Traumatic Brain Injury Common Among Wounded War Vets

With an increasing number of American soldiers coming home from Iraq and Afghanistan with traumatic brain injury (TBI), nurses must be ready to recognize symptoms and implement effective care.

TBI has become “the signature wound of the Iraq/Afghanistan wars,” said Captain Charles Kuhens of Walter Reed Army Medical Center at Tuesday’s session “Traumatic Brain Injury: Caring for Our Wounded Warriors.”

Kuhens said that 66% of wounds sustained in Iraq are blast injuries, and 41% of soldiers exposed to blasts show signs or symptoms of TBI. The army is addressing the growing problem of soldiers with mild or moderate TBI who wish to remain in or return to the field.

“They don’t want to leave their buddies fighting the fight that they can’t finish so a lot of time mild and moderate traumatic brain injury gets covered up by individuals who don’t want to leave,” Kuhens said.

Signs and Symptoms

TBI can occur in four ways. Primary injury results from direct exposure to an increase in air pressure that is caused by an explosion.

Secondary injury results from flying debris or bomb fragments. Many of these incidents involve improvised explosive devices, Kuhens said.

Tertiary injuries occur when soldiers are thrown into objects or structures in high energy explosions, and quaternary injuries include all other possible injuries.

“TBI is a jolt or a blow to the head...It can be penetrating or not penetrating, but basically the end result is that the brain isn’t functioning correctly,” Kuhens said.

TBI is classified as mild, moderate or severe depending on a range of variables including coma score, loss of consciousness, alteration in consciousness and post-traumatic amnesia. Classic symptoms of TBI include persistent headache, nausea, vomiting, dizziness, balance problems, drowsiness, memory and concentration difficulties and insomnia.

Diagnosis of TBI is complicated, according to Kuhens, because symptoms may be similar to those associated with post-traumatic stress disorder, notably irritability, depression and anxiety.

Therapy and Management

When it comes to TBI, care can be administered at the point of injury; at the battalion aid station; by the forward surgical team; at the combat support hospital; at the United States Army Hospital in Germany; or back in the United States.

In terms of penetrating trauma, first priority is given to removing the patient from danger, followed by establishing an airway.

“Field intubation has been shown to have a positive effect on patient outcome,” Kuhens said.

The next priority is the management of oxygenation, blood pressure and ICP.

“Our goal with penetrating trauma is just like here in the States; you want to prevent secondary injury,” Kuhens said. “This includes preventing hypotension and hypoxia.”

Once out of the field, patients with TBI require rest. Soldiers are educated on possible future symptoms and are offered supportive therapies. Kuhens noted that soldiers should be given acetaminophen only for headaches and should not receive platelet aggregates.

In terms of rehabilitation, patients typically use army-designed simulators for driving, riding in helicopters and operating firearms. Patients are also trained in relaxation techniques designed to control heart rate and emotion.

Kuhens stressed that any patient with TBI who intends to return to the field needs to be tested beforehand to ensure that he or she can handle the stresses of combat.