Special considerations in Case Of Skull Fracture

• Establish and maintain a patent airway; nasal airways are contraindicated in patients with possible basilar skull fractures. Intubation may be necessary.
• Suction the patient through the mouth, not the nose, to prevent the introduction of bacteria in case a CSF leak is present.
• Be sure to obtain a complete history of the trauma from the patient, his family, any eyewitnesses, and ambulance personnel.
• Ask whether the patient lost consciousness and, if so, for how long. The patient will need further diagnostic tests, including a complete neurologic examination, a CT scan, and other studies.
• Check for abnormal reflexes such as Babinski’s reflex.
• Look for CSF draining from the patient’s ears, nose, or mouth. Check bed linens for CSF leaks, and look for a halo sign. If the patient’s nose is draining CSF, wipe it—don’t let him blow it. If an ear is draining, cover it lightly with sterile gauze—don’t pack it.
• Position the patient with a head injury so secretions can drain properly. Elevate the head of the bed 30 degrees if intracerebral injury is suspected.
• Cover scalp wounds carefully with a sterile dressing; control any bleeding as necessary.
• Take seizure precautions, but don’t restrain the patient. Agitated behavior may stem from hypoxia or increased ICP, so check for these symptoms. Speak in a calm, reassuring voice, and touch the patient gently. Don’t make any sudden, unexpected moves.

• Obtain consent, as needed, to shave the patient’s head. Explain that you’re performing this procedure to provide a clean area for surgery. Type and crossmatch blood. Obtain baseline laboratory studies, such as a complete blood count, serum electrolyte studies, and urinalysis.
• After surgery, monitor vital signs and neurologic status frequently (usually every 5 minutes until the patient is stable, and then every 15 minutes for 1 hour), watching for any changes in LOC. Because skull fractures and brain injuries heal slowly, don’t expect dramatic postoperative improvement.
• Monitor intake and output frequently, and maintain patency of the indwelling urinary catheter. Take special care with fluid intake. Hypotonic fluids (even dextrose 5% in water) can increase cerebral edema. Their use should be restricted; give them only as needed.
• If the patient is unconscious, provide parenteral nutrition. (Remember, the patient may regurgitate and aspirate food if you use a nasogastric tube for feedings.)

If the fracture doesn’t require surgery:

• Wear sterile gloves to examine the scalp laceration. With your finger, probe the wound for foreign bodies and a palpable fracture. Gently clean lacerations and the surrounding area. Cover with sterile gauze. The patient may need suturing.
• Provide emotional support for the patient and his family. Explain the need for procedures to reduce the risk of brain injury.
• Before discharge, instruct the patient’s family to watch closely for changes in mental status, LOC, or respirations and to relieve the patient’s headache with acetaminophen. Tell them to return him to the hospital immediately if his LOC decreases, if his headache persists after several doses of mild analgesics, if he vomits more than once, or if weakness develops in his arms or legs.
• Teach the patient and his family how to care for his scalp wound. Emphasize the need to return for suture removal and follow-up evaluation.