Book
Depressed Skull Fractures
- Executive Summary
This topic is concerned with management guidelines of depressed skull fractures.
➡️Recommendations
Initial Management: (as a part of initial TBI management)
▪️ Avoid hypoxia.
² Strong recommendation.
▪️ Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2.
² Strong recommendation.
▪️ Avoid hypotension.
² Strong recommendation.
▪️ We recommend ICU admission and close neurosurgical observation with CT monitoring if needed (if not available, refer to a tertiary center).
² Strong recommendation.
▪️ The availability of equipped neurosurgery operating room is essential for management (if not available, refer to a tertiary center).
² Strong recommendation.
▪️ Anti-seizure 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).
² Conditional recommendation
➡️Definitive management
▪️ 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.
² Conditional recommendation
▪️ 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.
² Conditional recommendation
▪️ Surgery (if indicated) is recommended as soon as possible after stabilization and coverage of umbrella of antibiotics.
² Strong recommendation
▪️ patients with open (compound) depressed cranial fractures may be treated conservatively in the absence of the previously mentioned surgical indications.
² Conditional recommendation
