Skip to main content

Military Health System

Important Notice about Pharmacy Operations

Change Healthcare Cyberattack Impact on MHS Pharmacy Operations. Read the statement to learn more. 

Immediate Testing: How the Military Evaluates Risk For Brain Injuries

Image of Pfc. Thomas Icenogle, a student in the Army’s Combat Medic Specialist Training Program at the Medical Education and Training Campus on Joint Base San Antonio-Fort Sam Houston, Texas, conducts a Military Acute Concussion Evaluation 2 (MACE 2) on Pvt. Alejandro Leija, while Pvt. Dominic Dubois refers to the MACE 2 card. (Photo: Lisa Braun, Medical Education and Training Campus Public Affairs). Pfc. Thomas Icenogle, a student in the Army’s Combat Medic Specialist Training Program at the Medical Education and Training Campus on Joint Base San Antonio-Fort Sam Houston, Texas, conducts a Military Acute Concussion Evaluation 2 (MACE 2) on Pvt. Alejandro Leija, while Pvt. Dominic Dubois refers to the MACE 2 card. (Photo: Lisa Braun, Medical Education and Training Campus Public Affairs)

The United States military uses a standardized assessment tool to quickly evaluate for possible concussion. For any service member who is exposed to an explosion, a training accident or any other blow to the head, a key first step is to administer the Military Acute Concussion Evaluation 2, known as MACE 2. 

The MACE 2 is outlined on a portable pocket card to identify symptoms of a mild traumatic brain injury at the point of care. TBI symptoms can include headache, dizziness, and problems with sleep, vision or balance. 

“MACE 2 provides a common language and baseline criteria,” Stephanie Maxfield Panker, chief, research support cell with the Traumatic Brain Injury Center of Excellence said. 

TBI Testing: What is MACE 2? 

The military medical community began using MACE in 2006. An updated, six-part MACE 2, was developed in 2018 by adding relevant history questions and a screening for visual and dizziness related symptoms.  

“The changes improved the standard of care for patients by reducing the risks of overlooking patients with those problems,” Gary McKinney, a certified brain injury specialist and TBICoE chief of clinical practice and clinical recommendations, said. 

The MACE 2 provides detailed concussion screening, a cognitive test, a neurological exam, symptom specific questions and screening, and a history section on concussion.  

How Does the MACE 2 Evaluation Work? 

The MACE 2 assessment starts with monitoring for key or urgent signs of concern: 

  • worsening level of consciousness 
  • double vision or loss of vison 
  • restlessness, combative or agitated behavior 
  • repeated vomiting
  • seizures 
  • weakness or tingling in the arms or legs 
  • severe or worsening headache 

If the assessment identifies any of those red flags, the patient requires an immediate referral to a higher level of care. In a combat zone, that might warrant an urgent medical evacuation, McKinney said. 

If there are no red flags, the provider will ask questions about the event that caused the injury to determine if the patient has a changed level of consciousness or memory problems. The provider also asks for some medical history, such as whether the patient has had a concussion before, when, and how severe it was. 

The evaluator also conducts an initial mental function exam. For example, the provider might ask whether the patient knows where they are and can remember what happened right before the injury. 

A nervous system function exam is next. The evaluator will test a patient’s ability to speak coherently and to walk correctly. That’s followed by a test of the patient’s ability to concentrate and recall memories. Asking the patient to follow the evaluator’s finger movements can check for dizziness or eyesight problems. 

The initial MACE 2 score provides an assessment at that particular time. Future MACE 2 scores may help the provider understand how the patient’s symptoms are changing to determine if the patient’s mental status has improved or worsened over time. 

Concussion Testing on the Front Lines 

The joint services’ Medical Education and Training Campus at Joint Base San Antonio-Fort Sam Houston, Texas, trains combat medics, along with combat life savers, to recognize potential head injuries along with the signs and symptoms that would require a MACE 2 and further evaluation. 

“Combat medics are instrumental in identifying the possibility of a TBI based on mechanism of injury, signs and symptoms, assessing for severity, and administering the MACE 2 as soon as possible after evacuation from the point of injury,” Jeremy Clarno, METC’s Combat Medic Specialist Training Program field craft chief, said. “This is crucial because early detection and treatment are the keys to preventing long-term effects.” 

Evaluators typically perform MACE 2 evaluations at battalion-level aid stations or higher. 

You also may be interested in...

Infographic
Nov 29, 2023

TBICoE's Low-Level Blast Research Infographic

What is TBICoE doing to help warfighters exposed to low-level blast? Leading the charge: 1. Collaborated on Military weapons training studies and Epidemiology studies 2. Led health and performance efforts in support of the Section 734 Program Advancing the science: 1. Measured LLB exposure effects on performance 2. Provided recommendations on LLB surveillance 3. Advanced DOD’s understanding of LLB health and performance effects Answering the call: 1. Outlined next steps for LLB research 2. Helped to develop guidance for managing brain health risk from blast overexposure 3. Recommended the development of a tool to capture career blast exposure These efforts are in support of the Warfighter Brain Health Initiative LLB Relevant Aims 1. Understand the known and emerging threats and hazards to brain health 2. Monitor warfighters for brain exposures 3. Reduce risk of brain exposures that may negatively impact brain health

This infographic illustrates TBICoE's research activity on understanding how low-level blast influences warfighter brain health. This work directly supports Line of Effort 2 of the Warfighter Brain Health Initiative. Learn more about low-level blast exposure and TBI at health.mil/LLB.

Publication
Nov 29, 2023

TBICoE's Low-Level Blast Research Efforts Infographic

.PDF | 2.12 MB

This infographic illustrates TBICoE's work to better understand how low-level blast influences warfighter brain health. These efforts directly support Line of Effort 2 of the Warfighter Brain Health Initiative.

Article Around MHS
Nov 29, 2023

Green Beret Teams Up with the US Southern Command Warrior Care Program Care Coalition Competes in Department of Defenses Warrior Games Challenge and International Invictus Games

U.S. Army Sgt. 1st Class Jacob “Jake” Anthony competing in the 2023 Invictus Games held in Dusseldorf, Germany. (Courtesy photo)

Green Beret U.S. Army Sgt. 1st Class Jacob "Jake” Anthony was deployed to Afghanistan in 2005 on a mission to find a target. His team was breaching a door that turned out to be booby-trapped, resulting in an explosion that killed his teammate in front of him. Anthony would take shrapnel to the right frontal lobe to his brain and had to be initially ...

Calendar Event
Nov 21, 2023

TBICoE's Anomalous Health Incident Acute Assessment Training

This virtual training, hosted by the Traumatic Brain Injury Center of Excellence, will introduce learners to Anomalous Health Incidents and review assessment and treatment strategies. Detailed guidance on how to complete a medical evaluation using Anomalous Health Incident Acute Assessment (DHA Form 244), will be provided.

Calendar Event
Nov 21, 2023

TBICoE's Anomalous Health Incident Acute Assessment Training

This virtual training, hosted by the Traumatic Brain Injury Center of Excellence, will introduce learners to Anomalous Health Incidents and review assessment and treatment strategies. Detailed guidance on how to complete a medical evaluation using Anomalous Health Incident Acute Assessment (DHA Form 244), will be provided.

Calendar Event
Nov 21, 2023

TBICoE's Anomalous Health Incident Acute Assessment Training

This virtual training, hosted by the Traumatic Brain Injury Center of Excellence, will introduce learners to Anomalous Health Incidents and review assessment and treatment strategies. Detailed guidance on how to complete a medical evaluation using Anomalous Health Incident Acute Assessment (DHA Form 244), will be provided.

Calendar Event
Nov 21, 2023

TBICoE's Anomalous Health Incident Acute Assessment Training

This virtual training, hosted by the Traumatic Brain Injury Center of Excellence, will introduce learners to Anomalous Health Incidents and review assessment and treatment strategies. Detailed guidance on how to complete a medical evaluation using Anomalous Health Incident Acute Assessment (DHA Form 244), will be provided.

Video
Nov 6, 2023

The Warfighter Brain Health for Leaders Training Video

The Warfighter Brain Health for Leaders Training Video

The Warfighter Brain Health for Leaders Training video is an essential resource for enhancing the Department of Defense's Warfighter Brain Health Initiative. It empowers military leaders with strategies for preventing, protecting against, and managing brain injuries. Additionally, the video enhances leaders' abilities to assess and recognize symptoms ...

Fact Sheet
Nov 6, 2023

Warfighter Brain Health After TBI: Guidance for Leaders

.PDF | 895.85 KB

This TBICoE fact sheet, Warfighter Brain Health After TBI: Guidance for Leaders, condenses the basics of recognizing, reporting, and preventing TBI in service members. It updates and supersedes the Line Leader Policy Guidance fact sheet and includes a list of what the DOD has defined as potentially concussive events and outlines leaders’ ...

Publication
Sep 29, 2023

TBICoE Research Review: Mild TBI and PTSD

.PDF | 435.28 KB

This research review provides an in-depth summary of the available clinical research on the topic of co-morbid mild traumatic brain injury and posttraumatic stress disorder. Specifically, this review will address symptoms, anatomy, diagnosis, and treatment of mild TBI, PTSD, and the unique circumstances associated with the presentation of both.

Publication
Sep 29, 2023

Mild TBI and PTSD Clinical Pearls

.PDF | 924.82 KB

TBICoE's "Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Clinical Pearls," is a new supplemental product to the detailed research review. This resource is designed to be brief and provide key actionable “clinical pearls” that should be considered in the treatment of service members with comorbid mild TBI and PTSD.

Video
Sep 21, 2023

TBI and Low-Level Blast Exposure: What Medical Providers Need to Know

TBI and Low-Level Blast Exposure: What Medical Providers Need to Know

This educational video, produced by the Traumatic Brain Injury Center of Excellence, focuses on the effects of low-level blast and traumatic brain injury. Its purpose is to provide supplemental information on low-level blast to health care providers and beneficiaries.

Last Updated: December 01, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on X Follow us on YouTube Sign up on GovDelivery