Dear NACCS Member,

The British Journal of Anaesthesia has published the article Management of Perceived Devastating Brain Injury after Hospital Admission – A Consensus Statement from Stakeholder Professional Organisations” which is available online here and will be in print next month. A pdf copy can be downloaded here.

This is a joint consensus statement agreed between the Faculty of Intensive Care Medicine, Intensive Care Society, Welsh Intensive Care Society, Royal College of Emergency Medicine, Society of British Neurological Surgeons and Neuro Anaesthesia and Critical Care Society on the management of patients admitted to an emergency department (ED) who are perceived to have a devastating brain injury. This ‘diagnosis’ is usually arrived at following a computed tomographic (CT) scan of the head and discussion with a neurosurgeon, who advises there is ‘nothing neurosurgically to be done’ and in the past, many of these patients (who are often in a non-neurosurgical centre) would undergo tracheal extubation in the ED and embark on an immediate and precipitous end of life pathway.

The new guidance states that this practice is no longer justifiable as some of these patients make a good recovery and subsequently embark on an active care pathway (that may involve a delayed secondary transfer to a neuroscience ICU).

We recommend that patients with a ‘perceived devastating brain injury’, based on CT images and neurosurgical opinion, should be admitted to their local ICU for a period of observation to allow prognostication and identification of the small proportion of this population who may benefit from transition to an active care pathway. Patients who would not have been considered as candidates for ICU admission prior to the ‘devastating’ injury should not be admitted to ICU but instead started on a palliative care pathway as their potential for rehabilitation is extremely poor. Those patients whose tracheas were not intubated prior to their CT scan can have this period of observation in a general ward environment rather than an ICU.

This guidance is not significantly different from the current practice of offering ICU support to patients with hypoxaemic encephalopathy following cardiac arrest.

We do not believe this guidance will have a significant impact on neuroscience ICUs per se as most of these patients will present to non-neurosurgical centres. However, for neuroscience units in Trusts with a general ICU, a management pathway will need to be agreed with colleagues as to where local patients, with a diagnosis of ‘perceived devastating brain injury’, will have their period of ICU observation.

It is anticipated that for most patients this period of observation will allow confirmation of the initial prognosis and, in conjunction with families, they can be transitioned to a controlled end of life pathway.

Please read the guidance, distribute it widely to your anaesthesia, neurosurgical and ED colleagues to allow local pathways of care to be agreed.

NACCS Council.

December 29th, 2017.