1. Mild Traumatic Brain Injury/Concussion
Training Program for Line Leaders
Mild Traumatic Brain Injury/Concussion
“Medically Ready Force…Ready Medical Force”

2. “Medically Ready Force…Ready Medical Force”
Objectives
Understand how a concussion/mild traumatic brain injury (mTBI) can affect service members
Understand leadership’s responsibility in the mTBI recovery process
Understand how concussion impacts mission readiness
Review of Concussion Basics
Causes, signs, symptoms, recovery
Discuss available resources related to concussion
“Medically Ready Force…Ready Medical Force”

3. Warrior Management for mTBI
Goal: Create a military-wide cultural change following concussive events
Vision: Every Warrior treated appropriately to minimize concussive injury and maximize recovery
Mission: Produce an educated force trained and prepared to provide early recognition, treatment & tracking of concussive injuries in order to protect Warrior health
“Medically Ready Force…Ready Medical Force”

4. Department of Defense Definition* of Traumatic Brain Injury
TBI is a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force. TBI is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event:
Any period of loss of consciousness (LOC)
Any loss of memory for events immediately before or after the injury (PTA)
Any alteration in mental state at the time of the injury (AOC)
Neurological deficits that may or may not be transient (or permanent)
Intracranial lesion
*Woodson memo; ASD-HE Memo, April, 2015 TBI: Updated Definition and Reporting
“Medically Ready Force…Ready Medical Force”

5. Concussion/mTBI Definition
Concussion is also known as a mild traumatic brain injury (mTBI)
Concussion:
Is caused by a blow or jolt to the head
Can occur even without being knocked out
Can temporarily change the way the brain works
Important to seek medical attention after a concussion, no matter how mild it may seem
“Medically Ready Force…Ready Medical Force”

6. Knowledge Check 1
According to the Department of Defense a traumatic brain injury could be defined as (check all that apply)
any period of loss of consciousness
any loss of memory for events before or after the injury
a prolonged period of nausea and vomiting
any alteration in mental state at the time of the injury
physiological disruption of brain function

7. Knowledge Check 1 (answer)
According to the Department of Defense definition, a traumatic brain injury could be defined as (check all that apply)
any period of loss of consciousness
any loss of memory for events before or after the injury
a prolonged period of nausea and vomiting
any alteration in mental state at the time of the injury
physiological disruption of brain function

8. “Medically Ready Force…Ready Medical Force”
TBI Classification
TBI is classified as
Mild, Moderate, Severe, or Penetrating
Classification describes the severity at the time of injury
It does not describe the resulting impairments or duration of symptoms
The majority of Soldiers can expect a full recovery, even with multiple concussions
Early detection and treatment are essential
Recovery may take longer with recurrent concussions
“Medically Ready Force…Ready Medical Force”

9. “Medically Ready Force…Ready Medical Force”
Vital Information
The brain is complex. Leaders need to understand that concussed Soldiers may have different symptoms.
Soldiers recover at different rates and respond differently to treatment
Essential for Commanders to support medical guidance after a concussion
Will include restriction of physical activity and mental rest
“Medically Ready Force…Ready Medical Force”

10. Common Concussion Symptoms
Headache
Sleep disturbance
Fatigue
Dizziness/Balance problems
Visual disturbance/Light sensitivity
Ringing in ears
Slowed thinking
Difficulty finding words
Poor concentration
Memory problems
Anxiety/Depression
Irritability/Mood swings
“Medically Ready Force…Ready Medical Force”

11. The Impact of Concussion
Concussion symptoms may decrease a Soldier’s effectiveness and ability to do his/her job and negatively impact the Soldier’s unit
“Medically Ready Force…Ready Medical Force”

12. Short Term Impact of Concussion
Symptoms
Symptoms
Headache
Sleep disturbance
Fatigue
Dizziness / balance problems
Visual disturbance and light sensitivity
Ringing in ears
Slowed thinking
Difficulty finding words
Poor concentration
Memory problems
Anxiety / depression
Irritability / mood swings
Manifestation
Manifestation
Failure to sleep at night
Decreased energy
Slower reaction time
Difficulty negotiating uneven terrain
Easily distracted
Difficulty processing multiple sources of information
Interpersonal problems
Impact
Impact
Poor marksmanship
Decreased situational awareness
Difficulty performing quickly under time pressures
Difficulty multi-tasking: such as driving a vehicle while listening to instructions via radio
Performance difficulties that can affect self-esteem and confidence
Fear of performing in certain operational environments
“Medically Ready Force…Ready Medical Force”

13. As a Result Soldiers May Experience . . .
Difficulty sleeping at night
Decreased energy and alertness
Reduced work performance
Trouble multi-tasking
Easily distracted
Difficulty processing multiple sources of information
Interpersonal problems
“Medically Ready Force…Ready Medical Force”

14. Knowledge Check 2
Which of the following is not one of the impacts of untreated and undiagnosed concussion?
Decreased Soldier performance
Enhanced teamwork
Compromised unit safety
Reduced unit readiness

15. Knowledge Check 2 (answer)
Which of the following is not one of the impacts of untreated and undiagnosed concussion?
Decreased Soldier performance
Enhanced teamwork
Compromised unit safety
Reduced unit readiness

16. Common Causes of Concussion
Being near a blast
Multiple Causes
Falls resulting in a head injury
Blow to the head during sports or combatives
Vehicle Accident
“Medically Ready Force…Ready Medical Force”

17. Concussion Treatment and Recovery
The majority of Soldiers can expect a full recovery with symptoms resolving within hours to days
Full recovery is expected with multiple concussions. However, recovery may take longer
Cornerstones of recovery:
Patient education: emphasize recovery
Physical & mental rest
Treat symptoms
“Medically Ready Force…Ready Medical Force”

18. Approaches to Recovery
Rest HELPS Recovery
Body-
Keep heart rate low
Stay out of heat
Limit physical activity
Mind-
Allow downtime during the day
Allow adequate sleep at night
Exertion HURTS Recovery
Body-
Working
Heavy lifting
Alcohol use
Prevent another concussion
Mind-
Intensive writing
Intensive concentration
Playing video games
Inadequate sleep
Caffeine
“Medically Ready Force…Ready Medical Force”

19. Impact of Multiple Concussions
Symptoms may be more severe with each additional concussion and they may take longer to resolve
Theater Medical Management requires a longer rest period after 2 concussions (minimum 7 days) and a more in-depth evaluation for those who have sustained 3 or more concussions in 12 months
Leaders need to take steps to prevent a second concussion during recovery
No combatives, sports, etc. until cleared by medical
“Medically Ready Force…Ready Medical Force”

20. Knowledge Check 3
The key approaches to concussion treatment and recovery require the Care Provider to consider (check all that apply)
that concussion patients need physical and mental rest
that symptoms maybe more severe with each additional concussion
that service Members with concussion must be cleared by medical providers before returning to duty
that service members experiencing symptoms of concussion can wait up to 12 hours before getting checked out.

21. Knowledge Check 3 (answer)
The key approaches to concussion treatment and recovery require the Care Provider to consider (check all that apply)
that concussion patients need physical and mental rest
that symptoms maybe more severe with each additional concussion
that service Members with concussion must be cleared by medical providers before returning to duty
that service members experiencing symptoms of concussion can wait up to 12 hours before getting checked out.

22. Concussion in a Garrison Setting
Soldiers are at elevated risk for concussion both in Garrison and Deployed environments
They lead active lifestyles both at home and in the workplace
Training activities such as combatives, contact sports, and operational exercises may increase risk for concussion
“Medically Ready Force…Ready Medical Force”

23. Highlights from the DTM for Deploying Leaders
Event driven protocols: Exposure to potentially concussive events require mandatory medical evaluation and 24-hour rest period (downtime)
All sports and activities with risk of concussion are prohibited until medically cleared
Minimum 7 day mandatory rest period (down time) for Soldiers sustaining a second concussion within 12 months
In depth medical evaluation required for any Soldier sustaining multiple concussions (3 or more) within 12 months
Shared responsibilities between medical and line
“Medically Ready Force…Ready Medical Force”

24. “Mandatory Events” defined in DTM 09-033
Any Service Member in a vehicle associated with a blast event, collision or rollover
All within 50 meters of a blast (inside or outside)
Anyone who sustains a direct blow to the head
Command directed, including (but not limited to) repeated exposures to blasts
“Medically Ready Force…Ready Medical Force”

25. Knowledge Check 4
After a service member is exposed to a potential concussive event, all of the following required actions must take place except?
Leadership should refrain from acting, allowing the soldier to self-evaluate
Line leaders must report the incident and circumstances
All leadership must evaluate the service member’s medical examination
All leadership should utilize medical algorithms to better understand the service member’s condition

26. Knowledge Check 4 (answer)
After a service member is exposed to a potential concussive event, all of the following required actions must take place except?
Leadership should refrain from acting, allowing the soldier to self-evaluate
Line leaders must report the incident and circumstances
All leadership must evaluate the service member’s medical examination
All leadership should utilize medical algorithms to better understand the service member’s condition

27. Required Actions Following a Mandatory Event
Leadership Actions
Screen: Injury Evaluation Distance (IED)
Safety net to ensure “eyes-on” all Soldiers
It does not replace the medical evaluation
Enforce: 24-hour mandatory rest
Unit/Leader Actions
Report: SIGACTs
Combined Information Data Network Exchange (CIDNE)
Blast Exposure and Concussion Incident Report (BECIR)
Medical Actions
Evaluate: Medical examination
Utilize medical algorthms
Report: Screening and treatment encounters
Enter note into electronic medical record (EMR)
“Medically Ready Force…Ready Medical Force”

28. Required Actions Following a Mandatory Event (con’t)
Leadership Actions
Screen: Injury Evaluation Distance (IED)
Safety net to ensure “eyes-on” all Soldiers
It does not replace the medical evaluation
Enforce: 24-hour mandatory rest
Unit/Leader Actions
Report: SIGACTs
Combined Information Data Network Exchange (CIDNE)
Blast Exposure and Concussion Incident Report (BECIR)
Medical Actions
Evaluate: Medical examination
Utilize medical algorthms
Report: Screening and treatment encounters
Enter note into electronic medical record (EMR)
“Medically Ready Force…Ready Medical Force”

29. Leadership Assessment (part 1)
Commanders are required to report on all Soldiers involved in a mandatory event using the I.E.D. and H.E.A.D.S. checklist
Can also be used to assess Soldiers without apparent injury and who were not exposed to a mandatory event
Use three-step assessment process
1. Injury ( Yes or No)
Is there physical damage to SM body or body part?
“Medically Ready Force…Ready Medical Force”

30. “Medically Ready Force…Ready Medical Force”
Training Requirement
This training deck is intended for Primary Care Providers & Health Care Providers
…and satisfies the following:
Department of Defense Instruction (DoDI) (Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting)
NAVMED Policy (Navy Medicine Training Requirements for Health Care Professionals in Traumatic Brain Injury)
MARADMIN 294/12 (Marine Corps Traumatic Brain Injury Program)
“Medically Ready Force…Ready Medical Force”

31. Leadership Assessment (Part 2)
2. Evaluation: H.E.A.D.S (Yes/No)
H – Headache and/or vomiting
E – Ears ringing
A – Amnesia and/or Alteration of consciousness/Loss of Consciousness
D – Double vision and/or dizziness
S – Something feels wrong or is not right
“Medically Ready Force…Ready Medical Force”

32. Leadership Assessment ( Part 3)
3. Distance
Was SM within 50M of blast? (Y/N)
Record the distance from blast for ALL SM
“Medically Ready Force…Ready Medical Force”

33. “Medically Ready Force…Ready Medical Force”
H.E.A.D.S acronym
Encourage Soldiers to remember the HEADS acronym
This does not replace medical evaluation
Soldiers need to see medical immediately to assess for concussion
to order HEADS cards for your Deploying Soldiers
Consider mandating that Soldiers carry their HEADS card or validating that they know the symptoms of concussion/mTBI
“Medically Ready Force…Ready Medical Force”

34. Knowledge Check 5
According to this training, the Leadership Assessment is:
Leadership concussion reporting requirements
Guidelines for returning to duty after a concussion
The I.E.D and H.E.A.D.S checklist that commanders are required to use to report concussion events
Key point for how to diagnose a concussion

35. Knowledge Check 5 (answer)
According to this training, the Leadership Assessment is:
Leadership concussion reporting requirements
Guidelines for returning to duty after a concussion
The I.E.D and H.E.A.D.S checklist that commanders are required to use to report concussion events
Key point for how to diagnose a concussion

36. Commander/Leader Reporting Requirements (CENTCOM FRAGO 09-1656)
Monthly reports to CENTCOM will contain at a minimum the following data:
Date of Blast/Mandatory Event
Unit
Type of Mandatory Event triggering evaluation
Results of I.E.D Leader Screening (Yes/No for each part, plus distance from blast)
SIGACT number (if applicable)
24 Hour rest period waved by commander (Y/N)
Service (Navy, Air Force, Marine)
Combatant Command in which event occurred
Social Security Number / Name
Disposition of any mandated medical evaluation (RTD after 24hrs)
“Medically Ready Force…Ready Medical Force”

37. “Medically Ready Force…Ready Medical Force”
Returning to Duty
The medical provider will advise when it is safe for your soldiers to return to duty
Theater medical protocols may require exertional testing
Testing procedures are similar to those used for professional athletes for usual return to playing
The majority of symptoms resolve with proper treatment
“Medically Ready Force…Ready Medical Force”

38. “Medically Ready Force…Ready Medical Force”
Key Points for Leaders
Concussion /mTBI continues to be a major military concern with operational impact
Over 15,000 Soldiers were diagnosed with concussion/mTBI in and over 87,000 total since 2000
Early detection, leading to appropriate treatment, is the cornerstone for successful recovery
Soldiers need to get checked medical evaluation as soon as possible after the injury
Avoidance of a second concussion before adequate recovery is key to preventing a more serious injury
After a concussion, Soldiers need both physical and mental rest to allow the brain to heal
“Medically Ready Force…Ready Medical Force”

39. Concussion/mTBi Tools
These items are free upon request
Contact the Defense and Veterans Brain Injury Center (DVBIC)
dvbic.dcoe.mil OR
“Medically Ready Force…Ready Medical Force”

40. Questions/Discussion
TBI POCs: Medical Director: Rank, Name, (mobile phone/text) TBI Director: Name, (mobile phone/text)
“Medically Ready Force…Ready Medical Force”