Recommendation: A new system for categorizing injury in trauma care should be developed. (Recommendation 6.3)
For these reasons, among others, the considerable research on fluid resuscitation for hypovolemia has not led to the implementation of new clinical approaches that improve hemodynamics or significantly reduce the rate of mortality among injured combatants on the battlefield. Furthermore, the key to improved care may not involve hemodynamics alone but likely requires an understanding of the molecular and cellular responses that are triggered by massive blood loss and shock. The goals of volume replacement therapy therefore include not only hemodynamic stabilization but also amelioration of the chain of events that lead to irreversibility in severe prolonged shock. Major therapeutic advances are most likely to result from new approaches that address the metabolic and cellular consequences of shock, many of which are triggered by the impaired oxygen delivery to tissue that accompanies hemorrhage and ischemia. Resuscitation approaches that enhance oxygen delivery to tissue deserve further evaluation.
Recommendation: Evaluate the applicability of small-volume, stable oxygen (O2)-carrying and O2-facilitating agents that improve and sustain O2 delivery in the wounded subject for 24 to 48 hours. (Recommendation 4.1)
Finally, the complex events that result from the initial insult, tissue injury, and resuscitative attempts provide numerous potential therapeutic targets for novel interventions. Novel therapeutic strategies might be conveniently, if somewhat artificially, categorized as those that prevent the early complications of the shock syndrome (prevention), those that treat the complications of shock syndrome and reperfusion injury (intervention), and those that render the subject less vulnerable to hypoxia and its consequences (tolerance). The military should maintain a research interest, if not research support, in each of these areas, recognizing that some are approaching sufficient maturity for clinical trials, whereas others are still at an investigative, basic science stage. The committee found that much of the research on hemorrhagic shock has remained focused on hemodynamics or has been directed toward the correction of a single biochemical abnormality that accompanies hemorrhage. Such strategies are unlikely to be successful, because multiple pathways lead to the cell death that results from severe hemorrhagic shock. Rather, novel therapies should be aimed at the multiple metabolic and cellular derangements that accompany traumatic shock. These approaches should take advantage of advances in other related fields (such as ischemia-reperfusion research on specific organs) and should be approached in a systematic manner that involves prophylaxis, immediate intervention, or the development of tolerance to global ischemia.
The committee's recommendations are listed in their entirety in Box 1.