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  • Secondary brain injury from hypoxia and ischemia should be prevented by appropriate airway ventilatory and fluid management in all comatose patients.
  • In appropriately selected patients aggressive monitoring and treatment of intracranial pressure is warranted.
  • Early identification and evacuation of operable intracranial hematomas can be life-saving.
  • Change in the level of consciousness is one of the hallmarks of brain injury. Its recognition through careful history, physical examination, and close monitoring is therefore essential.
  • Prophylaxis and aggressive treatment of seizures following head injury must be instituted.
  • Maintenance of normal fluid and electrolyte balance and early provision of enteral nutrition is necessary.
  • Risk of central nervous system infection is reduced by surgical débridement and restoration of dural integrity in cases of open cranial injury.
  • Systemic sepsis often complicates recovery and should be diagnosed and treated aggressively.

The incidence of head injury in the United States is approximately 200 to 400 per 100,000 population per year. Similar incidence rates have been documented for other countries. Male-to-female incidence ratios vary between 2:1 and 3:1, and incidence peaks in the second and third decades of life.1 Patients with severe head injuries—i.e., those admitted in coma, with a Glasgow Coma Scale score (GCS) of 8 (Table 93-1)2,3—constitute a minority of head-injured patients admitted to hospital, but account for most of the morbidity and mortality (Fig. 93-1). Hospitals with a large primary care population see relatively fewer severely head-injured patients than do those functioning primarily as tertiary referral centers.

Table 93–1. The Glasgow Coma Scale Score
Figure 93–1.

Distribution of head injury severity (measured by the Glasgow Coma Scale score at admission) in 400 consecutive admissions to a tertiary care hospital neurosurgical unit.

The most common cause of closed head injury is road traffic collisions. These include injuries to vehicle occupants, pedestrians, motorcyclists, and bicyclists. Falls are the next most common cause of injury. Gunshot injuries are a major cause of penetrating head injury in the United States and account for up to 44% of head injuries in some series.1 Etiology varies considerably with local patient demographics and proximity to major highways, among other factors, and the resulting case mix will vary from center to center in terms of intracranial hematoma incidence, mean patient age, and consequently outcome from injury. Younger ...

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