What is the likely diagnosis and management for an 82-year-old female patient involved in a car vs truck accident, presenting with a Glasgow Coma Scale (GCS) score of 7, unconsciousness, a baseball-sized occipital hematoma, subdural bleeding with midline shift on imaging, and a chunky bloody nose resembling bone or brain tissue?

Cerebrospinal Fluid Rhinorrhea from Basilar Skull Fracture

The "chunky bloody nose" material was most likely cerebrospinal fluid (CSF) mixed with blood and bone fragments from a basilar skull fracture, which represents a critical neurosurgical emergency requiring immediate specialized care. 1

What This Finding Indicates

This patient has a basilar skull fracture with CSF rhinorrhea, which is one of the classic signs mandating immediate CT imaging in traumatic brain injury. 1 The presence of rhinorrhea (CSF leaking from the nose) in the context of severe TBI with GCS 7, subdural hematoma, and midline shift indicates:

• Direct communication between the intracranial space and the external environment through a skull base fracture 1
• Extremely high risk for meningitis if not managed appropriately
• Confirmation of severe, multi-compartment traumatic brain injury beyond just the subdural hematoma

The "chunky" appearance likely represents:

• CSF mixed with blood (creating a viscous, bloody fluid)
• Bone fragments from the fractured skull base
• Possibly dural tissue torn during the fracture

Immediate Management Priorities

Airway and Transfer

This patient requires immediate intubation (GCS 7 = severe TBI with GCS ≤8) and emergent transfer to a specialized neurosurgical center. 1 The combination of:

• GCS 7 (inability to protect airway)
• Subdural hematoma with midline shift
• Basilar skull fracture with CSF leak

creates a 75% mortality risk if secondary insults (hypotension, hypoxia) are not prevented. 1

Physiological Targets During Transport

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury 1, 2
• Maintain EtCO2 between 30-35 mmHg prior to arterial blood gas confirmation 1

Neurosurgical Intervention Indications

This patient meets absolute criteria for emergency neurosurgical evacuation based on: 1

• Subdural hematoma with midline shift (surgical indication regardless of thickness when midline shift is present)
• GCS 7 (severe TBI requiring surgical decompression)
• Basilar skull fracture (may require repair to prevent meningitis)

The 82-year-old age is not a contraindication to surgery when the patient has a monitorable neurological exam and meets surgical criteria. 3, 4 However, the GCS 7 with midline shift indicates this patient is beyond "monitorable" status and requires immediate intervention.

Critical Management Pitfalls to Avoid

Do NOT Delay Transfer

Specialized neuro-intensive care with neurosurgical capabilities is associated with significantly improved survival even in elderly patients with severe TBI. 1 Mortality is lower in neurosurgical centers compared to non-specialized centers, even for patients who don't ultimately require surgery. 1

Do NOT Pack the Nose

• Never pack the nose or attempt to stop CSF rhinorrhea in basilar skull fractures, as this increases infection risk
• The CSF leak allows decompression and should not be obstructed

Do NOT Administer Long-Acting Sedatives Before Neurosurgical Evaluation

Avoid long-acting sedatives or paralytics before neurosurgical assessment, as this masks clinical deterioration and prevents serial GCS monitoring. 3 Use short-acting agents only if intubation is required for airway protection.

Do NOT Make Premature Prognostic Decisions

No irreversible treatment limitation decisions should be made before 72 hours unless brain death criteria are met or there is clear clinical deterioration. 3, 5 Failure to show neurological improvement within 72 hours is a negative prognostic factor, but the 72-hour window must be observed. 5

Expected Clinical Course

This patient has an extremely high mortality risk (approximately 75% with secondary insults, 25% with optimal management). 1, 6 The combination of:

• Advanced age (82 years)
• Severe TBI (GCS 7)
• Subdural hematoma with midline shift
• Basilar skull fracture with CSF leak

represents one of the most severe traumatic brain injury presentations. However, with immediate neurosurgical intervention and prevention of secondary insults, survival is possible. 1

Serial neurological examinations every 15 minutes for the first 2 hours, then hourly for 12 hours, are essential to detect any improvement or deterioration. 3 Pupillary examination at each assessment is critical, as pupillary changes indicate herniation and require immediate surgical intervention. 3