Management of Mild Traumatic Brain Injury with Skull Fracture and Vomiting
Admit this patient for close neurological observation for 24-72 hours with serial neurological assessments, and do NOT use mannitol unless there are clear signs of elevated intracranial pressure or neurological deterioration. 1
Rationale for Hospital Admission
Your patient meets multiple high-risk criteria despite having a good GCS:
- Vomiting is a significant predictor of intracranial complications in mild traumatic brain injury, with studies showing it increases the risk of abnormal CT progression and need for intervention 2
- Skull fracture presence increases the risk of intracranial hemorrhage by approximately 20-fold, even with initially normal brain parenchyma on CT 3
- Delayed presentation (12 hours post-injury) means you're already in the window where deterioration commonly occurs - 57% of deteriorations happen within the first 24 hours, and an additional 18% occur between days 2-7 2
Observation Protocol
Perform hourly neurological assessments focusing on: 1
- Glasgow Coma Scale score
- Pupillary size and reactivity
- Motor strength in all extremities
- Level of confusion/orientation
Maintain normotension and adequate cerebral perfusion pressure throughout the observation period 2
Avoid long-acting sedatives or paralytic medications that could mask neurological deterioration 2
When to Consider Repeat CT Imaging
Obtain immediate repeat CT if any of the following occur: 4, 5
- Any decrease in GCS score (even 1-2 points)
- Development of new focal neurological deficits
- Worsening or persistent vomiting (≥2 episodes total)
- Severe or worsening headache
- Increasing restlessness or agitation
- Signs of herniation (pupillary changes, posturing)
The evidence shows that repeat CT obtained for neurological change leads to intervention in 38% of cases, whereas routine repeat CT without clinical change rarely leads to intervention in patients with mild TBI 6
Why Mannitol is NOT Indicated Currently
Mannitol should NOT be used in this patient because: 7, 2
- No evidence of elevated ICP: Your patient has a good GCS and normal brain parenchyma on CT. The isolated hairline skull fracture without underlying brain injury does not indicate raised intracranial pressure
- Mannitol is indicated for reduction of intracranial pressure at doses of 0.25-2 g/kg when there is documented elevated ICP or impending herniation 7
- Prophylactic use is not supported: A Cochrane review found no evidence that routine mannitol use reduces cerebral edema or improves stroke outcomes in the absence of documented elevated ICP 2
- Potential harm: Mannitol can cause renal complications, fluid/electrolyte imbalances, and may worsen outcomes if used inappropriately in patients without elevated ICP 7
Indications for Neurosurgical Consultation
Contact neurosurgery immediately if: 1
- Signs of herniation develop (pupillary asymmetry, motor posturing)
- GCS decreases by 2 or more points
- New focal neurological deficits appear
- Repeat CT shows progression of injury
Common Pitfalls to Avoid
Do not discharge based solely on "good GCS" - patients with GCS 15 can still have significant intracranial injuries requiring intervention (1.9% in one series required neurosurgery) 2, 1
Do not assume the skull fracture alone requires intervention - the fracture is a marker of significant force but doesn't automatically necessitate surgery unless there's underlying brain injury or it's depressed 2
Do not use mannitol empirically - wait for objective evidence of elevated ICP through clinical deterioration or ICP monitoring if placed 7, 2
Do not skip the observation period - even with normal brain parenchyma, the combination of skull fracture + vomiting + delayed presentation creates sufficient risk to warrant monitored admission 2, 1
Expected Outcome
With appropriate observation and no extracranial injuries, patients with normal brain parenchyma on CT typically make good recoveries, even when skull fractures are present 8. However, the vomiting and skull fracture mandate the observation period to ensure no delayed hemorrhage develops.