Depressed skull fracture

Question 1

A 26 YOM is brought to the ED after suffering a head injury in a fight. He is semiconscious and has a depressed fracture of the right parietal bone. How would yo manage him?

Answer 1

Impression
Depressed skull fracture, this is a surgical emergency demanding urgent treatment and management

Complications I am concerned about;
- TBI (long-term disability)
- intracranial bleed and iraised ICP
- risk of CNS infection, sepsis, seizures, etc

Goals
- call for senior help, begin A to E assessment screening for intracerebral complications, provide any resuscitative measures as necessary acutely before arranging appropriate definitive treatment with appropriate referral

Question 2

Depressed skull fracture - Assessment

Answer 2

Assessment
- obtain MIST AMPLE handover from ambo’s/collateral.

A - patent, maintaining, use pending GCS. Place in C-Spine collar for precautionary measures before clearing. no NP airways for ?base of skull fractures

B - RR/SP02 monitoring

C - HR/BP/ECG. control any bleeding. gain IV access and send pre-operative bloods, forensic BAC and drug screen. if concern re raised ICP, then head up 30 degrees, consider osmotic therapy with mannitol (with senior input). Consider administration of TXA with senior advice/input. prophylactic ABx administration.

D - Serial GCS, PEARL, cushings reflex assessment, focal neurology. consider CT Brain and C-Spine imaging. prepare for early transfer to theatres if requiring decompressive surgery (haematoma evacuation, etc). look for evidence of base of skull fractures.

E - exposure for other injuries, log roll, secondary survey. Aim for normothermia

F - G as normal.

Other acute management
- insert IDC
- NG tube and stomach decompression to limit risk of aspiration - altho orogastric if there are base of skull fractures
- pain management with appropriate analgesia

Question 3

Depressed skull fracture - history

Answer 3

History
- MIST AMPLE
- Will need collateral for MOI, etc

Question 4

Depressed skull fracture - examination

Answer 4

Examination
- General appearance + vitals
- Neuro exam for focal neurology, cushings reflex, evidence of raised ICP
- Inspection of head for superficial injuries, signs of base of skull fracture
- Secondary survey for additional injuries

Question 5

Depressed skull fracture - Investigations

Answer 5

Investigations
Key:
- non-con CTB
- C-spine imaging
- pre-operative bloods

Question 6

Depressed skull fracture - management

Answer 6

Management
- Aim to minimise secondary brain injury as cannot reverse initial injury.

Definitive
- IV ABx prophylaxis for increased risk of infection
- Tetanus prophylaxis
- Anticonvulsant meds as post-trauma seizure prophylaxis (leviteracitam or phenytoin)
- Neurosurg for definitive management

Supportive
- alert police if not already
- NBM
- VTE prophylaxis
- analgesia