TCRN Head and Neck Trauma Questions and Answers — Questions and Answers
Question 1: A trauma patient presents with periorbital ecchymosis (raccoon eyes), postauricular ecchymosis (Battle's sign), and clear fluid draining from the nares. Which type of head injury are these findings most indicative of?
- Epidural hematoma
- Basilar skull fracture (Correct answer)
- Le Fort III fracture
- Diffuse axonal injury
Correct answer: Basilar skull fracture
The classic signs of a basilar skull fracture include periorbital ecchymosis (raccoon eyes), postauricular ecchymosis (Battle's sign), hemotympanum (blood behind the eardrum), and cerebrospinal fluid (CSF) rhinorrhea or otorrhea. [2, 3, 4, 5] These signs result from fractures to the bones at the base of the skull.
Question 2: A patient involved in a high-speed motor vehicle collision has significant mid-face trauma, including mobility of the entire maxilla and zygomatic bones, resulting in craniofacial disjunction. Which Le Fort fracture classification does this presentation represent?
- Le Fort I
- Le Fort II
- Le Fort III (Correct answer)
- Le Fort IV
Correct answer: Le Fort III
A Le Fort III fracture, also known as craniofacial disjunction, is the most severe type of Le Fort fracture. It involves a transverse fracture line that passes through the nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch, effectively separating the entire facial skeleton from the cranial base. [17, 23, 27] Le Fort I is a horizontal maxillary fracture, and Le Fort II is a pyramidal fracture.
Question 3: A trauma nurse is assessing a patient with a penetrating neck injury located in Zone II. Which of the following is considered a 'hard sign' of significant vascular or airway injury, mandating immediate surgical exploration?
- Dysphonia
- Non-expanding hematoma
- Subcutaneous emphysema
- Pulsatile external bleeding (Correct answer)
Correct answer: Pulsatile external bleeding
Hard signs of penetrating neck trauma indicate a high probability of significant injury and often require immediate surgical intervention. These signs include active, pulsatile bleeding, an expanding hematoma, shock, diminished carotid pulse, bruit or thrill, and signs of airway obstruction like stridor. [7, 18] Dysphonia, non-expanding hematoma, and subcutaneous emphysema are considered 'soft signs,' which warrant further diagnostic evaluation but not necessarily immediate surgery.
Question 4: A patient arrives after being struck in the anterior neck with a baseball bat. They are hoarse, have subcutaneous emphysema, and are in moderate respiratory distress. What is the most appropriate initial airway management strategy for this patient?
- Rapid sequence intubation (RSI)
- Nasotracheal intubation
- Awake surgical cricothyroidotomy or tracheostomy (Correct answer)
- Placement of a supraglottic airway device
Correct answer: Awake surgical cricothyroidotomy or tracheostomy
In patients with suspected severe laryngeal or tracheal trauma, attempts at endotracheal intubation can worsen the injury, create a false passage, or cause complete airway obstruction. [16, 21, 22] Therefore, the safest and most definitive airway is an awake surgical airway (cricothyroidotomy or tracheostomy), performed by an experienced provider, to bypass the injured area.
Question 5: According to the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, which of the following findings would require cervical spine imaging in a trauma patient?
- Absence of posterior midline cervical spine tenderness
- Normal level of alertness
- A distracting painful injury, such as a femur fracture (Correct answer)
- No evidence of intoxication
Correct answer: A distracting painful injury, such as a femur fracture
The NEXUS criteria are used to clinically clear the cervical spine without imaging. Imaging is required if any of the five criteria are met: 1) posterior midline cervical tenderness, 2) focal neurologic deficit, 3) altered level of consciousness, 4) evidence of intoxication, or 5) a distracting painful injury. [1, 13] A distracting injury may prevent the patient from accurately reporting neck pain.
Question 6: A patient is diagnosed with a Le Fort I fracture following an assault. The primary goal in the surgical management of this specific fracture is to restore:
- Craniofacial height
- Naso-orbital-ethmoid complex
- Functional dental occlusion (Correct answer)
- Zygomatic projection
Correct answer: Functional dental occlusion
A Le Fort I fracture is a horizontal fracture of the maxilla that separates the tooth-bearing portion of the upper jaw from the rest of the midface. The primary goal of treatment is to restore the patient's pre-injury dental occlusion (how the teeth fit together) and ensure proper masticatory function. [14, 29] This is typically achieved through open reduction and internal fixation, often with the use of intermaxillary fixation to guide the reduction.
TCRN Head and Neck Trauma Questions and Answers
A trauma patient presents with periorbital ecchymosis (raccoon eyes), postauricular ecchymosis (Battle's sign), and clear fluid draining from the nares.
Which type of head injury are these findings most indicative of?