X-rays are examined to determine the distribution of bone and metallic fragments. Endotracheal intubation and general anesthesia are preferable in most cases.
Adequate blood is made available for wounds near major dural venous sinuses.
The scalp is scrubbed with an antiseptic solution, preferably an iodophor. The wound is copiously irrigated with 1-2 liters of sterile saline. The patient is positioned and draped so that entry and exit wounds are accessible and a contralateral burr hole can be made if needed. The head should be elevated slightly above heart level, to encourage venous return, but not so high as to risk air embolism. Devitalized scalp and foreign bodies are removed.