However with improvements in prehospital care and greater knowledge of brain injury, patients are arriving in emergency departments earlier and their brain injury may still be evolving. Therefore the following measures should be considered and porbably instituted in all patients with coma scores of 12 or below. Hypotension will adversely affect cerebral perfusion and therefore lower the Glasgow Coma Score. However brain injury management should be instituted on the basis of the initial examination and there should be no delay to assess whether the GCS improves with volume resuscitation. It is important to identify signs of impending transtentorial herniation as this will affect the course of the immediate management of these patients.
Serial assessment is vital.
Patients may arrive with a mildly impaired GCS and rapidly deteriorate due to expanding haematomas or increasing cerebral swelling. Pupils may be initially normal and then dilate as intracranial pressure rises and the brain starts to herniate. Early acute control of the above three parameters may have more impact than all other measures subsequently employed. Progressive neuronal loss occurs from the time of injury, not the time of arrival in hospital. Rapid sequence intubation should be used where available to secure the airway and maximally oxygenate the patient.