A female patient fell from a height onto her lower eyelid yesterday and today presents with periorbital bruising and generalized fatigue; what urgent evaluation and management should be undertaken?

Urgent Evaluation for Basilar Skull Fracture

This patient requires immediate non-contrast CT head imaging to rule out basilar skull fracture, as periorbital ecchymosis developing after head trauma is a classic high-risk sign that mandates urgent CT regardless of mental status. 1

Why This is a High-Risk Presentation

• Periorbital bruising ("blackish discoloration") appearing the day after head trauma is a hallmark sign of basilar skull fracture, automatically placing this patient in the high-risk category that requires immediate CT imaging and hospital admission 1
• The combination of delayed facial swelling with periorbital edema following head trauma specifically triggers the American College of Radiology's recommendation for urgent non-contrast CT head to evaluate for basilar skull fracture 1
• Generalized tiredness may represent subtle altered mental status or post-traumatic fatigue, both concerning in the context of delayed periorbital bruising 1

Immediate Imaging Protocol

• Obtain CT head without IV contrast immediately using bone windows with double fenestration to fully characterize any basilar skull fracture 1
• The scan must include multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 1
• Add thin-section orbital CT with multiplanar reconstructions if the patient reports visual changes, diplopia, or has restricted extraocular movements 1
• CT maxillofacial imaging is superior to plain radiographs for detecting facial fractures, with plain films having only 53-82% accuracy 2

Critical Clinical Assessment Before Imaging

• Check for visual changes or diplopia, which suggest orbital injury or optic nerve involvement requiring additional orbital imaging 1
• Assess for palpable skull fractures by careful palpation 1
• Evaluate occlusion by having the patient bite down—malocclusion indicates midface or mandible fracture 3
• Screen for airway compromise from hemorrhage, soft-tissue edema, or loss of facial architecture 2
• Document Glasgow Coma Scale score, as any score less than 15 is high-risk 1

Hemodynamic Management

• Maintain systolic blood pressure greater than 110 mmHg at all times—even single episodes of hypotension markedly increase mortality in head trauma 1
• Stabilize airway and circulation before CT, but do not delay imaging for non-critical interventions 1

Post-Imaging Management Algorithm

• Request neurosurgical consultation if CT shows intracranial hemorrhage, significant fractures, or mass effect 1
• Obtain CT angiography if basilar skull fracture is confirmed, as these fractures carry high risk for arterial dissection 1
• If naso-orbital-ethmoid fracture is identified, arrange subspecialist management to prevent enophthalmos, telecanthus, lacrimal obstruction, and ptosis 2
• Screen for associated injuries—68% of maxillofacial trauma patients have coexisting head injury 2

Critical Pitfalls to Avoid

• Never assume "no external head wound" means no serious injury—basilar skull fractures and intracranial hemorrhage frequently occur without visible external trauma 1
• Do not use MRI as initial imaging due to its slowness in acute trauma and inferior sensitivity for fractures compared to CT 1
• Do not delay CT for laboratory tests or prolonged observation—imaging must precede watchful waiting when periorbital bruising develops after head trauma 1
• Avoid missing vascular injuries by obtaining CT angiography in all basilar skull fractures 1