Traumatic brain injury (TBI) remains one of the signature wounds of modern combat operations, and moderate-to-severe TBI (msTBI) represents a true prehospital emergency where minutes and decisions matter. Unlike many battlefield injuries where hemorrhage control dominates the initial response, msTBI management is fundamentally about preventing secondary brain injury—the cascade of hypoxia, hypotension, hypercarbia, and intracranial hypertension that compounds the primary insult. This post reviews a practical, TCCC-aligned approach to recognition, immediate management, and transport considerations for moderate-to-severe TBI in the operational environment.
Glasgow Coma Scale (GCS) remains the field standard for severity stratification:
Any casualty with a GCS ≤8, deteriorating mental status, unequal or non-reactive pupils, posturing (decorticate/decerebrate), or signs of a basilar skull fracture (raccoon eyes, Battle's sign, hemotympanum, CSF rhinorrhea/otorrhea) should be managed as moderate-to-severe TBI until proven otherwise. Mechanism matters too—blast exposure, high-speed MVC, falls from height, and penetrating head wounds all raise your index of suspicion even when initial GCS looks reassuring, since deterioration can occur rapidly.
Document a baseline GCS and pupillary exam as early as possible and reassess frequently. Trending is more valuable than a single number—a casualty dropping from GCS 14 to 10 over 20 minutes is a different problem than one who's been stable at GCS 9 since point of injury.
Hypoxia is the single most preventable driver of secondary brain injury. Maintain SpO2 ≥92% — the current TCCC target for moderate/severe TBI. In casualties with GCS ≤8, the airway is at risk from loss of protective reflexes—have a low threshold for supraglottic airway placement or definitive airway management per your scope and TCCC guidelines, especially if evacuation will be prolonged.
Ventilation matters as much as oxygenation. Avoid both hypoxia and hyperventilation. Target normocapnia (EtCO2 35–40 mmHg) if capnography is available. Prophylactic hyperventilation is contraindicated—it drops cerebral blood flow via vasoconstriction and worsens ischemia. Reserve brief, controlled hyperventilation (EtCO2 30–35 mmHg) only for casualties showing acute signs of herniation: blown pupil, asymmetric posturing, or sudden GCS deterioration with other signs of increased ICP.
Hypotension is equally devastating to the injured brain. A single episode of systolic BP <90 mmHg has been associated with significantly worse outcomes in TBI literature. Current TCCC guidance for casualties with suspected TBI and hemorrhagic shock supports a systolic BP target of 100–110 mmHg (higher than the permissive hypotension target used for isolated hemorrhage without TBI). Use TXA per protocol if within the indicated window and no contraindications exist, and prioritize blood product resuscitation over crystalloids when hemorrhagic shock is present.
Beyond serial GCS and pupil checks, look for lateralizing signs and check blood glucose—hypoglycemia mimics and worsens neurologic injury and is a fast, correctable variable. Immobilize the C-spine given the mechanisms typically involved, but don't let spinal precautions delay airway management or hemorrhage control.
Fully expose to identify occult injuries, but aggressively prevent hypothermia. Hypothermia in TBI casualties is associated with coagulopathy and worse outcomes; use hypothermia prevention kits and warmed fluids when available.
Watch for the clinical triad suggesting impending or active herniation: rapidly decreasing GCS, unilateral or bilateral fixed/dilated pupil(s), and abnormal posturing. If these signs appear:
Moderate-to-severe TBI casualties require neurosurgical evaluation, and time to definitive care correlates with outcome. Key considerations:
Moderate-to-severe TBI management in the field is a race against secondary injury. There is no single dramatic intervention that "fixes" the brain injury itself—your job is to protect it from hypoxia, hypotension, hypercarbia, hyperthermia, and hypoglycemia while getting the casualty to definitive neurosurgical care as fast as possible. Disciplined application of the ABCDEs, vigilant reassessment, and rapid, well-coordinated evacuation give these casualties their best chance at a meaningful recovery.
At MilMedSim, our simulation scenarios are built to stress-test exactly these decision points—recognizing subtle deterioration, managing the airway under pressure, and coordinating evacuation logistics—so your team's first real TBI case in theater isn't the first time they've had to get it right.