Acute Mild Traumatic Brain Injury Assessment and Management in the Austere Setting - A Review

Abstract

Introduction: Traumatic brain injury (TBI) continues to be a major source of military-related morbidity and mortality. The insidious short- and long-term sequelae of mild TBIs (mTBIs) have come to light, with ongoing research influencing advances in patient care from point of injury onward. Although the DoDI 6490.11 outlines mTBI care in the deployed setting, there is currently no standardized training requirement on mTBI care in the far-forward deployed setting. As the Joint Trauma System (JTS) is considered to be one of the leaders in standard of care trauma medicine in the deployed environment and is often the go-to resource for forward-deployed medical providers, it is our goal that this review be utilized by the JTS with prominent mTBI resources to disseminate a clinical practice guideline (CPG) appropriate for the far-forward operational environment. Materials and Methods: The resources used for this review reflect the most current data, knowledge, and recommendations associated with research and findings from reputable sources as the Traumatic Brain Injury Center of Excellence (TBI CoE; formerly the Defense and Veterans Brain Injury Center), the Center for Disease Control and Prevention, as well as prominent journals such as Academic Emergency Medicine, British Journal of Sports Medicine, and JAMA. We searched for articles under keyword searches, limiting results to less than 5 years old, and had military relevance. About 1,740 articles were found using keywords; filters on our search yielded 707 articles, 100 of which offered free full text. The topic of far-forward deployed management of mTBI does not have a robust academic background at this time, and recommendations are derived from a combination of academic evidence in more traditional clinical settings, as well as author's direct experience in managing mTBI casualties in the austere environment. Results: At the time of this writing, there is no JTS CPG for management of mTBI and there is no pre-deployment training requirement for medical providers for treating mTBI casualties in the far-forward deployed setting. The TBI CoE does, however, have a multitude of resources available to medical providers to assist with post-mTBI care. In this article, we review these clinical tools, pre-planning considerations including discussions and logistical planning with medical command, appropriate evaluation and treatment for mTBI casualties based on TBI CoE recommendations, the need for uniform and consistent documentation and diagnosis in the acute period, tactical and operational considerations, and other considerations as a medical provider in an austere setting with limited resources for treating casualties with mTBIs. Conclusions: Given the significant morbidity and mortality associated with mTBIs, as well as operational and tactical considerations in the austere deployed setting, improved acute and subacute care, as well as standardization of care for these casualties within their area of operations is necessary. The far-forward deployed medical provider should be trained in management of mTBI, incorporate mTBI-associated injuries into medical planning with their command, and discuss the importance of mTBI management with servicemembers and their units. Proper planning, training, standardization of mTBI management in the deployed setting, and inter-unit cooperation and coordination for mTBI care will help maintain servicemember readiness and unit capability on the battlefield. Standardization in care and documentation in this austere military environment may also assist future research into mTBI management. As there is currently no JTS CPG covering this type of care, the authors recommend sharing the TBI CoE management guideline with medical providers who will be reasonably expected to evaluate and manage mTBI in the austere deployed setting.