Of 100 consecutive patients with severe head injury who arrived at a major trauma center, half of whom came direct from the accident site and half from another hospital, potentially serious systemic insults to the brain were present in 44 cases. Arterial hypotension (13 cases), anemia (12 cases), and hypercarbia (4 cases) were almost exclusively associated with multiple injuries, which were present in 57 patients and were caused usually by vehicular accidents. Hypoxia was seen in 30 patients, including several with brain injury alone. These systemic insults to the already injured brain were associated with an increase in mortality and morbidity. We believe that direct transfer to a trauma center that has full-time neurosurgical facilities for victims of automobile accidents and patients who have been rendered unconscious by a fall or blow on the head will increase survival. Care for the patient with head injuries should start at the roadside.