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Brief Summary

GUIDELINE TITLE

Guidelines for the field management of combat-related head trauma. Assessment: Glasgow Coma Scale scoring and assessment of pupils.

BIBLIOGRAPHIC SOURCE(S)

  • Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Assessment: Glasgow Coma Scale scoring and assessment of pupils. New York (NY): Brain Trauma Foundation; 2005. 10 p. [27 references]

GUIDELINE STATUS

This is the current release of the guideline.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Note from the Brain Trauma Foundation (BTF) and the National Guideline Clearinghouse (NGC): For the chapters on assessment, which included prognosis studies, the guideline authors summarized the evidence rather than made recommendations. Thus, their findings are listed as "Conclusions" for any diagnostic or prognostic assessment, and no "degrees of certainty" were assigned.

Conclusions

  1. Data are insufficient to support a treatment standard for Glasgow Coma Scale (GCS) scoring and pupil assessment in patients with severe traumatic brain injury (TBI) incurred in combat.
  2. Measuring GCS score and assessing pupils:
    1. How to measure:

      The GCS score and pupil assessment should be determined by direct clinical examination.

    2. Who should measure:
      1. The far forward first medical provider (medic) should obtain the first score. At each echelon of care, the primary medical care provider should be responsible for measuring the GCS and assessing the pupils.
      2. Competence in measuring the GCS and assessing the pupils should be maintained.
    1. When to measure:
      1. The GCS and pupils should be measured as soon as tactically possible.
      2. At regular intervals, the GCS and pupils should be reassessed, in addition to measuring GCS before transport to the next echelon of care and after arrival at the higher echelon.
  1. For acute pupillary dilation, brain herniation should be considered and appropriate intervention instituted (see the National Guideline Clearinghouse [NGC] summary of the Brain Trauma Foundation guideline Guidelines for the field management of combat-related head trauma. Treatment: brain-targeted therapies). However, patients exposed to chemical agents or explosive blast may experience iridoplegia, which is not indicative of herniation.

Summary

GCS scoring and assessment of pupils should be done in every patient with suspected TBI. The first provider should obtain these measurements as soon as possible, at regular intervals thereafter and before and after transport. Worsening of either should initiate appropriate treatment interventions.

No Class I evidence is available on which to base conclusions for these parameters. There are very limited numbers of studies conducted on the battlefield of any level on which to determine this. Studies performed in the civilian sector were reviewed in order to evaluate the situation. There are no data from the U.S. military indicating the reliability of the GCS or pupillary response to light as a reliable indicator of the severity of head injury incurred in battle. In the civilian sector, Class II data from civilian victims suffering from traumatic head injury does demonstrate GCS's reliability, particularly with repeated scoring and improvement or deterioration of the score over time. Class II data from civilian patients demonstrate pupil assessment as a useful method for prognosticating poor outcome and as a diagnostic indicator of brain dysfunction, including herniation.

CLINICAL ALGORITHM(S)

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

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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.

The conclusions are supported by seven class III studies, which include one or more of the following types of studies: moderate or poor quality cohort; moderate or poor quality case control; or case series, databases, or registries.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Assessment: Glasgow Coma Scale scoring and assessment of pupils. New York (NY): Brain Trauma Foundation; 2005. 10 p. [27 references]

ADAPTATION

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

DATE RELEASED

2005

GUIDELINE DEVELOPER(S)

Brain Trauma Foundation - Disease Specific Society

SOURCE(S) OF FUNDING

Brain Trauma Foundation

Uniformed Services University of the Health Sciences

GUIDELINE COMMITTEE

Not stated

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

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

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the Brain Trauma Foundation Web site.

Print copies: Available from the Brain Trauma Foundation, 708 Third Avenue, New York, NY 10017

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

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

COPYRIGHT STATEMENT

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.

DISCLAIMER

NGC DISCLAIMER

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Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
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