Tips on... How to spot a skull fracture

The days of inexperienced officers in the emergency department staring blindly at skull x rays are over. In the UK, we now have a clear set of evidenced based guidelines to follow.

1. With the availability of computerised tomography, and a new set of guidelines from the National Institute for Clinical Excellence (NICE), most emergency departments in the United Kingdom do not now routinely x ray skulls after head injuries.
2. Skull x rays were used in the past to determine who needed a computed tomography scan of the brain. If a fracture was found, then an intracranial haematoma was more likely. If no fracture was found, however, this did not necessarily rule out an intracranial haematoma.
3. Skull x rays are notoriously difficult to interpret. Even experienced doctors have been found to miss up to 10% of skull fractures, let alone the brand new senior house officer who has never seen one before.
4. The current NICE guidelines (www.nice.org.uk) on selecting patients with a head injury for computed tomography imaging of the head, state that a scan should be done within one hour if any of the following are present:

• A Glasgow coma score of less than 13 at any point since the injury
• A Glasgow coma score of 13 or 14 at two hours after the injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture. This includes haemotympanum (blood behind the eardrum), "panda" eyes, cerebrospinal fluid otorrhoea (leaking from the ear), Battle's sign (bruising over the mastoid)
• More than one episode of vomiting--use clinical judgment in children 12 years or younger
• Aged 65 years or more, if some loss of consciousness or amnesia has been experienced
• Post traumatic seizure
• Coagulopathy
• Focal neurological deficit

A computed tomograph should be taken within eight hours if any of the following are present:

• Amnesia for more than 30 minutes
• Dangerous mechanism of injury

If computed tomography is not indicated, the guidelines suggest that discharge is safe provided:

• No other factors are present that warrant admission, such as drug or alcohol intoxication, other injuries, shock, suspected deliberate injury, meningism, or cerebrospinal fluid leak
• There are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home)