The decision to perform a neurosurgical intervention in an austere location is best made with the telemedicine support of a neurosurgeon.
Telemedicine consult may be obtained from the closest neurosurgeon in the evacuation chain. In addition, worldwide neurosurgery consultation is available at:
- WRNMMC: 301-295-4000 (comm), 312-295-4000 (DSN) or 240-381-2528 (comm).
- SAMMC: 210-539-0817 (comm) or 312-429-2500 (DSN), 210-916-2500 (comm).
- Ask the hospital operator to contact the attending neurosurgeon on call.
In some locations, a CT scan may be available, greatly facilitating the appropriate intervention.
When a CT scan is not available, there is a high risk that procedures may be performed without correct localization of pathology. It is therefore necessary to make an accurate diagnosis, appropriately resuscitate, and exhaust all medical interventions prior to performing a procedure in this environment. Regardless of whether a CT scan is available, the indications for surgical intervention are clinical.
When to Perform Cranial Procedures
- A cranial procedure is recommended after teleconsultation with neurosurgery (when possible), and
- Severe closed supratentorial brain injury with a presenting GCS ≤ 8 AND lateralizing cortical dysfunction such as unilateral dilated pupil or hemiparesis
- Accompanied by hemodynamic dysfunction: hypertension, bradycardia, and respiratory variation (Cushing’s reflex), or
- Failure of maximal critical care management per the Neurosurgery and Severe Head Injury CPG2 to stabilize the patient. This may manifest by the occurrence of a new lateralizing cortical finding (hemiparesis, rapidly expanding pupil) and/or further decline in GCS off of sedation, and
- Evacuation to a neurosurgeon is not available within approximately 4 hours of injury, and
- Surgeon training and resources are adequate. See Appendix A (Training) and Appendix B (Resources).
When not perform cranial procedures
- Clinical condition and neurologic status stabilized or improved with aggressive medical management.
- Surgeon and resources are not adequate. See Appendix A (Training) and Appendix B (Resources).
- The patient has a post-resuscitation GCS = 3 with bilateral fixed and dilated pupils. This is non-survivable.