Acute Management of Mild Traumatic Brain Injury in Military Operational Settings

• Internet access and portability
• Time to administer metrics
• Ease of administration and training required
• Ease and speed of interpretation
• Ease and speed of data comparison across test administration
• Alternative forms for multiple administrations
• Flexibility of adding test modules or questions
• Ease of data transfer
• Cost per test and for maintenance and training
• Direct clinical application of results to return to duty recommendations
• Among others, there were four computerized neurocognitive assessment procedures discussed:
• Automated Neuropsychological Assessment Metrics (ANAM)
• Cognitive Stability Index (CSI) or Concussion Resolution Index (CRI) (Headminder)
• CogSport
• Immediate Post-concussion Assessment and Cognitive Testing (ImPACT)

None of the above computerized test batteries are in widespread use in theatre at this time. The ANAM has been used as part of clinical care and Headminder is currently being used in the context of a prospective clinical study within several combat sectors. Taking into consideration operational practicality, the group recommended a test time of under 20 minutes. In addition, in the absence of baseline neurocognitive testing, it is difficult to determine the degree of cognitive impairment, because interpretation of the scores must be based on a normative databank developed by each of the test publishers. This inherently lowers sensitivity and specificity in injury detection. The group reached broad consensus on recommending that baseline testing be considered in all service members in an effort to enhance the clinical interpretation and overall utility of post –injury neuropsychological testing. Prior to making a formal recommendation for use in the assessment of acute mTBI occurring in theatre, more evaluative work needs to be done by analyzing each tool regarding the variables listed above.

Assessment and Treatment of Acute Mild TBI

The following three algorithms, offered as clinical practice guidelines, should not be interpreted as a substitute for sound clinical judgment. Operational and tactical considerations may in some instances override the CPG.

Level I Algorithm (See Appendix B for a larger version)

Priorities:

• Evacuate if Red Flags are present.
• Evacuate for a full medical evaluation or neuroimaging.

Capabilities:

• History taking and assessment of symptoms (MACE # IV-VIII) and TBI screening.
• Exertional testing may be required prior to return to duty.
  

Level II Algorithm (See Appendix C for a larger algorithm)

Priorities:
Evacuate to Level III for

• Progressively declining loss of consciousness/neuro exam
• Pupillary asymmetry
• Seizures
• Repeated vomiting

Capabilities:

• Observe/holding capacity up to 7 days
• Trained on MACE tool

Level III Algorithm (See Appendix D for larger version)

Priorities:

Evacuate if symptoms persist for two weeks

Capabilities:

• Neuroimaging
• Full medical evaluation, to include a neurological, ear/nose/throat , ophthalmological, psychological exam
• - As part of the neurological exam, the Balance Error Scoring System (BESS) should be considered for evaluation of postural instability (Guskiewicz et al, 2001; Guskiewicz, 2001)
• More comprehensive neurocognitive tool
• Holding capacity for observation

Treatment of mTBI occurring in theatre

Treatment can be organized into four different areas: symptom management, rest/return to duty guidance, educational initiatives and supportive therapies. There are no clear randomized-controlled trials supporting therapy for mTBI, furthermore specific treatments have not been evidence-supported (Comper et al, 2005). However the following are recommendations based on clinical experience in the management of mTBI in theatre:

• In the acute environment, for headache management, use acetaminophen.
• Avoid the use of tramadol, narcotics, NSAIDS , ASA, or other platelet inhibitors until neuroimaging can confirm the absence of intracranial pathology.

Providing an educational intervention has demonstrated a reduction of symptoms in the civilian population with mTBI (Von Holst et al, 2004; Ponsford et al, 2002). An education sheet with instructions specific to combat environments should be distributed to all mTBI patients. The same model used for battle fatigue treatment highlighting that recovery is expected should be offered in this education process. Educational sheets should be distributed with one copy to the patient and one copy to the commander/squad leader. The command sheet should outline specific duty recommendations and restrictions to assist in duty assignments. An mTBI patient should not return to full duty until they are asymptomatic. Patients who are asymptomatic should be exertionally tested before returning to duty, as outlined in the algorithms. Exertional testing may include sit ups, push ups or running in place for 5 minutes. If TBI symptoms return after exertion, then continued observation and retesting in 24-48 hours is indicated.

Recommendations

• Incorporate Level 1,2,3 algorithms in theatre
• Create mechanism to collect operational data on the use and efficacy of the CPG in theatre and report on recommended changes
• - Standardize documentation of concussion occurring in theatre to enhance individual patient care as well as to provide operational reporting as to the frequency of concussion and treatment patterns.
• Initiate a focused educational package to include: