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  • Updated 08.21.2023
  • Released 06.18.1999
  • Expires For CME 08.21.2026

Severe closed head injury



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 update, the author discusses the prognostic value of markers of coagulopathy and recent attempts to influence outcomes by addressing fibrinogen deficiency.

Key points

• 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 (53). MacEwen described the diagnosis and evacuation of a subdural hematoma (52). 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 (26). Experience during World War II, the Korean conflict, and the Vietnam War taught neurosurgeons that rapid surgery could produce excellent survival statistics. The two 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 (101). The ability to rapidly diagnose and accurately describe injuries has been extremely beneficial to trauma patients.

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