Based on the evidence contained in the Guidelines for the Field Management of Combat-Related Head Trauma, the authors produced an assessment and treatment algorithm to be used as a framework to assess, treat, and transport combat casualties with traumatic brain injury (TBI). Individual service branch and tactical situations may require medical providers to modify the algorithm, because it may not be appropriate for all casualties, locations, or tactical situations. The following points provide more detail on the steps in the graphic algorithm. The decision to evacuate must be made based upon the immediate condition of the patient and the likelihood for short-term improvement, the threat that the injury poses to the patient, the threat that the patient may pose to the unit or mission, and the availability of evacuation assets. The authors recognize that some treatment recommendations may be outside of the levels of care prescribed by military doctrine. It is the hope of the authors that military medical direction will consider these recommendations in reviewing the current military doctrine affecting battlefield combat casualty care.

As previous chapters have noted, there are many factors influencing combat casualty care. The first and most important aspect to providing care in the forward environment is safety. Field medical personnel mitigate injuries sustained during combat operations and are often under fire when doing so. This unique austere environment challenges the provider to weigh personal safety against the needs of their injured team members. Frequently, these difficult choices are made under the most extreme circumstances of life and limb. The military ethos of not leaving a man behind often dictates acts of extreme heroism on the part of these medical providers. It is, however, still important for field medical providers to be vigilant of safety threats and other operational hazards they may encounter while performing these life saving skills.

The medical provider's first priority in assessing, stabilizing, and treating a TBI casualty is to follow basic resuscitation protocols that prioritize airway, breathing, and circulation assessment and treatment.

• Following stabilization of airway, breathing, and circulation, the medical provider assesses the casualty by first asking him or her, "What happened to you?"
• If the casualty opens his eyes, the provider then asks him the questions in the verbal and motor sections of the Glasgow Coma Scale (GCS) to determine the total score. Casualties with a GCS score of 9-13 (moderate TBI) and casualties with a GCS score 3-8 (severe TBI) should be evacuated from the forward environment.
• If the casualty does not open his eyes, the medical provider applies blunt pressure to the nail bed or pinches the anterior axillary skin to elicit eye opening.
• If the casualty opens his eyes with nail bed pressure or axillary pinch, the medical provider assesses the verbal and motor sections of the GCS to determine the total score.
• Casualties who are unresponsive with a GCS score 3-8 should be evacuated from the forward area to a medical facility with the following surgical capabilities:
  1. 24-hour CT scanning capability
  2. 24-hour available operating room and prompt neurosurgical care
  3. The ability to monitor intracranial pressure and treat intracranial hypertension as delineated in the Guidelines for the Management of Severe Head Injury
• Casualties with a GCS of 9-13 should be evacuated from the forward area. This field evacuation is not, however, as emergent as it is with the GCS 3-8 casualty. If prioritization of evacuations is necessary, special attention should be given to the field observation of this casualty as neurological deterioration is possible.
• If the casualty does not open his eyes with nail bed pressure or axillary pinch, he should be evacuated from the forward area to a medical facility.
• For unresponsive casualties who respond to nail bed pressure with extensor posturing or who are flaccid, the medical provider should secure the airway (intubate, if available) and hyperventilate (20 bpm).
• For unresponsive casualties who respond to nail bed pressure or axillary pinch with abnormal flexion or a higher GCS motor response, but have asymmetric and/or dilated and fixed pupil(s), the medical provider should hyperventilate at the rate described above.
• All TBI casualties should have their oxygenation assessed at least every 5 minutes and their O2 saturation maintained at 90%. Systolic blood pressure should also be measured and maintained greater than 90 mm Hg.
• Because the casualty's neurological status may change, the medical provider should fully assess the casualty every 5 minutes and treat or modify treatment as appropriate.
• Hypertonic saline at concentrations of 3.0-7.5% is both a safe and an effective means to resuscitate the TBI casualty in the field. Weight considerations and limitations make this a practical treatment option for field providers.
• Empirical administration of dextrose is not recommended. Providers should only administer dextrose when they have the means to measure serum glucose levels and have evidence of hypoglycemia (serum glucose levels ≤ 80 mg/dl).
• Casualties found to have GCS scores of 14-15 can remain in the forward area. They do need to be observed for any changes in neurological status. Since ICP changes can occur several hours post injury, all casualties with changes in neurological status need to be re-evaluated for fitness of duty if remaining in the forward area.
• Any casualty with a GCS < 15 should not return to full duty until GCS resolves to 15 and the casualty is back to his/her baseline.
• Symptomatic casualties (headaches, dizziness, not oriented to time and situation, or asking repetitive questions) may be kept in theater but should not return to full combat status.

There are several other important points for field medical providers to remember when treating the TBI casualty.

• As soon as it becomes available, oxygen should be administered to all TBI casualties.
• Not all TBI casualties will require ALS airway managements (ET intubation, Combitube®, etc.). Some casualties requiring airway support may be successfully managed using BLS adjuncts (oral or nasal airways) and either a pocket mask or bag valve mask.
• As soon as it becomes available, all casualties undergoing any ALS airway management should have their EtCO₂ monitored. These levels should be maintained between 25-35 mm Hg.
• Only casualties showing signs of cerebral herniation should be hyperventilated.
• Isolated TBI does not cause shock. If signs of shock are present in the casualty, the medical provider needs to assess the patient for other causes of shock.