Step by step, we are improving the care of the head injured patient

Up to 1 million people a year in the United Kingdom attend an accident and emergency department because of a head injury. Of these 90% are classified as minor (with a Glasgow coma score of 15) or mild (13 or 14), 5% as moderate (9-12), and 5% as severe (3-8).1 Road traffic accidents cause most of the severe head injuries and are likely to become the third most common cause of death and disability worldwide over the next 20 years.2 Even patients with “mild” injury (13 or 14) can suffer long term disability, with up to 47% being classed as moderately or severely disabled one year after injury.3 Magnetic resonance imaging of the brain of patients who have an initial Glasgow coma score of 13 or 14 shows a high incidence of parenchymal lesions, suggesting that even “mild” cases may sustain a significant brain injury.4 For such a major health problem, guidelines for management based on the best available evidence are essential. Although the literature on head injury might be criticised for lacking large randomised trials,5 notable improvements have been made in our management of this complex and heterogeneous condition over the past decade.

Initial assessment and triage of patients is now based …