Secondary insults during intrahospital transport of head-injured patients

doi:10.1016/0140-6736(90)90614-B

The Lancet

Volume 335, Issue 8685, 10 February 1990, Pages 327-330

https://doi.org/10.1016/0140-6736(90)90614-B Get rights and content

Abstract

Secondary pathophysiological insults occurring after injury have been prospectively assessed in 50 head-injured patients who required intrahospital transfer. 35 patients were transported from the intensive care unit (ICU) and 15 from the accident and emergency department. Physiological variables were recorded every minute in the four hours before transfer (ICU group only), during the move, and for four hours afterwards. Pretransfer insults were predictive of further insults during and after transport. There was significant correlation between increased frequency of insults post-transfer (compared with pretransfer) and high injury severity score. A greater proportion of the patients transported from the emergency department had secondary injuries post-transfer. Adequate resuscitation before moving the patient, especially in patients with multiple injury, is important.

References (17)

D. Gentleman et al.
Hazards of inter-hospital transfer of comatose head-injured patients
Lancet
(1981)
Di Graham et al.
Ischaemic brain damage is still common in fatal non-missile head injury
J Neurol Neurosurg Psychiatry
(1989)
Jd Miller et al.
Early insults in the injured brain
JAMA
(1978)
Jd Miller et al.
Further experience in the management of severe head injury
J Neurosurg
(1981)
Ym Kohi et al.
Extracranial insults and outcome in patients with acute head injury-relationship to the Glasgow Coma Scale
Injury
(1984)
G. Waddell et al.
Effects of ambulance transport in critically ill patients
Br Med J
(1975)
Jf Bion et al.
Validation of a prognostic score in critically ill patients undergoing transport
Br Med J
(1985)
Wa Knaus et al.
APACHE II: a severity of disease classification system
Crit Care Med
(1985)

There are more references available in the full text version of this article.

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Of the 59 Neurosurgical Departments identified, 29 (49.2%) completed the questionnaire. There was a wide variability in the number of patients treated per year between the different departments. The leadership of care often fell (58.6%) on the intensive care specialist. Many (69%) of the departments did not have a neurosurgeon specially dedicated to the management and monitoring of these patients. The initial care in the Emergency department usually fell (51.7%) on the general medicine practitioner. The availability of computed tomography (CT) was universal. The use of telemedicine was highly variable. ICP monitoring was performed on more than 75% of patients in most (89.7%) of departments, but there was limited use of other monitoring techniques. Most Departments followed the recommendations of the Brain Trauma Foundation (BTF) guidelines for the control of ICP.
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CLINICAL PRACTICESecondary insults during intrahospital transport of head-injured patients

Abstract

Lancet

Ischaemic brain damage is still common in fatal non-missile head injury

J Neurol Neurosurg Psychiatry

Early insults in the injured brain

JAMA

Further experience in the management of severe head injury

J Neurosurg

Extracranial insults and outcome in patients with acute head injury-relationship to the Glasgow Coma Scale

Injury

Effects of ambulance transport in critically ill patients

Br Med J

Validation of a prognostic score in critically ill patients undergoing transport

Br Med J

APACHE II: a severity of disease classification system

Crit Care Med

CLINICAL PRACTICE
Secondary insults during intrahospital transport of head-injured patients