Page 76 - Journal of Special Operations Medicine - Winter 2016

when such measures are implemented across large popu- because it has also been shown to augment muscle mass
lations of deployed troops. LOB-IT candidates must also and strength and inhibit exercise-induced muscle dam-
15
be specifically tailored to level of risk. Relative probabil- age. Nutritional strategies could also be implemented
16
ity of injury is both personnel and mission specific, and to improve immune function “in the field.” 17
such calculations are already commonplace in the plan-
ning of deliberate operations by military commanders. Physiologic preconditioning
LOB-IT candidates, therefore, may be stratified accord- The general principle for physiologic preconditioning
ing to their relative assessment of benefit according to would be to increase the physiologic reserve and car-
specific tasks and risks. Special Forces personnel would diovascular reactivity for optimum response to injury,
be some of the most likely to benefit from such interven- hemorrhage, and subsequent hypovolemia and acidosis.
tions because of the high-risk environment in which they Outcomes for critically ill trauma patients are worse when
operate and challenges in accessing timely medical care. they are smokers ; therefore, a useful pretrauma inter-
18
Conceptually, there are four ways in which an LOB-IT vention would be targeted smoking cessation. Preclinical
candidate modality might contribute to advancing experiments have shown that exercise preconditioning
trauma care (Figure 1): (a) monitoring and identification may protect against the effects of traumatic injury. 19–21
of individuals at risk; (b) prevention of death and mor- Furthermore, some authors have tested hemorrhagic pre-
bidity; (c) symptom control; and (d) mitigation of effects. conditioning by bleeding animals before a hemorrhagic
shock insult, and reported improved vascular reactivity.
22
Figure 1 Schematic representation of how “left of bang” Erythropoietin treatment may mitigate the organ injury
trauma interventions fit into the medical treatment of major and dysfunction secondary to hemorrhagic shock. 23
trauma patients.
Coagulation preconditioning
In one recent study of combat deaths, 91% of “poten-
tial survivors” were shown to have died secondary to
uncontrolled hemorrhage. Thus, prevention of cata-
24
strophic hemorrhage would be a crucial area to focus
on to improve survival. Tranexamic acid has recently
received a lot of attention as a safe and effective drug
to mitigate the effects of hemorrhagic shock, including
in a prehospital context. It has been reported to have
25
no serious adverse effects in this setting and there is a
26
benefit from early administration. Its use has shifted
27
from only trauma to perioperative use, reducing blood
Nutritional preconditioning loss and requirement for transfusion. The high po-
28
Nutritional optimization for strength and endurance is tential gain, low risk, and time-dependent benefits of
already relatively commonplace among modern military tranexamic acid make this an interesting potential LOB-
units. However, such an approach may be pushed fur- IT candidate.
ther by adopting a more injury prevention-centric model.
The benefits of muscle mass, strength, and aerobic and Antibiotic release after injury
anaerobic power may be increased by protein supple- Antibiotics are given routinely before infection-prone
ments, and oral carbohydrates taken before trauma surgical procedures and, therefore, may be of use after
29
11
and hemorrhage may also provide a survival benefit. trauma that requires surgical management. However,
12
Particular attention to weight and body mass index may the prolonged use of prophylactic antibiotics is fraught
also be required because of its effects on coagulation with the obvious problem of causing harmful antibiotic
after traumatic injury. 13 resistance. Furthermore, the time window of effective-
ness of presurgery administration of antibiotics is rela-
In terms of pharmacologic interventions, nutritional tively short, so their use as LOB-IT candidates may be
30
supplements could theoretically minimize trauma-re- limited. However, it is conceivable that antibiotic release
lated sarcopenia in critically ill trauma patients, with from a pre-implanted device may be triggered after trau-
potential survival benefit mediated through, for ex- matic injury or remotely by medical team activation.
ample, improved ventilator function. The leucine me- Such a speculative notion may not be entirely within the
tabolite β-hydroxy-β-methylbutyrate has been shown to realms of science fiction.
be a highly promising LOB-IT candidate because of its
ability to reduce the incidence of systemic inflammatory Symptom Control
response in trauma patients. This agent would be par- There is significant precedent in the area of preemptive
14
ticularly attractive to the uninjured military population analgesia in relation to planned surgery. Trauma is
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60 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016