You have a 30-year-old patient who was the driver of a vehicle that was hit in the driver’s side door. The patient is unresponsive, trachea is midline, neck veins are flat, lung sounds are absent on the left side, and percussion reveals hyporesonance. The patient has a rapid carotid pulse and absent radial pulses and is not demonstrating any paradoxical breathing, though appears to have some broken ribs on the left side. The abdomen is flat and non-tender. Which of the following is this patient MOST likely suffering from? ? Rupture of the aorta. ? Massive hemothorax. ? Simple pneumothorax. ? Tension pneumothorax.
The Correct Answer and Explanation is:
Correct Answer: Massive Hemothorax
Explanation:
This 30-year-old trauma patient presents with findings most consistent with a massive hemothorax, a life-threatening accumulation of blood in the pleural space that compromises ventilation and circulation. The clinical presentation includes absent breath sounds on the left, hyporesonance to percussion, flat neck veins, signs of hypovolemic shock (rapid carotid pulse with absent radial pulses), and evidence of blunt chest trauma (e.g., fractured ribs on the left).
In massive hemothorax, more than 1,500 mL of blood typically accumulates in the thoracic cavity. This explains the absent lung sounds and dullness (hyporesonance) on percussion on the affected side. Dullness (rather than hyperresonance) helps differentiate it from a pneumothorax, in which air in the pleural space causes hyperresonance.
The flat neck veins indicate hypovolemia, which is characteristic of significant blood loss, and also help rule out tension pneumothorax, which usually presents with distended neck veins due to increased intrathoracic pressure impeding venous return. Also, the trachea is midline here, whereas in tension pneumothorax, it is typically deviated away from the affected side.
A simple pneumothorax would not cause hemodynamic compromise (e.g., weak peripheral pulses), and breath sounds might be decreased but not necessarily absent.
Ruptured aorta may occur with significant deceleration trauma, but it typically presents with hypotension, upper extremity hypertension, or neurologic deficits due to compromised blood flow, and does not explain the unilateral absence of breath sounds and hyporesonance.
In summary, the constellation of findings — especially absent breath sounds, hyporesonance, flat neck veins, signs of shock, and chest trauma — is most consistent with a massive hemothorax, which requires immediate intervention such as chest tube placement and possibly surgical exploration.
