Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury

Management - Triage

United States Department of Defense

Subtle changes in neurological condition or state of consciousness can be the first or even the only sign of impending intracranial disaster. On the other hand, apparent neurological deterioration can be the first sign of systemic problems, such as hypoxia or shock.

As a first step, the airway must be cleared and maintained, even if this necessitates intubation or tracheostomy. Unconscious patients must not be transferred or evacuated without airway protection. Where there is hemorrhage into the upper airway, a cuffed endotracheal tube is imperative. The use of low-pressure cuffs obviates many problems.

Definitive neurosurgical management will rarely, if ever, be carried out at the front lines. Patients in extremis at the front line will not usually survive, regardless of what treatment is given. Many considerations will enter into the priorities of triage. As a rule, thoracic, vascular, and abdominal injuries take precedence over head wounds. Multiply-injured patients will require evaluation and treatment by several surgical teams simultaneously. When faced with a number of evacuated but untreated head-injured patients, the neurological surgeon will be required to make initial triage decisions on clinical grounds. Even the decision to send a patient to CT scan implies a commitment to a certain level of treatment. Deteriorating casualties who are not moribund are treated first. Alert patients with the potential to deteriorate are taken next. Among the stable patients, those with obtundation are evaluated before those who are awake. As a rule, head injuries are more urgent than spinal injuries.

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Operational Medicine 2001

Health Care in Military Settings

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