NREMT Paramedic Cognitive ExamTraumaHard
A 28-year-old male is found unresponsive after a high-speed motor vehicle collision. He has paradoxical chest wall movement on the right side. His jugular veins are distended, and breath sounds are absent on the right. Tracheal deviation is not noted. Which of the following conditions is most consistent with these findings?
- AMyocardial contusion with hemorrhagic shock
- BFlail chest with pericardial tamponade
- COpen pneumothorax with tension pneumothorax
- DFlail chest with massive hemothorax
Show answer & explanationAnswer & explanation
Correct answer: D. Flail chest with massive hemothorax
Paradoxical chest wall movement indicates a flail chest. Absent breath sounds on the right and jugular vein distension (JVD) without tracheal deviation strongly suggest a massive hemothorax, where significant blood accumulation collapses the lung and increases intrathoracic pressure, but does not typically cause tracheal shift as early as a tension pneumothorax.
Why the other options are wrong
- A. Myocardial contusion might explain JVD (if it causes heart failure), but it wouldn't cause absent breath sounds or paradoxical chest wall movement. Hemorrhagic shock would present with hypotension and tachycardia.
- B. Pericardial tamponade would cause JVD, but absent breath sounds are not a primary sign, and paradoxical chest movement is from flail chest, not tamponade.
- C. An open pneumothorax would have a sucking chest wound. A tension pneumothorax would cause absent breath sounds and JVD, but typically also causes tracheal deviation (which is absent here).
Massive Hemothorax
Rapid accumulation of more than 1500 mL of blood in the pleural space, often from chest wall or mediastinal vessel injury, leading to lung collapse and hypovolemic shock.
- Causes absent breath sounds on affected side.
- Can lead to jugular vein distension due to mediastinal shift or hypovolemia affecting venous return.
- Hypotension and tachycardia are common due to blood loss.
Memory trick: Chest Check: Breath, Blood, Bones, Big Veins