MedCom_TraumaticBrainInjury_1E_9789390553983_15,2x22,9_(6x9')SC_3Seiten_k8.indd part 1

[Audio] National Guidelines for the Management of Traumatic Brain Injury Neurotrauma Society of India (An NTSI-NSI Initiative) Editors Mathew Joseph Sumit Sinha Dhaval Shukla V.D. Sinha This project is supported by an unrestricted educational grant from Abbott India Limited to Thieme Medical & Scientific Publishers Pvt Ltd. as a service to the medical profession..

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[Audio] NationalGuidelinesfortheManagementofTraumaticBrainInjuryNeurotraumaSocietyofIndia(AnNTSI–NSIInitiative) EditorsMathewJosephSumitSinhaDhavalShuklaV.D.SinhaThiemeDelhi Stuttgart NewYork RiodeJaneiro.

[Audio] Director-Medical Communications & Corporate Sales: Dr Nitendra Sesodia Director-Editorial Services: Rachna Sinha Project Managers: Garima Sharma and Prakash Naorem Vice President-Sales and Marketing: Arun Kumar Majji Managing Director & CEO: Ajit Kohli © 2022. Thieme. All rights reserved. Thieme Medical and Scientific Publishers Private Limited A 12, Second Floor, Sector 2, Noida 201 301, Uttar Pradesh, India, +911204556600 Email: customerservice@thieme.in www.thieme.in Cover design: © Thieme Cover image source: © Thieme Page make-up by RECTO Graphics, India Printed in India by Balaji Art 5 4 3 2 1 ISBN: 978-93-90553-98-3 Important note: Medicine is an ever-changing science under going continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Thieme addresses people of all gender identities equally. We encourage our authors to use gender-neutral or gender-equal expressions wherever the context allows. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher's consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage..

[Audio] Dedicated to the millions of patients who have suffered from traumatic brain injury and to their loved ones who have shared the pain. SPECIAL THANKS Late Dr. A. P. J. Abdul Kalam Former President of India Who saw the need for these guidelines and encouraged their creation. Without his guidance this project would not have seen the light of day..

[Audio] ContentsFromtheEditor'sDeskxiForewordxiiiEditorsxv1.Introduction1 2.EpidemiologyofTBI9 G.Gururaj3.PrehospitalCareGuidelines13 V.D.SinhaandAmitChakrabarty4.HospitalCareGuidelines17 SumitSinhaandMathewJoseph5.NeurorehabilitationafterTraumaticBrainInjury29 DhavalShukla6.SummaryandConclusions37 SumitSinhavii.

[Audio] "Ingeneralthedocumentisveryusefulandifusedspeciallybysurgeonsindistricthospitalsandlocalgovernmentsadoptit,itwillbringaqualitativechangeinthemanagementandhencetheoutcomeofheadinjury. Mybestwishesforsuccessofthiswonderfuleffort." Prof.P.N.Tandonix.

[Audio] FromtheEditor'sDeskAgreatmajorityofpatientswhosufferheadinjuryarenotseenincentersthathaveestablishedneurosurgicalservices,andthereforereceivelessthanoptimalcareorsometimesnoneatall.Thisisoftenthecaseevenwhenthehospitalhasmanyofthefacilitiestoadequatelymanagethepatientduetothefactthatmostavailableprotocolsadviseonlytheidealtreatment,whichisperceivedascomplexandintimidating.Thetruthisveryfarfromthisbecausemostofthetreatmentrequiredbyapatientwithheadinjury,especiallyintheearlystages,iswellwithinthecapabilitiesofageneralmedicalsetup.Forexample,oneofthemostimportantfactorsthatinfluencetheoutcomeofapatientwithheadinjuryisthebloodpressure,anditisdisappointingtoseeapatientarriveintheemergencyroomfromanotherhospitalinshockfromscalpbleedingthatcouldhavebeeneasilycontrolledbeforereferral.Thisdocumentisintendedtoencourageeventhesmallesthospitaltoperformlife-savinginterventionswithinitscapabilitiesratherthanstating,"Wecan'tmanageheadinjuries." Theseguidelinesarenotpurelyevidencebasedbutcontainalargeproportionofexpertopinionsgatheredfromdoctorsinacademicandotherfieldstoprovidewhatwehopeisthebestpossibleadvicetoalldoctorswhoencounterheadinjuryintheirpractice.Theyhavebeencreatedforanenvironmentwhereidealtreatmentisnotuniversallyavailable.Eachsectiondescribesoptimaltreatment,butmoreimportantlyemphasizestheimportanceofdoingwhatispossiblewiththefacilitiesandtrainingavailableinastep-wisereductionofthecomplexityoftheintervention.Thisapproachcanbecriticizedasacceptingalowerqualityoftreatmentratherthanbringingupthelevelofcare,butwefeelthatgiventhevastsizeoftheproblem,itisimportanttoprovidepatientswithwhatevercareispossibleinthecurrentscenariountiltheoverallinfrastructureisimproved.Inaddition,itmustbeemphasizedagainthatthe"simple"interventionsofstabilizingbloodpressureandbreathinghaveatleastasmuch(orevenmore)influenceontheoutcomeofheadinjuryasneurosurgicalinterventionsinthevastmajorityofcases.Itisourearnesthopethatthisdocumentwillsavelivesandimproveoutcomesinheadinjurypatients. MathewJoseph,M.Ch.ProfessorofNeurosurgeryChristianMedicalCollegeVellore,TamilNaduxi.

[Audio] ForewordWearedelightedthattheguidelinesformanagementoftraumaticbraininjury(TBI)intheIndiansettingarebeingreleased.WeapplaudthemanydoctorswhohaveworkedonthisdocumentwhichrepresentsaveryimportantstepforwardinthegrowthoftraumaservicesinIndia.TheseguidelinesaretheresultofamultiyeareffortthathasculminatedinapracticalandusabletoolforthosewhomanageTBI.ThisisespeciallyimportantastraumaandheadinjuriesareextremelycommonproblemsinIndia,resultinginalotofdeathanddisability. TheguidelinesthatwehelpedtodevelopintheUnitedStatesover30yearsagohavebecomewidelyadoptedandhavedemonstrablyimprovedoutcomes.However,itwasrecognizedthatthoseguidelineswerenotdirectlyapplicableintheIndiansettingduetodifferentconditions,resources,andinfrastructure.Therefore,ateamofIndiandoctorsincollaborationwithinternationalexpertstookonthechallengeofcreatingIndia-centricrecommendations.Nodocumentisperfectandindeedsuchguidelinesarebytheirverynaturelivingdocumentsthatneedtobecorrected,updated,andconstantlyimprovedupon.TheUSversionisnowinits4theditionandwillnodoubtcontinuetoevolve. WehopethattheseguidelineswillproveusefultotheIndianmedicalandsurgicalcommunitiesandcongratulatealltheindividualswhoworkedtirelesslytomakethisareality.Weespeciallythankthemanyorganizationsthatcontributedmoneyandtalenttowardthisgoal.MaytheseeffortshelpmanyTBIpatientsandourcolleagueswholaboraroundtheclocktocareforthem. JogiV.Pattisapu,MD,FAAP,FAANS(L) PediatricNeurosurgeryUniversityofCentralFloridaCollegeofMedicineOrlando,FloridaRajK.Narayan,MD,FACS,FAANSProfessorofNeurosurgeryandChairmanEmeritusZuckerSchoolofMedicineatHofstra/NorthwellNorthwellHealth,Manhasset,NewYorkxiii.

[Audio] EditorsMathewJoseph,M.Ch.ProfessorofNeurosurgeryChristianMedicalCollegeVellore,TamilNaduSumitSinha,MS,DNB,M.Ch. Ex-ProfessorDepartmentofNeurosurgeryAIIMS,NewDelhi; Director,NeurosurgeryandSpineServicesParasHospitalGurugram,HaryanaDhavalShukla,M.Ch.ProfessorofNeurosurgeryDepartmentofNeurosurgeryNIMHANS,Bangalore,KarnatakaV.D.Sinha,MBBS,MS,M.Ch.SeniorProfessorDepartmentofNeurosurgeryS.M.S.MedicalCollegeJaipur,Rajasthanxv.

[Audio] Developed in consultation with the following listed experts. The individuals marked with an * were involved in the writing: Dr. Jameel Ali Dr. Amit Chakraborty* Dr. B. Indira Devi Dr. Steve Flanagan Dr. Gaurav Gupta Dr. Shakti Gupta Dr. G. Gururaj* Dr. Ravi Jahagirdar Dr. Seema Jain Dr. Mathew Joseph* Dr. V. Katoch Prof. Anil Kumar Dr. Shekar Kurpad Dr. R. C. Mishra Dr. Mahesh Misra Dr. Raj K. Narayan* Dr. Manas Panagrahi Dr. Jogi V. Pattisapu* Dr. K. Satyavara Prasad Dr. Rajendra Prasad Dr. G. V. Ramana Dr. M. Bhaskara Rao Dr. B. S. Sharma Dr. Jitendra Sharma Dr. Dhaval Shukla* Mr. Anwar Feroz Siddiqi Dr. Angel Rajan Singh Ms. Ruchika Singhal Dr. Sumit Sinha* Prof. V. D. Sinha* Dr. D. P. Sood Dr. Abhishek Srivastava Dr. R. P. Srivastava Ms. Anne Stake Dr. V. Sunder Cmd. Ranbir Talwar Prof. P. N. Tandon Dr. Piyush Tewari Dr. Arun Tiwari Dr. Balaji Utla Mr. Jonathan Washko xvi.

[Audio] With appreciation to the following institutions and associations: Andhra Medical College; King George Hospital, Visakhapatnam Association of Surgeons of India (ASI) Center for Advanced Brain and Spine Surgery, Super Specialty Hospital Chennai Christian Medical College, Vellore GVK Emergency Medicine Learning Center & Research India Head Injury Foundation Indian Council for Medical Research Indian Federation of Neurorehabilitation JPN Apex Trauma Center, AIIMS, Delhi Kokilaben Dhirubhai Ambani Hospital, Mumbai Medical Council of India National Brain Research Center, Haryana, India National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru Neurological Society of India Neurotrauma Society of India Nizam Institute of Medical Sciences, Hyderabad Rajendra Institute of Medical Sciences, Ranchi Save Life Foundation, Delhi School of Management Sciences at Hyderabad University SMS Medical College, Jaipur WHO Collaborating Center for Injury Prevention and Safety Promotion, NIMHANS, Bangalore Ziqitza Healthcare Head 108 Services, Punjab American Association of South Asian Neurosurgeons (AASAN), USA American College of Surgeons–ATLS Subcommittee Brain Trauma Foundation, USA Medical College of Wisconsin, Milwaukee WI, USA Medtronic, USA North Shore University Hospital, Manhasset, NY Rusk Rehabilitation NYU, NY, USA Section of Neurotrauma and Critical Care of the AANS/CNS, USA University of Toronto, Canada Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA xvii.

[Audio] TheGuidelinesDevelopmentCommitteewouldliketothankthefollowingspecialpeoplewithoutwhomthisprojectwouldnothavebeenpossible. � WethankandrecognizetheBrainTraumaFoundation,USA,sincetheirworkservedasareferencefortheseIndia-centricguidelines. � AmericanAssociationofPhysiciansofIndianOrigin(AAPI),itsofficebearers,anditsmembersincludingPresidentsDr.RaviJahagirdarandDr.SeemaJainfortheirunfailingsupportandencouragement. � ProfJogiV.PattisapuandProfRajK.Narayanforconceivingandspearheadingthisproject. � TheLateMr.AnwarFerozSiddiqiforhisrelentlessfocusedeffortsincoordinationandcollaborationacrossthemultiplestakeholders.xix.

[Audio] 1 IntroductionIndiahasunfortunatelybecomethetraumaticbraininjury(TBI)capitaloftheworld,andcountlesspatientssuffersuchaninjuryeachyear.Whilesomeseverelyinjuredvictimssuccumb,manysurvivewithvaryingdegreesofdisability,representingatremendousburdenontheaffectedfamiliesandthecountry.Wedonotyethaveanation-wideorganizedtraumacaresystem.Asafirststeptowardthisgoal,wetrustthatthisdocumentwillserveasausefulguide.Thistemplatemightalsobeusefulforotherdevelopingcountriesinasimilarsituation.TheIndianneurosurgicalcommunityiskeenlyawareofthecurrentstatisticsandisfocusingitsenergyandabilitiesonimprovingthistragicsituation. Severalyearsago,IndianneurosurgeonsjoinedvariousorganizationsincludingtheAmericanAssociationofPhysiciansofIndianOrigin(AAPI)toimproveTBImanagementinIndia.Thiswasamonumentaltaskandrequiredacoordinatedeffortwithsupportfrommanyindividualsandnumerousorganizations.Theinitialtaskforceincludedrepresentativesfromthecentralgovernment,epidemiologists,thegeneralpublic,media,ambulanceservicegroups,nongovernmentalorganizations,educationalinstitutions,andneurosurgeons. SomeofourteammembershadhelpedtoestablishtheoriginalTBIManagementGuidelinesintheUnitedStatesthatresultedinsubstantialimprovementinoutcomes.However,duetoinfrastructuredifferences,theseUSA-basedguidelineswerenotthoughttobeimmediatelyapplicabletotheIndiansituation.WethereforeembarkedondevelopingIndia-centricheadinjuryguidelinesthatcouldbeusedtoeducateandtrainphysicians,firstresponders,andtraumacareproviders,andthisdocumentistheculminationofsuchefforts.Theseguidelinesarea"livingdocument"thatwillbemodifiedandimprovedwithnewknowledgeandongoingexperience.Furthermore,whileeveryefforthasbeenmadetomaketheserecommendationsas"evidencebased"aspossible,thereislimitedClass1or2evidenceformanyaspectsoftraumacare.Therefore,manyoftherecommendationsarebasedonClass3evidenceandexpertconsensusopinions. BackgroundThepurposeoftheseIndia-centricguidelinesistoimprovetheentirespectrumofTBIcare—fromawarenessandprevention,toprehospitalcare,in-hospitalcare,andfinallyrehabilitation.Inthe1980s,theBrainTraumaFoundation,incollaborationwiththeAmericanAssociationofNeurologicalSurgeons(AANS).

[Audio] National Guidelines for the Management of Traumatic Brain Injury 2 and the Congress of Neurological Surgeons (CNS) developed evidence-based management guidelines for severe TBI.1 These guidelines have become widely used in the United States and are now in their 4th Edition. Modified versions of these guidelines, as well as the Advanced Trauma Life Support (ATLS) course, have been developed in other countries and have resulted in great improvements in the organization and treatment of trauma and specifically brain injury. Since trauma has become a major public health epidemic in India, and since the management of the injured patient remains quite variable, the need to create a document aimed at the Indian situation became apparent. Basic Principles of TBI The initial injury to brain (primary Injury) initiates several secondary processes (secondary Injury) that often lead to worse outcomes. Some of these secondary processes can be mitigated with timely interventions, and these guidelines aim to reduce such complications following TBI. This document will hopefully provide information for prompt treatment and appropriate care as to reduce secondary brain injury and optimize outcomes. In most countries, TBI occurs most commonly in young males, and usually a major cause of death and disability below age 44 years. Since most patients with mild and moderate head injuries survive, as well as at least 50% of those with severe TBI, several thousands of patients with disabilities are added to the population every year. Due to increasing longevity, a second wave in TBI incidence is now also being seen in the elderly (Fig. 1). The increasingly frequent use of anticoagulants in the elderly population can complicate their management and sometimes result in a disastrous outcome even after a relatively trivial injury. Male 140 120 100 80 60 Teens, young adults, and people over 75-especially males-are far more likely than others to die of traumatic brain injury Female 40 Rate per 100, 000 20 0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age group Fig. 1 Age distribution of traumatic brain injury..

[Audio] Introduction 3 For practical reasons, TBI is classified as mild, moderate, and severe. The vast majority of TBI is mild (80%), often seen in patients with brief loss of consciousness or temporary neurological dysfunction. Moderately injured patients have an altered level of consciousness and perhaps an asymmetric motor exam, but are usually able to follow simple commands. Severely injured patients are unresponsive and do not follow simple commands even after cardiopulmonary resuscitation. Severe hypotension or hypoxia can substantially impair the neurological examination. Furthermore, paralytic and sedative drugs can obviously obscure the exam. These confounding factors must therefore be kept in mind while assessing patients in the acute phase. The Glasgow Coma Scale (GCS) is the most commonly used tool to classify TBI. It describes a patient's ability to open eyes, speak, and move limbs as per simple commands2,3 (Table 1). A score of 15 is the maximum score and 3 is the minimum. Generally, a score of 14 to 15 is regarded as "mild," 9 to 13 as "moderate," and 3 to 8 as severe head injury. TBI can also be classified as closed (>90%) or penetrating, which occur due to gunshots, stabbing, shrapnel injuries, and so on. Table 1 Glasgow Coma Scale to assess the severity of TBI in adults Adult scale Eyes open Spontaneously 4 To speech 3 To pain 2 None 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response Obeys commands 6 Localizes pain 5 Withdrawal from pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Abbreviation: TBI, traumatic brain injury..

[Audio] National Guidelines for the Management of Traumatic Brain Injury 4 Importance of Guidelines Emergency Medicine and Trauma Surgery are relatively new disciplines in India, with inconsistent prehospital care and trained ambulance services available only in a few urban settings. Even when personnel and infrastructure are available, most emergency medical personnel and physicians are not trained in trauma care, and often find it difficult to keep up with the literature and current recommendations. The creation and implementation of evidence-based management guidelines in developed countries have resulted in a significant decrease in associated mortality and disability. The mortality from severe TBI in the United States has decreased from 51% in 1977 to around 20 to 30% currently. Contrary to the reasonable concern that some more patients would be saved only to survive in a vegetative state, recent data suggests that most of the survivors are categorized as good outcomes or moderately disabled. Interestingly, not a single drug has been proven to have a beneficial effect during this period when mortality from severe TBI has been reduced by almost 50%! Certainly, more than any medication, this significant improvement has been realized by education, verified trauma systems and centers with full-time specialists, immediate access to CT scanning, emergency surgery when needed, specialized intensive care units and better monitoring of critically ill patients, and TBI rehabilitation. Our understanding regarding the cascade of events that follow TBI has also improved, resulting in more appropriate and targeted interventions.4 Although the dramatic decline in mortality and morbidity from TBI over the past three decades indicates improved care delivery, it is much harder to scientifically prove a direct cause-and-effect relationship. Nevertheless, there is some compelling evidence that the establishment of management guidelines and their implementation is very effective in reducing mortality and improving outcomes5,6 (Fig. 2). For example, with the support of the Soros Foundation, the Brain Trauma Foundation was able to introduce surgeons in Croatia, Hungary, Slovakia, and Slovenia to TBI guidelines. This initiative resulted in a documented improvement in mortality. The Indian TBI Initiative We have taken a comprehensive approach to this major public health problem and separated our narrative into four phases: � Awareness and Prevention: There is a need to improve public awareness regarding the seriousness and high incidence of TBI and increase commonsense preventive measures. As widely accepted, prevention is far more effective than the best treatments that can be offered. Despite this understanding, basic preventive measures such as helmets, seat belts, and air bags are only sporadically used across the country. � Prehospital Care: This concept is in its nascent stages in India. Rescue squads have to be created and personnel appropriately trained..

[Audio] Introduction 5 GOOD OUTCOME $ costs Family Socially integrated No severe disabilities BAD OUTCOME $$$ costs Family Violence/ asocial behavior Severe disabilities Integrated rehab Prevent medical complications Delay in rehab Medical complications Brain pressure monitoring Optimize brain perfusion Bedside vigil Use of protocols No brain prressure monitoring Steroids No protocol Rapid surgeries 24hrs CT Scan Adequate facilities Surgical delays or omissions Inadequate resuscitation Inadequate facilities and personnel *First Brain injury may be so extensive that any treatment is futile based on Program Guidelines TBI-Trauma Center Full resuscitation Brain targeted therapy Nearest hospital Inadequate resuscitation Hyperventilation Scientific Guidelines Patient tracking/QA reports/Practice improvements OLD WAY NEW WAY* FIRST BRAIN INJURY SECOND BRAIN INJURY RECOVERY OUTCOME Fig. 2 Scientific guidelines: effective in reducing mortality and improving outcomes..

[Audio] National Guidelines for the Management of Traumatic Brain Injury 6 A systematic approach is essential, with designated trauma centers that are regularly inspected and their quality of care verified. � Hospital Care: This requires Emergency Rooms that are adequately equipped and staffed doctors and nurses who are trained in trauma care. Level 1 and 2 trauma centers need adequate intensive care units, preferably staffed by Trauma and Neuro critical care specialists. � Rehabilitation and Community Reintegration: Specialized TBI rehab programs that can assist TBI patients after hospitalization are greatly needed in India. Structured therapy to reintegrate the patient back into society is crucial and will be discussed. The health care infrastructure in India has been making good progress in recent years. However, trauma care facilities are almost exclusively confined to large urban areas, and the vast majority of districts and rural areas do not have easy access to quality care. Furthermore, trauma care in the private sector is expensive and often not affordable and at present health insurance coverage is limited. Need for TBI Guidelines The level of care that patients with TBI receive in India is extremely variable. While a few urban centers of excellence meet international standards, others have trouble administering even first aid. A plausible reason is the lack of established standards or verification of trauma care hospitals or systems. The development of guidelines for trauma care delivery in other countries has resulted in marked improvements in outcomes.7–14 It is essential that trauma centers be verified and designated by a reliable government or statutory agency. There are no established protocols for prehospital care, patient triage, and treatment at different levels of hospitals or continuing care. Nationally accepted guidelines on management of TBI will help improve many of these shortcomings. References 1. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery 2017;80(1):6–15 2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81–84 3. Reilly PL, Simpson DA, Sprod R, Thomas L. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst 1988;4(1):30–33 4. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34(2):216–222 5. Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with patient survival following traumatic brain injury: the excellence in prehospital injury care (EPIC) study. JAMA Surg 2019;154(7):e191152 6. Palmer S, Bader MK, Qureshi A, et al; Americans Associations for Neurologic Surgeons. The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. J Trauma 2001;50(4):657–664.

[Audio] Introduction 7 7. Patel HC, Bouamra O, Woodford M, King AT, Yates DW, Lecky FE; Trauma Audit and Research Network. Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2005;366(9496):1538–1544 8. Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med 2004; 32(11):2311–2317 9. Thillai M. Neurosurgical units working beyond safe capacity. BMJ 2000;320(7232): 399 10. Varelas PN, Conti MM, Spanaki MV, et al. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit Care Med 2004;32(11): 2191–2198 11. Visca A, Faccani G, Massaro F, et al. Clinical and neuroimaging features of severely brain-injured patients treated in a neurosurgical unit compared with patients treated in peripheral non-neurosurgical hospitals. Br J Neurosurg 2006;20(2):82–86 12. Brown JB, Stassen NA, Cheng JD, Sangosanya AT, Bankey PE, Gestring ML. Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury. J Trauma 2010;69(2):263–269 13. Tepas JJ III, Pracht EE, Orban BL, Flint LM. High-volume trauma centers have better outcomes treating traumatic brain injury. J Trauma Acute Care Surg 2013;74(1): 143–147, discussion 147–148 14. Pineda JA, Leonard JR, Mazotas IG, et al. Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol 2013;12(1):45–52.