Special Populations and Complications: Older Adults, Children, Athletes, Autonomic Dysreflexia, and Penetrating Spine Injury Practice Questions

25 multiple-choice questions on Special populations and complications: older adults, children, athletes, autonomic dysreflexia, and penetrating spine injury for paramedic and EMT students, from Chapter 35 (Head and Spine Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. An alert 79-year-old on warfarin hit his head in a fall and wants to refuse transport. After confirming his capacity, the most important information to give him is that:

   1. A. A normal exam now means he is not at risk
   2. B. His risk is low if he has no headache
   3. C. A CT can wait until his next checkup
   4. D. Brain bleeding can appear hours later
   Show answer

   Answer: D. Brain bleeding can appear hours later

   Anticoagulated older adults can develop intracranial bleeding that becomes symptomatic hours or days later, so they are advised to be evaluated with CT. If he still refuses, explain warning signs (headache, vomiting, confusion, weakness), ensure someone stays with him, and document. A normal exam or the absence of headache does not exclude delayed bleeding, and warfarin raises the risk enough that imaging should not be put off to a routine visit.

2. An 84-year-old fell, has a GCS of 15, and was alert on scene. Compared with a younger patient, this GCS in an older adult:

   1. A. Does not exclude a brain bleed
   2. B. Rules out any serious brain injury
   3. C. Means a CT scan is never needed
   4. D. Shows the fall was too minor to matter
   Show answer

   Answer: A. Does not exclude a brain bleed

   Brain atrophy gives blood room to collect before symptoms appear, so older adults can have a normal GCS with significant intracranial bleeding, especially on anticoagulants or antiplatelets. Field triage guidance lowers the threshold for transport in older adults with head injury. A normal GCS is reassuring only in part.

3. After a ground-level fall, an 80-year-old has neck pain. The cervical injury most common in older adults with this mechanism is a fracture of the:

   1. A. Spinous process of C7
   2. B. Body of the T12 vertebra
   3. C. Transverse process of C5
   4. D. Odontoid process of C2
   Show answer

   Answer: D. Odontoid process of C2

   Low-energy falls in older adults commonly fracture the dens of C2, which can be unstable despite a minor mechanism. Fractures of the C7 spinous process result from forceful flexion or muscle pull instead.

4. A 160-kg patient needs spinal motion restriction and becomes short of breath when laid flat on a backboard. The best adjustment is to:

   1. A. Tilt the backboard head-down slightly
   2. B. Move him to a scoop kept fully flat
   3. C. Use a vacuum mattress, head tilted up
   4. D. Add a second board to widen the surface
   Show answer

   Answer: C. Use a vacuum mattress, head tilted up

   Lying flat with straps across the chest restricts breathing in obese patients. A vacuum mattress or padded stretcher with the whole body tilted head up (reverse Trendelenburg) maintains alignment while easing breathing. Head-down tilt pushes the abdominal contents against the diaphragm, and a scoop or widened board that stays flat does not relieve the positional breathing problem.

5. When assessing mental status in an older adult with dementia after a fall, the most useful step is to:

   1. A. Assume any confusion is from the dementia
   2. B. Ask the caregiver about the usual baseline
   3. C. Score the GCS as normal if she is awake
   4. D. Delay the exam until she is at the hospital
   Show answer

   Answer: B. Ask the caregiver about the usual baseline

   Only a comparison with baseline reveals a new change that may signal an intracranial bleed. Attributing confusion to dementia is a common way head injuries are missed in older adults.

6. Young children are more likely than adults to injure the upper cervical spine (C1 to C3) because:

   1. A. Their vertebrae are fully ossified early
   2. B. Their neck muscles are stronger than adults
   3. C. Their spinal canal is narrower than adults
   4. D. Their heavy heads place the fulcrum higher
   Show answer

   Answer: D. Their heavy heads place the fulcrum higher

   A proportionally large head and weak neck muscles shift the point of maximal motion upward, so young children tend to injure C1 to C3. By about age 8 to 10, the pattern resembles that of adults.

7. Spinal cord injury without radiographic abnormality (SCIWORA) occurs mainly in children because their:

   1. A. Spinal cord is more resistant to compression
   2. B. Vertebrae fracture more easily than adult bone
   3. C. Ligaments and spine are flexible enough to stretch
   4. D. Injuries are usually missed by poor x-ray technique
   Show answer

   Answer: C. Ligaments and spine are flexible enough to stretch

   A child's elastic ligaments and shallow facet joints let the spinal column deform far enough to injure the cord and then spring back into alignment, leaving normal x-rays. The child's cord is not more resistant; it is less tolerant of stretch than the column around it. If the vertebrae fractured easily, the fracture would show on x-ray, which is the opposite of SCIWORA. SCIWORA is a real pattern of injury, not an imaging error; a normal film does not exclude cord injury in a child with neurologic signs, so keep motion restriction in place.

8. On the pediatric Glasgow Coma Scale, an infant earns the highest verbal score (5) when the infant:

   1. A. Coos and babbles as usual
   2. B. Cries irritably but can be consoled
   3. C. Cries only in response to pain
   4. D. Moans only in response to pain
   Show answer

   Answer: A. Coos and babbles as usual

   The pediatric verbal scale gives 5 for normal cooing and babbling, 4 for irritable but consolable crying, 3 for crying to pain, 2 for moaning to pain, and 1 for no response. Consolable irritable crying is the tempting choice, but it scores 4, not 5.

9. A 14-year-old football player took a hit to the head and now has a headache and dizziness, but says he feels fine to go back in. The coach asks your opinion. You should advise that:

   1. A. He may return if symptoms clear in 15 minutes
   2. B. He should not return to play today
   3. C. He may return once he can do push-ups
   4. D. He may return if he did not lose consciousness
   Show answer

   Answer: B. He should not return to play today

   Any athlete with suspected concussion is removed from play and does not return the same day; return requires evaluation and clearance by a qualified health care professional. Brief symptom resolution does not exclude concussion.

10. After a concussion, return to sport is generally managed by:

    1. A. Full contact practice on the day after the injury
    2. B. Strict bed rest in a dark room for at least 2 weeks
    3. C. A stepwise increase in activity after symptoms improve
    4. D. Avoiding all screens and school until fully symptom-free
    Show answer

    Answer: C. A stepwise increase in activity after symptoms improve

    Current consensus favors 24 to 48 hours of relative rest, then a graded, symptom-limited progression of activity toward contact, with clearance by a health care professional before full return. Full contact the next day skips the progression and exposes the athlete to repeat injury before recovery. Prolonged strict bed rest in a dark room is no longer recommended and can slow recovery. Complete cognitive rest until every symptom is gone is also outdated; light school and screen use within symptom limits is encouraged early.

11. A 17-year-old was diagnosed with a concussion yesterday. His parent calls EMS because he has had several episodes of vomiting, his headache is worsening, and he seems harder to wake. You should:

    1. A. Tell the parent this is normal recovery
    2. B. Transport him for emergency evaluation
    3. C. Advise rest and recheck in the morning
    4. D. Give oral fluids and observe at home
    Show answer

    Answer: B. Transport him for emergency evaluation

    Worsening headache, repeated vomiting, and increasing drowsiness are red flags for an expanding intracranial bleed or swelling and require urgent imaging. These are not features of normal concussion recovery.

12. A 35-year-old with a T4 spinal cord injury from years ago has a pounding headache, BP of 220/120 mm Hg, pulse of 50 beats/min, and flushed, sweaty skin above the nipple line. The most likely condition is:

    1. A. Autonomic dysreflexia
    2. B. Neurogenic shock
    3. C. Cushing reflex from a bleed
    4. D. Hypertensive encephalopathy
    Show answer

    Answer: A. Autonomic dysreflexia

    A stimulus below the injury triggers a massive sympathetic response that the brain cannot dampen, causing severe hypertension and reflex bradycardia, with flushing and sweating above the lesion. Neurogenic shock produces hypotension, not hypertension.

13. A man with a T4 injury has autonomic dysreflexia. You sat him up and drained his catheter, but his BP is still 210/110 mm Hg. You should next look for:

    1. A. A heart block causing his slow pulse
    2. B. Dehydration needing a large fluid bolus
    3. C. Pheochromocytoma as the real cause
    4. D. Other triggers, like tight clothing
    Show answer

    Answer: D. Other triggers, like tight clothing

    After the bladder, common triggers include fecal impaction, tight clothing or leg-bag straps, pressure sores, ingrown toenails, and burns below the injury level. Remove or relieve them, and give an antihypertensive per protocol if the pressure stays high. The slow pulse is a reflex response to the hypertension rather than a primary heart block, an adrenal tumor does not explain a classic dysreflexia picture in a known T4 injury, and a fluid bolus does nothing to remove the trigger.

14. For a patient with autonomic dysreflexia, your first actions should be to:

    1. A. Sit him up, loosen clothing, check the catheter
    2. B. Lay him flat and raise his legs to restore flow
    3. C. Apply a cervical collar and secure him to a board
    4. D. Give a nitrate before looking for the trigger
    Show answer

    Answer: A. Sit him up, loosen clothing, check the catheter

    Sitting the patient up lowers blood pressure by pooling blood in the legs, and loosening tight clothing and checking or draining the bladder catheter remove the most common triggers. Laying him flat with the legs raised would raise his pressure further. This is a chronic injury with no new trauma, so spinal motion restriction is not indicated and a board adds a pressure stimulus. An antihypertensive such as nitroglycerin may be used per protocol if pressure stays high, but only after positioning and a search for the trigger, because removing the stimulus is the definitive treatment.

15. A patient with a chronic T4 cord injury has autonomic dysreflexia, with flushing and sweating above the nipple line. Below the level of injury, his skin is typically:

    1. A. Flushed and sweaty, as above it
    2. B. Warm and dry from vasodilation
    3. C. Mottled and cyanotic from shock
    4. D. Pale and cool, with goosebumps
    Show answer

    Answer: D. Pale and cool, with goosebumps

    The trigger below the lesion sets off a sympathetic surge that the brain cannot dampen, so vessels below the injury constrict (pale, cool skin with piloerection) and drive the blood pressure up; the brain's attempt to compensate dilates vessels above the lesion, causing flushing and sweating there. The skin below does not match the skin above, because descending inhibition cannot cross the injury. Warm, dry skin from vasodilation describes neurogenic shock, not dysreflexia. Mottling and cyanosis suggest hypoperfusion, the opposite of this hypertensive crisis.

16. A 30-year-old was stabbed in the lower back, and the knife is still in place. He has weakness in his left leg. You should:

    1. A. Remove the knife so you can secure him flat
    2. B. Pull the knife out if bleeding is minimal
    3. C. Stabilize the knife in place and transport
    4. D. Push the knife in to steady it for transport
    Show answer

    Answer: C. Stabilize the knife in place and transport

    Impaled objects are stabilized in place, because removal can cause bleeding and further cord damage. Position him on his side or as needed to avoid pressure on the object while limiting spinal movement.

17. Unstable spinal fractures are uncommon after gunshot wounds because:

    1. A. Bullets usually miss the vertebral bodies
    2. B. The bullet seldom disrupts the supporting ligaments
    3. C. The cord absorbs most of the bullet's energy
    4. D. The paraspinal muscles splint the column after injury
    Show answer

    Answer: B. The bullet seldom disrupts the supporting ligaments

    A bullet can transect the cord but usually leaves the ligamentous structures intact, so the column remains stable. This is why routine SMR after penetrating trauma without deficits is not recommended. The cord does not soak up energy in a way that protects the bone, and muscle spasm cannot stabilize a truly unstable column; stability comes from the intact ligaments.

18. A pregnant woman at 32 weeks needs spinal motion restriction after a crash. To prevent supine hypotension, you should:

    1. A. Keep her flat and raise her legs 12 inches
    2. B. Tilt the device to the left or displace the uterus
    3. C. Place her prone with padding under the hips
    4. D. Sit her upright at 90 degrees on the stretcher to breathe
    Show answer

    Answer: B. Tilt the device to the left or displace the uterus

    In late pregnancy, the uterus compresses the inferior vena cava when the patient is supine, lowering cardiac output. Tilting the whole device to the left or manually displacing the uterus restores venous return while protecting the spine.

19. A 68-year-old with ankylosing spondylitis has neck pain after a minor fall, and his neck is fixed in a flexed position. You should:

    1. A. Straighten his neck to fit a standard collar
    2. B. Tilt the head back to look for deformity
    3. C. Pad and support him in the position found
    4. D. Clear the spine because the fall was minor
    Show answer

    Answer: C. Pad and support him in the position found

    Ankylosing spondylitis makes the spine rigid and brittle, so even minor falls can cause unstable fractures, and forcing neutral alignment can injure the cord. Support the existing curve with padding.

20. A 25-year-old with Down syndrome has neck pain after a fall. Particular concern for cervical injury is warranted because Down syndrome is associated with:

    1. A. Atlantoaxial instability
    2. B. Fused cervical vertebrae
    3. C. A congenitally wide canal
    4. D. Extra thoracic vertebrae
    Show answer

    Answer: A. Atlantoaxial instability

    Ligament laxity at the C1-C2 joint in Down syndrome makes the upper cervical spine vulnerable, even with minor trauma. Report any new neurologic findings and maintain motion restriction per protocol.

21. A 40-year-old found in an alley smells of alcohol, has a scalp hematoma, and is difficult to arouse. The most important principle in his assessment is to:

    1. A. Assume his decreased responsiveness is from alcohol
    2. B. Let him sleep it off and reassess in an hour
    3. C. Check a blood alcohol level before deciding
    4. D. Assume a head injury is present until excluded
    Show answer

    Answer: D. Assume a head injury is present until excluded

    Alcohol and head injury often coexist, and intoxication can mask a hematoma; attributing altered mental status to alcohol is a classic cause of missed TBI. Treat and transport as a head injury.

22. A 4-year-old fell from a second-story window and is pale, with a heart rate of 160 beats/min and a normal blood pressure. You should recognize that:

    1. A. His normal blood pressure rules out shock
    2. B. The heart rate is normal after a scary fall
    3. C. He may be compensating and in early shock
    4. D. Children do not bleed into the abdomen
    Show answer

    Answer: C. He may be compensating and in early shock

    Children maintain blood pressure until late in shock, so tachycardia and pallor are the early signs. Hypotension in a child is an ominous, late finding.

23. Patients with chronic spinal cord injuries who fall from a wheelchair may have fractures that go unnoticed mainly because:

    1. A. Their bones are unusually dense
    2. B. They cannot feel pain below the injury
    3. C. They are unable to bruise easily
    4. D. Their muscle spasm splints the fracture
    Show answer

    Answer: B. They cannot feel pain below the injury

    Absent sensation below the lesion hides the usual pain of a fracture, and disuse often makes their bones osteoporotic. Carefully inspect and palpate the limbs, and look for swelling or deformity.

24. An infant is brought in after a fall from a couch with a GCS of 15. Which finding should most raise concern for intracranial injury?

    1. A. A large, boggy hematoma on the side of the head
    2. B. A small abrasion on the bridge of the nose
    3. C. Crying that stops when the infant is held
    4. D. A single spit-up shortly before the fall
    Show answer

    Answer: A. A large, boggy hematoma on the side of the head

    In infants, a large parietal or temporal scalp hematoma is associated with an underlying skull fracture and intracranial injury even when the infant appears well. Consolable crying is reassuring rather than concerning.

25. A 6-year-old struck by a car cannot follow commands (motor GCS 4). His airway is open and he is breathing adequately. Under the 2021 field triage guideline, the preferred destination is:

    1. A. The closest emergency department
    2. B. An adult level III trauma center
    3. C. The nearest hospital with a CT scanner
    4. D. A pediatric-capable trauma center
    Show answer

    Answer: D. A pediatric-capable trauma center

    Inability to follow commands (motor GCS below 6) is a red criterion, so the child should go to the highest-level trauma center available, and the 2021 guideline adds that injured children meeting red criteria should preferentially go to pediatric-capable trauma centers. The closest emergency department is chosen only when the patient is in extremis and needs immediate stabilization, which an open airway and adequate breathing do not suggest. A level III adult center is not the highest level and may not have pediatric neurosurgery. The nearest hospital with a CT scanner does not provide the neurosurgical and pediatric critical care this child needs.