PHTLS Traumatic Brain Injury — Questions and Answers
Question 1: A patient with a severe TBI has a GCS of 6 and a systolic BP of 80 mmHg. What is the PHTLS priority for this patient?
- Administer mannitol immediately
- Restore systolic BP to ≥90 mmHg as quickly as possible (Correct answer)
- Hyperventilate to reduce ICP
- Perform rapid sequence intubation before fluid resuscitation
Correct answer: Restore systolic BP to ≥90 mmHg as quickly as possible
Hypotension (SBP <90 mmHg) doubles mortality in severe TBI, so restoring perfusion pressure is the immediate priority.
Question 2: Which herniation pattern is characterized by unilateral fixed and dilated pupil combined with contralateral motor weakness?
- Central herniation
- Uncal (transtentorial) herniation (Correct answer)
- Tonsillar herniation
- Upward cerebellar herniation
Correct answer: Uncal (transtentorial) herniation
Uncal herniation compresses CN III on the ipsilateral side, causing a blown pupil, and compresses the cerebral peduncle, causing contralateral weakness.
Question 3: In the context of TBI, what does the Monroe-Kellie doctrine state?
- Cerebral perfusion pressure equals MAP minus ICP
- The skull is a rigid compartment so any volume increase must displace another component (Correct answer)
- Autoregulation is lost at a CPP below 50 mmHg
- Cerebral blood flow is directly proportional to PaCO2
Correct answer: The skull is a rigid compartment so any volume increase must displace another component
The Monroe-Kellie doctrine holds that brain, blood, and CSF occupy a fixed skull volume, so expansion of one component compresses the others.
Question 4: A TBI patient is breathing at a rate of 6 breaths per minute. What is the PHTLS-recommended bag-valve-mask intervention?
- Assist ventilations to achieve 20 breaths/min
- Assist ventilations to achieve 10 breaths/min for adults (Correct answer)
- Allow the patient to self-regulate and provide supplemental O2 only
- Immediately hyperventilate at 20 breaths/min to decrease ICP
Correct answer: Assist ventilations to achieve 10 breaths/min for adults
PHTLS recommends assisting ventilation to approximately 10 breaths/min in adults to correct hypoventilation without causing harmful hypocapnia.
Question 5: Which of the following BEST describes cerebral perfusion pressure (CPP)?
- Systolic BP minus diastolic BP
- Mean arterial pressure minus intracranial pressure (Correct answer)
- Diastolic BP minus intracranial pressure
- Systolic BP minus intracranial pressure
Correct answer: Mean arterial pressure minus intracranial pressure
CPP = MAP − ICP; maintaining adequate CPP is the primary goal in managing severe TBI.
Question 6: During transport of a severe TBI patient, SpO2 drops to 88%. What is the correct action?
- Continue transport without adjustment as this is acceptable in trauma
- Increase supplemental oxygen and reassess airway positioning immediately (Correct answer)
- Hyperventilate the patient to compensate
- Administer furosemide to reduce cerebral edema
Correct answer: Increase supplemental oxygen and reassess airway positioning immediately
Hypoxia (SpO2 <90%) causes secondary brain injury; correcting it immediately with supplemental oxygen and airway optimization is the priority.
Question 7: A helmeted motorcyclist is unresponsive after a crash. When should the helmet be removed in the prehospital setting?
- Never; always leave the helmet in place until arrival at the ED
- Only if it prevents airway assessment or management (Correct answer)
- Immediately and always, to assess for skull fractures
- Only if the patient is conscious and requests removal
Correct answer: Only if it prevents airway assessment or management
PHTLS recommends helmet removal when it prevents adequate airway management or assessment, requiring a two-rescuer technique to maintain spinal alignment.
Question 8: A 30-year-old construction worker fell 20 feet and is confused (GCS 12). His right pupil is 6 mm and non-reactive. Which injury does this MOST suggest?
- Diffuse axonal injury
- Epidural hematoma with uncal herniation (Correct answer)
- Subdural hematoma without herniation
- Concussion with ocular contusion
Correct answer: Epidural hematoma with uncal herniation
A unilateral blown pupil following head trauma indicates uncal herniation, classically caused by an expanding epidural hematoma from a torn middle meningeal artery.
Question 9: Which TBI type is MOST commonly associated with rapid arterial bleeding between the skull and dura mater?
- Subdural hematoma
- Epidural hematoma (Correct answer)
- Intracerebral hemorrhage
- Subarachnoid hemorrhage
Correct answer: Epidural hematoma
Epidural hematomas result from tearing of the middle meningeal artery, causing rapid accumulation of arterial blood between the skull and the dura.
Question 10: Which patient population is at HIGHEST risk for subdural hematoma from seemingly minor head trauma?
- Healthy young athletes
- Elderly patients on anticoagulants (Correct answer)
- Children under age 5
- Patients with hypertension
Correct answer: Elderly patients on anticoagulants
Cerebral atrophy in the elderly stretches bridging veins, and anticoagulants impair clotting, dramatically increasing subdural hematoma risk even from minor falls.
Question 11: What is the significance of Cushing's triad in a TBI patient?
- It indicates adequate cerebral perfusion and a good prognosis
- It signals severely elevated ICP and impending brainstem herniation (Correct answer)
- It represents a benign vagal response to pain
- It is an early warning sign of mild concussion
Correct answer: It signals severely elevated ICP and impending brainstem herniation
Cushing's triad (hypertension, bradycardia, irregular respirations) is a late, ominous sign of critically elevated ICP with impending brainstem herniation.
Question 12: When is brief prophylactic hyperventilation (PaCO2 ~35 mmHg) acceptable in PHTLS guidelines for TBI?
- Routine use for all GCS <13 patients
- Only when signs of herniation (blown pupil, posturing) are present (Correct answer)
- Whenever SpO2 drops below 94%
- As standard care for any patient requiring intubation
Correct answer: Only when signs of herniation (blown pupil, posturing) are present
PHTLS permits brief targeted hyperventilation only as a temporizing measure for impending herniation, not as routine ICP management.
Question 13: A TBI patient exhibits decorticate posturing. Which brain region does this MOST likely indicate injury to?
- Cerebellar cortex
- Cerebral hemispheres or internal capsule above the midbrain (Correct answer)
- Pons and medulla
- Peripheral motor nerves
Correct answer: Cerebral hemispheres or internal capsule above the midbrain
Decorticate posturing (flexion of arms, extension of legs) indicates disruption of cortical and subcortical motor pathways above the red nucleus in the midbrain.
Question 14: During secondary assessment of a TBI patient, you note bilateral periorbital ecchymosis. This finding is MOST associated with:
- Direct orbital trauma only
- Basilar skull fracture (Correct answer)
- Epidural hematoma
- Diffuse axonal injury
Correct answer: Basilar skull fracture
Bilateral periorbital ecchymosis ('raccoon eyes') is a classic sign of anterior basilar skull fracture with blood tracking into the periorbital tissues.
Question 15: A pediatric TBI patient, age 4, has a GCS of 8 and blood pressure of 70/40 mmHg. What is the minimum acceptable systolic BP target in PHTLS for this child?
- 70 mmHg
- 80 mmHg (Correct answer)
- 90 mmHg
- 100 mmHg
Correct answer: 80 mmHg
PHTLS targets a minimum SBP of 80 mmHg for pediatric TBI patients, compared to 90 mmHg for adults, reflecting age-related physiologic norms.
Question 16: Which prehospital intervention has been shown to MOST reliably reduce secondary brain injury from TBI?
- Administration of hypertonic saline
- Prevention and correction of hypoxia and hypotension (Correct answer)
- Early mannitol administration
- Prophylactic anticonvulsants
Correct answer: Prevention and correction of hypoxia and hypotension
Preventing and correcting hypoxia and hypotension are the most impactful prehospital interventions to reduce secondary injury in TBI patients.
Question 17: A patient with known TBI begins having a generalized tonic-clonic seizure en route to the hospital. After ensuring airway safety, what is the next PHTLS priority?
- Initiate hyperventilation immediately
- Protect the patient from injury and monitor for airway compromise (Correct answer)
- Administer mannitol IV push
- Apply spinal immobilization board during seizure
Correct answer: Protect the patient from injury and monitor for airway compromise
Seizure management focuses on patient safety (preventing fall injury) and airway protection; definitive anticonvulsant treatment is typically a hospital intervention.
Question 18: Why is hyperthermia particularly harmful in TBI patients?
- It causes peripheral vasoconstriction reducing cardiac output
- It increases cerebral metabolic demand, worsening ischemia in injured tissue (Correct answer)
- It directly causes cerebral vasospasm
- It reduces cerebral blood flow by increasing blood viscosity
Correct answer: It increases cerebral metabolic demand, worsening ischemia in injured tissue
Hyperthermia raises cerebral metabolic rate, increasing oxygen demand in already-vulnerable injured brain tissue and exacerbating ischemic damage.
Question 19: A TBI patient who was initially alert (GCS 15) deteriorates to GCS 9 over 20 minutes. This pattern is MOST consistent with:
- Diffuse axonal injury
- Epidural hematoma with an expanding hematoma (lucid interval) (Correct answer)
- Concussion with post-traumatic amnesia
- Cervical spinal cord injury
Correct answer: Epidural hematoma with an expanding hematoma (lucid interval)
A lucid interval followed by rapid neurologic deterioration is the classic presentation of an expanding epidural hematoma compressing the brain.
Question 20: When managing a TBI patient's airway with BVM ventilation, what EtCO2 target should be maintained to avoid secondary injury?
- 20–25 mmHg
- 25–30 mmHg
- 35–40 mmHg (Correct answer)
- 45–50 mmHg
Correct answer: 35–40 mmHg
A target EtCO2 of 35–40 mmHg maintains normocapnia, preventing both vasodilatory hypercarbia and vasoconstrictive hypocapnia.
Question 21: Which mechanism BEST explains why hypocapnia worsens outcomes in most TBI patients?
- It causes systemic vasodilation and drops MAP
- It causes cerebral vasoconstriction, reducing cerebral blood flow and worsening ischemia (Correct answer)
- It increases intracranial pressure by raising CSF production
- It directly depresses brainstem respiratory centers
Correct answer: It causes cerebral vasoconstriction, reducing cerebral blood flow and worsening ischemia
Hypocapnia causes cerebral vasoconstriction, which reduces blood flow to already-injured tissue, converting ischemic penumbra to infarction.
PHTLS Traumatic Brain Injury
A patient with a severe TBI has a GCS of 6 and a systolic BP of 80 mmHg.
What is the PHTLS priority for this patient?
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