TBI Assessment and Management: GCS, Oxygenation, Perfusion, Ventilation, and Airway Practice Questions

25 multiple-choice questions on TBI assessment and management: GCS, oxygenation, perfusion, ventilation, and airway 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. The maximum scores for the three Glasgow Coma Scale components are:

   1. A. Eye 5, verbal 5, motor 5
   2. B. Eye 4, verbal 6, motor 5
   3. C. Eye 4, verbal 5, motor 6
   4. D. Eye 3, verbal 5, motor 7
   Show answer

   Answer: C. Eye 4, verbal 5, motor 6

   The GCS totals 3 to 15: eye opening 1 to 4, verbal response 1 to 5, and motor response 1 to 6. The motor scale has the most levels because it is the most predictive.

2. A motorcyclist opens his eyes only to a painful stimulus, says random inappropriate words, and pulls his hand away from a nail-bed squeeze. His GCS is:

   1. A. 8 (E2 V2 M4)
   2. B. 9 (E2 V3 M4)
   3. C. 10 (E3 V3 M4)
   4. D. 11 (E2 V4 M5)
   Show answer

   Answer: B. 9 (E2 V3 M4)

   Eye opening to pain is 2, inappropriate words is 3, and withdrawal from pain is 4. Scoring the words as confused speech (4) or the motor response as localizing (5) is the usual error.

3. A pedestrian struck by a car does not open his eyes, makes only moaning sounds, and extends his arms rigidly to pain. His GCS is:

   1. A. 6 (E1 V2 M3)
   2. B. 4 (E1 V1 M2)
   3. C. 7 (E2 V2 M3)
   4. D. 5 (E1 V2 M2)
   Show answer

   Answer: D. 5 (E1 V2 M2)

   No eye opening is 1, incomprehensible sounds are 2, and extension is 2. Flexion posturing would score a motor 3, which is why the type of posturing must be identified correctly.

4. When you squeeze the trapezius, a patient reaches across and tries to push your hand away. This motor response scores:

   1. A. 5, localizes to pain
   2. B. 4, withdraws from pain
   3. C. 6, obeys commands
   4. D. 3, abnormal flexion
   Show answer

   Answer: A. 5, localizes to pain

   Purposeful movement toward the stimulus to remove it is localization and scores 5. Simple withdrawal moves the limb away from the stimulus without locating it and scores 4.

5. A traumatic brain injury with a GCS of 10 is classified as:

   1. A. Mild
   2. B. Severe
   3. C. Minimal
   4. D. Moderate
   Show answer

   Answer: D. Moderate

   TBI is classified as mild (GCS 13 to 15), moderate (9 to 12), or severe (8 or less). A GCS of 10 falls in the moderate range.

6. Which Glasgow Coma Scale component best predicts outcome after TBI and should always be reported?

   1. A. Eye opening
   2. B. Motor response
   3. C. Verbal response
   4. D. Pupil size
   Show answer

   Answer: B. Motor response

   The motor score is the most reliable predictor of outcome and is unaffected by facial swelling or intubation, which limit eye and verbal scoring. Reporting the components, such as E2 V3 M4, is more useful than the total.

7. The Brain Trauma Foundation prehospital guideline defines hypoxemia in a patient with TBI as an oxygen saturation below:

   1. A. 94%
   2. B. 85%
   3. C. 90%
   4. D. 80%
   Show answer

   Answer: C. 90%

   The 3rd edition prehospital TBI guideline defines hypoxemia as SpO2 below 90% and recommends oxygen to keep saturation at 90% or higher, because a single episode below 90% is associated with markedly higher mortality; many systems aim higher, but 90% is the guideline threshold. 94% is the general oxygen-therapy target used in other guidelines (for example, AHA stroke and ACS care), not the TBI definition of hypoxemia. 85% and 80% are well into the range already associated with harm, so waiting for them accepts dangerous hypoxia.

8. In adults with TBI, a single episode of systolic hypotension has been shown to:

   1. A. Roughly double the risk of death
   2. B. Have no effect on outcome if brief
   3. C. Improve outcome by limiting bleeding
   4. D. Matter mainly when GCS is below 5
   Show answer

   Answer: A. Roughly double the risk of death

   Hypotension removes the pressure needed to perfuse a brain that has lost autoregulation, and even one episode markedly increases mortality. When hypoxia and hypotension occur together, the effect is greater still.

9. A 30-year-old with a severe TBI and a femur fracture has a BP of 84/52 mm Hg. Regarding fluid resuscitation, you should:

   1. A. Give isotonic crystalloid to avoid hypotension
   2. B. Withhold fluids to allow permissive hypotension
   3. C. Give fluid only if the GCS falls below 6
   4. D. Give D5W to reduce cerebral edema
   Show answer

   Answer: A. Give isotonic crystalloid to avoid hypotension

   Permissive hypotension may be used in penetrating torso trauma, but it is harmful with TBI, where cerebral perfusion depends on systemic pressure. D5W is hypotonic, moves into brain cells, and worsens edema.

10. Compared with adults, children with a moderate or severe TBI are more likely to:

    1. A. Develop a chronic subdural hematoma
    2. B. Need a lower oxygen saturation target
    3. C. Be safely sent home from the scene
    4. D. Have seizures soon after the injury
    Show answer

    Answer: D. Have seizures soon after the injury

    Early post-traumatic seizures are more common in young children, and a seizure worsens brain oxygen supply and raises ICP, so be ready to protect the airway and give a benzodiazepine. Chronic subdural hematomas are more typical of older adults, oxygen targets are not lower, and children with significant TBI need transport.

11. Continuous waveform capnography is especially important in an intubated TBI patient mainly because it helps you:

    1. A. Measure the intracranial pressure directly
    2. B. Estimate cerebral perfusion pressure
    3. C. Avoid unintended hypo- or hyperventilation
    4. D. Guide the dose of hypertonic saline
    Show answer

    Answer: C. Avoid unintended hypo- or hyperventilation

    Both hyperventilation (cerebral vasoconstriction) and hypoventilation (vasodilation, higher ICP) harm the injured brain, and ventilation rates drift during transport. Capnography lets you keep ETCO2 in the target range breath by breath and confirms tube position. It does not measure ICP or cerebral perfusion pressure, and osmotic therapy is guided by signs of herniation rather than by the ETCO2 reading.

12. An adult with a severe TBI and no signs of herniation is being ventilated with a bag-mask device. The appropriate ventilation rate is about:

    1. A. 20 breaths/min
    2. B. 10 breaths/min
    3. C. 30 breaths/min
    4. D. 6 breaths/min
    Show answer

    Answer: B. 10 breaths/min

    Adults are ventilated at about 10 breaths/min, adjusted to keep ETCO2 at 35 to 45 mm Hg. Twenty breaths/min is the adult herniation rate and would lower CO2 unnecessarily.

13. Your partner is ventilating an intubated TBI patient with no signs of herniation. The ETCO2 reads 24 mm Hg. You should:

    1. A. Slow the ventilation rate
    2. B. Increase the tidal volume
    3. C. Increase the ventilation rate
    4. D. Disconnect the capnography
    Show answer

    Answer: A. Slow the ventilation rate

    An ETCO2 of 24 mm Hg indicates hyperventilation, which constricts cerebral vessels and risks ischemia. Slowing the rate allows CO2 to rise into the 35 to 45 range; a larger tidal volume would lower it further.

14. A 26-year-old with a head injury has a GCS of 7, snoring respirations, and an SpO2 of 86%. The first action should be to:

    1. A. Perform rapid sequence intubation right away
    2. B. Open the airway and oxygenate with a bag-mask
    3. C. Obtain a blood glucose level before airway care
    4. D. Apply a cervical collar before moving the head
    Show answer

    Answer: B. Open the airway and oxygenate with a bag-mask

    Hypoxia must be corrected immediately with basic airway maneuvers, an adjunct, and bag-mask ventilation, while maintaining manual spinal stabilization. Proceeding straight to intubation in a hypoxic patient risks further desaturation.

15. When a TBI patient undergoes prehospital intubation, the most important goal during the procedure is to:

    1. A. Complete it before vital signs
    2. B. Use the largest possible tube
    3. C. Avoid any hypoxia or hypotension
    4. D. Intubate without any sedation
    Show answer

    Answer: C. Avoid any hypoxia or hypotension

    Studies of prehospital intubation in TBI show harm when attempts cause desaturation, hypotension, or hyperventilation. Preoxygenate, limit attempt duration, and confirm with waveform capnography.

16. During intubation of a trauma patient with suspected spinal injury, the cervical spine is protected by:

    1. A. Leaving the closed collar fully in place
    2. B. Placing the head in the sniffing position for laryngoscopy
    3. C. Securing the head to the board with tape
    4. D. Manual in-line stabilization by an assistant
    Show answer

    Answer: D. Manual in-line stabilization by an assistant

    An assistant holds the head neutral while the front of the collar is opened to allow mouth opening and laryngoscopy. The sniffing position extends the neck and should be avoided when spinal injury is suspected.

17. A 50-year-old found after a fall is combative and confused, with a small forehead abrasion. Before attributing his behavior to TBI, you should check:

    1. A. Blood alcohol and a urine drug screen
    2. B. Serum sodium and a liver function panel
    3. C. Capillary refill and lung sounds only
    4. D. Blood glucose and oxygen saturation
    Show answer

    Answer: D. Blood glucose and oxygen saturation

    Hypoglycemia and hypoxia can both mimic or worsen TBI and are quickly correctable in the field. Alcohol testing is not a field assessment, and assuming intoxication causes missed head injuries.

18. During transport, a head-injured patient's GCS falls from 14 to 11. The most important interpretation is that:

    1. A. The change is within the expected margin of scoring error
    2. B. His condition is deteriorating and needs reassessment
    3. C. He is falling asleep and should be left to rest
    4. D. His initial score was likely recorded incorrectly
    Show answer

    Answer: B. His condition is deteriorating and needs reassessment

    A decline of 2 or more points is significant and may signal an expanding lesion; recheck the airway, ventilation, pupils, and vital signs and notify the receiving hospital. Attributing it to sleep or scoring error delays recognition of herniation.

19. When assessing the pupils of a head-injured patient, a difference in size is considered significant when it exceeds about:

    1. A. 3 mm
    2. B. 5 mm
    3. C. 1 mm
    4. D. 0.1 mm
    Show answer

    Answer: C. 1 mm

    Pupils that differ by more than 1 mm, or that are sluggish or fixed, suggest pressure on the oculomotor nerve. Some people have mild baseline anisocoria, so ask about it and watch for change.

20. Under the 2021 National Guideline for the Field Triage of Injured Patients, a suspected open or depressed skull fracture in an alert adult is:

    1. A. A red criterion, highest-level center
    2. B. A yellow criterion for the nearest hospital
    3. C. Not a criterion if the GCS is still 15
    4. D. Only a criterion if he has a seizure
    Show answer

    Answer: A. A red criterion, highest-level center

    Skull deformity or a suspected skull fracture is listed among the red (high-risk) injury patterns that call for transport to the highest-level trauma center, regardless of the current mental status. A normal GCS does not remove the criterion, and a seizure is not required.

21. A 40-year-old with a severe TBI after a fall has a BP of 104/68 mm Hg. Under the 2023 Brain Trauma Foundation prehospital guideline, you should:

    1. A. Accept it, since only a systolic below 90 is low
    2. B. Treat it, aiming for a systolic of 110 or more
    3. C. Lower it further to limit intracranial bleeding
    4. D. Recheck it in 30 minutes before treating it
    Show answer

    Answer: B. Treat it, aiming for a systolic of 110 or more

    The 3rd edition prehospital guideline recommends targeting a systolic pressure of 110 mm Hg or greater in adults with TBI, because outcomes worsen progressively below that level, and treating hypotension with blood products or isotonic fluid while searching for its cause (the in-hospital BTF 4th edition uses 100 or more for ages 50 to 69 and 110 or more for ages 15 to 49 or over 70). The old threshold of below 90 mm Hg underestimates harm. Lowering the pressure further reduces cerebral perfusion in a brain that has lost autoregulation. Waiting 30 minutes prolongs hypotension; the guideline calls for checking pressure every 5 to 10 minutes and limiting hypotension to the shortest time possible.

22. A head-injured patient with spinal motion restriction begins to vomit. You should:

    1. A. Tilt the patient as a unit and suction
    2. B. Turn only the head to one side to drain
    3. C. Sit the patient upright at 90 degrees
    4. D. Remove the collar so he can clear vomit
    Show answer

    Answer: A. Tilt the patient as a unit and suction

    Rotating the whole patient or the device as a unit keeps the spine aligned while gravity and suction clear the airway. Turning only the head moves the neck, and removing the collar loses spinal protection.

23. Which IV fluid should be avoided in a patient with a significant TBI?

    1. A. Normal saline
    2. B. Lactated Ringer's solution
    3. C. 3% hypertonic saline
    4. D. 5% dextrose in water
    Show answer

    Answer: D. 5% dextrose in water

    D5W is effectively hypotonic once the glucose is metabolized and shifts water into brain cells, worsening edema; hyperglycemia also worsens outcome. Normal saline and lactated Ringer's are acceptable isotonic choices.

24. An intubated head-injured patient cannot be scored for verbal response. The correct way to document his GCS is to:

    1. A. Assign a verbal score of 5 to avoid penalizing the total
    2. B. Omit the GCS until he is extubated later
    3. C. Record the verbal score as T with eye and motor
    4. D. Use the verbal score from before sedation
    Show answer

    Answer: C. Record the verbal score as T with eye and motor

    The verbal component is recorded as T (for example, E1 VT M4) so that receiving clinicians know it could not be assessed. Assigning a number misrepresents the exam.

25. You are caring for a patient with a GCS of 13 after a fall. Which finding during reassessment would be most concerning?

    1. A. A newly dilated, sluggish left pupil
    2. B. A pulse that falls from 100 to 88
    3. C. A request for water and a blanket
    4. D. Bruising that slowly spreads on the scalp
    Show answer

    Answer: A. A newly dilated, sluggish left pupil

    A new unilateral pupil change suggests oculomotor nerve compression from an expanding lesion and demands urgent action. A modest fall in heart rate with stable mental status is not by itself a sign of herniation.