Indiscriminate use of skull radiographs triggered one of the earliest assessments for rational imaging use. In 1987, a prospective study of ED patients was performed to validate an expert guideline, which recommended that low-risk patients should not undergo routine skull radiography after head trauma in order to reduce radiation exposure and imaging cost.^6,7 Today, computed tomography (CT) is the imaging modality of choice in the initial evaluation of patients with emergent cranial and intracranial signs and symptoms. The need for imaging is usually based on the severity of head injury as indicated by initial Glasgow Coma Scale (GCS) (Table 1.1). With this scale, the three main aspects of neurologic function evaluated are (1) opening of the eyes to external stimuli, (2) verbal response, and (3) motor response to stimuli. Strong evidence supports the use of urgent head CT imaging for severe TBI (based on a GCS of 3 to 8) to identify lesions requiring surgical intervention. Clinical prediction rules, such as the Canadian Head CT rule and the New Orleans criteria, derived and validated using sophisticated scientific methodology inform evidence-based imaging recommendations with CT for mild TBI. The reader is directed to the
original citations for details.^8,9 Tong et al. have recently summarized the available evidence guiding imaging for TBI.¹⁰

In the initial assessment of any trauma patient, rapid identification and stabilization of life-threatening traumatic injuries is the primary goal. Airway protection and control of bleeding are mandated during this primary survey. To control bleeding from scalp lacerations, it is sometimes necessary to staple them closed in the prehospital setting to obtain adequate hemostasis.

Identification of skull fractures increases the chance of detecting associated cervical spine injuries to 15% or more, mandating prehospital spine precautions and careful evaluation of the craniocervical junction.