Ukrainian medic Henri talks with the Prolonged Field Care Collective about conditions in Ukraine: most common injury patterns, weather and exposure, access difficulties, Russian drone attacks on medics, trench foot, dressing complex wounds, penetrating pelvic trauma, prevalence of pneumo-hemothorax over tension pneumothorax, body armor selection factors, and more.
Sunday, December 31, 2023
Saturday, December 30, 2023
Blood Loss and the Lethal Triad
Symptoms of blood loss:
500 mL - well tolerated, may produce slight tachycardia, equivalent to a typical blood donation volume.
1000 mL - tachycardia over 100
1500 mL - changes in mental status, weak radial pulse, persistant tachycardia, tachypnea
2000 mL - confusion, lethargy, weak radial, tachycardia over 120, tachypnea over 35, might be fatal if not managed properly
2500 mL - unconsciousness, no palpable radial pulse, tachycardia over 140, tachypnea over 35, fatal without intervention
In patients with blood loss, the "Lethal triad"- is a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy.
Acidosis: Reduced circulating blood volume leads to shunting of blood from the periphery to vital organs in the core. Peripheral tissues resort to anaerobic metabolism, which creates lactic acid as a byproduct. This can be worsened by administration of large volumes of non-oxygen-carrying, acidic fluids, such as normal saline (pH 5.5).
Hypothermia: Develops easily and rapidly in trauma patents, even in warm conditions. Anaerobic metabolism, immobility, and other physiological responses to blood loss reduce heat production. Evidence shows that even small drops in body temperature (to 36C / 96.8F) can significantly increase mortality in trauma and burn patients. At core temperatures below 30C / 86F, patients stop shivering and cannot warm up without application of external heat, even if they are well-insulated. It is far easier to prevent hypothermia than to correct it.
Coagulopathy: Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Loss of clotting factors due to bleeding, acidosis, and hypothermia all produce coagulopathy, which in turn further exacerbates blood loss, acidosis, and hypothermia.
Preventing the Lethal Triad cycle is crucial; once established, it is difficult to interrupt. Field treatment of patients with significant blood loss should include oxygen, insulation from the ground, covering with blankets/space blankets/ready-heat systems, and placement in a heated environment if possible.
Friday, December 29, 2023
Antibiotics in trauma
Evidence from historical US conflicts makes it clear that early administration of antibiotics in the field improves outcomes for battlefield casualties. Safety profiles are good for field antibiotics used in US combat medicine, and adverse reactions are rare. Currently, moxifloxacin (4th generation flouroquinolone) is the US military oral antibiotic of choice. Ertapenem (a carbapenem) is the parenteral antibiotic of choice. Together, these drugs cover a wide spectrum of potential infectious microbes.
The US Combat Wound Medication Pack contains 400mg moxifloxacin, along with 15mg meloxicam and 500mg acetominophen. The Ukrainian medication pack contains a similar assemblage of pills.
Thursday, December 28, 2023
Ukraine: Jogging in Circles and Red Viburnum Tea
Staying fit during winter in the Eastern half of Ukraine can be challenging. Fortunately I've worked out a combination of pilates and jogging around a UXO- and stray-dog-free circuit. Twenty laps equals two miles. The background noise of local air defense artillery at work has become easy to ignore.
Winter is setting in in earnest; after a cold run, its a good time for a cup of vitamin-C rich Red Viburnum Tea. Crushed viburnum berries and honey are a traditional remedy for colds in Ukraine. The berries can also be eaten raw in small quantities or made into jams and pies. For example, the viburnum genus is large and widespread. New-world viburnums, also known as high-bush cranberries, were used by Native Americans as a vitamin-C-rich winter food.
Viburnum is not just a common hedgerow bush here; it's a national symbol of Ukraine. "Chervona Kalina" ("Red Viburnum") is an old Ukrainian folk song (lyrics below). Its first stage performance occurred in the 1914 Stepan Charnetsky play "Sun of Ruin". Popularized by the play, it became the anthem of the Ukrainian Sich Rifleman unit, which fought for Austria-Hungary. In 1944, Chervona Kalina was made into an arrangement by Ukraine National Chorus director Oleksander Koshets. Koshets made "Carol of the Bells" famous in the US, during the Chorus's post-WWI world tours. The tours were intended to promote Ukrainian culture and garner support for the Ukrainian Independence cause, after the Bolshevik invasion.
Chervona Kalina has been extremely popular with Ukrainian soldiers, both during WWII and the current war. It is effectively a second national anthem for modern Ukraine.
Here is a youtube link to a 2022 version performed by Pink Floyd Chervona Kalina, with Pink Floyd
Chervona Kalina, lyrics:
In the meadow, a red kalyna
In the meadow, there a red kalyna, has bent down low ,
For some reason, our glorious Ukraine, has been worried so.
And we'll take that red kalyna and we will raise it up,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
And we'll take that red kalyna and we will raise it up,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
Do not bend low, Oh red kalyna, You have a white flower.
Do not worry, glorious Ukraine, You have a free people.
And we'll take that red kalyna and will raise it up,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
And we'll take that red kalyna and will raise it up,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
Marching forward, our fellow volunteers, into a bloody fray,
For to free, our brother - Ukrainians, from hostile chains.
And we, our brother - Ukrainians, we will then liberate,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
And we, our brother - Ukrainians, we will then liberate,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
In the field, of early spring wheat, there's a golden furrow,
Then began, the Ukrainian riflemen to, engage the enemy,
And we'll take, that precious, early wheat and will gather it,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
And we'll take, that precious, early wheat and will gather it,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
When the stormy winds blow forth from the wide steppes,
They will glorify, through out Ukraine, the Sich riflemen.
And we'll take the glory of the riflemen preserving it,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
And we'll take the glory of the riflemen preserving it,
And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!
Wednesday, December 27, 2023
Tuesday, December 26, 2023
Giving Blood in the Field: current TCCC recommendations
Due to occasional severe transfusion reactions, whole blood fell out of favor after WWII. Separating blood into components, such as plasma, red blood cells (RBCs), and platelets allowed for a longer shelf life, easier transport and storage logistics, and reduced risk of disease and transfusion reactions. Separate blood components are needed for many medical interventions. An exception, however, is trauma with massive blood transfusion needed. Recent evidence suggests that, for trauma patients in hypovolemic shock, whole blood produces better outcomes.
TCCC recommendations have evolved through combat experience gained in Iraq and Afghanistan during the recent "Global War on Terror" (GWOT). Before the US invasion of Iraq, most forward resuscitation efforts for blood loss centered on providing non-blood products such as Hextend and PLASMA-LYTE. In 2003, TCCC recommended that blood be carried on casevac units if possible. In 2006, this recommendation was updated to specify low-titer type O blood. As ongoing studies demonstrated increased coagulopathy and reduced survival with non-blood product use, in 2014 TCCC moved blood products to the forefront of care for hemorrhagic shock. 2020 TCCC guidelines list whole blood as the "fluid of choice", with crystalloids, Hextend, and PLASMA-LYTE recommended only if blood products are unavailable.
Whole blood for trauma has a number of advantages. It contains clotting factors that are missing from individually packaged blood components, and has a reduced amount of artificial anti-clotting agents (which can lead to coagulopathy). Whole blood is faster and simpler to administer than individual blood products. This can be important during times of high demand on patient caregivers, reducing workload and opportunities for errors. In general, the sooner blood is given, the better the outcomes. A retrospective study of 502 US military combat casualties in Afghanistan between 2012 and 2015 showed that time to initial blood product transfusion was associated with a reduced 24-hour and 30-day mortality.
Non-blood products such as crystalloids, Hextend, and PLASMA-LYTE come with several negative side-effects. They may contribute to the "Lethal triad"- a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy which is hard to interrupt once it sets in. Expanding blood volume without adding RBCs does not increase oxygen-carrying capacity, leading to ongoing lactic acid production via anaerobic metabolism in oxygen-deprived tissues. Normal saline is acidic (pH 5.5) and infusing large volumes can cause acidosis. Lactated ringers is less acidic (pH 6.5), but is slightly hypotonic and some experts believe it may worsen swelling in TBI patients. Even isotonic crystalloids may seep into damaged tissues, rather than stay in the vascular compartment, due to osmotic differences. High-volume unwarmed fluids contribute to hypothermia, which develops easily and rapidly in trauma patients, due to reduced heat generation during anaerobic metabolism, reduced circulating blood volume, immobility, and physiologic responses to blood loss. Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Acidosis and hypothermia both produce coagulopathy, which in turn further exacerbates acidosis and hypothermia. Once established, the lethal triad cycle is difficult to interrupt.
The current TCCC-preferred fluid for blood loss replacement in trauma victims is "LTOWB": cold-stored, low-titer O-negative whole blood. The "ABO" blood groups refer to the presence of A-type and B-type antigens on the surface of red blood cells. Most antibodies are only produced after an exposure to an antigen ("sensitization"). For instance, someone with a severe allergy to bees only experiences an allergic reaction after their second bee sting- the first sting merely introduces foreign material that the body that incites antibody production. But, in the case of antibodies that act against A-type and B-type antigens, this is not true. Each person is born with innate A and/or B antibodies, with no foreign blood exposure required. If a patient with type-A blood is given a transfusion of type-B blood, each of the patient's anti-B antibodies will adhere to several type-B antigens in the donor blood. This causes the donor RBCs to clump together ("agglutination"). These clumps block small blood vessels throughout the body. As the cells of clumps break down ("hemolysis"), they release hemoglobin, which can clog the kidneys and result in kidney failure.
Image shows agglutination in a rapid blood-type test.
Those with blood type A innately have A antigens and anti-B antibodies. Those with blood type B have B antigens, and anti-A antibodies. Those with type O blood have no antigens, and both anti-A and anti-B antibodies. Therefore, type-O blood will not produce reactions in people with type A or B blood.
A second transfusion consideration is presence or absence of Rh factor. 85% of Americans are Rh-positive; they have Rh antigens, and therefore will not produce anti-Rh antibodies. Only Rh-negative individuals can produce anti-Rh antibodies, and they only do so after sensitization. Sensitization can occur via pregnancy with an Rh-positive fetus, or via an Rh-mismatched transfusion. In the case of pregnancy, Rh+ cells rarely cross the placenta; exposure may occur during childbirth, and may become an issue if a second pregnancy with an Rh+ fetus occurs. Similarly, a first transfusion with Rh-mismatched blood is not a problem, however a second transfusion or Rh+ pregnancy might cause a reaction.
Low-titer O blood refers to low levels of anti-A and anti-B antibodies in the type-O donor's blood. Titers below <256 are very unlikely to cause transfusion reactions in blood recipients. For massive transfusion purposes, low A/B antibody titers are more important than presence or absence of Rhesus factors (i.e. whether the blood is "O-positive" or O-negative". Because rhesus-negative patients don't develop sensitivity to Rh-positive products until several weeks after exposure, Rh+ blood can be given to Rh- acute trauma patients without significant risk of a transfusion reaction. So, while ABO-mismatched transfusion reactions can be severe, Rh-mismatch is less concerning in acute trauma situations. For acute trauma, low-titer O blood is best. For general medical transfusion applications, O-negative blood is most useful. Generally, people with type-O-negative blood are 'universal donors', and those with type AB-positive are 'universal recipients'.
TCCC Blood Products Order of Preference:
1) "LTOWB" Cold stored low-titer O negative whole blood. This product has had disease testing performed (HIV, HBV, HCV, West Nile, syphilis, HTLV, Chagas), anti-A/B antibody titer <256, and leukocyte reduction. Shelf life is 21-35 days.
2) "FWB" Pre-screened low-titer O fresh whole blood. 16ga IV should be used to collect from the donor; placement of an 18ga in the recipient is sufficient, safe, and encouraged. Shelf life 6-8 hours.
3) Plasma, RBCs, and platelets in 1:1:1 ratio
4) Plasma and RBCs in a 1:1 ratio. Shelf life 1 yr for plasma, 42 days for RBCs.
5) Plasma or RBCs alone. Some countries (including France, Germany, and South Africa) use freeze-dried plasma (FDP) for austere ops; FDP contains fibrinogen and other hemostatic factors.
Care should be used to prevent hypothermia; warm chilled blood before administration and use a filter to remove small clots. Citrate preservative used in blood collection bags binds with the patient's calcium, therefore 1g calcium should be given after administration of the first unit of blood (either 30mL 10% calcium gluconate or 10 mL 10% calcium chloride daily). Give blood until mental status improves, radial becomes palpable, or BP rises above 100.
Monitor for reactions:
1) Anaphylaxis: wheezing, stridor, shortness of breath, hypotension, hives. Give 0.3mg epi + 25mg benadryl and monitor airway. Optionally give 10-40mg methylprednisolone slow IVP.
2) Acute hemolytic reactions: rupture of RBCs and leakage of contents, generally due to blood mismatch. Symptoms include fever, flank pain, and red/brown urine. All 3 are rarely observed together in field, Pain may alternately occur in an arm, chest, or back, DIC may occur. Nausea may preceed other symptoms. Give 25mg benadryl via slow IV push.
Treatment measures for both anaphylactic and hemolytic reactions: immediately stop the transfusion, give normal saline, stabilize the patient, and try another blood product.
The Use of Low Titer Group O Whole Blood in Emergency Medicine
Mouse Fever- "Trench Nephritis"
During December of 2023, reports of Russian soldiers falling ill with fever, back and abdominal pain, red eyes, and kidney problems began to emerge from the trenches of Eastern Ukraine. Ukraine's Military Intelligence Directorate (GUR), has blamed the reports on "mouse fever", or Hemorrhagic Fever with Renal Syndrome (HFRS).
Although HFRS is poorly researched, it is likely this hemorrhagic viral disease accompanied many wars of the past. HFRS (aka Korean Hemorrhagic Fever, Epidemic Hemorrhagic Fever, or Nephropathia Epidemica), is a rodent-borne group of hantaviruses, of the family Bunyaviridae. Strains, which differ in their symptoms and epidemiology, include Hantaan, Dobrava (found in the Balkans), Saaremaa, Seoul (found worldwide), and Puumala (in Scandinavia, Russia, and W Europe). Poor wartime living conditions for soldiers and displaced populations contribute to both increases in rodent populations, and increased exposure to virus shed in the rodents' urine and feces. In Ukraine this year, warm fall weather and unharvested crops in fallow fields have led to a large winter rodent population. Life in the trenches increases soldiers' exposure to rodents. HFRS is spread by striped and yellow-necked field mice, norway rats, and bank voles, amongst others.
Unlike New World hantaviruses, which cause pulmonary disease with mortality rates of 40-50%, Old World hantaviruses tend to create generalized hemorrhagic symptoms and kidney problems. They are more likely to spread as epidemics and have lower case fatality rates (CFR 2-20%). Reports of wartime HFRS-like diseases have cropped up in many wars throughout history, often referred to as "trench nephritis", or mis-diagnosed as other conditions.
The first known written mention of HFRS was likely made in a Chinese medical book in AD 960. Mentions of "trench nephritis" during the US Civil War may be attributable to a kidney-targeting hantavirus, such as the Seoul strain. "Mouse Fever" appeared in a 1913 Vladivostok hospital record. "Field nephritis" affected both Allied and German troops in Flanders in WWI. During WWII, 10,000 Japanese soldiers fell victim to a HFRS-like illness in Manchuria, as did several hundred Russian soldiers in the Far East. More than 1,000 Finnish and German soldiers contracted what was probably the Puumala strain in Finland. 3,200 cases of HFRS were diagnosed amongst UN soldiers during the Korean War; these experienced a mortality rate of 15-20%. Numerous soldiers fell ill with HFRS symptoms during the Balkans war. Currently, an estimated 100,000 cases of HFRS occur each year worldwide. In Ukraine, one study found that 1.6% of healthy individuals have antibodies to hantaviruses.
HFRS is contracted by inhaling dried rodent urine, droppings, or saliva, or by touching mucous membranes after touching surfaces contaminated with rodent excrement. After a 1-2 week incubation, patients experience a sudden onset of flu-like symptoms. These can include severe headache, abdominal pain, nausea, vomiting, back pain, fever, chills, back pain, flushed face, red eyes, and blurred vision. In severe cases, the disease may progress to kidney failure, fluid overload, vascular leakage, hypotension, and possibly death. Hantaan and Dobrova strains are more like to cause severe illness; other strains tend to be more moderate. Ribavirin, if given very early, may help. Otherwise, supportive care focuses on maintaining fluid and electrolyte balance. Dialysis may be required. CFR ranges from 5-20% for Hantaan to <1% for Puumala virus. Complete recovery can take weeks or months. A vaccine for the Hantaan strain exists in Korea, but is little-used.
CDC HFRS page https://www.cdc.gov/hantavirus/hfrs/index.html
Article: Hemorrhagic Fever with Renal Syndrome
Hantaviruses: History and Overview
Monday, December 25, 2023
Christmas in Ukraine
Our Christmas Tree
Most people in Ukraine have shifted to celebrating Christmas Day on 25 December, instead of the Russian Orthodox tradition of 7 January. Thus, Christmas fell on our day off. We visited an old church, which was used as a sports hall during Soviet times, and has since been restored by donors.
We had a fairly simple Christmas repast. However, for many Ukrainians, old traditions have become more popular, such as caroling, serving 12 traditional dishes, and setting out a "dedukh" (rye sheath that symbolizes ancestral spirits).
Sunday, December 24, 2023
TCCC and Prolonged Field Care: more relevant than ever in Ukraine
For US medics in Afghanistan and Iraq, air superiority more often than not allowed for relatively quick evacuation of injured soldiers in need of advanced surgical care. In contrast, medics in Ukraine commonly are forced to provide prolonged care to patients at or near the frontlines. 4-12 hours, or more, may pass before conditions are safe enough for ground evacuation of patients. Air evacuation is generally impossible due to high risks from Russian air defense platforms, and to a lesser extent, Russian aircraft. Additionally, due to heavy use of artillery, patients often come in clusters. Attrition amongst experienced frontline medics has the potential to burden inexperienced replacement medics with multiple severely injured patients at once, who are in need of prolonged patient management under very austere circumstances.
Similar conditions might well prevail during a hypothetical ground war involving the US and either China, or a similarly strong alliance of powers. Under such conditions, ability to provide advanced prolonged care techniques in the field would be an important tool to improve patient outcomes.
US military working groups have made great progress on developing evidence-based prolonged field care guidelines, mostly based on experience in Iraq and Afghanistan over the past two decades. These guidelines are also applicable to traumatic injuries in many non-combat austere medical situations, such as maritime and wilderness environments. Tactical Casualty Combat Care - Prolonged Casualty Care Guidelines are published by the US Military Joint Trauma System here. In-depth podcasts on various prolonged field care topics can be found here, on the Prolonged Field Care Collective website, or on Spotify, and Youtube.
Saturday, December 23, 2023
ISW Report; THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND
"The ground truths of this war have not changed: Russia still explicitly intends to erase Ukraine as a concept, people, and state; Ukraine’s will to fight remains strong; Russia has made no operationally significant advances this year; and Ukraine’s will combined with the West’s collective capability (which dwarfs Russia’s) can defeat Russia on the battlefield.[1] US interests still include preventing future Russian attacks on Ukraine and helping Ukraine liberate its people and territory. Supporting Ukraine is still the best path for the United States to avoid higher costs, larger escalation risks, and a greater Russian threat. What’s changing is Americans’ perceptions of their interests, not the interests themselves. That American perceptions are changing is not an accident. It is, in fact, precisely the effect the Kremlin has been seeking to achieve. The Kremlin’s principal effort is destroying America’s will by altering Americans’ understanding of their interests, and this effort appears to be working. If Russia wins in Ukraine because of the collapse of Western aid, it will be because Russia has managed to shape Americans’ understanding of reality such that the United States willingly chooses to act against its interests and values without realizing that it is doing so. Russia will have manipulated America into abandoning its own interests in a fight it could and should have won. That’s a dangerous lesson for China, Iran, and other US adversaries to learn. America’s security now and in the future, in Asia and the Middle East as well as in Europe, depends on remaining solidly connected with our strategic interests and values and demonstrating that we will not fall prey to efforts to manipulate our perceptions of those interests."
-THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND
Dec 22, 2023 - ISW Press
Thursday, December 21, 2023
Ukraine War: Crush Injury Treatment
Heavy use of artillery has long been a defining trait of the Soviet and modern Russian militaries. During the Ukraine war, Russia has fired fast amounts of ordinance at Ukraine- peaking at 20,000 - 60,000 shells/day (Ukraine, in turn, holds the line using around 7,000 shells/day, depending on supply constraints). Traditional artillery such as mortars and rockets are now supplemented by loitering drone platforms, grenades attached to FPV hobby drones, purpose-built ballistic missiles, re-purposed anti-aircraft missiles, and GPS-guided bombs dropped by aircraft operating in the relative safety of Russian airspace. In addition to saturation bombing of frontline areas, civilian infrastructure in cities throughout Ukraine is frequently targeted. Since the start of the invasion, Russia has fired 7,400 missiles and 3,700 Shahed-type drones at Ukrainian territory.
All of this translates to a high rate of bombing-related trauma patients- not just for military medics, but also for municipal and national guard responders in civilian areas. It is estimated that in Ukraine, civilian deaths have passed 9,700, military deaths top 70,000, and injuries outnumber deaths by a factor of between 2:1 and 5:1. The war has caused an estimated 25,000-50,000 amputations within Ukraine.
Crush syndrome is an important phenomenon for medical responders to consider during conflict, It is often accompanied by a constellation of related injuries, including compartment syndrome and rhabdomyolysis.
Experience from earthquake and conflict response shows that up to 40% of multistory building collapse survivors experience crush syndrome. Crush syndrome, with ensuring rhabdomyolysis, is the 2nd most frequent cause of earthquake deaths (the 1st is direct trauma). Bombing can cause similar patterns of blunt trauma due to structural collapse and airborne debris.
Crush syndrome consists of direct damage to local tissue, and resulting systemic effects. Systemic effects include hypotension, hyperkalemia, hypocalcemia, dysrhythmias, and organ dysfunction. The initiating mechanism of crush syndrome is direct damage to the cell membranes surrounding muscle cells. Rhabdomyolysis, or muscle cell breakdown occurs (from the Greek rhabdos=rod + myo=muscle + lysis=breakdown).There is an influx of fluids and calcium into the damaged cells, and a release of cell contents such as potassium, phosphate, and creatine into the bloodstream. Systemic effects follow. Massive third spacing of fluids causes hypovolemia; 12 liters or more of fluids may migrate into crushed areas during the first 48 hours. Histamine and leukotriene release causes vasodilation and bronchoconstriction. General vasodilatory effects cause capillary bed leakage, which worsens edema, third spacing, and hypotension. Ongoing enzymatic damage occurs in muscles, accompanied by tissue hypoperfusion and hypoxia. Lactic acid from anaerobic respiration in damaged muscle tissue causes acidosis and dysrhythmias. Myoglobin and uric acid builds up in the kidneys faster than it is excreted, causing acute kidney failure. Potassium released from cells causes hyperkalemia and associated dysrhythmias. Thromboplastic release can lead to DIC.
Aggressive and comprehensive treatment of crush injuries is key, and should begin on-scene prior to patient extrication. Initiate early pain control using fentanyl or ketamine for preservation of blood pressure (IN route is an option). Avoid kidney-processed medications such as NSAIDs. Prevent hypothermia and consider TXA for bleeding. Begin fluid resuscitation without delay; a delay in fluids may increase incidence of renal failure by 50%, and a 12-hour delay in fluid administration has been associated with almost 100% rates of renal failure in crush injury patients. Renal failure carries a 20-40% mortality rate in crush injury victims. Administer 1.5L of NS over the first hour. Potassium-containing fluids such as lactated ringers and sterofundin ISO may exacerbate hyperkalemia and should be avoided. As a side note, in patients with noncompressible bleeding, fluids may worsen bleeding. Therefore, in some cases it may be necessary to balance the risk of uncontrolled hemorrhage with the risk of cardiotoxic levels of potassium. If extrication must be performed prior to IO/IV placement, consider short-term tourniquet placement. For prolonged field care, urine output of 100-200mL/hour is the target. if IV/IO access and fluids are not available, this may be achieved via oral or rectal hydration via ORS, pedialyte, or a water-sugar-salt-baking soda solution (1L water, 8tsp sugar, 0.5 tsp salt, 0.5tsp baking soda).
Patients should be transported gently and carefully monitored via EKG. In hyperkalemic patients 10 units regular insulin+50mL D50 glucose (onset 20 min,action duration 4-6 hrs), and high-dose albuterol (12mL of 2.5mg/3mL solution via nebulizor, onset 30min, action duration 2 hrs) help to push potassium out of circulation and back into cells. Correct hypocalcemia with 10 mL (10%) Calcium gluconate or calcium chloride administered over 2-3 minutes (action duration 30-60min). Recent studies have not found administration of bicarbonate or mannitol to have kidney-protective effects. Bicarb is not recommended in TCCC protocols for potassium reduction, due to its slow and unsustained effects on potassium levels. TCCC's prolonged care protocol recommends monitoring of potassium levels and use of sodium polystyrene sulfonate to permanently remove excess potassium from the body via the GI tract (other agents only temporarily force it back into cells).
All crush injury patients should be observed, even if they appear well. Significant toxin accumulation generally occurs after 4-6 hours of entrapment/tissue compression, but can occur in as little as 60 minutes. Unexpected mechanisms, such as prolonged immobilization due to unconsciousness, may result in crush or compartment syndrome within compressed tissue areas. Severe blunt trauma to an extremity, or reperfusion of a limb that has been tourniqueted for more than 2 hours may also result in crush-syndrome-like symptoms.
Signs of renal failure may be delayed. Most cases of acute renal failure will recover with dialysis, though recovery may take up to 60 days.
Compartment syndrome- swelling and pressure inside a muscle compartment, which impedes circulation within the compartment, may develop. Muscles are covered in dense membranes called fascia, which do not stretch under building pressure. Signs of compartment syndrome include extreme localized pain, pallor, pulselessness, paresthesia, and paralysis of the affected area. Presentation may be clandestine, due to local nerve damage or altered mental status. Muscle compartment pressures as low as 40mmHg can cause compartment syndrome, through pressures may reach 240mmHg after significant trauma. Fasciotomy may be required to relieve pressure.
2004 study: Brown C, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: Do bicarbonate and mannitol make a difference? J Trauma. 2004;56(6):1191—1196
2013 literature review: Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: A systematic review. Ann Pharmacotherapy. 2013;47(1):90—105.
Wednesday, December 20, 2023
Tuesday, December 19, 2023
TB and the Ukraine War
Not only does the current Russia-Ukraine pose unique risks of regional and global military escalation, it is also creating historic levels of population displacement and military mobilization of convicts, in one of the world's foremost multi-drug-resistant tuberculosis hotspots.
TB, or "consumption" is an ancient disease, closely associated with malnutrition and overcrowding. It is the disease that killed Chekhov, Chopin, Emily Bronte, Orwell, Kafka, Keats, Thoreau, and many others at the height of their creative years.
TB is caused by the bacteria 'Mycobacterium tuberculosis'. Mycobacteria have evolved a waxy coating which allows them to survive and reproduce inside macrophages, thus evading our immune system's first line of defense. Tuberculosis can remain latent within the body for many years, becoming active once the immune system is sufficiently weakened by factors such as malnutrition, diabetes, HIV, or smoking. A patient with latent TB has a 5-10% lifetime chance of developing active TB. Classic symptoms of active pulmonary TB include night sweats, weight loss, and a cough that produces blood-tinged sputum. Untreated, pulmonary TB eventually destroys the lungs in a "swiss cheese" pattern, and leads to patient death. TB bacteria may also disseminate throughout the body, creating a variety of symptoms, such as cutaneous nodules, engorged lymph nodes (scrofula), meningitis, and an array of internal organ problems.
TB is the world's top infectious disease killer, and fully 1/4 of the world population currently carries latent tuberculosis. Infection rates vary locally, ranging from as low as 3% in some developed countries, to 90%+ in parts of Africa. Only patients with active TB can pass the bacteria on to others, and may infect 15 other individuals per year. Conflict and other social disruption events can have a major impact on spread. Firstly, conflict subjects individuals to physical hardships, such as poor nutrition, inadequate housing, and exposure to other infectious diseases. Second, conflicts displace populations, and lead to overcrowding, poor sanitation, and breakdown of healthcare systems. Studies suggest that war increases annual TB incidence up by up to 20%. The 2022 Russian invasion of Ukraine has resulted in the fastest mass refugee migration since WWII. In 2022, the world-wide number of displaced persons hit a new record of over 100 million souls.
Social disruptions do not have to be conflict-based to facilitate the spread of TB. Russia and other former USSR members have the developed world's highest TB rates, due to social disruptions that occurred during the decade after the fall of the USSR. The 1990's reversed a huge amount of Soviet progress on TB control, which had been achieved via xray detection, isolation, and treatment in sanitariums. Infection rates in Russia fell from 1910 levels of 400/100,000, down to a rate of 17.3/100,000 (in men) and 1.9/100,000 (in women) in 1990. But post-Soviet poverty and healthcare system collapse caused Russian TB rates to double between 1991-1998. During the same time period, incarceration rates tripled in most post-Soviet states. By the late 1990's, TB had become a raging epidemic within the overcrowded Russian prison system, with prisoner infection rates averaging 4,000/100.0000, and in some regions reaching 7,000/100.000.
Mycobacterium tuberculosis's ability to hide from the immune system means that treatment regimes, even for cases that are susceptible to first-line antibiotics, are lengthy. If, due to treatment costs, disruptions in health services, or poor patient education, a patient stops treatment early, evolutionary forces favor the growth of antiobiotic-resistant bacteria within that patient's body. This resistant bacteria can then be passed on to others, garnering new opportunities, with each unsuccessful treatment course, to become resistant to additional medications. The result is multi-drug-resistant TB, or "MDR-TB"- one of today's major public health challenges. Treatment regimes for MDR-TB last up to two years, may cause uncomfortable side effects, and have a significant failure rate. To reduce risk of MDR-TB, DOTS, or Directly Observed Treatment, has become the gold standard for TB treatment worldwide.
However, in post-Soviet states, corruption and economic woes interfered with successful TB programs. Physicians opposed DOTs, feeling that it threatened their already precarious livelihoods. TB medications were re-purposed and sold in markets by crooked pharmacists, or traded for other items by prisoners in treatment programs. Until fairly recently, antibiotics were widely available without prescription at pharmacies in both Russia and Ukraine. It was quite common to self-prescribe an inappropriate course of antibiotics, for example, for a viral cold infection. By 1998 20% of Russian prison cases were MDR-TB. As prisoners were released mid-treatment, this trend spread into the general population. Eastern Europe now accounts for the largest MDR-TB burden in the world.
In recent years Russia, along with many former Soviet states, has resumed making progress on TB control. Between 2010-2020, Russian TB mortality halved, and general population infection rates fell to 45-50/100,000 (48% MDR-TB). WHO estimated 2021 TB incidence in Ukraine to be 71/100,000 (31% MDR-TB in new cases and 45% in relapse cases). In contrast, average 2021 TB incidence in the EU was 8.4/100,000 (33% MDR-TB). Thus, TB infection in refugee populations moving from Eastern to Western Europe is a major public health concern.
Despite progress within prisons, as well as amongst the general population, TB remains a major problem in Russian prisons. Russia has one the world's highest incarceration rates, with overcrowding and poor living conditions extremely common. A 2017 study estimated that 1 in 10 Russian prisoners have active TB, and that the majority of remaining prisoners have latent infections. A 2019 study found that Russia had the world's second-highest number of new active TB cases amongst prisoners (~13,000 cases, second only to 15,000 cases in Brazil). A 2-3 yr prison sentence leads almost inevitably to TB infection. 48% of Russian prison cases are multi-drug-resistant. Russia also has one of the highest rates in the world of "extensively drug-resistant TB", which is even more difficult to treat than MDR-TB. Russia's heavy reliance on convicts as soldiers, low health standards for enlistment, difficult frontline living conditions, unreliability of medication supplies, potential for injury or capture, and inter-mixing with and displacement of civilian populations all create a major risk for wartime transmission of TB, MDR-TB, and XDR-TB.
In the Ukraine war, post-Soviet health challenges are potentiated by the melange of convict soldiers, frontline conditions, and mass displacement of civilians. The result is a myriad of spread opportunities for the world's new diseases of disruption: MDR-TB, MDR wound infections, and potentially also novel respiratory viruses (think a new wartime COVID variant or a 1918-style influenza).
Spread of MDR-TB is not the only concern. TB comes in a variety of strains. Interestingly, the prevalent strain in Russia is the "Beijing" type. The Beijing TB strain, first described in 1995, has unique proteins. These potentially make it more infectious and more resistant to treatments. A 2020 literature review of studies involving 7,000 patients found strong support for correlation between the Beijing strain and more unfavorable treatment outcomes. Despite global implementation of DOTS, TB incidence seems to be declining at only 1-2%/yr- far slower than math models predict. The reasons for this include prevalence of HIV coinfection, diabetes, malnutrition, drug resistance, crowding, and poor control infrastructure. Arguably, another reason is the spread of Bejing subtypes- which will also likely be further facilitated by the disruptions of the Ukraine war.
There is hope on the horizon for TB control. A currently approved vaccine, the BCG TB vaccine, does not prevent TB, but it does serve to lessen risk of some severe forms of disseminated disease in children. Several vaccines designed to prevent pulmonary TB in all ages are currently under development. The most promising is M72. M72 was dropped by its original creator due to low profit potentials, but has recently been picked up by the Gates Foundation and has entered Phase III trials. M72 may be able to prevent pulmonary disease in 54% of infected adults. And for a disease that can take years to treat, and becomes active in 5-10% of patients, who go on to infect 15 other people per year, 54% prevention be a game-changing statistic.
WHO TB page
WHO TB Surveillance and Monitoring in Europe, 2023
The 2020 clinical update by the Global Tuberculosis Network
2020 Stanford-China study: Mycobacterium tuberculosis Beijing genotype strains and unfavourable treatment outcomes: a systematic review and meta-analysis
2017 literature review: Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review
Monday, December 18, 2023
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Sunday, December 17, 2023
Ukraine has seen 20,000-50,000 War-related Amputations
On 2 August 2023, a Wall Street Journal investigation found that Ukrainian amputations in the war came to between 20,000 and 50,000- including both military and civilians. WSJ's estimate is based on data from the world's largest prosthetics manufacturer, Ottobock. In comparison, during World War I, 41,000 British and 67,000 Germans needed amputations. For background, the US (population 330mil) experiences 185,000 amputations per year. If Ukraine (population 44 million) had a similar pre-war all-causes amputation rate, this would amount to approximately 25,000 amputations/yr. So wartime amputations would represent a 50-100% annual surge over normal amputation events (i.e. those caused by trauma, medical conditions, etc). While WWI featured a larger scale of combatant forces and casualties, modern-day antibiotics, surgical techniques, and frontline medical interventions allow a greater portion of those who experience loss of limb to survive their injury.
After WWII, the USSR took pains to hide war amputees from social spaces and official media images. In modern Ukraine, various governmental, civil society and international groups are beginning the long process of addressing the war's legacy of amputees. Ukrainian public spaces are generally not engineered to be handicap-friendly. Major conversations about legislating equal access measures for the disabled do not seem to have emerged yet; these may be forthcoming as war wounded become increasingly visible in the public eye.
There are currently over 80 prosthetics fitters in Ukraine, many of these having opened since the 2022 Russian invasion. In much of Europe and the US, a prosthetic leg can cost between $3,000-$24.000, and a bionic arm may cost $20,000-80,000 USD. The maximum Ukrainian government coverage for a prosthesis is about $50,000, and compensation amounts for military service members are three times higher than for civilians. A Ukrainian information center for amputees, Protez Hub, finds that 'current government funding for prosthetics is sufficient in the predominant number of cases, however providers said that additional funding was required in civilian cases'. Protez's polls also found that the approximate ratio of upper limb to lower limb amputations is 35% to 65%. Prosthetics require a lifetime of maintenance and parts replacement/prosthetic updates. Protez find that the Ukrainian prosthetics industry is well-developed, and there is healthy competition. The industry continues to develop further, and is coping with the current higher-than-normal number of amputees.
Some Ukrainians injured early in the war have received advanced prosthetics, and have won medals in competitions such as the international Invictus Games and US Warrior Games.
Anastasia Shestopal, athlete, Tiktok and Instagram influencer, lost her leg in the
Kramatorsk railway station bombing in April 2022. Photo by Ukrainian Vogue Visible social project
Porter, Tom (2 August 2023), "Amputations in Ukraine are as widespread as in the Trenches of World War I due to Russia's heavy use of mines and artillery: report" Business Insider.
1 Aug 2023, Wall Street Journal: In Ukraine, Amputations already evoke scale of WW1
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