| Case of the Month |
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CASE 2 ANSWER The patient had a nasogastric tube inappropriately inserted. The presence of bilateral Raccoon\'s eyes indicates a basilar skull fracture. Remember that fractures about the nose which extend into the cranial vault can make nasogastric or nasoendotracheal intubation risky. The tube may enter the cranial vault, which is obviously a tragic complication.
Traumatic brain injury (TBI) is a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairments of cognitive, physical, and psychosocial functions with an associated diminished or altered state of consciousness. Mechanism of injury: MVAs are the leading cause of TBI in the general population, especially among whites in the United States. MVAs account for approximately 50% of all TBIs.1 The diagnosis of basilar skull fracture should always be ruled out with major impact trauma. The mandibular condyles can perforate into the base of the skull, but more common is the extension of a linear fracture into the floor of the anterior and middle fossae.3 Immediately after trauma, fractured facial bones by themselves are usually unimportant. When you detect them, don\'t worry too much about the face. Instead, concern yourself with the structures that facial bones protect, realizing that the protection is now compromised.2 If the brain took a hit, the cranial vault may be broken, so look for signs: CSF leaks, Battle\'s sign, Raccoon\'s eyes, deformity, brain matter oozing out. The airway may be compromised in several ways: broken teeth, blood or vomitus may be aspirated; a fractured mandible can allow the tongue to occlude the pharynx, render a jaw thrust maneuver worthless, and make oral endotracheal intubation very difficult.2 
Diagnosis:
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This 26 year old male was an unrestrained driver and his head hit the windshield. At the scene of the accident, the paramedic\'s history indicates he had a brief loss of consciousness, with no memory of events leading up to or after the car hit the tree. His Glascow Coma Score was 12. His admitting diagnosis in the Emergency Department was traumatic brain injury, rule out basilar skull fracture.
