Patients with severe grades of life-threatening brain injury are commonly characterized as having devastating brain injury (DBI), which we have defined as: 'any neurological condition that is assessed at the time of hospital admission as an immediate threat to life or incompatible with good functional recovery AND where early limitation or withdrawal of therapy is being considered'. The outcome in patients with DBI is often death or severe disability, and as a consequence rapid withdrawal of life sustaining therapies is commonly contemplated or undertaken. However, accurate prognostication in life-threatening brain injury is difficult, particularly at an early stage. Evidence from controlled studies to guide decision-making is limited, and there is a risk of a 'self-fulfilling prophecy', with early prognostication leading to early withdrawal of life sustaining therapies and death. The Joint Professional Standards committee of the Faculty of Intensive Care Medicine and the Intensive Care Society convened a consensus group with representation from stakeholder professional organizations to develop clear professional guidance in this area. It recognized that the weak evidence base makes GRADE guidelines difficult to justify. We have made 12 practical, pragmatic recommendations to help clinicians deliver safe, effective, equitable, and justifiable care within resource constrained healthcare systems. In the situation where patient-centred outcomes are recognized to be unacceptable, regardless of the extent of neurological improvement, then early transition to palliative care is appropriate. These recommendations are intended to apply where the primary pathology is DBI, rather than where DBI has compounded a progressive and irreversible deterioration in other life-threatening comorbidities.

A f i t 27-year-old man presented with sewre ,fucial trauma .following an industrial accident. Initial assessment showed severe swelling around the lower .jaw arid haemorrhuge ,from the mouth, nose, scalp and left ear. The patient was conscious with a Glasgow Coma Score of 13 but in respiraiorv distress. Following adoption of the prone position his airway improved. Relief of the patient's airway obstruction M'US a priority and the patient underwent awake fibreoptic intubation in the prone position prior to induction ofanaesthesia. Computed tomography scans of his head and neck were unremarkable and after.fixation o f a bilateral mandibular ,fracture he made an uneventful recovery. Intubation in the semi-prone position may be a useful technique in injuries of this type. Key wordsIntubation, tracheal; awake fibreoptic nasal. A irway ; obstruction. Complications; trauma. Position; prone.Management of a compromised airway in a patient with maxillofacial trauma is often problematical [ 1-31. We report the immediate management of a patient with a potential closed head injury and an unstable jaw fracture who could not tolerate being in the supine or sitting position. To alleviate his respiratory distress he adopted the prone position in which his airway was secured by awake fibreoptic intubation. Case historyA previously fit 27-year-old man was admitted to the accident and emergency department. He had sustained trauma to the head and face from a metal bar while trying to free machinery used for crushing scrap metal. On admission he had a Glasgow Coma Score of 13 (accurate assessment was impossible since he count not speak), a blood pressure of 155/65 mmHg, pulse 95 beat.min -I and pulse oximetry showed 96% saturation while he was breathing an air-oxygen mix because he would not tolerate a face mask. A hard cervical collar was in place and it was not known whether he had lost consciousness at the time of the accident. Subsequently, he had no memory of the incident.Visible injuries consisted of gross swelling on the anterior and lateral surface of the jaw with disruption of the lower dentition and his mouth opening was severely limited. He had several small facial lacerations and there was active bleeding from his nose and left ear. A ragged 3 cm wound was present on the left frontotemporal region of his scalp. There were no other obvious injuries.The patient was agitated and in acute respiratory distress. After a brief struggle he turned himself into the prone position, at which point his breathing became far less noisy and he calmed down. Two large bore intravenous cannulae were inserted and fluid resuscitation was started.Control of the airway was a priority and, in view of the reduced level of consciousness and the haemorrhage from the ear, a CT scan of his head and neck X rays were regarded as urgent. The patient was transferred to an operating theatre for induction of anaesthesia.The patient was in the prone position supporting himself on his elbows (Fig I.) After consultation with a second anaesthetist the decisio...

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