“raccoon eyes.” The most common basilar skull fractureinvolves the
petrous portion of the temporal bone, the external auditory canal, and the
tympanic membrane. It is commonly associated with a torn dura leading to
cerebrospinal fluid (CSF) otorrhea or rhinorrhea. Other signs and symp-
toms of a basilar skull fracture include hemotympanum (eg, blood in the
tympanic cavity of the middle ear), vertigo, decreased hearing or deafness,
and seventh nerve palsy. Periorbital and mastoid ecchymosis develop grad-
ually over hours after an injury and are often absent in the ED. If clear or
pink fluid is seen from the nose or ear and a CSF leak is suspected, the fluid
can be placed on filter paper and a “halo” or double ring may appear. This
is a simple but nonsensitive test to confirm a CSF leak. Evidence of open
communication, such as a CSF leak, mandates neurosurgical consultation
and admission.
(a)LeFort factures typically result from high-energy facial trauma and
are classified according to their location. A LeFort Iinvolves a transverse
fracture just above the teeth at the level of the nasal fossa, and allows move-
ment of the alveolar ridge and hard palate. A LeFort IIis a pyramidal frac-
ture with its apex just above the bridge of the nose and extending laterally
and inferiorly through the infraorbital rims allowing movement of the max-
illa, nose, and infraorbital rims. A LeFort IIIrepresents complete craniofa-
cial disruption and involves fractures of the zygoma, infraorbital rims, and
maxilla. It is rare for these fractures to occur in isolation; they usually occur
in combination. (c and d)Otitis interna and externa are inflammation of
the inner ear and outer ear, respectively, and are not relevant in acute
trauma.(e)Tripod fractures typically occur from blunt force applied to the
lateral face causing fractures of zygomatic arch, the lateral orbital rim, the
inferior orbital rim, and the anterior and lateral walls of the maxillary sinus.
These fractures present clinically with asymmetrical facial flattening, edema,
and ecchymosis.
142.The answer is e.(Tintinalli, pp 1537-1540.)Based on the principles
of advanced trauma life support (ATLS), injured patients are assessed and
treated in a fashion that establishes priorities based on their presenting vital
signs, mental status, and injury mechanism. The approach to trauma care
consists of a primary survey, rapid resuscitation, and a more thorough sec-
ondary survey followed by diagnostic testing. The goal of the primary sur-
vey is to quickly identify and treat immediately life-threatening injuries. The
assessment of the ABCDEs (airway, breathing, circulation, neurologic
disability, exposure)is a model that should be followed in all patients.
Trauma Answers 159