Depressed Skull Fractures

Items:

Strength of Recommendation

Level of Evidence

▪️ Avoid hypoxia

Strong

Moderate-Quality Evidence⁴

▪️ Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2

Strong

Moderate-Quality Evidence⁴

▪️ avoid hypotension

Strong

Moderate-Quality Evidence⁴

▪️ We recommend ICU admission and close neurosurgical observation with CT monitoring if needed (if not available, refer to a tertiary center). 

Strong

High-Quality Evidence⁵

▪️The availability of equipped neurosurgery operating room is essential for management (if not available, refer to a tertiary center).

Strong

High-Quality Evidence⁵

▪️ Antiseizure medications (ASM):

Consider the use of ASMs (e.g., phenytoin, valproate, or carbamazepine) to decrease the incidence of early PTS (within 7 days of TBI).

Conditional

Moderate-Quality Evidence⁴

Strength of recommendation

Level of evidence

▪️ surgical management may be indicated in Patients with open (compound) depressed cranial fractures (evidenced by CT) with:

-   Depression greater than the thickness of the cranium.

-  Clinical (CSF leak / hernia cerebri) or radiographic (pneumocephalus) evidence of dural violation.

-  Underlying significant intracranial hematoma or hemorrhagic contusions.

- Frontal sinus involvement.

-  Gross cosmetic deformity.

-   Wound infection.

-  Dural venous sinuses compromise impeding blood flow as evident in 3D CT and MRV brain.

Conditional

Moderate certainty evidence^{2, 3}

▪️  Surgery may be indicated for closed depressed skull fractures if:

-   the depression is causing a focal deficit through pressure on the adjacent cortex.

-   the closed fracture is depressed and causing a cosmetic abnormality, for example fractures over the forehead.

Conditional

Moderate certainty evidence²

▪️ Surgery (if indicated) is recommended as soon as possible after stabilization and coverage of umbrella of antibiotics.

strong

Moderate certainty evidence²

▪️  patients with open (compound) depressed cranial fractures may be treated conservatively in the absence of the previously mentioned surgical indications.

Conditional

Moderate certainty evidence²