What is the diagnosis for a patient with no medical history, normal vital signs, a Glasgow Coma Scale (GCS) score of 14, bloody fluid from the left ear, and bruising behind the ear after being hit on the head?

Basilar Skull Fracture

This patient has a basilar skull fracture, evidenced by the classic clinical signs of hemotympanum (bloody fluid from the ear) and Battle's sign (retroauricular/postauricular bruising). 1

Clinical Presentation and Diagnosis

The combination of findings in this patient is pathognomonic for basilar skull fracture:

• Hemotympanum (bloody fluid from left ear) is a direct sign of basilar skull fracture involving the temporal bone 1
• Battle's sign (bruising behind the ear/retroauricular hematoma) is a classic sign of basilar skull fracture, though it may take hours to develop 1
• GCS of 14 automatically classifies this patient as high-risk regardless of other findings 1

Risk Stratification

According to the American College of Radiology PECARN criteria, this patient meets high-risk criteria for severe intracranial injury:

• GCS = 14 OR signs of basilar skull fracture places patients in the high-risk category 1
• This patient has both findings, making the risk particularly elevated 1
• Signs of basilar skull fracture include: rhinorrhea, otorrhea (bloody fluid from ear), hemotympanum, retroauricular hematoma (Battle's sign), and periorbital hematoma 1

Immediate Management Priorities

CT imaging is mandatory and should be performed immediately without delay:

• Brain CT scan should be performed systematically and without delay in any patient with GCS ≤ 14 1
• Patients with signs of basilar skull fracture require CT imaging regardless of GCS score 1
• The combination of GCS 14 and basilar skull fracture signs creates extremely high risk for clinically significant intracranial injury requiring intervention 1

Hospital admission with close neurological observation is required:

• Patients with GCS 14 and signs of basilar skull fracture require admission to a monitored setting for serial neurological assessments 2
• Hourly neurological assessments should focus on GCS score, pupillary size and reactivity, motor strength, and level of confusion/orientation 2
• Serial GCS scores are critical, as deterioration from GCS 14 strongly predicts need for neurosurgical intervention 3

Neurosurgical Consultation

Immediate neurosurgical consultation should be obtained:

• Patients with GCS 14 have approximately 23% risk of positive CT findings requiring intervention 3
• The presence of basilar skull fracture significantly increases the likelihood of associated intracranial hemorrhage or contusion 1
• Clinical deterioration can occur rapidly, and the window for optimal surgical intervention may be missed without specialist involvement 3

Critical Pitfalls to Avoid

• Do not assume GCS 14 represents "mild" head injury - this is a moderate traumatic brain injury requiring aggressive management 1
• Do not delay CT imaging to observe the patient first - imaging must be immediate 1
• Do not discharge based on "normal vital signs" - vital signs do not predict intracranial injury severity in head trauma 1
• Do not underestimate basilar skull fracture - these fractures are associated with significant morbidity including CSF leak, meningitis risk, and associated intracranial injuries 1