• 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: oxygenation and blood pressure. New York (NY): Brain Trauma Foundation; 2005. 11 p. [20 references]

This is the current release of the guideline.

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. Hypoxemia and hypotension are two considerable factors associated with poor prognosis in severe traumatic brain injury (TBI) patients in the prehospital setting.
2. All reasonable efforts should be made to avoid hypoxemia and hypotension in the brain injured casualty. Reasonable efforts will be dictated by situation, available resources, and the tactical situation.
   1. Hypoxemia should be prevented in the brain injured casualty. Pulse oxymetry should be instituted as soon as possible along the chain of evacuation. Low oxygenation should be addressed as soon as it is practical to do so along the chain of evacuating.
   2. Hypotension should be avoided. Blood pressure (BP) should be measured as soon as possible along the chain of evacuation. Fluid resuscitation should be instituted for patients with systolic pressure <90 as soon as resources and the tactical situation allow.

Level of Care Recommended within Certain Tactical and Operational Limitations

1. Combat Medic/Tactical Assessment: Determine patency of airway and note any obstruction. Ask the patient to speak. Look at the patient's chest and observe breathing motion. Feel for carotid and radial pulses. Mental status is very useful in assessing non-comatose patients since inadequate oxygenation and blood pressure may also alter mental status.
2. Evacuation Assessment: Measure oxygenation with a peripheral oxygen saturation (SPO₂) monitor. Measure BP and record. When possible, place a BP monitoring device.
3. Battalion Aid Station Assessment: If possible, measure oxygenation with SPO₂ monitor. When equipment is not available, assess patient as recommended for first responder. Measure BP and record. When equipment is not available, feel for carotid and radial pulses.
4. Forward Surgical Assessment: Measure oxygenation with SPO₂ monitor. Measure BP with BP monitoring device.

Summary

Patients with hypoxemia or hypotension have poorer outcomes from TBI than patients who avoid these conditions. It would therefore seem appropriate to correct these conditions as soon as resources and tactical situation allow.

A structured and prioritized approach to combat casualties is important because it enables a clear assessment process for the medic to follow. The guideline authors acknowledge the Advanced Trauma Life Support Course^™ of the Committee on Trauma of the American College of Surgeons. The course prioritizes airway before breathing and breathing before blood pressure and these strategies have been adopted worldwide. Other accepted methodological approaches to the comprehensive assessment and management of the TBI patient can be found in various sources. Standardized assessments are crucial to the appropriate assessment and then subsequent proper management of casualties in the forward area.

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.

The conclusions are supported by class III evidence (16 references), 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.

• 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: oxygenation and blood pressure. New York (NY): Brain Trauma Foundation; 2005. 11 p. [20 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.