The primary objectives of the emergency department are to (Chestnut, 1997):

1. Continue to protect the airway and maintain adequate breathing and normal blood pressure.
   • Establish an arterial line as quickly as possible, to monitor systemic blood pressure and expedite the maintenance of satisfactory cerebral perfusion during transfers, such as for CT scans
   • Establish central venous pressure as quickly as possible (particularly if pressors are used during resuscitation), as well as other monitoring systems, such as a Foley catheter, particularly if mannitol is administered
   • In addition to peripheral oxygen saturation monitoring, end-tidal CO2 monitoring should also be used to ensure adequate ventilation and prevent inadvertent hyperventilation

    If respiratory or hemodynamic instability persists despite aggressive therapies, an emergent laparotomy or thoracotomy may be required to stop internal hemorrhage and prevent prolonged hypotension, a major cause of secondary brain injury

2. Evaluate all extracranial organ systems in all comatose patients, for other injuries that commonly occur in TBI patients, such as:
   • Spinal Cord Injury, which can affect the neurological assessment and other life-saving measures. Click on Spinal Cord Injury Medicine for comprehensive information on SCI.
   • Fractures, which are associated with a high risk of heterotopic ossification, especially forearm, hip, and other large bone and joint fractures.
     • Fracture repair following:
       • Severe TBI should be delayed >24 hours postinjury, particularly femur repair, until adequate resuscitation has been achieved, to prevent secondary injury, such as hypoxia, hypotension, and low cerebral perfusion pressure (Townsend, et al 1998) and poor neurologic outcome (Jaicks, et al 1997).
       • Mild or moderate TBI should be done as early as possible to reduce pain, allow a shorter period of immobilty, early ROM exercises, less nursing care, and less interference with rehab interventions, which, in turn, prevent other complications, such as heterotopic ossification, spasticity, and contractures
         
         
   • Multisystem Injury, in which early timing of orthopedic and facial fracture fixation under general anesthesia was not associated with worse neuropsychological or functional outcome when compared with the outcomes associated with late surgery (>24 hours) (Wang, et al 2007).
   • Methods of fracture repair include:
     • Open reduction and internal fixation for fractures of the limb, often the treatments of choice for TBI patients in whom agitation and spasticity can result in malunion and flexion contractures. The exception is tibial fractures, for which operative and nonoperative outcomes are similar
     • Compression plating for nonoperative treatment of fractures of the humerus
     • Immobilization for fractures of the shoulder, followed by open reduction and internal fixation for nonunions
     • Traction, external fixation, or internal fixation for unstable fractures of the pelvis, particularly when disruption of the pelvic ring is seen; stable fractures do not require intervention
     • Closed fixation with intramedullary rods for fractures of the femur
     • Immobilization with a well-padded, long-leg plaster cast for fractures of the tibia

   • Facial fractures are not protective of head injury and should be treated with the same caution as patients with significant blunt head trauma (Martin, et al 2002)

3. Assess injuries with the Glasgow Coma Scale (GCS) to determine the severity of the injury and the likelihood of brain swelling, to detect damage to critical areas of the brain that may appear normal on the CT scan, and to audit the quality of care:

   The Glasgow Coma Scale
   		Score
   Eye opening:	Spontaneously To voice To painful stimuli Nil	4 3 2 1
   Verbalization:	Normal, conversant Confused, conversant Intelligible words, not conversant Unintelligible sounds Nil	5 4 3 2 1
   Motor(upper extremities):	Follows commands Localizes painful stimuli Withdraws from painful stimuli Flexion posturing Extension posturing Nil	6 5 4 3 2 1
   Total Score (eye opening + verbal + motor) = 3-15

   • The GCS score obtained at the close of resuscitation, when hypoxia and hypotension have been corrected, has the greatest prognostic value
   • The GCS is particularly useful to assess moderate or severe TBI, but is somewhat insensitive to neuropsychological deficiencies that may occur in mild TBI.
   • In addition to other extracranial injuries, the GCS can be affected by endotracheal intubation, sedation, neuromuscular blockade, and alcohol or drug intoxication. Although drug intoxication can usually be reversed pharmacologically, alcohol intoxication may result in the neurological assessment being delayed for several hours.

4. Consider ICP monitoring to help direct potentially risky ICP therapies, such as hyperventilation, help determine the urgency of CT scans or operative procedures, and initiate maneuvers that serve to lower ICP as early as possible during resuscitation (Brain Trauma Foundation, 2000h). Early ICP monitoring is recommended for PBI patients if clinician is unable to assess the neurologic examination accurately (click ICP Monitoring in the Management of PBI). There can be 3 steps to control ICP: initial slight hyperventilation; mannitol or hypertonic saline and hyperventilation; and barbiturate coma or decompressive craniotomy (Vincent & Berre, 2005).

5. Obtain a CT scan within the first 30 minutes after the patient's arrival, if at all possible, when there is neurological deficit or loss of consciousness, to identify the existence and location of intracranial lesions, usually indicated by neurological deterioration following the injury, advanced age, skull fractures, and/or blunt or low-velocity injuries. MR is useful when there are unexplained findings on CT scanning, to visualize posterior fossa or brain stem lesions, and certain secondary effects of trauma, such as altered neurochemistry, to delineate vascular or diffuse axonal injuries (Cihangiroglu, et al 2002) and to detect lesions in cerebral white matter, corpus callosum and a greater number of cerebral contussions (Lagares, et al 2006). Perfusion CT is more sensitive than conventional unenhanced CT in the detection of cerebral contusions and in patients with severe head trauma provides independent prognostic information regarding functional outcome (Wintermark, et al 2004).
   • Continuous observation and monitoring, and intervention if necessary, are essential during the CT scan
   • A transport pack, including mannitol, narcotics, sedatives, and neuromuscular blocking agents, should be available for all transports
   • Patients with severe TBI can be categorized by urgency of CT scan, if necessary, depending on the severity of other injuries, level of suspicion, patient load, etc:
     • "A" or Most Urgent - Ongoing evidence or a history of intracranial hypertension, which may involve herniation
       • Pupils are anisocoric, bilaterally dilated or nonreactive
       • May be motor posturing
     • "B" or Less Urgent - No evidence or progression of transtentorial herniation
     • "C" or Least Urgent - No external evidence of head injury
   • Patients with penetrating brain injury (click Neuroimaging in the Management of Penetrating Brain Injury)
     • CT is strongly recommended
     • Angiography is recommended when a vascular injury is suspected
     • MRI is not generally recommended
     • CT angiography and/or conventional angiography should be considered to identify a traumatic intracranial aneurysm (TICA) or arteriovenous fistula in patients with PBI involving an orbitofacial or pterional injury (click Vascular Complications of PBI)
   • Patients with minor head injury can be assessed against the Canadian CT Head Rule (Stiell, et al 2001) which has:
     • 5 high-risk factors - failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years, which require only 32% of patients to undergo CT
     • 2 medium-risk factors - amnesia before impact >30 min and dangerous mechanism of injury which require only 54% of patients to undergo CT

     Determination of S-100 protein in serum may be used to select patients with minor head injury for CT scanning (Ingebrigtsen, et al 2000). It is a valid measure of the presence and severity of TBI if performed within the first hours after a minor head injury (Ingebrigtsen, et al 1999). Serum S-100B concentration can be used in the emergency department to identify patients with head injury who are most likely to have a poor outcome at one month (Townend, et al 2002)

6. Consider diffusion-weighted imaging (DWI) of the brain which has proven to be highly sensitive in the early detection of acute cerebral ischemia and seems promising in the evaluation of traumatic brain injury. DWI can differentiate between lesions with decreased and increased diffusion. In addition, full-tensor DWI can evaluate the microscopic architecture of the brain, in particular white matter tracts, by measuring the degree and spatial distribution of anisotropic diffusion within the brain (Huisman, 2003). Fractional anisotropy (FA) is globally deceased in white matters, including mild TBI, possibly reflecting widespread involvement. FA changes appear to be correlated with injury severity suggesting a role in early diagnosis and prognosis of TBI (Benson, et al 2007).

7. Surgically remove posttraumatic lesions, such as subdural or epidural hematomas or large parenchymal contusions or hematomas, as quickly as possible before attempts to medically manage ICP are made (Marion, 1998).  Surgery within 2 vs. 4 hours postinjury can be life-defining. Anatomic location of injury can be predictive of early failure of nonoperative management, with frontal intraparenchymal hematomas being particularly prone to early failure (Patel, et al 2000).

8. Click Surgical Management of Penetrating Brain Injury for options. Surgical correction is recommended for CSF leaks that do not close spontaneously or are refractory to CSF diversion following primary surgery (click Management of Cerebrospinal Fluid Leaks). Standard trauma craniectomy significantly improves outcome in severe TBI with refractory intracranial hypertension resulting from unilateral frontotemporoparietal contusion with or without intracerebral or subdural hematoma (Jiang, et al 2005).

9. Use prophylactic broad-spectrum antibiotics for patient with PBI early after injury before there is any evidence of infection (click Antibiotic Prophylaxis for PBI)