小结
定义
颅脑损伤是指头部受到任何创伤，伴或不伴脑部损伤。根据损伤程度可分为轻微损伤、轻度损伤、中度损伤、重度损伤。轻微颅脑损伤是指受到头部损伤后无意识丧失、格拉斯哥昏迷量表 (Glasgow coma scale, GCS) 评分正常，并且没有颅脑损伤的症状。轻度颅脑损伤是指受到损伤后，GCS 评分为 13-15 分。[1]Centers for Disease Control and Prevention. Traumatic brain injury and concussion. July 2017. http://www.cdc.gov [Internet publication].http://www.cdc.gov/TraumaticBrainInjury/
阅读更多外伤性颅脑损伤 (traumatic brain injury, TBI) 是用于描述脑部钝性伤、贯通伤、爆裂伤的非特定术语。对于 TBI，可以根据伤后 GCS 评分和/或神经行为缺陷将其分为轻度、中度、重度。
在运动相关文献中，“脑震荡”一词常与轻度 TBI 和轻微或轻度颅脑损伤替换使用。CDC 和 WHO 都认为轻度 TBI 是由钝力或机械力导致的不超过 30 分钟的一过性意识模糊、定向力障碍或意识丧失，可能伴有一过性神经行为缺陷，并且 GCS 评分不低于 13-15 分。[2]McCrea HJ, Perrine K, Niogi S, et al. Concussion in sports. Sports Health. 2013;5(2):160-4.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658375/http://www.ncbi.nlm.nih.gov/pubmed/24427385?tool=bestpractice.comCDC: heads up然而，关于 GCS 评分为 13 分的患者是否应该归类为有中度 TBI 仍存在持续不断的争议。
分类
TBI 可以根据多种方法归类：包括类型、严重程度、部位、损伤机制、机体对损伤的生理反应。这种不统一性被看作是妨碍建立 TBI 有效治疗措施的重要因素之一。[3]Saatman KE, Duhaime AC, Bullock R, et al; Workshop Scientific Team and Advisory Panel Members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma. 2008;25(7):719-38.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721779/http://www.ncbi.nlm.nih.gov/pubmed/18627252?tool=bestpractice.com 英国和美国尝试规范了 TBI 疾病亚组的命名、定义及分类，这对于在 TBI 研究中减少资料编码的多变性和提高数据收集的质量有潜在意义。[4]Adelson PD, Pineda J, Bell MJ, et al. Common data elements for pediatric traumatic brain injury: recommendations from the working group on demographics and clinical assessment. J Neurotrauma. 2012;29(4):639-53.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289844/http://www.ncbi.nlm.nih.gov/pubmed/21939389?tool=bestpractice.com[5]Ardolino A, Sleat G, Willett K. Outcome measurements in major trauma - results of a consensus meeting. Injury. 2012;43(10):1662-6.http://www.ncbi.nlm.nih.gov/pubmed/22695320?tool=bestpractice.com[6]Berger RP, Beers SR, Papa L, et al. Common data elements for pediatric traumatic brain injury: recommendations from the biospecimens and biomarkers workgroup. J Neurotrauma. 2012;29(4):672-7.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289842/http://www.ncbi.nlm.nih.gov/pubmed/22106839?tool=bestpractice.com
按照临床严重程度分类
GCS评分被广泛用于 TBI 严重程度以及预后的分级。[7]Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017 Jan 1;80(1):6-15.https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/27654000?tool=bestpractice.com[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com 受到外伤性颅脑损伤后，GCS 评分与 CT 的阳性发现上存在负相关。事实上，当 GCS 评分由 15 分降到 14 分时，发生颅内损伤和需要神经外科干预的概率翻倍。[9]Smits M, Dippel DW, Steyerberg EW, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. 2007;146(6):397-405.http://www.ncbi.nlm.nih.gov/pubmed/17371884?tool=bestpractice.com[10]Ibañez J, Arikan F, Pedraza S, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. 2004;100(5):825-34.http://www.ncbi.nlm.nih.gov/pubmed/15137601?tool=bestpractice.com
轻微/轻度外伤性颅脑损伤：GCS 评分 13-15 分，死亡率为 0.1%
中度外伤性颅脑损伤：GCS 评分：9-12 分，死亡率为 10%
重度外伤性颅脑损伤：GCS 评分：<9 分，死亡率为 40%
很多学者出于对颅脑外伤患者颅内感染的高发以及不良预后的考虑，将 GCS 评分在 13 分的患者归为中度颅脑损伤，而不是轻微/轻度颅脑损伤。[11]Türedi S, Hasanbasoglu A, Gunduz A, et al. Clinical decision instruments for CT scan in minor head trauma. J Emerg Med. 2008;34(3):253-9.http://www.ncbi.nlm.nih.gov/pubmed/18180129?tool=bestpractice.com[12]Pearson WS, Ovalle F Jr, Faul M, et al. A review of traumatic brain injury trauma center visits meeting physiologic criteria from the american college of surgeons committee on trauma/centers for disease control and prevention field triage guidelines. Prehosp Emerg Care. 2012 Jul-Sep;16(3):323-8.http://www.ncbi.nlm.nih.gov/pubmed/22548387?tool=bestpractice.com[13]Mena JH, Sanchez AI, Rubiano AM, et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma. 2011;71(5):1185-92; discussion 1193.http://www.ncbi.nlm.nih.gov/pubmed/22071923?tool=bestpractice.com[14]Fabbri A, Servadei F, Marchesini G, et al. Observational approach to subjects with mild-to-moderate head injury and initial non-neurosurgical lesions. J Neurol Neurosurg Psychiatry. 2008 Oct;79(10):1180-5.http://www.ncbi.nlm.nih.gov/pubmed/18356255?tool=bestpractice.com 澳大利亚的临床指南意识到 GCS 评分下降到 13 分与发病率的增加之间存在联系，因此将轻度 TBI 患者的 GCS 评分归到 14 或 15 分。[15]New South Wales Ministry of Health. Closed head injury in adults - initial management. Feb 2012 [internet publication].http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_013.pdf
梅奥分级系统根据患者的临床和 CT 表现，将 TBI 患者分为肯定、可能性大和可能三种等级。[16]Malec JF, Brown AW, Leibson CL, et al. The Mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007 Sep;24(9):1417-24.http://www.ncbi.nlm.nih.gov/pubmed/17892404?tool=bestpractice.com
根据病因分类
钝性 TBI：发生在表面受到机械力作用，迅速地加速、减速时发生的脑损害。最典型的是发生在机动车相关的损伤中，跌倒、挤压伤或肢体冲突。
穿透性 TBI：发生在异物刺穿颅骨、破坏硬脑膜时，多常见于枪弹伤和刺伤。
冲击性 TBI：常见于炸弹爆炸后和战后，由接触力、惯力、压力过大和声波联合导致。[17]Ling G, Bandak F, Armonda R, et al. Explosive blast neurotrauma. J Neurotrauma. 2009 Jun;26(6):815-25.http://www.ncbi.nlm.nih.gov/pubmed/19397423?tool=bestpractice.com
根据受累区域分类
根据累及区域可以将 TBI 分为弥漫性和局灶性，但这两种类型经常同时存在。
弥漫性颅脑损伤包括：弥漫性轴索损伤 (diffuse axonal injury)、缺氧性脑损伤、弥漫性脑水肿、弥漫性血管损伤。[18]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41.http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
局部损伤包括：一些特定损伤，例如擦伤、颅内血肿、脑梗死、轴突断裂、脑神经离断、颅骨骨折。[18]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41.http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
根据损伤的发展分级
最初的损伤是由于直接的机械力,无论是钝性、穿透或爆炸，可能包括以下内容：
颅骨骨折
挫伤
血肿
蛛网膜下/硬膜下血肿
轴突离断或撕裂。
继发性损伤指原发性损伤不断演化的病理生理机制的结果，涉及很多原发性损伤后在细胞水平改变或启动的复杂神经生物学级联，可能包括以下：[18]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41.http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
脑水肿
颅内压力增高 (ICP)
出血
癫痫发作
缺血
感染。
TBI 的流行病学
TBI 是并发症和死亡的重要原因，每年在美国和英国分别导致超过 200 万次[19]Coronado VG, McGuire LC, Sarmiento K, et al. Trends in traumatic brain injury in the U.S. and the public health response: 1995-2009. J Safety Res. 2012 Sep;43(4):299-307.http://www.ncbi.nlm.nih.gov/pubmed/23127680?tool=bestpractice.com 和超过 100 万次的突发事件和急诊室就诊。[20]National Institute for Health and Care Excellence. Head injury: assessment and early management. Jun 2017 [internet publication].http://www.nice.org.uk/Guidance/CG176 一项 2017 年的综述强调了 TBI 给低收入国家所带来的残疾和死亡的负担，要多于高收入国家。[21]Maas AIR, Menon DK, Adelson PD, et al; InTBIR Participants and Investigators. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048.http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(17)30371-X/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/29122524?tool=bestpractice.com
约 80% 的 TBI 患者有轻度颅脑损伤，并且除接受影像学诊断外未接受入院治疗或干预。[22]Pandor A, Goodacre S, Harnan S, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011 Aug;15(27):1-202.http://www.journalslibrary.nihr.ac.uk/hta/volume-15/issue-27http://www.ncbi.nlm.nih.gov/pubmed/21806873?tool=bestpractice.com 约 20% 的患者需要住院治疗，6% 的患者永久残疾，死亡率约为 3%。[23]Faul M, Xu L, Wald MM, et al. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths 2002-2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf[24]Tennant A. Admission to hospital following head injury in England: incidence and socio-economic associations. BMC Public Health. 2005 Mar 4;5:21.https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-5-21http://www.ncbi.nlm.nih.gov/pubmed/15748288?tool=bestpractice.com
TBI 是引起 25 岁以下人群死亡的最常见原因。该病最常发生于婴幼儿（0-4 岁）以及青少年和青年人（15-24 岁），其次最常发生于老年人（>65 岁）。因 TBI 住院/死亡的人以老年人为主。[25]Butcher I, McHugh GS, Lu J, et al. Prognostic value of cause of injury in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007 Feb;24(2):281-6.http://www.ncbi.nlm.nih.gov/pubmed/17375992?tool=bestpractice.com[26]Fearnside MR, Cook RJ, McDougall P, et al. The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg. 1993;7(3):267-79.http://www.ncbi.nlm.nih.gov/pubmed/8338647?tool=bestpractice.com
在所有亚组的颅脑外伤的患者中，男性与女性的发病比例达到了 3:1。需要行神经外科干预（开颅手术、颅骨骨折修复术、颅内压监测、脑室引流）的患者包括将近 40% 的严重 TBI 患者、10% 的中度 TBI 患者、1% 的轻度 TBI 患者。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[27]Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 Suppl):S16-24.http://www.ncbi.nlm.nih.gov/pubmed/16710968?tool=bestpractice.com 脑震荡后综合征 (post-concussive syndrome, PCS) 是 TBI（即使是轻度）导致的神经行为后遗症，涉及身体、认知和情感范畴，患者常诉头痛、头晕、注意力不集中和抑郁。大约 30% 的儿童和成人在受伤超过 30 天后出现持续性脑震荡后症状。[28]Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25.http://www.ncbi.nlm.nih.gov/pubmed/26954410?tool=bestpractice.com[29]de Koning ME, Scheenen ME, van der Horn HJ, et al. Non-hospitalized patients with mild traumatic brain injury: the forgotten minority. J Neurotrauma. 2017 Jan 1;34(1):257-61.http://www.ncbi.nlm.nih.gov/pubmed/27029852?tool=bestpractice.com
在英国，估计每年医疗花费和因生产力暂时或永久性缺口导致的损失超过 150 亿英镑。[30]Parsonage M; Centre for Mental Health. Traumatic brain injury and offending: an economic analysis. Jul 2016 [internet publication].https://www.centreformentalhealth.org.uk/traumatic-brain-injury[31]Morris S, Ridley S, Lecky FE, et al. Determinants of hospital costs associated with traumatic brain injury in England and Wales. Anaesthesia. 2008 May;63(5):499-508.http://www.ncbi.nlm.nih.gov/pubmed/18412648?tool=bestpractice.com 在美国，这一花费为 700 亿美元。[32]American College of Surgeons: ACS TQIP best practices in the management of traumatic brain injury. Jan 2015 [internet publication].https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/traumatic%20brain%20injury%20guidelines.ashx 即使在轻度 TBI 病例中，也可能出现长久的神经系统认知障碍，对患者及其家人造成了巨大的精神负担，并给社会带来了经济负担。一些出院诊断为轻度 TBI 的患者在创伤后 3 个月仍有症状。 [33]Lannsjö M, af Geijerstam JL, Johansson U, et al. Prevalence and structure of symptoms at 3 months after mild traumatic brain injury in a national cohort. Brain Inj. 2009 Mar;23(3):213-9.http://www.ncbi.nlm.nih.gov/pubmed/19205957?tool=bestpractice.com
具体损伤的流行病学
大多数患者有复合伤。
TBI 患者 CT 最常见的是创伤性蛛网膜下腔出血，在中度/重度 TBI 患者中占到 30%-40% 的比例，在轻度 TBI 患者中占 5%。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[34]Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165.http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050165http://www.ncbi.nlm.nih.gov/pubmed/18684008?tool=bestpractice.com[35]Roberts I, Yates D, Sandercock P, et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15;364(9442):1321-8.http://www.ncbi.nlm.nih.gov/pubmed/15474134?tool=bestpractice.com 蛛网膜下腔出血常合并其他损伤。SAH 与中度或重度 TBI 患者的临床结局更差有关，但目前尚不清楚 SAH 是不是损伤严重程度的标志，也不清楚临床结局更差是否因之后的血管痉挛导致。[36]Kramer DR, Winer JL, Pease BA, et al. Cerebral vasospasm in traumatic brain injury. Neurol Res Int. 2013;2013:415813.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3703898/http://www.ncbi.nlm.nih.gov/pubmed/23862062?tool=bestpractice.com
硬膜下血肿 (Subdural haematomas, SDH) 是 TBI 最常见的病变类型，有 20% 左右的中重度 TBI 患者和 30% 的致命性 TBI 患者会发生 SDH，只有 3% 的轻度 TBI 患者会发生 SDH。导致住院或死亡的 SDH 最常继发于较年轻成人中的机动车相关损伤以及年龄较大的成人中的跌倒。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[27]Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 Suppl):S16-24.http://www.ncbi.nlm.nih.gov/pubmed/16710968?tool=bestpractice.com
硬膜外血肿 (Epidural haematomas, EDH)一般出现在 10% 的中重度 TBI 和 1% 的轻微 TBI 患者中。EDH 发生率最高的是青少年和 20-30 岁的成年人。 DH大多数病例是由交通事故、跌倒和暴力事件引起的。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[34]Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165.http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050165http://www.ncbi.nlm.nih.gov/pubmed/18684008?tool=bestpractice.com
脑挫裂伤发生在 20%-30% 有中度至重度 TBI 的患者和 6% 的轻度 TBI 患者。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[35]Roberts I, Yates D, Sandercock P, et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15;364(9442):1321-8.http://www.ncbi.nlm.nih.gov/pubmed/15474134?tool=bestpractice.com[37]Iaccarino C, Schiavi P, Picetti E, et al. Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg. 2014 Apr;120(4):908-18.http://www.ncbi.nlm.nih.gov/pubmed/24506250?tool=bestpractice.com
脑内血肿发生在 10%-30% 的中度至重度 TBI 患者，和<1%的轻微 TBI 患者。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[18]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41.http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
可能在某种程度上弥漫性轴索损伤 (Diffuse axonal injury,DAI) 存在于大部分 TBI 患者，虽然通常 CT 很难发现低级别的轴突损伤。首次 CT 检查正常的患者有 50%-80% 最终被诊断为 DAI，但 MRI 显示中度至重度 TBI 患者中有 70% 存在轴索损伤。CT检查显示轴突损伤 TBI 患者<1%，而 MRI 显示微观结构的损伤程度更大。认为所有 TBI 相关死亡和导致持续性植物状态的 TBI 都有一定程度的 DIA。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com[38]Skandsen T, Kvistad KA, Solheim O, et al. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg. 2010 Sep;113(3):556-63.http://www.ncbi.nlm.nih.gov/pubmed/19852541?tool=bestpractice.com
约 5% 轻度 TBI 患者和 50% 的重度 TBI 患者发生颅骨骨折。大多数的颅骨骨折是由于跌倒、暴力或与交通事故有关的伤害。最常见的骨折是单纯线性骨折，占所有颅骨骨折 50% 以上。不到 1% 轻微的 TBI 患者发生凹陷性颅骨骨折。[8]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com
穿透伤分为高速或低速，可能是自己造成的、非故意的或与暴力相关。头部有单处枪伤的死亡率约为 50%。[39]Cripps MW, Ereso AQ, Sadjadi J, et al. The number of gunshot wounds does not predict injury severity and mortality. Am Surg. 2009 Jan;75(1):44-8.http://www.ncbi.nlm.nih.gov/pubmed/19213396?tool=bestpractice.com
爆炸伤是战区现役军事人员损伤的主要原因，占重型颅脑损伤的 60%。[40]Defense and Veterans Brain Injury Center. Blast injuries. Oct 2017 [internet publication].http://dvbic.dcoe.mil/article/blast-injuries[41]DuBose JJ, Barmparas G, Inaba K, et al. Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma. 2011 Jan;70(1):11-8.http://www.ncbi.nlm.nih.gov/pubmed/21217475?tool=bestpractice.com
贡献者
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Albert J. Lauro Professor of Medicine/Emergency Medicine
Clinical Professor Medicine/Emergency Medicine
Director of Education
Section of Emergency Medicine
Louisiana State University Health Science Center
New Orleans
LA
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MJH is an author of a reference cited in this monograph.Dr Micelle J. Haydel would like to gratefully acknowledge Dr Victoria E. Johnson, Dr Marek Ma, Dr Nathan Ranalli, and Dr Douglas H. Smith, previous contributors to this monograph. VEJ, MM, NR, and DHS declare that they have no competing interests.
同行评议专家 查看所有
Director of Research
Department of Emergency Medicine
Emory University
Atlanta
GA
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DWW declares that he has no competing interests.Senior Lecturer In Neurology
Imperial College
London
UK
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DS declares that he has no competing interests.
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