Traumatic brain injuries (TBI), ranging from mild to severe, are one of the most common injuries a deployed surgeon will encounter. The surgeon must be properly trained and facile on the initial management of TBI. Although TBI encountered in combat is not distinctly different than civilian injuries, there are unique challenges in managing such injuries in the austere environment without immediate access to CT scan, critical care capabilities, and neurosurgical specialty care.

For TBI in particular, it is important to optimize the early care starting at the point of injury and continuing until arrival to a higher level of care where neurosurgical capabilities are available. Even a single episode of hypotension and/or hypoxia is associated with worse neurologic outcomes.

The surgeon must know the resources available to assist in management and decision-making. Probably the most important resource is the telephone—early teleconsultation with a neurosurgeon is important, particularly for severe TBI patients. The Defense and Veterans Brain Injury Center (DVBIC) website and the Joint Trauma System (JTS) clinical practice guidelines provide additional guidance.

In the multiple-injured casualty , do not let the brain injury become the priority until the trauma basics are controlled. A, B, and C come before D in all cases. Although every surgeon knows this, there are times when the motivation to get the patient to a neurosurgeon may lead to a decision to transport the patient prematurely. It is critical to ensure that bleeding is controlled before transporting a patient away from a surgical capability.

Be an optimist and give your casualty the best possible chance for a good outcome. Brain injuries may seem hopeless, and recovery is slow. However, we have had some amazing survivors—you may hear their stories from time to time. Listen for these long-term follow-ups—it will motivate you when things are not looking good.

On the other hand, even unsurvivable brain injuries may receive maximal initial care in some cases, with the hope of reuniting a casualty with their family before death. However, expectant management is necessary when resources are limited and with clearly unsurvivable open brain injuries.

Recognizing a brain injury starts with the initial assessment. It is critical to gather the information required for a neurologic assessment during the primary survey. If advanced airway management occurs before the neurologic exam, then the ability to obtain an accurate neurologic exam is lost. The basic neurologic exam can be obtained quickly prior to intubation by checking the pupils, talking to the patient, and asking them to follow commands to move the upper and lower extremities. This only takes seconds to do and provides valuable information to make decisions. If the casualty is unable to follow commands, then a painful stimulus should be applied to upper and lower extremities, and the response is observed. The eye opening, verbal , and motor responses are noted. This will give you all of the information you need to establish a Glasgow Coma Score as well as look for a spinal cord injury. In nearly every case, this can be done quickly just prior to intubation. It is also important to note any lateralizing signs—unequal pupils or asymmetric motor exam. Casualties with lateralizing signs have approximately 10% risk of a surgical hemorrhage in the brain.

It is not necessary to memorize the Glasgow Coma Score, as long as one remembers to assess eye opening, verbal, and motor responses. It is then an easy task to check a reference and calculate the GCS. The initial GCS is one of the most important prognostic indicators and is also a key factor in decision-making in regard to airway management, treatment of elevated intracerebral pressure (ICP) , and surgical intervention. A baseline GCS should be obtained during the initial assessment of every trauma patient.

It is difficult to determine whether decreased mental status is the result of hemorrhagic shock, brain injury, toxic ingestion, or any combination of the above. Always remember that hemorrhagic shock can alter the initial neurologic exam. It is therefore important to first look for and identify all sources of hemorrhage immediately—hemorrhage control is the best initial treatment for the injured brain as well.

Mild TBI is by definition based on initial GCS of 14–15. Mild TBI (aka concussion) casualties may or may not have a history of loss of consciousness (LOC) . If LOC occurred, it is usually brief (<5 min). LOC is not the sole determinant of TBI—some patients may have deficits and potentially serious TBI with or without LOC. Due to the many long-term sequelae related to concussions, recurrent concussions, and post-traumatic stress disorder within the DoD, it is mandated that all service members exposed to a potentially concussive event (involvement in vehicle blast event, collision, or rollover, presence within 50 m of a blast, direct blow to the head, witnessed LOC, or exposure to more than one blast event) should undergo a medical assessment involving, at a minimum, completion of the Military Acute Concussion Evaluation (MACE) . Since mild TBI is extremely common, every provider should be familiar with the MACE exam. Pocket cards for the MACE can be ordered for free on the DVBIC website (dvbic.dcoe.mil) or referenced online via the DVBIC or JTS websites. A MACE score < 25 mandates a 24-h recovery period, with no return to duty until symptoms are resolved and exertional testing is performed.

Routine use of head CT is not required for all mild TBI casualties. This is especially important to note if evacuation is required in order to obtain a head CT. Red flags suggesting the need for head CT, per DoD guidance, include declining level of consciousness, declining neurologic exam, pupillary asymmetry, seizure, repeated vomiting, GCS < 15, motor or sensory deficit, LOC > 5 min, double vision, worsening headache, inability to recognize people or disoriented to place, slurred speech, or unusual behavior. CT scan is typically used to determine if there is intracranial bleeding that can kill the casualty—altered mental examination is the key component to diagnose brain injury, and not the CT scan.

Although the DoD mild TBI policy is only mandated for service members, it does provide excellent guidance that will optimize outcomes in any casualty, and should be applied to all mild TBI casualties to the extent that resources are available.

Mild TBI is rarely an emergency. Urgent medical evacuation solely for management of mild TBI is not indicated; however, mild TBI casualties may be evacuated with other urgent casualties , and operational necessities may override medical indications to determine the degree of urgency.

Moderate and severe TBI are uncommon in comparison to mild TBI. According to DoD statistics for 2000–2015, 8.7% of brain injuries were defined as moderate (GCS 9–13), and 1% of brain injuries were severe (GCS ≤ 8). However, such injuries are the most challenging in terms of medical and surgical management.

In cases of suspected TBI, early patient management has a direct impact on the long-term outcome beginning at the point of injury. The same principles apply to prehospital and early inhospital care and should be reviewed with EMS providers in detail.