CASE SCENARIO

I. OVERVIEW OF THE EXISTING HEALTH PROBLEM

TRAUMATIC BRAIN INJURY ( BASILAR SKULL FRACTURE)

Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object that
goes through brain tissue, such as a bullet or shattered piece of skull, also can cause traumatic brain
injury.

Mild traumatic brain injury may affect your brain cells temporarily. More-serious
traumatic brain injury can result in bruising, torn tissues, bleeding and other physical
damage to the brain. These injuries can result in long-term complications or death.

BASILAR SKULL FRACTURE

A basilar skull fracture is a break of a bone in the base of the skull. Symptoms may
include bruising behind the ears, bruising around the eyes, or blood behind the ear drum.
A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and may result in fluid
leaking from the nose or ear.

The base of the skull is a complex structure that forms the floor of the cranial cavity and separates the
brain from the head and neck. It is composed of the temporal, occipital, sphenoid, and ethmoid bones
as well as the orbital part of the frontal bone. These bones contain numerous openings, or foramina,
that allow cranial nerves and blood vessels to pass from one region to another. With skull base
fractures, these structures can become damaged, resulting in serious and potentially life-threatening
complications.
 II. PROFILE OF THE PATIENT

PATIENT’S INFORMATION

FIRST NAME:
LAST NAME:
SEX:
AGE:
VITAL SIGNS:
PATIENT’S COMPLAINT:

III. ETIOLOGY

Most basilar skull fractures occur in the setting of severe head traumas, such as those
caused by motor vehicle accidents, motorcycle crashes, or pedestrian injuries. Other less
common causes include falls, penetrating injuries (e.g., gunshot wound), and assaults.
Because of the high amount of force required to produce a basilar skull fracture, these
types of fractures are more common in young individuals who are more likely to take part
in high-risk activities (e.g., rock climbing, skydiving, bungee jumping, etc.)

A basilar skull fracture is a break of a bone in the base of the skull. Symptoms may
include bruising behind the ears, bruising around the eyes, or blood behind the ear drum.
A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and may result in fluid
leaking from the nose or ear.
 IV. SIGNS AND SYMPTOMS

Clinical features of basilar skull fractures vary depending on the degree of the associated
brain and cranial nerve injury.
Patients may present with altered mental status, nausea, and vomiting. Oculomotor
deficits due to injuries to cranial nerves III, IV, and VI may be present. Patients may also
present with facial droop due to compression or injury to cranial nerve VII. Hearing loss
or tinnitus suggests damage to cranial nerve VIII.
Several clinical signs highly predictive of a basilar skull fracture include:

1.) Hemotympanum

Fractures that involve the petrous ridge of the temporal bone will cause blood to
pool behind the tympanic membrane causing it to appear purple. This usually
appears within hours of injury and may be the earliest clinical finding.

2.) Cerebrospinal fluid (CSF) rhinorrhea or otorrhea

“Halo” sign is the double ring pattern described when bloody fluid from the ear or
nose containing CSF is dripped onto paper or linen. This sign is based on the
principle of chromatography; components of a liquid mixture will separate when
traveling through a material. This sign is not specific to the presence of CSF, as
saline, tears or other liquids will also produce a ring pattern when mixed with
blood. CSF leaks may be delayed hours to days after the initial trauma.

3.) Periorbital ecchymosis (raccoon eyes)

Pooling of blood surrounding the eyes is most commonly associated with
fractures of the anterior cranial fossa. This finding is typically not present during
the initial evaluation and is delayed by 1 to 3 days. If bilateral, this finding is
highly predictive of a basilar skull fracture.

4.) Retroauricular or mastoid ecchymosis (Battle sign)

 Pooled blood behind the ears in the mastoid region is associated with fractures to
the middle cranial fossa. Like Raccoon eyes, this finding is frequently delayed by
1 to 3 days.

5.) Middle ear injury is seen in nearly one-third of patients and may present with
hemotympanum, disruption of the ossicles, hearing loss, and even CSF leak.

6.) Other features include dizziness, tinnitus, and nystagmus

 V. ANATOMY AND PHYSIOLOGY

Basilar skull fractures most commonly involve the temporal bones but may involve
the occipital, sphenoid, ethmoid, and the orbital plate of the frontal bone as well.

SKULL- is a skeletal framework of the head of vertebrates, composed

of bones or cartilage, which form a unit that protects the brain and some sense organs.
The upper jaw, but not the lower, is part of the skull. The human cranium, the part that
contains the brain, is globular and relatively large in comparison with the face. In most
other animals the facial portion of the skull, including the upper teeth and the nose, is
larger than the cranium. In humans the skull is supported by the highest vertebra, called
the atlas, permitting nodding motion. The atlas turns on the next-lower vertebra, the axis,
to allow for side-to-side motion.

VI. PATHOPHYSIOLOGY
LABORATORY STUDY

1.) Blood tests

blood test may help predict recovery from traumatic brain injury High levels of
a key blood protein point to brain shrinkage and damage to message-sending
axons The fatty material surrounding fibers that send signals between neurons
degenerates after a traumatic brain injury. A new study pinpoints a blood
biomarker that can predict this damage.

2.) X-ray
A diagnostic test that uses invisible electromagnetic energy beams to produce
images of internal tissues, bones, and organs onto film.

3.) Magnetic resonance imaging (MRI)

A diagnostic procedure that uses a combination of large magnets,
radiofrequencies, and a computer to produce detailed images of organs and
structures within the body.

4.) Computed tomography scan (also called a CT or CAT scan)

A diagnostic imaging procedure that uses a combination of X-rays and computer
technology to produce horizontal, or axial, images (often called slices) of the body.
A CT scan shows detailed images of any part of the body, including the bones,
muscles, fat, and organs. CT scans are more detailed than general X-rays.
Although an X-ray is useful when looking for a skull fracture, most skull fractures
can also be detected by a CT scan, which also produces images of the brain. If a
brain injury is suspected, a CT scan alone may be used to reduce the amount of
radiation the patient receives,

5.) Electroencephalogram (EEG)

 A procedure that records the brain's continuous, electrical activity by means of
electrodes attached to the scalp.

VII. MEDICAL MANAGEMENT

Step 1: Assess the severity of the skull injury. This will involve a thorough examination, including
imaging studies such as X-rays, CT scans, or MRI scans, to determine the type and extent of the
fracture.

Step 2: Manage pain and prevent infection. Pain management may include over-the-counter pain
relievers or prescription medications, depending on the severity of the pain. Antibiotics may be
prescribed to prevent infection, especially if there is an open wound or if bone fragments have
penetrated the skin.

Step 3: Observe for signs of brain injury. This may involve monitoring the patient's neurological status,
including their level of consciousness, pupil response, and motor function. Any changes in these areas
may indicate a brain injury that requires further evaluation and treatment.

Step 4: Determine the need for surgical intervention. If the fracture is severe, involves significant
deformity, or if there are bone fragments in the brain, surgery may be necessary to repair the fracture or
remove the fragments. This decision will be based on the patient's overall condition, the severity of the
injury, and the potential risks and benefits of surgery.

Step 5: Provide appropriate follow-up care. After the initial treatment, the patient will need ongoing
care to monitor their recovery and ensure that any complications are addressed promptly. This may
include additional imaging studies, physical therapy, or other interventions as needed.

VIII. SURGICAL MANAGEMENT

IX. DRUG STUDY
X. NURSING CARE PLAN