Appendix 8
Specialist Trauma Transfer Guidelines - 8.1 Neurotrauma

1. Neurological Deficits

• Deterioration of neurological status, for example worsening in conscious state (2 points on GCS), fits, increasing headache, new CNS signs.
• Confusion or other neurological disturbance (GCS <13), >2 hours, no fracture.
• Persistence of headache, vomiting 2 hours post admission.
• GCS<9 after resuscitation.

2. Skull Fracture

• Skull fracture, with confusion, decreased level of consciousness, seizure, focal neurological signs, and any other neurological signs or symptoms.
• Compound skull fracture or penetrating injury-known or suspected.
• Depressed skull fracture.
• Suspected base of skull fracture, for example blood and/or clear fluid from nose/ear, periorbital haematoma, mastoid bruising.

3. Abnormal CT Scan Findings

• Intracranial haematoma
• Cerebral swelling
• Aerocele
• Midline shift

Primary Hospital Management

Provisional Diagnosis	Large mass	Diffuse axonal injury	Possible mass	Vault # Basilar # Penetrating injury	Contusion Small mass Post - concussion	Concussion Fracture	Minor injury
TreatmentTreatment	Admit Intubate Ventilate (PaCO2: 30--35mmHg Mannitol Urgent CT	Admit Intubate Ventilate Urgent CT ICU Observe ICP	Admit Urgent CT ICU Observe	Admit Urgent CT Observe	Admit Urgent CT Observe	Admit Elective CT Observe	Observe for 4-6 hrs Discharge with instructions
Nsurg. consult	Immediate	Immediate	Urgent	Urgent	Urgent	Selective	Selective

GCS = Glasgow Coma Score	LOC = loss of consciousness	ICP = intracranial pressure monitor
ICU = intensive care with neurosurgical unit at a Major Trauma Service	# = fracture	CT = head computerised tomography scan

CommentComment

• The risk of intracranial haemorrhage is increased in the presence of a skull fracture and in a patient over 50 years of age. The need for transfer/retrieval will follow consultation.
• Adequate airway, breathing and circulatory control precede all the above interventions.

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Paediatric Neurotrauma

The patterns of head injury and the principles of management of head injuries in children are similar to those of adults, however, the following important differences should be noted.

(Read in conjunction with Neurotrauma Protocol.)

Assessment

• Fluctuation in neurological responses is more marked in children. Isolated observations may be misleading.
• The state of the fontanelle is a useful indicator of raised intracranial pressure.

Acute Brain Swelling

• Blunt trauma may be followed, within a short period from injury, by acute brain swelling. This may follow a relatively minor head injury and may be marked by rapid and profound decline in the conscious state.
• The small child's brain is more likely than an adult's to swell after blunt trauma, therefore, overtransfusion must be avoided.

Seizures

• Post-traumatic epileptic fit is not uncommon, even in minor head injury, but the following decline in conscious state may mask onset of intracranial haemorrhage. CT scan should be undertaken.
• In general, if the child makes a full and rapid recovery following a fit, there is no indication to place that child on anticonvulsants.

Localised Brain Injury

• Puncture wounds over a child's head frequently indicate direct injury to the underlying brain. Entry wounds should be inspected for signs of fracture, discharge of CSF or cerebral tissue. If there is any doubt, CT scan should be undertaken.
• Depressed fractures, simple or compound, are more common and may be associated with local damage to the underlying brain. Lack of history of loss of consciousness does not exclude the presence of severe focal injury.
• Elasticity of a small child's skull may result in no fracture but local injury to brain or meninges, resulting in an extradural haematoma.
• Significant blood loss impairing circulating blood volume may result from a bleeding scalp wound, scalp or intracranial haematoma. If planning any surgery, immediate steps must be taken to obtain blood for transfusion as intraoperative hypotension may occur.

(Adapted from The Management of Acute Neurotrauma in Rural and Remote Locations, Neurosurgical Society of Australasia, RACS, 1995.)