Specialist neurocritical care and outcome from head injury

Objectives: To document the effect of neurocritical care, delivered by specialist staff and based on protocol-driven therapy aimed at intracranial pressure (ICP) and cerebral perfusion pressure (CPP) targets, on outcome in acute head injury. Design: Retrospective record review to compare presentation, therapy and outcome in patients with head injury referred to a regional neurosurgical centre, before and after establishment of protocol-driven therapy. Setting: Neurosciences Critical Care Unit (NCCU). Participants: Two hundred and eighty-five patients aged 18-65 years with at least one reactive pupil, referred with a diagnosis of head injury, requiring tracheal intubation and mechanical ventilation. Interventions: Measurement of Glasgow Outcome Scale 6 months after injury. Results: Patients from the two epochs were well matched for admission Glasgow Coma Scale and extracranial injuries. When all referred patients were considered, institution of protocol-driven therapy was not associated with a statistically significant increase in favourable outcomes (56.0% vs. 66.4%). However, we observed a significant increase in favourable outcomes in the severely head injured patients studied (40.4% vs. 59.6%). The proportion of favourable outcomes was also high (66.6%) in those presenting with evidence of raised ICP in the absence of a mass lesion and (60.0%) in those that required complex interventions to optimise ICP/CPP. Conclusions: Specialist neurocritical care with protocol-driven therapy is associated with a significant improvement in outcome for all patients with severe head injury. Such management may also benefit patients requiring no surgical therapy, some of whom may need complex therapeutic interventions. We found it impossible to predict need for such interventions from clinical features at presentation. These data suggest that specialist critical care with ICP/CPP guided therapy may benefit patients with severe head injury.