Head and Neck Injuries Flashcards

In the AIS, a cerebral contusion with loss of consciousness lasting 31–60 minutes is coded at which severity level?

Answer: AIS 3

A cerebral contusion with LOC of 31–60 minutes corresponds to AIS 3 (Serious).

Which cervical spine injury descriptor is used in AIS when there is fracture of C1 (atlas) without evidence of spinal cord involvement?

Answer: Atlas fracture without cord injury

A C1 fracture without cord involvement is coded as 'Atlas fracture without cord injury' to distinguish it from cord-level injuries.

When coding a penetrating skull injury with retained foreign body but no documented brain laceration, which AIS code category applies?

Answer: Penetrating skull injury without brain injury

A penetrating skull injury with retained foreign body but no confirmed brain laceration is coded as penetrating skull injury without brain injury.

A patient has bilateral frontal lobe contusions on CT with GCS of 9. What AIS severity is most appropriate?

Answer: AIS 4

Bilateral frontal lobe contusions with moderate neurological impairment (GCS 9) typically code to AIS 4 (Severe).

Under AIS rules, which of the following neck soft-tissue injuries would receive AIS 1 (Minor)?

Answer: Cervical muscle strain without fracture

Cervical muscle strain without fracture or vascular injury is coded AIS 1 because it poses minimal threat to life.

What is the AIS coding principle when both a skull fracture and an intracranial hematoma are present in the same patient?

Answer: Both injuries are coded separately

AIS codes both the skull fracture and the intracranial hematoma separately, as each represents a distinct injury.

Which AIS body region contains injuries to the external ear and scalp?

Answer: Body Region 1 – Head

The scalp and external ear are classified within AIS Body Region 1 (Head).

A motorcyclist sustains a subdural hematoma with midline shift >5 mm on CT. What is the minimum expected AIS severity?

Answer: AIS 4

An acute subdural hematoma with significant midline shift is coded AIS 4 (Severe) or higher depending on clinical status.

In the AIS dictionary, 'diffuse axonal injury' (DAI) with coma lasting more than 6 hours is coded at which level?

Answer: AIS 5

DAI with coma exceeding 6 hours represents a life-threatening brain injury coded at AIS 5 (Critical).

Which of the following is an AIS 6 (Maximum/Untreatable) head injury?

Answer: Complete brainstem destruction

Complete brainstem destruction is virtually unsurvivable and is coded AIS 6.

When a patient has a C3 fracture with complete motor and sensory loss below that level, what AIS code applies?

Answer: AIS 5

A high cervical cord injury (C3) with complete neurological deficit is coded AIS 5 (Critical) due to the threat to respiratory function.

An intracerebral hemorrhage is found in the temporal lobe measuring 15 mL with GCS 14. Which AIS severity is most appropriate?

Answer: AIS 3

A small temporal intracerebral hemorrhage with near-normal GCS is coded AIS 3 (Serious).

In AIS, where is a fracture of the hyoid bone classified?

Answer: Neck region

The hyoid bone is an anatomical structure of the neck and its fracture is coded under the AIS Neck body region.

A patient presents with post-traumatic amnesia lasting 3 days without structural CT finding. How does AIS classify this?

Answer: AIS 2 – Moderate

Post-traumatic amnesia of several days without structural injury is coded AIS 2 because it reflects a moderate concussion.

For AIS coding purposes, which criterion distinguishes an epidural hematoma (EDH) coded AIS 4 from one coded AIS 5?

Answer: Volume of hematoma and associated brain shift

AIS severity for EDH escalates with larger hematoma volume and significant midline shift indicating greater mass effect.

Under the AIS 2015 update, subarachnoid hemorrhage (SAH) is primarily coded based on which factor?

Answer: Traumatic vs. spontaneous origin

AIS distinguishes traumatic SAH from spontaneous SAH because the AIS dictionary covers only traumatic injuries.

A pedestrian struck by a car has a depressed skull fracture with underlying dural laceration but no parenchymal injury on MRI. What AIS severity applies?

Answer: AIS 4

A depressed skull fracture with dural disruption but no brain parenchymal injury codes to AIS 4 due to the structural significance.

Which structure, when lacerated in a neck injury, most likely elevates the AIS severity to 4 or 5?

Answer: Common carotid artery

Laceration of the common carotid artery is a major vascular injury that elevates AIS neck injury severity to 4 or 5.

In AIS, the 'masked injury' rule states that if a more severe brain injury is identified later, the coder should:

Answer: Revise the AIS code to the higher severity injury

AIS coding is updated to reflect the most accurate diagnosis; the code is revised upward when a more severe injury is subsequently identified.

A cyclist falls and sustains loss of consciousness of 15 minutes with a GCS on arrival of 14. No CT abnormality is found. What is the AIS code?

Answer: AIS 2

LOC of 1–30 minutes with GCS ≥14 and no structural finding is coded AIS 2 (Moderate concussion).