Skull fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

⚲

447 items

☷ Legend

01Approach to the Critical Patient/attcp49

Primary survey and immediate threats

›Stabilization priorities

›If airway compromise or GCS 8 or less, intubation with cervical spine precautions

›Etomidate 0.3 mg/kg IV for induction

›If hypotension risk, ketamine 1 to 2 mg/kg IV as alternative

›Rocuronium 1.2 mg/kg IV for paralysis

›If succinylcholine appropriate, 1.5 mg/kg IV

›If hypoxia, oxygenation escalation to maintain SpO2 90% or higher

›Brain Trauma Foundation severe TBI guidance includes avoiding hypoxia SpO2 under 90% (Level III)

›If hypotension, resuscitation to avoid SBP under 90 mmHg

›Brain Trauma Foundation severe TBI guidance includes avoiding hypotension SBP under 90 mmHg (Level II)

›If active external bleeding, hemorrhage control before imaging

›Scalp laceration direct pressure

›Hemostatic dressing if persistent bleeding

›If seizure activity, immediate anticonvulsant therapy

›Lorazepam 0.1 mg/kg IV

›Maximum 4 mg per dose

›Early escalation and consultation

›If depressed skull fracture suspected, neurosurgery consultation

›If open depressed fracture, emergent operative planning

›If basilar skull fracture signs with neurologic decline, neurosurgery consultation

›ICU-level monitoring triggers

›Declining GCS

›New focal deficit

›If polytrauma, trauma team activation

›ATLS-based priorities with head injury precautions

Immediate imaging and monitoring targets

›Early diagnostics

›If suspected skull fracture with neurologic symptoms, non-contrast CT head

›If concern for cervical injury, CT cervical spine

›If open fracture, contamination concern, antibiotics before CT if no delay to life-saving imaging

›Time-to-antibiotics priority similar to open fracture principles

›Physiologic targets

›Normothermia

›Fever associated with worse neurologic outcomes in brain injury populations

›Normoglycemia

›Avoid marked hyperglycemia

›Head of bed 30 degrees if tolerated

›Venous outflow optimization

›Analgesia without hypotension

›Avoid oversedation that masks neurologic decline

Key concepts

›Injury pattern framing

›Linear skull fracture

›Often associated with intracranial hemorrhage risk depending on mechanism and location

›Depressed skull fracture

›Higher risk of dural tear, infection, seizures

›Basilar skull fracture

›CSF leak risk

›Meningitis risk over time

›Cranial nerve injury risk

›Vascular injury risk when carotid canal involved

02History/hx58

Mechanism and timeline

›History anchors

›Mechanism of injury

›Fall height or impact energy

›High-energy mechanism

›Assault

›Motor vehicle collision

›Penetrating injury

›Foreign body

›Time of injury

›Symptom progression since injury

›Loss of consciousness

›Duration estimate

›Amnesia

›Retrograde

›Anterograde

›Seizure

›Immediate

›Delayed

›Vomiting

›Number of episodes

›Headache

›Severity trajectory

›Neck pain

›Midline tenderness symptoms

Bleeding, infection, and leak clues

›Red flag features

›Clear rhinorrhea or otorrhea

›Salty or metallic taste

›Positional drainage

›Hearing change

›Tinnitus

›Hearing loss

›Vertigo

›Facial weakness

›Visual symptoms

›Diplopia

›Vision loss

›Periorbital bruising onset timing

›Delayed bruising after injury

›Postauricular bruising onset timing

›Delayed mastoid ecchymosis

›Fever after injury

›Concern for meningitis if CSF leak

Risk factors and modifiers

›Patient factors

›Anticoagulant use

›Warfarin

›DOAC

›Antiplatelet use

›Aspirin

›Clopidogrel

›Bleeding disorder

›Alcohol or substance intoxication

›Prior neurosurgery

›Craniotomy history

›Prior skull fracture

›Pediatric modifiers

›Non-accidental trauma concern

›Inconsistent history

›Delay to presentation

03Physical Exam/exam48

General and head and neck

›Examination framework

›Vital signs

›Hypotension as secondary brain injury risk

›Hypoxia as secondary brain injury risk

›Mental status

›GCS components

›Trend over time

›Scalp and skull

›Scalp hematoma

›Scalp laceration

›Palpable bony defect

›Step-off deformity

›Crepitus

›Cervical spine

›Midline tenderness

›Range of motion deferred if high-risk mechanism

Neurologic and cranial nerves

›Neurologic exam

›Pupillary size and reactivity

›Anisocoria

›Sluggish response

›Extraocular movements

›CN III palsy features

›CN VI palsy features

›Facial symmetry

›CN VII weakness

›Hearing

›Gross hearing deficit

›Motor exam

›Focal weakness

›Sensory exam

›Dermatomal deficits

›Coordination and gait

›Deferred if unstable

›Basilar skull fracture signs

›Periorbital ecchymosis

›Raccoon eyes

›Mastoid ecchymosis

›Battle sign

›Hemotympanum

›CSF rhinorrhea

›CSF otorrhea

PITFALLS

›Common misses

›Normal initial neurologic exam with evolving epidural hematoma

›Serial reassessment need

›Intoxication masking decline

›Lower threshold for imaging and observation

›Occult cervical spine injury in head trauma

›Maintain precautions until cleared

04Differential Diagnosis/ddx21

Intracranial injury associated with skull fracture

›Life threats to exclude

›Epidural hematoma (S06.4)

›Temporal bone fracture association

›Subdural hematoma (S06.5)

›Subarachnoid hemorrhage traumatic (S06.6)

›Intracerebral hemorrhage traumatic (S06.3)

›Cerebral contusion (S06.33)

›Diffuse axonal injury (S06.2)

Mimics and related trauma

›Alternative or concurrent diagnoses

›Concussion mild traumatic brain injury (S06.0)

›Cervical spine fracture (S12)

›Facial fractures

›Orbital fracture (S02.3)

›Maxillary fracture (S02.4)

›Mandible fracture (S02.6)

›Temporal bone fracture

›Otic capsule involvement

›Vascular injury

›Carotid artery dissection (I77.71)

›Vertebral artery dissection (I77.74)

›Meningitis after CSF leak (G00.9)

05Laboratory Tests/lt25

Hematology and coagulation

›Hemorrhage and coagulopathy evaluation

›Complete blood count for anemia or infection concern

›Hemoglobin trend if ongoing bleeding

›INR for warfarin effect

›Reversal planning if elevated with intracranial bleed

›aPTT for heparin effect

›Fibrinogen if major trauma with bleeding

›Type and screen

›If operative risk

›If major trauma with potential transfusion

Metabolic and toxicology

›Metabolic contributors

›Electrolytes including sodium for neurologic stability

›Hyponatremia as seizure risk

›Glucose

›Hypoglycemia mimic of altered mental status

›Substance and exposure

›Blood alcohol concentration if clinically relevant

›Toxicology screen if altered mental status unexplained

›Pregnancy testing

›Beta-hCG in reproductive-age patients before ionizing radiation considerations

CSF leak and infection workup

›Targeted testing

›Beta-2 transferrin for suspected CSF rhinorrhea or otorrhea

›High specificity for CSF

›Blood cultures if febrile with meningitis concern

›Prior to antibiotics when feasible without delay

06Diagnostic Tests/dt55

Scoring Systems

›Decision rule support for CT

›ACEP mild TBI clinical policy

›Use Canadian CT Head Rule in adults with minor head injury (ACEP Level A)

›High-risk features include suspected open or depressed skull fracture

›High-risk features include signs of basilar skull fracture

›High-risk features include vomiting multiple episodes

›High-risk features include age 65 years or older

›New Orleans Criteria

›Headache

›Vomiting

›Age over 60

›Drug or alcohol intoxication

›Persistent anterograde amnesia

›Visible trauma above clavicles

›Seizure

›Pediatrics decision support

›PECARN head trauma framework

›Palpable skull fracture as high risk in young children

›Basilar skull fracture signs as high risk in older children

MRI

›MRI brain considerations

›Persistent neurologic deficit with normal CT

›Suspected diffuse axonal injury

›Suspected cranial nerve injury with basilar fracture

›Targeted sequences per neuro radiology

›Suspected CSF fistula complications

›Meningoencephalocele evaluation

›Limitations

›Not first-line in acute unstable trauma

›Metallic foreign body contraindication screening

›CT head non-contrast

›Primary diagnostic study for skull fracture and acute hemorrhage

›Linear fracture detection

›Depressed fracture depth estimation

›Pneumocephalus detection

›CT bone windows

›Basilar fracture characterization

›Temporal bone fracture suspicion

›CT cervical spine

›High-risk mechanism

›Neck pain or tenderness

›CT angiography head and neck

›Basilar skull fracture involving carotid canal

›Basilar skull fracture with intracranial hemorrhage and middle cranial fossa involvement

›CT venography

›Occipital fracture crossing venous sinus

›Suspected dural venous sinus thrombosis

Ultrasound

›Point-of-care ultrasound adjuncts

›Ocular ultrasound avoided if globe rupture concern

›Limit in trauma with facial injury

›FAST exam in polytrauma

›Hemoperitoneum screening

›Pericardial effusion screening

›Soft tissue ultrasound

›Scalp hematoma extent in pediatrics as adjunct only

›Not a substitute for CT when skull fracture concern present

07Disposition/dispo31

Level of care selection

›Admission criteria

›Depressed skull fracture

›Neurosurgical management need

›Open skull fracture

›Operative debridement consideration

›IV antibiotics course

›Basilar skull fracture with CSF leak

›Observation for neurologic change

›Leak monitoring and follow-up planning

›Any intracranial hemorrhage on imaging

›Serial neurologic exams

›Persistent altered mental status

›Serial assessments

›ICU criteria

›Declining GCS

›Need for mechanical ventilation

›Refractory seizures

›Suspected elevated intracranial pressure

›Transfer criteria

›Neurosurgery not available locally

›Depressed fracture

›Open fracture

›Intracranial hemorrhage requiring intervention

Discharge and observation pathways

›Discharge candidates

›Isolated linear skull fracture without intracranial hemorrhage

›Normal neurologic exam

›Reliable supervision at home

›Clear return precautions

›Short ED observation pathway when indicated

›Serial neurologic exams

›Worsening symptoms triggers repeat imaging or admission

08Treatment/t58

Analgesia, nausea control, and supportive care

›Symptom control

›Acetaminophen 15 mg/kg PO or IV

›Maximum 1000 mg per dose

›Maximum 4000 mg per day

›Opioid analgesia if severe pain

›Fentanyl 0.5 to 1 mcg/kg IV

›Repeat dosing as needed with monitoring

›Antiemetic therapy for vomiting

›Ondansetron 4 mg IV

›Repeat 4 mg IV if needed

›CSF leak precautions

›If suspected CSF rhinorrhea or otorrhea, avoid nasogastric tube

›Intracranial placement risk in basilar fracture

›If suspected CSF leak, avoid nasal positive pressure when possible

›Reduced pneumocephalus risk

Open and depressed fracture infection prevention

›Antibiotic strategy

›Open skull fracture prophylaxis recommended in trauma practice guidelines

›EAST open fractures guidance supports prophylactic antibiotics for open skull fractures

›If open skull fracture without gross contamination, cefazolin 2 g IV every 8 hours

›Duration 72 hours in some institutional protocols

›SurgicalCriticalCare craniofacial guidance includes cefazolin 2 g IV every 8 hours for 3 days

›If open skull fracture with gross contamination, broader coverage per local protocol

›Ampicillin-sulbactam 3 g IV every 6 hours as an option

›Institutional trauma protocols include this approach for open skull fractures

›Tetanus prophylaxis per immunization status

›Tdap booster if indicated

›Tetanus immune globulin if high-risk and not immunized

›Basilar skull fracture antibiotics

›Prophylactic antibiotics not recommended for closed basilar skull fracture with or without CSF leak

›Cochrane systematic review evidence does not support prophylactic antibiotics

›AAST clinical consensus guidance does not recommend prophylactic antibiotics for post-traumatic CSF leaks

Seizure prevention and management

›Anticonvulsant considerations

›If depressed skull fracture with cortical injury, early seizure risk

›Levetiracetam 1000 mg IV load

›Maintenance 500 to 1000 mg PO or IV every 12 hours

›Typical duration 7 days in early post-traumatic seizure prophylaxis practice

›If active seizure, benzodiazepine first-line

›Lorazepam 0.1 mg/kg IV

›Maximum 4 mg per dose

›If persistent, levetiracetam 60 mg/kg IV load

›Maximum 4500 mg

Elevated intracranial pressure and herniation syndromes

›ICP management bundle

›Head of bed elevation 30 degrees

›Neutral neck position

›Hyperosmolar therapy for clinical herniation or progressive deterioration not otherwise explained

›Mannitol 0.25 to 1 g/kg IV

›Brain Trauma Foundation severe TBI guidance supports mannitol for raised ICP (Level II)

›Avoid hypotension SBP under 90 mmHg during therapy

›Hypertonic saline option

›3% saline 2 mL/kg IV bolus

›Maximum bolus volume per local protocol

›Ventilation strategy

›If impending herniation, brief hyperventilation to PaCO2 30 to 35 mmHg

›Bridge to definitive therapy and neurosurgical intervention

›Sedation for ventilated patients

›Propofol infusion 5 to 50 mcg/kg/min

›Titrate to sedation goal while maintaining blood pressure

›Hypotension avoidance priority in brain injury

09Special Populations/sp27

Pregnancy

›Pregnancy-specific considerations

›Maternal stabilization priority over fetal considerations

›Oxygenation and perfusion protection

›CT imaging when clinically indicated

›Risk from missed intracranial injury outweighs fetal radiation risk in emergencies

›Rh status and trauma

›Anti-D immune globulin if indicated for abdominal trauma

›Medication safety

›Avoid teratogenic anticonvulsants when alternatives exist

›Levetiracetam generally favored in pregnancy practice patterns

Geriatric

›Older adult considerations

›Higher risk of intracranial hemorrhage with minor trauma

›Lower threshold for CT imaging

›Anticoagulant and antiplatelet prevalence

›Reversal planning if hemorrhage present

›Frailty and fall recurrence risk

›Discharge planning includes home safety and follow-up

Pediatrics

›Pediatric considerations

›Non-accidental trauma screening when indicated

›Social work and child protection involvement triggers

›Palpable skull fracture and large scalp hematoma risk

›PECARN framework integration

›Weight-based medication dosing

›Levetiracetam 60 mg/kg IV load for seizures

›Maximum 4500 mg

›Disposition caution

›Lower threshold for observation with skull fracture even without hemorrhage in select cases

10Background/b32

Epidemiology

›Population patterns

›Skull fractures commonly occur with moderate to high-energy blunt head trauma

›Falls and motor vehicle collisions as frequent mechanisms

›Temporal bone fractures associated with basilar skull fractures

›Hearing and vestibular complications

›Pediatric skull fractures frequently associated with falls

›Non-accidental trauma remains an important subset

Pathophysiology

›Injury mechanisms

›Linear fracture reflects force transmission through calvarium

›Underlying vascular injury risk depending on location

›Depressed fracture implies focal inward displacement

›Dural tear and cortical laceration risk

›Infection pathway in open fractures

›Early post-traumatic seizure pathway

›Basilar fracture involves skull base bones

›Dural disruption and CSF fistula formation

›Ascending infection risk from sinonasal or middle ear flora

›Vascular canal involvement

›Carotid artery injury risk

Therapeutic Considerations

›Secondary brain injury prevention

›Hypotension avoidance associated with improved outcomes in severe TBI guidance

›Brain Trauma Foundation emphasizes SBP under 90 mmHg avoidance

›Hypoxia avoidance associated with improved outcomes in severe TBI guidance

›Brain Trauma Foundation emphasizes SpO2 under 90% avoidance

›Antibiotic strategy rationale

›Open skull fractures benefit from prophylactic antibiotics in trauma literature

›Staphylococcus aureus coverage as core target

›Basilar skull fracture CSF leak prophylaxis lacks demonstrated benefit in RCT evidence

›Cochrane review evidence does not support routine prophylaxis

›Imaging strategy rationale

›CT head is rapid and sensitive for acute hemorrhage and skull fracture

›MRI reserved for CT-negative persistent deficits or specific complications

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Discharge guidance

›Rest and gradual return to activity

›Avoid alcohol and sedating drugs for 24 hours

›Wound care if laceration present

›Keep clean and dry for first 24 hours

›If CSF leak suspected or confirmed

›No nose blowing

›Avoid heavy lifting and straining

›Head elevation during rest

›Return to ED immediately for red flags

›Worsening headache

›Repeated vomiting

›Increasing confusion or drowsiness

›New weakness or numbness

›Seizure

›Trouble speaking

›Vision changes

›Clear fluid from nose or ear

›Fever

›Neck stiffness

›Follow-up plan

›Primary care or concussion clinic follow-up within 1 to 3 days if symptoms persist

›ENT follow-up for hearing loss or persistent otorrhea

›Neurosurgery follow-up if skull fracture requires it

12References/r19

Clinical guidelines and decision tools

›Reference list

›ACEP Clinical Policy on mild traumatic brain injury

›Canadian CT Head Rule recommended for adults with minor head injury (ACEP Level A)

›Brain Trauma Foundation Guidelines for Severe TBI

›Avoid hypotension SBP under 90 mmHg (Level II)

›Avoid hypoxia SpO2 under 90% or PaO2 under 60 mmHg (Level III)

›Mannitol 0.25 to 1 g/kg effective for raised ICP (Level II)

›Cochrane Review on prophylactic antibiotics in basilar skull fractures

›No demonstrated meningitis prevention benefit with prophylactic antibiotics

›AAST critical care clinical consensus on prophylactic antibiotics in injury

›Prophylactic antibiotics not recommended for post-traumatic CSF leaks

›EAST practice management guideline on prophylactic antibiotics for open fractures

›Prophylactic antibiotics beneficial for open skull fractures

Evidence-based sources and protocols

›Additional sources

›Institutional craniofacial trauma antibiotic protocols

›Example cefazolin regimen for open skull fracture without contamination

›Example guidance against prophylaxis for closed or basilar skull fracture with CSF leak

›Trauma best practices guidelines for traumatic brain injury

›Systems-based care and transfer to neurosurgical capability when needed

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.