Forum Summary

War is a tragedy, but it provides an opportunity for the medical community to learn about caring for victims of life-threatening trauma.  Since the beginning of the War in Iraq, the U.S. military has suffered 33,000 casualties, including 4,000 deaths, and there have been at least one hundred thousand civilian casualties.  According to one recent study, approximately twenty percent of the soldiers killed in Iraq died of “potentially survivable” wounds.  To prevent deaths of this sort, the military needs better ways of controlling hemorrhages and faster ways of evacuating wounded soldiers. 

The majority of battlefield deaths are the result of uncontrolled bleeding, and most of these hemorrhages are non-compressible, meaning that they cannot be stopped with a tourniquet.  Most soldiers killed on the battlefield die within one hour of being injured, and during this “golden hour,” it is crucial that these soldiers be quickly stabilized and evacuated to a hospital.  The traditional approach to treating a trauma victim consists of securing the airway and then checking for problems related to breathing and circulation, but new guidelines suggest that problems related to circulation should be addressed immediately. 

Researchers are currently exploring a number of promising new ideas for controlling hemorrhages, and many of these ideas are related to the management of blood loss.  One idea is to use high-intensity focused ultrasound to promote coagulation, and another idea is to replace lost blood with artificial compounds capable of carrying oxygen.  A third idea is to control non-compressible hemorrhages by raising the pressure inside the abdominal cavity.  This approach is known as abdominal insufflation, and in animals, it has been shown to reduce blood loss by a factor of three. 
Demand-side interventions designed to reduce oxygen consumption and metabolism are also being explored.  The induction of hypothermia, for example, seems to slow the rate at which the body succumbs to injury.  Metabolic poisons such as hydrogen sulfide have been shown in animals to reduce the metabolic rate by as much as ninety percent, and slowing the metabolic rate seems to prolong survival. 

Finally, the military is interested in the possibility of providing soldiers with metabolic protection against hemorrhages.  A number of intriguing observations suggest that the idea of metabolic protection is not extremely far-fetched.  It has been shown that restricting the number of calories that an animal consumes makes that animal more tolerant to injury, and it has also been observed that estrogen offers some level of protection against fatal hemorrhages.  In and of themselves, these observations do not suggest a protective strategy applicable to soldiers, but they do suggest that there might be ways in which the body can be manipulated in order to reduce its susceptibility to hemorrhages.       

As many of these ideas related to the management and prevention of hemorrhages are explored, key goals of the military are to improve the rate at which wounded soldiers are evacuated to hospitals and to improve pre-hospital data collection.  Improved data collection would result in improved patient care and would make it easier for the military to study the effectiveness of different pre-hospital interventions.

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