Military Trauma
Clinical Knowledge Gaps
& Research Opportunities
COL Brian Eastridge, MD, FACS
Trauma Consultant, US Army Surgeon General
JTS, USAISR
Disclaimer
The opinions or assertions contained
herein are the private views of the
author and are not to be construed as
official or as reflecting the views of
the Department of the Army or the
Department of Defense.
Military Trauma Research
Gaps
Point of Injury / Pre-hospital Care
• Relevant and realistic documentation
solutions for pre-hospital care providers
• Life saving intervention efficacy
• Validation concepts Tactical Combat
Casualty Care
3
Military Trauma Research
Gaps
Hemorrhage
• Local and systemic hemostatic agents for the
control of compressible and non-compressible
hemorrhage
• Improved preservation, storage,
transportability, and processing of red blood
cells, platelets, and plasma
– Forward adaptability of damage control
resuscitation concepts
4
Military Trauma Research
Gaps
• Hemorrhage
• Treatments to enhance oxygen delivery and
perfusion
• Equipment and procedures for effective fluid
resuscitation of casualties
• Enhanced / optimized resuscitation fluids
Percent of Patients
DOW
Non-Survivable Etiology
100
90
80
70
60
50
40
30
20
10
0
83 %
16 %
1
Traumatic Brain Injury
Hemorrhage
Other
Eastridge et al, J Trauma 2011
Percent of Patients
DOW
Potentially Survivable Etiology
100
90
80
70
60
50
40
30
20
10
0
80 %
9%
Hemorrhage
8%
3%
Traumatic Brain Multiple Organ Other (Airway,
Injury
Failure
PTX,…)
Eastridge et al, J Trauma 2011
DOW (Potentially Survivable)
Hemorrhage Focus
21%
48%
31%
Truncal
Extremity
Junctional
Eastridge et al, J Trauma 2011
Military Trauma Research
Gaps
Coagulopathy
• Diagnostics and therapeutics to predict,
diagnose, prevent, and treat trauma
coagulopathy
• Noninvasive or minimally invasive sensors
to detect and warn of impending vascular
collapse and/or significant tissue damage
due to perfusion deficits
9
Blood / Coagulation
• Near Horizon
– Transition of Freeze-Dried
Plasma and Cryo-Preserved
Platelets to Advanced
Development (clinical trials)
• Current Focus Areas
– Understanding basic
mechanisms of traumainduced coagulopathy
– Developing improved
platelet storage systems
– Developing blood product
pathogen reduction
technologies
Military Trauma Research
Gaps
Orthopaedic Trauma
• Healing of segmental bone defects
• Prevention of heterotopic ossification
• Healing of massive soft tissue defects
• Tissue viability assessment and wound
irrigation / debridement technologies
• Wound Infection / Infection Control
11
Military Trauma Research
Gaps
Massive Soft Tissue Injury
• Drugs, devices, or novel surgical
techniques to decontaminate, debride,
protect, and stabilize hard and soft
tissue wounds to mitigate secondary
tissue damage
• Replacement or regeneration of lost
tissues / organs
12
Extremity Trauma &
Regenerative Medicine
• Defining the injury patterns
and resulting functional
outcomes
• Open fractures
• Soft tissue defects (muscle and
nerve)
• Wound irrigation and debridement
• Current Focus Areas
– Animal modeling of traumatic
injury
• Segmental defects
• Wound contamination and infection
– Muscle / bone regeneration
– Delivery of autologous stem cells
to treat defects
Battlefield Injury
Upper
Extremities
22%
Brain Injury (TBI) 12%
Shoulder/Upper Arm 6%
Forearm/Elbow 6%
Wrist/Hand/Fingers 7%
Other 3%
Face
7%
Eye
3%
Head/Neck
2%
Head/Neck Unspec
Spine/Back
3%
Torso
15%
Head/Neck
27%
3%
3%
Chest
5%
Hip/Upper Leg/Thigh 5%
Abdomen
6%
Knee/Lower Leg/Ankle 9%
Pelvis/ Urogenital 3%
Trunk/Back/Buttock 1%
Foot/Toes 5%
Lower
Extremities
31%
Other 12%
Other 2%
Military Trauma Research
Gaps
Traumatic Brain Injury
• Mitigation secondary brain/spinal cord
damage
• Non- or minimally-invasive sensors or
assays to rapidly diagnose the severity of
brain and spinal cord injury within the
battle area or as close to it as possible
• Drugs, biologics, or other agents to
mitigate post-injury neural and immune
cell over-stimulation, inflammation, cell
loss, and neurologic dysfunction
15
Military Trauma Research
Gaps
Secondary cell and organ damage
•
•
•
•
Ischemia/reperfusion injury
Cell death
Organ failure
Methods to reduce cellular demand for
oxygen and metabolic substrates
– Reframing physiologic maintenance
» Demand versus supply
• Therapeutics to modulate the immune
response to traumatic injury
16
Military Trauma Research
Gaps
Battlefield and En-route Pain
Management
• Minimal effects on physical and
cognitive performance for mission
capability
• Minimize cardiac and respiratory
depression
• Minimal or no potential for addiction
17
Pain Control
• Opportunities
– Novel agents / uses existing agents
• Battlefield, MTF, and enroute
– Regional pain therapy
– Defining the relationship between
pain control and Post Traumatic
Stress Disorder
– Nontraditional therapies
• Virtual reality immersive
environments for pain control
• Acupuncture
Military Trauma Research
Gaps
Evacuation of the Critically
Injured Casualty
• Hypobaria effects in stratevac
• Physiological effects of vibration, shock and Gforces
• Development of non-invasive sensors, diagnostic
and prognostic algorithms and processors for
remote triage, monitoring, and management of
casualties
• Decision support (computer assisted)
• Autonomous control systems
19
Military Trauma Research
Gaps
Burn
•
•
•
Viable transitional skin products to
austere environments
Protecting skin grafts from immune
recognition
Replacement and regeneration of
skin
20
Military Trauma Research
Gaps
Eye, Ear and Craniofacial Injury
• Prevention and treatment of
craniofacial and dental injury /
disease in austere environments
• Craniofacial reconstruction
alternatives
– Transplantation
– Tissue regeneration
21
Questions?