TBI Flashcards
Complications of TBI
herniation, hemorrhage, infection, post-concussive issues
Complications of TBI
(ABCs, herniation)
What will kill your patient?
(seizures, infections, suboptimal management)
What will harm your patient?
(mild TBI/concussions, long-term sequelae)
What is really common?
TBI Pathophysiolohy
A 25-year-old patient suffers a blunt head trauma in a motor vehicle accident. The direct mechanical force to the skull is described as the primary injury in TBI. Which of the following is most characteristic of a secondary TBI injury?
A. Immediate skull fracture from impact
B. Penetration of the dura by a knife
C. Ischemia and inflammation evolving hours to days after injury
D. Bullet trajectory causing a large cavitation track
C. Ischemia and inflammation evolving hours to days after injury
A 19-year-old with a severe TBI from a fall develops rising intracranial pressure (ICP) 6 hours after admission. Which explanation best fits the cause of this secondary brain injury?
A. Penetrating objects lacerating the frontal lobe
B. Initial linear skull fracture at the time of impact
C. Progressive cerebral edema and inflammatory cascades
D. Immediate disruption of the blood-brain barrier on impact
C. Progressive cerebral edema and inflammatory cascades
Which of the following best characterizes blunt trauma TBI from a high-speed motor vehicle collision?
A. Acceleration-deceleration forces with potential coup-contrecoup injuries
B. Piercing injuries that require bullet extraction
C. Shockwave injuries similar to blast trauma
D. Low risk for cerebral edema or hemorrhage
A. Acceleration-deceleration forces with potential coup-contrecoup injuries
A 72-year-old who fell at home and hit her head is hospitalized with a TBI. Statistically, falls are the most common mechanism of TBI in:
A. Infants under 1 year
B. Young adults in their 20s
C. Older adults (65+)
D. Teenagers
C. Older adults (65+)
A TBI patient with repeated blows to the head (e.g., contact sports) is at increased long-term risk for:
A. Immediate hearing loss
B. Chronic Traumatic Encephalopathy (CTE)
C. Life-threatening anaphylaxis
D. Rapid regeneration of neuronal tissue
B. Chronic Traumatic Encephalopathy (CTE)
A 50-year-old TBI patient survived a severe head injury several years ago and now presents with progressive cognitive decline consistent with early dementia. Which mechanism best explains this delayed manifestation?
A. Ongoing primary injury from prior skull fractures
B. Axonal degeneration and chronic neuroinflammation leading to secondary injury over time
C. Genetic mutation unrelated to TBI
D. Immediate effect of hemorrhage that started years ago
Diagnostic Reasoning
A 30-year-old patient with head trauma arrives in the ER. The patient opens eyes to voice, is confused but can speak, and withdraws from pain. Their Glasgow Coma Scale (GCS) score indicates which category of TBI?
* Eye opening to voice: E3
* Verbal response: Confused (V4)
* Motor response: Withdrawal from pain (M4)
A. Minor TBI (GCS 13–15)
B. Moderate TBI (GCS 9–12)
C. Severe TBI (GCS 3–8)
D. Unable to determine from the given data
B. Moderate TBI (GCS 9–12)
A patient with a suspected TBI has a GCS of 7. He is breathing spontaneously but with irregular respirations. What is the best next step in management to protect his airway?
A. Perform a jaw-thrust maneuver only
B. Place the patient on nasal cannula at 2 L/min
C. Intubate promptly (GCS <8 → intubate)
D. Wait until GCS drops below 5
C. Intubate promptly (GCS <8 → intubate)
A 29-year-old patient with a mild TBI (GCS 14) is complaining of persistent headaches and dizziness. Which imaging modality is most sensitive if microhemorrhages or diffuse axonal injury are suspected?
A. Noncontrast head CT
B. MRI of the brain
C. Carotid ultrasound
D. X-ray of the skull
B. MRI of the brain
On a noncontrast CT scan, a lenticular (biconvex) hyperdense collection between the skull and dura mater suggests:
A. Epidural hematoma
B. Subdural hematoma
C. Subarachnoid hemorrhage
D. Diffuse axonal injury
A. Epidural hematoma
A crescent-shaped hemorrhage conforming to the brain’s surface on CT is typical of:
A. Contusion
B. Epidural hematoma
C. Subdural hematoma
D. Intraventricular hemorrhage
C. Subdural hematoma
A 60-year-old patient arrives with confusion after a fall. The CT scan shows a small subdural hematoma that has likely accumulated over days. This presentation is common in older adults because:
A. They rarely have bridging vein tears
B. Venous bleeds can accumulate slowly, and cerebral atrophy increases vulnerability
C. They have fewer skull fractures
D. Their brain tissue is hyperdense, preventing hematoma expansion
B. Venous bleeds can accumulate slowly, and cerebral atrophy increases vulnerability
Which acute imaging finding is best identified on a noncontrast head CT in the emergency setting of TBI?
A. Diffusion-restricted ischemic stroke
B. Chronic contusions
C. Acute hemorrhages, skull fractures
D. Microscopic axonal shearing
C. Acute hemorrhages, skull fractures
A 22-year-old with suspected diffuse axonal injury has a normal CT scan but continues to have severe neurologic deficits. What is the most appropriate next diagnostic step?
A. MRI of the brain
B. Cerebral angiography
C. PET scan
D. Lumbar puncture
A. MRI of the brain
Management Immediate Priorities (ABCs & ICP)
A 40-year-old with severe TBI is admitted. What is the first priority in managing this patient?
A. Secure the airway and stabilize cervical spine
B. Perform immediate suboccipital decompression
C. Administer mannitol IV
D. Obtain an MRI
A. Secure the airway and stabilize cervical spine
A TBI patient with GCS 6 is intubated. ICP is 22 mmHg, CPP is 60 mmHg. Which positioning intervention best helps reduce ICP?
A. Keep the head of the bed at 0°
B. Elevate the head of the bed to 30° with neutral neck alignment
C. Hyperflex the patient’s neck to optimize venous outflow
D. Place the patient in Trendelenburg
B. Elevate the head of the bed to 30° with neutral neck alignment
Nonpharmacologic Interventions
Why are corticosteroids typically avoided in TBI management, even with signs of cerebral edema?
A. They worsen inflammation specifically in TBI
B. They have no proven mortality benefit and may increase complications in TBI
C. They only help if used with osmotic diuretics
D. They cause subdural hematomas
B. They have no proven mortality benefit and may increase complications in TBI
A 35-year-old with severe TBI is receiving mechanical ventilation. The nurse asks if hyperventilation should be continued to maintain PaCO₂ <25 mmHg long-term. According to best practices, the correct response is:
A. Prolonged hyperventilation is recommended to keep ICP as low as possible
B. Short-term hyperventilation is used only for acute herniation signs, not as a prolonged strategy
C. There is no benefit in lowering PaCO₂ in TBI
D. Maintaining PaCO₂ >60 mmHg is the gold standard
B. Short-term hyperventilation is used only for acute herniation signs, not as a prolonged strateg
In TBI, seizure prophylaxis (e.g., with levetiracetam or phenytoin) is often used to:
A. Lower the metabolic demand and prevent secondary brain injury
B. Reverse existing post-traumatic epilepsy
C. Reduce risk of GI bleeding
D. Increase systolic blood pressure
A. Lower the metabolic demand and prevent secondary brain injury
Early enteral nutrition in TBI patients is important primarily to:
A. Enhance renal clearance of mannitol
B. Boost serum sodium levels
C. Support metabolic demands and improve outcomes
D. Prevent hyperglycemia
C. Support metabolic demands and improve outcomes
Pharmacologic Interventions for ICP Control
A 60-year-old TBI patient’s ICP climbs to 28 mmHg. The team administers an IV bolus of mannitol (0.5 g/kg). Which key parameter should be closely monitored to avoid complications?
A. Serum osmolarity <320 mOsm/L
B. Blood ammonia levels
C. Serum troponin
D. Urine ketones
A. Serum osmolarity <320 mOsm/L
Which osmotherapy strategy might be used if mannitol alone is insufficient to control ICP in severe TBI?
A. Hypertonic saline (3% or 23.4%)
B. High-dose steroids in TBI
C. Low-dose heparin
D. Ringer’s lactate
A. Hypertonic saline (3% or 23.4%)
Which of the following is a common indication for pentobarbital coma in TBI management?
A. Any mild TBI with confusion
B. Refractory high ICP (>25–30 mmHg) not responding to standard measures
C. Every TBI patient who has a seizure
D. Patients with GCS of 15
B. Refractory high ICP (>25–30 mmHg) not responding to standard measures
Complications
What Will Kill Your Patient (ABCs)?
A 37-year-old with severe TBI (GCS 5) suddenly shows pupil asymmetry, bradycardia, and irregular respirations. BP spikes, creating a wide pulse pressure. Which lethal complication is most likely imminent?
A. Seizure activity
B. Brain herniation (Cushing’s Triad)
C. Myocardial infarction
D. Diffuse axonal injury
B. Brain herniation (Cushing’s Triad
What Will Harm Your Patient?
Despite initial management, a TBI patient develops a chronic subdural hematoma weeks later. Which patient population is at highest risk for this complication?
A. Adolescent athletes
B. Middle-aged individuals with no comorbidities
C. Elderly patients with cerebral atrophy
D. Children under age 5
C. Elderly patients with cerebral atrophy
A patient with a basilar skull fracture is at particular risk for:
A. Excess CSF production
B. CSF leak and meningitis
C. Immediate intraventricular hemorrhage
D. Hemorrhoids
B. CSF leak and meningitis
What Is Really Common?
A 22-year-old collegiate athlete suffers a concussion (mild TBI). He complains of headache, dizziness, and difficulty concentrating for several weeks. This constellation of lingering symptoms after mild TBI is known as:
A. Post-concussive syndrome
B. Subdural hematoma
C. Hydrocephalus
D. Immediate herniation
A. Post-concussive syndrome
A 54-year-old with severe TBI has been stabilized but now requires long-term rehabilitation. What is a common chronic consequence of TBI?
A. Immediate full recovery within days
B. Persistent cognitive deficits, depression, and memory issues
C. Zero risk for future seizures
D. Lower risk for dementia
B. Persistent cognitive deficits, depression, and memory issues
Which TBI subtype is most common and often underreported, yet can have significant sequelae?
A. Epidural hematoma
B. Severe TBI (GCS <8)
C. Mild TBI/Concussion
D. Subarachnoid hemorrhage
C. Mild TBI/Concussion
herniation, severe hemorrhage
- What will kill your patient?
(chronic hematomas, infections)
- What will harm your patient?
(mild TBI, post-concussive syndrome, cognitive sequelae)
- What is really common?
Primary vs. Secondary Injury
A 28-year-old sustains a significant head injury in a car accident. The initial skull fracture and direct brain contusion from the impact are considered part of the:
A. Secondary brain injury
B. Tertiary brain injury
C. Primary brain injury
D. Delayed brain injury
C. Primary brain injury
Twelve hours after a severe TBI, a patient’s ICP begins to rise due to cerebral edema and inflammatory processes. This phenomenon best illustrates:
A. Primary mechanical trauma
B. Blast injury
C. Secondary brain injury
D. Normal post-injury recovery
C. Secondary brain injury
A 37-year-old was involved in a high-speed motor vehicle accident and is suspected to have had acceleration-deceleration forces applied to the brain. This pattern of injury is most typical of:
A. Penetrating trauma
B. Blunt trauma
C. Blast trauma
D. Non-accidental poisoning
B. Blunt trauma
A soldier exposed to explosive devices in a conflict zone displays symptoms consistent with traumatic brain injury despite no visible skull fracture. The primary mechanism of injury is most likely:
A. Blast injury
B. Penetrating trauma
C. Ischemic stroke
D. Degenerative disease
A. Blast injury
A patient sustains a TBI after being stabbed in the temporal region. This injury is classified as:
A. Blast injury
B. Penetrating trauma
C. Blunt trauma
D. Secondary brain injury
B. Penetrating trauma
In younger populations, such as adolescents and young adults, the most common cause of TBI is:
A. Falls
B. Motor vehicle accidents
C. Stroke
D. Sports injuries
Sports injuries significant but MVAs leading cause in many younger pop
B. Motor vehicle accidents
Question 9 (Scenario-Based)
A 45-year-old patient who sustained multiple concussions during early adulthood now shows cognitive decline and behavioral changes. The patient’s neurologist discusses the association with chronic traumatic encephalopathy (CTE). Which of the following individuals is at highest risk for this condition?
A. A long-term soccer player who never had head impacts
B. A professional boxer or football player with repeated head trauma
C. An older adult with a single minor fall
D. A person who suffered a penetrating injury once
B — Individuals with repeated head trauma (e.g., boxers, football players)
Research suggests that, following TBI, there is a 63–96% increased risk of:
A. Immediate mortality
B. Hearing loss
C. Dementia
D. Type 2 diabetes
C. Dementia
Primary vs. Secondary Injury
A 25-year-old falls from a ladder, striking his head. Immediately after impact, he exhibits loss of consciousness and a frontal skull fracture. Several hours later, he begins to show signs of rising intracranial pressure (ICP). Which process underlies these later changes?
A. Continuation of primary mechanical damage
B. Secondary injury due to edema and inflammatory mediators
C. Immediate hemorrhagic stroke unrelated to TBI
D. Resolved brain insult with no further injury expected
B. Secondary injury due to edema and inflammatory mediators
Which of the following most accurately distinguishes secondary TBI from primary TBI?
A. Secondary TBI refers to initial direct trauma to the skull and brain
B. Secondary TBI involves delayed damage from ischemia, edema, or inflammation
C. Primary TBI occurs after hospital admission
D. Secondary TBI occurs only with penetrating head wounds
B. Secondary TBI involves delayed damage from ischemia, edema, or inflammation
Mechanisms of Injury
A 30-year-old patient sustains a penetrating head injury when struck by a projectile during a robbery. In terms of mechanism, which statement best applies?
A. This is a classic acceleration-deceleration blunt trauma
B. This mechanism usually spares cortical tissue
C. Penetration of the skull directly injures brain structures
D. All penetrating injuries have a better prognosis than blunt injuries
C. Penetration of the skull directly injures brain structures
A 45-year-old suffers a head trauma in a building explosion. Though he has no visible external injuries, imaging reveals diffuse cerebral contusions. This scenario exemplifies a:
A. Blunt trauma from a motor vehicle collision
B. Penetrating trauma from a sharp object
C. Blast injury leading to complex TBI patterns
D. Degenerative brain disease
C. Blast injury leading to complex TBI patterns
A 70-year-old presents with a subacute TBI after a minor fall at home. Imaging confirms a small subdural hematoma. Considering epidemiologic trends, which explanation is most consistent with this scenario?
A. Older adults frequently develop TBI from falls, which can lead to slow venous bleeds
B. Older adults rarely sustain TBIs from falling
C. Motor vehicle collisions remain the leading cause in all age groups
D. Subdural hematomas are exclusive to young athletes
A. Older adults frequently develop TBI from falls, which can lead to slow venous bleeds
Chronic exposure to repeated head injuries (e.g., multiple concussions in football) is strongly linked to which degenerative condition?
A. Amyotrophic lateral sclerosis (ALS)
B. Chronic traumatic encephalopathy (CTE)
C. Multiple sclerosis
D. Rheumatoid arthritis
B. Chronic traumatic encephalopathy (CTE)
A 60-year-old patient with a history of two severe head injuries in early adulthood is experiencing progressive memory loss and executive dysfunction. The risk of dementia after TBI is:
A. Unchanged compared to the general population
B. Moderately to significantly increased (63–96% higher risk)
C. Negligible if TBI was more than 10 years ago
D. Only relevant if there were more than five TBIs
B. Moderately to significantly increased (63–96% higher risk)
Parkinsonian features (e.g., tremor, rigidity) can develop years after TBI. This is thought to result from:
A. Immediate contusions in the prefrontal cortex
B. Chronic degeneration of dopaminergic pathways and post-traumatic inflammation
C. Complete regeneration of neural pathways
D. TBI has no association with Parkinson-like syndromes
B. Chronic degeneration of dopaminergic pathways and post-traumatic inflammation
A 58-year-old who suffered a severe TBI from a high-speed MVA two decades ago now presents with motor symptoms reminiscent of Parkinson’s disease, along with cognitive impairment. This clinical picture aligns with the idea that TBI can:
A. Eliminate the risk of any neurodegenerative disease
B. Lead to chronic neuroinflammation contributing to various long-term deficits
C. Prevent further neuronal death after the first year
D. Cause immediate lethal outcomes only, without delayed effects
B. Lead to chronic neuroinflammation contributing to various long-term deficits
clinica presentation
A 22-year-old motorcyclist is brought to the emergency department after an accident. He exhibits slurred speech, weakness in his right arm, and disorientation to time and place. Which category best describes these findings?
A. Altered level of consciousness with post-traumatic amnesia
B. Neurological deficits consistent with TBI
C. Non-neurological illness (e.g., hepatic encephalopathy)
D. Purely psychological stress response
- B – Neurological deficits (speech difficulty, weakness, disorientation)
A TBI patient complains of anterograde amnesia, where he cannot form new memories post-injury. This symptom aligns with which typical clinical presentation of TBI?
A. Simple confusion with no memory involvement
B. Post-traumatic amnesia
C. Depression from chronic illness
D. Delirium tremens
- B – Post-traumatic amnesia
A 30-year-old patient arrives after a head injury. He opens his eyes only to painful stimuli, speaks incomprehensibly, and withdraws from pain. Based on GCS scoring:
* Eye Opening = E2 (to pain)
* Verbal Response = V2 (incomprehensible sounds)
* Motor Response = M4 (withdraws from pain)
What is his total GCS score, and which severity category does it indicate?
A. GCS 8 → Severe TBI
B. GCS 8 → Moderate TBI
C. GCS 7 → Severe TBI
D. GCS 7 → Moderate TBI
- A – GCS 8 (E2 + V2 + M4 = 8) → Severe TBI
Which Glasgow Coma Scale range corresponds to moderate TBI?
A. GCS 13–15
B. GCS 9–12
C. GCS 3–8
D. GCS 4–9
- B – GCS 9–12 indicates moderate TBI
A patient with a GCS of 8 or less typically requires:
A. Immediate MRI for follow-up
B. Long-term EEG monitoring only
C. Intubation to protect the airway
D. No special interventions unless pupillary changes occur
- C – Intubation is recommended if GCS ≤8
A 65-year-old who fell at home has confusion and a history of chronic anticoagulant use. A non-contrast head CT is performed first. Why is this the initial imaging of choice for potential TBI?
A. It is more sensitive than MRI for microhemorrhages
B. It quickly identifies fractures and acute hemorrhages
C. It eliminates the need for cervical spine evaluation
D. It is the only test that can detect diffuse axonal injury
B. It quickly identifies fractures and acute hemorrhages
A 40-year-old patient has a mild TBI with persistent headaches and dizziness for several weeks, but initial CT was normal. Which imaging study is often more sensitive in detecting subtle injuries (e.g., diffuse axonal injury) at this stage?
A. Repeat non-contrast CT
B. MRI of the brain
C. Carotid Doppler ultrasound
D. X-ray of the skull
- B – MRI is more sensitive, especially for diffuse axonal injury
A patient’s head CT reveals a lenticular (biconvex), hyperdense bleed between the skull and the dura. This classic finding indicates:
A. Subdural hematoma
B. Epidural hematoma
C. Cerebral contusion
D. Intracerebral hemorrhage
- B – Epidural hematoma (lenticular/biconvex)
A 72-year-old presents with a crescent-shaped collection of blood on a head CT, conforming to the surface of the brain. This is typical of:
A. Skull fracture with CSF leak
B. Epidural hematoma
C. Subdural hematoma
D. Diffuse axonal injury
Subdural hematoma (crescent-shaped)
A 23-year-old with a severe TBI has a normal CT scan. Due to persistent coma and suspected diffuse axonal injury, an MRI is performed and shows multiple small microhemorrhages. This is consistent with:
A. Skull fracture
B. Contusion
C. Diffuse axonal injury
D. Epidural hematoma
- C – Diffuse axonal injury (microhemorrhages on MRI)
A 19-year-old college athlete is brought in after a head collision during a football game. He reports headache, dizziness, confusion, and doesn’t recall the events just before the impact. Which term best describes this lack of memory for events preceding the injury?
A. Anterograde amnesia
B. Retrograde amnesia
C. Post-traumatic dementia
D. Transient global amnesia
- B – Retrograde amnesia (loss of memory for events preceding the injury)
A 40-year-old patient arrives with a head injury. On exam, they open their eyes spontaneously, are oriented and conversant, and show localized withdrawal to a painful stimulus. What is their total GCS and TBI classification?
* Eye Opening: E4 (spontaneous)
* Verbal Response: V5 (oriented)
* Motor Response: M5 (localizes to pain)
A. GCS 14 → Mild TBI
B. GCS 14 → Moderate TBI
C. GCS 15 → Mild TBI
D. GCS 15 → Moderate TBI
Recall: E4 + V5 + M5 = 14. The mild TBI range is 13–15
- A – GCS 14 → Mild TBI (13–15 range)
A 32-year-old patient presents with mild TBI (GCS 14). The initial non-contrast CT is normal, but the patient has persistent headaches and blurred vision for 3 weeks. Which imaging study is most appropriate to detect subtle brain injuries (e.g., diffuse axonal injury)?
A. Repeat non-contrast CT
B. MRI of the brain
C. Carotid duplex ultrasound
D. Positron emission tomography (PET)
- B – MRI of the brain (more sensitive for subtle injuries)
A head CT of a trauma patient shows a rounded, biconvex hyperdensity that does not cross suture lines. This finding is classic for:
A. Subdural hematoma
B. Epidural hematoma
C. Subarachnoid hemorrhage
D. Diffuse axonal injury
- B – Epidural hematoma (biconvex, does not cross suture lines)
A 27-year-old motor vehicle accident victim arrives with confusion, slurred speech, and inability to recall the crash. GCS is 10 (E3, V3, M4). A non-contrast head CT reveals a crescent-shaped bleed along the convexity of the brain. Based on these findings, which statement is most accurate?
A. The patient has a severe TBI and an epidural hematoma.
B. The patient has a moderate TBI and a subdural hematoma.
C. The patient has a mild TBI and diffuse axonal injury.
D. The patient has a normal neurological exam and no hematoma.
- B – Moderate TBI (GCS 9–12) and subdural hematoma (crescent-shaped bleed)
Immediate Priorities (ABCs)
A 32-year-old crash victim arrives with a GCS of 7 and obvious head trauma. His breathing is labored, and cervical spine precautions are in place. According to the study guide, which initial management step is critical to avoid “what will kill your patient”?
A. Obtain an MRI to assess for axonal injury
B. Perform endotracheal intubation (since GCS <8) while maintaining cervical spine alignment
C. Administer high-dose corticosteroids to limit secondary injury
D. Check serum sodium and only intubate if sodium is abnormal
B. Perform endotracheal intubation (since GCS <8) while maintaining cervical spine alignment
A 45-year-old with severe TBI is hypotensive (BP 88/50 mmHg) after major trauma. Which best summarizes why hypotension is particularly dangerous in TBI management?
A. It directly causes vasogenic edema
B. It reduces cerebral perfusion, contributing to secondary injury
C. It causes an immediate risk of hypercapnia
D. It guarantees normal ICP if the patient is lying flat
- B – Hypotension lowers cerebral perfusion → secondary injury
A 60-year-old TBI patient’s ICP is 22 mmHg and CPP is 55 mmHg. The team elevates the head of the bed to 30° in neutral alignment. After 30 minutes, ICP drops to 16 mmHg, and CPP rises to 60 mmHg. Which principle of ICP management does this scenario best illustrate?
A. Bed positioning does not affect ICP
B. Elevating the HOB helps venous drainage, improving CPP
C. Flat positioning is usually preferred
D. ICP cannot change within minutes
- B – Elevating HOB facilitates venous drainage, optimizing ICP and CPP
Which finding in an intubated TBI patient might prompt brief hyperventilation as a rescue measure?
A. Persistent ICP of 15–18 mmHg
B. Evidence of acute herniation with ICP >25 mmHg
C. GCS improving to 13
D. Sodium levels over 150 mEq/L
- B – Brief hyperventilation is a rescue measure for acute herniation/high ICP
Question 5
According to guidelines, corticosteroids in TBI are:
A. Recommended in all TBI to reduce cytotoxic edema
B. Used only when vasogenic edema is suspected from a brain tumor
C. Used to manage moderate TBI for 7 days
D. Contraindicated due to lack of proven benefit and potential harm
- D – Steroids are contraindicated in TBI
A 50-year-old with a moderate TBI is started on levetiracetam for 7 days. The nurse asks why this is necessary since the patient has not had a seizure. Which answer best aligns with the study guide?
A. Levetiracetam is primarily for sedation
B. Short-term seizure prophylaxis prevents additional metabolic spikes that can harm the injured brain
C. Prophylaxis only helps if the patient had known epilepsy
D. It helps reduce serum glucose
B. Short-term seizure prophylaxis prevents additional metabolic spikes that can harm the injured brain
A patient’s ICP remains at 28 mmHg despite optimal head positioning and sedation. Which osmotherapy choice is first-line to pull fluid out of the brain tissue?
A. Intravenous furosemide drip
B. Mannitol (0.25–1 g/kg IV bolus) or 3% hypertonic saline
C. High-dose steroids in TBI
D. Intravenous albumin
B. Mannitol (0.25–1 g/kg IV bolus) or 3% hypertonic saline
complications
A TBI patient develops Cushing’s Triad (hypertension with widened pulse pressure, bradycardia, irregular respirations). This indicates:
A. Imminent spinal cord injury
B. Low ICP with normal perfusion
C. Impending herniation—a life-threatening emergency
D. Mild TBI with no urgent concerns
C. Impending herniation—a life-threatening emergency
A 40-year-old TBI patient with refractory ICP >25 mmHg receives a bolus of 23.4% sodium chloride. What is the primary goal of this intervention?
A. Drain CSF directly
B. Create an osmotic shift to rapidly reduce ICP
C. Increase sedation depth
D. Induce a mild hypercapnic state
- B – High-concentration saline shifts fluid out of brain tissue to reduce ICP
A 56-year-old TBI patient has persistently elevated ICP (>30 mmHg) despite mannitol, hypertonic saline, and sedation. The neurosurgeon considers a decompressive craniectomy. Which explanation best justifies this procedure?
A. It’s for cosmetic reasons post-injury
B. It cures TBI completely by removing brain tissue
C. Temporarily removing part of the skull accommodates swelling and can reduce ICP
D. It’s standard to do craniectomies for all TBI patients
C. Temporarily removing part of the skull accommodates swelling and can reduce ICP
rationale: Decompressive craniectomy helps relieve pressure by providing space for swelling
what will kill the patient
(e.g., herniation),
what can harm them
(untreated elevated ICP, infections, seizures)
what is common
(concussion, partial efficacy of sedation/positioning) in TBI management.
A patient with moderate TBI is receiving IV fluids for hypotension. Which statement best explains why maintaining adequate blood pressure is critical in TBI management?
A. It elevates PaCO₂, improving cerebral blood flow
B. It promotes vasoconstriction in cerebral arteries
C. It ensures cerebral perfusion pressure (CPP) remains ≥60 mmHg to prevent secondary injury
D. It guarantees normal intracranial pressure (ICP)
C. It ensures cerebral perfusion pressure (CPP) remains ≥60 mmHg to prevent secondary injury
A 25-year-old with a GCS of 6 is brought in by ambulance after a high-speed car accident. The cervical spine is immobilized, and he’s breathing erratically. Which immediate intervention is paramount to prevent fatal deterioration?
A. Obtain an MRI to look for diffuse axonal injury
B. Intubate with in-line cervical stabilization and ensure adequate ventilation
C. Administer mannitol to reduce ICP
D. Send labs to check for serum osmolarity
B. Intubate with in-line cervical
A 40-year-old with severe TBI has a temperature of 39.0°C (102.2°F). The nurse suggests giving antipyretics and using a cooling blanket. Why is prompt fever control so important?
A. Hyperthermia increases metabolic demand, potentially worsening ICP
B. Fever is harmless in TBI
C. High temperature guarantees better oxygen delivery to the brain
D. Fever is only relevant for infection, not TBI
A. Hyperthermia increases metabolic demand, potentially worsening ICP
Which nonpharmacologic measure is recommended to prevent secondary injury in moderate/severe TBI?
A. Prolonged bedrest without any nutrition
B. Early enteral feeding to support metabolic demands
C. Mandatory 24-hour sedation holiday
D. Strict fluid restriction to lower ICP
B. Early enteral feeding to support metabolic demands
Pharmacologic Interventions for ICP Control
A TBI patient has an ICP of 25 mmHg and a CPP of 55 mmHg despite head-of-bed elevation and sedation. You administer an IV bolus of mannitol (0.5 g/kg). What key lab value must be monitored closely to avoid complications?
A. Serum troponin I
B. Serum osmolarity (<320 mOsm/L)
C. Hemoglobin A1c
D. Renal tubular enzymes
B. Serum osmolarity (<320 mOsm/L)
If hypertonic saline (3%) is used to manage elevated ICP, the team should be vigilant about:
A. Uncontrolled hypokalemia and hypernatremia
B. Immediate hyperglycemia
C. Excess sedation
D. Mild dehydration without electrolyte shifts
A. Uncontrolled hypokalemia and hypernatremia
A 30-year-old with severe TBI is placed on levetiracetam prophylactically. After 1 week, the medication is discontinued. What is the main rationale for using short-term seizure prophylaxis?
A. It completely prevents all future seizures
B. It reduces the metabolic stress of early post-traumatic seizures
C. It treats post-concussive syndrome
D. It eliminates the need for mechanical ventilation
B. It reduces the metabolic stress of early post-traumatic seizures
A patient’s ICP remains above 30 mmHg despite mannitol, sedation, and elevated head of bed. The neurosurgeon administers a bolus of 23.4% saline. Which best describes the role of this intervention?
A. Provides mild sedation
B. Rapidly increases intravascular osmolarity, drawing fluid out of the brain
C. Replaces low calcium
D. Decreases blood pressure to reduce hemorrhage risk
B. Rapidly increases intravascular osmolarity, drawing fluid out of the brain
Question 9 (Scenario-Based)
A 65-year-old TBI patient has a large subdural hematoma causing a midline shift. The neurosurgical team rushes the patient to the OR. Which primary surgical intervention best reduces mass effect?
A. Decompressive craniectomy of the occipital bone only
B. Evacuation of the hematoma to relieve pressure
C. Placement of a lumbar drain
D. Application of external traction to the skull
B. Evacuation of the hematoma to relieve pressure
In a refractory TBI case (ICP >25 mmHg, unresponsive to standard measures), a pentobarbital coma may be initiated. The primary mechanism of benefit is:
A. Continuous vasodilation to the brain
B. Lowering cerebral metabolic demand, which decreases ICP
C. Worsening autoregulation
D. Directly shrinking the volume of the brain
B. Lowering cerebral metabolic demand, which decreases ICP
ABCs and maintaining adequate CPP
to avoid secondary injury.
(fever control, early nutrition) reduce metabolic demand and support recovery.
Nonpharmacologic strategies
Osmotherapy with mannitol or hypertonic saline requires
monitoring serum osmolarity and sodium/potassium levels.
Seizure prophylaxis and advanced hypertonic therapy reduce risks of
rmetabolic spikes and refractory ICP.
Surgical evacuation of hematomas and pentobarbital coma are critical advanced measures for
uncontrolled ICP and mass effect.
- A patient with a GCS of 7 requires what immediate intervention?
A) IV mannitol
B) Intubation
C) Administration of corticosteroids
D) EEG monitoring
Answer: B) Intubation
Rationale: A GCS ≤8 indicates need for airway protection with intubation.
- Which TBI finding is most concerning for brain herniation?
A) Fixed and dilated pupils
B) Nausea and vomiting
C) Mild confusion
D) Hyperreflexia
Answer: A) Fixed and dilated pupils
Rationale: Fixed and dilated pupils suggest brain herniation due to brainstem compression
A patient with a GCS of 7 requires what immediate intervention?
A) IV mannitol
B) Intubation
C) Administration of corticosteroids
D) EEG monitoring
Answer: B) Intubation
*Rationale: A GCS ≤8 indicates need for airway protection with intubation
Which TBI finding is most concerning for brain herniation?**
A) Fixed and dilated pupils
B) Nausea and vomiting
C) Mild confusion
D) Hyperreflexia
Answer A) Fixed and dilated pupils
Rationale: Fixed and dilated pupils suggest brain herniation due to brainstem compression.
A patient with a severe traumatic brain injury has an ICP of 35 mmHg. What is the most appropriate initial management strategy?
A) Lower the head of the bed to 10 degrees
B) Administer corticosteroids for cerebral edema
C) Initiate osmotherapy with mannitol or hypertonic saline
D) Hyperventilate the patient immediately to decrease CO2 levels
Answer: C) Initiate osmotherapy with mannitol or hypertonic saline
A patient with a traumatic brain injury develops Cushing’s triad. What does this indicate?
A) Imminent brain herniation
B) Recovery from increased ICP
C) Adequate cerebral perfusion
D) A metabolic cause of altered mental status
Answer: A) Imminent brain herniation
A 65-year-old patient presents with hydrocephalus and a suspected increase in ICP. What is the gold standard for monitoring ICP in this patient?
A) Non-contrast head CT
B) Intraparenchymal fiber optic transducer
C) Ventriculostomy with external transducer
D) Bolt monitor at the bedside
Answer: C) Ventriculostomy with external transducer
A patient with a history of traumatic brain injury is receiving mannitol for ICP management. Which parameter should be closely monitored?
A) Serum sodium levels
B) Serum osmolarity
C) Blood urea nitrogen (BUN)
D) Magnesium levels
Answer: B) Serum osmolarity
Which of the following patients is at the highest risk for developing vasogenic cerebral edema?
A) A 45-year-old with an ischemic stroke
B) A 60-year-old with a brain tumor
C) A 70-year-old with a history of hypoxic injury
D) A 55-year-old with hydrocephalus
Answer: B) A 60-year-old with a brain tumor
A nurse practitioner is caring for a patient with a closed head injury and signs of increased ICP. What is an appropriate non-pharmacologic intervention?
A) Keeping the patient’s head and neck in a neutral position
B) Elevating the head of the bed to 10 degrees
C) Administering high doses of corticosteroids
D) Encouraging frequent suctioning
Answer: A) Keeping the patient’s head and neck in a neutral position
Which of the following clinical findings would suggest that a patient with increased ICP is experiencing brain herniation?
A) Bradycardia, hypertension, and irregular breathing
B) Hypotension, tachycardia, and hyperthermia
C) Tachypnea, hypertension, and pupil dilation
D) Irregular pulse, fever, and nausea
Answer: A) Bradycardia, hypertension, and irregular breathing
. A patient with increased ICP due to cerebral edema is being considered for hypertonic saline therapy. What is a potential complication of this treatment?
A) Hypochloremic alkalosis
B) Central pontine myelinolysis
C) Metabolic acidosis
D) Respiratory alkalosis
Answer: B) Central pontine myelinolysis
Which factor is most likely to increase cerebral blood flow and exacerbate elevated ICP?
A) Hypocapnia
B) Hypertension
C) Hypoxia
D) Hyperthermia
Answer: C) Hypoxia
A patient has refractory ICP elevation despite initial treatment efforts. What is the next appropriate step?
A) Continue supportive care and reassess in 24 hours
B) Initiate pentobarbital coma
C) Increase the patient’s PEEP to improve oxygenation
D) Increase the patient’s hydration with normal saline
Answer: B) Initiate pentobarbital coma
A patient with hydrocephalus requires ICP monitoring, but their ventricles appear collapsed on imaging. What is the most appropriate method for ICP monitoring in this case?
A) Ventriculostomy
B) Brain tissue (intraparenchymal) monitor
C) Jugular venous bulb oximetry
D) Lumbar puncture
Answer: B) Brain tissue
(intraparenchymal) monitor
. A 54-year-old male with a severe traumatic brain injury has an ICP of 28 mmHg. Despite proper positioning, sedation, and osmotherapy, his ICP remains elevated. What is the next best step?
A) Increase PEEP to enhance oxygenation
B) Hyperventilate the patient to maintain PaCO2 < 25 mmHg
C) Consider initiating a pentobarbital coma
D) Administer corticosteroids
Answer: C) Consider initiating a pentobarbital coma
. A patient with severe traumatic brain injury (TBI) has a sustained ICP of 30 mmHg for 20 minutes despite initial interventions. What is the next step in management?
A) Continue current management and monitor for changes
B) Administer 23.4% hypertonic saline
C) Initiate a lumbar puncture to drain CSF
D) Increase PEEP to improve oxygenation
Answer: B) Administer 23.4% hypertonic saline
A patient with traumatic brain injury is being mechanically ventilated. What is the ideal PaCO2 target to prevent secondary brain injury?
A) 25-30 mmHg
B) 35-40 mmHg
C) 45-50 mmHg
D) 50-55 mmHg
Answer: B) 35-40 mmHg
A patient presents with suspected TBI. What diagnostic test should be performed first?
A) MRI brain
B) Lumbar puncture
C) Non-contrast head CT
D) EEG
Answer: C) Non-contrast head CT
A patient with severe TBI (GCS = 6) is in the ICU. What is the best way to monitor for increased ICP?
A) Serial GCS scoring
B) Fundoscopic exam for papilledema
C) Intraparenchymal ICP monitor or ventriculostomy
D) Continuous EEG
Answer: C) Intraparenchymal ICP monitor or ventriculostomy
A football player sustains a brief loss of consciousness followed by confusion but no abnormalities on CT. What is the likely diagnosis?
A) Epidural hematoma
B) Subdural hematoma
C) Concussion
D) Diffuse axonal injury
Answer: C) Concussion
A patient with TBI has a “lucid interval” followed by rapid neurologic deterioration. What is the most likely diagnosis?
A) Subdural hematoma
B) Epidural hematoma
C) Diffuse axonal injury
D) Brain contusion
Answer: B) Epidural hematoma
A patient with TBI has blurring of the gray-white matter junction on CT. What type of injury is this most suggestive of?
A) Epidural hematoma
B) Subdural hematoma
C) Diffuse axonal injury
D) Brain contusion
Answer: C) Diffuse axonal injury
Which intervention is contraindicated in the management of TBI?
A) ICP monitoring
B) Hypertonic saline for cerebral edema
C) Corticosteroids
D) Seizure prophylaxis for 7 days
Answer: C) Corticosteroids
A patient with a severe TBI has an ICP of 28 mmHg despite standard management. What is the next step?
A) Hyperventilation to PaCO2 < 25 mmHg
B) Induce a pentobarbital coma
C) Perform a lumbar puncture
D) Increase IV fluids
Answer: B) Induce a pentobarbital coma
A patient with TBI develops increasing ICP and bradycardia with a widened pulse pressure. What is the concern?
A) Spinal cord injury
B) Brainstem herniation
C) Early recovery phase
D) Post-concussion syndrome
Answer: B) Brainstem herniation
What is the most life-threatening immediate concern in a patient with severe traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS) of 5?
A) Increased intracranial pressure (ICP)
B) Hypotension
C) Airway compromise
D) Seizures
Answer: C) Airway compromise
A patient involved in a motor vehicle accident sustains a severe TBI with diffuse axonal injury. What is the underlying pathophysiology?
A) Bleeding into the subdural space
B) Shearing forces causing axonal disruption
C) Hemorrhagic contusions in the frontal lobe
D) Cerebral vasodilation due to ischemia
Answer: B) Shearing forces causing axonal disruption
A patient with TBI and a GCS of 6 presents to the ER. What is the most appropriate initial imaging modality?
A) MRI brain
B) Non-contrast CT head
C) Cerebral angiogram
D) EEG
Answer: B) Non-contrast CT head
A 28-year-old patient fell from a ladder and lost consciousness for 2 minutes. He now has a mild headache but a normal neurological exam. What is the appropriate next step?
A) Discharge home with observation
B) Perform a non-contrast head CT
C) Administer seizure prophylaxis
D) Perform an immediate MRI
Answer: B) Perform a non-contrast head CT
A 65-year-old patient with a TBI is receiving mechanical ventilation. What is the target PaCO2 range to prevent secondary injury?
A) 25-30 mmHg
B) 35-40 mmHg
C) 45-50 mmHg
D) > 50 mmHg
Answer: B) 35-40 mmHg
A patient with TBI has an ICP of 28 mmHg despite standard therapy. What is the next best step?
A) Hyperventilation to maintain PaCO2 < 25 mmHg
B) Induce a pentobarbital coma
C) Increase IV fluids
D) Administer high-dose corticosteroids
Answer: B) Induce a pentobarbital coma
. A patient with severe TBI develops Cushing’s triad (hypertension, bradycardia, irregular respirations). What is the most immediate concern?
A) Seizures
B) Herniation
C) Hypovolemic shock
D) Diffuse axonal injury
Answer: B) Herniation
A patient with a history of TBI presents with a fixed, dilated right pupil and left-sided hemiparesis. What type of herniation is most likely?
A) Tonsillar herniation
B) Uncal herniation
C) Subfalcine herniation
D) Central herniation
Answer: B) Uncal herniation
A patient with traumatic brain injury is being mechanically ventilated. What is the ideal PaCO2 target to prevent secondary brain injury?
A) 25-30 mmHg
B) 35-40 mmHg
C) 45-50 mmHg
D) 50-55 mmHg
Answer: B) 35-40 mmHg
. A 45-year-old male presents with a GCS of 7 after a fall. What is the immediate priority?
A) Obtain a non-contrast head CT
B) Administer mannitol for suspected increased ICP
C) Secure the airway with endotracheal intubation
D) Start seizure prophylaxis
Answer: C) Secure the airway with endotracheal intubation
A patient with severe TBI (GCS = 6) is in the ICU. What is the best way to monitor for increased ICP?
A) Serial GCS scoring
B) Fundoscopic exam for papilledema
C) Intraparenchymal ICP monitor or ventriculostomy
D) Continuous EEG
Answer: C) Intraparenchymal ICP monitor or ventriculostomy
. A patient presents with suspected TBI. What diagnostic test should be performed first?
A) MRI brain
B) Lumbar puncture
C) Non-contrast head CT
D) EEG
Answer: C) Non-contrast head CT
A football player sustains a brief loss of consciousness followed by confusion but no abnormalities on CT. What is the likely diagnosis?
A) Epidural hematoma
B) Subdural hematoma
C) Concussion
D) Diffuse axonal injury
Answer: C) Concussion
A patient with TBI has a “lucid interval” followed by rapid neurologic deterioration. What is the most likely diagnosis?
A) Subdural hematoma
B) Epidural hematoma
C) Diffuse axonal injury
D) Brain contusion
Answer: B) Epidural hematoma
A patient with TBI has blurring of the gray-white matter junction on CT. What type of injury is this most suggestive of?
A) Epidural hematoma
B) Subdural hematoma
C) Diffuse axonal injury
D) Brain contusion
Answer: C) Diffuse axonal injury
A patient with TBI develops increasing ICP and bradycardia with a widened pulse pressure. What is the concern?
A) Spinal cord injury
B) Brainstem herniation
C) Early recovery phase
D) Post-concussion syndrome
Answer: B) Brainstem herniation
What is the most life-threatening immediate concern in a patient with severe traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS) of 5?
A) Increased intracranial pressure (ICP)
B) Hypotension
C) Airway compromise
D) Seizures
Answer: C) Airway compromise
A patient with a severe TBI has an ICP of 28 mmHg despite standard management. What is the next step?
A) Hyperventilation to PaCO2 < 25 mmHg
B) Induce a pentobarbital coma
C) Perform a lumbar puncture
D) Increase IV fluids
Answer: B) Induce a pentobarbital coma
A patient involved in a motor vehicle accident sustains a severe TBI with diffuse axonal injury. What is the underlying pathophysiology?
A) Bleeding into the subdural space
B) Shearing forces causing axonal disruption
C) Hemorrhagic contusions in the frontal lobe
D) Cerebral vasodilation due to ischemia
Answer: B) Shearing forces causing axonal disruption
A patient with TBI and a GCS of 6 presents to the ER. What is the most appropriate initial imaging modality?
A) MRI brain
B) Non-contrast CT head
C) Cerebral angiogram
D) EEG
Answer: B) Non-contrast CT head
A 28-year-old patient fell from a ladder and lost consciousness for 2 minutes. He now has a mild headache but a normal neurological exam. What is the appropriate next step?
A) Discharge home with observation
B) Perform a non-contrast head CT
C) Administer seizure prophylaxis
D) Perform an immediate MRI
Answer: B) Perform a non-contrast head CT
A patient with TBI has an ICP of 28 mmHg despite standard therapy. What is the next best step?
A) Hyperventilation to maintain PaCO2 < 25 mmHg
B) Induce a pentobarbital coma
C) Increase IV fluids
D) Administer high-dose corticosteroids
Answer: B) Induce a pentobarbital coma
A 40-year-old male with a GCS of 7 and increased ICP (25 mmHg) is intubated and sedated. Which intervention is contraindicated?
A) Elevating the head of the bed to 30 degrees
B) Administering mannitol or hypertonic saline
C) Using corticosteroids for cerebral edema
D) Monitoring ICP with an external ventricular drain (EVD)
Answer: C) Using corticosteroids for cerebral edema
A 65-year-old patient with a TBI is receiving mechanical ventilation. What is the target PaCO2 range to prevent secondary injury?
A) 25-30 mmHg
B) 35-40 mmHg
C) 45-50 mmHg
D) > 50 mmHg
Answer: B) 35-40 mmHg
A patient with severe TBI develops Cushing’s triad (hypertension, bradycardia, irregular respirations). What is the most immediate concern?
A) Seizures
B) Herniation
C) Hypovolemic shock
D) Diffuse axonal injury
Answer: B) Herniation
A patient with a history of TBI presents with a fixed, dilated right pupil and left-sided hemiparesis. What type of herniation is most likely?
A) Tonsillar herniation
B) Uncal herniation
C) Subfalcine herniation
D) Central herniation
Answer: B) Uncal herniation
A patient with traumatic brain injury is being mechanically ventilated. What is the ideal PaCO2 target to prevent secondary brain injury?
A) 25-30 mmHg
B) 35-40 mmHg
C) 45-50 mmHg
D) 50-55 mmHg
Answer: B) 35-40 mmHg
. What is the most life-threatening immediate concern in a patient with severe traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS) of 5?
A) Increased intracranial pressure (ICP)
B) Hypotension
C) Airway compromise
D) Seizures
Answer: C) Airway compromise
A patient involved in a motor vehicle accident sustains a severe TBI with diffuse axonal injury. What is the underlying pathophysiology?
A) Bleeding into the subdural space
B) Shearing forces causing axonal disruption
C) Hemorrhagic contusions in the frontal lobe
D) Cerebral vasodilation due to ischemia
Answer: B) Shearing forces causing axonal disruption
A patient with TBI and a GCS of 6 presents to the ER. What is the most appropriate initial imaging modality?
A) MRI brain
B) Non-contrast CT head
C) Cerebral angiogram
D) EEG
Answer: B) Non-contrast CT head
. A 28-year-old patient fell from a ladder and lost consciousness for 2 minutes. He now has a mild headache but a normal neurological exam. What is the appropriate next step?
A) Discharge home with observation
B) Perform a non-contrast head CT
C) Administer seizure prophylaxis
D) Perform an immediate MRI
Answer: B) Perform a non-contrast head CT
