Head, Spine, and Neurotrauma - NREMT Paramedic Level

1. What is the key airway contraindication in suspected basilar skull fracture?

   Avoid nasopharyngeal airway (and nasal intubation). Nasal routes risk intracranial penetration through cribriform plate fractures in basilar skull injuries.

2. What is the classic Cushing triad associated with increased intracranial pressure?

   Hypertension, bradycardia, irregular respirations. These vital sign changes result from brainstem compression and compensatory responses to elevated intracranial pressure.

3. What is the most appropriate prehospital head position for suspected increased ICP when not hypotensive?

   Head-of-bed elevation about $30^{\circ}$ with neutral alignment. This positioning facilitates cerebral venous drainage, reducing intracranial pressure without compromising spinal alignment.

4. What motor posturing pattern indicates severe cerebral injury but better prognosis than decerebrate?

   Decorticate posturing (flexor). Flexor posturing indicates cortical or subcortical damage above the brainstem, often allowing better functional recovery.

5. What is the immediate management for an open skull fracture with visible brain tissue?

   Cover with moist sterile dressing; do not apply pressure. Moist dressings prevent desiccation of exposed tissue, while avoiding pressure minimizes further herniation or contamination.

6. Which clinical finding most strongly suggests cerebrospinal fluid leakage after head trauma?

   Clear otorrhea or rhinorrhea consistent with CSF leak. Clear fluid drainage from ears or nose post-trauma indicates dural tear allowing CSF escape, confirmed by beta-2 transferrin testing.

7. What Glasgow Coma Scale (GCS) score range defines severe traumatic brain injury?

   GCS $\leq 8$. Severe TBI is classified by GCS scores indicating profound neurological impairment requiring immediate intervention.

8. Which spinal cord syndrome causes ipsilateral motor loss with contralateral pain and temperature loss?

   Brown-Séquard syndrome (hemisection). Hemisection interrupts ipsilateral corticospinal and dorsal column tracts while sparing contralateral spinothalamic tracts.

9. What is spinal shock in the context of acute spinal cord injury?

   Transient loss of reflexes and flaccid paralysis below injury. Spinal shock involves temporary areflexia and paralysis due to disrupted descending neural pathways immediately after injury.

10. What is the preferred initial method of spinal motion restriction for suspected cervical injury?

    Manual in-line stabilization (MILS). MILS minimizes cervical spine movement during airway management to prevent exacerbation of potential unstable injuries.

11. What hemodynamic pattern best differentiates neurogenic shock from hemorrhagic shock?

    Neurogenic: hypotension with bradycardia and warm skin. Neurogenic shock from sympathetic disruption causes vasodilation and bradycardia, unlike tachycardia and vasoconstriction in hypovolemic states.

12. Which complication should you anticipate when a patient with high spinal cord injury is ventilated?

    Neurogenic shock with hypotension and bradycardia. High cervical lesions disrupt sympathetic innervation, leading to unopposed parasympathetic effects during positive pressure ventilation.

13. Which intracranial bleed is most associated with bridging vein rupture in older adults?

    Subdural hematoma. Venous bleeding from torn bridging veins accumulates slowly, with higher incidence in elderly due to brain atrophy and anticoagulation.

14. Identify the correct intervention when seizure activity occurs after head trauma in the field.

    Administer benzodiazepine per protocol and protect airway. Benzodiazepines terminate seizures to prevent increased metabolic demand and ICP elevation, with airway protection against aspiration.

15. Which end-tidal CO$_2$ (EtCO$_2$) range is appropriate for most ventilated TBI patients?

    EtCO$_2$ $35$ to $45\ \text{mmHg}$. Normocapnia prevents vasoconstriction or vasodilation that could alter cerebral blood flow and intracranial pressure.

16. What motor posturing pattern indicates brainstem involvement and worse prognosis in TBI?

    Decerebrate posturing (extensor). Extensor posturing reflects dysfunction at the midbrain or pons level, correlating with poorer recovery outcomes.

17. Which medication class is appropriate for chemical restraint in agitated suspected TBI when needed for safety?

    Sedative per protocol (for example, ketamine or benzodiazepine). Sedation controls agitation that could raise intracranial pressure, ensuring patient and provider safety during transport.

18. What oxygenation goal should you maintain in suspected TBI to prevent secondary injury?

    Maintain SpO$_2$ $\geq 94\%$ (avoid hypoxia). Hypoxia worsens cerebral ischemia, so targeting this level ensures sufficient oxygen delivery to injured brain tissue.

19. What is the primary goal in prehospital management of traumatic brain injury (TBI)?

    Prevent secondary brain injury (avoid hypoxia and hypotension). Secondary injuries exacerbate primary brain damage, so prehospital care prioritizes oxygenation and blood pressure maintenance to optimize cerebral perfusion.

20. Which EtCO$_2$ target is used for temporary hyperventilation in impending herniation?

    EtCO$_2$ $30$ to $35\ \text{mmHg}$ (short-term only). Temporary hypocapnia induces cerebral vasoconstriction to reduce intracranial pressure during acute herniation signs.

21. Which pupil finding is most consistent with uncal herniation in severe head injury?

    Unilateral fixed, dilated pupil. This finding reflects oculomotor nerve compression from temporal lobe herniation through the tentorial notch.

22. Which spinal cord syndrome is most associated with hyperextension injury in older adults?

    Central cord syndrome. Hyperextension damages central cervical tracts, disproportionately affecting upper extremities in patients with spondylosis.

23. What is the minimum systolic blood pressure target to reduce mortality in adult TBI?

    SBP $\geq 110\ \text{mmHg}$. Maintaining adequate cerebral perfusion pressure reduces secondary ischemic injury and improves outcomes in TBI patients.

24. Which skull fracture sign indicates a basilar skull fracture: Battle sign or raccoon eyes?

    Both are signs of basilar skull fracture. Battle sign (postauricular ecchymosis) and raccoon eyes (periorbital ecchymosis) both signify fractures involving the skull base.

25. Which intracranial bleed is classically associated with a lucid interval after head trauma?

    Epidural hematoma. Arterial bleeding from middle meningeal artery rupture causes rapid hematoma expansion after initial symptom resolution.

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