Patient Preparation

• Evaluate entrance and exit wounds
  
• Antiepileptic drug is loaded
  
• Intravenous antibiotics
  
• Tetanus booster

Operative Planning

• Review computed tomography imaging, plain skull x-ray
  
• Consider clinical history (rapid neurologic decline)

Anesthetic Issues

• Management of elevated intracranial pressure (ICP) by anesthesiologist and neurosurgeon
  
• Arterial and venous access
  
• Moderate hyperventilation pCO₂ 25 to 30 mm Hg (intraoperatively)
  
• Blood products available for transfusion (i.e., packed red blood cells, fresh frozen plasma, platelets, activated factor VIIa)
  
• Communicate with anesthesiologist any likelihood of venous air embolism

Positioning

• Head is elevated 20 to 30 degrees
  
• Supine with head on horseshoe or donut head rest, with shoulder roll when needed
  
• Position head to allow access for both entry and exit wounds as needed for adequate débridement and to allow extension of skin incision if needed

Planning of Incision

• Goals are to fashion a viable scalp flap that allows access to entrance and exit wounds for débridement, appropriate craniotomy or craniectomy for ICP control, repair of dura, and closure
  
  
  
  
  • Standard trauma flap
    
  • Curvilinear or linear incision
    
  • Bicoronal (develop pericranial flap for frontal sinus coverage if needed)
  
  
• Débridement of devitalized scalp

Bone Removal

• Fractured bone is removed by craniotomy or craniectomy usually incorporating an area greater than the fracture (do not follow fractures across dural sinuses) to facilitate exposure of dural defects
  
• Contaminated bone edges are débrided back to healthy bone
  
• Small bone fragments are discarded, large bone fragments are cleansed in Betadine and replaced primarily or at a second operation
  
• If the frontal sinus is entered, it should be exenterated, the frontal ostia packed with muscle, and a pericranial flap or fascial graft is harvested and overlaid to isolate the sinus from the intracranial dura

Dural Opening

• Dural tenting sutures
  
• Cruciate opening to adequately expose devitalized brain or hematomas that need evacuation (base the dural flaps toward the dural sinus)
  
• A lacerated dural sinus is packed, repaired directly, repaired with a rotated flap of adjacent dura, or with a pericranial or muscle patch

Débridement

• Mass occupying hematomas are evacuated
  
• Devitalized brain is resected
  
• Missile tract is explored to remove devitalized brain tissue and bone fragments
  
• Accessible metal fragments are removed; do not remove metal fragments that are not easily accessible
  
• Wash deeper portions of missile tract with irrigation

• As infection prevention is paramount, a watertight dural closure with 4–0 silk sutures is required
  
• Remaining dural defects are repaired with autologous pericranium, fascia, or muscle
  
• Large débrided bone fragments are replaced with titanium plates and screws unless left out for ICP control
  
• Temporalis fascia, galea, and the skin are closed in separate layers

• ICP monitoring as required by the GCS
  
• Continue aggressive medical management for maintenance of ideal cerebral perfusion pressure
  
• Antibiotic prophylaxis for 48 to 72 hours