Objectives Delayed inter‐hospital transfers of deteriorating neurotrauma patients from rural and regional hospitals to tertiary centres have seen the need for non‐neurosurgeons to undertake emergency intracranial haematoma evacuation surgery locally. In the present study, the authors contributed to the paucity in the literature regarding the widespread availability of cranial access equipment in non‐tertiary centres and patient outcomes in Queensland. Methods We surveyed delegates (senior theatre nurses or surgical service directors) from rural and regional Queensland hospitals if they were located outside the local catchment of a tertiary centre and had a CT scanner. Questions regarded availability, location and storage conditions of mechanical cranial access kits, as well as last usage, and associated patient outcomes. Results Twenty‐six delegates from eligible hospitals responded. Eighteen hospitals offered surgical services. Eleven hospitals housed complete mechanical cranial access kits. Five hospitals housed incomplete kits. Thirteen hospitals housed their equipment sterile in the operating theatre or ED. Eleven hospitals reported using the equipment, with last usage ranging from 4 months to over 30 years. Two hospitals reported using the equipment within 12 months while a further five reported using it within 10 years. Two hospitals reported ‘good’ outcomes, two ‘ok’ and one ‘poor’. Conclusions The availability of cranial access equipment outside Queensland tertiary centres has been limited. Inter‐hospital transfers are likely to persist in Queensland and haematoma evacuation surgery has been a life‐saving endeavour, so improving access to cranial access equipment in hospitals where it is currently lacking is highly warranted.

Background: Severe traumatic brain injury (TBI) management begins in the pre-hospital setting, but clinicians are left with limited options for stabilisation during retrieval due to time and space constraints, as well as a lack of access to monitoring equipment. Bolus osmotherapy with hypertonic substances is commonly utilised as a temporising measure for life-threatening brain herniation, but much contention persists around its use, largely stemming from a limited evidence base. Method: The authors conducted a brief review of hypertonic substance use in patients with TBI, with a particular focus on studies involving the pre-hospital and emergency department (ED) settings. We aimed to report pragmatic information useful for clinicians involved in the early management of this patient group. Results: We reviewed the literature around the pharmacology of bolus osmotherapy, commercially available agents, potential pitfalls, supporting evidence and guideline recommendations. We further reviewed what the ideal agent is, when it should be administered, dosing and treatment endpoints and/or whether it confers meaningful long-term outcome benefits. Conclusions: There is a limited evidence-based argument in support of the implementation of bolus osmotherapy in the pre-hospital or ED settings for patients who sustain a TBI. However, decades’ worth of positive clinician experiences with osmotherapy for TBI will likely continue to drive its on-going use. Choices regarding osmotherapy will likely continue to be led by local policies, individual patient characteristics and clinician preferences.

BackgroundCaffeine is the most utilised psychoactive drug worldwide. However, caffeine withdrawal and the therapeutic use of caffeine in intensive care and in the peri-operative period have not been well summarised. Our objective was to conduct a scoping review of caffeine withdrawal and use in the intensive care unit (ICU) and post-operative patients. MethodsPubMed, Embase, CINAHL Complete, Scopus and Web of Science were systematically searched for studies investigating the effects of caffeine withdrawal or administration in ICU patients and in the peri-operative period. Areas of recent systematic review such as pain or post-dural puncture headache were not included in this review. Studies were limited to adults. ResultsOf 2268 articles screened, 26 were included and grouped into two themes of caffeine use in in the peri-operative period and in the ICU. Caffeine withdrawal in the post-operative period increases the incidence of headache, which can be effectively treated prophylactically with peri-operative caffeine. There were no studies investigating caffeine withdrawal or effect on sleep wake cycles, daytime somnolence, or delirium in the intensive care setting. Administration of caffeine results in faster emergence from sedation and anaesthesia, particularly in individuals who are at high risk of post-extubation complications. There has only been one study investigating caffeine administration to facilitate post-anaesthetic emergence in ICU. Caffeine administration appears to be safe in moderate doses in the peri-operative period and in the intensive care setting. ConclusionsAlthough caffeine is widely used, there is a paucity of studies investigating withdrawal or therapeutic effects in patients admitted to ICU and further novel studies are a priority.