The prehospital and emergency department management of penetrating head injuries.

The prehospital and emergency department management of the patient with a penetrating cranial injury can be summarized by the following tenets: 1. Assume any alteration in level of consciousness to be a result of the brain injury and not from alcohol or illicit drug intoxication. 2. Have a low threshold to protect the patient's airway with endotracheal intubation and chemical paralysis if a surgical lesion is suspected, there is seizure activity, or the patient is too combative to obtain the necessary studies. 3. Always protect the cervical spine and do not remove the hard collar and spine board until adequate radiographs have been obtained and the patient is lucid enough to complain of any neck pain. 4. Do not delay CT scanning to obtain other studies in the presence of lateralizing neurologic findings. 5. Do not delay in obtaining neurosurgical consultation or in arranging transfer to a facility where definitive care can be provided. 6. Remember, first do no harm. The primary brain injury has already been done. The clinician maximizes preservation of viable brain tissue by preventing secondary injury.