Acute Mild Traumatic Brain Injury Assessment and Management in the Austere Setting—A Review

ABSTRACT Introduction Traumatic brain injury (TBI) continues to be a major source of military-related morbidity and mortality. The insidious short- and long-term sequelae of mild TBIs (mTBIs) have come to light, with ongoing research influencing advances in patient care from point of injury onward. Although the DoDI 6490.11 outlines mTBI care in the deployed setting, there is currently no standardized training requirement on mTBI care in the far-forward deployed setting. As the Joint Trauma System (JTS) is considered to be one of the leaders in standard of care trauma medicine in the deployed environment and is often the go-to resource for forward-deployed medical providers, it is our goal that this review be utilized by the JTS with prominent mTBI resources to disseminate a clinical practice guideline (CPG) appropriate for the far-forward operational environment. Materials and Methods The resources used for this review reflect the most current data, knowledge, and recommendations associated with research and findings from reputable sources as the Traumatic Brain Injury Center of Excellence (TBI CoE; formerly the Defense and Veterans Brain Injury Center), the Center for Disease Control and Prevention, as well as prominent journals such as Academic Emergency Medicine, British Journal of Sports Medicine, and JAMA. We searched for articles under keyword searches, limiting results to less than 5 years old, and had military relevance. About 1,740 articles were found using keywords; filters on our search yielded 707 articles, 100 of which offered free full text. The topic of far-forward deployed management of mTBI does not have a robust academic background at this time, and recommendations are derived from a combination of academic evidence in more traditional clinical settings, as well as author’s direct experience in managing mTBI casualties in the austere environment. Results At the time of this writing, there is no JTS CPG for management of mTBI and there is no pre-deployment training requirement for medical providers for treating mTBI casualties in the far-forward deployed setting. The TBI CoE does, however, have a multitude of resources available to medical providers to assist with post-mTBI care. In this article, we review these clinical tools, pre-planning considerations including discussions and logistical planning with medical command, appropriate evaluation and treatment for mTBI casualties based on TBI CoE recommendations, the need for uniform and consistent documentation and diagnosis in the acute period, tactical and operational considerations, and other considerations as a medical provider in an austere setting with limited resources for treating casualties with mTBIs. Conclusions Given the significant morbidity and mortality associated with mTBIs, as well as operational and tactical considerations in the austere deployed setting, improved acute and subacute care, as well as standardization of care for these casualties within their area of operations is necessary. The far-forward deployed medical provider should be trained in management of mTBI, incorporate mTBI-associated injuries into medical planning with their command, and discuss the importance of mTBI management with servicemembers and their units. Proper planning, training, standardization of mTBI management in the deployed setting, and inter-unit cooperation and coordination for mTBI care will help maintain servicemember readiness and unit capability on the battlefield. Standardization in care and documentation in this austere military environment may also assist future research into mTBI management. As there is currently no JTS CPG covering this type of care, the authors recommend sharing the TBI CoE management guideline with medical providers who will be reasonably expected to evaluate and manage mTBI in the austere deployed setting.

P080: Trauma experiences of rural emergency physicians: a self assessment

Introduction: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) practitioners are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. Our goal is to enhance rural trauma care by identifying obstacles rural EM physicians face in Saskatchewan. Methods: This was a cross sectional survey study, emailed to family physicians practicing rural EM in Saskatchewan identified through the Saskatchewan Medical Association database. Inclusion criteria included physicians who are providing EM care currently or within the past year. Rural was assumed to be communities in Saskatchewan that were outside of Saskatoon and Regina. The survey was an anonymous self-assessment regarding demographics, training, hospital resources and comfort. Results: 113 physicians of the 479 rural physicians agreed to participate, 78 met our inclusion criteria. Most (67%) were from communities with less than 10,000 population, 70% had less than 300 ED visits per month. Most (68%) were less than 45 years of age. In terms of training, 57% had completed undergraduate training out of Canada and 63% had completed residency training in Canada. Most had been practicing for more than 2 years (76%). Most (59%) had current ATLS credentials, however only 37% had ever completed the EDE course. Regarding available resources, most centers had plain radiography (99%), POCUS (68%), PRBC (78%) and TXA (93%). However, fresh frozen plasma (41%) and platelets (26%) were not widely available. Comfort was measured on a Likert scale. The types of trauma that respondents were least comfortable with included pediatric (39%), vascular (46%), spine (56%) and genitourinary (60%). The types skills that participants were least comfortable with included pericardiocentesis (19%), and surgical airway (25%). The majority had not performed Pediatric endotracheal tube insertion (79%), surgical airways (99%), pericardiocentesis (99%), central venous line placement (80%) and needle thoracentesis (71%) within the past 12 months. Conclusion: This self-assessment helped us identify aspects of rural trauma medicine that are the most challenging for rural practitioners. Understanding the most difficult challenges in light of the critical resources available to rural trauma medicine providers will inform future professional development initiatives.

Foley catheter balloon tamponade for penetrating neck injury management in military medicine: a case report

Background The use of Foley catheter balloon tamponade (FCBT) to address bleeding in the neck and maxillofacial area associated with penetrating trauma is widely accepted in South African Emergency Departments. Its efficacy has been documented in combat settings in the Iraqi area of operations, with significant improvement of patients survival rate. Despite such evidence, Special Operations Forces (SOF) medics training in these techniques is limited. Case We present the case of a partner forces (PF) soldier that received shrapnel injuries during combat operations, resulting in life-threatening haemorrhage from the neck. Conclusion The Special Operations Forces medics who treated this patient decided to apply FCBT to prevent re-bleeding during an unsupervised ground vehicle movement to the host nation (HN) definitive care. None of the SOF medics involved had received formal training in the technique prior to the case. Their only knowledge was based on anecdotal evidence and self-study of the literature. Due to the lack of accountability by admitting a patient into the HN chain of care, there is no information on the outcome other than the patient survived. FCBT was performed after the wound was packed ineffectively with hemostatic gauze resulting in an unstable clot that failed with patient movement resulting in a probable carotid artery Zone I I neck bleed. FCBT has the potential to be a quick and effective adjunct to control bleeding in the complicated narrow track wound patterns in the neck and maxillofacial area that are not amenable to manual pressure or hemostatic agents in combat trauma medicine. Keywords Foley; Foley catheter balloon tamponade; Special Operations forces Medics; Bleeding.

Multidisciplinary Patient Management Improves Mortality in Geriatric Trauma Patients

Improvement in the care of the traumatically injured patient should be a goal at all trauma centers. One purpose of the data generated by the Trauma Quality Improvement Program is to provide insight which will lead to quality improvement initiatives and to promote intrinsic improvement on a center by center basis. The primary objective of this study was to measure the efficacy of instituting a multidisciplinary Trauma Medicine (T-MED) program to improve geriatric mortality at Ventura County Medical Center (VCMC). Trauma Quality Improvement Program data at VCMC before October 2013 demonstrated poor performance in treating geriatric patients. To attempt to improve outcomes, a multidisciplinary T-MED program was instituted in October 2013, which included a mandatory consultation and collaborative management with hospitalist medicine physicians for all trauma patients 65 years of age or older. The T-MED program increased focus on preexisting conditions, medication management, and discharge planning, including rehabilitation and continuity of care. Institution of a T-MED program at VCMC resulted in significant improvement in mortality rates for geriatric trauma patients.

A focus on POCUS

Dr Rob Arntfield is a trained emergency physician, intensivist, and traumatologist here at London Health Sciences Centre (LHSC). Passionate about the use of ultrasonography and teaching, Dr Arntfield co-authored Point of Care Ultrasound1 (POCUS), which was published in 2014. A self-described London “townie”, he attended Western for medical school and continued in his hometown for a double emergency medicine and intensive care residency before pursuing a fellowship in New York City. We sat down with Dr Arntfield to discuss his work in critical care, trauma, and the rise of POCUS in trauma medicine.

Novel hemorrhage control technologies and their potential applicability in trauma medicine

Mortality due to hemorrhage is potentially preventable but remains a prevalent problem in trauma care. Despite advances in prehospital hemorrhage control, exsanguination remains the leading and second-leading cause of mortality in military and civilian trauma, respectively. Novel hemorrhage control technologies for military and civilian prehospital use include the iTClamp (iTraumaCare, Edmonton, Canada), a mechanical clamp used to close wounds; XStat (RevMedx, Wilsonville, OR), a syringe applicator that injects expandable cellulose sponges into a wound for internal compression and clotting acceleration; ResQFoam (Arsenal Medical, Watertown, MA), liquids injected into the abdominal cavity that mix and transform into an expandable solid to compress internal organ wounds; and TraumaGel (Cresilon, Brooklyn, NY), a biocompatible gel that promotes clotting and polymerizes to form a mesh to seal the wound. These 4 technologies all show promise in effective hemorrhage control, and have been designed for quick and easy use in the setting of prehospital trauma care. However, these products are still in the early stages of development with limited research data for human use. Therefore, efficiency of use, effectiveness in hemostasis, and safety should be examined for each technology to determine whether any of them warrant widespread adoption for hemorrhage control.

Trauma and orthopaedics

Recent advances in biomechanics and biomaterials are resulting in new and potentially improved implants and procedures in trauma medicine, often with more reliance on high-tech solutions. However, some new advances have resulted in disastrous outcomes. As it takes time for these complications to surface, many patients may be subject to the new technology and resulting consequences. Studying the clinical evidence around these technologies is therefore essential, and use of appropriate surrogate measures to assess the short-term in vivo performance of an implant is important to help predict long-term clinical outcome. Radiostereometric analysis and kinematic assessment are two such tools widely used in translational research and post-market surveillance in the field of joint replacement. It is only with high-quality research and awareness that true advances can be demonstrated and failures averted at the earliest stage. The principles of orthopaedics must remain to alleviate pain, correct deformity, and restore function, whatever technique is used.