INITIAL EVALUATION

Casualties should initially be evaluated and resuscitated based on JTS guidelines, Advanced Trauma Life Support (ATLS) principles, and Tactical Combat Casualty Care (TCCC) protocols after an acute injury, which may include a potentially concussive event (PCE). PCEs are defined in DoDI 6490.11 and include:

- involvement in a vehicle blast event, collision, or rollover
- presence within 50 meters of a blast (inside or outside)
- a direct blow to the head or witnessed loss of consciousness
- exposure to more than one blast event

The classification of head injury as mild, moderate or severe includes the results of imaging and reports of symptoms for up to 7 days. Thus, for the purposes of initial evaluation in the field, the GCS is the most appropriate initial assessment and has prognostic implications.

Head injured casualties are initially classified according to their GCS score:

- Mild: GCS 13-15
- Moderate: GCS 9-12
- Severe: GCS 3-8

NOTE: If the casualty has a GCS of 12 or less (moderate or severe TBI), please refer to the JTS Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment CPG. This Biomarker CPG does not apply.

If the casualty has no other injuries requiring evacuation, has a GCS of 13 or greater, the MACE2 should be performed. When the TBI whole blood biomarker test is not available, the MACE2 and Enclosure 3 of DoDI 6490.11 should guide initial evaluation in addition to these guidelines. (See Supporting TBI Resources for DoDI 6490.11)

This guidance and algorithm (Appendix A) expands upon the MACE2 and provides initial guidance for locations with access to the new TBI whole blood biomarker test. The TBI whole blood biomarker test should be used in the place of a “structural brain injury” detection device as listed on the MACE 2 under “red flags.” It is important to note that the blood biomarker test does not provide a definitive diagnosis of “structural brain injury” but a negative test result can help to rule it out, thus avoiding unnecessary transport and imaging. It should be used and interpreted in accordance with the intended use statement in Appendix B. The MACE2 red flags help to delineate which individuals should undergo assessment for structural brain injury. This CPG seeks to expand upon the MACE 2 to assist providers in understanding the most appropriate population for assessment with the TBI whole blood biomarker.