# "Raccoon Eyes"



## Life1234 (Aug 15, 2011)

Hello, just had a quick scenario with picture for further example (not picture from any report, just a random one that's closest to what I am describing).


A young female in her 20s, with swelling (reddish/purplish discoloration on both the eye lid and under the eye). Complains of slight headache and occasion pain in right eye, somewhat lethargic. No CSF, battle's sign or altered LOC, pupils same size, etc. Swelling has gone down within a day. Slight swelling on forehead and bridge of nose for one day, but swelling there has also gone down and not noticeable.

According the report the cause was self-destructive behavior (hitting self on head (upper forehead and top of head not near eyes) multiple times with empty glass bottle.) 

Would  it be considered 'raccoon eyes' indication of brain trauma or just bruising because the area around the eyes are sensitive. If this patient refused hospital care would it be a concern?


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## traumaluv2011 (Aug 15, 2011)

That just might be a minor head injury. If they patient directly hit herself with a bottle in the eye, that just might be a contusion from the blunt force. However, if she is doing that to herself, that might be considered an altered mental status patient and would need to go through a psych evaluation. I would ask for medical direction to see if you can transport the patient on implied consent.


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## usalsfyre (Aug 15, 2011)

It's still a "raccoon eyes" exam finding, but remember it doesn't have to be associated with the "classic" basilar skull fracture. Exam findings are just that, exam findings. Several of them together may lead you to a differential diagnosis. But outside of imaging studies, one finding doesn't equate to a condition being present (outside of perhaps, pulselessness) 

Hope that made sense.


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## Handsome Robb (Aug 15, 2011)

Broken nose will give you two black eyes, just sayin... swelling on the bridge of the nose made me think of this.

usalsfyre put it better than I ever could have.


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## Life1234 (Aug 15, 2011)

traumaluv2011 said:


> That just might be a minor head injury. If they patient directly hit herself with a bottle in the eye, that just might be a contusion from the blunt force. However, if she is doing that to herself, that might be considered an altered mental status patient and would need to go through a psych evaluation. I would ask for medical direction to see if you can transport the patient on implied consent.




Thank you for your response


From report, she did not hit herself directly in eye area, only upper forehead/top of head. Which made me question why she would would the bruising on both of her eyes, since there was no direct blunt trauma to eyes. So the concern would be more with whether or not she needed a psych evaluation rather than any type of skull fracture or internal bleeding?


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## Life1234 (Aug 15, 2011)

usalsfyre said:


> It's still a "raccoon eyes" exam finding, but remember it doesn't have to be associated with the "classic" basilar skull fracture. Exam findings are just that, exam findings. Several of them together may lead you to a differential diagnosis. But outside of imaging studies, one finding doesn't equate to a condition being present (outside of perhaps, pulselessness)
> 
> Hope that made sense.




Yes, this is was the main source of confusion, it did fit the description of raccoon eyes, but there was no trauma to the base of the skull which would rule out basilar skull fracture I think.


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## usalsfyre (Aug 15, 2011)

traumaluv2011 said:


> I would ask for medical direction to see if you can transport the patient on implied consent.


Unless she is having active suicidal or homicidal ideations, not likely. An alcoholic with liver failure can sign out and walk across the street to a liquor store, so just "self harm" doesn't really work.

Besides, even if you do get the go ahead, how do you plan on forcing her to go?


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## Life1234 (Aug 15, 2011)

NVRob said:


> Broken nose will give you two black eyes, just sayin... swelling on the bridge of the nose made me think of this.
> 
> usalsfyre put it better than I ever could have.



Her nose wasn't fractured at all, she did not apply any force to the nose/eye area...but there was a bit of swelling (the day after the incident) on the forehead and bridge of nose. The eye area was normal, it wasn't until the 2nd day that the swelling and discoloration occurred.


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## Life1234 (Aug 15, 2011)

usalsfyre said:


> Unless she is having active suicidal or homicidal ideations, not likely. An alcoholic with liver failure can sign out and walk across the street to a liquor store, so just "self harm" doesn't really work.
> 
> Besides, even if you do get the go ahead, how do you plan on forcing her to go.



Yes, there was no suicidal intention from what was reported. She claimed that she was just incredibly frustrated and angry after an argument and took it out on herself instead of in a constructive manner.


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## Akulahawk (Aug 15, 2011)

Yes, this is a "raccoon eyes" finding. In this instance, I don't think it's related to a basalar skull fracture. It's very possible to either bruise or fracture the bridge of the nose and not have it displaced enough to notice. The description leads me to think she probably did break the bridge of her nose, or at the very least, contuse the bone pretty well. She probably contused other parts of her head as well, and you'd just (finally) seeing the result of gravity draining some of it to the periorbital areas. Her other symptoms also scream out post-concussion syndrome. She probably rung her bell pretty darned good...

If she's alert/oriented, no repetitive questioning, good short & long term memory, and can formulate a plan for self care (whether or not she follows it or not is her business), I'd say she's good to go if she wants to refuse service/care.


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## Lady_EMT (Aug 15, 2011)

usalsfyre said:


> Unless she is having active suicidal or homicidal ideations, not likely. An alcoholic with liver failure can sign out and walk across the street to a liquor store, so just "self harm" doesn't really work.
> 
> Besides, even if you do get the go ahead, how do you plan on forcing her to go?




Because she is self harming, that right there is a red flag to the dispatchers to get the police enroute. That would be considered a psych call, and the pt must go to the hospital. If the pt will not willingly go, then the police will put her under protective custody and tell you to take her. 

And the alcoholic example doesn't at all relate. That's like forcing any smoker who is having difficulty breathing to go to the hospital. In the eyes of the medical gods, it's different.

I'm also beginning to think that my area has funky protocols and guidelines? A lot of things I'm forced to do doesn't coincide with what many members of this community do. Gotta love my med director!!


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## usalsfyre (Aug 15, 2011)

Lady_EMT said:


> Because she is self harming, that right there is a red flag to the dispatchers to get the police enroute. That would be considered a psych call, and the pt must go to the hospital. If the pt will not willingly go, then the police will put her under protective custody and tell you to take her.


I can also see how this call could pretty easily come in as a low-priority headache if the patient chooses to not tell the dispatcher she was beating her head on a jar the day before. Meaning no PD. So now your on scene of a conscious, alert, compliant, non-suicidal patient who's refusing transport. How do you forced her to go? Around here at least no officer is going to place her in custody. Not to mention what happens if the officers place her in custody, you transport her and 5 minutes in she demands you pull over and let her out?



Lady_EMT said:


> And the alcoholic example doesn't at all relate. That's like forcing any smoker who is having difficulty breathing to go to the hospital. In the eyes of the medical gods, it's different.


But depending on where your at the legal gods don't view it differently. And they're who your accountable to when you start taking peoples freedom away. If we transport this patient, should we transport every patient who's harmed themselves in any way in the past on a psych hold on the off chance they might do it again?



Lady_EMT said:


> I'm also beginning to think that my area has funky protocols and guidelines? A lot of things I'm forced to do doesn't coincide with what many members of this community do. Gotta love my med director!!


Have you sat down and talked to the medical director about it? Many times stuff like this is not their intention, instead it's the (wrong) inference of the providers involved that this is how a particular situation should be handled to "cover their rear". Very often they have a poor understanding of the issues involved, and pass this poor understanding down to providers they train.


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## Lady_EMT (Aug 15, 2011)

usalsfyre said:


> I can also see how this call could pretty easily come in as a low-priority headache if the patient chooses to not tell the dispatcher she was beating her head on a jar the day before. Meaning no PD. So now your on scene of a conscious, alert, compliant, non-suicidal patient who's refusing transport. How do you forced her to go? Around here at least no officer is going to place her in custody. Not to mention what happens if the officers place her in custody, you transport her and 5 minutes in she demands you pull over and let her out?
> *Well your protocols must be different from ours. Any pt who is at risk to harm themselves/those around them will be put into protective custody to be brought to the hospital for psych eval. Doesn't matter how she is now. and if she is alert and compliant, she'll understand that what she did isn't healthy to her or those around her, and will consent to transport and treatment.*
> 
> But depending on where your at the legal gods don't view it differently. And they're who your accountable to when you start taking peoples freedom away. If we transport this patient, should we transport every patient who's harmed themselves in any way in the past on a psych hold on the off chance they might do it again?
> ...



minimum characters.


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## usalsfyre (Aug 15, 2011)

I'm not familiar with CTs laws, so I'll just say this. In Texas you, the police officer, your agency and medical director and the LE agency and police chief would be open to being sued in to the stone age.

We really, really, really need to be careful when discussing psych holds. The truth is there is no difference between this girl, the COPD'er who continues to smoke, the multiple MI patient who's finishing off a plate of ribs before being transported for chest pain, the IV drug user, ect. They're all exhibiting known self-harm. Slippery slope and all...


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## Lady_EMT (Aug 15, 2011)

usalsfyre said:


> I'm not familiar with CTs laws, so I'll just say this. In Texas you, the police officer, your agency and medical director and the LE agency and police chief would be open to being sued in to the stone age.
> 
> We really, really, really need to be careful when discussing psych holds. The truth is there is no difference between this girl, the COPD'er who continues to smoke, the multiple MI patient who's finishing off a plate of ribs before being transported for chest pain, the IV drug user, ect. They're all exhibiting known self-harm. Slippery slope and all...




I think we should agree to disagree, and leave it at that   Protocols vary from place to place, and what we can agree on is that CT has a ways to go to become caught up with some other states.


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## usalsfyre (Aug 15, 2011)

Lady_EMT said:


> I think we should agree to disagree, and leave it at that   Protocols vary from place to place, and what we can agree on is that CT has a ways to go to become caught up with some other states.



Yeah, kinda the direction I was going with it as well. I can't speak intelligently on your situation without knowing the laws and local protocols.


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## Aidey (Aug 15, 2011)

I'm going to jump in here and mention that it is a _*HUGE *_pet peeve of mine when people assume those that self harm are an automatic risk to themselves. I think it is a perfect example of the total lack of understanding most EMS people (and even many RNs) have when it comes to psychiatric disorders. 

The short explanation is that if you talk to your patients who self harm they will very likely tell you one of two things. That they do it because they are overwhelmed and can't handle their emotions or because they are numb and want to feel something. It is used as a coping mechanism. 

The overwhelmed explanation is also why head-banging and other self harmful behaviors are seen in people who are significantly mentally handicapped, have autism, etc. These are people who also have trouble expressing themselves, get frustrated/upset and then engage in harmful behaviors as a self-soothing mechanism.  

Assuming all people who self harm are suicidal is just wrong. Sure, they may benefit from talking to psych services at the hospital, but forcing them to go under the guise that they post an immediate threat to their own life is asinine.

To the OP: The eyes are inferior to the forehead, blood follows gravity.


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## traumaluv2011 (Aug 15, 2011)

usalsfyre said:


> Besides, even if you do get the go ahead, how do you plan on forcing her to go?



I know the police in my town are pretty good at arresting drunk resistive patients. I've seen it done twice. Haha, you do have a good point though.


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## Life1234 (Aug 16, 2011)

Thank you all for the responses,

Yes, it does just seem to be the case that she rattled her head a bit and as you all said the blood/fluids followed into the periorbital cavities. So I just take it the only  thing she would do, would be to use a cold compress and wait for the bruising to subside probably within the week?


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## Life1234 (Aug 16, 2011)

Just to add/slightly more detail.

She initially slammed her head once against the wall and made a small indentation in the wall. Then she used her hands and struck the temples of head. Then used a glass bottle and repeatedly struck the top head/upper forehead region.

Day 1 (after incident):

Some swelling along forehead, bridge of nose, no discoloration but slight-mild headache throughout the day. Area around eyes showed no signs of bruising.

Day 2

Swelling on forehead, bridge of nose went down but still a bit tender to the touch. Area around eyes very swollen (similar to what would happened after a bad reaction from a bee/wasp sting). Lethargic, resting most of the day, some sleep disruption. Persistent but still slight headache throughout day. 

Day 3

Swelling in eye area gone down, discoloration set in. Swelling on head is virtually gone, but forehead/top of head still tender to touch. Slight pain on and off.


This would definitely just be a minor head injury as you guys have stated before...not one of those stories where you hear the person was for the most part okay, but a few days later something more serious occurred?


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## Akulahawk (Aug 16, 2011)

My thoughts inline in red... 



Life1234 said:


> Just to add/slightly more detail.
> 
> She initially slammed her head once against the wall and made a small indentation in the wall. Then she used her hands and struck the temples of head. Then used a glass bottle and repeatedly struck the top head/upper forehead region.
> It was the slamming the head into, and denting, the wall that is causing (IMHO) some of her symptoms.
> ...


The pain along the forehead and top of head is likely from whacking herself  with a bottle, crushing lots of tissue and now the body has to clean up and repair the mess. Lots of localized swelling/inflammation. Not at all surprised that she's got some pain.

The lethargy and headache (separate from the forehead/crown injury) is most likely from a concussion. There is some risk that she developed a bleed though. 

Minor Head Injury? I doubt it's really all that "minor" at all. Given the lethargy on day 2, I would have wanted her to be seen ASAP... because of the potential for a bleed, in particular, SAH. 

If she was photophobic at all, that is also a good clue that she injured her brain... Hopefully she learned that smashing her head into a wall and subsequently beating herself up for whatever reason _isn't_ all that brilliant of an idea to begin with.


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## Life1234 (Aug 17, 2011)

Akulahawk said:


> My thoughts inline in red...
> 
> 
> The pain along the forehead and top of head is likely from whacking herself  with a bottle, crushing lots of tissue and now the body has to clean up and repair the mess. Lots of localized swelling/inflammation. Not at all surprised that she's got some pain.
> ...




Thank you,

She wasn't photophobic, tolerated lighted areas well

Yeah, no matter how angry you get at yourself, still not a legitimate reason to cause your self bodily harm by any means. Totally agree.


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