Initial management

Care begins with resuscitation and diagnosis at the scene of the accident. The clinician should follow the ABCDE (airway, breathing, circulation, disability, exposure) rule of trauma management. If neurosurgical services are unavailable at the primary hospital, secondary referral and transport to a neurosurgical center may be indicated.

Initial periods of hypoxemia ( PaO2 < 8.5 kPa (62.5 mmHg)) and hypotension (systolic blood pressure below 90 mmHg) in head injury double mortality compared with a similar normoxemic and normotensive group (Chesnut.efa/ 199.3). Rapid diagnosis and therapy, with endotracheal intubation and ventilation and treatment of extracranial causes of hypotension, have led to a significant improvement in mortality and morbidity over the past two decades.

The ABCDE system Airway and breathing

Hypoxia, which is common in head injury patients (30 per cent), must be avoided to prevent secondary brain injury ( Chesnutefa/ 1993). A crash induction technique, such as rapid-sequence intubation, maintains an immobile cervical spine and should be employed. The patient is ventilated to normoxia and mild hypocapnia ( PaO2 = 13 kPa (97.5 mmHg), PaCO2 = 4-4.5 kPa (30-34 mmHg)), while maintaining sedation, analgesia, and paralysis as necessary. A thorough neurological examination should be completed only if it can be done safely.

Circulation

Hypotension (systolic blood pressure of 90 mmHg or less) occurs in about 30 per cent of patients with severe head injuries. Resuscitation must both treat the causes and correct the blood pressure. A high spinal cord transection can cause hypotension associated with bradycardia (Cushing's reflex).

Physiological saline, Hartmann's solution, or colloid solutions can all be administered initially via peripheral venous access. Blood should be given if hemorrhage is severe and persistent. Free water or 5 per cent glucose solution is contraindicated as it predisposes to cerebral edema and cerebral acidosis in ischemic conditions. Coagulopathies can occur and clotting profiles should guide appropriate replacement therapy.

In patients with severe head injury the early use of invasive arterial and central venous monitoring, as well as insertion of a urinary catheter and an orogastric tube, is mandatory to assess adequacy of resuscitation and prevent aspiration.

Disability

Early identification and evacuation of surgically correctable intracranial hematomas is mandatory and in part is guided by the Glasgow Coma Scale (GCS) and CT scanning (Table 1 and Table.,..?).

Table 1 Glasgow Coma Scale

1. Cona (ÛCS ^Sfl IW+ of ûûmaîoee- head i^ma. hj^e an i. Nferttycâ sgft seara)

4, Pitfrii wtf: Stajl Iwlw Prih y i*»t inpfiwi a*

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