ITLS - International Trauma Life Support Head and Spinal Trauma Questions and Answers 1 — Questions and Answers
Question 1: A 45-year-old male is found unconscious after falling from a ladder. His initial vital signs are BP 190/110 mmHg, HR 52 bpm, and he has irregular, gasping respirations. His right pupil is dilated and non-reactive. These findings are most indicative of:
- Spinal shock
- Neurogenic shock
- Cushing's triad due to increased intracranial pressure (Correct answer)
- Decompensated hemorrhagic shock
Correct answer: Cushing's triad due to increased intracranial pressure
The patient's clinical presentation of hypertension (with a widening pulse pressure), bradycardia, and irregular respirations constitutes Cushing's triad. This triad is a late and critical sign of severely increased intracranial pressure (ICP), suggesting impending brainstem herniation. [24, 25]
Question 2: You are treating a 22-year-old who was stabbed in the right side of his neck. Assessment reveals paralysis and loss of position sense in his right arm and leg, with a loss of pain and temperature sensation on his left side below the injury. This pattern of deficits is most consistent with which spinal cord syndrome?
- Anterior Cord Syndrome
- Central Cord Syndrome
- Cauda Equina Syndrome
- Brown-Séquard Syndrome (Correct answer)
Correct answer: Brown-Séquard Syndrome
Brown-Séquard Syndrome results from hemisection (one-sided damage) of the spinal cord. It is characterized by ipsilateral (same-side) loss of motor function and proprioception, and contralateral (opposite-side) loss of pain and temperature sensation. [17, 26, 27]
Question 3: A patient involved in a high-speed collision has a suspected high thoracic spinal cord injury. Which set of vital signs is most characteristic of neurogenic shock?
- BP 80/50 mmHg, HR 130 bpm, cool and clammy skin
- BP 86/58 mmHg, HR 58 bpm, warm and dry skin (Correct answer)
- BP 180/100 mmHg, HR 50 bpm, irregular respirations
- BP 110/70 mmHg, HR 110 bpm, pale and diaphoretic skin
Correct answer: BP 86/58 mmHg, HR 58 bpm, warm and dry skin
Neurogenic shock is a distributive shock resulting from the loss of sympathetic tone below the level of a high spinal cord injury. This leads to massive vasodilation, causing hypotension. The loss of sympathetic stimulation to the heart results in bradycardia (or a normal heart rate) rather than the expected tachycardia. The skin is typically warm and dry due to peripheral vasodilation. [1, 11, 12, 14]
Question 4: According to ITLS guidelines, which of the following patients requires the application of spinal motion restriction (SMR)?
- A 40-year-old with a gunshot wound to the abdomen who is ambulatory on scene.
- A 25-year-old who fell from a standing height, is alert and oriented, and denies any neck or back pain.
- A 60-year-old driver in a moderate-speed MVC who is intoxicated and has a distracting forearm fracture. (Correct answer)
- A 30-year-old with an isolated stab wound to the arm with controlled bleeding.
Correct answer: A 60-year-old driver in a moderate-speed MVC who is intoxicated and has a distracting forearm fracture.
ITLS guidelines recommend selective spinal motion restriction. SMR is indicated in blunt trauma patients with an altered level of consciousness, evidence of intoxication, a distracting injury, or focal neurologic signs/symptoms, as these factors make a spinal exam unreliable. Penetrating trauma does not typically require SMR unless there is a specific neurologic deficit. [7, 10, 16, 28]
Question 5: An elderly patient falls and strikes their chin, causing a hyperextension injury of the neck. They present with significant motor weakness in their arms and hands but are able to move their legs with near-normal strength. This clinical picture is most typical of:
- Brown-Séquard Syndrome
- Anterior Cord Syndrome
- Central Cord Syndrome (Correct answer)
- Posterior Cord Syndrome
Correct answer: Central Cord Syndrome
Central Cord Syndrome is characterized by motor impairment that is disproportionately greater in the upper extremities than the lower extremities. [2, 4, 5, 9] It is often caused by hyperextension injuries in older patients with pre-existing cervical spondylosis.
Question 6: When managing a patient with a severe traumatic brain injury who is showing signs of cerebral herniation (e.g., unilateral dilated pupil, posturing), what is the recommended immediate ventilation strategy according to ITLS?
- Hyperventilate the patient to maintain an EtCO2 of 20-25 mmHg.
- Maintain normal ventilation to achieve an EtCO2 of 35-45 mmHg.
- Provide mild, controlled hyperventilation to a target EtCO2 of 30-35 mmHg. (Correct answer)
- Allow permissive hypercapnia to increase cerebral blood flow.
Correct answer: Provide mild, controlled hyperventilation to a target EtCO2 of 30-35 mmHg.
While routine hyperventilation is harmful, in the presence of active cerebral herniation, ITLS guidelines recommend controlled, mild hyperventilation as a temporizing measure. Lowering the PaCO2 (and thus EtCO2) to 30-35 mmHg causes cerebral vasoconstriction, which can briefly reduce intracranial pressure until definitive care is available. [3, 22, 25]
ITLS - International Trauma Life Support Head and Spinal Trauma Questions and Answers 1
A 45-year-old male is found unconscious after falling from a ladder.
His initial vital signs are BP 190/110 mmHg, HR 52 bpm, and he has irregular, gasping respirations.
His right pupil is dilated and non-reactive.
These findings are most indicative of: