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Managing Severe Traumatic Brain Injury Outside of the Neurosciences Critical Care Unit

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Trauma and Combat Critical Care in Clinical Practice

Part of the book series: In Clinical Practice ((ICP))

Abstract

Traumatic brain injury (TBI) can commonly present to medical facilities without specialist neuroscience services and clinicians at these centers will be required to perform early stabilization and treatment. Early optimisation of cerebral perfusion pressure and oxygen delivery prevents secondary brain injury and has an important impact on mortality and long term outcomes. Important basic support measures have been shown to have positive mortality benefits, including optimal ventilation, prevention of pyrexia, and normoglycaemia, but management of intra-cranial hypertension is paramount given the association with poor outcomes. In specialist centers this is usually guided by the use of invasive intracranial pressure (ICP) monitoring; such techniques may not be available in a non-specialist centre. A method of TBI management based upon regular imaging and clinical examination (ICE) has been shown to be a comparable management strategy and is the standard of care used by the United Kingdom Defence Medical Services (UK DMS) when more advanced monitoring is not available. A developing method of measuring deterioration in ICP is the use of optic nerve sheath ultrasound, but the requirement for training, operator dependency, and current paucity of evidence prevents widespread adoption. This chapter will discuss the provision of basic support and homeostasis measures for the management of severe TBI outside of specialist centers, along with a suggested protocol for the management of intracranial hypertension in the absence of specialist expertise and monitoring.

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References

  1. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.

    Article  PubMed  Google Scholar 

  2. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D, Higgins A, et al. Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma. 2008;64(4):854–62.

    Article  PubMed  Google Scholar 

  3. Part 2: prognosis in penetrating brain injury. J Trauma. 2001;51(2 Suppl):S44–86.

    Google Scholar 

  4. Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92(1):1–6.

    Article  CAS  PubMed  Google Scholar 

  5. Balestreri M, Czosnyka M, Hutchinson P, Steiner LA, Hiler M, Smielewski P, et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care. 2006;4(1):8–13.

    Article  PubMed  Google Scholar 

  6. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma. 2007;24 Suppl 1:S37–44.

    PubMed  Google Scholar 

  7. Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ, Moons KG, Leenen LP, et al. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med. 2005;33(10):2207–13.

    Article  PubMed  Google Scholar 

  8. Shafi S, Diaz-Arrastia R, Madden C, Gentilello L. Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma. 2008;64(2):335–40.

    Article  PubMed  Google Scholar 

  9. Dawes AJ, Sacks GD, Cryer HG, Gruen JP, Preston C, Gorospe D, et al. Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: a propensity score-matched analysis. J Trauma Acute Care Surg. 2015;78(3):492–501; discussion 501 − 2.

    Article  PubMed  Google Scholar 

  10. Farahvar A, Gerber LM, Chiu YL, Carney N, Hartl R, Ghajar J. Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring. J Neurosurg. 2012;117(4):729–34.

    Article  PubMed  Google Scholar 

  11. Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, et al. Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program. J Neurotrauma. 2013;30(20):1737–46.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367(26):2471–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Chesnut RMML, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–22.

    Article  CAS  PubMed  Google Scholar 

  14. Jones PAAP, Midgely S, et al. Measuring the burden of secondary insults in head injured patients during intensive care. J Neurosurg Anesthesiol. 1994;6:4–14.

    Article  CAS  PubMed  Google Scholar 

  15. Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. 1991;75(5):731–9.

    Article  CAS  PubMed  Google Scholar 

  16. Network TARDS. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.

    Article  Google Scholar 

  17. Karabinis A, Mandragos K, Stergiopoulos S, Komnos A, Soukup J, Speelberg B, et al. Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial [ISRCTN50308308]. Crit Care (London, England). 2004;8(4):R268–80.

    Article  Google Scholar 

  18. Minton MD, Stirt JA, Bedford RF, Haworth C. Intracranial pressure after atracurium in neurosurgical patients. Anesth Analg. 1985;64(11):1113–6.

    Article  CAS  PubMed  Google Scholar 

  19. Schramm WM, Jesenko R, Bartunek A, Gilly H. Effects of cisatracurium on cerebral and cardiovascular hemodynamics in patients with severe brain injury. Acta Anaesthesiol Scand. 1997;41(10):1319–23.

    Article  CAS  PubMed  Google Scholar 

  20. Myburgh J, Cooper DJ, Finfer S, Bellomo R, Norton R, Bishop N, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–84.

    Article  CAS  PubMed  Google Scholar 

  21. Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg (Chicago, Ill: 1960). 2001;136(10):1118.

    Article  CAS  Google Scholar 

  22. Kelly DF, Goodale DB, Williams J, Herr DL, Chappell ET, Rosner MJ, et al. Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg. 1999;90(6):1042–52.

    Article  CAS  PubMed  Google Scholar 

  23. Sandiumenge Camps A, Sanchez-Izquierdo Riera JA, Toral Vazquez D, Sa Borges M, Peinado Rodriguez J, Alted LE. Midazolam and 2% propofol in long-term sedation of traumatized critically ill patients: efficacy and safety comparison. Crit Care Med. 2000;28(11):3612–9.

    Article  CAS  PubMed  Google Scholar 

  24. Albanese J, Viviand X, Potie F, Rey M, Alliez B, Martin C. Sufentanil, fentanyl, and alfentanil in head trauma patients: a study on cerebral hemodynamics. Crit Care Med. 1999;27(2):407–11.

    Article  CAS  PubMed  Google Scholar 

  25. Sperry RJ, Bailey PL, Reichman MV, Peterson JC, Petersen PB, Pace NL. Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology. 1992;77(3):416–20.

    Article  CAS  PubMed  Google Scholar 

  26. Haigh JD, Nemoto EM, DeWolf AM, Bleyaert AL. Comparison of the effects of succinylcholine and atracurium on intracranial pressure in monkeys with intracranial hypertension. Can Anaesth Soc J. 1986;33(4):421–6.

    Article  CAS  PubMed  Google Scholar 

  27. Temkin NR, Dikmen SS, Wilensky AJ, Keihm J, Chabal S, Winn HR. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990;323(8):497–502.

    Article  CAS  PubMed  Google Scholar 

  28. Temkin NR, Dikmen SS, Anderson GD, Wilensky AJ, Holmes MD, Cohen W, et al. Valproate therapy for prevention of posttraumatic seizures: a randomized trial. J Neurosurg. 1999;91(4):593–600.

    Article  CAS  PubMed  Google Scholar 

  29. Jones KE, Puccio AM, Harshman KJ, Falcione B, Benedict N, Jankowitz BT, et al. Levetiracetam versus phenytoin for seizure prophylaxis in severe traumatic brain injury. Neurosurg Focus. 2008;25(4):E3.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Szaflarski JP, Sangha KS, Lindsell CJ, Shutter LA. Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care. 2010;12(2):165–72.

    Article  CAS  PubMed  Google Scholar 

  31. Caballero GC, Hughes DW, Maxwell PR, Green K, Gamboa CD, Barthol CA. Retrospective analysis of levetiracetam compared to phenytoin for seizure prophylaxis in adults with traumatic brain injury. Hosp Pharm. 2013;48(9):757–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Lovell AT, Marshall AC, Elwell CE, Smith M, Goldstone JC. Changes in cerebral blood volume with changes in position in awake and anesthetized subjects. Anesth Analg. 2000;90(2):372–6.

    CAS  PubMed  Google Scholar 

  33. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg. 2002;72(6):389–91.

    Article  PubMed  Google Scholar 

  34. Ho AM, Fung KY, Joynt GM, Karmakar MK, Peng Z. Rigid cervical collar and intracranial pressure of patients with severe head injury. J Trauma. 2002;53(6):1185–8.

    Article  PubMed  Google Scholar 

  35. Sakurai A, Atkins CM, Alonso OF, Bramlett HM, Dietrich WD. Mild hyperthermia worsens the neuropathological damage associated with mild traumatic brain injury in rats. J Neurotrauma. 2012;29(2):313–21.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Rincon F, Patel U, Schorr C, Lee E, Ross S, Dellinger RP, et al. Brain injury as a risk factor for fever upon admission to the intensive care unit and association with in-hospital case fatality: a matched cohort study. J Intensive Care Med. 2015;30:107–14.

    Article  PubMed  Google Scholar 

  37. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197–206.

    Article  CAS  PubMed  Google Scholar 

  38. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994;330(6):377–81.

    Article  CAS  PubMed  Google Scholar 

  39. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med. 1998;338(12):791–7.

    Article  CAS  PubMed  Google Scholar 

  40. Barkun AN, Bardou M, Pham CQ, Martel M. Proton pump inhibitors vs. histamine 2 receptor antagonists for stress-related mucosal bleeding prophylaxis in critically ill patients: a meta-analysis. Am J Gastroenterol. 2012;107(4):507–20; quiz 521.

    Article  CAS  PubMed  Google Scholar 

  41. Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2013;41(3):693–705.

    Article  CAS  PubMed  Google Scholar 

  42. Lin PC, Chang CH, Hsu PI, Tseng PL, Huang YB. The efficacy and safety of proton pump inhibitors vs histamine-2 receptor antagonists for stress ulcer bleeding prophylaxis among critical care patients: a meta-analysis. Crit Care Med. 2010;38(4):1197–205.

    Article  CAS  PubMed  Google Scholar 

  43. Pilkington KB, Wagstaff MJ, Greenwood JE. Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature. Anaesth Intensive Care. 2012;40(2):253–9.

    CAS  PubMed  Google Scholar 

  44. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340(6):409–17.

    Article  PubMed  Google Scholar 

  45. Griesdale DE, Tremblay MH, McEwen J, Chittock DR. Glucose control and mortality in patients with severe traumatic brain injury. Neurocrit Care. 2009;11(3):311–6.

    Article  CAS  PubMed  Google Scholar 

  46. Green DM, O’Phelan KH, Bassin SL, Chang CW, Stern TS, Asai SM. Intensive versus conventional insulin therapy in critically ill neurologic patients. Neurocrit Care. 2010;13(3):299–306.

    Article  CAS  PubMed  Google Scholar 

  47. Krinsley JS, Grover A. Severe hypoglycemia in critically ill patients: risk factors and outcomes. Crit Care Med. 2007;35(10):2262–7.

    Article  PubMed  Google Scholar 

  48. Cammarata G, Ristagno G, Cammarata A, Mannanici G, Denaro C, Gullo A. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma. 2011;71(3):779–81.

    Article  PubMed  Google Scholar 

  49. Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059–68.

    Article  PubMed  Google Scholar 

  50. Geeraerts T, Launey Y, Martin L, Pottecher J, Vigue B, Duranteau J, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med. 2007;33(10):1704–11.

    Article  PubMed  Google Scholar 

  51. Huang SJ, Chang L, Han YY, Lee YC, Tu YK. Efficacy and safety of hypertonic saline solutions in the treatment of severe head injury. Surg Neurol. 2006;65(6):539–46; discussion 546.

    Article  PubMed  Google Scholar 

  52. Horn P, Munch E, Vajkoczy P, Herrmann P, Quintel M, Schilling L, et al. Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res. 1999;21(8):758–64.

    Article  CAS  PubMed  Google Scholar 

  53. Berger S, Schurer L, Hartl R, Messmer K, Baethmann A. Reduction of post-traumatic intracranial hypertension by hypertonic/hyperoncotic saline/dextran and hypertonic mannitol. Neurosurgery. 1995;37(1):98–107; discussion 107–8.

    Article  CAS  PubMed  Google Scholar 

  54. Cottenceau V, Masson F, Mahamid E, Petit L, Shik V, Sztark F, et al. Comparison of effects of equiosmolar doses of mannitol and hypertonic saline on cerebral blood flow and metabolism in traumatic brain injury. J Neurotrauma. 2011;28(10):2003–12.

    Article  PubMed  Google Scholar 

  55. Ichai C, Armando G, Orban JC, Berthier F, Rami L, Samat-Long C, et al. Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients. Intensive Care Med. 2009;35(3):471–9.

    Article  CAS  PubMed  Google Scholar 

  56. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. II. Hyperosmolar therapy. J Neurotrauma. 2007;24 Suppl 1:S14–20.

    PubMed  Google Scholar 

  57. Schwartz ML, Tator CH, Rowed DW, Reid SR, Meguro K, Andrews DF. The University of Toronto head injury treatment study: a prospective, randomized comparison of pentobarbital and mannitol. Can J Neurol Sci. 1984;11(4):434–40.

    Article  CAS  PubMed  Google Scholar 

  58. Roberts I, Sydenham E. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev. 2012;(12):CD000033.

    Google Scholar 

  59. Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg. 1988;69(1):15–23.

    Article  CAS  PubMed  Google Scholar 

  60. Jiang J, Yu M, Zhu C. Effect of long-term mild hypothermia therapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 cases. J Neurosurg. 2000;93(4):546–9.

    Article  CAS  PubMed  Google Scholar 

  61. Clifton GL, Valadka A, Zygun D, Coffey CS, Drever P, Fourwinds S, et al. Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011;10(2):131–9.

    Article  PubMed  Google Scholar 

  62. Clifton GL, Miller ER, Choi SC, Levin HS, McCauley S, Smith Jr KR, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344(8):556–63.

    Article  CAS  PubMed  Google Scholar 

  63. Adelson PD, Wisniewski SR, Beca J, Brown SD, Bell M, Muizelaar JP, et al. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. Lancet Neurol. 2013;12(6):546–53.

    Article  PubMed  Google Scholar 

  64. Georgiou AP, Manara AR. Role of therapeutic hypothermia in improving outcome after traumatic brain injury: a systematic review. Br J Anaesth. 2013;110(3):357–67.

    Article  CAS  PubMed  Google Scholar 

  65. Andrews PJD, Sinclair HL, Rodriguez A, Harris BA, Battison CG, Rhodes JKJ, et al. Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med. 0(0):null.

    Google Scholar 

  66. Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, et al. Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med. 2002;30(9):1950–9.

    Article  CAS  PubMed  Google Scholar 

  67. Sioutos PJ, Orozco JA, Carter LP, Weinand ME, Hamilton AJ, Williams FC. Continuous regional cerebral cortical blood flow monitoring in head-injured patients. Neurosurgery. 1995;36(5):943–9; discussion 949–50.

    Article  CAS  PubMed  Google Scholar 

  68. Diringer MN, Videen TO, Yundt K, Zazulia AR, Aiyagari V, Dacey Jr RG, et al. Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury. J Neurosurg. 2002;96(1):103–8.

    Article  PubMed  Google Scholar 

  69. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg. 2006;104(4):469–79.

    Article  PubMed  Google Scholar 

  70. Timofeev I, Czosnyka M, Nortje J, Smielewski P, Kirkpatrick P, Gupta A, et al. Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J Neurosurg. 2008;108(1):66–73.

    Article  PubMed  Google Scholar 

  71. Timofeev I, Hutchinson PJ. Outcome after surgical decompression of severe traumatic brain injury. Injury. 2006;37(12):1125–32.

    Article  CAS  PubMed  Google Scholar 

  72. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364(16):1493–502.

    Article  CAS  PubMed  Google Scholar 

  73. Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it”. Scand J Trauma Resusc Emerg Med. 2012;20:24.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Motohashi O, Kameyama M, Shimosegawa Y, Fujimori K, Sugai K, Onuma T. Single burr hole evacuation for traumatic acute subdural hematoma of the posterior fossa in the emergency room. J Neurotrauma. 2002;19(8):993–8.

    Article  PubMed  Google Scholar 

  75. Rinker CF, McMurry FG, Groeneweg VR, Bahnson FF, Banks KL, Gannon DM. Emergency craniotomy in a rural Level III trauma center. J Trauma. 1998;44(6):984–9; discussion 989–90.

    Article  CAS  PubMed  Google Scholar 

  76. Treacy PJ, Reilly P, Brophy B. Emergency neurosurgery by general surgeons at a remote major hospital. ANZ J Surg. 2005;75(10):852–7.

    Article  PubMed  Google Scholar 

  77. Wester K. Decompressive surgery for “pure” epidural hematomas: does neurosurgical expertise improve the outcome? Neurosurgery. 1999;44(3):495–500; discussion 500–2.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Defence Medical Services, Imperial School of Anaesthesia, London, UK

    George Evetts MBBS, BSc, MRCP, FRCA

  2. Department of Critical Care, Kings College Hospital, Denmark Hill, London, SE5 9RS, UK

    Sam D. Hutchings MRCS, FRCA, FFICM, DICM, DipIMC

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  1. George Evetts MBBS, BSc, MRCP, FRCA
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  2. Sam D. Hutchings MRCS, FRCA, FFICM, DICM, DipIMC
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Correspondence to George Evetts MBBS, BSc, MRCP, FRCA .

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  1. Royal Navy and King's College Hospital, London, United Kingdom

    Sam D. Hutchings

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Evetts, G., Hutchings, S.D. (2016). Managing Severe Traumatic Brain Injury Outside of the Neurosciences Critical Care Unit. In: Hutchings, S. (eds) Trauma and Combat Critical Care in Clinical Practice. In Clinical Practice. Springer, Cham. https://doi.org/10.1007/978-3-319-28758-4_11

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