Improving In-Theater TBI Screening Tools

Jagged debris lacerates the Marine’s face and hands as he dives behind the jeep seeking cover from an improvised explosive device blast 50 meters away.  He’s not sure how long it is before the unit corpsman reaches him and finds him conscious with superficial wounds.

Things seem a little fuzzy at first but he believes he’s ready to move back to his patrol. The corpsman asks him the first two questions from the Military Acute Concussion Evaluation (MACE) card he carries and that yields a clear decision — the next move for this Marine is a full MACE screening.

This all-too-common scenario illustrates the need for MACE, the Defense Department’s standard for clinical assessment of mild traumatic brain injury (TBI), also known as concussion, in deployed settings. It’s the most widely-used clinical interview tool for early detection of concussion, the most common form of TBI sustained in the military.

This year, the Defense Department redesigned MACE and the “Concussion Management in Deployed Settings” clinical algorithms, two critical tools used in conjunction with clinical judgment to help first-tier health care providers—combat medics, corpsmen and initial providers—improve cognitive and symptom screening, and neurological evaluation in theater.

The first two questions on the MACE ask about details of the injury event and whether there was alteration of consciousness, loss of consciousness or posttraumatic amnesia. According to the Defense Department, a combination of an injury event and one of the other conditions signifies a concussion has occurred and requires the provider to continue screening.

Small improvements with major impact filter through the redesigned tool: assessment tips are embedded with main questions to help guide MACE administration; three new word and number lists in the cognitive section reduce potential for memorized answers; balance testing informs neurological exam; and overall usability is improved, including reporting results.

Dr. Donald Marion, senior clinical consultant for Defense and Veterans Brain Injury Center (DVBIC), a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) center, was the lead consultant on the redesigned MACE. I asked him to help readers understand its significance.

Q: Why is it important to have these clinical tools in the deployed setting? 
Marion: Most combat medics and corpsmen are not medical doctors, and may not have had any significant medical training prior to enlisting in the military. While they do receive intensive training in basic life-support and life-sustaining techniques prior to deployment to a combat zone, they also benefit from “decision tree” type guidance to assess, stabilize and triage service members with traumatic brain injuries. MACE and concussion management algorithms provide this.

Q: What is their purpose? 
Marion: In addition to providing the highest level of evidence-based acute care guidance for service members suspected of having a TBI, by mandating that first responders follow these algorithms, the Defense Department assures that the delivery of TBI care is consistent throughout the department.

Q: What led to improving the 2010 MACE? 
Marion:During the past two years several new versions of the cognitive assessment portion of MACE were validated. Sports medicine specialists were also finding that a balance assessment was very important in return-to-play decision making, suggesting that balance testing should be part of the assessment of concussion in the military. Also, concerns about the readability of the 2010 version and the fact that the instructions were separate from the questions prompted changes.

DCoE hosted a July 26 webinar to review the new MACE and clinical algorithms. Providers can access TBI tools, mobile apps, patient educational materials and other resources at DVBIC, or email to request the MACE and “Concussion Management in Deployed Settings” pocket cards.

If you have used the MACE and have feedback, please send comments to the contact information identified on the card.

Posted by Jayne Davis, DCoE Strategic Communications


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