Dr. Huntley's
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Battle’s sign — ecchymosis over the mastoid process of the temporal bone — is typically the only outward sign of a basilar skull fracture. In fact, this type of fracture may go undetected even by skull X-rays. If left untreated, it can cause death due to involvement of nearby cranial nerves, brain stem, blood vessels, or meninges.
Appearing behind one or both ears, Battle’s sign is easily overlooked or hidden by the patient’s hair. During emergency care of a trauma victim, it may be overshadowed by more visible or imminently life-threatening injuries.
A force strong enough to fracture the base of the skull causes Battle’s sign by damaging supporting tissues of the mastoid area and causing seepage of blood from the fracture site to the mastoid. Battle’s sign usually develops 24 to 36 hours after the fracture and may persist for weeks.
Act Now: If you observe Battle’s sign, keep the patient flat and monitor neurologic signs closely. Prepare him for skull X-rays and a computed tomography (CT) scan.
Obtain the patient’s history, noting recent trauma to the head such as involvement in a motor vehicle accident. Assess his level of consciousness and the appropriateness of his responses to your questions.
Perform a complete neurologic assessment. Check the patient’s vital signs; stay alert for widening pulse pressure and bradycardia — these are signs of increased intracranial pressure. Assess cranial nerve (CN) function in CN II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Assess for cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. Test drainage to determine the presence of CSF. Follow the neurologic examination with a complete physical examination to detect other injuries associated with a basilar skull fracture.
Children who are victims of abuse frequently sustain basilar skull fractures from severe blows to the head. As in adults, Battle’s sign may be the only outward sign of fracture and, perhaps, the only clue to child abuse. If you suspect child abuse, follow facility protocol for reporting the incident.
Many elderly people experience some degree of functional loss with serious effects (such as falling) that can precipitate a basilar skull fracture. Elder neglect and abuse is also on the rise and should be considered when examining older patients.
Assess the patient’s neurologic function frequently. Keep him in a supine position to decrease pressure on dural tears and to minimize CSF leakage. Avoid nasogastric intubation and nasopharyngeal suction, which may cause cerebral infection. Also, caution the patient against blowing his nose, which may worsen a dural tear.
The patient may need skull X-rays and a CT scan to help confirm a basilar skull fracture and to evaluate the severity of the head injury. Typically, a basilar skull fracture and associated dural tears heal spontaneously within several days to weeks. However, if the patient has a large dural tear, a craniotomy may be necessary to repair the tear with a graft patch. If the injury was due to abuse, notify the appropriate authority in the facility.
Explain all procedures and tests. Inform the patient with a basilar skull fracture that he’ll require bed rest for several days to weeks. Explain the need to avoid placing pressure on the brain tissue, and advise him on proper positioning. Also tell him to refrain from blowing his nose.
If the injury was due to an accidental fall, advise the patient’s family to assess the household for safety hazards and remove precipitating factors such as throw rugs.
Read excerpts from these other book chapters related to Brain swelling:
Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-624-5 
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