TCRN TCRN Head and Neck Trauma 5 — Questions and Answers
Question 1: A patient with severe TBI has an ICP of 28 mmHg despite initial interventions. Which second-tier intervention is most appropriate?
- Increasing the head of bed to 45 degrees
- Decompressive craniectomy or barbiturate coma (Correct answer)
- Administering high-dose corticosteroids
- Reducing IV fluid to restrict cerebral edema
Correct answer: Decompressive craniectomy or barbiturate coma
Second-tier interventions for refractory ICP elevation include decompressive craniectomy or barbiturate (pentobarbital) coma when first-tier measures have failed.
Question 2: Which of the following is a contraindication to nasotracheal intubation in a head trauma patient?
- Suspected cervical spine injury
- Suspected basilar skull fracture (Correct answer)
- GCS of 12
- Facial lacerations
Correct answer: Suspected basilar skull fracture
Suspected basilar skull fracture is a contraindication to nasotracheal intubation due to the risk of passing the tube through the fractured skull base into the cranial vault.
Question 3: A patient with traumatic brain injury becomes hyponatremic with elevated urine sodium and urine osmolality. Which syndrome best explains this?
- Diabetes insipidus
- Syndrome of inappropriate ADH (SIADH)
- Cerebral salt wasting (Correct answer)
- Hyperaldosteronism
Correct answer: Cerebral salt wasting
Cerebral salt wasting after TBI causes hyponatremia with high urine sodium and high urine osmolality, but is distinguished from SIADH by volume depletion rather than euvolemia.
Question 4: Which zone of the neck contains the aortic arch, innominate artery, and proximal common carotid arteries?
- Zone I (Correct answer)
- Zone II
- Zone III
- Zone IV
Correct answer: Zone I
Zone I of the neck extends from the clavicles/sternal notch to the cricoid cartilage and contains major thoracic outlet vessels including the aortic arch and innominate artery.
Question 5: A trauma patient is noted to have bilaterally fixed and dilated pupils after a fall from height. Which intervention should still be performed immediately?
- Comfort care only — fixed dilated pupils indicate brain death
- Ensure adequate oxygenation, BP support, and neurosurgical consult (Correct answer)
- Administer naloxone to reverse opioid effect
- Hyperventilate to a PaCO2 of 25 mmHg
Correct answer: Ensure adequate oxygenation, BP support, and neurosurgical consult
Bilaterally fixed dilated pupils suggest severe herniation but do not confirm brain death; immediate resuscitation and neurosurgical evaluation should not be withheld.
Question 6: An intubated TBI patient has a sudden rise in ICP from 18 to 32 mmHg with simultaneous SpO2 drop. What is the most likely cause?
- Cerebral vasospasm
- Endotracheal tube obstruction or dislodgement (Correct answer)
- Seizure activity
- Osmotic diuresis from mannitol
Correct answer: Endotracheal tube obstruction or dislodgement
Simultaneous ICP spike and SpO2 drop suggest airway compromise such as ETT obstruction or dislodgement, causing hypoxia and secondary ICP elevation.
Question 7: A patient with traumatic subarachnoid hemorrhage is at highest risk for which delayed complication between days 3 and 14 post-injury?
- Rebleeding from the aneurysm
- Cerebral vasospasm causing delayed ischemia (Correct answer)
- Hydrocephalus requiring immediate VP shunt
- Coagulopathy from massive transfusion
Correct answer: Cerebral vasospasm causing delayed ischemia
Cerebral vasospasm peaks between days 3–14 after traumatic SAH, causing delayed neurological deficits from ischemia in vessels exposed to subarachnoid blood.
TCRN TCRN Head and Neck Trauma 5
A patient with severe TBI has an ICP of 28 mmHg despite initial interventions.
Which second-tier intervention is most appropriate?