Effective management of severe traumatic brain injury in a district hospital

The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provide a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.