Explosive Weapons Trauma Care Collective (EXTRACCT) Blast Injury Clinical Practice Guideline: Traumatic Brain Injury From Blast and Penetrating Mechanisms in Settings With Variable Resource Availability.

INTRODUCTION: Blast- and penetrating-mechanism traumatic brain injury (TBI) is increasingly prevalent in settings affected by conflict and explosive violence, including among local casualties in environments where neurosurgical infrastructure, advanced imaging, and critical care resources may be limited or absent. No protocols or guidelines comprehensively address the full spectrum of TBI from blast and penetrating mechanisms across variable resource levels. METHODS: The Explosive Weapons Trauma Care Collective (EXTRACCT) conducted a targeted narrative literature review across key clinical domains, including initial assessment, hemodynamic and airway management, medical treatment of intracranial hypertension, noninvasive neuromonitoring, surgical decision-making, and interfacility transport. Searches were performed in PubMed and supplemented by military, penetrating and trauma system clinical practice guidelines (Joint Trauma System, Brain Trauma Foundation, TCCC). Evidence was synthesized by a multidisciplinary authorship team and consensus was achieved through iterative expert review, following the AGREE II framework. RESULTS: This document provides stratified recommendations across variable resource contexts. Key recommendations include: early physiological stabilization with avoidance of hypotension and hypoxia; structured neurological assessment using postresuscitation GCS and pupillometry; noncontrast head CT as the primary imaging modality, with CT angiography for penetrating TBI and high-risk blunt mechanisms; hyperosmolar therapy as first-line treatment for intracranial hypertension; evidence-based sedation, analgesia, and neuromuscular blockade protocols; noninvasive multimodal neuromonitoring when invasive ICP monitoring is unavailable; surgical thresholds for decompressive craniectomy and craniotomy; and standardized transport protocols to minimize secondary brain injury during interfacility transfer. CONCLUSIONS: This document addresses a critical gap in context-appropriate blast-TBI management for settings with variable resource availability. Strict control of basic physiological parameters, structured clinical decision-making, and early transfer to neurosurgical care remain the primary determinants of outcome in resource-limited environments.