PURPOSE

These guidelines are not intended to supplant physician judgment. Rather, these guidelines are intended to provide a basic framework for those less experienced with the delivery of care in this setting to the brain injured patient, as well as to educate and provide insight to others on the delivery of care in a restrictive environment.

BACKGROUND

Traumatic brain injury (TBI) occurs in about one third of all trauma-related deaths in the United States and remains one of the most common causes of death on the modern battlefield.1,2 The Committee on Surgical Combat Casualty Care (CoSCCC) published a Neurosurgical Capabilities Position Statement in Feb 2023 given the importance of this issue. Specific to the combat environment:

- Positive outcomes are achieved through point of injury care to prevent secondary brain injury (avoid hypoxia, avoid hypotension), rapid evacuation from the battlefield, early medical management, timely neurosurgical intervention, meticulous critical care, and dedicated rehabilitation.3-9
- Optimal outcomes for severe TBI (Glasgow Coma Score [GCS] </=8) in theatre require a neurosurgical capability defined as a neurosurgeon, advanced imaging, required surgical sets, required monitoring, and critical care.
- For conflicts in Afghanistan and Iraq, Department of Defense Trauma Registry (DoDTR) data demonstrate: 10,11
  - 14% of casualties sustained a traumatic brain injury.10
  - TBI was the mechanism of death for 30% of prehospital deaths from 2001 to 2011 and 45% of hospital deaths from 2001 to 2009.12
  - From 2014 to 2021 Armed Forces Medical Examiner System (AFMES) data demonstrate TBI accounted for 23% of prehospital deaths and 30% of hospital deaths (Unpublished JTS-AFMES data).
  - Over 5,600 neurosurgical procedures were performed in-theater between 2002-2016.12
  - Casualties with a TBI and an indication for neurosurgical intervention were more likely to survive if they received surgery within 5 hours of injury.9
  - Neurosurgical interventions performed on the battlefield after penetrating injuries result in improved survival.13
- Severe TBI also occurs during routine and crisis contingency operations, both ground and maritime combat, with an associated mortality of 69.7%.
- The incidence of TBI after non-combat maritime mass casualty events such as collisions is 5.8%; during modern naval warfare when warships are attacked by missile strikes or other explosive devices, the incidence of severe TBI is 17.2%.14
- Some patients with severe closed and penetrating brain injury had favorable outcomes when treated in military medical treatment facilities (MTFs) and received timely and aggressive neurosurgical and neuro-critical care interventions.2-5,9

CLASSIFICATION

The classification of brain injury informs prognosis and care eligibility in the combat environment. Brain injury severity is classified according to their GCS.