Page 126 - JSOM Fall 2021

a thorough history and physical exam. Questions asked in- a MACE2 score of 25 or above and may not have been within
cluded where the Soldiers were during the attack, what per- 50 m of the blast. Consultation with the theater neurosurgeon
sonal protective equipment (PPE) they were wearing, their was considered; however, it was deferred due to the low acuity.
distance from the blast center, if they felt the blast wave, and if Additionally, surgical intervention was not indicated.
they were in the bunkers. As part of the physical examination,
each individual received a MACE2 exam. Most of the Soldiers
that were within 100 m of the blast exhibited symptoms of Lessons Learned
headaches, difficulty concentrating, memory concerns, tinni- Criteria and Timeline Regarding TBI Diagnosis
tus, irritability, and sleep issues. All of the evaluated Soldiers’ Diagnosis for a TBI is clinical and primarily dependent on a
neurologic exams were normal, and the majority of the Sol- patient’s history of symptoms. Though a MACE2 is a valuable
diers had a MACE2 score > 25, which is considered normal. tool, it needs to be executed within 12 hours of the event to
Additionally, several Soldiers reported exposure to fumes, par- have an optimal and clinically relevant value. Understanding
ticulates, and smoke from impact sites. In the end, 87 Soldiers the DoD/VA CPG on TBIs and DoD policy for managing TBI
were evaluated and diagnosed with TBIs within 24 hours. patients in a deployed setting – DoDI 6490.11 – is critical in
providing care to the patient and providing guidance for com-
mand teams. DoDI 6490.11 incorporates a 50-m radius from
Potential Causes and Definition of TBI
a blast for potential concussive events. However, it does not
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The Department of Defense Instruction (DoDI) 6490.11 de- account for all types of ordinances or channelization of the
fines a potentially concussive event as including, but not lim- terrain directing the blast wave. Therefore, medical person-
ited to: nel should be cognizant of the blast’s context and not forgo a
TBI diagnosis, even if the individual may not have been within
• Involvement in a vehicle blast event, collision, or rollover 50 m (Table 1).
• Presence within 50 m of a blast (inside or outside)
• A direct blow sustained to the head or witnessed loss of Accountability and Reporting
consciousness Timely and accurate reporting of injuries during a mass casualty
• Exposure to more than one blast event (the Servicemem- event may be limited, with the first reports possibly inaccurate.
ber’s commander should direct a medical evaluation Reporting casualties requires a medical provider to provide a
diagnosis and a command element to relay pertinent informa-
The 2016 DoD/Veterans’ Administration (VA) Clinical Prac- tion to higher commands. Therefore, a broken chain of report-
tice Guideline (CPG) defines a TBI as “a traumatically induced ing impacts timely and accurate information flow. As witnessed
structural injury and/or physiological disruption of brain func- during this event, the medical provider and platoon leader were
tion of an external force. . . .” In addition to a traumatic event both injured themselves. The injuries sustained by these key
to the brain, a Soldier must exhibit at least one of the follow- personnel were a potential contributing factor as to why the
ing symptoms: initial report was inaccurate, with only zero casualties initially
reported. All medical personnel should reach out to other units
• Any period of loss of or a decreased level of consciousness occupying the base. This would not only enable an accurate
• Any loss of memory for events immediately before or reporting of casualties but may also expeditiously identify any
after the injury (posttraumatic amnesia) medically compromised leadership that needs assistance.
• Any alteration in mental state at the time of injury (e.g.,
confusion, disorientation, slowed thinking, alteration of Documentation
consciousness/mental state) Accurate medical documentation of all injuries is critical to
• Neurologic deficits (e.g., weakness, loss of balance, ensuring continuity of care with future medical providers.
change in vision, praxis, paresis/plegia, sensory loss, This documentation is also a crucial component for awards
aphasia) that may or may not be transient such as Purple Hearts. In this situation, Standard Form (SF)
• Intracranial lesions 3 600s were written for the Soldiers involved and uploaded into
Armed Forces Health Longitudinal Technology Application
The majority of the Soldiers involved had symptoms consis- ( AHLTA)-Theater (AHLTA-T). However, roughly 10 days
tent with an alteration of consciousness immediately follow- passed between uploading the documents and when the docu-
ing the blast. Additionally, for several Soldiers, the symptoms ments became available in AHLTA-T. Notably, documenting a
were ongoing. Per the CPG for the alteration of consciousness concussion in AHLTA-T triggers additional reporting mecha-
(AOC), mental status is defined as “. . . immediately related nisms for potential casualties in a deployed location.
to the trauma to the head. Typical symptoms include: looking
and feeling dazed and uncertain of what is happening, confu- Role of Omega-3 in TBI Recovery
sion, difficulty thinking clearly or responding appropriately to Treatment for mild TBI (mTBI) is multifactorial. In addition to
mental status questions, and being unable to describe events brain rest and a gradual return to duty, Soldiers diagnosed with
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immediately before or after the trauma event.” While most a mTBI after the attack began taking omega-3 fish oils. The
of the Soldiers’ MACE2 scores were > 25, the sensitivity and protocol consists of 9g fish oil a day for week 1, 6g of omega-3
specificity of the cognitive test decrease significantly after 12 fish oils a day for week 2, and 3g of omega-3 fish oils daily for
hours from the event. Additionally, DoDI 6490.11 defines a maintenance thereafter. Though studies have primarily been
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potentially concussive event as being, but not limited to, within animal-based, omega-3 fish oils’ anti- inflammatory properties
50 m of a blast. Not all Soldiers were within 50 m of a blast but may assist in neuroprotection and regeneration postconcus-
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still sustained symptoms consistent with an AOC. Therefore, sion. The use of omega-3s have a low risk for adverse reaction
Soldiers were diagnosed with mild to moderate TBI if they fit such as increased bleeding but may have a significant impact
the criteria set forth by the CPG even though most of them had on a patient’s long-term cognitive health. 6

124 | JSOM Volume 21, Edition 3 / Fall 2021