Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Basal fracture with neurological decline
Skull-base injury may coexist with intracranial haemorrhage, carotid injury, cranial-nerve dysfunction and CSF leakage; deterioration can reflect expanding blood, herniation or airway compromise.
Action: Run ABCDE with cervical protection, document GCS, pupils and cranial nerves, avoid blind nasal tubes, request CT head within 1 hour under NICE criteria, and obtain immediate neurosurgical, ENT and vascular input for decline, significant leak, facial weakness or vascular signs.
Synopsis
Recognise clinical and radiological signs of anterior, middle and posterior skull-base fracture, protect the airway and cervical spine, avoid harmful nasal instrumentation, and manage CSF leak, cranial nerve and vascular complications.
Look deliberately for periorbital ecchymosis without direct eye injury, Battle sign, haemotympanum, clear rhinorrhoea or otorrhoea and cranial nerve dysfunction.
Basal-skull signs trigger CT head within 1 hour in adults and children under NICE head-injury guidance; plain skull radiography is not an alternative.
Protect airway and cervical spine, suction orally and use oral rather than blind nasal airway, gastric or tracheal instrumentation when anterior skull-base injury is possible.
Key red flags
Periorbital bruising without direct orbital trauma, mastoid bruising, haemotympanum or CSF leakage from nose or ear is a NICE one-hour CT indication for basal skull fracture.
Investigation priorities
01
First-line non-contrast CT headFirst stepFirst line
Identify fracture, intracranial haemorrhage, pneumocephalus and mass effect.
Management branches
ImmediateProtect and image
A basal-skull sign, cranial deficit or high-risk mechanism is identified.
Run ABCDE with cervical protection, document GCS components and pupils and address airway contamination using oral suction and oral access.
Avoid blind nasal airway, gastric tube and packing, and arrange non-contrast CT head within one hour under NICE guidance.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.