Raccoon eyes
Raccoon eyes: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Raccoon eyes are bilateral periorbital ecchymoses that don’t result from facial soft-tissue trauma. Usually an indicator of basilar skull fracture, this sign develops when damage at the time of fracture tears the meninges and causes the venous sinuses to bleed into the arachnoid villi and the cranial sinuses. Raccoon eyes may be the only indicator of a basilar skull fracture, which isn’t always visible on skull X-rays. Their appearance signals the need for careful assessment to detect any underlying trauma because a basilar skull fracture can injure cranial nerves, blood vessels, and the brain stem. Raccoon eyes can also occur after a craniotomy if the surgery causes a meningeal tear.
History and physical examination
After raccoon eyes are detected, check the patient’s vital signs and try to find out when the head injury occurred and the nature of the head injury. (See Recognizing raccoon eyes.) Then evaluate the extent of underlying trauma.
Start by evaluating the patient’s level of consciousness (LOC) using the Glasgow Coma Scale. (See Using the Glasgow Coma Scale, page 480.) Next, evaluate function of the cranial nerves, especially the first (olfactory), third (oculomotor), fourth (trochlear), sixth (abducens), and seventh (facial). If the patient’s condition permits, test his visual acuity and gross hearing. Note any irregularities in the facial or skull bones, as well as any swelling, localized pain, a Battle’s sign, or lacerations of the face or scalp. Check for ecchymoses over the mastoid bone. Inspect for hemorrhage or cerebrospinal fluid (CSF) leakage from the nose or ears.
Test any drainage with a sterile 4” x 4” (gauze pad, and note whether you find a halo sign—a circle of clear fluid that surrounds the drainage, indicating CSF. Use a glucose reagent stick to test any clear drainage for glucose. An abnormal test result indicates CSF, because mucus doesn’t contain glucose.
Medical causes
Basilar skull fracture
This injury produces raccoon eyes after head trauma that doesn’t involve the orbital area. Associated signs and symptoms vary with the fracture site and may include pharyngeal hemorrhage, epistaxis, rhinorrhea, otorrhea, and a bulging tympanic membrane from blood or CSF. The patient may experience difficulty hearing, headache, nausea, vomiting, cranial nerve palsies, and altered LOC. He may also exhibit a positive Battle’s sign.
Other causes
Surgery
Raccoon eyes occurring after craniotomy may indicate a meningeal tear and bleeding into the sinuses.
Special considerations
Keep the patient on complete bed rest. Perform frequent neurologic evaluations to reevaluate his LOC. Check vital signs hourly; be alert for such changes as bradypnea, bradycardia, hypertension, and fever. To avoid worsening a dural tear, instruct the patient not to blow his nose, cough vigorously, or strain. If otorrhea or rhinorrhea is present, don’t attempt to stop the flow. Instead, place a sterile, loose gauze pad under the nose or ear to absorb the drainage. Monitor the amount and test it with a glucose reagent strip to confirm or rule out CSF leakage.
To prevent further tearing of the mucous membranes and infection, never suction or pass a nasogastric tube through the patient’s nose. Observe the patient for signs and symptoms of meningitis, such as fever and nuchal rigidity, and expect to administer a prophylactic antibiotic.
Prepare the patient for diagnostic tests, such as skull X-ray and, possibly, a computed tomography scan. If the dural tear doesn’t heal spontaneously, contrast cisternography may be performed to locate the tear, possibly followed by corrective surgery.
Pediatric pointers
Raccoon eyes in children are usually caused by a basilar skull fracture after a fall.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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