Base of skull fracture

Question 1

What are the 4 key clinical signs of a basal skull fracture?

Answer 1

1. Bruising behind the ear (Battle’s sign)
2. Bleeding from the ear / haemotympanum
3. CSF rhinorrhoea/ otorrhoea
4. Extensive periobital haematomas (panda/raccoon eyes)

Question 2

What is the approach to management of patients with head trauma?

Answer 2

ABCDE algorithm, with focus on stabilising C-spine and aiway, recognising haemorrhage and treating pain

Question 3

What are 2 key interventions contraindicated in head trauma?

Answer 3

1. nasopharyngeal airways: can cause further damage
2. head tilt, chin lift - if C-spine injury can cause further instability and damage

Question 4

What is the first line imaging in head trauma?

Answer 4

plain CT head

Question 5

What additional imaging, in addition to a plain CT head, should be performed in head trauma? 3 examples

Answer 5

1. CT cervical spine - looking for fractures
2. CT angiogram - looking for local vascular injury
3. Plain skull X-ray - assessing for orbital fractures

Question 6

What are the 6 key situations when CT head after head injury is recommended?

Answer 6

1. Clinical evidence of skull fracture
2. >30 min retrograde amnesia
3. Focal neurological deficit or seizure
4. GCS <13 at any time (or <15 2hours after injury)
5. >1 episode of vomiting
6. Loss of consciousness and any amnesia in patients who:
   
   • are >65 years
   • suffered dangerous mechanism of injury e.g. great height, RTA
   • have evidence of coagulopathy, including anticoagulation with warfarin

Question 7

Which parts of the examination are key in suspected head injury? 5 aspects

Answer 7

rapid neurological assessment should only take a few minutes:

1. level of consciousness + motor function with GCS
2. size, shape and reactions of pupils to bright light
3. resting eye position and spontaneous eye movements observed
4. test corneal reflex (cranial nerve V afferent, VII efferent)
5. look for features suggesting brain shift and herniation

Question 8

Which cranial nerves are assessed by testing the corneal reflex?

Answer 8

cranial nerve V afferent, VII efferent

Question 9

What are 5 key aspects of the immediate management of head injury?

Answer 9

1. After resuscitation, take blood for FBC, G&S, U&Es, ABGs, if circumstances of injury not clear: toxicology screen
2. Admission if indicated
3. Urget CT scan (if meet criteria)
4. Treatment of raised ICP (elevate head of bed, hyperventilation, mannitol)
5. Surgery may be indicated for extradural, subdural and some intracerebral haemorrhage and compound depressed skull fractures

Question 10

What is a general rule for when neurosurgery is required for urgent evacuation of extradural haematomas?

Answer 10

those which produce midline shift of 5mm or more and/or 25ml in calculated volume

if too small, repeat scan after a few hours regardless of whether deterioration in patient condition - may have got bigger

Question 11

What is the management generally for most basal skull fractures and what is the exception?

Answer 11

• most do not require treatment and heal themselves
• persistent CSF leakage may warrant operative repair of the leakage, specifically CSF leaks related to frontal bone and cribriform plate fractures