A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 22-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained driver. After extrication, he had severe neck pain and was unable to move his arms and legs. On arrival, he is lethargic and cannot provide a history. Hospital records show that eight months ago, he underwent an open reduction and internal fixation of the right humerus. His neck is immobilized in a cervical collar. Intravenous fluids are being administered. His pulse is 64/min, respirations are 8/min and irregular, and blood pressure is 104/64 mm Hg. Examination shows multiple bruises over the chest, abdomen, and extremities. There is flaccid paralysis and absent reflexes in all extremities. Sensory examination shows decreased sensation below the shoulders. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. There is swelling of the right ankle and right knee. Squeezing of the glans penis does not produce anal sphincter contraction. A focused assessment with sonography for trauma shows no abnormalities. He is intubated and mechanically ventilated. Which of the following is the most appropriate next step in management?
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A
Placement of Foley catheterCorrect. Foley catheterization is essential to relieve neurogenic urinary retention from spinal shock and monitor output in the trauma resuscitation.
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B
Intravenous dexamethasone therapyIncorrect. High-dose corticosteroids (methylprednisolone, NASCIS protocols) are no longer recommended for acute spinal cord injury — modern guidelines find no net benefit and increased complications.
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C
Cervical x-rayIncorrect. Cervical x-ray has been largely supplanted by CT cervical spine for acute trauma; either way, immediate imaging is not the FIRST step before basic supportive measures like bladder decompression.
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D
MRI of the spineIncorrect. MRI provides excellent cord/ligament detail but is performed after the patient is hemodynamically stabilized, the airway secured, and basic interventions (catheter, NG tube) completed.
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E
Lumbar punctureIncorrect. Lumbar puncture has no role in acute traumatic spinal cord injury and is contraindicated when cord compression or spinal instability is suspected — bladder decompression takes priority.
↑ Tap an answer to reveal the reasoning
Answer: A. High-speed MVC, severe neck pain, flaccid quadriparesis with absent reflexes, sensory loss below the shoulders, hypoventilation, and absent bulbocavernosus reflex (squeezing glans → anal sphincter contraction) define complete cervical spinal cord injury with spinal shock. He is intubated for respiratory failure (loss of intercostal/diaphragmatic innervation depending on level) and the cervical spine is immobilized. The clinical priority shifts to managing complications of cord injury.
Neurogenic detrusor areflexia in spinal shock causes acute urinary retention; an indwelling Foley catheter must be placed early to prevent bladder overdistention (which itself can cause autonomic dysreflexia, particularly with lesions above T6, and bladder rupture). Foley placement also enables strict urine output monitoring during resuscitation and is part of the routine ATLS secondary survey in spinal injury.
Imaging (CT cervical spine — the modern initial study; MRI to evaluate cord, ligaments, and disk) follows once the patient is stabilized. High-dose corticosteroids (NASCIS protocol) are NO LONGER recommended for acute spinal cord injury because risks outweigh modest benefits. Hemodynamic and ventilatory support and prompt neurosurgical consultation are core management.
**Why each option:**
**A.** Correct. Foley catheterization is essential to relieve neurogenic urinary retention from spinal shock and monitor output in the trauma resuscitation.
**B.** High-dose corticosteroids (methylprednisolone, NASCIS protocols) are no longer recommended for acute spinal cord injury — modern guidelines find no net benefit and increased complications.
**C.** Cervical x-ray has been largely supplanted by CT cervical spine for acute trauma; either way, immediate imaging is not the FIRST step before basic supportive measures like bladder decompression.
**D.** MRI provides excellent cord/ligament detail but is performed after the patient is hemodynamically stabilized, the airway secured, and basic interventions (catheter, NG tube) completed.