Guidelines for Field Management of Combat-Related Head Trauma
View the complete Guidelines, including methods and detailed evidence review here
The index of Guideline recommendations can be found below
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A. Hypoxemia and hypotension are two considerable factors associated with poor prognosis in severe traumatic brain injury (TBI) patients in the prehospital setting.
B. All reasonable efforts should be made to avoid hypoxemia and hypotension in the brain injured casualty. Reasonable efforts will be dictated by situation, available resources, and the tactical situation.
• Hypoxemia should be prevented in the brain injured casualty. Pulse oxymetry should be instituted as soon as possible along the chain of evacuation. Low oxygenation should be addressed as soon as it is practical to do so along the chain of evacuating.
• Hypotension should be avoided. Blood pressure should be measured as soon as possible along the chain of evacuation. Fluid resuscitation should be instituted for patients with systolic pressure < 90 as soon as resources and the tactical situation allow.
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A. Data are insufficient to support a treatment standard for Glasgow Coma Scale (GCS) scoring and pupil assessment in patients with severe traumatic brain injury (TBI) incurred in combat.
B. Measuring GCS score and assessing pupils:
How to measure: The GCS score and pupil assessment should be determined by direct clinical examination.
Who should measure:
• The far forward first medical provider (medic) should obtain the first score
• At each echelon of care, the primary medical care provider should be responsible for measuring the GCS and assessing the pupils
• Competence in measuring the GCS and assessing the pupils should be maintained.
When to measure:
• The GCS and pupils should be measured as soon as tactically possible.
• At regular intervals, the GCS and pupils should be reassessed, in addition to measuring GCS before transport to the next echelon of care and after arrival at the higher echelon.
C. For acute pupillary dilation, brain herniation should be considered and appropriate intervention instituted (see Treatment section). However, patients exposed to chemical agents or explosive blast may experience iridoplegia, which is not indicative of herniation.
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A. Standards
Data are insufficient to support a treatment standard for airway, ventilation, and oxygenation management techniques in the out-of-hospital or tactical environment.
B. Guidelines
Routine or prophylactic hyperventilation is not recommended and should be avoided.
C. Options
• Airway management is crucial for the TBI patient and oxygen tension should be monitored and maintained at a SaO2 ≥ 90. When the assessment indicates an obstructed airway, the management depends on the skills of the health care provider.
• Adequacy of ventilation is measured by pCO2 or to a lesser degree of accuracy by end tidal carbon dioxide (EtCO2) measurement. Endotracheal intubation (ETI) by an experienced provider using direct laryngoscopy (DL) is accepted as the optimal method of airway control. There is evidence that the Intubating Laryngeal Mask Airway (ILMA®), the Combitube®, and the Fiberoptic Intubation device (FI) may be useful for the less experienced care giver.
• While a chest radiograph is the traditional way to confirm endotracheal tube placement, there is evidence that the Self-Inflating Bulb (SIB) device and/or measurement of EtCO2 (except in a cardiac arrest situation) are useful tools for confirming placement along with auscultation of the chest (when the environment would allow and when chest radiography is not an option).
• Hyperventilation should only be done if patients are exhibiting signs of cerebral herniation such as posturing with asymmetric or bilateral dilated pupils. If done, hyperventilation is defined as 20 breaths per minute for adults. Hyperventilation should be discontinued as soon as signs of herniation normalize.
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A. Standards
Data are insufficient to support a treatment standard for fluid resuscitation in the patient with severe traumatic brain injury (TBI).
B. Guidelines
It is customary to treat hypotension with fluids in patients with TBI. Inadequate data exist to support a specific target blood pressure. Inadequate clinical outcome data exist to prefer one resuscitation fluid choice over another; however, hypertonic saline and colloids offer clear logistical advantages over isotonic crystalloids in a combat environment. Hypertonic saline in the prehospital phase is safe in doses < 500 ml and can be used for hypovolemia.
C. Options
Hypotension (systolic blood pressure < 90 mm Hg) in patients with TBI has an association with poor outcome. Fluid therapy can be used to maintain adequate cerebral perfusion pressure and limit secondary brain injury. Inadequate fluid resuscitation with aggressive diuresis can precipitate hypotension and should be avoided in the field setting. Hypertonic saline resuscitation, with or without dextran, has been used with some encouraging results compared to isotonic fluids. If a casualty requires additional fluids after the administration of 500 ml of hypertonic saline, isotonic fluids or colloids can be used.
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A. Standards
Class I data regarding management of pain in the prehospital setting is insufficient to support a standard of treatment.
B. Guidelines
Evidence regarding management of pain in the prehospital setting does not exist to support guidelines on this topic.
C. Options
There are valid reasons to sedate TBI patients (i.e. to reduce the risk of further harm to self or others and to facilitate evaluation or evacuation) and analgesic medications are a standard part of most sedative regimens. In this case, analgesic medications should be administered in small incremental doses and with appropriate physiologic monitoring of blood pressure, oxygenation (PaO2 or SaO2), and ventilation (pCO2 or EtCO2).
There is no scientific data or physiologic evidence to support a hypothesis that pain relief improves outcomes in TBI patients, but there is some evidence to support the possibility that the most commonly available analgesic medications (including opiates and Ketamine) increase ICP and may thereby be harmful. Therefore, withholding analgesics from TBI patients who cannot self-score pain (Glasgow Coma Scale score [GCS] < 13; see Guidelines on Assessment: Glasgow Coma Scale Score) for short periods in the prehospital phase, where monitoring is unavailable, is a reasonable option.
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A. Standards
Insufficient data to support a treatment standard for any brain-targeted therapy for patients with severe head injury.
B. Guidelines
Data supports the use of mannitol in response to herniation at doses of 1.4-2.1 g/kg if supported by the capacity to provide high fluid volume compensation for any ensuing urine loss.
C. Options
Hypertonic Saline
Hypertonic saline appears to reduce ICP when given as a bolus and may be given for this purpose although an improvement in neurological outcome with resuscitation with hypertonic saline over standard fluid resuscitation has not been demonstrated.
Hyperventilation
Hyperventilation is to be avoided both as an intended therapy and inadvertently as part of other airway management, except in the context of visible signs of cerebral herniation, when its use may delay herniation.
Antibiotic Prophylaxis for Penetrating Brain Injury
Use of prophylactic broad-spectrum antibiotics is recommended for patients with penetrating brain injury.
Treatments to optimize patient transport
While sedation and analgesia will be given for many reasons to the brain-injured patient, no literature supports a specific brain-targeted or protective effect from these medications.
Treating other causes of altered mental status
Hypoglycemia can result in altered mental status and coma. Exact correlation between symptoms and serum glucose levels does not exist. Finger-stick serum glucose should be obtained as soon as possible in the patients care and any hypoglycemia corrected.
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A. Standards
Class I data are insufficient to support a treatment standard for this topic.
B. Guidelines
Class II data are insufficient to support a treatment standard for this topic.
C. Options
• Class III data support the assertion that civilian regions having organized trauma care systems have better outcomes. This, combined with Class III data from military studies, would suggest that continuing to improve on the military’s existing organized trauma care system is appropriate.
• Class III civilian data supports the recommendation that patients with GCS score 9-13 should be transported to a trauma center for evaluation.
• Patients with Glasgow Coma Scale (GCS) score 14 should not return to duty until disorientation resolves. GCS data obtained in the hyperacute setting, particularly concerning decisions for expectant management, should be used cautiously as it may overestimate the severity of intracranial injury. Pupillary examination may have limited usefulness due to the frequency of blast injury and the potential for traumatic iridoplegia resulting in fixed, dilated pupils which are not indicative of severe brain injury. Both GCS score and pupillary examination should be obtained, documented and repeated throughout the transport as frequently as is practical in order to follow and report the patient’s clinical course.