American Civilian Contractors in Iraq
Traumatic Brain Injury
The Signature Wound of the Iraq
and Afghanistan Wars

The symptoms of mild traumatic brain injury and post traumatic
stress disorder can be identical and you may have both.

Auditory system injuries and concussions are easily overlooked.
Explosions and Blast Injuries


Explosives are categorized as high-order explosives (HE) or low-order
explosives (LE).

High-order explosives produce a defining supersonic over-pressurization
shock wave. Examples of HE include TNT, C-4, Semtex, nitroglycerin,
dynamite, and ammonium nitrate fuel oil (ANFO).

Low-order explosives create a subsonic explosion and that does not
produce over-pressurization. Examples of LE include pipe bombs,
gunpowder, and most purely petroleum-based bombs such as Molotov
cocktails or aircraft improvised as guided missiles. High-order and low-
order explosives cause different injury patterns.

Explosive and incendiary (fire) bombs are further characterized based on
their source.

Manufactured implies standard military-issued, mass-produced, and
quality-tested weapons. Improvised describes weapons produced in small
quantities, or the use of a device outside its intended purpose, such as
converting a commercial aircraft into a guided missile.

Manufactured (military) explosive weapons are exclusively HE-based.
Terrorists will use whatever is available—illegally obtained manufactured
weapons or improvised explosive devices (IEDs) that may be composed of
HE, LE, or both. Manufactured and improvised bombs cause markedly
different injuries.


Mechanisms of Injuries
The four basic mechanisms of blast injury are termed as primary,
secondary, tertiary, and quaternary (Table 1). An example that causes
primary injury is blast wave, which refers to the intense over-
pressurization impulse created by a detonated HE. Blast injuries are
characterized by anatomic and physiologic changes that occur when the
direct or reflective over-pressurization force impacts the body's surface.
The HE blast wave (over-pressure component) should be distinguished
from blast wind (forced superheated air flow). Blast wind may be
encountered with both HE and LE.

Low-order explosives are classified differently because they lack the
defining over-pressurization wave of HEs. Low-order explosives cause
injury from ballistics (fragmentation), blast wind (not blast wave), and
thermal. There is some overlap between LE descriptive mechanisms and
HE's secondary, tertiary, and quaternary mechanisms.

Up to 10% of all blast survivors have significant eye injuries, generally due
to perforations from high-velocity projectiles. They can occur with minimal
initial discomfort, and present for care days, weeks, or months after the
event. Symptoms include eye pain or irritation, foreign body sensation,
altered vision, periorbital swelling, or contusions. Findings can include
decreased visual acuity, hyphema, globe perforation, subconjunctival
hemorrhage, foreign body, or lid lacerations. Liberal referral for
ophthalmologic screening is encouraged.


Primary blast waves can cause concussions or mild traumatic brain injury
(TBI) without a direct blow to the head. Consider the proximity of the victim
to the blast, particularly when the patient complains of headache, fatigue,
poor concentration, lethargy, depression, anxiety, insomnia, or other
constitutional symptoms. The symptoms of concussion and post
traumatic stress disorder can be similar.

The signs and symptoms of a TBI can be subtle. Symptoms of a TBI may
not appear until days or weeks following the injury or may even be missed
when patients appear fine, even though they may act or feel differently
(CDC, 2005b).

Diagnosing a TBI is challenging because symptoms are often common to
other medical conditions and the severity of the symptoms can change
over time. Any patient may have a TBI who has a history of head trauma or
who is suffering from confusion, disorientation, amnesia of events around
the time of injury, loss of consciousness of 30 minutes or less, neurologic
or neuropsychological problems, or who has a Glasgow Coma Scale
(GCS) score of 13 or higher. Taking a careful medical history can be key to
detecting a TBI. Any unusual or unexplained signs or symptoms should be
evaluated further (CDC, 2005b).

Auditory system injuries and concussions are easily overlooked. The
symptoms of mild traumatic brain injury and post traumatic stress
disorder can be identical.

In the war in Iraq and Afghanistan, improvised explosive devices create
blast injuries, which are the most common cause of TBI in the theater
of combat. Mild and moderate TBI’s are more prevalent in this conflict
due to the vast improvement in protective gear worn by our service
members. Blast injuries can result in the full spectrum of closed and
penetrating TBIs (mild, moderate, and severe). The mild to moderate
blast related TBI’s are often over looked in the presence of more
severe polytrauma. Blast injuries are defined by four potential
mechanism dynamics:

Primary Blast:
Atmospheric over-pressure followed by under-pressure or vacuum.

Secondary Blast:
Objects placed in motion by the blast hitting the service member.

Tertiary Blast:
Service member being placed in motion by the blast.

Quaternary Blast: Other injuries from the blast such as burns, crush
injuries, toxic fumes.

Traumatic Brain Injury in the Context of War

Of the patients who required medical evacuation from theater (war zone) to
Walter Reed Army Medical Center (WRAMC), 32% had TBI.1 Of these
patients, severe and penetrating TBI comprised only 8% of the total number
of TBI patients.

Although MRI is more sensitive for the detection of diffuse axonal injury,
roughly 80% of SMs seen at the WRAMC are ineligible for MRI procedures
because of the presence of metal fragments in their bodies.
If you were injured in or near a blast
do not presume that you were
screened for traumatic brain injury

Only the most obvious cases were
acknowledged by military medical
until recently.

DoD Avoided Brain Injury

authorize screening for TBI

CNA just denied TBI screening to a
survivor of a cluster bomb that went
off right at his feet.  He was blown
up, down, and apart but
"suspected" TBI does not qualify
until it is medically proven.

This story in Salon

"I am under a lot of pressure
to not diagnose PTSD"

includes this quote

McNinch added that he also
received pressure not to properly
diagnose traumatic brain injury, Sgt.
X's other medical problem.

"When I got there I was told I was
overdiagnosing brain injuries and
now everybody is finding out that,
yes, there are brain injuries," he
McNinch said he argued, "'What are
we going to do about treatment?'
And they said, 'Oh, we are just
counting people.
We don't plan on treating them.'"

McNinch replied, "'You are bringing
a generation of brain-damaged
individuals back here. You have got
to get a game plan together for this
public health crisis.'"
Comments from the Brain Injury
Association of America on
RIN 2900-AM75-“Schedule for
Rating Disabilities; Evaluation
of Residuals of Traumatic Brain
Injury (TBI).
click here

Better brain trauma testing
called for in Iraq

Brain Injured troops face
unclear long term risks

New IOM Report Predicts
Long-Term Health Problems,
Including Neurological

Traumatic Brain Injury and

Report to Congress Urges
Accelerated Efforts to Create
Breakthroughs on Traumatic
Brain Injury

Brain Trauma in Iraq
Thousands of U.S. soldiers have
survived powerful explosions in
Iraq. Many are returning home
with brain injuries that could
result in long-term disabilities.

Invisible Wounds of War

Veterans suffering from Brain
Injuries often have
accompanying impairments

The Delicate Brain
Post Traumatic Brain Injury
Hormonal Deficiency Syndrome

Sleep Apnea caused by TBI
T Christian Miller of ProPublica and
Daniel Zwerdling, NPR

Brain Injury
Full Coverage