Box 21 A patient with a traumatic brain injury should be discussed with neurosurgery

• When a CT scan in a general hospital shows a recent intracranial lesion

• When a patient fulfils the criteria for CT scanning but this cannot be done within an appropriate period

• Whatever the result of any CT scan, when the patient has clinical features that suggest that specialist neurological assessment, monitoring, or management are appropriate. These reasons include:

- Persisting coma (GCS <9, no eye opening) after initial resuscitation

- Confusion persists for more than 4 hours

- Deterioration in conscious level after admission (a sustained decrease in one point in the motor or verbal GCS subscores, or 2 points on the eye opening subscale of the GCS)

- Persistent focal neurological signs

- A seizure without full recovery

- Compound depressed fracture

- Definite or suspected penetrating injury

- A CSF leak or other sign of base of skull fracture can be minimised by resuscitation before transfer, invasive monitoring, and care by appropriately trained staff, before, during and after transport.

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