The first principle to be followed is to anticipate and prevent an additional brain insult resulting from an abnormal physiological event, which further damage the already traumatized brain and predispose to additional morbidity and even to death.  These �second accidents� are often overlooked.  They happen at the scene of injury, during emergency transport, in the emergency room, in the operating room during induction and even in the intensive care unit.

At the scene of injury:

It has been estimated that up to 20% of injured patients die after accidents because of inadequate treatment prior to hospitalization.  Serious systemic abnormalities resulting from major trauma are common and include shock, hypoxic, hypercarbia and anemia.  The most pressing immediate requirement is to establish adequate oxygenation.   Patients may be hypoxic from upper airway obstruction or hypoventilation.  Emergency care begins with suctioning of blood and vomitus from the airway as well as the removal of other foreign obstructing objects such as loose or false teeth.  At a minimum an oral airway should be placed.  Artificial respiration, if necessary, shall be begun by mouth-to-mouth, Ambu bag or other means.  Additional oxygen by nasal catheter, or mask should be given and this is mandatory in patients who are not responsive to verbal commands regardless of their ventilatory status.  The feasibility of endotracheal intubation at the scene of accident by paramedics has been proposed despite the many associated problems.

All possible attention to other injuries such as bleeding wounds and splinting an obvious fracture should be carried out at the site of the event.

In case of open head injury, brain prolapses should be covered with sterile sponges soaked with physiological saline; penetrating foreighn  bodies should be left in situ.

Transport:

After emergency ventilatory care, the patient should be rapidly moved to a hospital facility.  Distance traveled is not the primary consideration.  The only indication for transporting to a local receiving hospital is a patient in shock or inability to establish an airway. Ideally the patient should be transported directly to a hospital where CT and comprehensive neurosurgical care are immediately available.  Prolonged delays should be avoided.

During the transport, the patient should be maintained with nasal oxygen or if intubated, with 100% oxygen until blood gas analysis.  The patient should be transported in the neutral position as it facilitates easy airway attention with suction, clinical observation and vital sign monitoring and also provide better protection of the spinal cord. 

 Emergency room care:

This falls into

1) Restitution and maintenance of vital functions.

2) Clinical general and neurological examinations.

3) Limited therapy.

4) Diagnostic procedures and follow on.

An important principle is, until a good quality X-ray is available, patient should be presumed to have fracture of cervical spine and the spine must be protected.

Ideally, all patients who are not verbalizing and cannot follow any commands should be intubated promptly.  In case of difficulty an anesthetist should be called.  If necessary, patient may be temporarily paralyzed.  ABG should be measured promptly,

 If the patient is hypotensive, the pressure should, of course, be brought to acceptable ranges before anything else.  Neurological examination is misleading in an hypotensive from the brain injury itself is seen only when medullary failure and such patients will also have other signs of impending brain death.

 2) Following stabilization, a general and neurological examination is undertaken and problems requiring prompt therapy must be defined, General examination should detect long bone fracture and any source of internal bleeding which must be attended to immediately.

Neurological examination remains the single most comprehensive process in the diagnostic evaluation of the patient, providing a rapidly available index of generalized and focal dysfunction of the nervous system.  Serial examinations will indicate progress or deterioration of the patient.  The depth of the neurological examination will vary according to the type and degree of brain injury.  The neurological examination should include:

 a)     Level of consciousness  (GCS)

 b)    Pupils

 c)     Eye movements

 d)     Motor strength

 e)     External Examination

Subsequent examination is appropriately expanded.

a.) Level of consciousness (Glasgow coma scale):

The GCS is  is the internationally accepted standard scale to quantify the neurological state after head injury.

It is recommended that the best response in each category be used in grading the patient�s reaction.  The best way to apply pain stimulus is by deep nail bed pressure.  Testing of eye opening is most significant within the first 72 hrs.  After this even patients who will remain vegetative may open their eyes spontaneously.

b    b.) Careful examination of the pupillary size and response to light is of utmost importance during the initial examination.  A well-known early sign of temperature lobe herniation is mild dilation of the ipsilateral pupil and sluggish response to light.

 Bilateral dilated and fixed pupills can be due to elevation of ICP to a degree that impairs CBF or due to hypotension secondary to blood loss.

Midposition pupills with variable light responses are observed in all stages of coma.

C)  Eye movements are an important index of the functinal activity within the brainstem reticular formation, oculocephalic or oculovestibular response determines the eye movement in states of depressed consciousness.  Head is raised 30 degrees from the supine position and briskly rotated to and fro in the horizontal plane.  In the normal � dolls eye� response, both eyes tend to maintain their position in space by moving opposite to the rotation of head.  Full response indicates the problem is above pons.  Absence of their response indicates severe pathological process extending to the lower pons.

 Divergence of eyes is a sign of brainstem pathology.

 Failure of upward gaze may suggest posterior thalamic.

d) The basic neurological examination is completed by a test of motor strength in patients who are sufficiently responsive.