Page 77 - Journal of Special Operations Medicine - Winter 2016

unplanned, however, and pain secondary to major cryopreservation may help mitigate reproductive limi-
trauma is challenging to control and incompletely un- tations after traumatic loss of testicular tissue and has
derstood. Although some patients report no pain after been used by military personnel. Although conferring
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even the most severe injuries, others experience pain no survival benefit to the individual, the knowledge that
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that cannot be controlled by any means. Part of the sperm had been preserved before injury may contribute
problem is that after major trauma, peripheral or oral to morale and be protective against psychological mor-
absorption of analgesia is limited by peripheral and gut bidity postinjury.
hypoperfusion secondary to hypovolemic shock. Anal-
gesia is unlikely to provide a favorable risk-benefit ra- Discussion
tio when delivered before injury, given the side-effects:
opiates have potential to cause cognitive impairment, As long as human combatants are required to engage in
addiction, tolerance, and respiratory depression. Non- armed conflict, the unfortunate and tragic consequence
steroidal anti-inflammatory drugs predispose to renal of violence, injury, and death will follow. Preparedness
injury, gastric bleeding, impairment of fracture heal- for traumatic injury and mitigation of its effects as early
ing, and, possibly, intracranial hemorrhage after head as possible has been the focus of attention recently.
injury. However, analgesia that is already surgically However, rather than focus on “early” care, here we
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implanted or ready to deploy as described may be a po- propose that the timeline of trauma care be shifted left-
tential LOB-IT candidate. ward to a point before injury has even occurred.

Physiological Monitoring Evidence Base
Wearable clothing that provides continuous monitoring Generating the evidence base to support LOB interven-
of physiology is already available. This technology al- tions in trauma will be challenging because military
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lows remote monitoring (e.g., from a military medical campaigns may be sudden, impossible to predict, and
facility), and may provide immediate, real-time data resources for medical research may be sparse. Many of
after injury of a casualty. Applying this technology to the potential LOB-IT candidates would be suitable for
combatants before injury has an advantage over con- testing using animal models of battlefield injury. How-
ventional monitoring because it is immediate (provid- ever, there are obvious translatability issues with such
ing data before, during, and after injury), and can be preclinical studies, and robust clinical data would be re-
accessed by medical providers on scene and remotely quired if animal studies showed some avenues of prom-
at any medical facility in the chain of evacuation. Such ise. High-quality medical research in the military and
data provide an obvious advantage in the treatment of civilian trauma environments is not impossible and has
traumatic injury through the goal-directed guidance of been instrumental in driving practice change. A key ex-
interventions such as fluid resuscitation. ample is the use of tranexamic acid in hemorrhage (e.g.,
the CRASH-2 [Clinical Randomization of an Antifibri-
Mitigation of Secondary Effects of Trauma nolytic in Significant Hemorrhage] trial). 27
In addition to the acute effects mentioned, there may be
a role for LOB-IT candidate treatments in the preven- Ethical Considerations and Risk Stratification
tion of early morbidity and mortality after trauma. For Trauma, although devastating, is relatively rare among
example, experimental studies have shown that pretreat- the majority of troops and, therefore, risk stratification
ment with curcumin can mitigate secondary brain injury would be crucial in deciding who should and should not
in rodent models of head injury. 35,36 This “remarkably receive LOB-IT treatments. Furthermore, experience has
non-toxic” agent could be given to those who were shown that compliance with prophylaxis among troops
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are a high risk of receiving a head injury. Furthermore, may be poor, especially when the risk is perceived as low
there is some evidence that statins administered before and the adverse events high. 40,41 In military campaigns,
injury may reduce mortality and infection after general the population at risk for exposure to major trauma will
trauma and traumatic brain injury, giving it a place as a vary depending on multiple factors, including the phase
hypothetical LOB-IT drug. 38 of the campaign, role of the personnel, and evolution
of threats. For example, Airborne Forces undertaking
Mitigation of Psychological Effects of Trauma a parachute insertion onto enemy-held rocky terrain at
Massive lower limb and pelvic trauma has been a sig- night will be more likely to be exposed to major trauma
nature injury pattern during the recent conflicts in Af- than will support staff in a clerical role in headquar-
ghanistan and Iraq. As well as the obvious consequences ters. The decision as to which population should receive
of disfigurement, loss of physical functional, and long- trauma prophylaxis, and which should not, would de-
term rehabilitation, the important psychosocial conse- pend on knowledge of the adverse effects of the medical
quences of loss of sexual and reproductive function have treatment and a prediction of the risk for exposure to
profound effects on veterans’ well-being. Prior semen trauma. In addition to risk stratification, the autonomy

Pretrauma Interventions: Preventing Battlefield Injuries 61