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be addressed promptly. In light of all these considerations and Forward surgical teams have been established to push forward
challenges, cervical spine immobilization by forward providers the reach of advanced surgical care into active combat areas.
should be performed promptly with manual inline immobili­ Golden Hour Offset Surgical Transport Teams push the enve­
zation followed by application of a hard collar. Given the cha­ lope further, allowing for establishment of highly mobile and
otic nature of forward combat zones, it is recommended that light surgical capabilities to support Special Operations mis­
clearance of the cervical spine and removal of the collar only sions. 40,41 They are equipped to establish surgical airways in
be performed when patients are transported to a higher­level addition to performing other basic damage control surgery.
41
facility. Clearance of the cervical spine may then be performed A recent publication reported their experiences over the course
as appropriate based on well­established criteria. 8,26 of a deployment and indicated treatment of patients with facial
trauma and concomitant compromised airway. These teams
40
The reported rate of traumatic brain injury associated with are likely to see facial trauma as Special Operations missions
CMF trauma and facial fractures varies widely in the litera­ continue around the globe.
ture, from 5.4% to 85%. 28–32 This wide variation is partly due
to different diagnostic algorithms used by different groups, Conclusion
traumatic mechanism, and severity, but the variation could
also represent the challenge in recognizing these injuries. More It is important for Echelon I and II providers to understand
importantly, when traumatic brain injury is present, it is usu­ the management of patients with combat­sustained CMF in­
ally associated with a high mortality rate. 13,33 Life­threatening juries and what can be done to decrease mortality and mor­
traumatic brain injuries often necessitate prompt neurosur­ bidity rates. Continued education about and training in this
gical interventions, including evacuation of hematomas and anatomic region is critical for forward providers.
monitoring of intracranial pressures. Because these interven­
tions are not available in the austere environment, it is critical Disclosures
for forward trauma team members to have a heightened level The authors have indicated they have no financial relation­
of clinical vigilance when conducting primary and secondary ships relevant to this article to disclose.
surveys on patients with CMF trauma, to recognize any sign
of disability. Early recognition of disability would then prompt Author Contributions
conducting primary stabilization in a hasty and efficient man­ SJF and RSK collected pertinent data and compiled the man­
ner accordingly, followed by evacuation of affected patients uscript draft after thorough review of the topic. All authors
to higher­level facilities where neurosurgical interventions are contributed to editing and final approval of the manuscript.
available.

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