Battlefield Medicine
Date: 6/2/2010
According to many medical professionals, combatrelated traumatic brain injuries (TBI) are becoming a signature injury of the Iraq and Afghanistan wars. Hemorrhage and head injury are the two greatest causes of death on the battlefield.
U.S. Special Operations Command is currently working with industry on innovative ideas in terms of equipment and material regarding the SOF Tactical Combat Casualty Care Increment II-CASEVAC, said Major Wes Ticer with USSOCOM Public Affairs.
Army Medical Research and Materiel Command (MRMC) has achieved significant improvements in controlling hemorrhage from wounds on the surface of the body and from the legs and arms. ‘We are still struggling to identify an effective non-surgical technology to stop internal bleeding,” Colonel Dallas Hack, combat casualty care director at MRMC, told SOTECH. “Furthermore, hemorrhage is often so severe that a casualty must be resuscitated by infusing fluid to maintain blood pressure and oxygen delivery to vital tissues. Finding the best method to resuscitate a casualty is challenging because hemorrhage is not only characterized by the loss of blood, but by activation of a large number of body responses which attempt to compensate for the loss of blood.”
Many of these responses include alterations in body systems such as immune, inflammation and blood clotting functions. Despite decades of research into the best method and fluid(s) to resuscitate a casualty, a fully effective method to replace fluid volume while also correcting the altered body functions has not yet been identified, Hack said.
MRMC’s two major concerns about TBI center on its diagnosis and treatment. It is important to diagnose the occurrence and severity of a TBI, since this information will be used to guide how the casualty is managed. “An ongoing concern is that TBI occurrence and severity, specifically with respect to mild TBI (aka concussion) cannot yet be objectively identified in the field, although significant progress is occurring in development of devices and biological assays to address this challenge,” Hack said. Traumatic brain injury is an event, much like a heart attack. In a heart attack doctors can identify the underlying pathologies of coronary artery disease and its effects. However, Hack said TBI is characterized by a variety of alterations in cellular structure and function, which progress for days, weeks and sometimes months and years after the injury. “While a tremendous amount of research is currently ongoing into the pathology and treatment of TBI, no therapies to prevent the altered cellular function or to repair neural tissues are presently available to treat our casualties in the field, where treatment is most beneficial,” he said. “Treatment for mild TBI is symptom-based.”
The Army MRMC has a long-standing and productive relationship with the PEO soldier who is responsible for acquiring and fielding soldier protective equipment, such as body armor and combat helmets. The command contributes to the development of soldier protection equipment by conducting medical research to develop injury criteria, design standards and protection equipment performance testing methods for PEO soldier.
The command’s mission with respect to the development of new soldier protection equipment is to provide PEO soldier with injury criteria, design standards and protection equipment performance testing methods. PEO soldier uses these medical research products to develop performance specifications for new protection equipment. In addition to the injury prevention considerations provided by the command, these performance specifications also include a wide spectrum of other critically important performance considerations, such as ballistic protection and the ability of the soldier to effectively perform required tasks while wearing the protection equipment. Ultimately, Hack said industry’s challenge is to design and build protection equipment that meets or exceeds these specifications.
MRMC needs from industry “improved equipment and methods to diagnose and treat hemorrhage and TBI, particularly those that can be used in the field as soon after injury as possible,” Hack said. “Even after the original injury occurs, it will be possible to protect against the ongoing damage to tissues caused by altered body/cellular functions.”
The command’s medical research programs have provided the PEO soldier with information needed for the development of effective soldier protection equipment. For example, the command’s research on head-supported mass provided design guidelines to ensure that the weight and placement of helmet-mounted equipment, such as night vision goggles, are optimized to prevent neck injuries. Research on behind body armor blunt trauma is providing a new method for accurately testing the effectiveness of body armor in preventing behind armor blunt injuries. Finally, current research projects within the command and across DoD are examining the existence and mechanisms of non-impact, blast-induced mild TBI, or concussion, and the findings from these projects will help PEO soldier design the next generation combat helmet.
EPIC Helmet Liner
Team Wendy LLC is one company that makes a product to protect soldiers’ heads during blast occurrences. Their latest product is the EPIC helmet liner system: EPIC standing for enhanced protection, individual comfort. This product is an evolution of their current Zorbium Action Pad (ZAP) system, using the same patented Zorbium foam that has been proven through years of use by U.S. servicemembers in Iraq and Afghanistan. The current ZAP system is the only helmet pad system authorized for use in the ground combat helmets worn by members of the U.S. Army (Advanced Combat Helmet) and Marine Corps (Marine Lightweight Helmet), said Ron Szalkowski, senior product development engineer at Team Wendy.
The ZAP system uses seven separate pads, or eight in the SOF configuration, to better accommodate communications gear. These pads are attached to the inside of the helmet shell. “Each pad in the ZAP system has two different layers on the inside—one is firmer and provides impact protection, and the other is soft and provides comfort and stability,” said Szalkowski. “The EPIC system is different in that it includes a single impact liner that folds to the inner contour of the shell and covers nearly the entire inside surface. This makes the impact liner impossible to install incorrectly, for example in a way that hardware may become exposed, or that a large gap could occur between the pads.” Once this one-piece impact liner is installed, there are soft comfort pads that are attached to it in any configuration the wearer chooses. Each system includes 22 of these comfort pads, with thin and thick pads of various sizes and shapes. This allows every helmet to be custom fit.
The comfort pad set also includes two types of specialty pads. The first is the Ultra Grip pad, which has a high-grip surface designed for added stability. The pads are especially effective when using NODs (night observation devices). Four Ultra Grip pads are included with every system. The other specialty pad is the sweatband, which is wringable and highly moisture absorbent. Two sweatbands are included with every system.
Team Wendy designed the EPIC system so that even when no comfort pads are installed it will surpass the impact requirements of the ACH and LWH. “Impact testing involves measuring G-forces experienced by the head during an impact, with higher forces correlating to an increased risk of severe TBI,” said Szalkowski. “The EPIC design has shown a significant increase in protection by reducing high-G impacts without adversely affecting weight or heat dissipation.”
Team Wendy’s future developments are highly focused on improved energy-absorbing materials for helmet applications. They are currently conducting development under a Phase I small business innovation research (SBIR) award from the U.S. Army that aims to develop a material that will take impact protection to the next level. They are closing in on a system that could handle three times the energy input of the current pad systems. This is equivalent from increasing the impact speed from 6.8 mph to 11.8 mph while providing the same level of protection against brain injury.
Combat Gauze Z-Fold
The Combat Gauze Z-Fold is the only hemostatic agent currently recommended by the Committee on Tactical Combat Casualty Care (TCCC). It is issued one per every soldier, three per every combat lifesaver and five per every medic. “Combat Gauze requires little more training than a soldier already has to pack gauze into a bleeding wound and apply pressure,” said Jessica Perkins, CEO at Combat Medical Systems LLC. “It was tested by both the Naval Medical Research Center and the U.S. Army Institute for Surgical Research in 2008, and found to be the best solution for non-tourniquetable hemorrhage due to its efficacy and form factor ease of use. It was also awarded as one of the top 10 greatest inventions by the U.S. Army in 2008.”
According to the U.S. Army Institute of Surgical Research, hemorrhage accounts for 50 percent of the deaths among combat casualties, and a high percentage of these deaths are potentially preventable with prompt and effective treatment of hemorrhage. The development of combat gauze offers the medic a simple, cost-effective hemostatic product to treat severe external bleeding, especially in areas where a tourniquet cannot be applied. It is a large-sized flexible roll of non-woven medical gauze impregnated with a contact pathway activating clotting agent known as kaolin. The dressing can be used on surface wounds and has been proposed to treat deep bleeding at the end of a long wound tract.
“The Combat Gauze Trauma Pad is designed to address an unmet need: provide reliable hemostasis for large soft tissue wounds. With blast being the main mechanism of injury in our current conflict, there are often times large shark bite type wounds that require a large surface hemostatic solution,” said Perkins. “The Trauma Pad addresses this need. It is built on the same kaolin technology of Combat Gauze, but covers more area at once and is easy to apply. Its 12 inch by 12 inch configuration allows it to adequately address bleeding from blast and large surface wounds.”
HEADS Sensor
BAE Systems has been developing technologies designed to better monitor soldiers and identify their risk levels for combat-related TBIs since 2008, when the company first introduced its HEADS sensor. Since then, close to 7,000 of the company’s HEADS units have been fielded to the U.S. Army.
BAE Systems recently unveiled its next generation head-borne energy analysis and diagnostic system (HEADS) sensor. The HEADS sensor, like its predecessor, provides medical professionals with a detailed analysis of a blast/impact by recording accelerations and atmospheric pressures associated with a significant event such as an IED explosion. The HEADS device itself is a small, unobtrusive sensor which is easily secured inside a standard issue combat helmet. The HEADS package is extremely sensitive and is automatically activated when it senses an event. The sensor then records critical data—information identifying the severity of the impact—and stores the data until it can be easily and quickly downloaded.
The latest HEADS sensor stands apart from other systems because it is equipped with an LED visual display that automatically will begin flashing once a predetermined impact threshold has been met. Medical professionals and/or soldiers will know immediately if a soldier has sustained a concussion or worse. Additionally, the new system also incorporates radio frequency identification technology.
When asked about the difficulty often associated with identifying combat-related TBIs (soldiers will sometimes continue with their mission, unaware that the concussion from a blast may have lingering effects), Greg Kraak, director of V. S. military programs, security and survivability at BAE Systems, said, “With the next generation HEADS system, even if the injury isn’t obvious, a soldier will know instantly—via a visual LED display on the helmet—if they, or a fellow soldier, may have sustained a brain injury.”
In addition to alerting soldiers of possible concussions, the HEADS smart sensor is designed to provide medical professionals with important data that may help determine the severity of a soldier’s TBI, as well as treatment options. “With our next generation HEADS system, we’re providing medical teams with a valuable diagnostic tool that utilizes radio frequency technology,” Kraak said. “With our new ‘smarter’ sensor, if a soldier experiences a concussion in the field, not only will the visual display be triggered at the time of the event, but once a soldier enters a specified area, such as a forward operating base or dining facility, a series of strategically placed antennae will scan all available HEADS units and send data to a computer, identifying any soldiers who may have sustained a blast-related brain injury.” ?
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