Page 134 - Journal of Special Operations Medicine - Fall 2017

An Ongoing Series

Traumatic Brain Injury Management in Prolonged Field Care

David Van Wyck, DO *; Paul Loos, 18D ; Nathan Friedline, MD ; Drew Stephens, MD ;
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Brian Smedick, PA-C ; Randall McCafferty, MD ; Stephen Rush, MD ;
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Sean Keenan, MD ; Doug Powell, MD ; Stacy Shackelford, MD 10
his Role 1, prolonged field care (PFC) guideline is intended Prompt evaluation and intervention are necessary to reduce
Tto be used after Tactical Combat Casualty Care (TCCC) disability and mortality.
Guidelines when evacuation to a higher level of care is not im-
mediately possible. A provider of PFC must first be an expert Rapid evacuation and neurosurgical evaluation, while desir-
in TCCC. This clinical practice guideline (CPG) is meant to able, are not always feasible in austere environments. Never-
provide medical professionals who encounter traumatic brain theless, recent data from the conflicts in Iraq and Afghanistan
injury (TBI) in austere environments with evidence-based have shown improved mortality among military TBI casualties
guidance. Recommendations follow a “best, better, minimum” when compared with similar, propensity score–matched civil-
format that provides alternate or improvised methods when ian TBIs. This is due partly to the aggressive resuscitation that
optimal hospital options are unavailable. A more comprehen- began at the point of injury. PFC providers, therefore, should
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sive guideline for TBI management is available in the Joint be prepared to use resources at hand for aggressive medical
Theater Trauma System Clinical Practice Guideline for Neuro- management in these patients until additional medical and
surgery and Severe Head Injury at http://www.usaisr.amedd surgical assets can be made available.
.army.mil/cpgs.html.
Regardless of mechanism, two categories of injury occur with
TBI occurs when external mechanical forces impact the head TBI: primary and secondary. Primary injury occurs at the time
and cause an acceleration/deceleration of the brain within the of injury and results in irreversible damage to brain tissue.
cranial vault that results in injury to brain tissue. TBI may be There are no effective treatments for primary injury.
closed (blunt or blast trauma) or open (penetrating trauma).
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Signs and symptoms of TBI are highly variable and depend Secondary injury, in contrast, occurs as a result of a complex
on the specific areas of the brain affected and the injury se- inflammatory cascade that results in rapid development of
verity. Alteration in consciousness and focal neurologic defi- brain swelling, rise in intracranial pressure, and subsequent
cits are common. Various forms of intracranial hemorrhage decrease in cerebral perfusion. When severe, this can lead to
(ICH), such as epidural hematoma, subdural hematoma, sub- massive swelling, compression of the brainstem, and, ulti-
arachnoid hemorrhage, and hemorrhagic contusion can be mately, death. Thus, the primary focus of TBI management is
components of TBI. The vast majority of TBIs are categorized on limiting the effects of secondary brain injury. The brain pos-
as mild and are not considered life threatening; however, it is sesses minimal cellular oxygen reserve and, therefore, is highly
important to recognize this injury because if a patient is ex- dependent on a continuous supply of oxygenated blood. A
posed to a second head injury while still recovering from a systolic blood pressure (SBP) <90mmHg or oxygen saturation
mild TBI, they are at risk for increased long-term cognitive via pulse oximetry (Spo ) <90% more than doubles the risk
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effects. Moderate and severe TBIs are life-threatening injuries. of death from brain injury. The management of hypotension,
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*Correspondence to david.vanwyck.mil@mail.mil
1 MAJ Van Wyck, MC, USA, completed fellowship training in neurocritical care at Duke University Hospital in Durham, NC, and is a neurolo-
gist at Womack Army Medical Center, Fort Bragg, NC. SFC Loos, 18D, USA, is the Noncommissioned Officer in Charge of Special Forces
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Medical Sergeant Surgery, Anesthesia, Records and Reports at the Joint Special Operations Medical Training Center, Special Warfare Medical
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Group at Fort Bragg, NC. MAJ Friedline, MC, USA, is a board-certified emergency medicine physician on the teaching staff in the Madigan
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Army Medical Center Emergency Medicine Residency Program. LTC Stephens, MC, USA, is a physician instructor at the International Special
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Training Center, Pfullendorf, Germany and director of surgical critical care, Case Medical Center, Cleveland, OH. MAJ Smedick, PA-C, USA,
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is an aeromedical physician assistant (PA) and the PA for the 4th Battalion 3rd Special Forces Group (Airborne). Col McCafferty, MC, USAF,
is Air Force surgeon general consultant for neurosurgery and master clinician at San Antonio Military Medical Center and is programmatic
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chairman of the congressionally directed Spinal Cord Injury Research Program. Lt Col Rush, MC, USAF, is the USAF pararescue medical
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director and flight surgeon for the 103rd rescue squadron in the Air National Guard, Westhampton Beach, COL Keenan, MC, USA, is com-
mand surgeon, Special Operations Command, Europe. He has previously served as battalion surgeon in both 1st and 3rd SFG(A), and as group
surgeon, 10th SFG(A). He is a member of the Special Operations Medical Association Prolonged Field Care Working Group Steering Commit-
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tee. MAJ Powell, MC, USA, is an intensive care physician currently serving as the 4th Battalion 3rd Special Forces Group (Airborne) Surgeon
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and a staff intensivist at Womack Army Medical Center, Fort Bragg, NC. Col Shackelford, MC, USAF, is chief of performance improvement,
Joint Trauma System, San Antonio, TX.
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