D. 35 °C (95 °F)

    Clotting enzymes and platelets function poorly below about 35 °C (95 °F), and mortality rises with each degree lost. Waiting for 30 °C (86 °F), well into severe hypothermia (below 32 °C in ATLS trauma staging), misses the point at which bleeding worsens.

18. The 'lethal diamond' adds which factor to the trauma lethal triad?

    1. A. Hypocalcemia
    2. B. Hyperglycemia
    3. C. Hypernatremia
    4. D. Hypomagnesemia
    Show answer

    Answer: A. Hypocalcemia

    Hypocalcemia from injury and citrated blood products impairs clotting and cardiac contractility, joining hypothermia, acidosis, and coagulopathy. That is why calcium is given early with blood.

19. Vasopressors in early hemorrhagic shock are generally:

    1. A. Preferred over blood because they act faster
    2. B. Avoided, since the problem is lost volume
    3. C. Given before any fluid or blood
    4. D. Required when the SBP is under 100
    Show answer

    Answer: B. Avoided, since the problem is lost volume

    The vessels are already maximally constricted; the problem is an empty tank. Vasopressors may increase bleeding and mortality and do not replace blood and surgical control.

20. The pneumatic antishock garment (PASG) for hemorrhagic shock is now:

    1. A. Required for every hypotensive patient
    2. B. Preferred over a pelvic binder
    3. C. Used first for penetrating chest trauma in adults
    4. D. Rarely used, as it showed no survival benefit
    Show answer

    Answer: D. Rarely used, as it showed no survival benefit

    Studies found no survival benefit, and PASG may increase bleeding in penetrating chest injuries. A pelvic binder is the preferred device for stabilizing pelvic fractures.

21. The PAMPer trial found that prehospital thawed plasma for injured patients at risk of shock during air transport:

    1. A. Increased transfusion reactions
    2. B. Had no effect on mortality
    3. C. Improved 30-day survival
    4. D. Raised the rate of pulmonary edema
    Show answer

    Answer: C. Improved 30-day survival

    PAMPer showed lower 30-day mortality with two units of plasma given before arrival. Like whole blood, plasma replaces the clotting factors that crystalloid dilutes.

22. Which set of findings makes up the ABC score that predicts the need for massive transfusion?

    1. A. Penetrating injury, SBP ≤ 90, HR ≥ 120, positive FAST
    2. B. Blunt injury, SBP ≤ 120, HR ≥ 90, abdominal tenderness
    3. C. Age over 65, GCS ≤ 8, RR ≥ 30, chest pain
    4. D. Head injury, SBP ≤ 100, HR ≥ 100, low SpO2
    Show answer

    Answer: A. Penetrating injury, SBP ≤ 90, HR ≥ 120, positive FAST

    Two or more of the four criteria predict massive transfusion. Prehospital use of the ABC score or shock index can trigger early blood bank activation.

23. Your partner wants to start IV access on scene for a critically bleeding trauma patient. The best timing for IV access is:

    1. A. On scene before the patient is moved
    2. B. Only after arrival at the receiving trauma center
    3. C. En route, so it does not delay transport
    4. D. Only once the SBP is below 70 mmHg
    Show answer

    Answer: C. En route, so it does not delay transport

    IV or IO access matters for blood, TXA, and analgesia, but it should not prolong scene time for a patient who needs surgery. If IV access fails, IO is a fast alternative.

24. A bleeding trauma patient in shock has no airway problems. You should position him:

    1. A. Supine and kept warm
    2. B. In steep Trendelenburg
    3. C. Sitting upright at 90°
    4. D. Prone with the legs raised
    Show answer

    Answer: A. Supine and kept warm

    The Trendelenburg position does not meaningfully improve blood pressure and can impair breathing. Keep the patient supine unless the airway or other injuries dictate otherwise, and prevent heat loss.

25. A 28-year-old has a leg amputation with a tourniquet in place, HR 136, and SBP 78 mmHg. Your service carries whole blood. The best resuscitation plan is to:

    1. A. Infuse 2 L of saline and then reassess the vitals
    2. B. Give TXA and withhold all fluids
    3. C. Start a norepinephrine infusion first
    4. D. Transfuse whole blood, give TXA, and keep warm
    Show answer

    Answer: D. Transfuse whole blood, give TXA, and keep warm

    This patient is in hemorrhagic shock with a controlled source, so whole blood, TXA within 3 hours, calcium per protocol, and warming address both volume loss and coagulopathy. Two liters of saline before blood dilutes clotting factors and cools the patient.