DOCSLIB.ORG

HEAD INJURY (GENERAL) Trh1 (1)

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
HEAD INJURY (GENERAL) Trh1 (1) HEAD INJURY (GENERAL) TrH1 (1) Head Injury (GENERAL) Last updated: December 19, 2020 DEFINITIONS, CLASSIFICATIONS ............................................................................................................. 2 EPIDEMIOLOGY ........................................................................................................................................ 2 Incidence ............................................................................................................................... 2 Morbidity ............................................................................................................................... 2 Mortality ................................................................................................................................ 2 ETIOLOGY ................................................................................................................................................ 2 PATHOPHYSIOLOGY (PRIMARY VS. SECONDARY INJURY) ..................................................................... 3 PRIMARY BRAIN INJURY ......................................................................................................................... 3 Mechanisms ........................................................................................................................... 3 SECONDARY BRAIN INJURY .................................................................................................................... 3 PATHOPHYSIOLOGY (CEREBRAL BLOOD FLOW, EDEMA) ..................................................................... 3 PATHOPHYSIOLOGY (BIOCHEMISTRY) ................................................................................................... 4 PATHOLOGY, CLINICAL FEATURES ........................................................................................................ 4 CONCUSSION .......................................................................................................................................... 5 DIFFUSE AXONAL INJURY (DAI) ........................................................................................................... 6 CONTUSION AND LACERATION............................................................................................................... 6 INTRACEREBRAL HEMORRHAGE (TRAUMATIC ICH, TICH) .................................................................... 9 MISSILE (GUNSHOT) INJURY .................................................................................................................. 9 Self-inflicted injuries ........................................................................................................... 12 STAB INJURY (IMPALEMENT) ............................................................................................................... 12 COMPRESSION INJURY ......................................................................................................................... 13 DEGREES OF SEVERITY .......................................................................................................................... 13 PREHOSPITAL MANAGEMENT ................................................................................................................ 14 1. Oxygenation .................................................................................................................... 14 2. Blood Circulation ............................................................................................................ 14 3. Cervical Spine Stabilization ............................................................................................ 15 4. Brief Neurologic Status ................................................................................................... 15 5. Transportation ................................................................................................................. 15 DIAGNOSTIC EVALUATION .................................................................................................................... 15 Diagnosis in Latin ............................................................................................................... 15 HISTORY .............................................................................................................................................. 15 PHYSICAL EXAMINATION ..................................................................................................................... 15 IMAGING .............................................................................................................................................. 16 Imaging modalities ......................................................................................................................... 16 CT without contrast ............................................................................................................. 17 Plain skull radiographs ........................................................................................................ 18 Nonenhanced MRI .............................................................................................................. 18 Angiography ........................................................................................................................ 19 Ultrasonography .................................................................................................................. 19 Conditions ...................................................................................................................................... 19 Concussion .......................................................................................................................... 19 Diffuse axonal injury ........................................................................................................... 19 Scalp Injuries ....................................................................................................................... 20 Contusion ............................................................................................................................. 20 Penetrating injuries .............................................................................................................. 21 OTHER NEUROLOGIC TESTS ................................................................................................................. 22 NON-NEUROLOGIC TESTS .................................................................................................................... 22 MANAGEMENT ....................................................................................................................................... 22 DISPO ................................................................................................................................................... 23 Hospitalization ..................................................................................................................... 23 Transfer ............................................................................................................................... 23 ABC .................................................................................................................................................... 23 Airway, Ventilation ........................................................................................................................ 23 Blood pressure ................................................................................................................................ 23 Resuscitation fluids ............................................................................................................. 23 GENERAL MEASURES ........................................................................................................................... 24 Regimen, Activity ............................................................................................................... 24 Nutritional Support .............................................................................................................. 24 DVT prophylaxis ................................................................................................................. 24 Hemoglobin ......................................................................................................................... 24 NEUROLOGICAL MEASURES ................................................................................................................. 24 ICP management ............................................................................................................................ 24 Monitoring ........................................................................................................................... 24 Treatment ............................................................................................................................. 25 CPP ................................................................................................................................................. 27 Advanced brain oxygenation / metabolic status monitoring .......................................................... 27 Oximeters ............................................................................................................................ 27 TCD ..................................................................................................................................... 28 Microdialysis ......................................................................................................................
Load more

Recommended publications
  • A Rare Case of Penetrating Trauma of Frontal Sinus with Anterior Table Fracture Himanshu Raval1*, Mona Bhatt2 and Nihar Gaur3
    ISSN: 2643-4474 Raval et al. Neurosurg Cases Rev 2020, 3:046 DOI: 10.23937/2643-4474/1710046 Volume 3 | Issue 2 Neurosurgery - Cases and Reviews Open Access CASE REPORT Case Report: A Rare Case of Penetrating Trauma of Frontal Sinus with Anterior Table Fracture Himanshu Raval1*, Mona Bhatt2 and Nihar Gaur3 1 Department of Neurosurgery, NHL Municipal Medical College, SVP Hospital Campus, Gujarat, India Check for updates 2Medical Officer, CHC Dolasa, Gujarat, India 3GAIMS-GK General Hospital, Gujarat, India *Corresponding author: Dr. Himanshu Raval, Resident, Department of Neurosurgery, NHL Municipal Medical College, SVP Hospital Campus, Elisbridge, Ahmedabad, Gujarat, 380006, India, Tel: 942-955-3329 Abstract Introduction Background: Head injury is common component of any Road traffic accident (RTA) is the most common road traffic accident injury. Injury involving only frontal sinus cause of cranio-facial injury and involvement of frontal is uncommon and unique as its management algorithm is bone fractures are rare and constitute 5-9% of only fa- changing over time with development of radiological modal- ities as well as endoscopic intervention. Frontal sinus inju- cial trauma. The degree of association has been report- ries may range from isolated anterior table fractures causing ed to be 95% with fractures of the anterior table or wall a simple aesthetic deformity to complex fractures involving of the frontal sinuses, 60% with the orbital rims, and the frontal recess, orbits, skull base, and intracranial con- 60% with complex injuries of the naso-orbital-ethmoid tents. Only anterior table injury of frontal sinus is rare in pen- region, 33% with other orbital wall fractures and 27% etrating head injury without underlying brain injury with his- tory of unconsciousness and questionable convulsion which with Le Fort level fractures.
    [Show full text]
  • Traumatic Brain Injury
    REPORT TO CONGRESS Traumatic Brain Injury In the United States: Epidemiology and Rehabilitation Submitted by the Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Unintentional Injury Prevention The Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation is a publication of the Centers for Disease Control and Prevention (CDC), in collaboration with the National Institutes of Health (NIH). Centers for Disease Control and Prevention National Center for Injury Prevention and Control Thomas R. Frieden, MD, MPH Director, Centers for Disease Control and Prevention Debra Houry, MD, MPH Director, National Center for Injury Prevention and Control Grant Baldwin, PhD, MPH Director, Division of Unintentional Injury Prevention The inclusion of individuals, programs, or organizations in this report does not constitute endorsement by the Federal government of the United States or the Department of Health and Human Services (DHHS). Suggested Citation: Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. Executive Summary . 1 Introduction. 2 Classification . 2 Public Health Impact . 2 TBI Health Effects . 3 Effectiveness of TBI Outcome Measures . 3 Contents Factors Influencing Outcomes . 4 Effectiveness of TBI Rehabilitation . 4 Cognitive Rehabilitation . 5 Physical Rehabilitation . 5 Recommendations . 6 Conclusion . 9 Background . 11 Introduction . 12 Purpose . 12 Method . 13 Section I: Epidemiology and Consequences of TBI in the United States . 15 Definition of TBI . 15 Characteristics of TBI . 16 Injury Severity Classification of TBI . 17 Health and Other Effects of TBI .
    [Show full text]
  • Degloving Injury: Different Ways of Management 76
    CASE REPORT Journal of Nepalgunj Medical College, 2018 Degloving Injury: Different Ways of Management Nakarmi KK1, Shrestha SP2 ABSTRACT Degloving injury involves shearing of the skin from the underlying tissue due to differential gliding in response to the tangential force applied to the surface of the body leading to disruption of all the blood vessels connected to skin. The flap of degloved skin has precarious blood supply making it almost impossible for the flap to survive. We describe two cases of degloving of thigh managed differently in different settings. Keywords: degloving; excision; split skin graft INTRODUCTION management of these patients have been associated with Degloving injuries occur when there is sufficient tangential force lesser number of surgeries and shorter hospital stay6. Clinical to a body surface to disrupt the structures connecting skin and evaluation aided by use of fluorescein dye to assess the flap subcutaneous tissues to the superficial fascia. There may also be viability will guide whether skin can be harvested from the associated injuries to the underlying soft tissues, bone, nerves flap which can be stored for later use if general condition and vessels. It involves the young males, and most are related to does not allow immediate grafting7. Use of the degloved flap road traffic accident constituting upto 4% of all the trauma after defatting along with negative pressure wound therapy related admissions. Treatment guidelines are not clear1. The has also been described8. injury may be so severe that the limb is non-viable and requires amputation. It has been classified into three group based on Cases whether only skin, underlying soft tissue or bone is involved in Case 1 the injury process2.
    [Show full text]
  • 5 Things to Know About Traumatic Brain Injuries
    5 Things to Know About Traumatic Brain Injuries What is a Traumatic Brain Injury? A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. The severity of such an injury may range from: “mild” – i.e., a brief change in mental status or consciousness, to “severe” – i.e., an extended period of unconsciousness or amnesia after the injury. What Causes a Traumatic Brain Injury? A TBI occurs when an outside force impacts the head hard enough to cause the brain to move within the skull, or if the force causes the skull to break and directly hurts the brain. Rapid acceleration/deceleration of the head can also force the brain the move back and forth inside the skull, which pulls apart nerve fibers and causes damage to brain tissue. The most common causes of TBI are: Falls Motor vehicle-traffic crashes Physical violence Sports accidents What are the symptoms of a TBI? A person with a brain injury can experience a variety of symptoms, but not necessarily all of the following symptoms: Lethargy (sluggish, sleepy, gets tired easily) Continuous headache Confusion Ringing in the ears, or changes in ability to hear Vision changes (blurred vision, seeing double, light-sensitive) Dilated pupils Difficulty thinking (memory problems, poor judgment, poor attention span, slow thought process) Dizziness or balance problems Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing) Difficulty speaking (slurred speech) Respiratory problems (slow or uneven breathing) Vomiting Body numbness or tingling Paralysis (difficulty moving body parts, weakness, poor coordination) Semi-comatose (not alert and unable to respond to others) Loss of consciousness Who is at Highest Risk for TBI? The two age groups at the highest first for TBI are 0-4 year olds and 15-19 year olds.
    [Show full text]
  • Penetrating Injury to the Head: Case Reviews K Regunath, S Awang*, S B Siti, M R Premananda, W M Tan, R H Haron**
    CASE REPORT Penetrating Injury to the Head: Case Reviews K Regunath, S Awang*, S B Siti, M R Premananda, W M Tan, R H Haron** *Department of Neurosciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, **Department of Neurosurgery, Hospital Kuala Lumpur the right frontal lobe to a depth of approximately 2.5cm. SUMMARY (Figure 1: A & B) There was no obvious intracranial Penetrating injury to the head is considered a form of severe haemorrhage along the track of injury. The patient was taken traumatic brain injury. Although uncommon, most to the operating theatre and was put under general neurosurgical centres would have experienced treating anaesthesia. The nail was cut proximal to the entry wound patients with such an injury. Despite the presence of well and the piece of wood removed. The entry wound was found written guidelines for managing these cases, surgical to be contaminated with hair and debris. The nail was also treatment requires an individualized approach tailored to rusty. A bicoronal skin incision was fashioned centred on the the situation at hand. We describe a collection of three cases entry wound. A bifrontal craniotomy was fashioned and the of non-missile penetrating head injury which were managed bone flap removed sparing a small island of bone around the in two main Neurosurgical centres within Malaysia and the nail (Figure 1: C&D). Bilateral “U” shaped dural incisions unique management approaches for each of these cases. were made with the base to the midline. The nail was found to have penetrated with dura about 0.5cm from the edge of KEY WORDS: Penetrating head injury, nail related injury, atypical penetrating the sagittal sinus.
    [Show full text]
  • Major Extremity Trauma Module
    MAJOR EXTREMITY TRAUMA MODULE INTRODUCTION Extremity trauma in general is extremely common, and may be characterised by the following: • Occur in isolation, or in the multiply injured patient; • Be limb threatening and occasionally life threatening • Occur secondary to blunt or penetrating trauma • Present with degrees of severity from a closed, neurovascularly intact simple fracture through to a mangled extremity or traumatic amputation • Involve skeletal, soft tissue, vascular and neurological structures in various combinations While the principles of assessment are consistent irrespective of the severity of the injury, this module does not specifically address simple closed fractures. Rather, this module focuses on the assessment and management of more severe limb trauma and its complications. The most common mechanisms for major extremity trauma are open fractures, crush injuries and major soft tissue injury from motor vehicle crashes, pedestrian injuries, falls from heights and industrial accidents. 1 The lower limb is more frequently involved than the upper limb. Penetrating trauma resulting in vascular injuries is unfortunately increasing in frequency. Assessment and management of major extremity trauma must occur in the context of assessing and managing the patient as a whole. Life-threatening injuries, which should be identified as part of the primary survey, will always take precedence over limb-threatening injuries, which may not be identified until the secondary survey. Life threatening extremity injuries include: • Pelvic
    [Show full text]
  • Neurologic Deterioration Secondary to Unrecognized Spinal Instability Following Trauma–A Multicenter Study
    SPINE Volume 31, Number 4, pp 451–458 ©2006, Lippincott Williams & Wilkins, Inc. Neurologic Deterioration Secondary to Unrecognized Spinal Instability Following Trauma–A Multicenter Study Allan D. Levi, MD, PhD,* R. John Hurlbert, MD, PhD,† Paul Anderson, MD,‡ Michael Fehlings, MD, PhD,§ Raj Rampersaud, MD,§ Eric M. Massicotte, MD,§ John C. France, MD,࿣ Jean Charles Le Huec, MD, PhD,¶ Rune Hedlund, MD,** and Paul Arnold, MD†† Study Design. A retrospective study was undertaken their neurologic injury. The most common reason for the that evaluated the medical records and imaging studies of missed injury was insufficient imaging studies (58.3%), a subset of patients with spinal injury from large level I while only 33.3% were a result of misread radiographs or trauma centers. 8.3% poor quality radiographs. The incidence of missed Objective. To characterize patients with spinal injuries injuries resulting in neurologic injury in patients with who had neurologic deterioration due to unrecognized spine fractures or strains was 0.21%, and the incidence as instability. a percentage of all trauma patients evaluated was 0.025%. Summary of Background Data. Controversy exists re- Conclusions. This multicenter study establishes that garding the most appropriate imaging studies required to missed spinal injuries resulting in a neurologic deficit “clear” the spine in patients suspected of having a spinal continue to occur in major trauma centers despite the column injury. Although most bony and/or ligamentous presence of experienced personnel and sophisticated im- spine injuries are detected early, an occasional patient aging techniques. Older age, high impact accidents, and has an occult injury, which is not detected, and a poten- patients with insufficient imaging are at highest risk.
    [Show full text]
  • 18.2 1 Degloving Injuries
    18.2 1 Degloving Injuries R. Reid Hanson, DVM, Diplomate ACVS and ACVECC Introduction Management of Degloving Injuries Healing of Distal Limb Wounds Wound Preparation and Evaluation Vascularity and Granulation Surgical Management Wound Contraction Open Wound Management Second Intention Healing Immobilization of the Wound Sequestra Formation Management of Sequestra Impediments to Wound Healing Skin Grafting Healing of Degloving Wounds Conclusion Complications Associated with Denuded References Bone Methods to Stimulate the Growth of Granulation Tissue Introduction Horses are subject to trauma in relation to their locale, use, and character. Wire fences, sheet metal, or other sharp objects in the environment, as well as entrapment between two immovable objects or during transport, are often the cause of injury. The wounds are commonly associated with extensive soft tissue loss, crush injury, and harsh contamination, which necessitate open wound management and second intention healing. One of the most difficultof these wounds to heal is the degloving injury that exposes bone by avulsion of the skin and subcutaneous tissues overlying it. Exposed bone is defined as bone denuded of periosteum, which in an open wound can delay second inten- tion healing indirectly and directly.' The rigid nature of bone indirectly inhibits contraction of granulation tissue and can prolong the inflammatory phase of repair.' Prolonged periods may be required for extensive wounds of the distal extremity with denuded bone and tendon to become covered with a healthy, uniform bed of granu- lation tiss~e.~Desiccation of the superficial layers of exposed bone can lead to sequestrum formation, which is one of the most common causes for delayed healing of wounds of the distal limb of horse^.^ Rapid coverage of exposed bone with granulation tissue can decrease healing time and prevent desiccation of exposed bone and subsequent sequestrum formation.
    [Show full text]
  • Degloving Wound Management by Second-Intention Healing
    CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED TEACHING TARGET IN-HOSPITAL TREATMENT AND AT-HOME CARE OF WOUND HEALING BY SECOND INTENTION ARE EQUALLY IMPORTANT COMPONENTS OF OPEN WOUND MANAGEMENT. CLIENT EDUCATION IS CRITICAL FOR A SUCCESSFUL OUTCOME. Degloving Wound Management by Second-Intention Healing Caleb Hudson, DVM, MS, DACVS (Small Animal) Gulf Coast Veterinary Specialists Houston, Texas Case Summary Rosie, a 6-month-old spayed female region, and right forelimb radiographs Chihuahua mix, presented for showed fractures of the third, fourth, evaluation after being hit by a car and fifth metacarpal bones and the several hours earlier. No systemic first phalange of digit 3. Carpal abnormalities were noted. Physical palpation revealed no evidence of examination disclosed a large varus or valgus instability, indicating degloving injury over her right the carpal collateral ligaments were forelimb proximal to the carpal intact. Thoracic radiographs disclosed joint and extending distally to the clear lung fields and a normal-sized tips of the phalanges. cardiac silhouette with no evidence of pulmonary contusions. The wound involved approximately 50% of the distal limb circumference Surgical debridement was indicated, and consisted of full-thickness soft- and Rosie was premedicated with Photo courtesy of Dana Gale, DVM tissue loss on the dorsal aspect of the d FIGURE 1 Degloving wound at initial hydromorphone and midazolam. presentation with exposure of the third metacarpus with exposure of the Anesthesia was induced using metacarpal bone second, third, and fourth metacarpal propofol and maintained using bones. (See Figure 1.) The carpal and isoflurane inhalant anesthesia. digital pads were intact. Palpation of The degloving wound was flushed was collected from the wound site the distal right forelimb elicited thoroughly with sterile saline and and submitted for bacterial culture instability and crepitus in the wound surgically debrided.
    [Show full text]
  • Traumatic Brain Injury(Tbi)
    TRAUMATIC BRAIN INJURY(TBI) B.K NANDA, LECTURER(PHYSIOTHERAPY) S. K. HALDAR, SR. OCCUPATIONAL THERAPIST CUM JR. LECTURER What is Traumatic Brain injury? Traumatic brain injury is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration impact, blast waves, or penetration by a projectile, leading to temporary or permanent impairment of brain function. Traumatic brain injury (TBI) has a dramatic impact on the health of the nation: it accounts for 15–20% of deaths in people aged 5–35 yr old, and is responsible for 1% of all adult deaths. TBI is a major cause of death and disability worldwide, especially in children and young adults. Males sustain traumatic brain injuries more frequently than do females. Approximately 1.4 million people in the UK suffer a head injury every year, resulting in nearly 150 000 hospital admissions per year. Of these, approximately 3500 patients require admission to ICU. The overall mortality in severe TBI, defined as a post-resuscitation Glasgow Coma Score (GCS) ≤8, is 23%. In addition to the high mortality, approximately 60% of survivors have significant ongoing deficits including cognitive competency, major activity, and leisure and recreation. This has a severe financial, emotional, and social impact on survivors left with lifelong disability and on their families. It is well established that the major determinant of outcome from TBI is the severity of the primary injury, which is irreversible. However, secondary injury, primarily cerebral ischaemia, occurring in the post-injury phase, may be due to intracranial hypertension, systemic hypotension, hypoxia, hyperpyrexia, hypocapnia and hypoglycaemia, all of which have been shown to independently worsen survival after TBI.
    [Show full text]
  • Morel-Lavallée Lesion: a Case Report of a Large Post-Traumatic Subcutaneous Lumbar Hematoma and Literature Review
    Open Journal of Modern Neurosurgery, 2016, 6, 29-36 Published Online January 2016 in SciRes. http://www.scirp.org/journal/ojmn http://dx.doi.org/10.4236/ojmn.2016.61006 Morel-Lavallée Lesion: A Case Report of a Large Post-Traumatic Subcutaneous Lumbar Hematoma and Literature Review Dominique N’Dri Oka*, Daouda Sissoko, Alban Slim Mbende Neurosurgery Unit, Yopougon Teaching Hospital, Abidjan, Côte d’Ivoire Received 9 November 2015; accepted 8 January 2016; published 12 January 2016 Copyright © 2016 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/ Abstract Morel-Lavallée Lesions (MLL), described in 1863 by French surgeon Victor-Auguste-François Morel- Lavallée, are rare posttraumatic closed degloving injuries, occurring as a result of tangential sheer forces, in which the skin and subcutaneous tissue separate abruptly from the underlying deep fas- cia, causing fluid collection with liquefied fat. A 31-year-old policeman involved in a road traffic accident, presented with a gradually expanding lumbar swelling, which was soft, fluctuant and painful with contused skinon examination. Computed Tomography (CT) scan of the lumbar spine revealed a large subcutaneous hematoma on axial view, extending from the 12th thoracic vertebra down to the first sacral vertebra. There was no skeletal lesion. The treatment consisted of surgical excision/drainage of the collection followed by continuous suction with drainage tubes for two days. The collection is completely resolved; the patient made a full recovery and has been asymp- tomatic. Since there was a history of blunt trauma and given the nature and the location of the col- lection over osseous prominences, we report this rare case of a large posttraumatic lumbar he- matoma diagnosed on clinical and CT scanning grounds as a Morel-Lavallée lesion.
    [Show full text]
  • UHS Adult Major Trauma Guidelines 2014
    Adult Major Trauma Guidelines University Hospital Southampton NHS Foundation Trust Version 1.1 Dr Andy Eynon Director of Major Trauma, Consultant in Neurosciences Intensive Care Dr Simon Hughes Deputy Director of Major Trauma, Consultant Anaesthetist Dr Elizabeth Shewry Locum Consultant Anaesthetist in Major Trauma Version 1 Dr Andy Eynon Dr Simon Hughes Dr Elizabeth ShewryVersion 1 1 UHS Adult Major Trauma Guidelines 2014 NOTE: These guidelines are regularly updated. Check the intranet for the latest version. DO NOT PRINT HARD COPIES Please note these Major Trauma Guidelines are for UHS Adult Major Trauma Patients. The Wessex Children’s Major Trauma Guidelines may be found at http://staffnet/TrustDocsMedia/DocsForAllStaff/Clinical/Childr ensMajorTraumaGuideline/Wessexchildrensmajortraumaguid eline.doc NOTE: If you are concerned about a patient under the age of 16 please contact SORT (02380 775502) who will give valuable clinical advice and assistance by phone to the Trauma Unit and coordinate any transfer required. http://www.sort.nhs.uk/home.aspx Please note current versions of individual University Hospital South- ampton Major Trauma guidelines can be found by following the link below. http://staffnet/TrustDocuments/Departmentanddivision- specificdocuments/Major-trauma-centre/Major-trauma-centre.aspx Version 1 Dr Andy Eynon Dr Simon Hughes Dr Elizabeth Shewry 2 UHS Adult Major Trauma Guidelines 2014 Contents Please ‘control + click’ on each ‘Section’ below to link to individual sections. Section_1: Preparation for Major Trauma Admissions
    [Show full text]