AbstractThe magnitude of the cerebral injury is the ultimate determining factor in survival versus death and ability versus disability in most multiple trauma patients. The acute failures of oxygen transport that occur in these patients can clearly increase the magnitude of the brain injury. This occurs either via cardiopulmonary failure or prolonged epileptic seizures. Both sources must be quickly reversed. The magnitude of the brain injury may also be increased by delayed diagnosis of expanding intracranial lesions. The rapid availability of computed tomography (CT) scans of the head is of great importance in the early diagnosis of intracranial lesions. In the absence of CT scans, skull x‐rays and cerebral angiography in association with sequential evaluations of consciousness and neurological function are useful. Medications that change the state of consciousness interfere with such follow‐up and should be avoided if at all possible.Acute extradural hematomas are generally not associated with much initial brain damage and produce rapidly progressive brain damage. Therefore, their treatment constitutes an absolute neurosurgical emergency. If these coexist with intra‐abdominal bleeding, then 2 operating teams should proceed simultaneously. In contrast, both intracerebral and subdural hematomas reflect relatively severe initial brain damage which cannot be changed and produce a slower rise in pressure and thus a slower rate of destruction of additional brain tissue. The time scale for treatment of these lesions is, therefore, longer than that for extradural hemorrhages.Additional brain damage may also be produced by cerebral edema. The intracranial pressure is best monitored in trauma cases by pressure monitoring bolt. The preferred agents for therapy are clearly mannitol acutely (0.5 to 1.5 g/kg body weight as a single dose) followed by a continuous infusion with an osmolality maintained at 315 to 320 mOsm. Lasix® may also be used. In the absence of control of intracranial pressure, then barbiturate coma may be utilized (3 to 5 mg/kg as an initial dose followed by maintenance of plasma levels at 2.5 to 3.5 mg/100 ml).