Skull depression fracture clinical pathway standard inpatient procedure.
I. Applicable objects.
First diagnosis of skull depression fracture (ICD-10: S02, 902)
Perform skull depression fracture revision or skull titanium plate, silicone plate, plexiglass repair (ICD-9-CM-3: 02, 02-02, 06)
Second, the basis of diagnosis.
According to the Clinical Diagnosis and Treatment Guide-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Health Publishing House), Clinical Technical Practice Specification-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Military Medical Publishing House), Wang Loyalty Neurosurgery (edited by Wang Loyalty, Hubei Science and Technology Publishing House), Neurosurgery (edited by Zhao Jizong, People’s Health Publishing House).
1.Clinical manifestations.
(1) Medical history: mostly a history of head trauma.
(2) Scalp hematoma: scalp hematoma or contusion at the point of force.
(3) Local subsidence: local bone subsidence can be examined in the acute stage.
(4) Focal symptoms: When the fracture fragment is deeply sunken, it may puncture the dura mater, damaging and compressing the brain tissue leading to corresponding symptoms such as hemiparesis, aphasia and/or focal epilepsy.
2.Auxiliary examinations.
(1) cranial radiographs: including ortho, lateral and tangential radiographs of the fracture site, the latter of which can show the depth of fracture fragment into the skull.
(2) CT scan of the head (including bone window image): signs of depressed fracture, except for the presence of secondary intracranial abnormalities on plain scan.
(3) Blood count.
(3) The basis for selecting the treatment plan.
According to the Clinical Diagnosis and Treatment Guide-Neurosurgery Branch (edited by Chinese Medical Association, People’s Health Publishing House), Clinical Technical Practice Specification-Neurosurgery Branch (edited by Chinese Medical Association, People’s Military Medical Publishing House), Wang Loyalty Neurosurgery (edited by Wang Loyalty, Hubei Science and Technology Publishing House), Neurosurgery (edited by Zhao Jizong, People’s Health Publishing House).
1, skull depression fracture diagnosis is clear, fracture depression depth > 1cm, clinical symptoms of focal symptoms or intracranial pressure increase symptoms, need to perform depression fracture repair: more fixed depression fracture, using the depression around the drilling, milling (or sawing) under the bone flap, to reshape it and then reset fixed; comminuted depression fracture, surgery to remove the free bone fragment, retain the bone fragment with periosteum, reduce the area to be repaired later In the case of comminuted fractures, the free bone fragment is removed and the bone fragment with periosteum is preserved to reduce the area to be repaired later.
If there is no obvious clinical symptom, even if the fracture is deeper, the fracture can be observed and operated at a later stage after adequate preparation.
3, Combined brain injury or large depression area, resulting in increased intracranial pressure, CT shows displacement of midline structures, and signs of brain herniation, craniotomy for decompression of bone flap is performed.
4.For open comminuted depressed fractures, surgical debridement and bone fragment removal is performed.
5.For those who are at greater risk of surgery (advanced age, pregnancy, combined with more serious medical diseases), patients or family members should be informed of their condition; if they do not agree to surgery, they should be fully informed of the risks, perform signature procedures, and be closely observed.
6. For patients under close observation and conservative treatment, emergency surgery should be performed if there are signs of increased intracranial pressure.
IV. The standard hospitalization day is 9 days.
V. Entry pathway criteria.
1. The first diagnosis is in accordance with ICD-10: S02, 902 skull depression fracture disease diagnosis code.
2.When the patient also has other disease diagnoses but does not require special treatment during hospitalization and does not affect the implementation of the clinical pathway process for the first diagnosis, he/she can enter the pathway.
3.When the patient has dilated pupils bilaterally, stopped breathing spontaneously for more than one hour, or is in a dying state, he/she will not enter this pathway.
VI. Preoperative preparation (suitable for emergency surgery)
1.Required examination items.
(1) routine blood, urine routine, blood type.
(2) Coagulation function, liver and kidney function, blood electrolytes, blood glucose, infectious disease screening (hepatitis B, hepatitis C, AIDS, syphilis, etc.).
(3) electrocardiogram, chest x-ray plain film.
(4) CT scan of the head (including bone window image).
2.According to the patient’s condition, the recommended examination items.
(1) CT scan of the neck, X-ray plain film.
(2) Ultrasound of the abdomen.
(3) Cardiopulmonary function assessment and echocardiography for patients aged >65 years.
VII. Prophylactic antimicrobial drug selection and timing of use.
Select the drugs according to the Guidelines for Clinical Application of Antimicrobial Drugs (Wei Medical Development [2004] No. 285). Decide the timing of antimicrobial drug use according to the presence or absence of contamination and infection in the wound.
VIII. The day of surgery is the day of admission for emergency surgery.
1.Anesthesia mode: general anesthesia.
2.Surgical method: Cranial depression fracture revision or skull titanium plate, silicone plate, plexiglass repair.
3.Intraoperative materials: skull, dural repair materials, skull fixation materials, etc.
4.Intraoperative medication: antibacterial drugs, dehydration drugs.
5.Blood transfusion: decided according to the blood loss of surgery.
9.Post-operative hospital recovery ≤ 8 days.
1.Checkup items that must be reviewed: cranial CT (plus bone window image) on the day of surgery and on the 7th postoperative day (if the patient’s condition changes drastically, arrange to review at any time); blood routine, urine routine, liver and kidney function, blood electrolytes.
2.According to the patient’s condition, suggested optional examinations: head and neck MRI, chest and abdomen X-ray plain film, abdominal ultrasound.
3.Postoperative medications: antibacterial drugs, dehydration drugs, and anti-epileptic drugs for 7 days for those with severe brain contusion.
X. Discharge criteria.
1.The patient’s condition is stable, the body temperature is normal, the surgical incision is healing well; the vital signs are stable.
2. There are no complications and/or comorbidities that require hospitalization.
XI. Analysis of variants and causes.
1, Postoperative secondary epidural hematoma, subdural hematoma, intracerebral hematoma, cerebral contusion and intracranial hypertension at other sites, which in severe cases required re-craniotomy, resulting in prolonged hospital stay and increased costs.
2.Postoperative incision, cranial or intracranial infection, rejection reaction of built-in material, and serious neurological complications, leading to prolonged hospitalization with increased costs.
3.Concomitant other diseases requiring further consultation and treatment, leading to prolonged hospitalization.
4.Non-emergency patients are not included in this pathway.