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Early in-theater management of combat-related traumatic brain injury: A prospective, observational study to identify opportunities for performance improvement

Fang, Raymond MD; Markandaya, Manjunath MD, MBBS; DuBose, Joseph J. MD; Cancio, Leopoldo C. MD; Shackelford, Stacy MD; Blackbourne, Lorne H. MD

Journal of Trauma and Acute Care Surgery: October 2015 - Volume 79 - Issue 4 - p S181–S187
doi: 10.1097/TA.0000000000000769
Clinical Science

BACKGROUND Combat-related moderate-to-severe traumatic brain injury (CRTBI) is a significant cause of wartime morbidity and mortality. As of August 2014, moderate-to-severe traumatic brain injuries sustained by members of the Department of Defense worldwide since 2000 totaled 32,996 cases. Previously published epidemiologic reviews describe CRTBI management at a “strategic” level, but they lack “tactical” patient-specific data required for performance improvement. In addition, scarce data exist regarding prehospital CRTBI care.

METHODS This is a prospective observational study of consecutive CRTBI casualties presenting to US Role 3 medical facilities. Admission variables including demographics, initial clinical findings, and laboratory results were collected. Head computed tomographic scan findings were noted. Interventions in the first 72 postinjury hours were recorded. Early in-theater mortality was noted, but longer-term outcomes were not.

RESULTS Casualties were predominately injured by explosive blasts (78.6%). Penetrating injuries occurred in 42.9%. On arrival, Glasgow Coma Scale (GCS) score was less than 8 for 47.7%. Hypothermia (temperature < 95.0°F) was present in 4.5%, and hypotension (systolic blood pressure < 90 mm Hg) in 21.1%. Hypoxia (O2 saturation < 90%) was observed in 52.5%. Both hypercarbia (Paco2 > 45 mm Hg, 50%) and hypocarbia (Paco2 < 36 mm Hg, 20.3%) were common on presentation. Head computed tomographic scan most commonly found skull fracture (68.9%), subdural hematoma (54.1%), and cerebral contusion (51.4%). Hypertonic saline was administered to 69.7% and factor VIIa to 11.1%. Early in-theater mortality at Role 3 was 19.4%.

CONCLUSION Avoidance of secondary brain injury by optimizing oxygenation, ventilation, and cerebral perfusion is the primary goal in the contemporary care of moderate-to-severe CRTBI. Ideally, this crucial care must begin as early as possible after injury. Given the frequency of hypotension, hypoxia, and both hypercarbia and hypocarbia upon Role 3 arrival, increased emphasis on prehospital management is indicated.

LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.

From the United States Air Force Center for Sustainment of Trauma and Readiness Skills (R.F., J.J.D., S.S.); and R Adams Cowley Shock Trauma Center (M.M.), University of Maryland Medical Center, Baltimore, Maryland; and United States Army Institute for Surgical Research (L.C.C., L.H.B.), Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas.

Submitted: October 22, 2014, Revised: May 4, 2015, Accepted: May 18, 2015.

This study was presented at the Military Health System Research Symposium, August 18–21, 2014, in Fort Lauderdale, Florida.

The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the US Air Force, the US Army, the Department of Defense, or the US Government.

Address for reprints: Raymond Fang, MD, United States Air Force Center for Sustainment of Trauma and Readiness Skills, 22 South Greene St, Baltimore, MD, 21201; email:

© 2015 Lippincott Williams & Wilkins, Inc.