S.B. is a 22-year-old man who lost control of an all-terrain utility vehicle and struck a tree. He was not

Question

restrained and his face hit the windshield on impact. When paramedics arrived, S.B.

was responsive but
confused, had significant facial swelling, and complained of pain in his right wrist and left forearm. The
paramedics initiated cervical spine precautions, started oxygen at 15 L/min via a non-rebreather mask,
and started a 16-gauge intravenous (IV) line with 0.9% normal saline. His vital signs (VS) were 120/75, 125,
36, and Spo2 94%. On arrival at the local emergency department (ED) 15 minutes later, his VS are 110/62,
110 regular, 28 to 32 and shallow, and Spo2 99%. An additional 16-gauge IV is inserted, and samples are
drawn for the following laboratory tests: complete blood count (CBC), type and crossmatch, complete
metabolic panel, prothrombin time/partial thromboplastin time (PT/PTT) and international normalized
ratio (INR), and alcohol level. The trauma physician completes a head-to-toe assessment; the findings are
shown in the chart.
Chart View
Physician Note
Obeys commands, responds to voice, but not oriented to time or place. Generalized facial edema
with full-thickness 2-cm cheek laceration. Blood behind left tympanic membrane, edema with
slight discoloration over left mastoid process. Clear drainage coming from the left naris. Mid- to
upper-chest contusions without crepitus, breath sounds clear. Abdomen slightly firm but not
tender. Catheterized for 500 mL clear yellow urine; negative for blood, glucose, ketones. Positive
deformity of right wrist and diffuse tenderness of left lower forearm.
What is the significance of the slight discoloration over the left mastoid process, blood
behind the left tympanic membrane, and drainage from the nose?

Answer 1

These findings indicate the likelihood of a basilar skull fracture (BSF).