TNCC - Trauma Nurse Core Curriculum Spinal Cord and Vertebral Trauma Questions and Answers 1 — Questions and Answers
Question 1: A patient involved in a high-speed motor vehicle collision has a suspected C4-level spinal cord injury. The patient's blood pressure is 82/44 mmHg, heart rate is 54 beats/min, and their skin is warm and dry below the level of the injury. This clinical presentation is most consistent with which type of shock?
- Cardiogenic shock
- Hypovolemic shock
- Neurogenic shock (Correct answer)
- Anaphylactic shock
Correct answer: Neurogenic shock
Neurogenic shock, a form of distributive shock, is characterized by hypotension, bradycardia, and warm, dry skin. [1, 9, 13] This occurs due to the interruption of sympathetic nervous system pathways after a high-level spinal cord injury (typically at or above T6), leading to unopposed parasympathetic stimulation and widespread vasodilation. [1, 21] Hypovolemic shock would present with tachycardia and cool, clammy skin.
Question 2: A patient with a penetrating injury to the right side of their thoracic spine presents with paralysis and loss of proprioception on the right side, and loss of pain and temperature sensation on the left side below the injury. These findings are characteristic of which spinal cord syndrome?
- Anterior Cord Syndrome
- Central Cord Syndrome
- Cauda Equina Syndrome
- Brown-Séquard Syndrome (Correct answer)
Correct answer: Brown-Séquard Syndrome
Brown-Séquard syndrome results from a hemisection (damage to one half) of the spinal cord. [2, 3] This causes ipsilateral (same side) loss of motor function and proprioception/vibration sense, and contralateral (opposite side) loss of pain and temperature sensation below the level of the lesion. [3, 4, 5]
Question 3: Which of the following clinical findings in an alert, non-intoxicated adult patient with blunt trauma is a primary indication for maintaining spinal motion restriction?
- A large hematoma on the scalp
- Midline cervical spine tenderness upon palpation (Correct answer)
- A closed fracture of the clavicle
- Reported pain score of 8/10 from an extremity injury
Correct answer: Midline cervical spine tenderness upon palpation
According to established clinical decision rules like the NEXUS criteria, the presence of midline spinal tenderness is a key indicator of a potential vertebral column injury that necessitates spinal motion restriction until the spine can be radiologically cleared. [12, 14, 18] A distracting injury (severe pain elsewhere) is also an indication, but midline tenderness itself is a direct sign of potential spinal injury.
Question 4: A patient with a known T5 spinal cord injury presents to the ED with a pounding headache, profuse sweating above the T5 level, flushed skin, a blood pressure of 200/105 mmHg, and a heart rate of 48 beats/min. Which of the following is the priority nursing action?
- Administer an IV beta-blocker immediately.
- Place the patient in a flat, supine position.
- Assess for a noxious stimulus, such as a kinked urinary catheter. (Correct answer)
- Prepare for emergent endotracheal intubation.
Correct answer: Assess for a noxious stimulus, such as a kinked urinary catheter.
This patient is exhibiting classic signs of autonomic dysreflexia, a medical emergency triggered by a noxious stimulus below the level of injury in patients with SCI at T6 or above. [27, 28] The priority is to sit the patient upright and immediately identify and remove the stimulus. [28, 29] The most common cause is bladder distention from a blocked catheter. [24, 27] Removing the cause will usually resolve the hypertension.
Question 5: Which statement best differentiates spinal shock from neurogenic shock in the context of acute spinal cord injury?
- Spinal shock is a hemodynamic state of hypotension and bradycardia, while neurogenic shock involves a loss of reflexes.
- Spinal shock is permanent, whereas neurogenic shock is always transient and resolves within hours.
- Spinal shock is a temporary loss of all reflex and motor activity below the injury level, while neurogenic shock is a circulatory collapse due to loss of sympathetic tone. (Correct answer)
- Neurogenic shock is characterized by flaccid paralysis, while spinal shock results in spasticity.
Correct answer: Spinal shock is a temporary loss of all reflex and motor activity below the injury level, while neurogenic shock is a circulatory collapse due to loss of sympathetic tone.
Spinal shock is a neurologic phenomenon characterized by the temporary loss or depression of all spinal reflexes below the level of injury, resulting in flaccid paralysis. [21, 26] Neurogenic shock is a hemodynamic (circulatory) phenomenon resulting from the loss of sympathetic nervous system tone, which leads to hypotension and bradycardia. [1, 20, 21] A patient can experience both simultaneously. [26]
Question 6: During the primary survey (ABCDE) of a trauma patient who was a driver in a head-on collision and is complaining of neck pain and an inability to move their legs, what is the most critical assessment component under 'D' for Disability?
- Obtaining a detailed history of the event from paramedics.
- Performing a Glasgow Coma Scale (GCS) score, assessing pupils, and determining a gross motor and sensory level. (Correct answer)
- Checking for a positive Babinski reflex.
- Removing the cervical collar to assess for tracheal deviation.
Correct answer: Performing a Glasgow Coma Scale (GCS) score, assessing pupils, and determining a gross motor and sensory level.
In a trauma patient with a suspected spinal cord injury, the 'D' (Disability) portion of the primary survey goes beyond just GCS and pupils. [19] It must include a rapid, gross assessment of motor function (e.g., can you move your hands/feet?) and sensory level (e.g., where can you feel me touching you?) to establish a baseline neurologic deficit early in the resuscitation. [7, 23]
TNCC - Trauma Nurse Core Curriculum Spinal Cord and Vertebral Trauma Questions and Answers 1
A patient involved in a high-speed motor vehicle collision has a suspected C4-level spinal cord injury.
The patient's blood pressure is 82/44 mmHg, heart rate is 54 beats/min, and their skin is warm and dry below the level of the injury.
This clinical presentation is most consistent with which type of shock?