This article includes discussion of severe closed head injury, severe brain injury, and severe head injury. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Surgical and medical management of closed head injury continues to evolve. Although no one has yet identified the "magic bullet" to prevent secondary injury after head trauma, several promising novel strategies are being employed. In this article, the author has provided an update of comparative efficacy of mannitol versus hypertonic saline.
• Wartime experience has continuously influenced and improved civilian management of severe traumatic brain injury.
• Predictors of outcome include the Glasgow Coma Scale and Injury Severity Scores and aspects of the neurologic exam of the comatose patient, such as the pupillary exam.
• Contemporary brain injury management has shifted from intense hyperventilation and mannitol administration to maintaining tissue oxygenation and employing hypertonic saline.
Historical note and terminology
Evidence from the antiquities suggests that there were cases of neurosurgical intervention for brain injuries by the Chinese, the Incas, and the Greeks, among others (Jennett 1996). MacEwen described diagnosis and evacuation of a subdural hematoma (Jennett 1976). Much trauma experience has been obtained from war. In specific, Cushing's attention to antisepsis and early debridement produced improved mortality figures in World War I (Cushing 1918). Experience during World War II, the Korean conflict, and the Vietnam War taught neurosurgeons that rapid surgery could produce excellent survival statistics. The 2 most important developments in the evolution of head trauma care have been the introduction of the CT scan by Houndsfield and colleagues in the 1970s and the introduction of the Glasgow Coma Scale by Teasdale and Jennett during the same period (Teasdale 1974). The ability to rapidly diagnose and accurately describe injuries has been extremely beneficial to trauma patients.
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