Management of Basilar Skull Fractures

Initial Assessment and Imaging

Immediate CT head without delay is mandatory to identify the fracture pattern, associated intracranial hemorrhage, and other traumatic brain injuries, according to the American College of Radiology 1, 2
CT imaging should include bone windows with double fenestration to fully characterize the basilar skull fracture, as recommended by the American College of Radiology 1, 2
CT angiography of supra-aortic and intracranial vessels should be performed given that basilar skull fractures are a specific risk factor for traumatic arterial dissection, as stated by the American College of Radiology 1, 2, 3

Maintain systolic blood pressure >110 mmHg at all times to prevent secondary brain injury and reduce mortality, according to the American Heart Association 1, 2, 3
Use vasopressors immediately if hypotension develops, rather than waiting for delayed effects of fluid resuscitation, as recommended by the American Heart Association 1, 2
Avoid hypotensive sedative agents during initial management, as stated by the American Heart Association 1, 2

Airway control is a priority—consider early intubation if Glasgow Coma Scale is compromised or if there is risk of deterioration, according to the American College of Surgeons 1, 2, 3
Maintain end-tidal CO2 monitoring to prevent both hypercapnia and hypocapnia, as recommended by the American Thoracic Society 1, 2
Mechanical ventilation should be adjusted to facilitate central venous return, as stated by the American Thoracic Society 1, 2

Immediate neurosurgical evaluation is required for basilar skull fractures associated with acute subdural or epidural hematoma, multiple hemorrhagic contusions, significant mass effect or midline shift, or deteriorating neurological examination, as recommended by the Congress of Neurological Surgeons 3
Deteriorating neurological examination requires immediate neurosurgical evaluation, according to the Congress of Neurological Surgeons 1, 2

Signs of basilar skull fracture place patients in the "high risk" category even with GCS 15, according to the American College of Radiology 4, 5
High-risk patients require CT imaging and admission for observation, as recommended by the American College of Radiology 4, 5

Admit for close neurological observation with serial neurological examinations, as stated by the American College of Emergency Physicians 6, 7, 3
Repeat CT imaging at 6-12 hours if initial examination shows associated intracranial injury, as recommended by the American College of Radiology 3
Monitor for delayed complications including vascular injury/dissection, as stated by the American Heart Association 1, 2

Do not discharge patients with basilar skull fractures without adequate observation period, even if initial GCS is 15, as recommended by the American College of Radiology 4, 6, 5
Do not miss associated vascular injuries—always obtain CT angiography given the high-risk nature of basilar skull fractures for arterial dissection, according to the American Heart Association 1, 2, 3