together we can take out the trauma from traumatic brain injury
TRANSCRIPT
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Together We can take out the
Trauma from Traumatic Brain Injury
By: Amanda Di Florio RN, BN, CNCC(C)
Sandra Cook RN, BN, CNCC(C)
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Potential Conflict of Interest
Disclosure
• Amanda Di Florio
• Sandra Cook
• I do not declare any potential conflict of
interest
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The Brain Trauma Foundation
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Introduction
• Approximately 18,000 hospitalizations associated
with TBI diagnosis annually in Canada Brain Injury Association of
Canada website at www.biac-aclc.ca
• 50,000 Canadians sustain brain injuries each year, • 50,000 Canadians sustain brain injuries each year,
and incidence rates are rising. www.torontorehab.com
• TBI’s accounted for 151.7 million in direct costs to
Canadians. Brain Injury Association of Canada website at www.biac-aclc.ca
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Introduction
• Leading causes of TBI: (In U.S)
• Falls 35.2%
• Motor Vehicle – Traffic • Motor Vehicle – Traffic 17.3%
• Struck by- against events – 16.5%
• Assaults – 10%• http://www.brainline.org/content/2008/07/fact
s-about-traumatic-brain-injury.html
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Mr. G.
• Mr. G. 18 y.o. No known PMHx.
• Daily ETOH use
• Mechanism of Injury:
• MVA hit a tree at 150 km per hour• MVA hit a tree at 150 km per hour
• Seat belt Utilised
• Air bag deployed
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Mr. G. at the Scene….
• Presence of Urgence – Sante:
• GCS 13 on 15
• Becomes agitated and confused
• Stable BP, Tachycardia• Stable BP, Tachycardia
• Saturating at 100% on fio2: 100 % via
Rebreather
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Mr. G.’s Injuries….
• Injuries:
• Right Ribs 3 to 7 #s - Left Ribs 3 to 5 #s
• Transverse Process # -
• Left Epidural Bleed with a midline Shift of 1.7 mm• Left Epidural Bleed with a midline Shift of 1.7 mm
• ETOH of High level
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Golden Hour
• The time interval lasting for one hour from injury
to obtaining medical care.
• All patients must be transported so that they are
able to receive surgery within the first hours after able to receive surgery within the first hours after
injury.
• Prompt medical treatment will prevent death
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Initial Assessment
• Primary Survey:
• Airway
• Breathing
• Circulation
• Secondary Survey:
• Signs and Symptoms
• Allergies
• Medication• Circulation
• Disabilities
• Medication
• Past medical history
• Last meal
• Events prior
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Airway
• Unpredictable Clinical Course - Low threshold
for securing the airway.
• A Loss of Consciousness correlates with an
increased incidence of an acute intracranial increased incidence of an acute intracranial
injury.
• Potential Cervical Spine Injury
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Oxygenation
• Keep O2Sat. greater than 90%
• Measured continuously with a
pulse oximeter
• Hypoxia to be avoided and • Hypoxia to be avoided and
immediately corrected d/t Higher
Mortality
• Supplemental O2, and airway
adjuncts
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Who Does Not Benefit from
Intubation
• Ground transported pts. in urban environments,
• Spontaneously breathing, and maintaining an Spo2
above 90% on supplemental oxygen
• Without signs of active herniation• Without signs of active herniation
• Protects their own Airway
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Why its not a Benefit….
• Increased risk of Hypoxia
• Bradycardia
• Prolonged scene time
• Inadvertent Hyperventilation after • Inadvertent Hyperventilation after
Intubation
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Who Does Benefit from Endotracheal
Intubation
• Severe TBI with GCS Score of <8,
• Unconscious with ineffective ventilation
• Inability to maintain an adequate airway, no
gag reflexgag reflex
• Hypoxemia not corrected by supplemental
oxygen and adjunct airways
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End-Tidal Co2 Monitoring
• Monitoring of ETCO2 is fundamental to TBI
management (if intubated).
• Lower incidence of Hyperventilation and
Lower MortalityLower Mortality
• Not only in the hospital but also in pre-
Hospital arena.
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Limitations to ETCO2
• ETCO2 and PaCO2 levels correlates well in
healthy patients.
• Difference in PaCO2 and ETCO2 due to;
– Poly-Trauma– Poly-Trauma
– Severe chest trauma
– Hypotension
– Heavy blood loss.
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Consequences of Hypotension..
• Keep Systolic Blood Pressure greater than 90mmHg
• Single episode of Hypotension Doubles mortality and
an increased morbidity.
• Increased risk of 30 day in-hospital mortality. • Increased risk of 30 day in-hospital mortality.
• More valuable to maintain Higher MAP than to
Maintain Systolic BP > 90mmHg
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Hypotension in a TBI…
• Could be caused by a
Source of Major bleeding
elsewhere other than the
HeadHead
• Signs of Hemorrhagic
Shock treat as so…
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Fluid Resuscitation
• Ringers Lactate or Normal Saline as initial fluid
bolus. (1 -2 Liters based on fluid/blood loss)
• Crystalloid fluid mostly used
• Hemoglobin substitutes • Hemoglobin substitutes
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Hyperosmolar Therapy
• Treatment option for TBI with GCS less than 8
with active signs of Herniation
• Mannitol can be administered
• Can be used to Temporarily Decrease ICP before • Can be used to Temporarily Decrease ICP before
Surgical Intervention.
• No evidence to support its use in the pre-
hospital setting.
• If used inappropriately can increase mortality
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Why do Glasgow Coma Scale Score
• A significant and reliable
indicator of the severity
• Frequent GCS ( q1hr and
prn) prn)
• To Identify improvement
or deterioration over
time.
• Obtain best Score
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When to do a GCS Score
• After ABC’s are assessed
and managed.
• Pre and Post
administration of administration of
sedative or paralytic
agents.
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Types of Painful Stimulus
• Sternal Rub – Avoid in chest trauma
• Trapezius pinch
• Supraorbital Pinch – Avoid if ocular facial
deformitiesdeformities
• Nail bed pain (peripheral stimulation)
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Responses to Painful Stimulus
• Localizing - An organized attempt to Localize
and remove painful stimulus
• Withdrawing – withdraws extremity from
source of painful stimulussource of painful stimulus
• Decortication- abnormal flexion
• Decerebration – abnormal extension
• Flaccid
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Decortication
- The Upper Arms
move towards the
Chest with Elbows,
Wrists and FingersWrists and Fingers
Flexed
- Legs extend with
Internal rotation
and the Feet Flex
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Decerebration
- The Neck extends,
-The Jaw clenches, -The Jaw clenches,
- Arms Pronate and
extend straight out
- The feet plantar
flex
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Why do a Pupillary Exam…
• Guide to immediate medical decision making
• Long term prognosticator in combination with physical findings.
• Strong correlation between fixed, dilated • Strong correlation between fixed, dilated pupils and ultimate mortality
• Pupil examination can be an indicator of anatomical location and severity of TBI
• 3rd cranial nerve compression from uncalherniation
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When to Exam Pupils
• For use in diagnosis,
treatment, and
prognosis
• After the patient has • After the patient has
been resuscitated and
stabilized
• Before and After Opioid
administration
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What to Observe in the Pupils….
• Size and Shape
• Symmetry
• Reaction to light in • Reaction to light in
both pupils.
• Light Reflex
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Abnormal Pupillary Findings
• Unilateral or Bilateral dilated pupils
• Fixed and dilated Pupil(s)
• Asymmetry: Greater than one millimeter difference
• Asymmetry: Greater than one millimeter difference in diameter
• Fixed pupils: Less than one millimeter response to bright light
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Mode of Transportation
• Selected to minimize total pre-hospital time.
• Ground ambulance versus helicopter
• Pre-hospital care providers select the
appropriate destination facility.appropriate destination facility.
• 7 % Decreased mortality when treated in a
Trauma Center compared to other hospitals.
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Decision Making
• 70% decrease in mortality if patient
evaluation is performed within two hours of
injury.
• Those treated within 4 hours there was a 10% • Those treated within 4 hours there was a 10%
absolute reduction in mortality compared to
those treated greater than 4 hours.
• Outcomes are better with an Organized EMS
system for trauma Patients.
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Use of Helicopters….
• A 9% reduction in Mortality for TBI patients transported by helicopter compared to ground ambulance.
• In the Baxt study, Helicopters were staffed by a MD and a RN, while the staffed by a MD and a RN, while the ground ambulance was staffed by a paramedic.
• Helicopter had better odds of survival, compared to ground transport, after controlling for a number of potential confounding variables.
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Upon Arrival to MGH ER…..!!!!
• Adequate oxygenation: PaO2 >60 mmHg, Oxygen
sat. > 90%, Capnography
• Hemodynamics: Sys. BP > 90mmHg, Monitor
Heart Rate Heart Rate
• Temperature: (36.5 to 37.5)
• Neuro Exam ASAP: GCS score
• GCS less or equal to 8 = SEVERE TBI
• Risk of Deterioration until 72 hrs after injury!!!
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Laboratory Workup
• Assess for other systemic trauma
• Complete Blood Count;(Hb, WBC)
• Electrolyte and Acid Base alterations, Glucose
• ETOH level, Toxicology screen
• Coagulation Fac. &Cross Match
• Correcting INR if applicable (FFP’s, Beriplex)
• Should be done by transferring hospital (when appropriate)
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CT Head Stat…!!!
• Neuro Imaging
• Ct scan will detect:
• Skull #’s
• Intracranial hematomas • Intracranial hematomas
• Cerebral edema
• Neurosurgery consult
ASAP!
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TBI Severity Score Scale
• Obtaining a CT scan
should not delay
patient transfer to a
trauma center
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Types of Brain Injuries
• Blunt brain injury: automobile collisions, falls,
and assaults with blunt weapons
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Types of Brain Injuries
• Penetrating brain injury: gunshots and stab
wounds
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Epidural Hematoma
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Types of Brain Injuries
Subdural hematoma Intracerebral hemorrhage
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Types of Brain Injuries
Subarachnoid Hemorrhage Cerebral contusions
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Diffuse Axonal Injury (DAI)
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Signs of Increased ICP
Pt’s with suspected High ICP are at risk of Brain
Herniation!
• Signs and Symptoms:
• Unilaterally or bilaterally • Treatment:
• Head elevation • Unilaterally or bilaterally
fixed and dilated pupils
• Decorticate or Decerebrate
posturing
• Cushing’s Triad
• Decrease in LOC and GCS
• Head elevation
• Osmotic therapy
(Mannitol 1g/kg IV)
• Hyperventilation (CO2
between 30-35)
• Neurosurgical
intervention
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Cushing’s Triad
• Systolic BP increases
• Widening pulse pressure (the difference
between systolic and diastolic BP)
• Bradycardia• Bradycardia
• Irregular breathing (such as Cheyne-Stokes)
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Types of Brain Herniation
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Admission to ICU
• Principal focus of critical
care management for
severe TBI is to limit
secondary brain injury
• Optimizing:
• Oxygenation
• Blood pressure
• Managing Temperature
• Treatment Priorities:
• ICP management
• Maintenance of CPP
• Managing Temperature
• Glucose
• Seizures
• Isotonic fluids (NS only)
(Never Dextrose!)
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Monro-Kellie Doctrine
• Blood
• CSF
• Brain
• If increase in size of one compartment (ie: compartment (ie: hematoma)
• With no decrease in size from other compartments
• Then ICP will increase
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Intracranial Pressure Monitoring
• Assist neurosurgeon with EVD insertion
• EVD allows monitoring of ICP and drainage of
CSF to decrease ICP
• Drain CSF to keep ICP < 20 mmHg • Drain CSF to keep ICP < 20 mmHg
• Codman (monitoring of ICP only)
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Normal ICP waveforms
• Represents the Pulsation from in the Brain
from Intracranial Arteries and Veins.
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Neurosurgical Interventions
• Craniotomy: bone flap is
temporarily removed from
the skull to access the
brain brain
• Burr Holes: a hole is drilled
or scraped into the skull,
exposing and penetrating
the dura mater
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Neurosurgical Interventions
• Decompressive
Craniectomy:
• portion of skull removed in
order to reduce increased
ICP
*Caution! Do not turn the
patient onto the side of
Craniectomy - no skull!*
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Hyperosmolar Therapy
• Mannitol 20% Hypertonic saline 3%
• Creates an osmotic gradient, drawing H20 across the blood-brain barrierblood-brain barrier
• Leads to decrease in interstitial volume and a decrease in ICP
• Monitor serum sodium and serum osmolality levels
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Sedation
• Lowers ICP by reducing metabolic demand
• Sedation: Propofol, Versed, Fentanyl
• Assure that pain is well controlled (Fentanyl)!
• Propofol preferred for sedation: short duration of • Propofol preferred for sedation: short duration of
action (neuro exams), causes decreased cerebral
metabolic rate, can decrease ICP
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Ventilation
• Maintenance of CO2 between 35 and 38 mmHg
• Hyperventilation: Should be avoided
Due to Vasoconstriction –• Due to Vasoconstriction –Impairs Cerebral Perfusion (CPP)
• Leads to Cerebral Ischemia (Secondary Injury)
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Hemodynamics
• CPP = (MAP – ICP)
• CPP between 60 and 70
mmHg
• Vasopressors;
Levophed, VasopressinLevophed, Vasopressin
• Monitoring CVP’s
(administration of
fluids)
• Strict Intake and
Output.
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Barbiturate Therapy
• Barbiturate coma:
• Used less often (Used only in severe cases of
ICP management issues)
• Decreases metabolic rate of brain tissue• Decreases metabolic rate of brain tissue
• Reduce spread of epileptic focus
• Decreases intracranial hypertension
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Seizures
• Increase Metabolic demand on damaged brain tissue
and may aggravate secondary brain injury
• 15 to 25% of pt’s with severe TBI will have non-
convulsive seizures
• Seizure prophylaxis: Dilantin for 7 days• Seizure prophylaxis: Dilantin for 7 days
• If Seizure activity present, than continue anticonvulsive
medication
• EEG Monitoring; Continuous or 24 hour EEG.
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Paralysis
• Rocuronium infusion:
• Monitoring the TOF (train of four) watching
for muscle twitching
• Ensure adequacy of Sedation Prior• Ensure adequacy of Sedation Prior
• Used when ICP is difficult to manage
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Induced Hypothermia
• Should only be used with patients with elevated ICP
(cooling blanket)
• Prevents secondary brain injury
• Potential to reduce ICP • Potential to reduce ICP
• Provides Neuro-protection
• Danger of pt Shivering
• Ensure adequately sedated!
• Regular antipyretics can be used adjuvant to cooling
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Glucose Management
• Maintain between 6-10 mmol/L
• Frequent capillary glucose check
• Intermittent Humulin R subcutaneously
• If persistent Hyperglycemia • If persistent Hyperglycemia
• May require need for continuous Insulin
infusion
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Preventative Care
• DVT prophylaxis:
• Deltaparin, Fragmin, etc..
• Check with Neurosurgery for
appropriate time to start appropriate time to start
anticoagulation.
• Risks vs. benefits must be outweighed
• Use of Inferior Vena Cava Filter
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Nutrition
• Dietician consult for feeding
ASAP.
• Under nutrition is associated
with higher mortality.
• Continuous Enteral Feeding
• Stress Ulcer Prophylaxis -
Famotidine
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Vasospasm
• Onset typically 4 to 10 days after subarachnoid hemorrhage.
• Blood vessel spasm leads to vasoconstriction
• Causing tissue ischemia and • Causing tissue ischemia and tissue necrosis
• Symptomatic vasospasm or delayed cerebral ischemia is a major contributor to post-operative stroke and death.
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Vasospasm
• Prevention:
• Calcium Channel
Blocker’s - Nimodipine
• Treatment:• Treatment:
• HHH Therapy:
Hypervolemia,
Hypertension,
Hemodilution
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New Technologies
• Cerebral Oxygen
Monitoring
• Jugular Bulb Oximetry • Jugular Bulb Oximetry
(SjvO2)
• Brain Tissue Oxygen
Tension (PtiO2)
• Intracerebral
Microdialysis
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Conclusion
• Continuous assessment is extreme importance.
• Complex patient population
• Slight changes can be significant.
• GCS and Pupil assessment have some degree of subjectivity subjectivity
• However, it should be reproducible and reliable!
• Neuro exam must not be Forgotten or Omitted
• Treat other Traumatic Injuries
• Continue ICP Monitoring (even in OR)
• Don’t delay transfer in order to do a CT Head.
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Thank you!!!
• Dr. Andrew Beckett, Trauma Staff MGH
• Dr. Charles Couturier, Neurosurgery Resident
• Julie Kinnon R.N, Nurse Educator, ICU MGH• Julie Kinnon R.N, Nurse Educator, ICU MGH
• Colleen Stone R.N, Nurse Manager, ICU MGH
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Questions?
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References• Brain Trauma Foundation Online TBI Guidelines, 2010.
• Brain Trauma Foundation, “Pre Hospital Emergency Care”, January, March 2007, Vol. 12, Number 1.
• Caroline, Nancy L. Emergency Care in the Streets, 5th Edition, 1995.
• Emergency Nurses Association “Trauma Nursing Core Course” Sixth Edition, 2007.
• Hernando, R. A-M., Castellar-Leones, S. M., & Moscote- Salazar, L.R., “Intravenous Fluid Therapy in Traumatic Brain Injury and Decompressive Craniectomy” Bullitin of Emergency and Trauma, 2014; 2(1):3-14.
• Hemphill and Phan, UpToDate “Management of Acute Severe Traumatic Brain Injury” 2013.
• Guidelines for the Pre-Hospital Care of Patients with Severe Head Injury. Intensive Care Med. (1998) 24: 1221 -1225.
• Kiehna, E. N., Huffmyer, J. L., Thiele, R. H., Scalzo, D.C., & Nemergut, E. C. “Use of the Intrathoracic Pressure regulator to lower Intracranial Pressure in Patints with altered Intracranial Elastance: A Pilot Study. J. Neurosurg, September 2013. Vol. 119: 756 – 759.
• Kaplow and Hardin “Critical Care Nursing” 2007.
• Wagner, K. D., Johnson, K. L., and Hardin-Pierce, M. G., High- Acuity Nursing, 5th Edition, 2010.
• Metheny, Norma M., Fluid and Electrolyte Balance Nursing Considerations, 4th Edition, 2000.
• Urden, L.D., Stacey, K.M., Lough, M.E., Thelan’s Critical Care Nursing Diagnosis and Management, 5th Edition, 2006.
• Topping, Claude. & Ducharme, James. “Prehospital Intubation for Patients with severe head injury: More is not necessarily better” CJEM Journal Club. March 2008; 8 (2).
• Tolias, C., Wyler, A. R., Initial Evaluation and Management of CNS Injury, Medscape References, (2013, September).
• Schimpf, Melissa M. “Diagnosing Increased Intracranial Pressure” Journal of Trauma Nursing, July-September 2012.
• Shirley, I. Stiver,. & Geoffrey, T. Manley., “Pre- Hospital Management of Traumatic Brain Injury” NeuroSurg Focus, 2008: 25 (4):E5.
• Smith, E. R., Amin-Hanjani, S., Aminoff, M. J. , & Wilterdink, J. “Evaluation and Management of Elevated Intracranial Pressure in Adults” Up to Date. 2013.
• http://biac-aclc.ca/2011/03/17/the-brain-injury-association-of-canada-supports-governments-investment-to-injury-prevention/