Traumatic brain injury (TBI) in the military rose to prominence in the early 2000s and was called the signature injury of the wars in Iraq and Afghanistan. Although generally adhering to commonly used academic definitions, the Department of Defense (DoD) differs in the use of imaging findings in the determination of TBI severity; any computed tomography (CT) abnormalities raise the severity level to at least moderate ( Table 49.1 ). Using these definitions, the US military reported about 380,000 TBI among military servicemembers between 2000 and 201810; current incidence rates are about 17,000 per year. Over 80% of brain injuries in active duty personnel are classified as mild. Prevalence studies estimated that approximately 20% of those who deployed to Iraq or Afghanistan sustained a TBI.
| Criterion | Mild | Moderate | Severe |
|---|---|---|---|
| Structural imaging | Normal | Normal or abnormal | Normal or abnormal |
| Loss of consciousness | 0–30 min | 30 min to 24 hours | >24 h |
| Alteration of consciousness | Up to 24 h | >24 h; severity based on other criteria | >24 h; severity based on other criteria |
| Posttraumatic amnesia | 0–1 day | 1–7 days | >7 days |
| Glasgow Coma Scale score (best in first 24 hours) | 13–15 | 9–12 | 3–8 |
a If the patient meets criteria in more than one category, the higher severity level is selected.
A disproportionate fraction of combat-related military TBIs are associated with high-energy explosions. Blast-related injures can be primary (overpressurization), secondary (penetrating trauma or fragmentation injuries), tertiary (injury from being thrown by the blast or structural collapse caused by the blast), or quaternary (burns or toxic exposures after the blast). Blast mechanism of injury is often associated with polytrauma, or injuries to multiple body regions and/or systems, in addition to TBI. Nevertheless, many TBIs in the military occur in garrison (i.e., not in war zones) and are caused by falls, sports and recreational activities, and military training exercises.
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Approximately 20% of those who deployed to Iraq or Afghanistan sustained a TBI.
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Over 80% of brain injuries in active duty military personnel are classified as mild.
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Combat-related military TBIs are often the result of a blast or high-energy explosion.
Screening
Medics and corpsmen serve as the first responders for military medicine, and they perform a Military Acute Concussion Examination (MACE) when servicemembers present with suspected acute TBI. This tool is derived from the Sideline Assessment of Concussion (SAC) and shares many similarities. It includes red flags denoting when patients should be elevated to the next level of care. If TBI is not immediately identified or reported in theater, screening for TBI injury events and historical or current postconcussive symptoms is performed routinely after deployment as part of the DoD’s Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) programs. These are completed within 30 days and within 3 to 6 months after return from deployment, respectively.
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Medics and Corpsmen are the military’s first responders.
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The MACE is performed when servicemembers present with suspected acute TBI.
Management
The US military has resources around the world to manage all levels of trauma and TBI, including a robust medical evacuation system and partnerships with local healthcare organizations and trauma centers. For active duty servicemembers who require inpatient rehabilitation for TBI, the military often partners with the Department of Veterans Affairs (VA) Polytrauma System of Care. For the most part, TBI in military populations is managed the same way as it’s managed in civilian settings, particularly when it comes to trauma resuscitation. As in the civilian population, clinicians must be vigilant for cooccurring behavioral health conditions because these can alter management and the trajectory of recovery.
A specific concern in the military population is posttraumatic stress disorder (PTSD) ( Table 49.2 ). Rates of comorbid PTSD among veterans with TBI are as high as 44%. This presents a particular challenge because PTSD shares many symptoms with concussion, including sleep disturbance, neurocognitive symptoms, and mood/behavior changes. In the majority of mild TBI (mTBI) cases, neurocognitive dysfunction resolves over time, typically within 3 months. There is a growing body of literature that suggests that postconcussion symptoms are more strongly correlated with measures of PTSD and depression than TBI, and veterans with psychiatric disorders more frequently meet diagnostic criteria for postconcussive syndrome than those with mTBI alone. PTSD requires specific treatment, and thus its diagnosis is critically important to the patient’s long-term recovery. Unfortunately, the stigma in military culture associated with seeking behavioral healthcare frequently contributes to misattribution of symptoms, because servicemembers are often reluctant to attribute difficulties to a mental health problem as opposed to a physical one. Treatment of PTSD often leads to an improvement in symptoms attributed to concussion.
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Rates of cooccurring PTSD in veterans with a history of TBI are as high as 44%.
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Treatment of PTSD often leads to improvement in symptoms attributed to concussion.
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