[Update on medical management of severe head trauma]

Significant progress in prognosis after brain injury has been achieved over the last 20 years. Knowledge of post-traumatic brain hypersensitivity to ischemic events is critical for management. Therefore, all recommended emergency treatments (intubation, oxygenation, prevention of hypotension) focus on situations where oxygen delivery to the brain is compromised (peripheral hypoxia or hypotension but also compressible cerebral hematoma). Analysis of European prehospital medical care showed success in peripheral oxygenation but no real benefit regarding blood pressure. Guidelines for osmotherapy in patients with pupil abnormalities are not followed despite recent studies emphasizing better prognosis after acute perfusion of high-dose mannitol followed by rapid surgical treatment. It is well known that a short delay between trauma and surgery improves prognosis. After controlling peripheral hemodynamics and hemostasis, multimodal monitoring (intracranial pressure, transcranial Doppler, SvjO(2)) is necessary to achieve cerebral hemodynamic equilibrium. Management during the first hours after trauma is important for outcome in patients with traumatic brain injury. A well-organized medical referral system with close collaboration between specialists will be able to control this socially accepted silent epidemic.