The location of care for many brain-injured patients has changed since 2012 following the development of major trauma centres. Advances in management of ischaemic stroke have led to the urgent transfer of many more patients. The basis of care has remained largely unchanged, however, with emphasis on maintaining adequate cerebral perfusion as the key to preventing secondary injury. Organisational aspects and training for transfers are highlighted, and we have included an expanded section on paediatric transfers. We have also provided a table with suggested blood pressure parameters for the common types of brain injury but acknowledge that there is little evidence for many of our recommendations. These guidelines remain a mix of evidence-based and consensus-based statements. We have received assistance from many organisations representing clinicians who care for these patients, and we believe our views represent the best of current thinking and opinion. We encourage departments to review their own practice using our suggestions for audit and quality improvement.

SummaryThe location of care for many brain‐injured patients has changed since 2012 following the development of major trauma centres. Advances in management of ischaemic stroke have led to the urgent transfer of many more patients. The basis of care has remained largely unchanged, however, with emphasis on maintaining adequate cerebral perfusion as the key to preventing secondary injury. Organisational aspects and training for transfers are highlighted, and we have included an expanded section on paediatric transfers. We have also provided a table with suggested blood pressure parameters for the common types of brain injury but acknowledge that there is little evidence for many of our recommendations. These guidelines remain a mix of evidence‐based and consensus‐based statements. We have received assistance from many organisations representing clinicians who care for these patients, and we believe our views represent the best of current thinking and opinion. We encourage departments to review their own practice using our suggestions for audit and quality improvement.

STUDY DESIGN:Case report.OBJECTIVE:To report the first case in the literature of a traumatic cervical spine subdural cerebrospinal fluid (CSF) collection (hygroma) under tension causing cord compression. We suggest etiopathogenesis and modality of treatment.SUMMARY OF BACKGROUND DATA:Hygromas are subdural cranial CSF collection. A literature review showed no previous published case of post-traumatic spinal hygroma. This was a potential life-threatening sequelae of a high cervical injury that warranted early diagnosis and emergency treatment.METHODS:We present a case of a young adult who sustained a traumatic vertical atlantoaxial dislocation associated with a type III odontoid fracture. He was initially scored C6 ASIA D. Magnetic resonance imaging (MRI) demonstrated cord contusion at the craniocervical junction and a small fluid collection anterior to the cervical cord. On day 5 after his injury he developed complete paraplegia and priapism. An urgent MRI of his spine revealed expansion of the intraspinal fluid collection with distortion of the cord. He was treated with an emergency surgical decompression. The cervical fluid collection was found to be subdural extra-arachnoidal CSF. A subdural-pleural shunt was inserted. The atlantoaxial injury was reduced and fixed with posterior instrumentation.RESULTS:At 1 year from the injury the patient was independent and fully ambulant. MRI and computed tomography images of his spine demonstrated complete resolution of the cervical hygroma, appropriate placement of the cervical-pleural shunt, and stability of the atlantoaxial injury.CONCLUSION:We describe a unique case of post-traumatic spinal hygroma causing cord compression in a patient with an unstable craniocervical injury. The early recognition and correction of this dangerous complication is of paramount importance to savage cord function.LEVEL OF EVIDENCE:5.

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

AnaesthesiaVolume 70, Issue 3 p. 367-368 CorrespondenceFree Access Skin antisepsis guidelines – presentation or concentration? J. A. Hell, J. A. Hell john.hell@uhs.nhs.uk University Hospital, Southampton, UKSearch for more papers by this authorT. D. Madamombe, T. D. Madamombe University Hospital, Southampton, UKSearch for more papers by this authorM. Cordingly, M. Cordingly University Hospital, Southampton, UKSearch for more papers by this authorC. A. Eynon, C. A. Eynon University Hospital, Southampton, UKSearch for more papers by this author J. A. Hell, J. A. Hell john.hell@uhs.nhs.uk University Hospital, Southampton, UKSearch for more papers by this authorT. D. Madamombe, T. D. Madamombe University Hospital, Southampton, UKSearch for more papers by this authorM. Cordingly, M. Cordingly University Hospital, Southampton, UKSearch for more papers by this authorC. A. Eynon, C. A. Eynon University Hospital, Southampton, UKSearch for more papers by this author First published: 11 February 2015 https://doi.org/10.1111/anae.13026Citations: 2 No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat We were interested to read the recent AAGBI guidelines on skin antisepsis for central neuraxial blockade 1. We note the concerns surrounding the use of chlorhexidine in 70% alcohol and its potential to cause adhesive arachnoiditis if injected or allowed to contaminate anything injected into the spinal canal. The letter in response to the recommendation to use 0.5% chlorhexidine in 70% alcohol from West and Pawa appeared sensible and balanced 2: skin antisepsis using a swabstick to apply chlorhexidine in alcohol prevents the solution being injected, so long as it is allowed to dry completely. The only formulation currently available as a swabstick is 2% chorhexidine in 70% alcohol. Therefore, whilst a lower concentration of chlorhexidine may reduce the risk of neurotoxicity, it is not available in the safest form of applicator, and is not likely to be released in that form in the forseeable future. We welcome a full and open discussion about this topic, which affects not just all anaesthetists but anyone that performs neurosurgery, lumbar punctures or spinal drain insertions. We suggest that there are certain core principles that are not in dispute: The technique of skin disinfection must avoid any possibility of chlorhexidine in alcohol's contaminating any fluid that is injected into the spinal canal; The safest current method of applying skin antisepsis is to use a swabstick that can be disposed of immediately after use. This avoids the risk of antiseptic solutions’ being injected, splashed or aerosolised and contaminating the sterile procedure trolley; The lowest concentration of chlorhexidine that achieves the maximal degree of skin disinfection should be employed, provided that it is available in a swabstick; The antiseptic solution applied must be allowed to dry completely and the gloves used for its application changed to a new, dry, sterile pair before the procedure trolley is accessed; Tinted antiseptic solutions allow better identification of the area of skin disinfected. They also ensure that it is immediately obvious if any solution should contaminate any part of the procedure trolley or sterile gloves; Chlorhexidine in alcohol is a more effective skin antiseptic than povidone iodine. As such, it should be the agent of choice. After consulting with the lead neurosurgical, neuroanaesthetic and neurointensive care consultants at our hospital, we have decided to continue using swabsticks containing 2% chlorhexidine in 70% alcohol for skin disinfection. References 1 Association of Anaesthetists of Great Britain and Ireland Obstetric Anaesthetists’ Association Regional Anaesthesia UK Association of Paediatric Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade, 2014. Anaesthesia 2014; 69: 1279– 86. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2West SJ, Pawa A. Continuing to use 2% chlorhexidine applicators. Anaesthesia 2015; 70: 234– 5. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar Citing Literature Volume70, Issue3March 2015Pages 367-368 ReferencesRelatedInformation

Where a ‘time-critical’ condition exists and care cannot be provided at the patient's current hospital, traditional ‘refer and accept’ pathways of care may delay immediate transfer. This paper describes how to identify time-critical patient groups and the sources of delay. This enabled a local clinical network to redesign the transfer process, resulting in the removal of specialist teams from the transfer decision-making process, changing the process from ‘refer and accept’ to ‘send and inform.’ In cases where referral to and acceptance by specialist teams were removed from the decision-making pathway, a median time saving of 1 hour 38 minutes was achieved.

Background Kitesurfing and kiteboarding are so-called extreme sports, whereby participants are attached to powerful kites, which propel the user over water or land. The sports have grown rapidly over the last decade. The impact, burden and mechanism of major neurological injuries resulting from these sports in the United Kingdom are unknown. Methods We reviewed patients requiring admission following kitesurfing or kiteboarding injuries to a regional Neurological Trauma Centre over a five-year period. Results Four cases were identified – two polytrauma and two spinal injuries, representing ∼0.5% of trauma admissions. All occurred due to impact onto land or objects after being lifted by the kite. Conclusions Participants in kitesurfing and kiteboarding must be aware of the possibility of serious injury. Despite the sports’ rapid, recent expansion, the number of injuries requiring admission to our unit over a five-year period was small but included one fatality. All of the injuries resulted from high-energy impact with land rather than in the water. Future safety guidance should include emphasis on care and measures to prevent injuries occurring at the water’s edge. We recommend that personal injury as well as liability insurance is obtained before participation in such sport.

BACKGROUND:In November 2011, University Hospital Southampton (UHS), now a major trauma centre, opened its onsite helipad, allowing patients to be brought to the emergency department (ED) directly by air ambulance. Prior to this, helicopters were required to land at a local playing field and the patient had to be transferred by land ambulance. This study aims to investigate the impact this change in practice has had on the flow of patients to the ED.METHODS:The authors completed a retrospective case analysis of the first 100 patients brought directly to UHS by helicopter. Data were obtained from ED notes and helicopter provider databases. Analysis was conducted on the type of incident and appropriateness of referral. Incident locations were plotted geographically.RESULTS:100 patients arrived at UHS ED by helicopter between 17 November 2011 and 31 March 2012. Of these, 79 were primary helicopter emergency medical service (HEMS) missions and 21 were secondary transfers from other hospitals. Of the HEMS patients, 38 were likely to have been transported to another hospital, had there not been an onsite helipad at UHS. 29 passed another suitable receiving hospital en route and therefore may have come to UHS for speciality services.CONCLUSIONS:The provision of an onsite, 24 h helipad facility at UHS has resulted in a significant number of patients being transported to the hospital by helicopter who might otherwise have attended an alternative hospital.

A 29-year-old female presented to the intensive care unit with refractory status epilepticus. Despite treatment with anticonvulsants and sedation, she continued to have EEG evidence of seizure activity that terminated only with volatile anaesthetic agents. There was serological evidence of exposure to a flavivirus. In the UK the only endemic flavivirus is Louping ill, which is closely related to tick-borne encephalitis. It was likely that this was the cause. She remained on intensive care for almost six months and failed to regain consciousness.

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

We present a case of a previously healthy 19-year-old man who was admitted to our intensive care unit (ICU) with meningitis and signs of cerebral coning. Investigation confirmed raised intracranial pressure (ICP) with cerebellar tonsillar herniation and cerebral venous thrombosis. Blood polymerase chain reaction (PCR) demonstrated evidence of Neisseria meningitides, serogroup Y. Besides antibiotics and steroids, treatment included intubation and ventilation to maintain a PaO2 >11 kPa, PaCO2 approximately 4.5 kPa, maintenance of a mean arterial pressure >80 mm Hg, regular IV mannitol, therapeutic anticoagulation and an external ventricular drain. Three weeks following admission, he was fully alert and orientated with no focal neurological deficits. Although elevated ICP is expected in cases of meningitis, we have demonstrated that aggressive measures to reduce ICP are worthwhile, even in the presence of clinical signs of coning, which in this case resulted in a good outcome.

Induced hypothermia has established indications in cardiac arrest in adults and in hypoxic-ischaemic encephalopathy in infants. Despite substantial research effort its application in the setting of trauma remains controversial. In head and spinal trauma mild cooling may help to limit secondary injury. In penetrating trauma, profound cooling at the time of cardiac arrest may offer an extended window to control haemorrhage before irreversible ischaemic brain damage occurs. Both of these potential indications are the subject of clinical trials. This review seeks to set in context these studies and previous work in this field.

An elderly female presented for an emergency neurosurgical procedure under general anaesthesia. Her past medical history included chronic kidney disease but there was no history of liver or neuromuscular disease or recent use of drugs known to interact with neuromuscular blocking drugs. We induced anaesthesia with 1.5 μg.kg−1 fentanyl, 1.4 mg.kg−1 propofol and 0.09 mg.kg−1 vecuronium, given through an existing 20-G venous cannula in the left antecubital fossa. However, after two minutes we did not see any obvious effect, despite the presence of a freely running infusion of 0.9% saline through the cannula. Over the following three minutes, we administered a further 1.7 mg.kg−1 propofol, again with minimal effect. We then noted the left arm was cool and swollen above the site of the cannula and we therefore suspected subcutaneous leakage from the cannula. We then sited a second cannula, and gave a further 0.8 mg.kg−1 propofol and 0.06 mg.kg−1 vecuronium with immediate effect. Tracheal intubation proceeded uneventfully and surgery continued as planned. When surgery was completed 135 min later, supramaximal train-of-four (TOF) stimulation of the ulnar nerve produced no palpable twitch, even though we had not administered any further vecuronium during surgery. We maintained anaesthesia in the intensive care unit until the fourth twitch on TOF stimulation returned 4 h after induction. Our patient’s trachea was extubated the following day without complication. Erythema at the site of injection peaked on the second day after surgery, and resolved within 7 days. Three days after surgery, she was discharged from the intensive care unit with a Glasgow Coma Score of 15. Vecuronium is an aminosteroid neuromuscular blocking drug with an onset of action of 2 min and a recovery time of 14–30 min after an initial bolus of 0.08–0.1 mg.kg−1 [1]. Liver failure increases the duration of action but renal failure has not caused prolongation of neuromuscular blockade in prospective studies [2]. To our knowledge, this is the first reported case of accidental subcutaneous injection of vecuronium. Similar effects have been reported with pancuronium, when subcutaneous injection resulted in a delayed block with unpredictable duration of action [3]. Our accidental subcutaneous injection of vecuronium appeared to result in neuromuscular blockade lasting approximately 4 h. We recommend vigilance when injecting neuromuscular blocking drugs, with careful observation for signs of subcutaneous injection.

Following admission to the intensive care unit (ICU), patients or their relatives may need legal advice. This is a retrospective review of the impact of an in-house legal service able to provide legal advice acutely, in a specialised 13-bed neurosciences ICU in a University Hospital over a two and a half year period. All patients admitted to the ICU were considered. Consent for approach by the legal service was taken from the patient if possible. If not possible, assent was obtained from the next of kin. Solicitors were available for one afternoon per week on the ICU or within one day in emergency situations. The amount of time spent in discussion of non-compensation issues arising as a result of admission was measured as well as the time spent identifying potential claims for compensation against a third party and resulting in legal firms being instructed to pursue claims. One hundred and nine legal audits were undertaken. Non-compensation advice was provided in all cases. Possible compensation claims were identified in 63 cases. Of these, the advising firm of solicitors was instructed in 14 cases. Significant numbers of ICU patients and their families have legal issues arising as a result of acute hospitalisation. In many instances, these are not dealt with while the patient is seriously ill. Early identification and management of these issues helps to relieve the anxiety experienced by families.

Shah and Darwent's paper highlights the difficulty in diagnosing pulmonary embolism but also suggests that medical staff are not aware of the correct management of massive pulmonary embolism and its critical …

BACKGROUND:Acute disseminated encephalomyelitis (ADEM) is a rare, acute demyelinating condition. Although it usually presents in an acute or subacute manner over days, its clinical course may be rapid with symptoms and signs of severe intracerebral mass effect secondary to cerebral oedema.METHODS:Case report and literature review.RESULTS:We report a case of a patient presenting with a hyperacute course manifested by rapid loss of consciousness and focal neurological signs. Management with emergency hemicraniectomy and steroids resulted in rapid neurological improvement and minimal long-term deficit.CONCLUSIONS:We believe that only surgical decompression is likely to be life saving in similar cases of hyperacute cerebral oedema due to ADEM. The wide decompression performed was concordant with that indicated for traumatic brain swelling. Such aggressive management is vindicated by the rapid recovery shown by our patient within days of surgery and the finding of minimal neurological sequelae at 3 months.

Southampton University Hospitals NHS Trust; Southampton, UK The author has not disclosed any potential conflicts of interest.

Traumatic brain injury (TBI) remains the commonest cause of death in the first four decades of life, accounting for 15–20% of deaths between 5 and 35 years. 1 There is a ten-fold greater mortality in trauma patients with a head injury compared to those without. 2 The effects of head injury for survivors, their families and for society can be devastating; TBI is the cause of severe disability for 150–200 people per million annually. 3,4 Perhaps it is better if we do nothing, don't contact the neurosurgeons, don't admit them to specialist units, don't treat the pneumonia that develops – keep them comfortable, allow them some dignity? Or is this a situation where therapeutic nihilism leads to a self-fulfilling prophecy of poor outcome?