How Much Monitoring Is Needed for Basilar Skull Fractures? Martin Koonsman, MD, Ernest Dunn, MD, Kent Hughes, MD, Brad Kendrick, MD, James Moody, MD, Dallas,Texas
Basilar skull fractures account for approximately 19% of all skull fractures. There have been little data published concerning the need for intensive care monitoring in this injury. We retrospectively studied 2 5 9 patients admitted to our trauma center over an 8-year period with a diagnosis of basilar skull fracture. All patients were evaluated with cranial computed tomographic (CT) scans. These patients were admitted to the trauma service, and neurosurgical consultation was obtained in all cases. The diagnosis was made by clinical signs in 207 patients ( 8 0 % ) , by CT scan in 47 ( 1 8 % ) , and by plain films in 5 ( 2 % ) . Ninety-two patients (group I) had intracranial pathology in addition to basilar skull fracture. Twenty-one patients in this group underwent craniotomy. In this group, the morbidity and mortality rates were 11% and 7%, respectively. Forty-four patients (group II) had no intracranial pathology and a Glasgow Coma Score (GCS) of less than 13. The morbidity was 2%, and the mortality was 2%. One hundred twenty-three patients (group III) had no intracranial pathology on CT scan and a GCS of 13 or greater. The complication rate in this group was 1%, and there was no neurologically related mortality. Patients who are admitted with a diagnosis of basilar skull fracture and who have a GCS of 13 or greater with no intracranial pathology on CT can be managed without intensive care monitoring.
From the MethodistMedical Center, Departmentof Surgery,Dallas, Texas. Requests for reprints should be addressed to Ernest Dunn, MD, Methodist Medical Center, Medical EducationDepartment, PO Box 655999, Dallas, Texas75265-5999. Presented at the 44th Annual Meeting, Southwestern Surgical Congress,Scottsdale,Arizona,April 26-29, 1992.
B
asilar skull fractures account for approximately 19% of all skull fractures and are thus a frequently encountered problem [1]. There has been considerable debate in the literature over topics such as the use of prophylactic antibiotics and the appropriate management of cerebrospinal fluid (CSF) fistulas. Little information has been published concerning the need for intensive care monitoring in patients with basilar skull fractures. As the costs of health care increase and the demand for trauma beds becomes more acute, the utilization of these resources needs to be analyzed. This retrospective study was undertaken to determine the incidence of complications associated with basilar skull fractures and the need for intensive monitoring. PATIENTS AND M E T H O D S All patients admitted to Methodist Medical Center over an 8-year period with a diagnosis of basilar skull fracture were considered eligible for the study. All patients were initially evaluated by general surgery residents and emergency department physicians and subsequently admitted to the trauma service. Neurosurgical consultation was obtained in all cases. The Glasgow Coma Score (GCS) was determined in the emergency department by the trauma team surgical residents. Plain skull radiographs or cranial computed tomographic (CT) scans were obtained for all patients at the time of admission. The diagnosis was based on clinical evidence of basilar skull fracture (hemotympanum, CSF otorrhea or rhinorrhea, and Battle's sign or raccx~n eyes) or radiographic evidence of basilar skull fracture. Patients who had a significant loss of consciousness or an altered mental status at the time of admission were admitted to the intensive care unit (ICU). Our 27-bed ICU is staffed by a general surgeon director and 24-hour general surgery resident coverage. ICU care included hourly measurements of vital signs and neurologic evaluations in addition to telemetry. Patients were discharged from the ICU by the neurosurgical service when they could maintain an adequate airway and their mental status had stabilized. Data were obtained by a retrospective review of patients' hospital records. Differences in group proportions were tested using X2 analysis. Results were deemed significant at the p
Basilar skull fractures account for approximately 19% of all skull fractures. There have been little data published concerning the need for intensive care monitoring in this injury. We retrospectively studied 2 5 9 patients admitted to our trauma center over an 8-year period with a diagnosis of basilar skull fracture. All patients were evaluated with cranial computed tomographic (CT) scans. These patients were admitted to the trauma service, and neurosurgical consultation was obtained in all cases. The diagnosis was made by clinical signs in 207 patients ( 8 0 % ) , by CT scan in 47 ( 1 8 % ) , and by plain films in 5 ( 2 % ) . Ninety-two patients (group I) had intracranial pathology in addition to basilar skull fracture. Twenty-one patients in this group underwent craniotomy. In this group, the morbidity and mortality rates were 11% and 7%, respectively. Forty-four patients (group II) had no intracranial pathology and a Glasgow Coma Score (GCS) of less than 13. The morbidity was 2%, and the mortality was 2%. One hundred twenty-three patients (group III) had no intracranial pathology on CT scan and a GCS of 13 or greater. The complication rate in this group was 1%, and there was no neurologically related mortality. Patients who are admitted with a diagnosis of basilar skull fracture and who have a GCS of 13 or greater with no intracranial pathology on CT can be managed without intensive care monitoring.
From the MethodistMedical Center, Departmentof Surgery,Dallas, Texas. Requests for reprints should be addressed to Ernest Dunn, MD, Methodist Medical Center, Medical EducationDepartment, PO Box 655999, Dallas, Texas75265-5999. Presented at the 44th Annual Meeting, Southwestern Surgical Congress,Scottsdale,Arizona,April 26-29, 1992.
B
asilar skull fractures account for approximately 19% of all skull fractures and are thus a frequently encountered problem [1]. There has been considerable debate in the literature over topics such as the use of prophylactic antibiotics and the appropriate management of cerebrospinal fluid (CSF) fistulas. Little information has been published concerning the need for intensive care monitoring in patients with basilar skull fractures. As the costs of health care increase and the demand for trauma beds becomes more acute, the utilization of these resources needs to be analyzed. This retrospective study was undertaken to determine the incidence of complications associated with basilar skull fractures and the need for intensive monitoring. PATIENTS AND M E T H O D S All patients admitted to Methodist Medical Center over an 8-year period with a diagnosis of basilar skull fracture were considered eligible for the study. All patients were initially evaluated by general surgery residents and emergency department physicians and subsequently admitted to the trauma service. Neurosurgical consultation was obtained in all cases. The Glasgow Coma Score (GCS) was determined in the emergency department by the trauma team surgical residents. Plain skull radiographs or cranial computed tomographic (CT) scans were obtained for all patients at the time of admission. The diagnosis was based on clinical evidence of basilar skull fracture (hemotympanum, CSF otorrhea or rhinorrhea, and Battle's sign or raccx~n eyes) or radiographic evidence of basilar skull fracture. Patients who had a significant loss of consciousness or an altered mental status at the time of admission were admitted to the intensive care unit (ICU). Our 27-bed ICU is staffed by a general surgeon director and 24-hour general surgery resident coverage. ICU care included hourly measurements of vital signs and neurologic evaluations in addition to telemetry. Patients were discharged from the ICU by the neurosurgical service when they could maintain an adequate airway and their mental status had stabilized. Data were obtained by a retrospective review of patients' hospital records. Differences in group proportions were tested using X2 analysis. Results were deemed significant at the p
