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AANS Neurosurgeon | Volume 27, Number 3, 2018

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The Future of Battlefield Neurotrauma

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Battlefield neurotrauma care in the United States Military Health System (MHS) is rapidly changing and will encounter real and virtual threats from adversaries. It is projected that the future strategies the U.S. Military will employ to counter these threats are as follows:

Prolonged Field Care (PFC)
This strategy deploys military forces to remote locations, far from medical support or evacuation chains. It is diametrically opposed to what was done during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).6 Medical providers operating in such environments face significant challenges, including diversity of medical issues encountered, limited medical facilities, supplies and higher-level care providers.3 PFC requires all providers to be well versed in advanced resuscitation.  

Forward Surgical Teams (FST)
First used in OEF, FSTs are equipped to receive prehospital casualties and provide early damage control, resuscitation and surgery. It is anticipated that future conflicts may require more agile and flexible FSTs.

Neuroprognostication and Salvage
Technological advances in trauma care have revolutionized the way in which ‘non-salvageable’ lives and limbs are managed with more favorable outcome.11 For patients with traumatic brain injury (TBI), several devices have recently been approved by the U.S. Food and Drug Administration for use in evaluating acute TBI. These include non-invasive devices as well as the identification of brain-specific biomarkers. It is anticipated that use of these tools may lead to some improvement in quality of life for those afflicted with a traumatic injury.

Trauma Education
Military surgeon training requires the deployed surgeon and surgical staff be trained in all aspects of trauma surgery, including aspects of combat surgery that are absent in an urban setting. To address this need, the National Defense Authorization Act (NDAA) for Fiscal Year 2017 provided trauma education for deployed surgeons2 through partnerships with regional health systems in the private sector. This act also mandated that the MHS establish standards of care for trauma services, translate research into standards of care and facilitate incorporation of partnership lessons into clinical practice. The 2017 NDAA has been impactful; several active duty military surgeons are employed in civilian Level I trauma centers.

  1. Joint Trauma System (JTS)

Three decades ago, organized neurosurgery recognized that evidence-based acute care of patients with severe TBI, as prescribed through clinical practice guidelines (CPGs), can significantly improve outcomes. While the Joint Trauma System (JTS) created a series of CPGs that have contributed to decreased battlefield mortality, in current military operations CPGs are followed to varying degrees.10 Given the current numbers, PFC of severe TBI will often be the responsibility of non-neurosurgeons. A JTS CPG has been created that provides guidance for non-neurosurgeons on the evaluation and management of a patient with severe TBI. 

In summary, future battlefield neurotrauma care will likely involve PFC in austere environments with limited resources. FSTs will include general surgeons equipped with CPGs and advanced non-invasive monitoring devices that allow for assessment of injured service members. Recent legislation recommends that all deployed surgeons have advanced trauma training, including cranial surgery, at civilian trauma centers prior to deployment.

 

References

1. Bazarian, J. J., Biberthaler, P., Welch, R. D., Lewis, L. M., Barzo, P., Bogner-Flatz, V., . . . Jagoda, A. S. (2018). Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): A multicentre observational study. The Lancet Neurology, 17(9), 782-789.

2. Coasho, R. (2017). National Defense Authorization Act for Fiscal Year 2017, in Defense (ed). U.S. Government Publishing Office.

3. Corso, P., Mandry, C., & Reynolds, S. The Sole Provider: Preparation for Deployment to a Medically Austere Theater. J Spec Oper Med, 17, 74-81.

4. DuBose, J.J., Martens, D., Frament, C., Haque, I., Telian, S., & Benson P.J. Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use. J Spec Oper Med, 17, 68-71.

5. Hanley, D., Prichep, L. S., Badjatia, N., Bazarian, J., Chiacchierini, R., Curley, K. C., . . . Huff, J. S. (2018). A Brain Electrical Activity Electroencephalographic-Based Biomarker of Functional Impairment in Traumatic Brain Injury: A Multi-Site Validation Trial. Journal of Neurotrauma, 35(1), 41-47.

6. Keenan, S., & Riesberg, J. C. (2017). Prolonged Field Care: Beyond the “Golden Hour”. Wilderness & Environmental Medicine, 28(2).

7. Kim, A. L. (2015). Portable Traumatic Brain Injury Detection With Near-Infrared Technology: Infrascanner Model 2000. Military Medicine, 180(5), 597-598.

8. Kotwal, R. S., Staudt, A. M., Mazuchowski, E. L., Gurney, J. M., Shackelford, S. A., Butler, F. K., . . . Mann-Salinas, E. A. (2018). A US Military Role 2 Forward Surgical Team Database Study of Combat Mortality in Afghanistan. Journal of Trauma and Acute Care Surgery, 1.

9. Leon-Carrion, J., Dominguez-Roldan, J. M., Leon-Dominguez, U., & Murillo-Cabezas, F. (2010). The Infrascanner, a handheld device for screeningin situfor the presence of brain haematomas. Brain Injury, 24(10), 1193-1201.

10. Plackett, T. P., Cherry, D. C., Delk, G., Satterly, S., Theler, J., Mcvay, D., . . . Shackelford, S. A. (2017). Clinical practice guideline adherence during Operation Inherent Resolve. Journal of Trauma and Acute Care Surgery, 83.

11. Puri, B. (2017). Forward surgical care: Emerging issues and challenges. Medical Journal Armed Forces India, 73(4), 380-383.

12. Roberts, H., Osborn, P., Wood, T., Aden, J. K., & Stinner, D. J. (2017). Being Prepared for the Next Conflict: A Case Analysis of a Military Level I Trauma Center. Military Medicine, 182(5).

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