Brief Resume of the Intended Work s3

Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

DISSERTATION PROPOSAL

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING FIRST AID AND EMERGENCY MANAGEMENT OF HEAD INJURY AMONG IV YEAR BSC NURSING STUDENTS IN SELECTED COLLEGE, BANGALORE CITY”.

SUBMITTED BY,

Ms. GREESHMA JOY.V,

1ST YEAR M.Sc NURSING,

BHAGATH COLLEGE OF NURSING,

#60, UTTARAHALLI MAIN ROAD,

UTTARAHALLI HOBLI,

BANGALORE- 560061.

1 Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

1 Name of the Candidate and Address GREESHMA JOY.V, 1ST YEAR M.Sc NURSING, BHAGATH COLLEGE OF NURSING, #60, UTTARAHALLI MAIN ROAD, UTTARAHALLI HOBLI, BANGALORE: 560061. 2 Name of the Institution Bhagath College of Nursing.

3 Course of study and subject 1ST Year M.Sc Nursing, Medical Surgical Nursing. 4 Date of admission to Course 01/10/2011

5 Title of the Topic “A Study to Assess the Effectiveness of Structured Teaching Programme Regarding First Aid and Emergency Management of Head Injury Among IV Year Bsc Nursing Students in Selected College, Bangalore city.”

6 Brief resume of the intended work: 6:1 Need for the study Enclosed 6:2 Review of literature Enclosed 6:3 Objectives of the study Enclosed 6:4 Operational definitions Enclosed 6:5 Hypothesis of the study Enclosed 6:6 Assumptions Enclosed 6:7 Delimitations of the study Enclosed 6:8 Pilot study Enclosed 6:9 Variables Enclosed Materials and Methods 7 7:1 Source of data- Data will be collected from IV year nursing students In selected college, Bangalore city. 7:2 Method of collection of data: Structured Knowledge questionnaire. 7:3 Does the study require any investigation or interventions? Yes. 7:4 Has ethical clearance been obtained from our institutions? Yes, Ethical committee’s report is here with enclosed.

8 List of references Enclosed

2 Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

1 Name of the Candidate and Address GREESHMA JOY.V,

1ST YEAR M.Sc NURSING,

BHAGATH COLLEGE OF NURSING,

#60, UTTARAHALLI MAIN ROAD,

UTTARAHALLI HOBLI, BANGALORE: 560061.

2 Name of the Institution Bhagath College of Nursing.

3 Course of Study and Subject 1st Year M.Sc Nursing,

Medical Surgical Nursing.

4 Date of Admission to Course 01/10/2011

5 Title of the Topic

“A Study to Assess the Effectiveness of Structured Teaching Programme Regarding First Aid and Emergency Management of Head Injury Among IV Year Bsc Nursing Students in Selected College, Bangalore city.”

6. BRIEF RESUME OF THE INTENDED WORK

3 INTRODUCTION

"Safety first is Safety always" Charles.M.Hayes

Accidents, tragically, are not often due to ignorance, but are due to carelessness, thoughtlessness, and over confidence. Human, vehicle and environmental factors play roles before, during or after a trauma event. Accidents, therefore, can be studied in terms of agent, host and environmental factors and epidemiologically classified into time, place and person distribution.

Head injury refers to trauma of the head. This may or may not include injury to the brain. The incidence (number of new cases) of head injury is 300 of every 100,000 per year (0.3% of the population), with a mortality rate of 25 per 100,000 in North America and 9 per 100,000 in Britain. Head trauma is a common cause of childhood hospitalization1.

Common causes of head injury are motor vehicle traffic collisions, home and occupational accidents, falls, and assaults. Bicycle accidents are also a cause of head injury-related death and disability, especially among children. Wilson’s disease has also been indicative of head injury.

Common symptoms of head injury include coma, confusion, drowsiness, personality change, seizures, nausea and vomiting, headache and a lucid interval, during which a patient appears conscious only to deteriorate later.

Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding. If the brain has been severely damaged by trauma, neurosurgical evaluation may be useful. Treatments may involve controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and hypothermia.

4 Although all of these methods have potential benefits, there has been no randomized study that has shown unequivocal benefit2.

When an injury occurs, loss of brain function can occur even without visible damage to the head. Force applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the brain tissue, or damage the nerve connections within the brain.

Caring for the victim with a head injury begins with making certain that the A B Cs of resuscitation are addressed (Airway, Breathing, Circulation). Many individuals with head injuries are multiple trauma victims and the care of their brain may take place at the same time other injuries are stabilized and treated3.

6.1 NEED FOR THE STUDY

5 “Exercise can preserve something of our early strength even in old age.”

Cicero Roman 0rato

Traumatic head injuries are a major cause of death, and disability but it might be best to refer to the damage done as traumatic brain injury.

The purpose of the head, including the skull and face, is to protect the brain against injury. In addition to the bony protection, the brain is covered in tough fibrous layers called meninges and bathed in fluid that may provide a little shock absorption.

Head injury can be defined as any alteration in mental or physical functioning related to a blow to the head. Loss of consciousness does not need to occur. The severity of head injuries is most commonly classified by the initial post resuscitation Glasgow Coma Scale (G C S) score, which generates a numerical summed score for eye, motor, and verbal abilities. Traditionally, a score of 13-15 indicates mild injury, a score of 9-12 indicates moderate injury, and a score of 8 or less indicates severe injury. In the last few years, however, some studies have included those patients with scores of 13 in the moderate category, while only those patients with scores of 14 or 15 have been included as mild. Concussion and mild head injury are generally synonymous4.

Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, traumatic brain injuries contribute to a substantial number of deaths and cases of permanent disability. Recent data shows that, on average, approximately 1.7 million people sustain a traumatic brain injury annually.

Each year, an estimated 1.7 million people sustain a TBI annually.TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States. About 75% of TBIs that occur each year are concussions or other forms of mild TBI.

There are 2 million Traumatic Brain Injuries each year (One every 15 seconds).500,000 of these injuries require hospital admission. Every 5 minutes someone dies from a head injury. Over half of the deaths occur at the time of the incident or within two hours of hospitalization. Every 5 minutes someone

6 becomes permanently disabled due a head injury. 70,000 - 90,000 of those who survive will have lifelong disabilities.2,000 more will live in a persistent vegetative state. Over 50% of those who sustain a Brain Injury have been intoxicated at the time or injury. The cost of Traumatic Brain Injuries in the U.S. is over $48 Billion each year5.

The study was conducted on management of minimal, mild and moderate head injury. The aim of the present study was to investigate guideline compliance after an educational intervention.The 1 180 patients were 759 (64 %) males and 421 (36 %) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63 %) patients were managed in accordance with the guidelines and 442 (37 %) were not. Compliance was not significantly different between minimal (56 %) and mild (59 %) injuries, while most moderate (93 %) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30 %) and undertriage in 80 (7 %). Guideline compliance was 54 % in 2005, 71 % in 2007, and 64 % in 20096.

The study was conducted on management of head injuries by the Scandinavian Neurotrauma Committee. The results showed that the Patients with Minimal injuries (no loss of consciousness (LOC), Glasgow Coma Scale (GCS) score 15) can be safely discharged. Routine early computerized tomography (CT) scan is recommended in cases with Mild injuries (history of LOC, GCS 14-15) and patients with normal scans may be discharged. CT scan and admission is mandatory in Moderate injuries (GCS 9-13). The SNC suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild and moderate head injuries7.

These studies show that the accidents leads to head injury are a common public health problem even in the developed countries. There is a need to give adequate knowledge to the IV year Bsc students regarding first aid and emergency management of head injury in providing effective care in their practice . So that the researcher thought of taking this study to investigate and to improve the knowledge of students.

6.2 REVIEW OF LITERATURE

7 Review of literature provides basis for future investigation, justifies the need for replication, throws light up on feasibility of the study and indicates constraints of data collection and help to relate findings of one another. The scope of literature review should be broad enough to allow the reader to become familiar with the research problems and narrow enough to include predominantly relevant sources.

1. Review related to the prevalence of head injury

The Prospective study was conducted on prevalence of head injury. The result showed that the incidence of TBI is 332 per 100 000 head of population. The GCS (Glasgow Coma Scale) or other forms of neurological examinations were performed in only 56% of all cases. According to the GCS status, 90.2% are classified as mild, 3.9% as moderate and 5.2% as severe. Intubation is given only to 76.1% of patients with severe TBI. Lethality was 1%. The predominant cause of TBI is falls, with 52.5% of all cases, while 26.3% were due to road accidents. The time elapsing between the accident event and initial examination at the hospital is less than 1 hour in 63% of all cases. X-rays were taken in 82% of all cases of TBI, with 19.3% of the patients receiving a CT scan; 58.7% of all TBI patients have additional injuries of the facial skull, 8.8% of the vertebral column, 7.2% of the thorax, 2.6% of the abdomen, 3.4% of the pelvis and 19.6% of one or more extremities. One year after the accident, 50% of all patients still required treatment even after mild TBI8.

The prospective study was conducted on skull fractures in children to investigate feasibility and evaluate test characteristics for the detection of skull fractures. The result showed that the Forty-six patients were enrolled. The median age was 2 years (range, 2 months to 17 years). Eleven patients (24%) were diagnosed with skull fractures on CT scan. Bedside ultrasound had a sensitivity of 82% (95% confidence interval [CI], 48%-97%), specificity of 94% (95% CI, 79%-99%), positive predictive value of 82% (95% CI, 48%-97%), and negative predictive value of 94% (95% CI, 79%-99%)9.

The study was conducted on long term sequences of repetitive brain trauma.Results of neuropathologic research has shown that CTE may be more common in former contact sports athletes than previously believed. It is believed that repetitive brain trauma, with or possibly without

8 symptomatic concussion, is responsible for neurodegenerative changes highlighted by accumulations of hyperphosphorylated tau and TDP-43 proteins. Focused and intensive study of the risk factors and in vivo diagnosis of CTE will potentially allow for methods to prevent and treat these diseases. Research also will provide policy makers with the scientific knowledge to make appropriate guidelines regarding the prevention and treatment of brain trauma in all levels of athletic involvement as well as the military theater10.

A Descriptive Retrospective study was conducted on paediatric traumatic head injury. The result showed that the 100 children with head injury needed neurointensive care or neurosurgery for their injury in southern Sweden. Traffic accidents (50%) were the main cause of head trauma, followed by falls (36%). Thirty-two percent of all children were injured in bicycle and motorcycle accidents. Both loss of consciousness and amnesia were absent in 23% of the children with intracranial injury. Seven children with intracranial injury, 6 of them requiring neurosurgery, were classed as having minimal head injury according to the Head Injury Severity Scale (HISS). Interesting differences in intracranial injuries between helmet users and nonusers were observed11.

2. Review related to the causes of head injury

The study was conducted to to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children. The result showed that the Fifty-four subjects were enrolled at 9 sites. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < . 001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury12.

The study was conducted on causes of head injury. The result showed that the abusive head injuries are among the most common causes of serious and lethal injuries in children.

9 These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration-deceleration movements which may create inertial movement of the brain within the cranial compartment. Differential movement between the brain and skull may result in subdural and subarachnoid hemorrhages and traumatic diffuse axonal injury. This paper will discuss the unique anatomical and developmental features of the immature brain, skull, and neck which render young children particularly vulnerable to shearing injuries, the pathology of those injuries, and the mechanisms of these injuries13.

The Retrospective study was conducted on causes of accidental and non accidental injuries. The result showed that the homogeneous hyperdense subdural hematoma was significantly more common in children with accidental head trauma (28 of 38 [74%]; nonaccidental head trauma: 3 of 9 [33%]), whereas mixed-density subdural hematoma was significantly more common in cases of nonaccidentalhead injury (6 of 9 [67%]; accidental head trauma: 7 of 38 [18%]). Twenty-two (79%) subdural hematomas were homogeneously hyperdense on noncontrast computed tomography performed within two days of accidental head trauma, one (4%) was homogeneous and isodense compared to brain tissue, one (4%) was homogeneous and hypodense, and four (14%) were mixed-density14.

3. Review related to the management and treatment of head injury

A Retrospective analysis was undertaken of 41 patients who had had a decompressive craniectomy for severe head injury in the years 2006 and 2007 at the two major hospitals in Western Australia, Sir Charles Gairdner Hospital and Royal Perth Hospital.Complications attributable to the decompressive surgery were: herniation of the cortex through the bone defect, 18 patients (51%); subdural effusion, 22 patients (62%); seizures, five patients (14%) and hydrocephalus, four patients (11%). Complications attributable to the subsequent cranioplasty were: infection, four patients (11%) and bone flap resorption, six patients (17%). Syndrome of the trephined occurred in three (7%) of those patients whose bone flap had significantly resorbed. Two deaths (5.5%) occurred as a direct complication of the craniectomy or cranioplasty procedure. I attempted to define what may be regarded as a complication of the decompressive procedure rather than what may be a consequence of the primary pathological process of traumatic brain injury15.

10 A Prospective study conducted over a period of four months in our center, all patients with mild head injury (defined as Glasgow Coma Scores (GCS) 13-15) were admitted to the head injury unit . The result showed that theThree hundred and eighty one patients were included in the study. Of these males constituted 63%, females 17% and children 20%. RTA was the most common mode of injury. Seventy five percent of the patients had GCS of 15, 15% had GCS of 14 and 10% had GCS of 13. Thirty eight percent of the patients had positive findings on the CT. Age, mode of injury, loss of consciousness, post-traumatic seizures, ENT bleeding, vomiting, scalp injury and polytrauma were not found to be predictors of positive CT. Seven percent of patients required surgical intervention. Six percent of patients showed neurological deterioration and there was one death in this series of MHI patients16.

The article reviews data about the most modern means of managing pediatric traumatic brain injury. The role of prehospital care, emphasizing on airway management, adequate ventilation, oxygenation, and perfusion in order to preclude secondary brain injury, which begins straight after trauma, is being noted. Establishing trauma system and patient's treatment in pediatric traumacenters, where child gets urgent and sufficient help, reduces mortality and improves outcomes. Pediatric patient's triage using patient's status scoring and trauma scoring systems is recommended. The role of intracranial pressure and cerebral perfusion pressure is crucial. Immediate management of intracranial pressure reduces mortality and improves outcomes. Techniques of intracranial pressure monitoring and management strategies of intracranial hypertension, their advantages and possible disadvantages are described17.

The study was conducted on prehospital and emergency department management of head injury. The result showed that the hypoxia and hypovolemia are individual predictors of poor outcome in the patient with severe head trauma. Management begins in the field and is focused on ensuring oxygenation and maintaining a blood pressure that supports cerebral perfusion. In the trauma center, intracranial pressure monitoring may be helpful in guiding the management of increased intracranial pressure. Mannitol, given in intermittent bolus infusions, is the therapy of choice for increased intracranial pressure. Hyperventilation has been shown to decrease cerebral perfusion and should be avoided; it is a temporizing procedure that is reserved for those cases that demonstrate signs of increased intracranial pressure pending initiation of other therapies18.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge of IV Year Nursing Students regarding the First Aid and Emergency Management of Head injury.

2. To develop and conduct a structured teaching programme among IV Year Nursing Students regarding the First Aid and Emergency Management of Head injury.

3. To evaluate the effectiveness of structured teaching programme among IV Year Nursing Students regarding the First Aid and Emergency Management of Head injury by posttest.

4. To find out the association between knowledge level and selected demographic variables of IV Year Nursing Students

6.4 OPERATIONAL DEFINITIONS

1. Assess: Assess refers to the critical analysis and evaluation or judgement of the status or quality of First Aid and Emergency Management of Head injury among IV Year Bsc Nursing Students.

2. Effectiveness: Effectiveness refers to the difference which is expected in the knowledge score values of the IV year Bsc students.

3. Structured teaching programme: It is a planned systematic information, instruction or training giving to a person or a group regarding the First Aid and Emergency Management of Head injury.

5.Emergency Management: It refers to the emergency medical services provided by an emergency medical technician to the victim of head injury.

12 6.Head Injury: A head injury is any trauma that leads to injury of the scalp, skull, or brain.

6.5 HYPOTHESIS OF THE STUDY

H1: There will be statistically significant association between IV Bsc Year Nursing Students knowledge regarding First Aid and Emergency Management of Head injury and other selected demographic variables.

H2: There will be statistically significant difference between pre and post test knowledge scores of IV Bsc Year Nursing Students regarding First Aid and Emergency Management of Head injury.

6.6 ASSUMPTIONS:

1. IV Bsc Year Nursing Students may have some knowledge regarding the First Aid and Emergency Management of Head injury. 2. IV Bsc Year Nursing Students knowledge regarding the First Aid and Emergency Management of Head injury can be measured by using a structured knowledge questionnaire. 3. IV Bsc Year Nursing Students knowledge regarding First Aid and Emergency Management of Head injury can be improved by structured teaching programme.

6.7 DELIMITATIONS OF THE STUDY

1. The study is limited only to IV Bsc Year Nursing Students who are at the age between 20-35Yrs. 2. The study is limited only to IV Bsc Year Nursing Students who are studying in a selected college, Bangalore city. 3. The study is limited only to IV Bsc Year Nursing Students who are able to read and write English.

6.8 PILOT STUDY:

13 The study will be conducted with 6 samples. The purpose to conduct pilot study is to find out the feasibility for conducting the study and design on plan of statistical analysis.

6.9 VARIABLES:

Variables are qualities, properties or characteristics of persons, things or situations that change or vary and are manipulated or measured in research.

 Dependent variables: Knowledge level of IV Bsc Year Nursing Students regarding the First Aid and Emergency Management of Head injury.  Independent variables: Structured Teaching Programme  Extraneous variable: Age, gender, educational status, source of information, previous knowledge.

7 MATERIAL AND METHODS:

7.1 SOURCE OF DATA:

The data will be collected from all IV Year Bsc Nursing Students who are studying at a selected college, Bangalore.

7.1.1 RESEARCH DESIGN

The research design adopted for this study is Pre experimental in nature. One group pretest- posttest design.

7.1.2 RESEARCH APPROACH:

Evaluative research approach

7.1.3 SETTING OF THE STUDY:

14 The study will be conducted at a selected college, Bangalore city.

7.1.4 POPULATION:

All the IV Bsc Year Nursing Students who meet all the inclusion criteria and are studying at a selected college, Bangalore.

7.2 METHODS OF COLLECTION OF DATA (INCLUDING SAMPLING PROCEDURE):

The data collection procedure will be carried out for a period of one month. The study will be conducted after obtaining permission from the concerned authorities. The investigator collects data from IV Year Bsc Nursing Students by using a structured knowledge questionnaire regarding the First Aid and Emergency Management of Head injury.

The data collection instrument consists of following sections

Section A: Demographic Data

Section B: Questions related to the knowledge of IV Year Bsc Nursing Students regarding the First Aid and Emergency Management of Head injury.

7.2.1 SAMPLING TECHNIQUE:

Non-probability convenience sampling will be used to select the IV Year Bsc Nursing Students who are studying in a selected college, Bangalore city.

7.2.2 SAMPLE SIZE:

Sample consists of 60 IV Year Bsc Nursing Students who are studying in a selected college, Bangalore city.

SAMPLING CRITERIA:

15 7.2.3 INCLUSION CRITERIA:

1. IV Year Bsc Nursing Students who are studying in a selected college, Bangalore city. 2. IV Year Bsc Nursing Students who are available at the time of study. 3. IV Year Bsc Nursing Students who are able to read and write English. 4. IV Year Bsc Nursing Students who are willing to participate in the study

7.2.4 EXCLUSION CRITERIA:

1. IV Year Bsc Nursing Students with contagious diseases. 2. IV Year Bsc Nursing Students who are selected for pilot study. 3. IV Year Bsc Nursing Students with hearing disabilities. 4. IV Year Bsc Nursing Students with loss of vision.

7.2.5 TOOLS FOR DATA COLLECTION:

A structured knowledge questionnaire is used to collect the data from the IV Year Bsc Nursing Students.

7.2.6 DATA ANALYSIS METHOD:

The data collected will be analyzed by using descriptive and inferential statistics

Descriptive statistics:

Frequency and percentage for analysis of demographic data and mean, mean percentage and standard deviation will be used for assessing the level of knowledge.

Inferential statistics:

Chi-square test will be used to find out the association between knowledge of IV Year Bsc Nursing Students and selected demographic variables. Paired‘t’ test will be used for evaluating the effectiveness of Structured Teaching Programme.

16 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INVESTIGATIONS TO BE CONDUCTED ON PATIENTS OR HUMANS OR ANIMALS?

Since the study is Pre experimental in nature, investigation or interventions are required.

7.4 ETHICAL CLEARENCE:

Yes, ethical committee’s is here with enclosed. The main study will be conducted after the approval of research committee of the college. Permission will be obtained from the head of the institution. The purpose and details of the study will be explained to the study subjects and assurance will be given regarding the confidentiality of the data collected.

17 LIST OF REFERENCES (VANCOUVER METHOD FOLLOWED)

1. Wikepedia free Encyclopedia related to Head Injury, Available from: http://en.wikipedia.org/wiki/Head_injury .

2. Article related to first aid and emergency treatment of Head injury. Available from: http://www.nlm.nih.gov/medlineplus/ .

3. Thomas W Wang. Traumatic Brain Injury. Available from: http://www.cdc.gov/traumaticbraininjury/ .

4. Stephanie Crumley Hill. Head injury and its management. Available from: http://www.emedicinehealth.com/head_injury

5. Article related to statistics on head injury. Available from: http://www.headinjuryctr- stl.org/statistics.html

6. Heskestad BO, Waterloo K, Ingebrigtsen T. Management of Minimal, Mild and Moderate Head Injury. 2012 Apr 17;20(1):32.Available from: http://www.ncbi.nlm.nih.gov/pubmed

7. Romner B, Ingebrigtsen T, Kock-Jensen C. management of head injuries. Evidence- based management of minimal, mild and moderate head injuries. 2000 Jun 28;97(26-27):3186- 92.Available from: http://www.ncbi.nlm.nih.gov.pubmed

18 8. Rickels E, von Wild K, Wenzlaff P. A population-based prospective study on epidemiology, causes, treatment and outcome of all degrees of head-injury . 2010;24(12):1491- 504.Available from: http://www.ncbi.nlm.nih.gov/pubmed

9. Riera A, Chen L. Ultrasound Evaluation of Skull Fractures in Children: A Feasibility Study. 2012 Apr 23. http://www.ncbi.nlm.nih.gov/pubmed

10. Stern RA, Riley DO, Daneshvar DH, Nowinski CJ, Long-term consequences of repetitive brain trauma: 2011 Oct;3(10 Sup):S460-7.Available from: http://www.ncbi.nlm.nih.gov/pubmed

11. Hymel KP, Stoiko MA, Herman BE, Combs A. Head injury depth as an indicator of causes and mechanisms. 2010 Apr;125(4):712-20, Available from: http://www.ncbi.nlm.nih.gov/pubmed

12. Case ME. Abusive head injuries in infants and young children. 2007 Mar;9(2):83-7, Available from: http://www.ncbi.nlm.nih.gov

13. Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD. Comparison of accidental and nonaccidental traumatic head injury. 2006 Aug;118(2):626-33. Available from: http://www.ncbi.nlm.nih.gov

14. Astrand R, Undén J, Hesselgard K, Reinstrup P, Romner B. Clinical factors associated with intracranial complications after pediatric traumatic head injury. 2010 Aug;46(2):101-9, Available from: http://www.ncbi.nlm.nih.gov

19 15. Honeybul S. Complications of decompressive craniectomy for head injury. 2010 Apr;17(4):430- 5, Available from: http://www.ncbi.nlm.nih.gov/pubmed

16. Thiruppathy SP, Muthukumar N. Mild head injury: revisited. 2004 Oct;146(10):1075-82

Available from: http://www.ncbi.nlm.nih.gov

17. Grinkeviciūte D, Kevalas R, Tamasauskas A. Severe pediatric head injury. 2006;42(4):278- 87.Available from: http://www.ncbi.nlm.nih.gov

18. Silvestri S, Aronson S. Severe head injury: prehospital and emergency department management. 1997 Sep-Oct;64(4-5):329-38., Available from: http://www.ncbi.nlm.nih

20 Signature of the Candidate

Remarks of the Guide

Name and Designation of

11.1 Guide

11.2 Signature

11.3 Co-Guide

11.4 Signature

11.5 Head of Department

11.6 Signature

12.1 Remarks of the Chairman &

Principal

12.2 Signature