The care of the head-injured patient begins in the pre-hospital setting with EMS personnel. Assessing the history of the event and the patient's condition and mental status immediately after the injury is important. Securing the patient's airway and cervical spine, establishing IV access, and controlling bleeding are the initial priorities. Hypoxia and hypotension need to be identified and corrected rapidly on the scene. As discussed earlier, hypotension (SBP <90 mmHg) has been associated with a significant increase in mortality. Patients with isolated severe head trauma resuscitated with 250 cc of hypertonic (7.5%) saline in the prehospital setting had a significantly higher SBP on arrival to the emergency department and significantly decreased mortality rate when compared to those resuscitated with lacerated ringers alone.17 A retrospective review of 169 consecutive TBIs found that patients with more severe TBIs tended to have higher admission and postoperative glucose values, and patients with glucose levels greater than 150 mg/dL had worse neurologic outcomes. 18 In animal models, hyperglycemia may aggravate ischemic neurologic injury. However, "separation of cause and effect is difficult because hyperglycemia constitutes a hormonally mediated response to more severe injury."19 Therefore, it is recommended that glucose should not be administered without first checking a blood glucose finger stick in the comatose trauma patient.

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