1. Neuro-critical Transfers
NE NC London Critical Care Network

2. Case summary
65 year old brought to ED after a fall while coming out of pub.
Confused and agitated.
Contusion over right temporal region
Smelling of alcohol
SpO2 96%; HR 95/m; BP 140/90

3. What is your immediate concern? How will you manage this case?
What will you do?
What is your immediate concern?
How will you manage this case?
ATLS Protocol; ABCDE approach
Cervical stabilisation? Agitated patient
Prevention of secondary brain injury is priority

4. Anatomy & relevance of secondary brain injury
Prevention of secondary brain injury
Why this is important?
Cerebral perfusion pressure
Why it is important to maintain it?
Discuss Rigid skull, Mass effect of expanding brain- Monro-Kellie Doctrine
Autoregulation, CBF and ICP and effect on Cerebral perfusion Pressure

5. Severity of brain injury
GCS Score- what are the components? E V M
Severity of brain injury based on GCS
Mild ? GCS
Moderate
Severe
Explain GCS and how it is calculated.
Mild GCS13-15
Moderate GCS 9-12
Severe GCS 3-8

6. Indication for CT Scan CT Scan
High Risk Patient
GCS score still < 15 two hours after injury
Neurologic deficit
Open skull fracture
Sign of basal skull fracture
Extremes of age

7. Indication for CT Scan CT Scan
Moderate risk patients
“Dangerous mechanism”
Retrograde amnesia > 30 minutes in duration
Severe headache
Vomiting > 2 episodes
GCS < 13
Warfarin or bleeding disorder
Different rule for non-trauma and Age < 16 year

9. Difference between extradural and subdural
Diffuse injury Vs localised
Subdural Vs Extradural
Midline shift?

10. Management priorities
ABCDE
Prevention of Secondary brain injury
Adequate oxygenation
Adequate ventilation
Adequate blood pressure
Focussed neurological exam
GCS
Pupil
Lateralising signs
Elaborate more on individual part if time permits

11. After Initial management
Transfer of image &
Referral to neurosurgical centre
Time critical Transfer

12. Airway Indications for intubation Secured with ET tube RSI induction
Low GCS <9
Rapidly falling GCS >2 points
Control of PaO2 & PaCO2
Significant oral / Max Fax bleeding
Secured with ET tube
RSI induction
NG insertion

13. Urgent Neurosurgery ASDH EDH Posterior fossa bleed Acute hydrocephalus
SAH with deteriorating GCS

14. Referral to Specialist Neurosurgical Centre….
Time critical transfer
What needs to be done before transfer takes place?
Primary vs secondary brain injury

15. Breathing Mechanical ventilation PaO >11kPa PaCO2 4.5-5.0
Arterial blood gas
EtCO2

16. Circulation 2 x large bore cannula IABP Fluid resuscitation
Central line access (but not to cause delay)
Ensure good jugular venous drainage
MAP >80mmHg (CPP >60mmHg)
CPP = MAP - ICP

17. Disability Reduce Cerebral Metabolic O2 requirements
Sedation / Paralysis
Treat seizures (Phenytoin 15mg/kg)
Pupils
Hyperosmolar therapy (1-1.4g/Kg 20% Mannitol)
Na <155 Posm <320
BM 6-10

18. Exposure
Normothermia
Catheterise
…..AND EVERYTHING ELSE!

19. A Systematic Approach Assessment of the patient Organisational
Airway & Cervical spine
Breathing -PaO2, EtCO2, ventilator & suction
Circulation - lines, “uppers”, monitoring
Disability - sedation, paralysis, neuro protection
Exposure - Blankets, other injuries
Fluids – crystallloid, hypertonics, blood, electrolytes, catheterise
Gut - ?NG, antiemetics
Haematology – FBC/U&Es/Clotting/G&S
Imaging & Notes
Journal - transfer documents
Organisational
Kit – transfer bag, pumps, power cables, monitor
Location (phone numbers / contact)
Money
Nourishment
Outdoor protection
Phone
Ready to ….