Acute resuscitation of the patient with head and spinal cord injuries

Trauma is a major epidemic in the United States and CNS injuries are major contributors to this epidemic. There are a number of axioms for the handling of patients with head and/or spinal injuries that the emergency physician must follow. As with any multiply traumatized patient, the assessment and treatment of compromised airway, breathing, or circulation has the highest priority. In managing the airway, assume that a neck injury is present until proven otherwise. One cannot expect a brain without perfusion to function properly. The corollary of this is that one must be aggressive in giving adequate volume replacement to persons in hypovolemic shock despite a concomitant head injury. The emergency physician must stop external hemorrhage and complete the search for occult hemorrhage. The major immediate goal in handling CNS injuries is to prevent the second injury resulting from 'hypotension, hypoxemia, hypercarbia, intracranial hypertension, infection,' and unnecessary motion of an unstable spinal column. Hyperventilation is the swiftest way to decrease rising intracranial pressure. It should be applied immediately to any patient with severe head injury who is not already spontaneously hyperventilating. Patients with severe open head injuries often do surprisingly well and so should be resuscitated aggressively. The final axiom is to avoid 'tunnel vision' by considering the many other etiologies for the patient's decreased level of consciousness. If the emergency physician applies the fundamentals of trauma resuscitation and carefully avoids and treats the second injuries, he and his patients with CNS injuries will achieve optimal results.