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The rapid and accurate clinical assessment of a head-injured patient is crucial. The initial management should be governed by attention to the airway, breathing and circulation according to the principles of the Advanced Trauma Life Support (ATLS) care system. This is vital not only to identify immediately life-threatening injuries but also to prevent secondary cerebral insults. The cervical spine should be immobilised, since patients with a head injury may also harbour a cervical spine injury.1 The level of consciousness and pupil size and reaction should be determined early and at regular intervals when managing patients with TBI.