Spinal Cord Injury Considerations — MCQs
A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?
A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because it interrupts the
In an accident case, after the arrival of medical team, all should be done in early management except;
A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
A patient met with an accident and presents with paralysis of both upper and lower limbs. The patient has not passed urine and tenderness is elicited in the cervical region. What is the most appropriate immediate management?
In an accident involving potential cervical spine damage, the first line of management is:
Vasopressor of choice in hypotension produced during subarachnoid block is
After a road traffic accident, a patient presented to casualty with vitals showing BP of 90/60 mm Hg and heart rate of 56 bpm. Which kind of shock occurs?
A patient in shock comes to you in the trauma ward. You examine him and decide not to give him vasoconstrictors. Which type of shock is your patient having?
Most common type of shock in emergency room is
Spinal Cord Injury Considerations Indian Medical PG Practice Questions and MCQs
Question 1: A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?
- A. Halothane
- B. Succinylcholine
- C. Thiopentone (Correct Answer)
- D. Ketamine
Explanation: ***Thiopentone*** - It is a **short-acting barbiturate** that causes **rapid unconsciousness** and **reduces cerebral blood flow** and **intracranial pressure (ICP)**, which is beneficial in head injury. - It also has **cardiovascular-depressant effects** that can help manage hypertension, though in this hypotensive patient, careful titration is needed, but its **ICP-lowering effect** is crucial. *Halothane* - Halothane is a **volatile anesthetic** that can cause **dose-dependent myocardial depression** and a **decrease in blood pressure**, which would worsen the patient's existing hypotension. - It also tends to **increase cerebral blood flow**, which is counterproductive in a patient with a head injury and potential increased ICP. *Succinylcholine* - Succinylcholine is a **neuromuscular blocker** used for **rapid sequence intubation**, not as an anesthetic induction agent. - It can cause a **transient increase in ICP** and **hyperkalemia**, both of which can be detrimental in a trauma patient with head injury. *Ketamine* - Ketamine is a dissociative anesthetic that can **increase heart rate** and **blood pressure**, which could be beneficial in a hypotensive patient. - However, it also tends to **increase cerebral blood flow** and **intracranial pressure (ICP)**, making it less ideal for a patient with a head injury.
Question 2: A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because it interrupts the
- A. Left Dorsal Column
- B. Left Lateral Spinothalamic Tract (Correct Answer)
- C. Right Corticospinal Tract
- D. Right Lateral Spinothalamic Tract
Explanation: ***Left Lateral Spinothalamic Tract*** - A ventrolateral cordotomy is a surgical procedure that specifically targets the **spinothalamic tract** to relieve chronic, intractable pain. - Pain signals from the right leg cross over in the spinal cord and ascend via the **contralateral (left) lateral spinothalamic tract**. Therefore, interrupting this tract on the left side relieves pain from the right leg. *Left Dorsal Column* - The dorsal columns (fasciculus gracilis and cuneatus) primarily carry information about **fine touch, vibration, and proprioception**, not pain. - Interrupting the dorsal column would lead to deficits in these sensory modalities, not pain relief. *Right Corticospinal Tract* - The corticospinal tract is a **descending motor pathway** responsible for voluntary movement, originating from the cerebral cortex. - Interrupting this tract would result in **motor deficits** (paresis or paralysis), not pain relief. *Right Lateral Spinothalamic Tract* - The lateral spinothalamic tract carries pain and temperature sensation, but the fibers **cross over** at the segmental level of entry into the spinal cord. - Therefore, pain from the right leg ascends in the **left** lateral spinothalamic tract, making the right tract irrelevant for right leg pain relief through cordotomy.
Question 3: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.
Question 4: A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery
- A. O2 inhalation
- B. I.V. fluid
- C. Foley catheterization
- D. Supine position (Correct Answer)
Explanation: ***Supine position*** - Maintaining a **supine position** in a pregnant woman can lead to **aortocaval compression**, reducing **venous return** and **cardiac output**, which compromises uterine blood flow and fetal oxygenation. - To prevent this, the patient should be placed in a **left lateral tilt** (wedge under the right hip) to displace the uterus off the great vessels. *O2 inhalation* - Administering **oxygen via face mask** increases the mother's partial pressure of oxygen (PaO2), which can improve **fetal oxygenation** and potentially alleviate fetal distress. - This is a standard and safe intervention to maximize oxygen delivery to the fetus, especially in cases of **fetal compromise** indicated by variable decelerations. *I.V. fluid* - Administering **intravenous fluids** helps maintain maternal hydration and **circulatory volume**, crucial for adequate uterine perfusion. - This can improve **placental blood flow**, potentially reducing the frequency or severity of variable decelerations by increasing amniotic fluid volume and relieving **cord compression**. *Foleys catheterisation* - **Foley catheterization** is essential before a Cesarean section to **decompress the bladder**, preventing injury during surgery and improving surgical exposure. - A full bladder can obstruct the surgical field and increases the risk of accidental incision, therefore, it is a routine pre-operative step.
Question 5: A patient met with an accident and presents with paralysis of both upper and lower limbs. The patient has not passed urine and tenderness is elicited in the cervical region. What is the most appropriate immediate management?
- A. The doctor will instruct the radiographer to take cervical and chest x-ray
- B. The doctor should order a cervical x-ray and shift the patient from the trolley by himself
- C. The patient should not be shifted and portable x-ray machine should be used after neck stabilization (Correct Answer)
- D. The doctor will instruct the radiographer to take cervical x-ray AP and lateral view without any cervical support
Explanation: ***The patient should not be shifted and portable x-ray machine should be used after neck stabilization*** - This approach minimizes movement of a potentially unstable cervical spine fracture, preventing further neurological damage and optimizing patient safety. - **Spinal immobilization** (e.g., with a cervical collar and backboard) is the first priority before any diagnostic imaging to protect the spinal cord. - Using a **portable X-ray** avoids the need to transport the patient to radiology, adhering to trauma management principles. *The doctor will instruct the radiographer to take cervical and chest x-ray* - While cervical and chest X-rays are appropriate investigations, this option lacks the critical detail of **neck stabilization** and the need for a **portable X-ray** to avoid patient movement. - Moving the patient to a radiology suite for standard X-rays can exacerbate a spinal injury, especially without proper immobilization. *The doctor should order a cervical x-ray and shift the patient from the trolley by himself* - Shifting the patient from the trolley without adequate assistance and proper technique carries a high risk of causing further **spinal cord damage** due to uncontrolled movement. - This approach directly violates principles of **spinal precautions** in trauma management and requires at least 4-5 trained personnel for safe log-rolling. *The doctor will instruct the radiographer to take cervical x-ray AP and lateral view without any cervical support* - Taking X-rays without **cervical support** or immobilization is extremely dangerous in a patient with suspected cervical spine injury and paralysis. - Lack of support during imaging can lead to increased spinal instability and potentially irreversible **neurological deficits** or even death.
Question 6: In an accident involving potential cervical spine damage, the first line of management is:
- A. x-ray
- B. turn head to side
- C. maintain airway (Correct Answer)
- D. stabilize the cervical spine
Explanation: ***Correct: Maintain airway*** - In trauma management, the **ATLS protocol** follows the **A-B-C-D-E** approach where **Airway is the first priority** - In suspected cervical spine injury, airway management is performed **with concurrent cervical spine protection** (using jaw thrust maneuver instead of head tilt-chin lift) - A compromised airway leads to death within minutes, making it the **immediate first-line intervention** - **Cervical spine stabilization is performed simultaneously** during airway assessment and management, not as a separate preceding step - The correct approach: **"Airway with cervical spine protection"** - both are done together, but airway assessment/management takes priority *Incorrect: Stabilize the cervical spine* - While **cervical spine stabilization** is critical and must be maintained throughout trauma management, it is **not performed before airway assessment** - Manual inline stabilization and cervical collar application are done **during** airway management, not before it - ATLS teaches that C-spine protection is **integrated into** airway management, not a separate first step *Incorrect: X-ray* - **X-ray** is a diagnostic tool performed after initial stabilization and resuscitation - Imaging is part of the **secondary survey**, not primary trauma management - Never delay life-saving interventions for diagnostic studies *Incorrect: Turn head to side* - **Turning the head** is absolutely contraindicated in suspected cervical spine injury - Any movement can convert an unstable fracture into a **complete spinal cord injury** - If airway management is needed, use **jaw thrust** or **chin lift without head tilt**
Question 7: Vasopressor of choice in hypotension produced during subarachnoid block is
- A. Ephedrine (Correct Answer)
- B. Mephentermine
- C. Epinephrine
- D. Dobutamine
Explanation: ***Ephedrine*** - **Ephedrine** is a sympathomimetic with both direct (on adrenergic receptors) and indirect (releasing norepinephrine) effects, causing vasoconstriction and increased heart rate, making it suitable for treating **hypotension** during **subarachnoid block**. - Its slower onset and longer duration of action compared to direct-acting vasopressors can be beneficial for sustained pressure support in this context. *Mephentermine* - While mephentermine is also an indirect-acting sympathomimetic used for hypotension, it has a **slower onset** and a more prolonged effect compared to ephedrine. - Ephedrine is generally preferred due to its faster action in acute settings like **subarachnoid block-induced hypotension**, where rapid correction is often required. *Epinephrine* - **Epinephrine** is a potent vasopressor with significant alpha and beta-adrenergic effects, leading to strong vasoconstriction and cardiac stimulation. - Its use might lead to **tachycardia** and arrhythmias, which are generally undesirable when milder agents like ephedrine can achieve the desired effect. *Dobutamine* - **Dobutamine** is primarily a beta-1 adrenergic agonist, meaning it mainly increases cardiac contractility and heart rate with minimal effect on systemic vascular resistance. - It is not the agent of choice for hypotension due to **vasodilation** from subarachnoid block, as it does not sufficiently address the primary problem of decreased vascular tone.
Question 8: After a road traffic accident, a patient presented to casualty with vitals showing BP of 90/60 mm Hg and heart rate of 56 bpm. Which kind of shock occurs?
- A. Cardiogenic
- B. Neurogenic (Correct Answer)
- C. Hypovolemic shock
- D. Septic shock
Explanation: ***Neurogenic*** - This patient presents with **hypotension** (BP 90/60 mm Hg) and **bradycardia** (heart rate 56 bpm), which is a classic presentation of neurogenic shock due to **loss of sympathetic tone** following a spinal cord injury [2]. - The road traffic accident suggests a potential **spinal cord injury**, leading to disruption of the autonomic nervous system's control over heart rate and vascular tone. *Cardiogenic* - Cardiogenic shock is characterized by **hypotension** and **tachycardia**, often due to the heart's inability to pump blood effectively, such as in a myocardial infarction [1]. - The reported **bradycardia** in this patient makes cardiogenic shock unlikely. *Hypovolemic shock* - Hypovolemic shock results from significant **fluid loss**, leading to **hypotension** and a compensatory **tachycardia**. - The presence of **bradycardia** rules out hypovolemic shock, as the body would typically try to increase heart rate to compensate for volume depletion. *Septic shock* - Septic shock is caused by a severe **infection**, leading to widespread vasodilation, **hypotension**, and often **tachycardia** with signs of systemic inflammation. - There is no indication of infection, and the **bradycardia** is inconsistent with the typical presentation of septic shock.
Question 9: A patient in shock comes to you in the trauma ward. You examine him and decide not to give him vasoconstrictors. Which type of shock is your patient having?
- A. Cardiogenic shock
- B. Distributive shock (Correct Answer)
- C. Neurogenic shock
- D. Hemorrhagic shock
Explanation: ***Distributive shock*** - Distributive shock, particularly **septic shock**, often presents with **peripheral vasodilation** and a low systemic vascular resistance. - Administering additional **vasoconstrictors** in this context could worsen tissue perfusion if not carefully titrated, as the primary issue is maldistribution of blood flow rather than inadequate vascular tone alone. *Cardiogenic shock* - In **cardiogenic shock**, there is **myocardial dysfunction** leading to decreased cardiac output. - **Vasoconstrictors** may be used cautiously to maintain systemic perfusion pressure and improve coronary perfusion, although inotropes are often prioritized. *Neurogenic shock* - **Neurogenic shock** is a form of distributive shock caused by the **loss of sympathetic tone** due to spinal cord injury, leading to widespread vasodilation [1]. - **Vasoconstrictors** are a primary treatment in neurogenic shock to restore vascular tone and increase blood pressure [1]. *Hemorrhagic shock* - **Hemorrhagic shock** results from **significant blood loss**, leading to decreased circulating volume and reduced cardiac output. - The immediate priority is **fluid resuscitation** and **stopping the bleeding**, but vasoconstrictors are not typically the primary treatment and can worsen perfusion in some vascular beds [1].
Question 10: Most common type of shock in emergency room is
- A. Obstructive
- B. Hypovolaemic (Correct Answer)
- C. Cardiogenic
- D. Neurogenic
Explanation: ***Hypovolaemic*** - **Hypovolemic shock** is the most frequent type of shock encountered in emergency rooms due to its association with a wide range of common conditions, such as **hemorrhage** (trauma, gastrointestinal bleeding) and severe dehydration. - It results from a significant **loss of circulating blood volume**, leading to inadequate tissue perfusion [2]. *Obstructive* - **Obstructive shock** occurs when there is a physical obstruction to blood flow, such as in **pulmonary embolism** [1] or **cardiac tamponade** [3]. - While serious, these conditions are less common overall in the emergency setting compared to causes of hypovolemia. *Cardiogenic* - **Cardiogenic shock** is caused by the heart's inability to pump sufficient blood, typically due to **myocardial infarction** [3] or severe heart failure. - Although life-threatening, it is less common than hypovolemic shock as a primary presenting etiology in the emergency department. *Neurogenic* - **Neurogenic shock** is a distributive shock caused by a severe injury to the **central nervous system**, leading to loss of sympathetic tone and widespread vasodilation. - While it can be seen in severe trauma, it is a specific and less common form of shock compared to hypovolemia.
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