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Moderate to severe traumatic brain injury S023

Document
Last amended 
25 October 2018
Current RMA Instruments
Reasonable Hypothesis SOP
94 of 2018
Balance of Probabilities SOP
95 of 2018
Changes from previous Instruments

SOP Bulletin 205

 ICD Coding:
  • ICD-9-CM Codes:  850.2-4
  • ICD-10-AM Codes: S06.03, S06.04, S06.05
Brief description

This SOP covers significant brain damage as opposed to the temporary brain disturbance covered by the companion SOP for ‘concussion’.  The SOP covers the direct effects of injury only.

If the brain injury was associated with munitions discharge, then the SOP for ‘physical injury due to munitions discharge’ could also apply.  A decision will then need to be made as to which SOP is appropriate in the circumstances of the case.

Confirming the diagnosis

This diagnosis requires contemporary military medical documents which indicate:

  • A transfer of kinetic energy to the head and
  • Evidence of significant disturbance in neurological function as defined in the SOP. That is:
    • Loss of consciousness for 30 minutes or more
    • Anterograde amnesia for 24 hours or more
    • Glasgow coma score of less than 13 out of 15
    • Physical evidence of intracranial trauma on imaging, or
    • Penetration of the skull at least past the first coverings of the brain being the dura mater.

A report from a neurologist is likely to be required to adequately investigate a claim.  Any neuropsychological testing that is undertaken should preferably be ordered by a neurologist.  If performed independently, results need to be provided to a neurologist and should not be used on a stand alone basis for diagnostic purposes.

Alterations in consciousness and memory can also occur as a psychological response to a severe stressor. Hence care needs to be taken when considering a claim that has potentially physical and psychological (psychiatric) elements.

Other SOPs that should be considered
  • Cerebrovascular accident (intracerebral haemorrhage)
  • Concussion
  • Fracture
  • Physical injury due to munitions discharge
  • Subarachnoid haemorrhage
  • Subdural haematoma
Conditions excluded from SOP
  • Post concussion syndrome (not a disease or injury - as declared by the RMA)
  • Acute stress disorder*
  • Post traumatic stress disorder*

* another SOP applies

Clinical onset

The clinical onset will be at the time of the head injury event (the transfer of kinetic energy to the head).

Clinical worsening

As the SOP covers only the direct effects of an acute injury, the issue of clinical worsening should not arise.

Further comments

The principal aetiological factor in the SOP is that of experiencing a significant force from a specified event at the time of the clinical onset of the injury. The ingredients of this factor are:

  • Significant force – This is an analysis of the severity of the transfer of kinetic energy to the head. Obviously moving one’s head backward and forward whilst nodding in agreement to a colleague would not be regarded a significant acceleration or deceleration of the brain, but suffering the same manner of movement during a high speed motor vehicle crash would be considered as significant.
  • Specified Event:

(a)        the head being struck by an object

(b)        the head striking an object

(c)        the brain undergoing an acceleration or deceleration movement without direct external trauma to the head

(d)        a foreign body penetrating the brain

(e)        an explosion or explosive blast.

 
Family of Head injury SOPs

            Event

Type of event

Body region or system

SOP

Confirmed event of kinetic energy transfer to body

Munitions discharge

Psyche

Acute stress disorder - PTSD

 

 

Physically anywhere

Physical injury due to munitions discharge

 

 

Brain

Physical injury due to munitions discharge

Concussion (MTBI) OR

Moderate to severe traumatic brain injury

Seizures

Epilepsy

Subdural haematoma

Subarachnoid haemorrhage

CVA (intracerebral haemorrhage)

 

 

Face

Physical injury due to munitions discharge

Fracture

Confirmed event of kinetic energy transfer to body

No Munitions discharge

 

Brain

Concussion (MTBI) OR

Moderate to severe traumatic brain injury

Seizures

Epilepsy

Subdural haematoma

Subarachnoid haemorrhage

CVA (intracerebral haemorrhage)

 

 

Face

Fracture

Cut, stab, abrasion and laceration

 
Glossary:

Amnesia – memory loss

Anterograde – Proceeding forward in time.

Concuss – Latin term which literally means ‘with shake’.

Post concussion syndrome – A controversial term which is not considered a specific disease or injury by the Repatriation Medical Authority. As such the symptoms of which the veteran complains, should be the focus of the claim investigation, rather than the ‘post concussion syndrome’, in the same way that back pain is not a valid injury or disease, and requires the delegate to find an organic pathology which is causing the symptoms or to determine that there is no injury or disease present.

Retrograde – Proceeding backward in time.

an explosion or explosive blast

Whilst it is clear that an Improvised Explosive Device (IED) blast which occurred 2 km away would not affect the veteran, and that an IED exploding 5 metres away would affect the veteran, it is less clear in the interval distance.

A veteran in close vicinity to an IED discharge can suffer:

  • Primary effects of blast – Veteran’s brain suffering an injury indirectly by the blast pressure and velocity air waves set up by the distant IED explosion, impacting on the head and being transmitted across the structure of the skull and layers of the brain.
  • Secondary effects of blast – Veteran struck by missile set in motion by IED blast suffering an injury in the form of blunt or penetrating traumatic injuries. This missile could be an integral component of the device or collected by the blast wave.
  • Tertiary effects of blast – Veteran is thrown against an object by the blast suffering injury.

It is the primary blast effect which is difficult for compensation purposes, since there is no confirmatory tell tale injury signs of blast exposure. Note that it is the blast air pressure and air velocity at the air-skull interface which is the pathological stress driving a potential traumatic brain injury.

An explosion produces a travelling pressure wave with the peak pressure falling inversely with distance and is proportional to the square root of the mass of the explosive. A pressure wave passes through the air and additionally through the ground.

Though in the military situation, the mass of explosive detonated may be unknown, the distance from the detonation is still of importance.

Further it is important to identify the nature of any blast shielding interposed between the detonation site and the veteran. A veteran dug into the ground will not suffer significant air blast but may suffer from a ground shock particularly if the walls of the gun pit or trench are too narrow.

A veteran riding in an armoured motor vehicle may be well isolated from the ground wave by the rubber tyres, and shielded from the air blast wave by the armour, but can suffer from tertiary injuries by being thrown about the vehicle during the blast, or struck by the vehicle during the blast. Note also that a local direct blast injury can occur if the body is touching the inside of the vehicle which is exposed to the blast.

Issues that may be relevant to determining whether there has been a significant force from an explosion

  • Nature of a blast source
  • Distance from the detonation.
  • Nature of the shielding between the veteran and the detonation source.
  • Any structures between the veteran and the explosion
  • Hill
  • House
  • Wall
  • Hedge
  • Other vehicles – nature of vehicles – smaller or larger than veteran’s vehicle.
  • Orientation of body – standing, sitting, lying
  • Wearing helmet/ no helmet
  • In a gully
  • In a gun pit/trench – half in half out; fully covered.
  • Inside vehicle; on observation point of vehicle with head outside vehicle; sitting outside vehicle.
  • Evidence of blast damage between the veteran and the detonation source:
  • Damaged vehicles; damaged walls
  • Fatalities
  • Damage to veteran’s vehicle
  • Fatalities and injuries to passengers of veteran’s vehicle.