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.
• Glasgow Coma Scale (GCS) score less than 15 on initial assessment.
• Any loss of consciousness related to the injury.
• Any focal neurological deficit since the injury.
• Suspected complex skull fracture, penetrating head injury, or basal skull fracture.
• Amnesia for events before or after the injury (where assessable).
• Seizure since the injury.
• High-energy head injury.
• History of bleeding or clotting disorders or current anticoagulant/antiplatelet treatment (except aspirin monotherapy).
• Clinical suspicion of raised ICP signs such as tense fontanelle in infants, irritability or altered behaviour especially in children under 5 years.
• Any safeguarding concerns including possible non-accidental injury or vulnerable persons affected.
• Ongoing clinical concern or diagnostic uncertainty about the severity or nature of symptoms.

Information to include in the referral:

• Patient demographics and contact details.
• Detailed history of the injury including mechanism, timing, and symptoms such as loss of consciousness, vomiting, headache, seizures, and neurological deficits.
• Initial and current Glasgow Coma Scale score.
• Findings from neurological examination and any focal signs.
• Relevant past medical history including previous brain surgery, bleeding/clotting disorders, and current medications especially anticoagulants or antiplatelets.
• Details of any safeguarding concerns or suspicion of non-accidental injury.
• Results of any investigations performed (e.g., CT head scan results if available).
• Information on the presence and competence of accompanying adult during transfer.
• Contact details of the referring professional and the receiving hospital informed of the transfer.

Referral should be urgent and accompanied by a competent adult during transport to a hospital with appropriate resources for resuscitation, investigation, and management of intracranial complications and cervical spine injury. The referring professional should notify the destination hospital by phone of the impending transfer ¹,²,⁴.