NREMT Paramedic Cognitive ExamTraumaHard
A 19-year-old male is found at the base of a cliff after falling approximately 50 feet. He is unconscious, GCS 4. His pupils are unequal, with the right pupil dilated and fixed. Vitals are BP 180/80 mmHg, HR 55 bpm, RR 8 bpm. There is no external bleeding. Based on these findings, which of the following is the most likely underlying injury?
- ADiffuse axonal injury
- BAcute epidural hematoma
- CSubdural hematoma
- DSubarachnoid hemorrhage
Show answer & explanationAnswer & explanation
Correct answer: B. Acute epidural hematoma
The classic presentation of an acute epidural hematoma includes a lucid interval (though not always present, especially in severe cases like this fall), rapid neurological deterioration, ipsilateral pupillary dilation (right pupil dilated and fixed), and signs of increased ICP (Cushing's Triad: hypertension, bradycardia, bradypnea). The initial impact can cause a skull fracture and laceration of the middle meningeal artery.
Why the other options are wrong
- A. Diffuse axonal injury (DAI) is associated with immediate and prolonged unconsciousness, but specific focal signs like a unilateral fixed and dilated pupil are less characteristic than for a hematoma causing direct brain compression.
- C. Subdural hematomas typically have a slower onset of symptoms and are more common in the elderly or those with chronic alcohol use, though acute subdural can be severe. The specific pupil and vital sign combination points more to epidural.
- D. Subarachnoid hemorrhage often presents with a sudden, severe headache ('worst headache of my life') and nuchal rigidity, and while it can cause increased ICP, the specific pupil and vital signs are less classic than for epidural.
Acute Epidural Hematoma
A collection of blood between the dura mater and the skull, typically caused by arterial bleeding (often middle meningeal artery) from a skull fracture, leading to rapid neurological deterioration.
- Often associated with a 'lucid interval' followed by rapid decline.
- Classic signs include ipsilateral pupil dilation and contralateral motor deficits.
- A surgical emergency requiring immediate decompression.
Memory trick: Brain Bleeds: Epidural Fast, Subdural Slow, SAH Thunder, DAI Diffuse