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Transport Service
Traumatic Brain Injury
Document Control Information Author Position Document Owner Document Owner Position Document Version Replaces Version First Introduced Review Schedule Active Date Next Review CATS Document Number 2002122013 Applicable to All CATS employees
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
1. Assessment
o Loss of consciousness at scene and subsequent GCS
o Resuscitation required at scene and subsequently
o If intubated, necessity for sedation and paralysis to do so
o GCS (attention to trend of motor component- may be predictive)
Haemotympanium, “panda” eyes, CSF otorrhoea, Battle’s sign
o External signs of head injury including skull fractures
o Assessment of spinal cord function (movement of limbs, priapism, spinal shock)
o Results of full secondary survey (needs senior orthopaedic surgeon/general surgeon to review) and presence of other injuries - see trauma referral form
o Trauma imaging (including abdominal assessment- FAST scan +/or CT), particularly
2. 1 Initial management
2.1.1. Stabilisation of airway and cervical spine, breathing and circulation (ABC) is the priority for
all patients before attention to other injuries.
Hypotension and hypoxaemia are strongly associated with poor outcome.
2.1.2. Immobilise cervical spine if any suspicion of cervical spine injury, ie if:
o Focal neurological deficit, paraesthesia
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
2.1.3. If cardiovascularly unstable and requiring volume resuscitation, consider other sites of
blood loss: chest, abdomen, pelvis and major limb fracture.
2.1.5 Cross match blood and transfuse to Hb 10g/dL.
2.1.6 Pass urinary catheter and orogastric tube
2.1.8 Consider NAI, especially in children < 2 years of age
2.2 Indications for CT scanning
2.2.1 GCS<13 at any time since injury
2.2.2 GCS equal to 13 to 14 at 2h after the injury
2.2.3 Suspected open or basal skull fracture
2.2.7 Amnesia > 30 minutes of events before impact
Cervical spine imaging:
10 yr can be treated as adults for the purpose of cervical spine imaging (plain
films- 3 view series: AP, AP peg view, lateral- must include C7-T1 junction which may require swimmer’s view; CT neck if intubated particularly for adequate high spine views)
10 yr should receive AP and lateral views without an AP peg view. CT should be
reserved for those with inadequate plain films or if there is a suspicion of injury despite
Make the appropriate referral
2.3.1 Criteria for referral to ICU/Neurosurgery include:
2.3.2 Great Ormond Street Hospital is the receiving centre for all head injury patients in North
Thames. If the child is accepted by Great Ormond Street, the case must also be discussed
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
with the neurosurgical registrar on call. In the event of any difficulty contacting the
neurosurgical registrar, contact the neurosurgical consultant on call.
2.3.3 If no bed is available at GOS, the child should be referred to King’s College Hospital.
2.3.4 If no bed is available in South Thames, refer to Addenbrookes Hospital.
3. Indications for intubation
Ventilatory insufficiency (PaO2 <9 on air, <13 in oxygen or PaCO2 >6)
Spontaneous hyperventilation (PaCO2 3.5)
4. Management post intubation
4.1.1 Ensure adequate circulating volume
4.1.2 Mandatory continuous in-line immobilisation of cervical spine
4.1.3 Intubation should be by an anaesthetist if possible
4.1.4 Thiopentone, suxamethonium, rapid sequence induction (see induction of
4.1.5 Intubation must be with an oral tube.
4.1.6 Secure well, preferably with Melbourne strapping (tight ties around neck can
Maintain full in-line immobilisation with hard collar/sandbags/tapes and log rolling with use
of an orthopaedic scoop stretcher for all movements
Sedate and paralyse adequately with morphine, midazolam and vecuronium infusions
Use fentanyl (5-10 mcg/kg) +/or midazolam (0.1 mg/kg) boluses for procedures, eg
Ventilate to a normal PaCO2 4.7 – 5.3 kPa, mandatory ETCO2 monitoring
Aim for saturations of ≥94% and PaO2 of ≥13 kPa
Maintain mean arterial pressure (MAP) to maintain cerebral perfusion pressure (CPP), with
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
Fluid restrict to 50% maintenance of isotonic solution, eg 0.9% NaCl
Maintain blood glucose in normal range – add dextrose to 0.9% if
4.10 Load with phenytoin if any suggestion of seizure activity.
4.11 Consider mannitol or 3% NaCl (aim serum Na 145) if lateralising pupillary signs (discuss
with CATS consultant and neurosurgical SpR on call prior to administration).
4.12 Monitor temperature: aim 35-37C centrally. Avoid hyperthermia.
4.13 Antibiotic prophylaxis is recommended with:
Use Co-amoxiclav 20mg/kg or cefuroxime 20mg/kg + metronidazole 7.5mg/kg. 5. Transport considerations
5.1
If a child has an intracranial lesion requiring urgent neurosurgery (eg extradural
haematoma), the referring hospital should bring the child to the neurosurgical centre to avoid any delay. See neurosurgical emergency guideline.
Thorough resuscitation and stabilization of the patient should be completed before transfer.
A patient persistently hypotensive despite resuscitation should not be transported until all
possible causes have been identified and the patient is stabilized.
An appropriate inotrope, eg noradrenaline, should be connected to a three way tap and
Assume spinal injury: maintain in line immobilization throughout, e.g. vacmat fully suctioned
Hard collars should not be applied if they are likely to obstruct venous return and therefore increase ICP (the risks of incomplete immobilization should be balanced against
the risks of raised ICP). You should be able to pass a finger down a collar with ease if
Prepare sedation boluses: midazolam 0.1mg/kg boluses and/or fentanyl 5-10g/kg iv if
requires suction or responds to movement.
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great
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Please list all medications (even over-the-counter medications and herbal supplements). Note all strength and dosages. Bring this along with your visit. Do you know of any blood relative who has or had: (Circle and Give Relationship) Stroke ______________ Tuberculosis __________ Blood Disease _________ Arthritis _________ if diagnosed by a doctor, is it __________ Rheumatoid Arthritis ___________
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
Transport Service 
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1. Assessment 
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
2.1.3. If cardiovascularly unstable and requiring volume resuscitation, consider other sites of
blood loss: chest, abdomen, pelvis and major limb fracture.
2.1.5 Cross match blood and transfuse to Hb 10g/dL.
2.1.6 Pass urinary catheter and orogastric tube
2.1.8 Consider NAI, especially in children < 2 years of age
2.2 Indications for CT scanning 
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
with the neurosurgical registrar on call. In the event of any difficulty contacting the
neurosurgical registrar, contact the neurosurgical consultant on call.
2.3.3 If no bed is available at GOS, the child should be referred to King’s College Hospital.
2.3.4 If no bed is available in South Thames, refer to Addenbrookes Hospital.
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
Fluid restrict to 50% maintenance of isotonic solution, eg 0.9% NaCl
Maintain blood glucose in normal range – add dextrose to 0.9% if
4.10 Load with phenytoin if any suggestion of seizure activity.
4.11 Consider mannitol or 3% NaCl (aim serum Na 145) if lateralising pupillary signs (discuss
with CATS consultant and neurosurgical SpR on call prior to administration).