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Which Patients Should Be Transferred to Neuroscience Centres?
A large retrospective cohort study using prospectively recorded data from the Trauma and Audit Research Network database showed that since 2003 there has been an average 12% reduction in the adjusted log odds of death per annum in patients with TBI (n=15 173), following the introduction of the NICE guidelines and increased treatment of severe TBI in neuroscience centres. There is now increasing recognition that patients with severe and moderate TBI should be managed in neuroscience centres, regardless of the need for neurosurgical intervention (class II evidence). However, due to current resource constraints, in terms of neuroscience beds and staff, this may not always be possible. In such cases, ongoing liaison with a neurosurgeon over clinical management is essential. The Association of Anaesthetists of Great Britain and Ireland published a set of recommendations for the safe transfer of patients with brain injury in 2006. In general, patients with a GCS of eight or less requiring transfer should be intubated and ventilated. Although such transfers are often urgent, life-threatening extracranial injuries must be attended to at the referring hospital according to the advanced trauma life support guidelines, as haemodynamic and respiratory stability are a pre-requisite for a safe transfer. In the context of TBI with deteriorating consciousness, a new-onset unilateral pupillary dilatation indicates transtentorial herniation usually due to an expanding mass lesion. Administration of mannitol can buy time in such a situation; however, it should not be given to hypotensive patients.
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