What are the indications for referring a patient with ICP to a specialist, and what information should I include in the referral?

Indications for referring a patient with increased intracranial pressure (ICP) to a specialist include:

• Persistent or worsening clinical features after head injury such as vomiting, headaches, or new-onset focal neurological signs indicating possible complications ¹,³.
• Glasgow Coma Scale (GCS) score less than 15 on initial assessment ³.
• Any loss of consciousness due to injury ³.
• Any focal neurological deficit since the injury ³.
• Suspected open or depressed skull fracture, basal skull fracture, or penetrating head injury ¹,³.
• Amnesia for events before or after the injury ³.
• Seizure since the injury ³.
• High-energy head injury ³.
• History of bleeding or clotting disorders or current anticoagulant/antiplatelet treatment (except aspirin monotherapy) ¹,³.
• Clinical suspicion of subarachnoid haemorrhage, especially with thunderclap headache or neurological signs ².
• Signs of increased ICP such as altered consciousness, neck stiffness, photophobia, nausea, vomiting, or new neurological deficits ².
• Any safeguarding concerns or suspicion of non-accidental injury ¹.

Information to include in the referral:

• Patient demographics and presenting symptoms including onset, duration, and progression of symptoms ¹,².
• Details of the injury or precipitating event, including mechanism and timing ¹,³.
• Neurological examination findings including GCS score, focal neurological signs, and any seizures ¹,³.
• Relevant medical history such as previous brain surgery, bleeding/clotting disorders, and current medications including anticoagulants ¹,³.
• Results of any investigations performed, such as CT head scan findings if available ².
• Any concerns about safeguarding or vulnerability ¹.
• Contact details of the referring clinician and confirmation that a competent adult will accompany the patient if transfer is urgent ¹.

Referral should be made urgently to an emergency department or specialist neurosurgical centre depending on severity, with prior telephone notification to the receiving hospital ¹,².