• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Triage and transport decisions. New York (NY): Brain Trauma Foundation; 2005. 11 p. [23 references]

This is the current release of the guideline.

"Degrees of Certainty" (Standards, Guideline, Options) and "Classification of Evidence" (Class I to III) and the correlation between the two are defined at the end of the "Major Recommendations" field.

Recommendations

1. Standards

   Class I data are insufficient to support a treatment standard for this topic.

2. Guidelines

   Class II data are insufficient to support a treatment standard for this topic.

3. Options
   1. Class III data support the assertion that civilian regions having organized trauma care systems have better outcomes. This, combined with Class III data from military studies, would suggest that continuing to improve on the military's existing organized trauma care system is appropriate.
   2. Class III civilian data supports the recommendation that patients with Glasgow Coma Scale (GCS) score 9–13 should be transported to a trauma center for evaluation.
   3. Patients with GCS score 14 should not return to duty until disorientation resolves. GCS data obtained in the hyperacute setting, particularly concerning decisions for expectant management, should be used cautiously as it may overestimate the severity of intracranial injury. Pupillary examination may have limited usefulness due to the frequency of blast injury and the potential for traumatic iridoplegia resulting in fixed, dilated pupils which are not indicative of severe brain injury. Both GCS score and pupillary examination should be obtained, documented and repeated throughout the transport as frequently as is practical in order to follow and report the patient's clinical course.

Summary

The combat management of the acutely head injured patient is complicated by tactical, logistical, and medical considerations. Ideally, this "fog of war" would clear, allowing the combat medic the luxury of being able to provide the best available care based on civilian standards practiced in the U.S. on a sunny day with no distractors. Unfortunately, this is likely to be the exception in combat, and the medics must be given the tools, training, and confidence to be able to provide optimal care under these most demanding of circumstances to the most deserving patients in the world.

Definitions:

Classes of Evidence

Class I: Evidence from good quality randomized controlled trials (RCT)

Class II: Evidence from moderate or poor quality RCT, good quality cohort, or good quality case-control studies

Class III: Evidence from moderate or poor quality cohort; or moderate or poor quality case-control; or case series, databases, or registries

Degrees of Certainty

Standards: Reflect a high degree of clinical certainty as indicated by the scientific evidence available (supported by Class I evidence).

Guidelines: Reflect a moderate degree of clinical certainty as indicated by the scientific evidence available (supported by Class II evidence).

Options: Reflect unclear clinical certainty as indicated by the scientific evidence available (supported by Class III evidence).

A clinical algorithm for "Field Management of Combat-Related Head Trauma" is provided in the original guideline document.

An evidentiary table appears at the end of each major section of the guideline document, which classifies each citation based on the quality of the evidence (Class I-III; see "Major Recommendations" for definitions). The recommendations in this summary are supported by 14 Class III studies.

• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Triage and transport decisions. New York (NY): Brain Trauma Foundation; 2005. 11 p. [23 references]

Not applicable: The guideline was not adapted from another source.

2005

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation

Uniformed Services University of the Health Sciences

Not stated

Authors: Tom Knuth, MD, MPH, FACS, COL, Medical Corps, US Army, Chief, Combat Casualty Care Integrated Concepts Team, Directorate of Combat Doctrine and Development, Army Medical Department Center and School, Fort Sam Houston, Texas; Peter B. Letarte, MD, FACS, Neurosurgeon, Hines VA Medical Center, Loyola University Medical Center; Geoffrey Ling, MD, PhD, LTC, Medical Corps, US Army, Professor and Vice-Chair of Neurology, Director of Critical Care Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Leon E. Moores, MD, FACS, LTC, Medical Corps, US Army, Assistant Professor of Surgery and Pediatrics, Uniformed Services University of the Health Sciences, Chief of Neurosurgery, Director of Pediatric Neurological Surgery, Walter Reed Army Medical Center; Peter Rhee, MD, MPH, FACS, FCCM, CAPT, Medical Corps, US Navy, Professor of Surgery/Molecular Cellular Biology, Director, Navy Trauma Training Center, Los Angeles County Medical Center, University of Southern California; David Tauber, CCEMT-P, NREMT-P, I\C, Executive Director, Advanced Life Support Institute (New Hampshire) Medical Specialist/Hazardous Materials Technician, FEMA USAR Team MA1; Art Trask, MD, FACS, INOVA Regional Trauma Center, INOVA Fairfax Hospital

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on August 24, 2007. The information was verified by the guideline developer on January 28, 2008.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.