Skip to main content

Military Health System

Clear Your Browser Cache

This website has recently undergone changes. Users finding unexpected concerns may care to clear their browser's cache to ensure a seamless experience.

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...

Article
Sep 30, 2022

Top U.S. Military Enlisted Leader Shares Experience of Stigma Surrounding TBI

A man wearing headphones in front of his computer

Senior Enlisted Advisor to the Chairman Ramón “CZ” Colón-López shared his compelling story of recognizing and getting help for traumatic brain injuries on the Picking Your Brain podcast, from the Defense Health Agency’s Traumatic Brain Injury Center of Excellence.

Fact Sheet
Sep 14, 2022

Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet

.PDF | 168.72 KB

The Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet, developed by TBICoE, is a one page document that gives primary care managers (PCMs) an overview of neuroendocrine dysfunction (NED) that can occur after concussion, or mild TBI. It highlights conditions with overlapping symptoms, screening and treatment considerations, ...

Report
Aug 24, 2022

2000-2022 (Q1) DOD Worldwide Numbers for TBI

.PDF | 428.88 KB

TBICoE is the Defense Department’s office of responsibility for tracking traumatic brain injury data in the U.S. military. Here you’ll find data on the number of active-duty service members—anywhere U.S. forces are located—with a first-time TBI diagnosis from calendar year 2000 through the first quarter of 2022. The data is also broken down by each ...

Video
Jul 18, 2022

Interview with the SEAC: TBI from a Joint Perspective

Picking Your Brian Podcast. Interview with the SEAC: TBI from a Joint Staff Perspective

In this episode of Picking Your Brain, Traumatic Brain Injury Center of Excellence Branch Chief Capt. Scott Cota and clinical moderator Amanda Gano interview the Senior Enlisted Advisor to the Chairman of the Joint Chiefs of Staff (SEAC), Ramón Colón-López. The discussion covers the health impacts of TBI and blast-related concussion stemming from the ...

Publication
Jun 8, 2022

DOD Warfighter Brain Health Initiative Strategy and Action Plan

As a Department, we are committed to protecting the health and well-being of our people in order to maximize our ability to defend the nation. Brain health has historically been defined in terms of human performance optimization. The most accepted and familiar aspect of human performance has been physical performance (e.g., agility, endurance, ...

Fact Sheet
Jun 8, 2022

Talking to Your Child about TBI: A Guide for Caregivers of Service Members and Veterans

.PDF | 246.77 KB

This TBICoE fact sheet includes age-appropriate strategies adults can use to speak with children about traumatic brain injury—or concussion. It also includes tips on how to help kids cope with changes that impact the family unit.

Fact Sheet
Jun 8, 2022

Addressing Family Needs: A Guide for Caregivers of Service Members and Veterans

.PDF | 116.93 KB

This TBICoE fact sheet includes ways to build stronger family ties and develop coping strategies for challenges the family may experience after a loved one sustains a concussion—or TBI—such as substance misuse, psychological and emotional trauma, and financial changes.

Fact Sheet
Jun 8, 2022

Taking Care of Yourself: A Guide for Caregivers of Service Members and Veterans

.PDF | 121.29 KB

This TBICoE fact sheet is directed towards caregivers and provides self-care strategies to avoid caregiver burnout and fatigue when caring for a loved one who has sustained a traumatic brain injury.

Fact Sheet
Jun 8, 2022

Intimacy and Sexuality Following TBI: A Guide for Caregivers of Service Members and Veterans

.PDF | 121.48 KB

This TBICoE fact sheet provides caregivers and those diagnosed with a traumatic brain injury—or concussion— with information for addressing intimacy and sexuality concerns following injury. It includes information on how TBI can affect sexual functioning and behavior, and tips on improving intimacy after a brain injury.

Fact Sheet
Jun 8, 2022

Returning Home After TBI: A Guide for Caregivers of Service Members and Veterans

.PDF | 137.09 KB

This TBICoE fact sheet shares information and adaptation tips when a loved one diagnosed with a TBI—or concussion—returns home. It includes hot topics such as driving following TBI and ways to avoid a second traumatic brain injury.

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