The acute management of head injury.

The management of traumatic brain injury has undergone extensive revision as the results of large collaborative outcome studies have cast doubt on many traditional 'common sense' practices. The primary goal of identifying and treating intracranial hypertension has given way to a focus on secondary brain ischemia, in which cerebral perfusion pressure and oxygen delivery have gained new importance. With the exception of impending herniation, the routine use of hyperventilation and high-dose barbiturates is no longer recommended. Hypertonic saline, given as intermittent boluses, has joined mannitol as an effective means of reducing cerebral edema. Preliminary results from a large multi-center study have cast doubt on the benefit of the broad application of hypothermia in improving outcome in traumatic brain injury.