Traumatic Brain Injury in the Military

Aden McLaughlin

Intensive Care Department, Gold Coast Hospital, Gold Coast, Australia.

DOI: 10.4236/ojmn.2013.32005                

Abstract

Traumatic brain injury (TBI) is a devastating and extraordinarily expensive entity. It is becoming increasingly burdensome in the military setting with societal costs of managing the sequelae of TBI running into the billions of dollars (US$) each year. Increasing awareness among non-neurosurgical medical personnel of the pathophysiology of TBI and rapid and appropriate assessment, triage and treatment will increase the likelihood of a better outcome in any given head injured patient. Careful attention to prevention of secondary injury is vital if further decline following the initial insult is to be achieved. Early and repeated neurological assessment, and aggressive management of intracranial hypertension and disorders affecting airway and cardiorespiratory systems are the mainstay of managing moderate to severe TBI. This management may involve medical and surgical options and often requires battlefield assessment prior to aeromedical evacuation. The unique profile and epidemiology of TBI in the military, necessitates ongoing research into primary prevention and appropriate, cost-effective means of assessing and treating these often debilitating injuries. Improvements in the prevention and care of these individuals will lead to enormous individual and societal gains.

Keywords

Traumatic; Brain; Injury; Military; Primary Injury; Secondary Injury; Triage; Assessment

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Military Health System [Homepage on the Internet], 2011. http://www.health.mil/Research/TBI_Numbers.aspx
[2]	Deployment Health Clinical Centre [Homepage on the Internet], 2011. http://www.pdhealth.mil/TBI.asp
[3]	J. Ali, C. Aprahamian, R. Bell, C. D. Boyle, D. Feliciano, et al., “Advanced Trauma Life Support for Doctors,” 6th Edition, American College of Surgeons, Chicago, 1997.
[4]	C. Hoge, D. Mcgurk, J. Thomas, et al., “Mild Traumatic Brain Injury in US Soldiers Returning from Iraq,” The New England Journal of Medicine, Vol. 358, No. 5, 2008, pp. 453-463. doi:10.1056/NEJMoa072972
[5]	N. Ford and J. Rosenfeld, “Mild Traumatic Brain Injury and Bomb Blast: Stress, Injury or Both?” ADF Health, Vol. 9, No. 2, 2008, pp. 68-73.
[6]	R. Bell, C. Mossop, et al., “Early Decompressive Craniectomy for Severe Penetrating and Closed Head Injury during Wartime,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E1. doi:10.3171/2010.2.FOCUS1022
[7]	The Brain Trauma Foundation [Homepage on the Internet], 2011. http://www.braintrauma.org/pdf/protected/btf_field_management_guidelines.pdf
[8]	G. Ling, et al., “Explosive Blast Neurotrauma,” Journal of Neurotrauma, Vol. 26, No. 8, 2009, pp. 815-825. doi:10.1089/neu.2007.0484
[9]	S. T. Dawodu, “Traumatic Brain Injury (TBI)-Definition, Epidemiology, Pathophysiology,” eMedicine, 2011. http://emedicine.medscape.com/article/326510-overview
[10]	A. Mayo and Y. Kluger, “Blast Induced Injury of AirContaining Organs,” ADF Health, Vol. 7, 2006, pp. 4044.
[11]	K. I. Mathai, et al., “Decompressive Craniectomy in Traumatic Brain Injury,” Indian Journal of Neurotrauma, Vol. 7, No. 1, 2010, pp. 9-12.
[12]	N. J. Cowley and E. J. da Silva, “Prevention of Secondary Brain Injury Following Head Trauma,” Trauma, Vol. 10, No. 1, 2008, pp. 35-42. doi:10.1177/1460408608089322
[13]	A. Unterberg, K. Kiening, P. Schmiedek, et al., “LongTerm Observations of Intracranial Pressure after severe Head Injury. The phenomenon of Secondary Rise of Intracranial Pressure,” Neurosurgery, Vol. 32, No. 1, 1993, pp. 17-24.
[14]	R. M. Chesnut, L. F. Marshall, M. R. Klauber, et al., “The Role of Secondary Brain Injury in Determining Outcome from Severe Head Injury,” The Journal of Trauma, Vol. 34, No. 2, 199, pp. 216-222. doi:10.1097/00005373-199302000-00006
[15]	C. Stevenson, “Evolving Mechanisms and Patterns of Blast Injury and the Challenges for Military First Responders,” Journal of Military and Veterans’ Health, Vol. 17, No. 4, 2009, pp. 17-21.
[16]	F. Plum and J. Posner, “The Diagnosis of Stupor and Coma,” 3rd Edition, F. A. Davis, Philadelphia, 1982.
[17]	W. P. Jones, S. A. Loe, S. K. Krach, R. Y. Rager and H. M. Jones, “Automated Neuropsychological Assessment Metrics (ANAM) and Woodcock Johnson III Tests of Cognitive Ability: A Concurrent Validity Study,” Clinical Neuropsychology, Vol. 22, No. 2, 2008, pp. 305-320. doi:10.1080/13854040701281483
[18]	S. L. Bratton, et al., “Brain Trauma Foundation: Blood Pressure and Oxygenation,” Journal of Neurotrauma, Vol. 24, Suppl. 1, 2007, pp. S7-S13.
[19]	J. Kragh, D. Baer and T. Walters, “Extended (16 Hour) Tourniquet Application after Combat Wounds. A Case Report and Review of the Current Literature,” Journal of Orthopaedic Trauma, Vol. 21, No. 4, 2007, pp. 274-278. doi:10.1097/BOT.0b013e3180437dd9
[20]	M. Eisenburg, M. Christie and P. Mathew, “Battlefield Neurosurgical Care in the Current Conflict in Southern Afghanistan,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E7. doi:10.3171/2010.2.FOCUS108
[21]	S. I. Stiver and G. T. Manley, “Prehospital Management of Traumatic Brain Injury: Prevention of Secondary Injury in the Prehospital and Emergency Setting,” eMedicine, 2011. http://www.medscape.com/viewarticle/585165_3
[22]	M. R. Bullock and J. T. Povlishock, “Guidelines for the Management of Severe Traumatic Brain Injury,” Journal of Neurotrauma, Vol. 24, 2007, pp. 87-91.
[23]	J. A. Doyle, D. P. Davis and D. B. Hoyt, “The Use of Hypertonic Saline in the Treatment of Traumatic Brain Injuries,” The Journal of Trauma, Vol. 50, No. 2, 2001, pp. 367-383. doi:10.1097/00005373-200102000-00030
[24]	C. Hoge, H. M. Goldberg and C. Castro, “Care of War Veterans with Mild Traumatic Brain Injury-Flawed Perspectives,” The New England Journal of Medicine, Vol. 360, No. 16, 2009, pp. 1588-1591. doi:10.1056/NEJMp0810606
[25]	N. Juul, G. F. Morris and S. B. Marshall, et al., “Intracranial Hypertension and Cerebral Perfusion Pressure: Influence on Neurological Deterioration and Outcome in Severe Head Injury,” Journal of Neurosurgery, Vol. 92, No. 1, 2000, pp. 1-6. doi:10.3171/jns.2000.92.1.0001
[26]	A. H. Ropper, “Raised Intracranial Pressure in Neurological Disease,” Seminars in Neurology, Vol. 4, No. 4, 1984, pp. 397-407.
[27]	I. Roberts, D. Yates, et al., “Effect of Intravenous Corticosteroids on Death within 14 Days in 10,008 Adults with Clinically Significant Head Injury (MRC CRASH Trial),” Lancet, Vol. 364, No. 9442, 2004, pp. 1321-1328. doi:10.1016/S0140-6736(04)17188-2
[28]	R. Bullock, R. M. Chestnut, G. Clifton, et al., “Guidelines for the Management of Severe Head Injury,” The Brain Trauma Foundation, The American Association of Neurological Surgeons, and The Joint Section of Neurotrauma and Critical Care, New York, Park Ridge, 1995.
[29]	N. R. Temkin, S. S. Dikmen, A. J. Wilensky, et al., “A Randomised, Double-Blind Study of Phenytoin for the Prevention of Post-Traumatic Seizures,” The New England Journal of Medicine, Vol. 323, 1990, pp. 497-502. doi:10.1056/NEJM199008233230801
[30]	R. Bullock, R. M. Chestnut, J. Ghajar, et al., “Surgical Management of Depressed Cranial Fractures,” Neurosurgery, Vol. 58, No. 3, 2006, pp. S56-S60. doi:10.1227/01.NEU.0000210367.14043.0E
[31]	P. Agarwalla, G. Dunn and E. Laws, “An Historical Context of Modern Principles in the Management of Intracranial Injury from Projectiles,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E23. doi:10.3171/2010.2.FOCUS1038
[32]	R. Bell, R. Ecker, et al., “The Evolution of the Treatment of Traumatic Cerebrovascular Injury during Wartime,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E5. doi:10.3171/2010.2.FOCUS1025
[33]	B. Ragel, P. Klimo, et al., “Wartime Decompressive Craniectomy: Technique and Lessons Learned,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E2. doi:10.3171/2010.3.FOCUS1028
[34]	R. Fang, G. Dorlac, P. Allan and W. Dorlac, “Intercontinental Aeromedical Evacuation of Patients with Traumatic Brain Injuries during Operations Iraqi Freedom and Enduring Freedom,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E1.
[35]	J. Reno, “Military Aeromedical Evacuation with Special Emphasis on Craniospinal Trauma,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E12. doi:10.3171/2010.2.FOCUS1023
[36]	F. Stephens, et al., “Cranioplasty Complications Following Wartime Decompressive Craniectomy,” Neurosurg Focus, Vol. 28, No. 5, 2010, p. E3. doi:10.3171/2010.2.FOCUS1026