Military Trauma Clinical Knowledge Gaps & Research Opportunities

1. Military Trauma Clinical Knowledge Gaps & Research Opportunities COL Brian Eastridge, MD, FACS Trauma Consultant, US Army Surgeon General JTS, USAISR

2. 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.

3. 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

4. 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

5. 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

6. DOWNon-Survivable Etiology Eastridge et al, J Trauma 2011

7. DOWPotentially Survivable Etiology Eastridge et al, J Trauma 2011

8. DOW (Potentially Survivable)Hemorrhage Focus Eastridge et al, J Trauma 2011

9. 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

10. 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 trauma-induced coagulopathy • Developing improved platelet storage systems • Developing blood product pathogen reduction technologies

11. 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

12. 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

13. 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

14. Battlefield Injury Upper Extremities 22% Head/Neck 27% Brain Injury (TBI) 12% Shoulder/Upper Arm 6% Face 7% Forearm/Elbow 6% Eye 3% Wrist/Hand/Fingers 7% Other 3% Head/Neck 2% Head/Neck Unspec 3% Spine/Back 3% 3% Lower Extremities 31% Chest 5% Hip/Upper Leg/Thigh 5% Torso 15% Abdomen 6% Knee/Lower Leg/Ankle 9% Pelvis/ Urogenital 3% Foot/Toes 5% Trunk/Back/Buttock 1% Other 12% Other 2%

15. 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

16. 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

17. 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

18. 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

19. Military Trauma Research Gaps Evacuation of the Critically Injured Casualty • Hypobaria effects in stratevac • Physiological effects of vibration, shock and G-forces • 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

20. Military Trauma Research Gaps Burn • Viable transitional skin products to austere environments • Protecting skin grafts from immune recognition • Replacement and regeneration of skin

21. 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

22. Questions?