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There is no clear consensus on this in our ED. I start of with simple measures like

a. loosening the semirigid neck collar (but ensuring that the patient doesn't move his head!) but with the blocks and tape still on

b. 15-30 degrees 'head end up' position once other significant spinal injuries are ruled out

c. Between Mannitol and hypertonic saline, we've used them occassionally (more so after the patient shows signs of uncal herniation). We now have stopped using hypertonic saline (after the major trial that was being done in US has been stopped rather prematurely as initial results showed no benefits!!! This was just a few months ago...)

d. we have never used Oral Glycerol. I have also never used dexamethasone for head injuries though I've used it for spinal cord injuries.

e. Used Barbiturates once for this purpose. But our patient had a good blood pressure. I would have thought twice (or not even consider) if he was hypotensive...

f. Most importantly, I make sure that the patient has a continous EtCO2 monitoring on and aim to keep it tightly between 4 - 4.5 kPa

g. Maintain normoglycaemia and normothermia

Issues for me are mainly around Mannitol/Hypertonic saline, Barbiturates and steroids as it is never too clear....