PHTLS Traumatic Brain Injury 5 — Questions and Answers
Question 1: A patient with TBI has decerebrate posturing. Compared to decorticate posturing, this suggests injury at which level?
- Cortex and internal capsule
- Below the red nucleus at the level of the midbrain or upper pons (Correct answer)
- Medulla and spinal cord
- Cerebellum only
Correct answer: Below the red nucleus at the level of the midbrain or upper pons
Decerebrate posturing (extension and internal rotation of all extremities) indicates injury at or below the midbrain red nucleus, a deeper and more ominous injury than decorticate.
Question 2: In the PHTLS trauma assessment, which component of the GCS is considered the MOST prognostically significant for TBI?
- Eye opening (E)
- Motor response (M) (Correct answer)
- Verbal response (V)
- All three components are equally weighted
Correct answer: Motor response (M)
The motor component of the GCS has the strongest correlation with TBI outcome and neurological prognosis in trauma research.
Question 3: A patient with TBI has CSF rhinorrhea (clear fluid from the nose). This finding indicates:
- Anterior fossa basilar skull fracture with dural tear (Correct answer)
- Nasal bone fracture only
- Maxillary sinus hemorrhage
- Elevated intracranial pressure without skull fracture
Correct answer: Anterior fossa basilar skull fracture with dural tear
CSF rhinorrhea results from a basilar skull fracture that tears the dura in the anterior fossa, allowing CSF to drain through the cribriform plate into the nasal cavity.
Question 4: What is the PHTLS recommendation regarding spinal motion restriction in a TBI patient with a significant mechanism?
- Rigid collar and long backboard are mandatory for all TBI patients
- Use selective spinal motion restriction based on clinical assessment and NEXUS/Canadian C-Spine criteria (Correct answer)
- Spinal motion restriction is contraindicated in TBI as it raises ICP
- Apply only a cervical collar and forgo backboard to speed transport
Correct answer: Use selective spinal motion restriction based on clinical assessment and NEXUS/Canadian C-Spine criteria
PHTLS recommends selective spinal motion restriction based on validated clinical criteria rather than universal immobilization for all trauma patients.
Question 5: A restless, agitated TBI patient is pulling at his oxygen mask. What is the MOST appropriate PHTLS response?
- Allow the patient to remove the mask to reduce agitation and ICP
- Reassess and manage pain/agitation while maintaining oxygenation and monitoring neuro status (Correct answer)
- Administer benzodiazepines to sedate the patient immediately
- Apply physical restraints and document as combative patient
Correct answer: Reassess and manage pain/agitation while maintaining oxygenation and monitoring neuro status
Agitation in TBI may reflect hypoxia, pain, or worsening brain injury; the priority is to identify and treat the cause while maintaining oxygenation and monitoring for deterioration.
Question 6: Which finding on assessment of a TBI patient would prompt the PHTLS provider to initiate the FASTEST transport to a trauma center?
- GCS 14 with mild headache and nausea
- GCS 8 with one fixed dilated pupil and hypotension (Correct answer)
- GCS 13 with scalp laceration requiring hemorrhage control
- Isolated post-traumatic amnesia with normal vital signs
Correct answer: GCS 8 with one fixed dilated pupil and hypotension
A GCS of 8 with a blown pupil (herniation) and hypotension represents immediate life threats requiring neurosurgical intervention unavailable in the field.
Question 7: What is the PRIMARY purpose of the SAMPLE history in prehospital TBI assessment?
- To document the scene for legal purposes
- To identify medications, allergies, and baseline conditions that affect TBI management and triage (Correct answer)
- To calculate the Revised Trauma Score
- To determine if the patient has advance directives
Correct answer: To identify medications, allergies, and baseline conditions that affect TBI management and triage
SAMPLE history reveals anticoagulants, antiplatelets, prior neurologic conditions, and allergies that directly influence TBI management and hospital destination decisions.
PHTLS Traumatic Brain Injury 5
A patient with TBI has decerebrate posturing.
Compared to decorticate posturing, this suggests injury at which level?