Answer: Not isolated subarachnoid hemorrhage.
Caveats abound, of course. In this retrospective review of 404 patients transferred to a facility with neurosurgical capabilities for traumatic intracranial hemorrhage, only 48 suffered subsequent neurologic deterioration. Of this cohort, 75 were isolated traumatic SAH, and only 1 deteriorated – and that was due to an aspiration event in a 98 year-old male. Therefore, these authors, citing prior literature, feel this population appropriate for a prospectively-evaluated more-restrictive transfer protocol.
Their study is, of course, retrospective. Their sample size is rather small. There’s no granular data on characteristics of individual head injuries; not all traumatic SAH or SDH is created equal. Few of their odds ratios for deterioration were helpful in making predictions; isolated SAH had an OR for deterioration of 0.078, while SDH and epidural injuries were twice as likely to deteriorate as baseline (particularly since they tended to co-occur with other intracranial injuries).
But, in our era of cost-conscious medicine, these authors clearly describe the presence of a spectrum of intracranial disease that does not benefit from transfer or hospitalization.
“Patients with traumatic subarachnoid hemorrhage are at low risk for deterioration or neurosurgical intervention”
www.ncbi.nlm.nih.gov/pubmed/23694879
Sadly, most of us are still going to be required to accept these in transfer because of "higher level of care". Arguably, a good veterinary clinic is a higher level of than some rural hospitals, but fat chance in getting any place to admit one of these to their ICU without neurosurgery coverage (even though the data shows they don't need operative managment).
Of course – one retrospective study won't change anything. Needs additional confirmatory research, higher statistical power – and then guidelines to incorporate specific recommendations to not transfer. However, it will probably initially depend more on the profit to the hospital and neurosurgeon livelihood whether those guidelines are ever sufficiently motivated.
Of course – one retrospective study won't change anything. Needs additional confirmatory research, higher statistical power – and then guidelines to incorporate specific recommendations to not transfer. However, it will probably initially depend more on the profit to the hospital and neurosurgeon livelihood whether those guidelines are ever sufficiently motivated.
Seriously, I have neurosurgical coverage at my comunity hospital, but they would never keep this patient. Into town they go
Seriously, I have neurosurgical coverage at my comunity hospital, but they would never keep this patient. Into town they go