Case report: use of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) to assist with return to duty determination of special operations soldiers who sustained mild traumatic brain injury.

48 CASE REPORT A team of Special Operations Soldiers in Iraq and their Host Nation (HN) counterparts were enroute to a target in a convoy of High Mobility Multi-Wheeled Vehicles (HMMWVs) when one of their vehicles swerved and violently flipped. The result was the death of one host nation occupant, and the ejection of two U.S. Soldiers. Both U.S. casualties were confused but responded appropriately to questions, with only minor complaints, and no life-threatening injuries. Due to the mechanism of injury, they were immediately evacuated to a Role 3 facility for further evaluation. After arrival at the Role 3, both casualties were evaluated with a detailed neurological exam, a trauma panel of labs, x-rays, and a head CT. All exams and tests were unre-markable. Both casualties were discharged later that day back to their unit. Within hours of returning to their unit, both Soldiers began experiencing symptoms of headache, fatigue, " feeling foggy " , and balance problems. Both attempted to minimize their symptoms in order to continue with missions. The medic recognized the signs of mild traumatic brain injury (mTBI) which prompted him to conduct further evaluation in order to elicit the true severity of their condition. The medic had access to a computer-based neu-ropsychological test called the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) exam which he administered to both Soldiers. Because their unit had the ImPACT program as a tool for this type of situation, both Soldiers already had pre-injury, or " baseline " , exams available for comparison. Initial results highlighted a significant difference between the baseline and post-injury tests, which suggested ongoing cognitive sequelae that may have been underappreciated by both the medical providers who had initially cleared them, as well as the patients themselves. As a result, the medic recommended that both Soldiers be restricted from missions and strenuous activity in order to manage their injury properly. The medic then emailed the results to and consulted with his medical officer and a task force psychologist by phone for further interpretation of the test results. Both agreed that the test revealed deficits in several areas, and agreed the medic's management plan was clinically appropriate. Over the next week, the Soldiers' conditions improved and their symptoms subsided. A subsequent ImPACT exam given 48 hours after the initial post-injury test confirmed their improvement. One Soldier had a complete resolution of symptoms and his ImPACT results returned to …