Traumatic Brain Injury Management in Prolonged Field Care

INTRODUCTION

This Role 1, prolonged field care (PFC) guideline is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines when evacuation to a higher level of care is not immediately possible. A provider of PFC must first be an expert in TCCC. This clinical practice guideline (CPG) is meant to provide medical professionals who encounter traumatic brain injury (TBI) in austere environments with evidence-based guidance. Recommendations follow a “best, better, minimum” format that provides alternate or improvised methods when optimal hospital options are unavailable. Refer to the JTS Traumatic Brain Injury and Neurosurgery in the Deployed Environment, 15 Sep 2023 CPG for more comprehensive guidelines for TBI management

TBI occurs when external mechanical forces impact the head and cause an acceleration/deceleration of the brain within the cranial vault which results in injury to brain tissue. TBI may be closed (blunt or blast trauma) or open (penetrating trauma).1 Signs and symptoms of TBI are highly variable and depend on the specific areas of the brain affected and the injury severity. Alteration in consciousness and focal neurologic deficits are common. Various forms of intracranial hemorrhage (ICH), such as epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and hemorrhagic contusion can be components of TBI. The vast majority of TBIs are categorized as mild and are not considered life threatening; however, it is important to recognize this injury because if a patient is exposed to a second head injury while still recovering from a mild TBI, they are at risk for increased long-term cognitive effects. Moderate and severe TBIs are life-threatening injuries.

Prompt evaluation and intervention are necessary to reduce disability and mortality. Rapid evacuation and neurosurgical evaluation, while desirable, are not always feasible in austere environments. Nevertheless, recent data from the conflicts in Iraq and Afghanistan have shown improved mortality among military TBI casualties when compared with similar, propensity score–matched civilian TBIs. This is due partly to the aggressive resuscitation that began at the point of injury.2 PFC providers, therefore, should be prepared to use resources at hand for aggressive medical management in these patients until additional medical and surgical assets can be made available.

Regardless of mechanism, two categories of injury occur with TBI: primary and secondary. Primary injury occurs at the time of injury and results in irreversible damage to brain tissue.

There are no effective treatments for primary injury. Secondary injury, in contrast, occurs as a result of a complex inflammatory cascade that results in rapid development of brain swelling, rise in intracranial pressure, and subsequent decrease in cerebral perfusion. When severe, this can lead to massive swelling, compression of the brainstem, and, ultimately, death. Thus, the primary focus of TBI management is on limiting the effects of secondary brain injury. The brain possesses minimal cellular oxygen reserve and, therefore, is highly dependent on a continuous supply of oxygenated blood. A systolic blood pressure (SBP) <90mmHg or oxygen saturation via pulse oximetry (SpO2) <90% more than doubles the risk of death from brain injury.3 The management of hypotension, hypoxia, hypocarbia or hypercarbia, hypoglycemia, and signs of elevated intracranial pressure (ICP) is essential.

Telemedicine – Management of TBI is complex. Establish a telemedicine consultation as soon as possible.