Summary points

• Management of severe traumatic brain injury is focused on rapid transfer to secondary care while preventing secondary brain injury

• Airway compromise and inadequate ventilation are common and should be addressed immediately

• Prehospital endotracheal intubation should be undertaken with the assistance of anaesthetic drugs by appropriately trained physicians

• Hypotension is an independent risk factor for mortality; small boluses of isotonic crystalloid fluids should be given if it occurs

• Patients may be best managed in a neurosurgical centre where they should receive definitive neurosurgical treatment within 4 hours of injury

• There is no role for the routine use of corticosteroids in patients with head injury

Sources and selection criteria

We searched Medline 1980-2008, Pubmed and the Cochrane library for clinical trials and reviews. The medical subject headings “head injury”, “brain injury”, “trauma”, “prehospital”, and combinations thereof were used. Individual therapeutic options (such as “mannitol”) were also searched for. Search results were individually reviewed and manually cross referenced. Reference lists were searched for additional works. Priority was given to review articles, meta analyses, and well designed large trials. The websites www.braintraumafoundation.org, www.trauma.org, and www.east.org were also searched for additional information.