WHAT’S YOUR DIAGNOSIS?

FACIAL BRUISING AND ALTERED MENTAL STATUS AFTER A FALL

Jennifer Junnila, MD, LTC, MC, USA

A pediatric patient with this presentation had normal vital signs and no other indications of serious trauma. Can you guess what these signs suggest?

three-year-old boy, withdrawal from painful stimuli) possibility of an intracranial abnor- with an unremarkable (Table). The remainder of the exami- mality. Periorbital ecchymosis medical history, was nation was unremarkable, with no (sometimes called “raccoon eyes”) A brought to the U.S. Army other signs of serious trauma. and retroauricular ecchymosis Hospital at Bagram, Afghanistan (also know as Battle’s sign) specifi- after he had fallen approximately What’s your diagnosis? cally suggest a basilar skull frac- 8 ft from the roof of his home. ture. In most cases, this fracture Upon admission, he was placed in OUR DIAGNOSIS occurs at the temporal bone, lead- a cervical collar and was immobi- Suspecting a basilar skull fracture, ing to such common signs as cere- lized on a spine board. we performed a computed tomog- brospinal fluid (CSF) rhinorrhea Physical examination revealed raphy (CT) scan of the brain. The and otorrhea, hemotympanum, and facial bruising predominately CT revealed a fracture in the orbital pneumocephalus. Additionally, be- around the left eye and left roof portion of the left frontal bone, cause basilar fractures can com- retroauricular area (Figure 1). with probable extension into the press the cranial nerves that pass His pupils were equal in size and sphenoid (Figure 2). through the basal foramina, the pa- reactive to light. The patient responded well to tient may display facial paralysis, His vital signs were stable, with supportive care. Within about 48 hearing loss, nystagmus, and other normal respirations. His Glascow hours, he was alert enough to re- neurologic symptoms. Coma Scale (GCS) score was 10 ceive oral nutrition. He recovered The case presented here, how- (inappropriate speech, eye opening fully with no observed neurologic ever, underscores the fact that basi- upon verbal stimulation, and sequelae after seven days (Figure 3). lar skull fracture should not be excluded from the differential diag- ABOUT THE CONDITION nosis of a patient with altered men- LTC Junnila is a family physician and faculty development fellow at the Madigan Army Medical Altered mental status following a tal status and facial bruising after a Center, Tacoma, WA. fall should alert clinicians to the fall—even when vital signs are nor-

10 • FEDERAL PRACTITIONER • JUNE 2005 sociated with this type of skull frac- the skull base and possibly intro- ture, and as such, patients should duce bacteria into the skull. If be immobilized on a spinal board ventilatory support is required, tra- with a cervical collar until thor- cheostomy or orotracheal intuba- oughly assessed for other injuries. tion is preferred. Initial treatment should focus on If a dural tear occurs secondary maintaining ventilatory stability, to a basilar skull fracture, infection avoiding hypotension, and prevent- also may be introduced into the ing hypothermia. cranium through direct spread of Because sedation interferes with organisms from the nasopharynx, neurologic examination and subse- nasal or mastoid sinuses, or the ex- quent treatment, it should be ternal auditory canal. Because the avoided if not clinically indicated. time to possible development of Figure 1. Photograph of the patient showing Reserve intubation for patients meningitis is highly variable, how- periorbital and retroauricular ecchymosis. who meet established clinical cri- ever, antibiotic prophylaxis is not teria, which include a GCS score of recommended in patients with 8 or less, hypoxia, hypercapnia, basilar skull fractures resulting mal and other neurologic abnor- spontaneous hyperventilation, from nonpenetrating head trauma, malities are absent. Although it’s apnea, or loss of gag reflex.2 Na- with or without CSF leakage.3 typically caused by substantial im- sopharyngeal intubation is con- pact forces, basilar skull fracture is traindicated in patients with a Managing basilar skull fracture not always associated with severe suspected basilar skull fracture, as Patients with basilar skull fractures underlying brain injury. insertion risks inadvertent place- typically are managed conserva- Nevertheless, there is the possi- ment of the tube into the cranial tively with neurosurgical consul- bility of other significant trauma as- cavity. This could further disrupt tation. Supportive care should

Table. Glascow Coma Scale (GCS)*,1

Motor response Verbal response Assigned Adults and Infants and Adults and Infants and Eye opening value verbal children preverbal children verbal children preverbal children response† 6Obeys Spontaneous commands

5 Localizes Purposeful/localizes Oriented Coos, babbles

4Withdraws Withdraws Confused Irritable, cries Spontaneous

3Flexor posturing Flexor posturing Inappropriate Cries to pain To voice words

2 Extensor Extensor Incomprehensible Moans to pain To pain posturing posturing sounds

1 None/flaccid None/flaccid None None None

Table adapted from: Pediatric Clinics of North America, Vol. 51, Dias MS, Traumatic brain and spinal cord injury, Pages 271Ð303, Copy- right 2004, with permission from Elsevier. *The patient is assigned a number value from 1 to 6 for each of the three categories (motor, verbal, and eye opening). Combined, these values give the GCS score, which ranges from 3 to 15 points. Scores of 13 to 15 are defined as mild, 9 to 12 as moderate, and 3 to 8 as severe head injuries.1†Same for adults/verbal children and infants/preverbal children.

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JUNE 2005 • FEDERAL PRACTITIONER • 11 WHAT’S YOUR DIAGNOSIS?

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Persistent CSF leakage, which can cause meningitis, may be treated successfully with CSF diversion through serial lumbar punctures, continuous lumbar drainage, or external ventricular drainage. Di- rect surgical repair generally is reserved for cases in which either CSF leaks have persisted beyond one to two weeks despite CSF di- version or the leaks have caused re- peated episodes of meningitis.1 ●

The author would like to thank Figure 3. The patient, fully recovered, after Figure 2. Computed tomography scan of John Iskandar, MD, LTC, MC, seven days. the brain, showing a fracture in the orbital USA, staff neurosurgeon at roof portion of the left frontal bone, with Madigan Army Medical Center, tions, contraindications, warn- probable extension into the sphenoid. Tacoma, WA for assisting in the ings, and adverse effects—before preparation of this manuscript. administering pharmacologic include intravenous hydration and therapy to patients. nutritional supplementation until The opinions expressed herein are the patient’s neurologic status has those of the author and do not nec- REFERENCES improved to the point of tolerating essarily reflect those of Federal 1. Dias MS. Traumatic brain and spinal cord injury. Pediatr Clin North Am. 2004;51:271–303. oral intake. Patients may benefit Practitioner, Quadrant HealthCom 2. Enrione MA. Current concepts in the acute man- from positioning the head of the Inc., the U.S. government, or any agement of severe pediatric head trauma. Clin Pediatr Emerg Med. 2001;2(1):28–40. bed at an elevation of 20º to 30º to of its agencies. This article may 3. ASHP Therapeutic Guidelines for Nonsurgical facilitate adequate cerebral venous discuss unlabeled or investiga- Antimicrobial Prophylaxis. American Society of 2 Health-System Pharmacists. Am J Health Syst and CSF drainage. tional use of certain drugs. Please Pharm. 1999;56:1201–1250. CSF rhinorrhea stops sponta- review complete prescribing infor- 4. Wilberger J, Chen DA. Management of head in- jury. The skull and meninges. Neurosurg Clin N neously in nearly all cases, and CSF mation for specific drugs or drug Am. 1991;2:341–350. otorrhea stops in 85% of cases.4 combinations—including indica-

CLINICAL DIGEST

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N A TIVE A MERICAN tistics have indicated dis- Since the 1950s, the IHS misclassification. The Den- H EALTH proportionately low CVD has compiled mortality ver researchers analyzed mortality rates. Now, re- reports, using population these IHS-adjusted data, Disparity Be- searchers from the Univer- estimates from census along with earlier IHS data sity of Colorado Health reports and vital event data (between 1989 and 1993) tween CVD Risk Sciences Center, Denver from the National Center they adjusted themselves. and Mortality? say the answer to this for Health Statistics, for The adjustments raised Native Americans are at conundrum is that racial roughly 60% of the total mortality rates for heart higher risk for cardiovas- misclassification has con- Native American popula- disease and cerebrovascu- cular disease (CVD) than tributed to falsely low tion. It wasn’t until the lar disease in the IHS popu- the rest of the U.S. popula- CVD mortality rates in 1990s, however, that it lation by 18% and 11%, tion—yet national vital sta- the national data. began to adjust for racial respectively, pushing them

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