PHTLS Spinal Trauma Management — Questions and Answers

Question 1: A patient involved in a high-speed MVC is found ambulatory at the scene but complains of neck pain. What is the PHTLS-recommended approach to spinal motion restriction (SMR)?

Advise the patient to walk to the ambulance carefully
Apply a cervical collar and consider full SMR based on mechanism and symptoms (Correct answer)
Immobilize only if the patient is unconscious
Spinal precautions are unnecessary if the patient is walking

Correct answer: Apply a cervical collar and consider full SMR based on mechanism and symptoms

PHTLS recommends applying a cervical collar and evaluating for full SMR when significant mechanism is combined with neck pain, even in ambulatory patients.

Question 2: Which vertebral region is MOST commonly injured in blunt trauma due to its transitional anatomy?

Cervical-thoracic junction (C7-T1)
Mid-thoracic (T5-T8)
Thoracolumbar junction (T12-L1) (Correct answer)
Lumbar-sacral junction (L5-S1)

Correct answer: Thoracolumbar junction (T12-L1)

The thoracolumbar junction (T12-L1) is the most common site of blunt spinal injury because the rigid thoracic spine meets the more mobile lumbar spine here.

Question 3: During extrication of a seated vehicle crash victim, which technique best maintains spinal alignment?

Rapid extrication without a collar to save time
Manual in-line stabilization throughout the move (Correct answer)
Allow the patient to self-extricate with verbal guidance
Use a short backboard only if the patient is symptomatic

Correct answer: Manual in-line stabilization throughout the move

Manual in-line stabilization must be maintained throughout extrication to prevent secondary spinal cord injury.

Question 4: A patient with a cervical spinal cord injury presents with bradycardia and hypotension but warm, dry skin. This pattern is MOST consistent with:

Hemorrhagic shock
Neurogenic shock (Correct answer)
Obstructive shock
Cardiogenic shock

Correct answer: Neurogenic shock

Neurogenic shock from high cervical cord injury causes loss of sympathetic tone, producing hypotension and bradycardia with warm, dry (vasodilated) skin.

Question 5: When applying a cervical collar to a trauma patient, what is the FIRST step?

Select the correct collar size
Apply manual in-line stabilization (Correct answer)
Log-roll the patient supine
Assess for distracting injuries

Correct answer: Apply manual in-line stabilization

Manual in-line stabilization must be established before any device is applied to prevent movement during sizing and collar placement.

Question 6: A PHTLS provider assesses a patient with a stab wound to the posterior neck at C4. The patient has bilateral arm weakness but intact leg function. This pattern suggests injury to the:

Anterior cord
Posterior cord
Central cord (Correct answer)
Brown-Séquard (hemicord)

Correct answer: Central cord

Central cord syndrome produces greater weakness in the upper extremities than the lower extremities, often from hyperextension injuries or penetrating wounds near the cord center.

Question 7: Which finding would SUPPORT withholding spinal motion restriction in a conscious, alert trauma patient per PHTLS selective SMR criteria?

Tenderness over the spinous processes
Intoxication with alcohol
No midline spinal pain or tenderness and no neurologic deficit (Correct answer)
Distracting painful injury to the extremity

Correct answer: No midline spinal pain or tenderness and no neurologic deficit

PHTLS selective SMR criteria allow withholding immobilization when the patient is alert, has no midline pain or tenderness, and has no neurologic deficits.

Question 8: A football player sustains an axial loading injury to the cervical spine and is found prone on the field. The FIRST priority in management is:

Remove the helmet immediately
Establish manual in-line stabilization and assess airway (Correct answer)
Log-roll to supine and apply a cervical collar
Check for helmet removal guidelines before touching the patient

Correct answer: Establish manual in-line stabilization and assess airway

Airway and breathing are always the first priorities; manual in-line stabilization is maintained while the airway is assessed and managed.

Question 9: In a helmet-wearing athlete with suspected cervical spine injury, PHTLS recommends leaving the helmet in place UNLESS:

The helmet prevents adequate airway assessment or management (Correct answer)
The patient is responsive and cooperative
Bystanders have already partially removed it
The event occurred during a contact sport

Correct answer: The helmet prevents adequate airway assessment or management

Helmets should remain in place unless they prevent airway assessment/management, are improperly fitted, or the patient is in cardiac arrest.

Question 10: Which spinal cord injury pattern produces ipsilateral motor loss and contralateral loss of pain and temperature below the injury level?

Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Brown-Séquard syndrome (Correct answer)

Correct answer: Brown-Séquard syndrome

Brown-Séquard syndrome results from hemicord injury (often penetrating), causing ipsilateral motor/proprioception loss and contralateral pain/temperature loss.

Question 11: During a long spine board (LSB) application, a patient complains of difficulty breathing when strapped. The MOST appropriate action is:

Tighten the straps to secure the patient fully
Loosen chest straps slightly while maintaining head and pelvic securing (Correct answer)
Remove the LSB and use a vacuum mattress instead
Reassure the patient that mild discomfort is expected

Correct answer: Loosen chest straps slightly while maintaining head and pelvic securing

Chest straps that are too tight can restrict respiratory excursion; they should be loosened enough to allow adequate ventilation while the head and pelvis remain secured.

Question 12: A patient with suspected thoracic spine fracture has absent sensation below the nipple line bilaterally. Which dermatome level does this MOST closely correspond to?

T4 (Correct answer)
T6
T10
T12

Correct answer: T4

The T4 dermatome corresponds to the nipple line; absent sensation below this level bilaterally suggests a cord injury at approximately T4.

Question 13: What is the primary goal of PHTLS spinal motion restriction compared to traditional full spinal immobilization?

Eliminate all spinal movement using rigid devices
Limit harmful motion while allowing necessary movement for patient care (Correct answer)
Reduce scene time by skipping spinal assessment
Immobilize only penetrating spinal injuries

Correct answer: Limit harmful motion while allowing necessary movement for patient care

PHTLS SMR focuses on limiting potentially harmful motion rather than achieving absolute immobilization, acknowledging that some movement during care is unavoidable.

Question 14: A patient is found supine with suspected lumbar spine injury after a fall. Which device provides the BEST immobilization for transport?

Cervical collar alone
Long spine board with head blocks and straps
Scoop stretcher without additional securing
Vacuum mattress with straps (Correct answer)

Correct answer: Vacuum mattress with straps

A vacuum mattress conforms to the patient's body contours, distributes pressure evenly, and provides excellent spinal immobilization with reduced pressure injury risk.

Question 15: A patient with a cervical collar in place develops increasing respiratory distress after trauma. What complication related to the cervical collar should be considered?

Cervical collar causing jugular vein compression increasing ICP (Correct answer)
Collar migrating into the airway
Collar inducing vagal bradycardia
Pressure from the collar causing esophageal rupture

Correct answer: Cervical collar causing jugular vein compression increasing ICP

Excessively tight cervical collars can compress the jugular veins, impairing venous drainage and raising intracranial pressure, which is especially dangerous in head-injured patients.

Question 16: Which mechanism of injury carries the HIGHEST risk of unstable cervical spine injury according to PHTLS?

Low-speed rear-end collision at less than 15 mph
Axial loading with flexion (diving into shallow water) (Correct answer)
Ground-level fall in an elderly patient
Isolated facial laceration from a blunt object

Correct answer: Axial loading with flexion (diving into shallow water)

Axial loading with flexion, such as diving into shallow water, creates compressive and flexion forces that commonly produce unstable burst or wedge fractures.

Question 17: When managing a patient with suspected spinal injury who requires airway intervention, what is the PREFERRED prehospital airway technique?

Blind nasotracheal intubation without any stabilization
Orotracheal intubation with manual in-line stabilization (Correct answer)
Surgical cricothyrotomy as the first line
Jaw thrust with BVM while awaiting hospital arrival

Correct answer: Orotracheal intubation with manual in-line stabilization

Orotracheal intubation with manual in-line stabilization maintains the airway while minimizing cervical spine movement and is the preferred PHTLS approach.

Question 18: A conscious trauma patient has priapism. In the context of spinal trauma, this sign indicates:

Hemorrhagic shock with pelvic fracture
Autonomic dysfunction from spinal cord injury (Correct answer)
Bladder rupture causing fluid redistribution
Normal physiologic stress response to pain

Correct answer: Autonomic dysfunction from spinal cord injury

Priapism in a male trauma patient indicates loss of inhibitory sympathetic control from a spinal cord injury, causing uncontrolled parasympathetic stimulation.

Question 19: During rapid extrication of a critically injured patient, which condition JUSTIFIES accelerating the process despite potential spinal risk?

Patient is anxious and uncooperative
Scene is becoming unsafe or patient has a life-threatening condition requiring immediate intervention (Correct answer)
Family members are pressuring the crew to move faster
Transport time to the hospital is long

Correct answer: Scene is becoming unsafe or patient has a life-threatening condition requiring immediate intervention

PHTLS allows rapid extrication when the scene becomes unsafe or when the patient has an immediately life-threatening condition that cannot be managed in place.

Question 20: What is the significance of a 'chance fracture' in the context of prehospital spinal trauma?

A fracture with no neurologic deficit, considered benign in the field
A horizontal fracture through the vertebral body, pedicles, and spinous process often from lap-belt restraint (Correct answer)
A hairline fracture visible only on CT imaging
A fracture occurring only in osteoporotic patients

Correct answer: A horizontal fracture through the vertebral body, pedicles, and spinous process often from lap-belt restraint

A Chance fracture is a flexion-distraction injury through all three columns of the vertebra, classically associated with lap-belt use in MVCs, and is highly unstable.

Question 21: A patient is immobilized on a long spine board and complains of pain at the occiput and heels. After 30 minutes en route, the BEST action is:

Reassure the patient that discomfort is expected on a spine board
Document the complaint and reassess upon hospital arrival
Pad the bony prominences without removing the board or straps (Correct answer)
Remove the spine board immediately to relieve pressure

Correct answer: Pad the bony prominences without removing the board or straps

Padding bony prominences such as the occiput and heels reduces pressure injury risk while maintaining spinal immobilization during transport.

PHTLS Spinal Trauma Management

A patient involved in a high-speed MVC is found ambulatory at the scene but complains of neck pain.
What is the PHTLS-recommended approach to spinal motion restriction (SMR)?

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