An audit was conducted of all serious head injured patients received at Atkinson Morley's Hospital over 1 year. One hundred and fifty-four were received, of whom 65 (42.2 per cent) had multiple injuries; 137 (89 per cent) patients were intubated and the overall incidence of hypoxia was 9.7 per cent. The incidence of hypercarbia was 25.9 per cent and was unrelated to the mode of ventilation. Hypotension was present in 11 patients (7.1 per cent) and hypovolaemia in 16 (10.5 per cent). During transfer 39 (28.9 per cent) intubated patients received no sedation, although 29 (21.5 per cent) were given neuromuscular blocking agents alone. The incidence of actual cervical injury was 3.2 per cent and in all five patients the neck was adequately stabilized pre-transfer. The incidence of thoracid injury was 19.5 per cent and of these four patients (13.3 per cent) warranted thoracotomy. Abdominal trauma occurred in eight (5.2 per cent) patients and in only one patient was laparotomy not performed pre-transfer. The accompanying doctor was a SHO with less than 6 months experience in anaesthetics in 33 per cent of transfers. Arterial blood pressure was monitored in only 50 per cent of transfers. The initial management of patients was generally satisfactory, and in particular the avoidance of hypoxia by a high rate of intubation was a significant improvement over other studies.