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Traumatic brain injuries can have distinct exceptions that necessitate deep sedation and immobility. How then can we apply the ABCDEF bundle to protect injured brains and restore lives? Charlotte Davis, BSN, RN, CCRN and Richard Rivera, BSN, RN-BC share their expertise and their team’s incredible success with the ABCDEF bundle in the settings of TBI.

Episode Transcription

Kali Dayton 0:38
Okay, last episode we explored the ABCDEF bundle in the trauma ICU. We know that sedation and immobility can be absolutely essential interventions in the setting of a traumatic brain injury. Yet, I have heard concerns from listeners and trauma units that their TBI patients are oftentimes needlessly suffering the classic effects of prolonged sedation and immobility.

Many have given me heartbreaking examples in which patients spent far more time trapped in mechanical ventilation and sedation than was likely essential for the initial TBI. Much of what I hear is related to the difficulties in dealing with agitation, confusion, and the habit of running back to deep sedation without other tools and support and responding to the likely delirium or even deficits of the TBI. This leads to additional days to weeks on the ventilator and in the ICU.

They have told me that the extra work, slow bed flow, various complications and poor outcomes are weighing on their teams and contributing to the burnout and the mass exodus from the ICU. So this episode, let’s get into TBI is how does the ABCDEF bundle apply to traumatic brain injuries? Does a TBI always necessitate sedation and immobility?

How can we exercise caution when administering neurotoxic medications during a brain injury? How can trauma teams navigate the utilization of sedation to preserve brain function, but minimize the dose and duration so as to give patients the best chance to survive and thrive? Charlotte Davis and Richard Rivera Join us now to share their expertise and their team’s incredible mastery of the ABCDEF bundle in the setting of a traumatic brain injury. Charlotte Richard, thank you for coming on the podcast. Do you mind introducing yourself and Richard if you start?

Richard Rivera 2:38
Sure. My name is Richard Rivera. I’m the currently the Assistant Chief Nursing Officer at HCA, Florida Ocala hospital, been a nurse for 23 years trained at the University of Miami and spent 18 years in Miami working in various roles there. And then came up to this North Central Florida market in Florida. Very different rural, and have a great team here and doing some wonderful things and trauma care.

Kali Dayton 3:05
Excellent. And Charlotte, tell us about yourself.

Charlotte Davis 3:07
My name is Charlotte Davis, and I’m a trauma critical care nurse have been for the past. I’m gonna have to start fetching all this paper we’re gonna figure out how old I am 34 years 30 to 34 years now, but I love what I do. I’ve done a little bit of everything from community ICU to but my primary love is trauma, ICU cvicu, anything neuro ICU as well too. But my true love is trauma ICU. I’ve done flight nursing community community help us you nursing large trauma centers. I’ve been a division trainer, flight nurse, little bit of everything, but in trauma critical care. I love it.

Kali Dayton 3:43
And I am so excited to have you guys with me today because trauma TBIs are not my specific expertise. And I’ve gotten a lot of really good questions about how to apply the ADF bundle to patients with TBI is we talk a lot about delirium throughout the podcast and how to prevent it. And by doing so we prevent a lot of confusion and agitation. But when you have TBI patients, you may have other causes of those symptoms. And so for you both Why is delirium concerning in the setting of a TBI and what can what can we do to help prevent delirium on top of a TBI?

Richard Rivera 4:22
Like, I think one of the main things that we have to think about is severe TBI guys are going to spend a lot of time in the ICU longer they’re in the ICU, and we’re at risk to delirium they are and that has nothing to do with a neurological sequelae of the injury. So to assume or think that the patient is not undergoing some sort of delirium state would really, really short the patient on the care that they they deserve it.

Kali Dayton 4:49
And how do you tell the difference between confusion, agitation or coma from delirium versus a TBI?

Charlotte Davis 5:02
With your patients, a lot of this is going to be injury driven and pattern of injury, timing of injury as well to when these patients come in that initial presentation is going to tell us a lot about that patient if a patient comes in and they are non responsive, and they have a Glasgow Coma Scale less than eight, and they’re intubated in midfield due to the severity of the injury.

Now, this is going to take an actually tell us a lot about that patient on how long you’re going to have to keep them sedated just for Neuro protection, because we’re not necessarily doing this for sedation for them to be able to tolerate the ventilator management, the pulmonary component of it. A lot of this is actually to control the intracranial pressure to take an actually minimize the agitation that’s going to be going to be potentially increasing the ICP on that patient and causing long term damage.

And again, you know, not just not just our car accidents for our MBAs for traumatic brain injuries. This could also be a subarachnoid hemorrhage and AVL malformation that’s ruptured. So when we talk about tbs, typically we are talking about, you know, your skull fractures are diffuse at injuries. But but you know, those are, are significantly, we’re going to have to probably keep them intubated and sedated for a prolonged period of time. And we know that, based on the severity of the injury, like whether dar this is going to be a devastating neurological insult to that patient, we’re going to anticipate that patients ICP is going to be very hard initially when we place that EVD or both in that patient.

And that initial opening tap pressure of the ICP is going to be a really good clinical indicator on the severity of that injury as well to when they place that end. And then ICP is and we’re looking at less than two hours post injury from scene to the hospital to scanning and now we’re placing the EVD if that initial opening we call it tap pressure of your ICP that initial reading of your ICP if it’s over 22, that’s a crisis right off the bat. Typically, you don’t hit your peak swelling times for your bright forever brain injury until 24 to 72 hours later. So if your initial ICP is already crossed his heart, you know the worst is yet to come. So we’re probably going to look at even more aggressive pharmacological interventions to keep that patient sedated for us CP management and neuro protection.

Richard Rivera 7:19
And Charlotte does bring up a very valid point depending on the severity of the initial injury, then the decisions that are made on how to manage it, whether it be more medical management, whether it be an EVD or whether it be a craniotomy/craniectomy. Very, very different, right. And then we’ve got to look at that point, based on what the decision has been. Sorry, based on what the neurosurgeon has decided to do. Now we’ve got to tailor what we’re doing because we’re targeting neuro protection first. Right?

In the very early state of the injury, we know we’re gonna have to deal with delirium and TBI sequela, later, more than likely, but the front end has to be taken care of first. So we don’t have a patient to work with. So to her point, that’s key. We’re going to dry drive that first. And I appreciated I was in a conversation with a neurocritical care physician. And I asked him what his thoughts were on, you know, booths three, for example. And he says,” Are you trying to start an argument?” I was like, “no, no, no, not at all. I just, I just want your take, how do you view it.”

And to his point, he was like, sometimes, doctors are pushing so hard to get that brain tissue oxygenation level where they want it to be, where they feel it’s, it’s the right rage, that within 24 to 36 hours, they have a cardiac arrest, because they’ve just pressed the heart so hard to feed the brain, that now you don’t have a patient to take care of.

Kali Dayton 8:54
Now there’s the rest of the big picture.

Richard Rivera 8:57
Right? Right. And sometimes, you know, the neuro folks will be neuro, just like the cardiac folks will be cardiac. So how important it is to have a global approach to address the ICP management, the neuro management hemodynamics that go with that. But also keeping in mind that we have to preserve our end organ function, right? Otherwise, we’re not going to have a patient at the end of this journey.

Kali Dayton 9:20
And it’s so tricky because you’re bringing up specific exceptions to when sedation is actually needed. Throughout the podcast, we talk about other specialties of the ICU in which sedation really isn’t needed, in most cases that we’re using them. You do not have to sedate any patient just because they’re on mechanical ventilation. Yes, but with these brain injuries, they do need to have the pressure controled, they need to take a break, need to take a rest. But how tricky is that when we know that sedation increases mortality, as well as deep sedation? So how does how do your teams navigate what kind of sedation to give what’s necessary and how deeply to sedate patients?

Charlotte Davis 10:00
So I can answer that. Really, again, it goes back to clinical presentation, because we would love to say we have a cookie cutter approach. And we do, we have an algorithm that we take and actually follow, but it’s based on a patient’s clinical presentation because every single patient is different. And so if this patient’s initial opening, RCP pressure is above 22, we know we’re gonna have to go for a swim with this patient, because when they do hit that peak swelling time of 24 to 72 hours later, we know we’re going to have to look at more aggressive therapy, therapeutic interventions, surgical interventions, we can take, you know, we can try our we follow the ACS three tiers of traumatic brain injury care, the American College of Surgeons, their guidelines for traumatic brain injury care, and it’s a three tiered approach a more escalating aggressive therapy.

And so and there’s also another set of TBI guidelines by the Brain Trauma Foundation, which is written by neurosurgeons. But most of your trauma centers often do tend to gravitate towards the ACS American College of Surgeons TV, I got, it’s an escalating approach of three tiers. And at the top of the tear the last one or approach when, when they failed tier one, which is maybe placing that abd to try intermittent draining of CSF off, because again, your friend your vault is an enclosed look at a call it a good analogy for is it’s like a pressurized round ball. It’s a pressurized round bottle with a pressure relief valve on it.

And so instead of that pressure us bottle round bottle, we have three things, we had two brain, we have our vasculature or arteries in our minds, and we have CSF. And so anytime we have an increase in one of those things, it’s a pressurized bottle, there’s no extra space in there, we have to decrease one of the other two, we really can’t decrease the blood flow, because we know that it’s going to result in cerebral anoxia. So we have to adjust the CSF, there’s only so much CSF that we can really pull off you have about dependent depending on your patient, male, female, you have around 70-75 cc’s of CSF, maybe 80 cc’s is floating around inside that cranial vault at any one time.

We can safely drain off about 30 CC’s an hour. But that’s it. And so if that’s not enough to relieve that pressure inside that pressurized bottle of your of your rigid cranial vault, we have to look at something else. And Richard touched on this, you know, we have other things that we can try, we have, we can actually take the water content of the brain out and given them 3% Saline are 23.4% Saline bolus and then starting them on a 3% drip. And that will take some of the water content out of the brain give it a little extra room swell. Because when that brain swells and hits that non moving glass wall of the cranial vault, it’s going to start compressing all those beautiful arteries and veins that lay on top of that brain.

And so then you do have Cerebral anoxia that’s going to be occurring is it’s an ischemic stroke that’s happening and you have nothing really to prevent it. So you can try 3%, you can try mannitol, hypertonic saline solutions depending on what their serum sodium level is, their serum Osmo level is. And if they fail that, we go to the top tier, which at our facility we use, like a pinbar coma, we’ll do a loading dose of one to five milligrams on this patient. And then we’ll do a maintenance dose of one to five milligrams and we’re usually if we’re to that point, we usually Max them out at five milligrams a continuous kind of artery up and trying to really slow there are suppression that patients patients now going to finally have aggressive invasive hemodynamic monitoring, multiple ones, probably multiple pressors, at least one EVD, maybe more, maybe a bolt, maybe a PVC, or to monitor like ox catheter.

And we also may try a decompressive craniotomy, where that we actually remove a large a large bone flap out the ACS just its updates, I believe in 2016 2000, no, 2018, I believe it was because we were they approved a larger cranial vault wall to come out. So they were removing just a very small window, about a four by four window. And then they took with updates, they proved a larger wall, which is about the size of my hand, fingertips included come off allowing that bring extra room swell. So I mean, it’s a lot. So all of these things kind of balance that on the patient. So when the patient feels that first tier level, we’re going to go to the next more aggressive to your level. And so if they feel that level, we’re going to we’re going to try everything because if that patient has a full code, we all firmly believe that if somebody’s mother, brother, father, sister child there, we’re going to try everything to save that patient.

Kali Dayton 14:27
And how do you how do you sedate them during the first level?

Charlotte Davis 14:30
Well, we’re gonna try minimal sedation if they can tolerate that. And when we say tolerate that we’re not really looking at the pulmonary function. We’re looking at a couple things. We’re looking at the patient’s O2 sats, yes, but we’re looking at their ICP. And so if that patient is moving, if their RASS is zero, and they’re still awake, and and we have that evenly placed, which can be uncomfortable for that patient brain is swelling, it’s going to cause some confusion, some agitation is going to cause increased cerebral pain metabolic activity, which is going to cause an increased ICP, and the more agitated they get, the more their ICP goes up because they have more cerebral activity, which causes more agitation, which causes the brain to swell more so vicious cycle. So always try and stop that cycle. And this is one of those this one of those exceptions to what we do look at more aggressive sedation, and it’s for the long term functional outcome of the patient to preserve that neurological tissue.

Kali Dayton 15:26
No, that makes absolute sense. And what kind of agents do you use? Do you use benzodiazepines or do you use propofol?

Charlotte Davis 15:33
We do use propofol some. So we do use propofol, we also use versed. we also use fentanyl quite a bit. We try and stay away from any of the diazepams as a general rule of thumb, we just don’t use them. Our primary go to is going to be is going to be versed and fentanyl. And if we have to we’re going to add propofol as well, too.

Kali Dayton 15:54
And is there a reason that propofol wouldn’t be a primary, your initial agent?

Charlotte Davis 15:59
Well, in our perfect world would use precedex on everyone. And so again, it’s going to be it’s going to be the presentation of the patient. So if we can, if we can control them on precedents, we’re going to keep them on precedents, because every patient is different or unique. We go by the clinical presentation, we don’t just say this is a DA if you say so injury, so therefore, we know we have a massive severe, severe injury. So it with a with a very high mortality rate. Every patient is different. So every patient’s unique,

Richard Rivera 16:28
To Charlotte’s point, for example, for precedex, we have a non intubated indication and then and then a mechanically ventilated indication for that drip at a higher dose, dose range, but it is allowed to be tailored so that the patient can interact. One of the things that’s interesting when you when you’ve got some of these cases, and and we’re worried about, we don’t know how far it’s going to go.

It’s the first 24 hours trying to find that balance, you know, helping that patient through it. Incorporating the family having familiar voices there, can really help with some of the agitation that can occur because they’re in a foreign environment, foreign noises, they’re feeling, you know, post injury, they’re like, “wait, what has happened? The last thing they remember is I was in my jeep.”

Right, and now they’re starting to get glimpses of something that and they’re trying to figure out what happened in the last 16,18, 24, 36 hours. So it’s very powerful to really incorporate that we do that with regularity in our organization, that’s very helpful to have family presence there. And that way, they can help calm and guide. It also helps them to, quite frankly, because instead of calling the nurse every hour on the hour, they’re present, they see the update, they talk to the physicians, they see what’s being done for their family member, and then they collaborate quite a bit. So it is very helpful to do that.

We always do have a conversation with the family and make sure they understand it’s really important to keep the stimulation down to a minimum, please silence their phones, you know, so there aren’t these loud noises going off. It’s enough with the cardiac. No, that’s and so these are things that help to provide the right type of stimulation, help the patient have some orientation, but avoid overstimulating without side things.

Kali Dayton 18:27
And there you have the F of the ABCDEF bundle of the family involvement and how they can actually help the team do the best thing for the patient.

Charlotte Davis 18:35
We actually involve the families and interdisciplinary rounds. We have those twice a day. We have them on day shift where are attending trauma attending will take an extra round with all the residents also with respiratory therapy with physical therapy with the nurses with pharmacy, we have a critical care ward certified pharmacist is there on day shift, I think also on night shift as well, too. I’m not sure on their staffing right now.

But it’s usually a board certified critical care pharmacist. That makes rounds as well to twice a day. And so we have the whole team there. But we involve that family and we encourage the family if we keep whiteboards in the room in court and encourage the families if they’re not there write their questions down because we’re gonna look at that whiteboard and see what it is that’s important to them to hear today.

What are their questions for the day if they can’t be there? So we try and end when we do check it out. She called them we’ll do we’ll do zoom calls FaceTime calls where they were trying to really involve them because again, we’re these TBS, we have a very high success rate on on saving these patients and Richard is like a walking textbook on all of our stats on that he’s amazing, but we have a very, very high success rate for saving patients that in most facilities would be unsalvageable and and in, in those rare situations where we do have a patient who can save we, we consider the last final gift we can give to that patient is the gift of taking care of their family when when they no longer can.

We know that it’s going to be a patient of most no matter what. And these are going to be patients that their opening tap pressure might be 32 for their ICP, and even after we do a decompressive craniotomy, it’s going to be 30 to 34, we’re going to have downward gazes, it’s going to take an actually single, that’s going to take an extra single, maybe like an uncle herniation, or, or a patient that comes in in respiratory arrest with a really high ICP, you know. So again, it’s not one of those cookie cutter things. But we do take and actually try and make sure that we always include those families.

Kali Dayton 20:33
And that’s that’s a beautiful addition to the to the bundle, and the families get to actually understand what’s been attempted. Do you have visiting hours for your families? Are there regulations?

Richard Rivera 20:45
So we did we did have some structure because of COVID, based on what CDC was crashing down. Prior to that, we were open to visitation 24 hours a day. And we’re, we’re we’re basically moving back to that, because we’ve been cleared of the COVID restrictions. So the ICU is it’s basically open.

Kali Dayton 21:06
That is an A-F bundle ICU!

Richard Rivera 21:08
right, now, obviously, trauma, there are some security concerns that could require us to to lock down the unit temporarily, until we get the clear from from law enforcement. But but that is an exception, not the rule. We are we are open for our families.

Kali Dayton 21:26
I love that I’m constantly families that they are part of the ICU, they are part of the team. But when do you lock Respiratory Therapy out of the unit? Are there certain hours that they can only come? No! So why would any member of the ICU be locked out at certain points, especially when it’s their loved one. So I love that that’s what your team is doing. And I think that I would assume that would be part of your big success. And maybe it’ll save so many people.

Charlotte Davis 21:48
It is with the exception, with rare exception, because 99% of our families, they’re very, you know, they’ve had all the decision that we don’t see them on the best day of their life. We see them on the worst day of their lives. And they have had all the decisions taken away from them. And so we try and include down but and give them give them options. Let them be part of the team, part of the interdisciplinary rounds.

And the only time that that like Richard said that is an exception to that is when we have a potential injury there and we don’t know who the assailant was. Because we have had situations to where like all large cities, we we have a very low gang right here. But we have had conflicting robbery injuries, well, one on one side of the unit and we got a very large trauma ICU, one on the other side of the unit. And we had a lockdown family and friends from visiting because they would walk the other other side of the hallway.

And also we’ve had spouses that have harmed their loved harm their mother, brother, father, sister child, so just because it is a family, we do have to keep that that in mind. If we don’t know who the assailant was, initially, we will update the family. But we may not let them visit initially until we get more information because of safety issues. Because I mean, frankly, all across the United States we’ve had shootings and asked us is just a simple fact. We’re we’re our loved ones or friends foes, relationships that have fallen out with families and friends, they’ve came back to the units and escalated to where nurses have been harmed. And so we we put our staff site safety as a priority and our patients safety as a priority on those rare instances.

Richard Rivera 23:33
It’s very rare. In that regard, a rare very close synergy with law enforcement is very valuable. They they’re out there, they’re hearing things and there’s one situation I can think of where our off duty officer came to us and said, I think y’all need to go on lockdown. There’s a threat out and out site in the community had no idea about it. But they got wind of it, they notified us. And based on the recommendation, we locked down until they clear and so that’s very valuable, because we want to make sure that every patient is safe. The visitors that are inside are safe, and also our team members, because how do we take care of our community without our team members intact?

Kali Dayton 24:14
Oh, absolutely right. And the phrase that I’ve used on the podcast before keeps coming to mind. I’ve said you can’t optimize care until you customize it. So every situation, every patient, every family, is unique and different. But I love that you have these values of understanding that this is not just about in the bed. It’s a patient that come with a whole life history and hopefully life ahead. And you customize care for that. And it sounds like you have a really good rounds process where you involve the whole team and the family as a member of the team. And how do you communicate amongst yourselves like the RASS goal and how to titrate and navigate sedation according to that patient’s physiological needs at the time. How was that communicated throughout the team?

Charlotte Davis 25:03
Well, again the patient’s clinical presentation. So just like with most most things we’re looking at stable versus unstable and our definition of unstable is, what is the ICP? And if they have a lockbox Catherine, what is that PVC02? Because if we place a lockbox catheter adjacent to that area of injury, we’re gonna say that they have a right basilar skull fracture. Our neurosurgeons would go in, they would place a lockouts catheter adjacent to that area of injury not in the area of injury, but maybe an inch or two way.

And they’re going to measure the oxygenation of that of that area of the brain. And so that PVCO2 is going to drop dramatically quicker than what the ICP is actually going to take it actually go be trending up. So it’ll be an early indicator. So we can we can actually optimize the care of that patient by increasing their Fi02 on the ventilator to increase their PVC02 to to perfusion to that brain when we’re doing aggressive therapies like that, or we’re doing aggressive, aggressive therapies like 3%, saline boluses in and maintenance doses.

And, and when I say boluses, we’d do like an initial 23.4 dose for that patient before we start, like a 3% drips on some of our patients. And we’re we’re really taking and closely managing, you know, some very, very fine therapies for those patients. We’re, we’re draining off CSF, maybe we we’ve done a decompressive craniotomy, we’re doing PVC02.

Again, all of these things, we’re looking at all those numerical values. And also looking at that map and the cerebral perfusion pressure. Ideally, we want to keep that map above or the cerebral perfusion pressure above 60. If we’re able to do that, then we can start weaning off of that sedation, we can look at that. But if we can’t get adequate cerebral perfusion pressure, to where we can maintain it at 60, we can’t wean that, because then we’re sacrificing long term neurological outcomes for these patients for just waiting just for the purpose of weaning. And we can’t do that. Our goal is functional, full functional recovery for that patient, because every patient is somebody’s mother, brother, father, sister child, and we want them back to their full functional optimization.

Richard Rivera 27:13
So one of the things that that is done, even if the patient can’t tolerate it at that moment, and to your question, Kali, is that at the most multidisciplinary round, and then subsequently, because the physician will set that goal, here’s where the RAS needs to be, the nurse will work that process, when they hand off care, they actually document, “here’s our RASS at handoff, this is where the RASS goal is, and what we’re using to maintain it.”- And that transition is maintained from caregiver to caregiver to make sure that we don’t go off goal.

Now, twice a day, there are options where nurses can can implement their spontaneous awakening trial, we do it on day shift, we do it on a night shift, and sedation is cut in half, for 30 minutes to assess the response of the patient. Now, it’s addressed every shift. If the patient clinically cannot tolerate it, then we have to fail that process. And we’ll check it again in 12 hours. But we are continually looking at it as part of our nursing process to make sure we’re giving patients every chance to deescalate sedation and deescalate therapy, if possible. Every shift, and that’s what’s powerful. Our physicians are at arm’s length, they are present in the unit 24 hours a day, we actually have to intensive as teams. So nurses have the support of their physician partners. It’s not a it’s not a telephone call to them present and then get an order. No, it’s Hey, come check this patient. They’re doing great after the LSAT. Let’s see what’s next. And the physician is there in five or 10 minutes.

Kali Dayton 28:59
Oh I love it. The fact that there’s an assessment every multidisciplinary assessment every shift- that’s incredible. That there’s a process[- a set process- to have RNs communicate the RASS goal. It seems like in the ICU community in general, a lot of times it’s just start sedation, but we’re gonna put in the orders a certain RASS just because that’s habit, but “it’s subjective, So do whatever you want. And then once the ventilator settings are low, we’ll reassess we’ll start taking it off and if they come agitated, we’ll just turn it back on, at whatever dose, whatever RASS you feel like it’s necessary.” —- I’m kind of exaggerating, but sometimes not so much of an exaggeration.

But the fact that your your nurses are talking to each other saying, And the whole team, understands “This is why the patient is sedated. These are their needs. This is what they did last week awakening trial.” And then together, the nurses are saying, “I have them at a RASS of negative two.” And the next nurse is saying okay, “I see that negative two.” They’re maintaining that and if it’s a fail, they have other people to connect with to communicate with as far as, “that was a fail”, or “why did that patient fail?”

What some of the fail criteria? I see that a lot of teams have a fail criteria as agitation, for example. But if agitation is from delirium. And then we resume sedation, we keep them on this roller coaster. But for with a TBI, you could have agitation, but may not need to be sedated anymore. So what kind of things qualify as a failed awakening trial? And how does your team respond to it?

Richard Rivera 30:28
So one of the things that does come up quite a bit is, you know, agitation is one of the things that’s looked at. But agitation by itself is not the criteria for failing that that trial.

Kali Dayton 30:43
Thank you! Yeah!

Richard Rivera 30:43
Right. We just talked a lot about neurological response, because of agitation, didn’t we? Charlotte commented on that quite a bit. And she’s right on point. So if you’re ICPs, are elevating your brain tissue oxygenation is dropping, those are reasons to fail. Get them back on the sedation, right? If you’re having hypoxic issues, they can’t ventilate right they’re tachypneic, those are appropriate reasons to say, wait a minute, let’s get them back. They’re not ready. Right? Because we’re going to jeopardize our end profussion.

Kali Dayton 31:18
On the brain, right? Especially for TBI.

Charlotte Davis 31:21
And also too, your patient. Again, looking at every single patient, do we have the pupils? Are they do we have an ipsilateral dilation? Do we have nystagmus with a downward gaze? All these things can be an early indicator that that ICP is going to be at across this level, you may be at 18 or 19. Right at that threshold. But you know, you know that these are symptoms that don’t have a good outcome.

So we look at everything, even down to our therapy, therapeutic labs, if we’re doing a grid, if they failed the ACS tier one, they failed ACS tier two. And and we’re discussing all of this during the interdisciplinary rounds, you know, what your is appropriate for that patient right now? Can we take them down to tier to tier two? Or do we have to keep them at the tier three interventions?

You know, we try and normalize those patients as quickly as possible. But when we are doing those aggressive therapies, we have to look at everything down to their serum labs. If we’re doing 3% hypertonic saline on these patients, we have to make sure that we’re not increasing that serum sodium level by more than five in a 12 hour period of about more than 10 minutes in a 24 hour period. Because that, in and of itself, just the therapy that we’re using to treat that patient can also cause a brain injury, if you raise it serum sodium level too quickly, that can cause central pontine melanosis, we’re basically kind of shares with some very rough analogy of it, but it kind of shears the axons that are connecting each each nerve that could be communicating axons to where they can cause long term devastating effects.

Those patients can be left locked in fully aware of everything going on around them, they hear everything at the end of their full recovery of their TBI, they hear everything, they can process everything, but they can no longer move or speak. And that’s central pontine melanosis. And it’s just raising the serum sodium level too quickly. So we have to be we have to look at everything. It’s not just it is the patient’s physiological response. But it’s also their serum response to that to the therapists that were doing this for us up there PVC02 agitation. It’s a neuro patient, it’s a TBI patient, we’re not so worried about that our nurses can deal with that we put families in the room. And that usually keeps him calmer. But we’re looking at the whole picture of the patient. And this is why we have the whole team there for rounds, including the patient’s family. So we can look at everything, we can also share that with the family so they have a better understanding of what we’re doing.

Richard Rivera 33:43
That makes sense. And I I’d like to add, you know, we’re talking about TBI patients. And it’s it’s sometimes you get an isolated traumatic brain injury. But more often than not, there are polytrauma patients that happens to be a traumatic brain injury patient. So there are a whole lot more factors to Charlotte’s point that have to be included. And there are a lot of other things that can generate agitation that could cause a failure. Have you managed their pain appropriately? Because they, their trauma patient may hurt if you don’t treat their pain, and now you wake them up. They might want to choke you, and rightfully so. So, how important it is that we think about what are fundamental to human anxiety and suffering. “Hey, I need to breathe.”

Kali Dayton 34:37
Right.

Richard Rivera 34:38
And things have to be in good order. So if my brain is in distress, I’m going to be thrashing.

Kali Dayton 34:44
And what’s causing that distress? I think we think that if we when we turn sedation back on and we stopped the movement that we’ve treated the pain or that we’ve they’re no longer in terror that we fixed them that they are as comfortable as they look. So how did your team communicate it when you You see a failed awakening trial? What is that process then to reevaluate? Does it just turn station back on the level it was at? And then how do we look at all those different causes of a failed trial?

Charlotte Davis 35:12
Richard brought up a really good, really good point. And so I’m gonna, I’m gonna add on to his point here. So he talked about polytrauma. So let’s say we do have a tibia. And again, these patients typically don’t come in just for the tibia. This usually polytrauma, they’re gonna have rib fractures, or they’re gonna have maybe a pelvic fracture. And so keep in mind with your abdomen, and that pelvic cavity, you have about about 55 to 60% of all your blood supplies in your gut is in that in that pelvic area there.

And so when you do have those helmet crushing injuries that come in, they will have on like, I will use a tpod binder or an abdominal binder, to kind of tamponade off some of that bleeding that’s there. But at the end of the day, with those when we have those polytraumas, and pelvic fracture is a really good example. And you have all of this, all of these little mini shards of pelvic bone that are free floating with very sharp edges, like little mini knobs and, and so maybe they’re doing well with a TBI. But we haven’t reached the point to where we are taking them to the or to stabilize that pelvic fracture.

So if we wake them up, the first thing they’re going to do is move. And so when they move, we have all those free floating little mini shards of bones that are moving inside that pelvic cavity with all of that vasculature. They’re all those arteries and veins. And so one little movement can pierce one of those. And so sometimes it’s not necessarily just after we get them over that 24,48,&2 hours, 96 hours of that initial TBI and then ICP starts going down. Sometimes we do have to keep them sedated. But and simply for safety because of other polytrauma risk, like the pelvic fracture until we actually get that pelvic fracture stabilized and surgically fixated. And so it’s a lot of it’s a lot of factors. So even if we get them after the, you know, over the TBI neuro insult risk, it’s still a safety risk. So we still have to keep them sedated. So it’s not a cookie cutter option, every patient is different.

Kali Dayton 37:14
Absolutely.

Richard Rivera 37:15
That’s very true. And I was gonna add Kelly that, you know, since the nurses cutting that that dose in half, or that awakening trial, they had a dose that was effective and had them at goal. So they would return them to that goal. We’re not adding additional boluses or trying to get them to a higher level of sedation, we just want to restore that status that we had to reduce the the indicators that we have, that they are in distress, right, whether it be their ICP, their brain tissue oxygenation, their Pa02 because they’ve got that blunt chest trauma. Many number of things, maybe they have a cardiac contusion and just that dip in, in oxygen level can make that pump less effective. Right, and we see their cardiac index drop. So whatever indication there is that says, “Wait, this is not ready,” the nurse then would restore that sedation standby so that it resumes. And then of course report to the physician on duty, so that they’re aware, “this is what happened when we, when we reduce them” – that way they the physicians know their response,

Charlotte Davis 38:18
I do have to share with wonderful thing that Richard actually brought to the forefront in all of the ICUs. All of the leaders they all have the ICU directors, they look at and managers- they run reports daily. And so when we do get that patient in initially those that interdisciplinary team, that provider is gonna run an order for an initial starting dose for that sedation.

So our nurses do not have a discretion of sorting them way above that just because it is allowed in the facility. That is not an option. They start them at that minimal dosage. And if they have to increase from that minimal dosage, they have to communicate that with our team. We have imobiles there that all of our providers have, which is basically an iPhone. They can FaceTime with that provider, let them see in real time what’s happening with that patient for they can change those orders immediately. So… and we run reports on that not just once a day, twice a day. And those nurses Richard can tell you, we love our nurses, but we have that benchmark set, and we check it.

Richard Rivera 39:21
So Charlotte brought that up. And the quality aspect is really critical. One of the things that I endeavored to do is make sure our nurses have a safe environment to practice in. And they should never be put in a situation where they have to practice outside of their scope.

Kali Dayton 39:39
Yep.

Richard Rivera 39:40
And making those adjustments without a physician and put without the appropriate documentation in the record– because a nurse’s note is not an order. Right? And the physician progress note is not an order. Physicians have to write their orders. And that’s really critical so that the patients are getting the right care in is tailored to them. And our nurses are practicing the appropriate way.

So for example, Charlotte mentioned those audits that we do look at the titration. We do look at the RASS that is documented, we also look at the rascal that was prescribed by the physician. Do we have a nurse was over sedating a patient beyond what the physician has ordered? Or do we see them titrating down because suddenly, the patient got over the hump, and now their RASS increased? I should see them titrating down that drip to get back to goal. Right? So we look at that daily, we look at the previous 24 hours. And in part of that, it’s not, it’s not to get a nurse in trouble. That’s not the goal. The goal is to make sure they’re practicing within their scope. That way, when a regulatory agency comes in, we have a very solid process to say, our our nurses are within scope.

Kali Dayton 40:56
You have me giddy over here, because that addresses so many problems that I am seeing within teams is that one RASS has been taken very subjectively. A RASS negative two could be really negative 4 to a nurse. A lot of that comes down to education and training. There’s also no communication about the RASS between shifts, let alone during rounds, there’s a misunderstanding that we can….. just because we have a drip going that as RNs, that we can just titrate to whatever we think is needed.

And you make such a good point that is not within the scope, where you would never just say, “Oh, I think I’m gonna give, you know, an extra gram of this antibiotic.” You wouldn’t. Especially when we know that sedation is can be so lethal, and harmful to patients. You’re talking about preserving their functional status, and that is such a fine line and these patients, but if you’re given an extra 10 milligrams of versed an hour, because that’s what that’s the rate you like to run it at.. that can be lethal to a patient and the short and long term.

So having a system to keep nurses supported, on track, making a safe environment, you don’t want patients that are thrashing, trying to be violent against nurses, but you also don’t want to make them liable for oversedating a patient and causing their death. I have numerous case studies on my website of deaths that are attributable to oversedation. And I don’t think nurses usually realize how lethal those practices can be. They think sedation is pretty benign for the most part.

So you came in and change the system so that they are practicing within their scope. It’s safe practice for the nurses and the patients. But not just “Hey, keep then at a RASS of of zero in when you feel like the patient is unsafe, and we may or may not answer your pages.”– You have a system there the nurses have someone to go to, to discuss these concerns with and they’re supportive in that. Everyone understands why the patient’s sedated, are constantly trying to minimize sedation and get it off and re-assessing as far as when Is that safe? And when the after a few days after TBI, when they’re looking safer…What is access successful awakening trial? And then what’s the next step?

Charlotte Davis 43:05
We have to look at their patient’s response too like on the ventilator. So now, now they’ve recovered from this traumatic brain injury. So we’re going to take an actually look at that patient. So when we put them on SMIV or on CPAP, and we are starting to take an actually trial them, you know, how are they doing? You know, do they have increased work of breathing? Are they able to maintain their o2 sats? Are they getting to tachypneic, or you know, maybe, maybe they’re maybe they fail it after an hour this time, but then the next 12 hours we can take can actually re-trial them.

But again, it’s the whole team. So we we have processes in place to make sure that if we ever had a nurse that worked, that was using more sedation there, what didn’t what they needed, it would quickly come to the forefront of the entire team every 12 hours because our attendings are very, are very, very hands on. They are very thorough, they’re going to our attendings go in every room of every trauma patient every 12 hours with those residents. They’re going to make sure that that RASS is where they want it to be. And if it’s not, they’re going to have that discussion not to take and get a nurse in trouble not to get a resident trouble. But to make sure everyone is on the same page so that we’re all working for one goal.

We want to reduce that sedation on those patients because at the foundation of everything is Dr. Wes Ely. Everything comes back to everything comes back to some of his foundational research. We want to take and actually safely wean patients when we can but we’re looking at those patients, what are what’s their peak plateau pressure, you know, what is their what level of PEEP they add, or know if they’re 15 of PEEP, we’re gonna have to start to slowly wean that down. So when we’re talking about weaning, that may be weaning them from 15, down to 12, then down to 10, then down to a nine to five and then actually sorting them on a spontaneous breathing trial.

So it’s not just a cookie cutter everybody’s gonna get when it’s Really looking at the patient’s response? What kind of what kind of tidal volumes? Are they able to pull on an independent breath? What are their 02? What’s their work of breathing? Are they using accessory muscles? Are they to kidney? You know, what’s their peak plateau pressure? You know what Sir chest X ray look like? What are other injuries as well too, so we’re looking at everything. But our end goal is to opt is to reduce that. Reduce that sedation on every patient. To make sure everyone is aware of the goal, everyone is aware of the plan, and that we all stay on one page. And we have systems in place to make sure our nurses stay on the same on the same page and as a treatment plan. And our attendings have the same processes in place for those residents. Because if our residents tried to vary from what our attendings want, that becomes a very difficult conversation during rounds, because they they are held accountable, there is a level of expectation that they are benchmark that they must rise to not sink to rise to.

Richard Rivera 45:58
Charlotte is absolutely right. And I would also like to bring in our pharmacy partners into this conversation, she mentioned that we have the board certified critical care pharmacists, we actually have three now that are working within our units. And, for example, some of the things that our pharmacy team has built in is that our sedation drips orders expire after 24 hours to be renewed every day,

Kali Dayton 46:23
Every day. That’s making me salivate. I mean, imagine it that’s just all the time,

Richard Rivera 46:29
right? And so since it has to be looked at the physician is really have to look at and decide, is this the best drug for what I’m seeing? Is this the best outcome for what we want for this patient? And that really drives the conversation. Now pharmacies present for the rounds, so they discuss it. They look at lab work, they’re like, “Yes, this is working well, yes. let’s renew it. Okay. Are we at goal with this dose? Yes.” Guess what? They know how many how many bags, they’re burning in 24 hours. So they know if if the RAS is being met with the goal with the dose that’s ordered, or if somebody’s playing with with the dosing.

Kali Dayton 47:11
Wow. I mean, we have to renew soft limb restraints every 24 hours. sedation is a chemical restraint. Why wouldn’t we have to renew it? I guess I hadn’t even thought of that. I have helped teams change their EMR so that when we order sedation, we had to put an indication for it. But that’s my next idea.

Charlotte Davis 47:31
Every 24 hours they expire.

Kali Dayton 47:34
Okay, yep. So in the future, get ready. That’s gonna be my next suggestion.

Richard Rivera 47:40
We also built an auto stop when they do the ventilator, stop the ventilator sedation, DC’S automatically

Charlotte Davis 47:51
Yeah, that’s linked to our mortality and our outcomes, too. So we have, I don’t know how many hospitals we have right now, Richard?

Richard Rivera 48:02
187? Something like that. 187, I think,

Charlotte Davis 48:06
yeah. And over, I’ll have to look and say, I want to say around like 780 ICUs. And for quality, where we’re ranking, we were ranked number one and all of the ICUs in our corporation were the largest for profit in the end in the US. So we were sitting at number one, we stay in the top 10. Anyway, and a lot of it… and for our trauma, ICU clinical outcomes. Richard can tell you about those, but even during COVID, our clinical outcomes are some of the best in the nation. Because we look at everything, everything is important. All of these ordered all of these sedation orders, they all had to be renewed every single day. And we keep the entire team accessible invested from CNO to this ACNO, you know, to me, to our bedside nurses, our attendings, our residents, pharmacist, families…

Kali Dayton 48:54
I give everyone just a huge round of applause. Because you clearly have patients that do initially have to have sedation. My perspective with medical surgical patients, those type of patients, it’s easier just to never start sedation. You don’t get that luxury. So it takes so much more to navigate when and how to turn it off, especially when they have persistent indications for it. But then navigating things like, like agitation, I keep coming back to that, because that’s when the trauma team keeps on saying our patients can become so agitated. That’s what you’re saying. “We’re not afraid of agitation we’re looking at- is that agitation hurting their brain? Is it effecting the rest of the body? Are they at risk of anything else happening?”

Whereas teams that don’t even have a real indication for sedation are continuing sedation for agitation, even without any other harm or risk of physiological reason for it. Yet your team so masterfully navigates this. But when you have a patient that has agitation, but maybe they’re ICP doesn’t go up, they don’t have any other real risks. And they probably …it’s probably time for them to get off the ventilator but they have agitation. How does your team navigate that to get them extubated? And then how do they treat that agitation?

Richard Rivera 50:03
We’ve got to look at the cause. Most times, it’s pain management. And when we handle the pain, we can get them off the ventilator. And with these patients, for example, we’ll start with, as Charlotte mentioned, they might be off for an hour or so but then they get tired. So we catch them back up. So there’ll be off the bat for four hours. And then they’ll go back on for rest. And then little by little, we extend those periods, until we can get into a trade color and the end, and they’re on their own. And maybe when they go to sleep, they just get rest for six hours, and then back off the vent, and they’re working. And of course, their therapy. Work is increasing as that comes to bear. So really addressing the cause of the agitation is key and saying, oh, it’s it’s the TBI may be the easy thing to say. But there are other factors there.

Kali Dayton 50:56
Right. So you just you get a patient midazolam for the TBI. Now the pressures have been controlled at times, but because the midazolam your high risk of having delirium, but does it make sense to then resumed that the sedation that’s probably caused that delirium on top of a brain injury? Do we need to injure the brain even more? When you talk about the tachypnea as part of the fail criteria for an awakening trial, you bring out cases in which you’re increasing the time during a brief and trial trying to rehabilitate the diaphragm re strengthen the muscles to be able to breathe. So when we have to tachypnea, some people will just look at the numbers say, “oh, that, you know, they’re breathing over 30, we have to turn sedation back on.”- It doesn’t make sense to me.

When is the tachypnea for? Is it pain? Is it delirium? Is it just because the respiratory muscles are so weak? So do they need to go in a controlled setting again? But if they have to go back on AC, do they have to be sedated again? So what do you do with patients that maybe have been on a ventilator for so long, that now they’re too weak to take their own breaths or sustain their own breathing? But they have agitation do they have to? Are they sedated again are you resumed sedation, when you go back into a controlled setting?

Richard Rivera 52:05
We have patients that don’t have sedation. I mean, they they’ve been on a lot. They may have a spinal cord injury, they may have other other issues. We talked to them, this is what we’re doing. And they understand. And they acknowledge and they say yes, let’s, let’s go ahead. So, you know, as these patients progress, it’s really important to have conversations with them explain what we’re doing what we’re not doing, and Charlotte jump jump in. Absolutely. Because it’s really important to not be reliant on things that they can’t use. Outside of the hospital, we’ve got to get them to neuro rehab, we’ve got to get them to home, we’ve got to help them get better. If we keep snowing them, they’re just going to atrophy, they lose their their, their cardiac output, they lose their lung function, we just get immobile little people in beds, which doesn’t reach the goal.

Kali Dayton 52:58
It’s like that big picture is what’s helped seems to be what has helped your team move past this belief that just because they’re intubated, they have to be sedated.

Charlotte Davis 53:07
Yes, and we also have like a, we have a rehab facility too, that’s associated with our hospital we just opened but we also have other rehab hospitals too. So they’re evaluated every day to see if we can move them because we want to our goal is functional recovery for this patient to return them back to their to their pre hospital level of functioning. And so we have lots of patients that are actually intubated or their own, you know, they’re trying to have their own event but they have zero sedation.

We have families there. It’s uh, you know, we keep their wake sleep cycle very clearly defined for those patients we take in, and we allow those families to come in not overstimulate the patient but it calms the patient, we’re able to. And just because there are TBI does not mean they need sedation. And just because they’re there to be as resolved does not mean they don’t still need sedation depends on what the other injuries are.

So you have to look at every patient, every patient and what they need. If they’re TBI is their only primary injury, then once that’s over, our goal is to get them out to rehab hospital. If that’s if we don’t have full functioning recovery in the hospital with our speech therapy or physical therapy or OT PT, it’s already in the ICU us working with them from day one. A lot of our patients are polytrauma. So we’re we don’t have a lot of these patients that are up walking on event because they are poly traumas, but we do get them out to the rehab hospitals to where we can we can normalize them to optimize their functional recovery because that’s what all of our goal is for every 12 hours.

Every shift every nurse we look at everything every med every year, even the lines even down to the invasive ones. Every Foley is looked at every 12 hours. Every central line is looked at every 12 hours. We pull those audits. I even look at like the proper follow up pull tubing to make sure it’s changed every 12 hours. I look at every chest tube dressing to make sure it’s cleared running tag. So we have everybody that’s invested in all of these patients and all of these amazing nurses that we have. And that’s how we get our functional MRI. And our mortality rate rates are so low, I’d say one team one goal.

Richard Rivera 55:13
Yeah, there’s there’s something else. I mean, our trauma team does this very regularly. With with our traumatic brain injury patients, they do assess first utilization or neuro stimulation therapy. And so they will prescribe some some medications. And they’ll talk to pharmacy about when that that’s the right balance, to get them to wake up, a little bit more take over the breathing, work, and so forth. And then we’re getting rid of sedation, we’re getting rid of all these things, because this patient functionally should be be awake, but they’re not. And so that that’s actually part of part of the recipe to success as well. Because we get these patients find the right mix and get them get them to respond. And then they can really participate in their therapy.

Kali Dayton 55:58
Is that when they’re still kind of sluggish for maybe the sedation, or now the hypoactive delirium or even just the TBI?

Richard Rivera 56:06
I’ve seen when we’ve leaned down sedation and they’re still not waking up. Yeah. And so they’re working on it on getting the right mix of neuro stimulant mats so that they can they can move past that from their injury.

Kali Dayton 56:20
And what role do your therapist play? Your occupational, physical, speech therapists? At what point did they get involved? And how does early early mobility even with all these different polytraumas, how does that coordinate with the rest of the team?

Richard Rivera 56:35
They’re part of rounds there in the units, we usually have three to four therapists in our units. We have and we do ambulate vents. It just depends on the situation. Charlotte brought up a great point polytrauma pelvic crush, they’re not moving.

Kali Dayton 56:50
Right.

Richard Rivera 56:53
You know? Yeah. So So depending on the case.

Kali Dayton 56:56
Yeah.

Richard Rivera 56:57
We’re gonna we’re gonna optimize physical therapy, occupational therapy, speech. For each of those patients. Those resources are well embedded in the work we do.

Kali Dayton 57:07
But that door is open because there’s not a belief that just because they’re vented, they have to be sedated or they have to be immobilized. It’s just amazing to hear how much you’ve progressed, how much you’re able to customize care, because you’ve overcome those cultural barriers that a lot of clinicians and teams still struggle with, even with patients that don’t even have a reason to be sedated.

Charlotte Davis 57:29
Yeah, we follow the evidence. And so the evidence does not support just sedating a TBI just because their injury is a TBI. These are not cookie cutter patients. And just because this patient has a traumatic brain injury even just because this patient has a dar diffuse axonal injury, which has been a very high mortality rate associated with the severity of that injury does not mean that they’re going to get sedated every patient’s sedation is tailored to their clinical presentation to the hemodynamic funding is to the intracranial pressure to end organ perfusion.

Our goal is end organ perfusion, is that patient awake? Are they able to oxygenate Are they able to take next you perfused all of their digital organs and tissues if they are and there’s no physiological risk for additional injury, we’re going to wean that patient, and we look to make sure that the we’re using a minimal amount of sedation, each and every shift and every 24 hours. It’s the seat where it has to be a topic of discussion at every single round.

Kali Dayton 58:25
And that is the ABCDEF bundle, ladies and gentlemen, I love it. That is how it’s applied to TBIs. That is so powerful. And, Richard, you track a lot of the data…

Richard Rivera 58:39
Well, so our demographics, it’s important to start there. So we are our facility is located about 30 miles north of the largest retirement community in the United States. And then to the west of us, there’s another retirement community. So our demographics are about 31% over the age of 65. The average population for most hospitals about 17% over 65. So that looks different. Our trauma population then is approximately 17 years older than the average for T quick. So make that looks a little bit different. Right?

Kali Dayton 59:23
Yeah,

Richard Rivera 59:23
Now, all of our T equip indicators are actually in the black and we’ve got a few in the green. Our traumatic brain injury has come down significantly and saw our performance has improved quite quite a bit. We had to learn this process because there isn’t a lot of literature on managing geriatric trauma patients. Why? Because it was a “young male disease”. Let’s be honest.

Kali Dayton 59:46
Yeah,

Richard Rivera 59:46
Right? The risk taker, that is the traditional trauma patient trauma is now looking a little bit different. If you look at the retirement communities around us, they’re very active group. They still are active, they’re exercising, they’re out doing the things I unfortunately took care of a man that got run over by a golf cart, never knew that a golf cart could be so dangerous or they were ejected from a golf cart, or whatever the case may be, you had no idea that these types of injuries would be these would be the mechanism for injury in a population.

So that’s, that’s what it looks like. 4000, little over 4000 trauma admissions last year 3600 stroke admissions last year. So a large number of patients, a lot of those coming through our ICUs, we run 68 critical care beds at our facility. So in in that mortality rate running around point, point four, eight, an expected of one. So doing very well, with the sickest of the thing that includes our neuro, our cardiovascular population, and, of course, our trauma population and our in our general medical ICU population. So little bit of everything all rolled in there. Add to that.

One of the interesting recognitions that we received lately, actually came from our organ procurement organization. They actually recognize that our ICU care allows for organs to be transplantable Wow happened to be one of the largest providers in their catchment area. Because although the traumatic brain injury may be something that ends up being like a dai that Charlotte mentioned, that is not really survivable, or because of a prolonged transport time they had an anoxic injury prior to arriving to the hospital, which is something we can’t reverse, we can still execute the care effectively, so that the next steps can can be successful. So there was quality and survival. There’s also quality at a transition at the end of life. So we’re pretty proud of the work we’re doing but but it’s one case at a time, one patient at a time. If we don’t do it that way. We won’t succeed.

Kali Dayton 1:02:13
And you involve all the tools, all the disciplines at the United Front, which is incredible. Thank you so much for everything that you’ve shared. And Charlotte, I think we’ll have another episode with you talking about how to support nursing education, to empower next generation of nurses and I’m really excited to have other trauma units, follow your example and hopefully have the same outcomes. Thank you so much.

Charlotte Davis 1:02:37
You’re You’re very fabulous.

Richard Rivera 1:02:39
Thank you so much.

Transcribed by https://otter.ai

 

References

TQIP Best Practice Guidelines for the Management of Traumatic Brain. Injury

Management of acute moderate and severe traumatic brain injury

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