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Care advances could boost survival rates

New initiatives by medical leaders could reduce by nearly half the number of battlefield deaths due to hemorrhages, and enhance the identification and treatment of traumatic brain injuries.

These two efforts were the centerpiece of the 12th annual Advanced Technology Applications for Combat Casualty Care Conference, held the week of Aug. 16 in St. Petersburg Beach, Fla. Some 1,400 were in attendance, including leading military and civilian medical providers, and researchers. The conference was touted as the Defense Department’s “premiere scientific meeting to address critical advances in trauma medicine and the unique needs of the warfighter.”

“If you are wounded by hostile action, you now have approximately a 90 percent probability of survival,” said Col. Dallas Hack, director of Combat Casualty Care. “However we still need to continue to work on improving trauma care. We believe that some of these deaths could be prevented if we had better technology, better knowledge, better products and systems to take care of these severe combat wounds.”

A clear priority is the treatment of hemorrhaging, or bleeding, to death, which is the largest cause of mortality on the battlefield. For penetrating trauma to the trunk of the body, including injuries to the chest, abdomen and pelvis, “we currently do not have an answer for this injury in the pre-hospital arena,” said Col. Lorne Blackbourne, commander of U.S. Army Institute for Surgical Research.

“The pre-hospital technology available to the combat medic ... has not kept pace with combat arms or in-hospital advances.”

An evaluation presented at the conference by the Armed Forces Medical Examiner’s office found that 50 percent of patients who arrived with vital signs at a deployed medical facility but later died had potentially survivable injuries. The solution, experts say, is found in a practice that was common during World War II but stopped in the early ’60s because of the hepatitis risk.

Today, combat medics provide intravenous infusions of clear fluids on the battlefield. These dilute the patient’s ability to form a clot. As a result, bleeding fails to stop — and can even increase, Blackbourne said. When that same patient arrives at a deployed surgical hospital, however, he receives intravenous clotting factors such as plasma, red blood cells and platelets. Clear fluids are avoided.

Experts are now looking to provide dried plasma on the battlefield to give clotting factors to wounded soldiers before they reach a deployed hospital. With such treatment, Hack said four out of five of soldiers with potentially survivable injuries would pull through, even if the medic couldn’t put pressure on that area.

Unlike QuikClot, which is applied to the wound, the dried plasma would enter the bloodstream through an IV catheter, or could be injected directly into bone marrow with manual pressure using a strong needle called an interosseous catheter. This procedure may require “remote damage-control resuscitation,” involving the remote presence of a physician or physician’s assistant to aid the medic.

While medical experts appeared enthusiastic about the possibilities, the question remains as to when the combat medic may be able to apply these advances on the battlefield.

“That’s a question we work on every single day, to make that as soon as possible,” Hack said. “It’s amazing how difficult all of that can be because, for good reason, the FDA requires us to do clinical trials at several levels before these types of products get approved.”

The Army is funding a couple of different efforts, Hack said, and the first of those products has entered the initial human studies.

“Right now, through our normal channels, it’ll be about three to five years,” before the product is available, he said. “We’re working very, very hard to speed that up.”

Brain injury research

Traumatic brain injury remains a “complex insult” that cannot be effectively treated, the medical experts said at the conference.

“In the entire field of traumatic brain injury, there is no way to really objectively diagnose brain injury and no way to treat it,” Hack said. “Once the tissue is damaged, we don’t really have any treatment that helps to heal that damaged brain tissue.”

Adding to the dilemma is the fact that blast-induced traumatic brain injury has unique components, such as malignant swelling in the victim and damage to connections in the brain.

“Traumatic brain injury is a very complex insult,” said Dr. Pat Kochanek, professor of critical care and director of Safar Center at the University of Pittsburgh. “What we really need [is] something like a magic bullet … we need a very specific neuroprotective therapy.”

Most treatment looks to control pressure and swelling while optimizing blood flow to the brain. But Kochanek said he and others are looking for something far more selective that targets subtle damage in the neurons or the long connections in the brain, called axons.

The Defense Department is funding more than 20 clinical trials in humans. Kochanek, who called this “a golden age in traumatic brain injury research,” said progesterone and cyclosporine are two agents that are “very meritorious” in this endeavor.

Hack cited studies involving Nurin, which is part of a naturally occurring substance in the brain that helps reduce inflammation. Such swelling is common after a brain injury and often causes further damage.

The experts were quick to note that they not only want to treat traumatic brain injuries — they also want to enable medics to diagnose them in the field. Currently, soldiers within 50 meters of a blast are taken back to base and checked for such injury or any signs of a concussion.

Kochanek said future, on-site diagnoses could come through blood tests, much like the detection of troponin in blood tests indicates a heart attack.

Another possibility would be to use electrophysiological tests, in which a miniature electroencephalogram, or EEG, might show the wave pattern has been acutely altered.

“You know, these things do take some time,” he said. “But I certainly in my 25 years in traumatic brain injury have never seen a more concerted effort, to try to launch as many clinical trials and pre-clinical trials, as is going on right now.”

OUR VIEW: Don’t delay new dried plasma treatment