Emergency resuscitation and diagnosis

Patients who are rapidly deteriorating or already are unconscious require immediate resuscitation followed by a diagnostic CT scan. In head-injured patients it is recommended to keep systolic blood pressure higher than 90 mmHg and arterial partial pressure of oxygen (Pao2) higher than 8 kPa or arterial oxygen saturation greater than 90%. Patients with a Glasgow Coma Score (GCS) of 8 or less need to be intubated and ventilated to protect their airways prior to scanning. An intravenous bolus of mannitol 20% (2 ml/kg over 15 minutes) may be required if there is evidence of coning such as pupillary dilatation. Acute ventricular dilatation demands immediate ventricular drainage - bilateral if the lesion is midline. Hyperacute ventricular dilatation following subarachnoid haemorrhage or in association with a third ventricular lesion need not be gross to cause death. Significant space occupying lesions require surgical intervention, and abscesses require tapping. If an intracranial tumour or abscess is identified as the cause of intracranial hypertension, dexamethasone (initial dose 10-20 mg IV bolus) can be given.

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