Occurrence of Secondary Insults of Traumatic Brain Injury in Patients Transported by Critical Care Air Transport Teams From Iraq/Afghanistan: 2003–2006

Abstract

Traumatic brain injury patients are susceptible to secondary insults to the injured brain. A retrospective cohort study was conducted to describe the occurrence of secondary insults in 63 combat casualties with severe isolated traumatic brain injury who were transported by the U.S. Air Force Critical Care Air Transport Teams (CCATT) from 2003 through 2006. Data were obtained from the Wartime Critical Care Air Transport Database, which describes the patient's physiological state and care as they are transported across the continuum of care from the area of responsibility (Iraq/Afghanistan) to Germany and the United States. Fifty-three percent of the patients had at least one documented episode of a secondary insult. Hyperthermia was the most common secondary insult and was associated with severity of injury. The hyperthermia rate increased across the continuum, which has implications for en route targeted temperature management. Hypoxia occurred most frequently within the area of responsibility, but was rare during CCATT flights, suggesting that concerns for altitude-induced hypoxia may not be a major factor in the decision when to move a patient. Similar research is needed for polytrauma casualties and analysis of the association between physiological status and care across the continuum and long-term outcomes.

En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan

“…Multiple studies have been conducted evaluating the en route care of patients during transport from point of injury to first MTF (role 2 and/or 3) 5,12,[14][15][16][17][18][19][20][21][22] and out of theater to the role 4 medical center in Landstuhl, Germany. 12,[19][20][21][22][23][24][25][26][27][28] A few published reports have described patients treated by individual forward surgical teams (role 2) during specific deployments, but these studies do not include information related to patient transport.…”

“…12,[19][20][21][22][23][24][25][26][27][28] A few published reports have described patients treated by individual forward surgical teams (role 2) during specific deployments, but these studies do not include information related to patient transport. These reports described cases and procedures performed by the surgical teams from data sets collected prospectively by the surgical team.…”

Innovations in the En Route Care of Combat Casualties

“…The austere ERC environment poses challenges to the monitoring and care of patients with TBI, and the stresses of fl ight can potentially contribute to secondary neurological insults (Fang, Dorlac, Allan, & Dorlac, 2010;Goodman et al, 2010). A study was conducted of secondary insults (e.g., hypotension, hypoxia, hyperthermia, hypothermia, hyperglycemia, and hypertension) which occurred in patients with severe TBI who were evacuated from Iraq or Afghanistan from 2003 to 2006 (Dukes, Bridges, & Johantgen, 2013). This study found that hyperthermia was the secondary insult documented most frequently, with 47% of the patients suffering at least one episode of an increased temperature.…”

Where are we in the modelling of traumatic brain injury? Models complicated by secondary brain insults

“…For obvious ethical reasons, a prospective randomized controlled clinical study concerning the adverse effects of secondary insults on outcomes from TBI has never been done [1,4]. However, an increasing body of experimental results and clinical retrospective studies in the past few decades have demonstrated that such secondary insults occurred frequently after TBI and exerted a powerful, detrimental influence on recovery from TBI [1,[5][6][7].…”

“…Primary injury refers to the immediate, irreversible parenchymal and vessel damage occurring at the time of injury, while secondary injury refers to potentially avoidable damage that occurs at variable times after the initial injury and can be further aggravated and prolonged or even initiated by secondary insults [6][7][8][9][10][11] (Figure 1). Secondary insults are most common immediately after the primary injury, but can also occur throughout the whole recovery period.…”