It is important to consider the effects of the structure of the trauma service on the care of patients with severe TBI. In the United Kingdom, this was addressed in the recent Working Party Report from the Royal College of Surgeons of England. Neurosurgical services are structured on a regional basis, with one tertiary referral centre serving many hospitals that admit patients with traumatic injuries. The trauma service is structured on a district basis; this means that many patients are managed by clinicians without neurosurgical centres who have little experience or expertise in this field. As a result, management is often discussed by telephone, many patients are transferred between hospitals with the additional risks involved, and some are actually managed outside neurosurgical centres for the duration of their hospital stay.53 It must be admitted, however, that management often varies even

Table 2.2 (a) Risk of an operable intracranial haematoma in brain-injured patients



Other features



1 in 3615


1 in 31 300


1 in 6700

amnesia (PTA)

Skull fracture

1 in 81

Skull fracture and PTA

1 in 29


1 in 51

No fracture

1 in 180

Skull fracture

1 in 5


1 in 7

No fracture

1 in 27

Skull fracture

1 in 4

Table 2.2(b) Canadian CT head rule - minor head Injury*

Five high-risk factors:

1. Failure to reach GCS of 15 within 2 hours

2. Suspected open skull fracture

3. Sign of basal skull fracture

4. Vomiting >2 episodes

Two additional medium-risk factors:

1. Amnesia before impact >30 minutes

2. Dangerous mechanism of injury

The 3121 patients had the following characteristics: mean age 38-7 years; GCS scores of 13 (3-5%), 14 (16-7%), 15 (79-8%); 8% had clinically important brain injury; and 1% required neurological intervention.52

The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98-4% sensitive (95% CI 96-99%) and 49-6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT.

*Data from Stiell et al.52

between neurosurgical centres.54,55 The publication of guidelines will hopefully standardise and improve care.56

Patients with an impaired level of consciousness have physiological instability that can result in secondary insults during transport and a worse outcome. These adverse events

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