PHTLS Traumatic Brain Injury 3 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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.
PHTLS Traumatic Brain Injury 3
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?