CFRN Neurological Trauma Management 4 — Questions and Answers
Question 1: A trauma patient is found unresponsive with decorticate posturing. Which brain region is most likely affected?
- Cortical or subcortical white matter pathways above the midbrain (Correct answer)
- Pontine or medullary level
- Cerebellar involvement bilaterally
- Isolated frontal lobe contusion
Correct answer: Cortical or subcortical white matter pathways above the midbrain
Decorticate posturing (flexion of arms, extension of legs) indicates disruption of cortical or subcortical pathways above the level of the red nucleus in the midbrain.
Question 2: When managing a patient with suspected increased ICP, what is the recommended head-of-bed position during transport?
- 30-degree elevation with midline head position (Correct answer)
- Flat supine to maximize cerebral perfusion
- Trendelenburg position to improve venous return
- Lateral decubitus to prevent aspiration
Correct answer: 30-degree elevation with midline head position
Elevating the head 30 degrees in the midline optimizes cerebral venous drainage without significantly compromising MAP or CPP.
Question 3: A flight nurse prepares to administer ketamine for sedation in a TBI patient. What is the current evidence-based stance on this practice?
- Ketamine is acceptable when used with controlled ventilation and does not significantly worsen ICP (Correct answer)
- Ketamine is absolutely contraindicated in all TBI due to ICP elevation
- Ketamine is the preferred first-line sedative for all TBI patients
- Ketamine must be combined with mannitol to offset its ICP effects
Correct answer: Ketamine is acceptable when used with controlled ventilation and does not significantly worsen ICP
Current evidence suggests ketamine does not significantly raise ICP in ventilated, normoventilated TBI patients and offers hemodynamic stability, making it a viable option.
Question 4: A pediatric patient with TBI has a bulging fontanelle and is bradycardic. What does the bulging fontanelle indicate in this context?
- Elevated intracranial pressure transmitted through the open fontanelle (Correct answer)
- Normal physiologic variation in infants during crying
- Dehydration and decreased CSF production
- Subarachnoid hemorrhage without elevated ICP
Correct answer: Elevated intracranial pressure transmitted through the open fontanelle
A tense or bulging fontanelle in an infant with altered mental status and bradycardia indicates elevated ICP—the open fontanelle provides a clinical window into intracranial dynamics.
Question 5: Which medication should be given prophylactically during RSI for TBI to blunt the ICP spike from laryngoscopy?
- Lidocaine 1.5 mg/kg IV given 3 minutes before intubation (Correct answer)
- Atropine 0.5 mg IV immediately before succinylcholine
- Midazolam 0.1 mg/kg as the sole premedication
- Fentanyl 3 mcg/kg as the paralytic agent
Correct answer: Lidocaine 1.5 mg/kg IV given 3 minutes before intubation
Lidocaine IV given 3 minutes before laryngoscopy may blunt the catecholamine surge and ICP increase associated with airway manipulation in TBI patients.
Question 6: A patient with a spinal cord injury above T6 develops sudden hypertension (BP 210/115), bradycardia, and pounding headache during a Foley catheter change. What condition is occurring?
- Autonomic dysreflexia triggered by a noxious stimulus below the level of injury (Correct answer)
- Cushing's reflex from acute intracranial hypertension
- Malignant hypertension from pre-existing renal disease
- Sympathetic storming from diffuse axonal injury
Correct answer: Autonomic dysreflexia triggered by a noxious stimulus below the level of injury
Autonomic dysreflexia is a life-threatening exaggerated sympathetic reflex in SCI above T6, triggered by a noxious stimulus (e.g., bladder distension) causing severe hypertension.
Question 7: During fixed-wing transport, a TBI patient is on a ventilator. Which EtCO2 parameter should the flight nurse target to avoid secondary brain injury?
- 35-45 mmHg (normocapnia) (Correct answer)
- 25-30 mmHg (mild hyperventilation)
- 50-55 mmHg (permissive hypercapnia)
- 20-25 mmHg (aggressive hyperventilation)
Correct answer: 35-45 mmHg (normocapnia)
Normocapnia (EtCO2 35-45 mmHg) is the standard goal in TBI; hypocapnia causes cerebral vasoconstriction and ischemia, while hypercapnia causes vasodilation and worsens ICP.
CFRN Neurological Trauma Management 4
A trauma patient is found unresponsive with decorticate posturing.
Which brain region is most likely affected?