tag:blogger.com,1999:blog-4832086601920169632024-03-19T17:38:24.945+13:00SOUTHERN CROSS SOJOURNTALES FROM A PARAMEDIC, PILOT, CAVER, and FIREFIGHTER, WHO MEET IN ANTARCTICA, AND GO ON TO HAVE MANY ADVENTURES IN NEW ZEALAND, TONGA, FIJI, VANUATU, WEST AFRICA, AND UKRAINE. . . . . . . . . . . . . . .
Structural Firefighting/ARFF/Joint Antarctic Search and Rescue Team at McMurdo Station Winfly- Summer- Winterover.
Sailing a 37' Tayana sailboat in the South Pacific. Ebola Response. Wildland firefighting. War Medic in Ukraine.Unknownnoreply@blogger.comBlogger273125tag:blogger.com,1999:blog-483208660192016963.post-60471219942193939992024-01-14T03:51:00.025+13:002024-01-20T04:02:58.968+13:00Ukraine: Bradley IFVs taking on T90 tanks<p> </p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='479' height='398' src='https://www.blogger.com/video.g?token=AD6v5dwFBm9E24m-_XJMJ3biQPL52ko1yMhVT5S5FnU8aEW1E0qBCbc3Cgd5V42e4d31h30lRDuJWet-_OyStmCMRg' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><p></p><p><br /></p><p>Several videos have emerged this week, showing Bradley Fighting Vehicles successfully taking on advanced Russian T-90 tanks.</p><p><a href="https://x.com/bayraktar_1love/status/1745933354845815034?s=20" target="_blank"><span style="font-size: large;">From Special Kherson Cat on Twitter, video of Bradley IFV vs T-90 in Avdiivka</span></a></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-6034106111998607482024-01-13T05:07:00.331+13:002024-01-14T09:00:57.791+13:00Ukraine: Types of Missiles that Russia Commonly Fires at Ukrainian Cities<p> </p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dxOEXIijSO1HpqqgHTt_pXCYrmC8581bTrj5YfQBXKkrfHD9z9PkexgUO7A6IwHEtS5Ha2NbOaLc4koOECxPw' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><p></p><p></p><div class="separator" style="clear: both; text-align: center;"> <br /></div><br /><u style="font-weight: bold;"><br /></u><p></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvTt_PrXf4gwz07IUzfamfJlJza2TlCsXfGxnt8zIO-84_iddEEh_ZD_0_dHcULwGznWE2sJlmyfyGQ8t_7MsDM9m2UKQfX3gHANVI8Vbb50KivDqUuDkEqpyhoKKilKyTmMPKDu3fGCo3Cg_Fouhi9ABoxyDlQIJPGVPtS8FDjnrUTCT8hx5Ebekmg42o/s1280/S-300PMU2_complex.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="909" data-original-width="1280" height="226" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvTt_PrXf4gwz07IUzfamfJlJza2TlCsXfGxnt8zIO-84_iddEEh_ZD_0_dHcULwGznWE2sJlmyfyGQ8t_7MsDM9m2UKQfX3gHANVI8Vbb50KivDqUuDkEqpyhoKKilKyTmMPKDu3fGCo3Cg_Fouhi9ABoxyDlQIJPGVPtS8FDjnrUTCT8hx5Ebekmg42o/w318-h226/S-300PMU2_complex.jpg" width="318" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrBhiMpixhk8qzgFXZgmVb5FmCzg_ax46WkA1jr97pkEFYe_xAxLVPyRcOAzR5pL4V1vx9qTOdWuWF39Wj3YJ2dexOYEMRxE4x9JAgTRAqATOZ0RIkT64rgNyAqcLa4_3NeaG_4YFYiX6zap_7Mvzk3QcD9C0yWf3XfzC369z54iO8RxKNFoyIX4uch45X/s1280/S-300BG_Parade.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="960" data-original-width="1280" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrBhiMpixhk8qzgFXZgmVb5FmCzg_ax46WkA1jr97pkEFYe_xAxLVPyRcOAzR5pL4V1vx9qTOdWuWF39Wj3YJ2dexOYEMRxE4x9JAgTRAqATOZ0RIkT64rgNyAqcLa4_3NeaG_4YFYiX6zap_7Mvzk3QcD9C0yWf3XfzC369z54iO8RxKNFoyIX4uch45X/w300-h225/S-300BG_Parade.jpg" width="300" /></a><u style="font-weight: bold;"> </u><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;"><br /></u></div><div><br /></div><div><u style="font-weight: bold;"><br /></u></div><div><u style="font-weight: bold;">S-300 / S-400</u> a potent, long range, surface-to-air, anti-aircraft guided missile, S300 developed in 1978, S400 in 2007. Fully automated, or can be manually piloted. Launched form a command post, which include acquisition and guidance radar, transportation, and launch vehicles. May be used to intercept aircraft or other missiles. Possessed by a number of countries in Europe and the Middle East, and used in conflicts including Syria and Nagorno-Karabakh. Used extensively against ground targets in Ukraine. <span style="font-size: xx-small;">Image by By Tourbillon - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=6714828. </span><p></p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivAg7f0Mf10LmfjQ5yOwEWfWkOjvGpZGfOipWzHxdYcluB5ma-ovG1h0AjAcn6NNLFNmXKlYmSUBfGd3OqWdP3uDy7s9xfBLbopHbwtJkQBFxrJTVLPp7nhTJInIGfxviBSC-5malybB1lOFv4h-fexyJRWN7_pNjxfev401lelKTS39eL-2ZbSOGYxWAj/s1880/2018_Moscow_Victory_Day_Parade_66.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1160" data-original-width="1880" height="246" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivAg7f0Mf10LmfjQ5yOwEWfWkOjvGpZGfOipWzHxdYcluB5ma-ovG1h0AjAcn6NNLFNmXKlYmSUBfGd3OqWdP3uDy7s9xfBLbopHbwtJkQBFxrJTVLPp7nhTJInIGfxviBSC-5malybB1lOFv4h-fexyJRWN7_pNjxfev401lelKTS39eL-2ZbSOGYxWAj/w400-h246/2018_Moscow_Victory_Day_Parade_66.jpg" width="400" /></a></div><p><u style="font-weight: bold;">Kh-47 Kinzhal</u> hypersonic air-launched ballistic missiles, NATO name "Killjoy", entered service in 2017, design based on the older Iskander missile, uses standard ballistic missile technology at greater speeds. After launch, the missile rapidly reaches cruising speeds of Mach 4, and up to Mach 10 on a downward trajectory. Maneuverable, erratic flight path. Originally touted as "impossible to intercept" by Russia, Kinzhals have been used extensively in Ukraine, and a significant proportion of them were successfully shot down by Patriot air defense systems in 2023. They have also proven to be fairly inaccurate. <span style="font-size: xx-small;">Image from By kremlin.ru, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=68926303</span></p><p><br /></p><p><u style="font-weight: bold;">Kaliber </u>cruise missile, in service 1994, some models are capable of a supersonic terminal sprint, traves at ~70' over water, or ~150-350' over land, uses inertial guidance +terminal radar or satellite guidance, </p><p><b><u><br /></u></b></p><p><b></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhh6Q6n4rkyOPZb7t0BIQw1T10VWzrRNjAlQAPvNqG3nYraszFAoIbV-KMG5Qd_QZyae9r3iTWEIzRDv2FleftLlMuPPcQ9fYcuN9JcdRnnit_ll_V21Pl30XxraaQ5CSOpCABo6IyCAebugb-oOQBT-qQmTwKP-nVOXXEeR5DIIo-aYwlftg6BUGjag83q/s2250/Army2016demo-075.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1465" data-original-width="2250" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhh6Q6n4rkyOPZb7t0BIQw1T10VWzrRNjAlQAPvNqG3nYraszFAoIbV-KMG5Qd_QZyae9r3iTWEIzRDv2FleftLlMuPPcQ9fYcuN9JcdRnnit_ll_V21Pl30XxraaQ5CSOpCABo6IyCAebugb-oOQBT-qQmTwKP-nVOXXEeR5DIIo-aYwlftg6BUGjag83q/s320/Army2016demo-075.jpg" width="320" /></a></b></div><p></p><p><u style="font-weight: bold;">Iskander</u> mobile ground-launched, short-range hypersonic ballistic missile, NATO name "Stone", first launched in 1996, as a replacement to the SCUD missile, uses inertial guidance or GPS, depending on model, can be re-targeted midflight, uses evasive maneuvers and decoys during terminal flight, travels at an altitude of 20,000-160,000 feet. Used in Syria, Georgia, Nagorno-Karabakh, and Ukraine wars. In the summer of 2023, an Iskander was used to destroy Ria Pizzeria, a restaurant in Kramatorsk, Ukraine, frequented by journalists, aid workers, and military members. The famous Ukrainian writer Victoria Amelina was killed, along with a pair of 14-year-old twin sisters, and 10 others. Dozens were injured.</p><p>I<span style="font-size: xx-small;">mage from Vitaly V. Kuzmin - http://www.vitalykuzmin.net/Military/ARMY-2016-Demonstration/, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52213498</span></p><p><b><u><br /></u></b></p><p><b></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKX4S6C9yXLGf-4dxJjyeyxOFyX9UI1Z7RpEmaV8hjmwi0vP8aQcqak9WGiQB4tM0-R5lpguvG_gfcuEOCpl0Zu8D7T62wgwh4-6ONfmm7rae57CP_GWw3_UqN35YQpg0GLBn2ZjJEaX7pOOaL9_8sgsUJtl6hkI5IExwVME8t7OYrOyzvnruEnZyuasJy/s1920/1920px-H-55_AS-15_Kent_2008_G1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1179" data-original-width="1920" height="197" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKX4S6C9yXLGf-4dxJjyeyxOFyX9UI1Z7RpEmaV8hjmwi0vP8aQcqak9WGiQB4tM0-R5lpguvG_gfcuEOCpl0Zu8D7T62wgwh4-6ONfmm7rae57CP_GWw3_UqN35YQpg0GLBn2ZjJEaX7pOOaL9_8sgsUJtl6hkI5IExwVME8t7OYrOyzvnruEnZyuasJy/s320/1920px-H-55_AS-15_Kent_2008_G1.jpg" width="320" /></a></b></div><p></p><p><u style="font-weight: bold;">Kh-101 / Kh-555 / Kh-55</u> family of air-launched subsonic cruise missiles, Nato name "Kent", in service 1983, inertial guidance with terminal radar/terrain map, capable of cruising at tree-top level, the original Kh-55 ran on a Ukrainian-made Sich motor, used in Syria and Ukraine wars</p><p><br /></p><p><b></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXCyCd1vTG7LV5yCnjBwgd6DGj3gz02az80rEKlCOtgU2pDN4_Hsdhcl_1ayBoD_6Vvw-m23jpCq77s_diSGbKr4qrwbvkndjaU1GtM70Z9xm3IVRmhAPAuPDAJgJd9vz6zv1gMnDewwvxrVTF4nPEskznC5cpBUx0JRmytMp3BqlEBIMPNyHTJVHeHMyQ/s1840/Raduga_Kh-22,_side_view.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="560" data-original-width="1840" height="121" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXCyCd1vTG7LV5yCnjBwgd6DGj3gz02az80rEKlCOtgU2pDN4_Hsdhcl_1ayBoD_6Vvw-m23jpCq77s_diSGbKr4qrwbvkndjaU1GtM70Z9xm3IVRmhAPAuPDAJgJd9vz6zv1gMnDewwvxrVTF4nPEskznC5cpBUx0JRmytMp3BqlEBIMPNyHTJVHeHMyQ/w400-h121/Raduga_Kh-22,_side_view.jpg" width="400" /></a></b></div><p></p><p><u style="font-weight: bold;">Kh-22</u> "Storm" missiles. NATO name "Kitchen". Large, long-range anti-ship missile developed in 1962. Climbs to either 89,000' (high-altitude mode) or 39,000' (low-altitude mode), then hits top speed while dropping towards target. Guided by radio altimeter and gyroscope-stabilized autopilot. A 1,000kg shape-charge load results in a 16' wide, 40' deep hole. First combat use was in May of 2022 in Ukraine. Use against targets in civilian areas of Ukraine has been criticized due to low accuracy. <span style="font-size: xx-small;">Image by By Антон Бородин - Музей авиационной техники, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=10658517</span></p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwubq7PiIwefllRdDfX_RZQyfrVBjjoFjUxkYpOhEWyirr0bIdLk43tJ4t5d0IfIfBJnG_bLQcd1YHJC9stuzY28hTAJnRiUgSFFMq63dkOVzFzMXdEsdGds-wIqAFK6f35KlbYZBjJOE3w-ktkuemI_d5kQ41c6mYbJWAZj6sqTc3VvT9paj0-Cj1nqFn/s2440/Kh-59MK2_maks2009.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1308" data-original-width="2440" height="215" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwubq7PiIwefllRdDfX_RZQyfrVBjjoFjUxkYpOhEWyirr0bIdLk43tJ4t5d0IfIfBJnG_bLQcd1YHJC9stuzY28hTAJnRiUgSFFMq63dkOVzFzMXdEsdGds-wIqAFK6f35KlbYZBjJOE3w-ktkuemI_d5kQ41c6mYbJWAZj6sqTc3VvT9paj0-Cj1nqFn/w400-h215/Kh-59MK2_maks2009.jpg" width="400" /></a></div><p><b><u>Kh-59</u></b> "Ovod" or "Gadfly" guided aerially-launched land-attack cruise missiles. Developed in the 1980's. Flies at about 22' above water, or 300-3,000' above ground, using a radio altimeter. Used in Chechnya and Ukraine.</p><p><br /></p><p><span id="docs-internal-guid-5d4cdeb0-7fff-aef5-0c62-bf7d02e218ef"></span></p><div align="left" dir="ltr" style="margin-left: 0pt;"><table style="border-collapse: collapse; border: none; table-layout: fixed; width: 468pt;"><colgroup><col></col><col></col><col></col><col></col><col></col><col></col><col></col><col></col></colgroup><tbody><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;"><br /></td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Cost #USD</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Warhead Size</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Warhead Type</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Missile Length, Speed</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Engine</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Range, Accuracy</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Launch Platform</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">S300<span> </span></td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">1 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">up to 143 kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">19,000-36,000 metal frag,s</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">~25'</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;"><br /></td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">up to 250 nm</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">vehicle-based</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Kinzhal</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">10 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">480kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Conventional or nuclear</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">25'<br /><br />Mach 10</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">solid-fuel rocket</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">300nm</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Tu-22<br />Mig-31</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Kaliber</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">1 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">500kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Conventional or nuclear</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">~25'<br /><br />Mach 3</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">solid-fuel rocket or turbojet</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">up to 1300nm</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Air, ship, or sub launched</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Iskander</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">3 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">480-700kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Cluster, thermobaric, EMP, frag, bunker busting, nuclear</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">25'<br /><br /><br />Mach 7</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">single-stage solid propellant</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">300nm<br /><br /><br />3' - 100'</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">vehicle</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Kh-101</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">13 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">400mg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">conventional or nuclear</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">24'<br /><br />Mach 0.7</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">turbofan jet</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">3500nm<br /><br />20-33'</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">bomber aircraft</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Kh-22</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">1 million</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">1,000 kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">RDX or thermo - nuclear</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">38'<br /><br />Mach 4.6</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">liquid - fueled rocket</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">320 nm 300-900'</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Tu-22 Tu-95</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Kh-59<br /><br /><br /><br /></td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">500,000</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">320 kg</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Cluster, Shape-Charge Frag</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">18'<br /><br />Mach 0.8</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">2-stage rocket</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">60-160nm</td><td style="border-bottom: solid #000000 1pt; border-color: rgb(0, 0, 0); border-left: solid #000000 1pt; border-right: solid #000000 1pt; border-style: solid; border-top: solid #000000 1pt; border-width: 1pt; overflow-wrap: break-word; overflow: hidden; padding: 5pt; vertical-align: top;">Sukhoi and Mig jets</td></tr></tbody></table><br /></div><div align="left" dir="ltr" style="margin-left: 0pt;"><br /></div><div align="left" dir="ltr" style="margin-left: 0pt;"><span id="docs-internal-guid-ddc07d62-7fff-2d0e-ecab-e5fc04a25a97"><div align="left" dir="ltr" style="margin-left: 0pt;">Notes: "hypersonic" missile is somewhat of a misnomer; nearly all ballistic missiles reach hypersonic speeds at some point during flight</div><div align="left" dir="ltr" style="margin-left: 0pt;"><br /></div><div align="left" dir="ltr" style="margin-left: 0pt;">"Kh" and "X" are both transliteration options for the same Russian letter, (X)</div></span></div><p><a href="https://web.archive.org/web/20110102154357/http://www.janes.com/articles/Janes-Air-Launched-Weapons/Kh-59-Ovod-AS-13-Kingbolt-Russian-Federation.html" target="_blank">Info from Jane's Air-Launched Missiles</a></p><p><br /></p><p><br /></p><p><b><u><br /></u></b></p><p><b><u><br /></u></b></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-8406177096038705082024-01-12T03:30:00.000+13:002024-01-20T03:50:20.401+13:00Ukraine: Drones and Dogwalking<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='400' height='322' src='https://www.blogger.com/video.g?token=AD6v5dw_WxezFi0DL-opENKwBkm6noJ26dWCb1gKLmoXHpcfB8NUAxiY2ifHzZESHwUdgm_g1opuch07HRhDtyT4-Q' class='b-hbp-video b-uploaded' frameborder='0'></iframe><div><br /></div><div>While GPS, mass consumer production, and AI have revolutionized use of warfare drones in Ukraine, early drones were a feature of many 20th century conflicts. Radio-controlled planes flew in WWI, and the Warsaw Uprising Museum in Warsaw has a display featuring a WWII "Goliath tracked mine" unmanned ground vehicle. Drones have increasingly been utilized in small-scale conflicts of the pre-Ukraine-war 21st century. </div><div><br /></div><div>In Ukraine, large-scale use of surveillance and attack drones have complicated traditional combined arms warfare. Surprise attacks have become more difficult, and countermeasures, such as armor, avoiding vehicle travel near the front, and signals jamming, have become crucial. Development of ever-more sophisticated drone tactics and countermeasures will be a hallmark of the Ukraine war, throughout its duration. </div><div><br /></div><div>And, as we see in the video, drones are not just good for war. They are also great for dog-walking.</div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-66932006120695803262024-01-11T05:04:00.000+13:002024-01-14T05:09:38.683+13:00Ukrainian Army Recruiting Posters<p> Recruiting for the 3rd Storming Brigade</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMwNPgQ3MtGSHC3rqd_G_AglJ-PWkXeCbCbt2ZBRi9xniB_LYpvothIm0LEVpGuBZnfBj24vsoWGgScwkomPJtIS1Jyq-cJMlJd0YQktkGMizMxz_AyyPGhCrU0mfjFyf6fEccq2AOI6zVoecwGiz6G33kdxT5CbPWlRTnPx-aRBXloircJLUyl5yotvOg/s690/IMG_2599.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="387" data-original-width="690" height="358" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMwNPgQ3MtGSHC3rqd_G_AglJ-PWkXeCbCbt2ZBRi9xniB_LYpvothIm0LEVpGuBZnfBj24vsoWGgScwkomPJtIS1Jyq-cJMlJd0YQktkGMizMxz_AyyPGhCrU0mfjFyf6fEccq2AOI6zVoecwGiz6G33kdxT5CbPWlRTnPx-aRBXloircJLUyl5yotvOg/w640-h358/IMG_2599.jpeg" width="640" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhur5gueui5CaFNFVHyjuOuGqzz_cGEeA7kBPGObMkFxH3sSIH7rZ8yWlXTB5adQiyoDWaNwdMkuz8o9k2355sp5KR4e_Y9YLQ6-arOYmc5nAixfUxKRAhAqPvZzWaCgzqnw-XCEjyy-LyKWdDNPhfqCDENcHpJltUbkm0d6NRK5Am4lnZm_MT8LBRL77dd/s278/IMG_2600.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="138" data-original-width="278" height="318" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhur5gueui5CaFNFVHyjuOuGqzz_cGEeA7kBPGObMkFxH3sSIH7rZ8yWlXTB5adQiyoDWaNwdMkuz8o9k2355sp5KR4e_Y9YLQ6-arOYmc5nAixfUxKRAhAqPvZzWaCgzqnw-XCEjyy-LyKWdDNPhfqCDENcHpJltUbkm0d6NRK5Am4lnZm_MT8LBRL77dd/w640-h318/IMG_2600.jpeg" width="640" /></a></div><br /><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-87774081325407161812024-01-10T21:20:00.152+13:002024-01-14T05:10:01.205+13:00Ukraine: How Long can a Tourniquet be left in place before the limb must be amputated?<p>Prospects for limb salvage after tourniquet placement has become a crucial matter for thousands of soldiers and their surgeons in the Ukraine war. Near-peer fighting conditions, and lack of air superiority, can create extended evacuation times for casualties. Drone threats to moving vehicles have become so pervasive that, in many areas, the last few miles up to the zero line area only traversable on foot. Beyond this zone, mud, bombing damage, UXOs, and the impossibility of road maintenance make vehicle evacuation slow and bumpy. Patients must often wait for nightfall to evacuate, and dawn-dusk day length at the height of summer on the Eastern Front is 17 hours. Today, almost two years into the war, high attrition rates amongst experienced frontline medics means loss of TCCC tourniquet conversion knowledge along the frontline. </p><p>For medics and doctors in forward casualty collection and stabilization points, who are receiving tourniqueted patients after prolonged evacuations from a near-peer conflict area, assessing patient candidacy for tourniquet conversion (i.e. removal and replacement with a simple pressure dressing) or movement of tourniquet to a more distal location is a critical outcome-changing skill. Just as important as assessing limb salvageability is 1) readiness to manage acute complications such as acidosis and dysrhythmias, and 2) ensuring that timely transfer to higher-level care is available for potential mediu-term complications, such as compartment syndrome and acute renal failure. </p><p>Current TCCC guidance assumes that limb salvage becomes highly unlikely 6 hours or more after tourniquet placement. However, this guidance is unavoidably based on the extremely limited data pool available to date. Limb salvage after tourniquet placement is a young and weak science, which stands to benefit greatly from case reporting and retrospective studies originating from the Ukrainian conflict. If we look only at the small pool of my personal experience as a paramedic in Ukraine, several case examples of physician-directed conversions of tourniquets in place for over 6 hours have been performed, or given post-conversion management, by either myself or my immediate colleagues. Clearly, amputating every limb that has been touniqueted for more than 6 hours would result in unnecessary negative life impacts for patients.</p><p>Current tourniquet science is based on animal studies done in controlled environments, and a very small number of human case reports. Tourniquets are widely used in routine surgeries, but tourniquet use in traumatic wartime injuries is a completely different animal. The reality of warfare adds in a number of important and unforeseen variables, which defy efforts to cleanly categorize patients as <6 hours vs >6 hours:</p><p>1) initial tourniquet placement is likely to occur under extreme conditions. Often, the soldier placing the tourniquet has minimal medical training, may be physically and/or mentally exhausted (many Ukrainian soldiers have been deployed for nearly 2 years with little or no leave), he or she may be receiving and returning fire, and may be working in conditions of darkness, loud noise, and confusion. The soldier placing the tourniquet may have reduced fine motor control due to cold, exhaustion, or adrenaline, or may be injured themselves. Weather and fighting conditions may have led to heat exhaustion, dehydration, nutritional deficits, soaked clothing, icy gear, numb fingers, or cold injuries of feet and hands, and rapid assessment and tourniquet placement and/or other bleeding control measures may have to be performed over/through multiple layers of clothing and body armor. Tourniquet availability on the frontlines is limited and likely to consist of a mish-mash of tourniquet brands and styles. These factors often conspire to create "partial-tourniqueted" patients. Tourniquets may be tightened enough to slow, but not fully stop, bleeding and limb perfusion. Venous and capillary return may be cut off, without halting arterial inflow. </p><p>2) Due to frontline conditions, time of original placement of tourniquets is frequently estimated, or missing altogether.</p><p>3) Environmental conditions and threats during evacuation may necessitate rapid movement and rough handling of the patient, which may lead to tourniquet loosening or temporary dislodgement. Poorly made or re-used tourniquets may stretch over time or fail, lead to placement of multiple tourniquets, and intermittent periods of reperfusion or partial reperfusion. </p><p>4) Intentional attempts at tourniquet conversion may be made in the field. Due to fighting conditions, these field attempts may or may not be accurately recorded in the documentation that reaches field hospitals. Patients evacuation routes shift frequently, and patients may pass through multiple patient care teams, comprised of a shifting cast of medical providers.</p><p>5) The tourniqueted limb may be subjected to a variety of physiological and environmental conditions, including varying levels of external cooling, varying states of patient blood loss and shock, and varying levels of resuscitative care received.</p><p>Due to these variables, Ukrainian doctors cannot rely on hard-and-fast rules such as the 6-hour tourniquet rule. Many tourniquets were placed with good intent, but were never necessary in the first place. Doctors are often forced to decide, based on clinical observations and professional experience, whether tourniquet removal is in the patient's best interest. Does the probability of limb salvage outweigh potential systemic risks to patients? Objective numerical values from blood testing can inform these decisions, if lab services are available. But more often, the critical time for this decision occurs at minimally-equipped forward field treatment points, and thus it must be made based on time of injury, exposure to weather, limb skin color and temperature, injury patterns, and overall patient presentation. </p><p>Here is an interesting <a href="https://apps.dtic.mil/sti/tr/pdf/ADA627896.pdf" target="_blank">case report from Kragh et al, published in Orthopedic Trauma in 2007</a>, which represents the realities of tourniquet placement in conflicts, as well as variability in limb salvage times. The patient, an American helicopter pilot in Afghanistan, was shot in the hand and received RPG shrapnel to one leg. Hemorrhage from the hand was stopped 1 hour after injury by a combination of one purpose-built and one improvised tourniquet. Bleeding recurred 6 hours after injury, and was stopped by tightening the tourniquet. The pilot lay in a snowdrift, with temperatures at -15C, for a half-day after injury. After that, he was insulated by blankets made from cut-out aircraft insulation. Evacuation was delayed due to an ongoing firefight, mountainous terrain, and inclement weather. The patient arrived at a forward surgical facility after 16 hours of continuous tourniquet placement. He had severe soft tissue loss, irreparable radial artery damage, and compartment syndrome. He underwent surgical debridement and irrigation, radial artery ligation, and 3 dorsal + 2 ventral hand fasciotomies, and the operating surgeon deemed hand preservation was questionable. Repeated surgical debridement and irrigation took place over the next month, first at Landstuhl, Germany, then at Walter Reed, before primary wound closure was accomplished. Several more surgeries and physical therapy followed, to correct pain and stiffness. By three years after injury, the patient had recovered sufficiently to use the hand for activities of daily living, and to return to piloting Chinook helicopters.</p><p><br /></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-35008012244246359412024-01-09T20:36:00.027+13:002024-01-13T21:20:31.819+13:00Aug 2023: 'The Spectator' Article on military medicine in Ukraine<p>From <i>The Spectator,</i> 23 Aug 2023: <a href="https://www.spectator.co.uk/article/ukraines-real-killing-fields-an-investigation-into-the-wars-first-aid-crisis/" target="_blank">'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'</a></p><p>In this article, Spectator reporters interview medics from the Hospitallers and the Ukrainian military. Challenges such as military bureaucratic hurdles for replacing medical equipment, corruption, and medical training and staffing shortcomings,</p><p>The Spectator is a politically conservative UK magazine. It is the oldest political affairs magazine in print, and its former editors include Boris Johnson and several former UK cabinet members. Until recently the Spectator, along with the Telegraph, was owned by the Barclay Brothers. Back in 2014, the Telegraph Group was criticized for taking Russian funds in exchange for publishing links and supplements of Russian propaganda on Telegraph Group venues. This included reports downplaying Russian involvement in shooting down Flight MH17. These links were later removed. Since the start of the full-scale invasion, the Spectator and the Telegraph have leaned pro-Ukrainian, and have provided a wealth of in-depth reporting on Ukrainian and Russian affairs. </p><p><br /></p><p><a href="https://www.telegraph.co.uk/ukraine/" target="_blank">The Telegraph Ukraine reporting and daily hour-long Ukraine podcast</a></p><p>From <i>The Spectator,</i> 23 Aug 2023: <a href="https://www.spectator.co.uk/article/ukraines-real-killing-fields-an-investigation-into-the-wars-first-aid-crisis/" target="_blank">'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'</a></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-22972479003923818182024-01-08T17:57:00.000+13:002024-01-10T18:01:29.249+13:00Video of hospital in Pokrovsk, Ukraine, at moment of bomb impact<p> </p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='355' height='277' src='https://www.blogger.com/video.g?token=AD6v5dw53GrL5TPXBV5leRRt71S0wq6jEeKVbkS-hC92wmlh8hnv1R4HBfwvFNbP6ObKEmLSqW0pvFARUkYVMm58SA' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><p></p><p>Here is a video posted to the english-language Telegram Channel Live:Ukraine on 9 Feb 2023, allegedly showing a hospital in Pokrovsk, Ukraine, at the moment of a bomb impact.</p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-85950557872073296792024-01-05T22:45:00.000+13:002024-01-09T03:16:46.810+13:00Ukraine: Air Raid!<p><span style="font-family: arial; font-size: medium;"> A fascinating feature of the Ukraine war is the amount of real-time information (and propaganda) available to civilians. Daily updates are put out on Telegram, Facebook, and other platforms by the Ukrainian Ministry of Defense, Russian Ministry of Defense, and an array of milbloggers. Civilians post videos of rockets and missiles impacting, or being shot down, which provide the opposing side with battle damage assessments and information of air defense locations. Various 3rd-party open-source intelligence groups collate data and publish up-to-date maps of reported Russian and Ukrainian positions. A network of Ukrainian observers and defense agencies provide instant reporting on Aerial threats via a variety of Telegram channels. This includes radar-detected movements and takeoffs of missile-launching platforms such as Tupolev bombers and MIG jets, launches, locations, and vectors of incoming missiles (including hypersonic ballistic Kinzhals and Iskanders, Kaliber cruise missiles, repurposed S-300 surface-to-air missiles, and Shahed drones. Here's a typical series of missile updates from this week, courtesy of the Telegram channel "Radar".</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfCXkB8thJQ0srQGdpQDTcmCspWFxwlsKs4gBOkTSSFOKWxynWMqgssiKX8pOgw9ZRnku_xss9F0q2IHNmqF5ohNhl2L1wAAIkEDqOnjLwl8i6kx723aFHqqJwwNJ7UV_QWp3QGvG6TKgcUPpNKL4zONfm_rNZNfYqP1E57ucLM6hC5ZB9mtonVsUdDLZJ/s1636/F02EEDF4-B253-4166-883A-B6252B26E889.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1636" data-original-width="960" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfCXkB8thJQ0srQGdpQDTcmCspWFxwlsKs4gBOkTSSFOKWxynWMqgssiKX8pOgw9ZRnku_xss9F0q2IHNmqF5ohNhl2L1wAAIkEDqOnjLwl8i6kx723aFHqqJwwNJ7UV_QWp3QGvG6TKgcUPpNKL4zONfm_rNZNfYqP1E57ucLM6hC5ZB9mtonVsUdDLZJ/w235-h400/F02EEDF4-B253-4166-883A-B6252B26E889.jpeg" width="235" /></span></a></div><span style="font-family: arial; font-size: medium;"><br /></span><p><span style="font-family: arial; font-size: medium;"><b>13:57 </b><span> Attention! There is activity of enemy tactical aviation in the eastern and south-eastern directions! Threat of aerial weapons launch! In case of air raid alarm announcement in your area, seek shelter. <span> - 39,000 views</span></span></span></p><p><span><span><span style="font-family: arial; font-size: medium;"><b>14:02</b><b> </b> Air alarm for Dnipropetrovsk Oblast!<span> - 38,000 views</span></span></span></span></p><p><span><span><span style="font-family: arial; font-size: medium;"><b>14:02</b> <span> Air alarm for Zaporizhya Oblast!<span> </span><span> - 37,800 views</span></span></span></span></span></p><p><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:06</b><span> X-59 threat for areas where the Alarm is<span> </span><span> - 38,900 views</span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:18</b><span> X-59 headed towards Dnipro<span> </span><span> </span><span> </span><span> - 38.600 views</span></span></span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:19</b><span> Dnipro: take shelter!<span> </span><span> - 39,100 views</span></span></span></span></span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:19</b><span> Zaporizhya: take shelter!<span> - 39,600 views</span></span></span></span></span></span></span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:19</b><span> X-59 Rocket approaching Dnipro Region<span> - 39.800 views</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:21</b><span> Dnipro: Explosions<span> </span><span> - 41,000 views</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></p><p><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span style="font-family: arial; font-size: medium;"><b>14:24</b><span> The rocket has been destroyed! (by air defense)<span> -41,000 views</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></p><p><span style="font-family: arial; font-size: medium;"><br /></span></p><p><span><br /></span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-33400373884071405382024-01-04T02:11:00.055+13:002024-01-09T02:44:53.673+13:00Combat Medicine: Pelvic Fractures<p><span style="font-family: arial; font-size: medium;">The pelvis has major blood vessels running throug it; fracture or penetrating injury can easily lead to a fatal amount of massive hemorrhage. Pelvic fractures with hemodynamic instability have a 40% mortality. 26% US mil deaths in Afghanistan and Iraq had a pelvic fracture.</span></p><p><span style="font-family: arial; font-size: medium;">Pelvic fractures are generally caused by severe blunt force or blast trauma. Signs and symptoms include:</span></p><p><span style="font-family: arial; font-size: medium;">Pelvic pain and/or crepitus</span></p><p><span style="font-family: arial; font-size: medium;">Deformed or unstable pelvis, unequal leg lengths, or outward rotation of legs (open-book fracture)</span></p><p><span style="font-family: arial; font-size: medium;">Bruising at bony prominences of pelvic ring, anal/vaginal/urethral bruising or bleeding</span></p><p><span style="font-family: arial; font-size: medium;">Neurological deficits in lower extremities</span></p><p><span style="font-family: arial; font-size: medium;">Major lower limb amputation or near amputation</span></p><p><span style="font-family: arial; font-size: medium;">Unconsciousness</span></p><p><span style="font-family: arial; font-size: medium;">Shock</span></p><p><span style="font-family: arial; font-size: medium;">Pelvic binders help return the pelvis to its natural position and lessen bleeding and further damage. There are several purpose-made varieties; an improvised binder may also be made using a sheet or similar object. Pelvic binders should be placed low, at the level of the greater trochanters ("bottom of the patients' pocket openings"). Higher placement can actually leverage open lower-pelvic fractures, increasing damage. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838689/" target="_blank">One assessment at a major UK trauma center found that 41% of pelvic binders were placed too high. </a> Outward rotation of legs may be observed in displacement pelvic fractures; in these cases legs should also be bound together, in order to prevent further displacement. </span></p><p><span style="font-family: arial; font-size: medium;"><br /></span></p><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838689/" target="_blank"><span style="font-family: arial; font-size: medium;">An Assessment of Pelvic Binder Placement at a Major UK Trauma Center</span></a></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-16605692062470462542024-01-03T02:04:00.002+13:002024-01-09T02:06:46.640+13:00TCCC<p><span style="font-family: arial; font-size: medium;">1996 CAPT Frank Butler formalizes concepts and experiences from lessons learned in prior conflicts into first TCCC guidelines, and publishes them as an article. These guidelines were presented to DoD leadership, but were not immediately implemented as a universal standard. However, they were adopted by the Naval Special Warfare Command, 75th Ranger Regiment, the Army Special Missions Unit, and Air Force pararescue community. </span></p><div style="text-align: left;"><span style="font-family: arial; font-size: medium;">Medical research efforts by the US Special Operations Command led to the initiation of the 42-member Committee on TCCC (CoTCCC). CoTCCC's mission is<span style="background-color: #274e13;"><span style="color: #b6d7a8;"> <span>“To develop on an ongoing basis the best possible set of trauma care guidelines customized for the tactical environment and to facilitate the transition of these recommendations into battlefield trauma care practice.”</span></span><span style="color: #212529;"> </span></span>CoTCCC membership includes representatives from all service branches, and includes surgical specialists, emergency physicians, combat medical educators, physicians assistants, nurses, and medical planners. At least 30% of the voting membership must be active or former combat medics, paramedics, or pararescuemen. TCCC guidelines are based on evidence-based medicine, not anecdotal instances. </span></div><p><span style="font-family: arial; font-size: medium;">In 2013 CoTCCC was moved under the Joint Trauma System's jurisdication (JTS). JTS was put together in order to improve military care of trauma patients. It has 6 components:</span></p><p><span style="font-family: arial; font-size: medium;">1) DOD Trauma Registry Management</span></p><p><span style="font-family: arial; font-size: medium;">2) Defense Committee on Trauma</span></p><p><span style="font-family: arial; font-size: medium;">3) Performance Improvement</span></p><p><span style="font-family: arial; font-size: medium;">4) Combatant Command Trauma System Management</span></p><p><span style="font-family: arial; font-size: medium;">5) Joint Trauma Education and Training</span></p><p><span style="font-family: arial; font-size: medium;">6) Defense Medical Readiness Institute</span></p><p><span style="font-family: arial; font-size: medium;">JTS develops and maintains Clinical Practice Guidelines, recommending combat casualty care training requirements, evaluating new medical equipment, facilitating medical performance improvements, facilitating collection and sharing of combat casualty data, maintaining the DOD Trauma Registry, and improving the organization and delivery of trauma care. </span></p><p><span style="font-family: arial; font-size: medium;">Some level of TCCC is required for all US service members. The levels are listed below; ASM is the most basic, and CPP is the most advanced.</span></p><p><span style="font-family: arial; font-size: medium;">ASM All Service Members</span></p><p><span style="font-family: arial; font-size: medium;">CLS Combat Lifesaver</span></p><p><span style="font-family: arial; font-size: medium;">CMC Combat Medic/Corpsman</span></p><p><span style="font-family: arial; font-size: medium;">CPP Combat Provider Paramedic</span></p><p><span style="font-family: arial; font-size: medium;">The latest version of TCCC was released in 2020 and can be found here.</span></p><p><a href="https://deployedmedicine.com/#" target="_blank"><span style="font-family: arial; font-size: medium;">Deployed Medicine.org by the US Defense Health Agency provides online combat medicine learning materials, including Combat Lifesaver, Medic, and Paramedic courses and Prolonged Field Care Guidelines</span></a></p><p><span style="font-family: arial; font-size: medium;"><a href="https://tccc.org.ua/en/guide/module-1-principles-and-application-of-tccc-cmc" target="_blank">TCCC Tactical Casualty Care, full Combat Medic/ Corpsman Course, Prolonged Field Care, and other resources at tcc.org English and Ukrainian versions available</a> </span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-13926333557758001472024-01-02T07:54:00.003+13:002024-01-08T21:58:54.942+13:00Tourniquet Conversion<span style="font-family: arial; font-size: medium;"><br /></span><p><span style="font-family: arial; font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7KJJ_CrnKc2j7chKxKuEbcpkkDU__qBUBX8hQTozuY_qemDCkzYngzHNqi5qHNi3mJ_yWxbR-JJ-Qn7r0rqGc5_hn0FhN3_GzYUbESR9aw76K6Iocv1MD9WcDP_IlG8a3Hv-Wplo1mwc0J5ngf3z5Yj6dsLW6zfxiUxSHXqn8KRSoEURvAS52oP_p6H8E/s10240/TCCC%20tq%20conversion.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="5760" data-original-width="10240" height="371" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7KJJ_CrnKc2j7chKxKuEbcpkkDU__qBUBX8hQTozuY_qemDCkzYngzHNqi5qHNi3mJ_yWxbR-JJ-Qn7r0rqGc5_hn0FhN3_GzYUbESR9aw76K6Iocv1MD9WcDP_IlG8a3Hv-Wplo1mwc0J5ngf3z5Yj6dsLW6zfxiUxSHXqn8KRSoEURvAS52oP_p6H8E/w660-h371/TCCC%20tq%20conversion.png" width="660" /></span></a></div><p></p><p><span style="font-family: arial; font-size: medium;"> <span>So far, an estimated 25,000-50,000 amputations having already occurred on the Ukrainian side of the war. Patients with tourniquets may not reach definitive care for 24 hours or more after tourniquet placement. Tourniquet times of less than 2 hours have a negligeable impact on limb salvage rates; tourniquet times over 4 hours are associated with reduced limb salvage rates. Amputation of a tourniqueted limb is very likely after 24 hours. Therefore, assessing whether stable patients who arrive at our near-frontline medical facility are candidates for a tourniquet conversion is a priority. "Tourniquet conversion" refers to the process of replacing a tourniquet with a simple pressure dressing. </span></span></p><p><span style="font-family: arial; font-size: medium;">While civilian prehospital medical personnel are generally taught to never remove a tourniquet once placed, in the US military tourniquet conversion is a basic-level medical intervention. The TCCC guideline, taught to all US military members, is "every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled by other means". Temporary tourniquet placement of up to 3 hours, with no resulting tissue damage, is also a common technique used by surgeons.</span></p><p><span style="font-family: arial; font-size: medium;">The process for converting a tourniquet is:</span></p><p><span style="font-family: arial; font-size: medium;">1) pack the wound and apply pressure for 3 minutes</span></p><p><span style="font-family: arial; font-size: medium;">2) apply pressure dressing</span></p><p><span style="font-family: arial; font-size: medium;">3) slowly release tourniquet over 1 minute, watching for bleeding. If bleeding resumes, re-tighten the tourniquet. Re-attempt conversion in 2 hours, as long as it hasn't been more than 6 hours since original application.</span></p><p><span style="font-family: arial; font-size: medium;">4) If conversion is successful, note release time and leave loosened tourniquet on the limb, just above the wound, in case tourniquet re-application is needed later.</span></p><p><span style="font-family: arial; font-size: medium;">Tourniquet conversion is contra-indicated in patients who are in shock, have an amputation below the tourniquet, or who cannot be monitored closely for bleeding. Tourniquets that have been on for more than 6 hours should not be converted. Intermittent reperfusion (Loosening a non-covertable tourniquet temporarily at intervals in an attempt to preserve the limb), is a common surgical technique. However, in field situations without ability to replace lost blood, this is dangerous and ineffective, and not recommended by TCCC.</span></p><p><a href="https://www.sciencedirect.com/science/article/abs/pii/S0020138319305431" target="_blank"><span style="font-family: arial; font-size: medium;">A 2019 study in rats found that tourniquet application reduced uptake of prophylactic antibiotics in the ischemic limb, both during tourniqueting, and for up to 72 hours after release. https://www.sciencedirect.com/science/article/abs/pii/S0020138319305431</span></a></p><h1 class="Head u-font-serif u-h2 u-margin-s-ver" id="screen-reader-main-title" style="--sd-ui-line-height: calc(1em + 10px); box-sizing: border-box; color: #1f1f1f; font-weight: 400; line-height: var(--sd-ui-line-height) !important; margin-bottom: 16px !important; margin-left: 0px; margin-right: 0px; margin-top: 16px !important; margin: 16px 0px; padding: 0px; word-break: break-word;"><span class="title-text" style="box-sizing: border-box; font-family: arial; font-size: medium; margin: 0px; padding: 0px;"><a href="https://www.sciencedirect.com/science/article/abs/pii/S0020138323000360" target="_blank">Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review</a></span></h1><p><br /></p><p><br /></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-63368211966820086452024-01-01T02:51:00.005+13:002024-01-09T02:07:57.887+13:00Ukraine: Combat TBIs<div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">TBIs and their sequelae have long been associated with wars. </span></div><div style="line-height: 1.125; margin: 0px 0px 0.6923em; text-align: left;"><span style="font-weight: normal;"><span style="background-color: #274e13; font-family: arial; font-size: medium;"><a href="https://www.ncbi.nlm.nih.gov/books/NBK299230/" target="_blank">Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects: Chapter 2: Combat TBI History, Epidemiology, and Injury Modes*</a> by Ralph G DePalma offers a brief and fascinating historic overview, starting with Iliad accounts of TBIs, PTSD, and post-war mental illness from the legendary Trojan War. This chapter contains a wealth of links to pieces on "shell shock" blast injuries of WWI and WWII. </span></span></div><div style="line-height: 1.125; margin: 0px 0px 0.6923em; text-align: left;"><span style="font-weight: normal;"><span style="background-color: #274e13; font-family: arial; font-size: medium;"><br /></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">Between 2000-2012, 255,852 US military service members sustained TBIs. 83% of these were mild, and 80% were estimated to have occurred in non-deployed settings, for example during training, sports, or vehicle accidents. <a href="https://www.nytimes.com/2023/11/05/us/us-army-marines-artillery-isis-pentagon.html" target="_blank">A New York Times investigation examined TBI rates amongst US artillery companies</a> who conducted heavy shelling campaigns against ISIS during the 2016-2017 anti-ISIS offensive. Some soldiers fired over 10,000 artillery shells in the space of just a few months. <a href="chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.hqmc.marines.mil/Portals/61/Users/019/71/4371/Overpressure%20Study%20Report%2020191025.pdf?ver=Nta6RKsuKvaHCTG_HrY1MQ%3D%3D" target="_blank">A military-ordered study of Fox battery</a>, 2nd Battalion, 10th Marines, found that half of the unit had sustained TBIs during artillery firing operations. Study of microscopic damage caused by repeated lower-level blast exposures, or "Chronic Traumatic Encephalopathy" (CTE) is a young science. Under pressure from Veteran's groups, between 2018-2022 Congress passed bills ordering the Pentagon to start a large "<a href="chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://health.mil/Reference-Center/Presentations/2022/11/30/Presentation-Warfighter-Brain-Health-Initiative" target="_blank">Warfighter Brain Health Initiative</a>". This initiative will endeavor to measure blast exposure and create protocols to protect troops. A growing pool of data suggests that safe blast exposure levels may be much lower than was previously assumed. The issue of CTE recently featured in the headlines; the brain of Robert Card, a former military grenade instructor who had a sudden onset of psychosis at age 40 and committed a mass shooting in Maine, will be examined for signs of blast-related CTE.</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">Massive use of heavy artillery in the current Ukraine War (firing up to 7,000 shells/day by the Ukraine side, and up to 60,000/day by the Russians), along with increased blast survivability made possible by modern medicine and armor, has created potential for long-term TBI impacts on a scale not seen since WWII. Heavy use of thermobaric weapons increases the risk of blast-wave injury.</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><span style="font-family: arial;"> Manpower shortages mean a l</span><span style="font-family: arial;">ack of post-injury recovery time away from the front. Casualties with mild TBIs are often re-subjected to repeated blasts as soon as a day or two post-injury. As these challenges are likely to be seen in other potential future near-peer conflicts, it can be hoped that Ukraine will systematically work to gather data and implement measures to improve TBI outcomes, and share lessons learned with overseas medical practitioners.</span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><span>In his book, Ralph G. DePalma postulates:<span style="background-color: #274e13;"> "</span></span><i style="background-color: #274e13;"><span style="text-align: left;">Closed blast TBI has been postulated to relate to vascular surge from the thorax through the neck vessels, air embolism, and piezoelectric currents generated between the skull and the shock wave (</span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r26" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #2f4a8b; text-align: left;">Johnson, 2010</a><span style="text-align: left;">). Viscoelastic dynamic rippling of the skull secondary to the blast has been postulated based on modeling (</span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r41" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #2f4a8b; text-align: left;">Moss et al., 2009</a><span style="text-align: left;">). Interactions between the advancing shock wave and blast overpressure, the configuration of the skull, and the brain, including its meninges and cerebrospinal fluid, are complex and cause heterogeneous injury patterns including brain swelling, cerebral vasospasm (</span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r2" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #2f4a8b; text-align: left;">Armonda et al., 2006</a><span style="text-align: left;">), and diffuse axonal injury (DAI) with disruption across attentional networks (</span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r53" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #2f4a8b; text-align: left;">Vakhtin et al., 2013</a><span style="text-align: left;">)... </span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r31" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #985735; outline: 0px; text-align: left;">Kucherov et al. (2012b)</a><span style="text-align: left;"> postulated a novel mechanism of primary nonimpact blast injury. Calculations show a dramatic shortening the linear scale of the blast shock wave as it passes through brain tissue. The example of a shock wave interacting with water was used, with the assumption that brain tissue’s physical properties, on the whole, are quantitatively similar to the properties of water. CSF is even closer to water in its physical characteristics. The proposed mechanism, based upon the dynamic behavior of phonons in water, predicts the length scale of damage to be ~30–200 nm. This phonon-based model recently has been shown to accurately describe failure waves in brittle solids (</span><a aria-expanded="false" aria-haspopup="true" class="bk_pop" data-bk-pop-href="#ch2_r30" href="https://www.ncbi.nlm.nih.gov/books/NBK299230/#" role="button" style="color: #2f4a8b; text-align: left;">Kucherov, 2012a</a><span style="text-align: left;">). A shock wave traveling through the brain is characterized by a shock front, which is a thermodynamic boundary between shocked and nonshocked states of water. The shock front thickness depends on several parameters and decreases in dimensions relative to the intensity of the shock or blast. For intense shocks, the shock wave front equals the interatomic spacing in the specific medium of propagation. The difference between the two states, the blast wave front and the blast wave pressure, is that some of the energy gets deposited behind the shock front, causing a change in thermodynamic parameters of pressure, volume (density), and temperature. For intense shocks, the change in these parameters becomes pronounced, predicting nanoscale damage occurring within microseconds, in contrast to acceleration injuries having durations measured in milliseconds."</span></i></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><i><span style="background-color: white; text-align: left;"><br /></span></i></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">A TBI can present as loss or alteration of consciousness at the time of the injury, a confused or disorientated state and/or memory loss during the first 24 hours, and/or abnormal brain imaging. GCS of 13-15 characterizes a mild TBI, 9-12 characterizes a moderate TBI, and 3-8 characterize a severe TBI. </span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">A growing body of evidence shows that prehospital care greatly affects outcomes in TBI patients. While the initial trauma sustained by the patient results in a certain level of irreversible brain cell death, additional secondary injury due to hypotension and hypoxia may be preventable during pre-hospital care.</span></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">The EPIC project is a collaboration between the University of Arizona, Arizona Department of Public Health, and over 130 Arizona Fire Departments, and ground and air EMS transport services. The goal of the EPIC Project is to "dramatically increase the number of severe TBI victims who survive with good neurologic outcome by thoroughly implementing the national EMS TBI guidelines." EPIC trained 11,000 EMTs and Paramedics, with emphasis on avoiding hypotension and hypoxia, and maintaining eucapnia. 21,852 patients were included in the effort between 2009-2015. After implementation of the EPIC guidelines, patient survival-to-discharge doubled. Survival tripled amongst TBI patients who required intubation. </span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">A<span style="background-color: #274e13;"> <a class="Link" data-cms-ai="0" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5173421/" rel="noopener" style="background-repeat: no-repeat; box-sizing: border-box; text-align: start; touch-action: manipulation;" target="_blank">2017 study published in the Annals of Emergency Medicine</a> f</span>ound that odds of death increased by 2.5x with a single episode of hypoxia <90%, by 3x with an episode of hypotension <90, and by 6.1x in patient with at least one episode of both hypoxia and hypotension. EPIC guidelines call for pre-oxygenation, with the aim of maintaining an O2 level of 100%. This should be done by applying immediate and continuous high-flow O2 via NRB, starting prior to extrication if applicable. In TBI patients, the risks from short-term hyperoxia are dwarfed by the risks from potential hypoxia.</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">The target capnography reading is 35-45. It is crucial to avoid hyperventilation, which reduces blood flow and oxygenation of brain tissues. A possible exception is during active brain herniation. Current TCCC guidelines still recommend hyperventilation at 20/minute for patients with signs of brain herniation. However, EPIC guidelines recommend against hyperventilation in any situation, having found that it did not enhance survival to discharge in herniating patients, and caused active harm to non-herniating patients who presented with herniation-like signs. </span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;">Opiate pain medications and benzodiazepines may cause blood pressure to drop suddenly in patients with compensated shock, and should be used with extreme caution. </span></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhUtzKZYRJasCQZW2uhTmVYk_jgac95leurNQ3kgGJAWPVJl6vQgVoPrU0GwK5F9r_3_x10KHCaazeSH4LOSY6bxRTrdYluAKOMKA33DkZB8dmySaMNKV56erbXC_7YzCySLILc0GOZCesB7AfYDQzpkBRaUikHyHlZQSKLYxmMz8KPt-p1tM470hy9-e6r/s960/module-13-head-injuries-11.jpg" style="margin-left: 1em; 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text-align: center;"><br /></div><br /><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwDCrdg9faPtTXLqudHIrI_iVPwdqYbT4McTlvEEjBR589TX7u-PFhAVRqUNRxeHxgxCcEpDDJK0aKUUDFnc-9bwgeG91DEFGCzsQrdZHzJZ4fi-b9CynWt_q5VNZgfWInxv9TEvM90RBKgesPwsYj35CBkm5dc4RQzGwfYOToCnsGKFotdl3viqwR6DLy/s960/module-13-head-injuries-16.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwDCrdg9faPtTXLqudHIrI_iVPwdqYbT4McTlvEEjBR589TX7u-PFhAVRqUNRxeHxgxCcEpDDJK0aKUUDFnc-9bwgeG91DEFGCzsQrdZHzJZ4fi-b9CynWt_q5VNZgfWInxv9TEvM90RBKgesPwsYj35CBkm5dc4RQzGwfYOToCnsGKFotdl3viqwR6DLy/w640-h360/module-13-head-injuries-16.jpg" width="640" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhip1SUv7hkq1GPW7tEo5eh13MGn2bxuo48aJq7CLzYquvw1pdaqoVrCx5KTBucv_lPIYVwTQKDzRFwhs29iz2uSeVcaU7lJtdn8WpNuhZMIUpnwiKyVqpOGTA_4wrVFxex-crt1zObWZqJP23aKRbQLC4D4qf09PeLxOXujIv2Sski8Oy18nVcYiVCyXh1/s960/module-13-head-injuries-17.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhip1SUv7hkq1GPW7tEo5eh13MGn2bxuo48aJq7CLzYquvw1pdaqoVrCx5KTBucv_lPIYVwTQKDzRFwhs29iz2uSeVcaU7lJtdn8WpNuhZMIUpnwiKyVqpOGTA_4wrVFxex-crt1zObWZqJP23aKRbQLC4D4qf09PeLxOXujIv2Sski8Oy18nVcYiVCyXh1/w640-h360/module-13-head-injuries-17.jpg" width="640" /></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><a href="chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://health.mil/Reference-Center/Publications/2020/07/30/Military-Acute-Concussion-Evaluation-MACE-2" target="_blank"><span style="font-family: georgia; font-size: medium;">Link to Health.mil fillable MACE 2 evaluation pdf</span></a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><a href="https://epic.arizona.edu/" target="_blank"><span style="font-family: georgia; font-size: medium;">Link to University of Arizona EPIC 2.0 program</span></a></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><h1 class="content-title" style="box-sizing: inherit; clear: initial; font-weight: 400; letter-spacing: -0.01em; line-height: 22.5pt; margin: 20pt 0px 10pt; text-align: start;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9705431/" target="_blank"><span style="background-color: #274e13; font-family: georgia; font-size: medium;">War in Ukraine: a neurosurgical perspective <span face="Helvetica Neue, Helvetica, Arial, sans-serif" style="color: #376faa;"><span style="box-sizing: inherit; text-wrap: nowrap;">Daniel Dubinski</span></span><span face=""Helvetica Neue", Helvetica, Arial, sans-serif" style="box-sizing: inherit; color: #212121; line-height: 0; position: relative; top: -0.5em; vertical-align: baseline;"><img alt="corresponding author" src="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/corrauth.gif" style="border: 0px; box-sizing: inherit; max-width: 100%;" /></span><span face=""Helvetica Neue", Helvetica, Arial, sans-serif" style="color: #212121;"> </span><span face=""Helvetica Neue", Helvetica, Arial, sans-serif" style="color: #212121;">and</span><span face=""Helvetica Neue", Helvetica, Arial, sans-serif" style="color: #212121;"> </span><span face="Helvetica Neue, Helvetica, Arial, sans-serif" style="color: #376faa;"><span style="box-sizing: inherit; text-wrap: nowrap;">Volodymyr Kolesnyk</span></span></span></a></h1><div><br /></div><div style="text-align: left;"><a href="https://tccc.org.ua/en/guide/module-13-head-trauma-cmc" target="_blank"><span style="font-family: georgia; font-size: medium;">US DOD's TCC/Combat Medic Online Module on Head Trauma</span></a></div></div><a href="chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://health.mil/Reference-Center/Publications/2020/07/30/Military-Acute-Concussion-Evaluation-MACE-2" target="_blank"><br /></a><p><br /></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-3283982037664807842023-12-31T20:52:00.000+13:002024-01-08T20:53:28.601+13:00Ukraine: Great PFC Podcast episode<p> <a href="https://www.youtube.com/watch?v=niSTkKE27RI" target="_blank">Ukrainian medic Henri talks with the Prolonged Field Care Collective</a> 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.</p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="517" src="https://www.youtube.com/embed/niSTkKE27RI" width="622" youtube-src-id="niSTkKE27RI"></iframe></div><br /><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-65423281120879277322023-12-30T02:46:00.004+13:002024-01-08T06:34:23.644+13:00Blood Loss and the Lethal Triad<p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">Symptoms of blood loss:</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">500 mL - well tolerated, may produce slight tachycardia, equivalent to a typical <span> </span><span> </span><span> </span><span> </span><span> </span><span> </span>blood donation volume.</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">1000 mL - tachycardia over 100</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">1500 mL - changes in mental status, weak radial pulse, persistant tachycardia, <span> </span><span> </span><span> </span><span> </span><span> </span><span> </span>tachypnea</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">2000 mL - confusion, lethargy, weak radial, tachycardia over 120, tachypnea over <span> </span><span> </span><span> </span><span> </span><span> </span>35, might be fatal if not managed properly</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">2500 mL - unconsciousness, no palpable radial pulse, tachycardia over 140, <span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span>tachypnea over 35, fatal without intervention</span></p><p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyYmzhcVyfceXL1zFYutnLo1KxCMZR7IqZGxfrqh88ntTvAiJaHoBw2zR9c75wMADm_j4zvFX-TbCbGkGp-2-grsjdJt7B5seHEhrdBHDnu-9Ve6PysdDhT02pfwPt3CEyVITIxm2zyILcojIlV6J6nw3tWUmMAhsHCyF0imngl02Gaw53TEicrnI34lSm/s960/TCCC%20blood%20loss.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="359" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyYmzhcVyfceXL1zFYutnLo1KxCMZR7IqZGxfrqh88ntTvAiJaHoBw2zR9c75wMADm_j4zvFX-TbCbGkGp-2-grsjdJt7B5seHEhrdBHDnu-9Ve6PysdDhT02pfwPt3CEyVITIxm2zyILcojIlV6J6nw3tWUmMAhsHCyF0imngl02Gaw53TEicrnI34lSm/w638-h359/TCCC%20blood%20loss.jpg" width="638" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgd86CT612lUeDas69I2CGa8e1QjFrIEY1qn7GrKkSmQ12-pifvuRnhc3ATGzfryloS5TD3CSWjDvK-wAO01_AO-MpUVuqN-6Q8ZQ1yyxwHbg-Tn24lC9o0haohjpbuRDf64rMvyf9ZOzn7tZQQi5CkNIOrpfJSYRVmCMFzZsMzLR8oEeHwQe3TyUe83Qt6/s960/module-19-fractures-06.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgd86CT612lUeDas69I2CGa8e1QjFrIEY1qn7GrKkSmQ12-pifvuRnhc3ATGzfryloS5TD3CSWjDvK-wAO01_AO-MpUVuqN-6Q8ZQ1yyxwHbg-Tn24lC9o0haohjpbuRDf64rMvyf9ZOzn7tZQQi5CkNIOrpfJSYRVmCMFzZsMzLR8oEeHwQe3TyUe83Qt6/w640-h360/module-19-fractures-06.jpg" width="640" /></a></div><div class="separator" style="clear: both; text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><span style="text-align: left;"> In patients with blood loss, t</span><span style="text-align: left;">he "Lethal triad"- is a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy.</span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><span style="background-color: #274e13; color: #d9ead3; text-align: left;"><br /></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">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). </span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">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. </span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="background-color: #274e13;"><span style="color: #d9ead3;"><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">Coagulopathy: </span></span><span style="font-family: arial; font-size: large; text-align: left;">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. </span></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;"><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;">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.</span></span></div><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><h1 class="entry-title entry-title-singular" style="line-height: 1.2; margin: 20px 0px; text-align: start;"><span style="color: #d9ead3; font-family: arial; font-size: medium;"><a href="https://www.jems.com/patient-care/trauma-s-lethal-triad-hypothermia-acidos/" style="background-color: #274e13;" target="_blank">Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy Create a Deadly Cycle for Trauma Patients</a></span></h1></div><span style="background-color: #274e13;"><span style="color: #d9ead3;"><br /> </span></span><p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-69689542987328079712023-12-29T08:31:00.001+13:002024-01-07T08:44:56.118+13:00Antibiotics in trauma<p><span style="font-family: arial; font-size: medium;"><br /></span></p><p><span style="font-family: arial; font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjojXFnuPUINe0rg0ul3E7oXy66GTo9W241yKQw-o3KB9wf2mzbHzmKAlIA-JRNqW2qGoR8BsFlsYki8-u3wza4FM6kgPb4LOFcZSP9B7k6Z3N1O64Vosd9WG_4_tFIVq2YlXM6u6c5TMZQKkCdKEWMXIA7MN5u7wwrDVL2Vcro7reTwnUuKDiLOyBn5ep/s960/module-16-antibiotic-administration-05.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjojXFnuPUINe0rg0ul3E7oXy66GTo9W241yKQw-o3KB9wf2mzbHzmKAlIA-JRNqW2qGoR8BsFlsYki8-u3wza4FM6kgPb4LOFcZSP9B7k6Z3N1O64Vosd9WG_4_tFIVq2YlXM6u6c5TMZQKkCdKEWMXIA7MN5u7wwrDVL2Vcro7reTwnUuKDiLOyBn5ep/w640-h360/module-16-antibiotic-administration-05.jpg" width="640" /></a></span></div><span style="font-family: arial; font-size: medium;"><br />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. </span><p></p><p><span style="font-family: arial; font-size: medium;">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. </span></p><p><span style="font-family: arial; font-size: medium;"><br /></span></p><p><a href="https://tccc.org.ua/en/guide/module-16-antibiotics-administration-cmc" target="_blank"><span style="font-family: arial; font-size: medium;">TCCC Combat Medic/Corpsman Antiobiotics Administration, TCCC.org https://tccc.org.ua/en/guide/module-16-antibiotics-administration-cmc</span></a></p><p><br /></p><div><h1 class="Head u-font-serif u-h2 u-margin-s-ver" id="screen-reader-main-title" style="--sd-ui-line-height: calc(1em + 10px); box-sizing: border-box; color: #1f1f1f; font-weight: 400 !important; line-height: var(--sd-ui-line-height) !important; margin-bottom: 16px !important; margin-left: 0px; margin-right: 0px; margin-top: 16px !important; padding: 0px; word-break: break-word;"><span class="title-text" style="box-sizing: border-box; margin: 0px; padding: 0px;"><a href=" https://www.sciencedirect.com/science/article/abs/pii/S0020138319305431" target="_blank"><span style="font-family: arial; font-size: medium;">Duration of extremity tourniquet application profoundly impacts soft-tissue antibiotic exposure in a rat model of ischemia-reperfusion injury</span></a></span></h1></div><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-37913884337439552632023-12-28T04:52:00.016+13:002024-01-07T07:39:31.538+13:00Ukraine: Jogging in Circles and Red Viburnum Tea<div class="separator" style="clear: both; text-align: left;"><span style="font-family: arial; font-size: medium;">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. </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: arial; font-size: medium;">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.</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8nZ53-5rY0LeYRIjX3gyjEMquLAr9bNFy0Gclg4RfuoVE5OUFddhs9WE9wNAAhn1vw5-JpTOj9XwheLapLsGzzjXCI6DUYmlPzg4Jm_PO_v2UkN_S2cOBDVpk5T4fHD-4KOf53NfEgXWKkIDGTcG5wZuIsR8jNMIVNnpzMJ_wjrW4brWG6Eo0LI5NW57r/s824/viburnum-trilobum-2.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="618" data-original-width="824" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8nZ53-5rY0LeYRIjX3gyjEMquLAr9bNFy0Gclg4RfuoVE5OUFddhs9WE9wNAAhn1vw5-JpTOj9XwheLapLsGzzjXCI6DUYmlPzg4Jm_PO_v2UkN_S2cOBDVpk5T4fHD-4KOf53NfEgXWKkIDGTcG5wZuIsR8jNMIVNnpzMJ_wjrW4brWG6Eo0LI5NW57r/w640-h480/viburnum-trilobum-2.jpg" width="640" /></span></a></div><span style="font-family: arial; font-size: medium;"><div><span style="font-family: arial; font-size: medium;"><br /></span></div>Pensions are very small in Ukraine, so it's extremely common for pensioners to set up small tables on the sidewalk in town to sell home-grown produce. This time of year, a grandmother might sell butternut squash, jam, or jars of pickled vegetables. Some folks spend all afternoon sitting out in the cold, just to sell a few bunches of Red Viburnum berries. When in town, I try to buy from pensioners and small shopkeepers, rather than line the pockets of supermarket-owning "mini-oligarchs".</span><div><span style="font-family: arial; font-size: medium;"><br /></span><div><span style="font-family: arial; font-size: medium;">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. </span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;">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.</span><p><span style="font-family: arial; font-size: medium;">Here is a youtube link to a 2022 version performed by Pink Floyd <a href="https://www.youtube.com/watch?v=Wyjseraz5qs" target="_blank">Chervona Kalina, with Pink Floyd</a> </span></p><div id="translation-title" style="background-color: white; height: 39px; margin: 0px 0px 1.5em; padding: 0px;"><p style="line-height: 1.3em; margin: 0px 0px 0.5em; padding: 0px; text-align: left;"><span style="font-family: arial; font-size: medium;"><span style="color: #444444;"><span style="font-weight: 500;"><br /></span></span></span></p><p style="line-height: 1.3em; margin: 0px 0px 0.5em; padding: 0px; text-align: left;"><span style="font-family: arial; font-size: medium;"><span style="color: #444444;"><span><u><b>Chervona Kalina, lyrics:</b></u></span></span></span></p><p style="line-height: 1.3em; margin: 0px 0px 0.5em; padding: 0px; text-align: left;"><span style="font-family: arial; font-size: medium;"><span style="color: #444444;"><span style="font-weight: 500;">In the meadow, a red kalyna<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">In the meadow, there a red kalyna, has bent down low ,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">For some reason, our glorious Ukraine, has been worried so.<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take that red kalyna and we will raise it up,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take that red kalyna and we will raise it up,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;"> <br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">Do not bend low, Oh red kalyna, You have a white flower.<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">Do not worry, glorious Ukraine, You have a free people.<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take that red kalyna and will raise it up,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take that red kalyna and will raise it up,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;"> <br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">Marching forward, our fellow volunteers, into a bloody fray,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">For to free, our brother - Ukrainians, from hostile chains.<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our brother - Ukrainians, we will then liberate,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our brother - Ukrainians, we will then liberate,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;"> <br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">In the field, of early spring wheat, there's a golden furrow,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">Then began, the Ukrainian riflemen to, engage the enemy,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take, that precious, early wheat and will gather it,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take, that precious, early wheat and will gather it,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;"> <br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">When the stormy winds blow forth from the wide steppes,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">They will glorify, through out Ukraine, the Sich riflemen.<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take the glory of the riflemen preserving it,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we'll take the glory of the riflemen preserving it,<br /></span></span><span style="color: #444444;"><span style="font-weight: 500;">And we, our glorious Ukraine, shall, hey - hey, cheer up - and rejoice!</span></span></span></p><h1 dir="auto" style="line-height: 1.3em; margin: 0px 0px 0.5em; padding: 0px;"><br /></h1></div></div></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-32430867945624995282023-12-27T02:07:00.013+13:002024-01-05T05:21:20.225+13:00Good new Video: Ukraine’s SBU SpecOps Medics<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf_G6NF_iLjplYaXLIamMIP4frFKJT3TdEg0yHg7LQaXF9FQZ_8wBLhn5c4wDw2mIhV62B4EHXalGnW8m7E7FihsbQhVNRa47MC5ZvyqmXIYmPTLPBQdpMafmmS35GiQlTcBJ5ML4j1d0hZ96fYU0ckjIny3SmtLVPQJhfFlY7ysMZTViffRfACiZJvxMg/s2079/IMG_2483.PNG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="960" data-original-width="2079" height="181" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf_G6NF_iLjplYaXLIamMIP4frFKJT3TdEg0yHg7LQaXF9FQZ_8wBLhn5c4wDw2mIhV62B4EHXalGnW8m7E7FihsbQhVNRa47MC5ZvyqmXIYmPTLPBQdpMafmmS35GiQlTcBJ5ML4j1d0hZ96fYU0ckjIny3SmtLVPQJhfFlY7ysMZTViffRfACiZJvxMg/w392-h181/IMG_2483.PNG" width="392" /></a></div><br /><p></p><h2 class="slim-video-information-title slim-video-metadata-title-modern" style="-webkit-box-orient: vertical; -webkit-line-clamp: initial; -webkit-text-size-adjust: 100%; caret-color: rgb(241, 241, 241); color: #f1f1f1; display: -webkit-box; font-family: Roboto, Arial, sans-serif; font-weight: 500; line-height: 2.6rem; margin: 0px 0px 3px; max-height: none; overflow: hidden; text-overflow: ellipsis; text-size-adjust: 100%;"><span class="yt-core-attributed-string" role="text" style="font-size: large;"><a href="https://m.youtube.com/watch?v=PnCgATphvLs&pp=QACIAgHKBUJTQlUgU3BlY2lhbCBvcGVyYXRpb25zIG9mIHZpY3RvcnkuIENvbWJhdCBtZWRpY3MuIERlYXRoIHdpbGwgd2FpdC4%3D&rco=1" target="_blank">SBU Special operations of victory. Combat medics. Death will wait</a>.</span></h2><h2 class="slim-video-information-title slim-video-metadata-title-modern" style="-webkit-box-orient: vertical; -webkit-line-clamp: initial; -webkit-text-size-adjust: 100%; caret-color: rgb(241, 241, 241); color: #f1f1f1; display: -webkit-box; font-family: Roboto, Arial, sans-serif; font-weight: 500; line-height: 2.6rem; margin: 0px 0px 3px; max-height: none; overflow: hidden; text-overflow: ellipsis; text-size-adjust: 100%;"><span class="yt-core-attributed-string" role="text" style="font-size: large;"><br /></span></h2><h2 class="slim-video-information-title slim-video-metadata-title-modern" style="-webkit-box-orient: vertical; -webkit-line-clamp: initial; -webkit-text-size-adjust: 100%; caret-color: rgb(241, 241, 241); color: #f1f1f1; display: -webkit-box; font-family: Roboto, Arial, sans-serif; font-weight: 500; line-height: 2.6rem; margin: 0px 0px 3px; max-height: none; overflow: hidden; text-overflow: ellipsis; text-size-adjust: 100%;"><span style="font-size: large;"><span class="yt-core-attributed-string" role="text"> </span><a href="https://m.youtube.com/watch?v=PnCgATphvLs&pp=QACIAgHKBUJTQlUgU3BlY2lhbCBvcGVyYXRpb25zIG9mIHZpY3RvcnkuIENvbWJhdCBtZWRpY3MuIERlYXRoIHdpbGwgd2FpdC4%3D&rco=1">https://m.youtube.com/watch?v=PnCgATphvLs&pp=QACIAgHKBUJTQlUgU3BlY2lhbCBvcGVyYXRpb25zIG9mIHZpY3RvcnkuIENvbWJhdCBtZWRpY3MuIERlYXRoIHdpbGwgd2FpdC4%3D&rco=1</a></span></h2><h2 class="slim-video-information-title slim-video-metadata-title-modern" style="-webkit-box-orient: vertical; -webkit-line-clamp: initial; -webkit-text-size-adjust: 100%; caret-color: rgb(241, 241, 241); color: #f1f1f1; display: -webkit-box; font-family: Roboto, Arial, sans-serif; font-weight: 500; line-height: 2.6rem; margin: 0px 0px 3px; max-height: none; overflow: hidden; text-overflow: ellipsis; text-size-adjust: 100%;"><span class="yt-core-attributed-string" role="text" style="font-size: large;"> . </span></h2>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-91468760207398317752023-12-26T20:53:00.063+13:002024-01-08T02:56:45.063+13:00Giving Blood in the Field: current TCCC recommendations<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6rFd9y5KwtiHHHNTT1iyeNR1M3iIloJAfARUd29C7RLtoohlmVSv9TdxXU6UAHsn6fsUoZOcMND3HJLi7l1kHQ_ZPlHFLu78vmKmY0SGDB2Omu536N2gYtikupWQjcE9gIuNl8mrzBESQFqNXZe4XDqgw9MxI7_mZIXT6lZzO9hgP6rX4tL_j8LYowIhW/s960/module-11-hemorrhagic-shock-fluid-resuscitation-07.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="347" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6rFd9y5KwtiHHHNTT1iyeNR1M3iIloJAfARUd29C7RLtoohlmVSv9TdxXU6UAHsn6fsUoZOcMND3HJLi7l1kHQ_ZPlHFLu78vmKmY0SGDB2Omu536N2gYtikupWQjcE9gIuNl8mrzBESQFqNXZe4XDqgw9MxI7_mZIXT6lZzO9hgP6rX4tL_j8LYowIhW/w619-h347/module-11-hemorrhagic-shock-fluid-resuscitation-07.jpg" width="619" /></span></a></div><p><span style="font-family: georgia; font-size: medium;">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. </span></p><p><span style="font-family: georgia; font-size: medium;">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.</span></p><p><span style="font-family: georgia; font-size: medium;">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. </span></p><p><span style="font-family: georgia; font-size: medium;">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.</span></p><p><span style="font-family: georgia; font-size: medium;"><span>The current TCCC-preferred fluid for blood loss replacement in trauma victims is "LTOWB":</span><span> 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. </span></span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuYJ7GLUT_m2fz_5KKsnJIogz-QPAHGOQcDInmbqtM-rMhLzjFLHtacFmfKvsyqQ91P8E1ZXO0aYlzN6Agu6IF4DDfe77glTycxvjBzQBOfeNdaPdoT-LVkhlds9ndmQnZaPYjgOrBlGDkDvUkTc5SFeZUkSWxcdbqCUX4bQOcHGMH_wUvrWd2yqk7MHeV/s300/agglutination.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="168" data-original-width="300" height="168" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuYJ7GLUT_m2fz_5KKsnJIogz-QPAHGOQcDInmbqtM-rMhLzjFLHtacFmfKvsyqQ91P8E1ZXO0aYlzN6Agu6IF4DDfe77glTycxvjBzQBOfeNdaPdoT-LVkhlds9ndmQnZaPYjgOrBlGDkDvUkTc5SFeZUkSWxcdbqCUX4bQOcHGMH_wUvrWd2yqk7MHeV/s1600/agglutination.jpg" width="300" /></span></a></div><span style="font-family: georgia; font-size: medium;"><div style="text-align: center;">Image shows agglutination in a rapid blood-type test.</div></span><p></p><p style="text-align: center;"><span style="font-family: georgia; font-size: medium;">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. </span></p><p><span style="font-family: georgia; font-size: medium;">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.</span></p><p><span style="font-family: georgia; font-size: medium;">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'. </span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhk68D68y7SXlW_CZJJC-X5rv3l70Cg1Uvu76I51kPC5it9kHaZtbSeYVC8ZRPR9zl6_dIw4QTedFrWiyUx-25rH2caGhaq5hj2L_Sk_wTqvf_CUGHEFbYJfXEFqE2unb8kWrbdS9T5INYZA4C2dYSVwI5dtOX1w1os6DaVNn0uqQ_MPW3ljQhkrXTGAhHL/s1100/blood-type-compatibility-chart.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="922" data-original-width="1100" height="340" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhk68D68y7SXlW_CZJJC-X5rv3l70Cg1Uvu76I51kPC5it9kHaZtbSeYVC8ZRPR9zl6_dIw4QTedFrWiyUx-25rH2caGhaq5hj2L_Sk_wTqvf_CUGHEFbYJfXEFqE2unb8kWrbdS9T5INYZA4C2dYSVwI5dtOX1w1os6DaVNn0uqQ_MPW3ljQhkrXTGAhHL/w406-h340/blood-type-compatibility-chart.jpg" width="406" /></span></a></div><span style="font-family: georgia; font-size: medium;">Because supplies of blood products may be limited in the field, TCCC guidelines offer simplified criteria for when to give blood, and targets for holding off on giving additional units of blood. Patients who do not have signs of shock- such as altered mental status or a weak or absent radial pulse- do not require IV fluid resuscitation. These patients may be given oral fluids if available. Risk of vomiting and aspiration during surgery is very low. Patient outcomes are improved by using oral rehydration to resolve pre-existing dehydration which may have occurred during combat operations. Placement of IVs in stable patients who can be orally re-hydrated unnecessarily wastes supplies and caregiver time, increases risk of infection, hypothermia, and other complications, and is discouraged. However, early placement of IV/IO should be done in unstable patients, or those who may later decompensate. Saline locks should be flushed every two hours.</span><p></p><p><i><span style="font-family: georgia; font-size: medium;">TCCC Blood Products Order of Preference:</span></i></p><p><span style="font-family: georgia; font-size: medium;">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.</span></p><p><span style="font-family: georgia; font-size: medium;">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. </span></p><p><span style="font-family: georgia; font-size: medium;">3) Plasma, RBCs, and platelets in 1:1:1 ratio</span></p><p><span style="font-family: georgia; font-size: medium;">4) Plasma and RBCs in a 1:1 ratio. Shelf life 1 yr for plasma, 42 days for RBCs.</span></p><p><span style="font-family: georgia; font-size: medium;">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.</span></p><p><span style="font-family: georgia; font-size: medium;">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. <br /></span></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7bSL0eJE-Q_SI2lT1jrSHhyphenhyphenau9a5-PayMULOaNmkl89E0jrIUJEalIdpwE-2PYCQe4GpiqBt9khRb5G75WdkRm1RY7ehLZseKM1_4hKqP6xzd51wjgQxAWBL6e73veTKja4-WLoNGzr_2Mjv-dG2L8hBPa_20NLz0yq_Rh7rFR3bbPkGSdaH9VzTNwBMU/s960/TCCC%20whole%20blood.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="362" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7bSL0eJE-Q_SI2lT1jrSHhyphenhyphenau9a5-PayMULOaNmkl89E0jrIUJEalIdpwE-2PYCQe4GpiqBt9khRb5G75WdkRm1RY7ehLZseKM1_4hKqP6xzd51wjgQxAWBL6e73veTKja4-WLoNGzr_2Mjv-dG2L8hBPa_20NLz0yq_Rh7rFR3bbPkGSdaH9VzTNwBMU/w640-h362/TCCC%20whole%20blood.jpg" width="640" /></a></div><span style="font-family: georgia; font-size: medium;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgd1zYKuZo1pF7_GJhvbfjusjeTIZdOqQ1PNa_DtDcxI0CiBPErnEaDWTy5u5SxHAzNleTesSEKaBD_zMEsj9HWHJUru-mwnqNnjY6HGJA61Rf6vd1A3Qkm7jV4Xa8qN7FoGaqXHUcdF6te6l-Ze1RjPRUnGUjo7Dmlb2EP5_Pp8Aabrlt9hSWbJllb9wzT/w640-h360/TCCC%20administer%20blood.jpg" width="640" /></span></div><span style="font-family: georgia; font-size: medium;"><br /><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0VdIDKOzKgTLiHbKavv8CVffN7jo023i-_vPt69INCl86Irbl1zQSQozqdhII9pmpqJONEywu2wrBvqvV_ywcr_ZRhxeYC44aBJg8QsYRHGOHfC0ttve8a_kw-Vs5VDBwZ7V9DrxmvpZsqVoWCJV5Hkb_pYqkll2HT2V4qAbWwqoaMREPVUsMGxe2aSQA/s960/TCCC%20FWB.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="359" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0VdIDKOzKgTLiHbKavv8CVffN7jo023i-_vPt69INCl86Irbl1zQSQozqdhII9pmpqJONEywu2wrBvqvV_ywcr_ZRhxeYC44aBJg8QsYRHGOHfC0ttve8a_kw-Vs5VDBwZ7V9DrxmvpZsqVoWCJV5Hkb_pYqkll2HT2V4qAbWwqoaMREPVUsMGxe2aSQA/w640-h359/TCCC%20FWB.jpg" width="640" /></span></a></div><span style="font-family: georgia; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimQ-YSLr2Xwnvm7NeW0UD_EkRwS2zOsKiJ49ovaSImny7phagFRiqw5i_lMOcJpkZwu1fmH06Oa-RMaEbUV5usE3mDKYIj9tzW3RLMkMKJCavDofsC8IFw-7pvsdgnYR9ZcxxaoG6CBN9qX3UJp72TvWGGU52CXeV1EhizIrOYfNWRFNutBltvLpZtjUma/s960/TCCC%20blood%20collection.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimQ-YSLr2Xwnvm7NeW0UD_EkRwS2zOsKiJ49ovaSImny7phagFRiqw5i_lMOcJpkZwu1fmH06Oa-RMaEbUV5usE3mDKYIj9tzW3RLMkMKJCavDofsC8IFw-7pvsdgnYR9ZcxxaoG6CBN9qX3UJp72TvWGGU52CXeV1EhizIrOYfNWRFNutBltvLpZtjUma/w640-h360/TCCC%20blood%20collection.jpg" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjg3TPhSYhcxQ47MZHITdQQbYNquubyeacCzL6OOBMrplMSY6J30c50-jOSWWhmmnLoQnXPxHmqXT-dbsd1M8xe1k3xqITvGzCI3FS8h5EphJ22CNRiD6qHNxIf461lI30Uxv6GLPMmIfGTQKk-4atvluiW-8c9DyZ8Vx8fDhYchN44c_p3WD5kYA7Eqfdx/s960/TCCC%20component%20blood.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjg3TPhSYhcxQ47MZHITdQQbYNquubyeacCzL6OOBMrplMSY6J30c50-jOSWWhmmnLoQnXPxHmqXT-dbsd1M8xe1k3xqITvGzCI3FS8h5EphJ22CNRiD6qHNxIf461lI30Uxv6GLPMmIfGTQKk-4atvluiW-8c9DyZ8Vx8fDhYchN44c_p3WD5kYA7Eqfdx/w640-h360/TCCC%20component%20blood.jpg" width="640" /></span></a></div><span style="font-family: georgia; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium; margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUe15UR3Pf3JIYibZIYjKucHN1_cNHQq12hAcXm3HL58WctJs_9xU3yhzgy4_lz0q3ek_vxoab_IMFXRp_I_t0mPXsnQaYEK2J-ErRgj_1LF57gHzO6dCUJTMEwZnmTCueHyxwO7tOaNuQY7mBlv8L__DjLJKeMtvARYaqD24CHuOPw2s67rfmuGO8KZ0H/w640-h360/TCCC%20FFP.jpg" width="640" /><br /></span></div><p></p><p><span style="font-family: georgia; font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXiQaRpWPXViuTFXyy6KpnLFQPqDcCUwXVMUOFR37M6IMfiDKfU26OrgQ4DMMcIkjmXfRsKzyC8irJNo88HJdmnKaN3QMlDt68vrPrgOMDeATbz6UnwoUvpKXUs5Ga7Ax4Km-Q_T5ywN7_DVjHEXHgpmJHBqIQIzMSROreEYziInOWefuOn4BzjFOKEqoy/s960/TCCC%20Ca%20admin%202%20blood%20loss.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="361" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXiQaRpWPXViuTFXyy6KpnLFQPqDcCUwXVMUOFR37M6IMfiDKfU26OrgQ4DMMcIkjmXfRsKzyC8irJNo88HJdmnKaN3QMlDt68vrPrgOMDeATbz6UnwoUvpKXUs5Ga7Ax4Km-Q_T5ywN7_DVjHEXHgpmJHBqIQIzMSROreEYziInOWefuOn4BzjFOKEqoy/w640-h361/TCCC%20Ca%20admin%202%20blood%20loss.jpg" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><span style="font-family: georgia; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiqNV5kvAbZkkO-MdGYRqtCRFLq-8TYqD5GIle_gb8VoGLikSMjDcrcP8y5cqR4479amxdWtcWny0Y9jCyzWQRu3-CcNXawFCqBaqgRjl0czVozf-1_gMjSPcHeRDJt-a_toljLp9IJGMPmdFl7Nw6elt3XkkgUpXpSoixuMrAjdzizZjOHnRl0sAttioF/s960/TCCC%20Ca%20admin%20blood%20loss.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="359" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiqNV5kvAbZkkO-MdGYRqtCRFLq-8TYqD5GIle_gb8VoGLikSMjDcrcP8y5cqR4479amxdWtcWny0Y9jCyzWQRu3-CcNXawFCqBaqgRjl0czVozf-1_gMjSPcHeRDJt-a_toljLp9IJGMPmdFl7Nw6elt3XkkgUpXpSoixuMrAjdzizZjOHnRl0sAttioF/w640-h359/TCCC%20Ca%20admin%20blood%20loss.jpg" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF3JTCEP1y2BmG2UU6t7c7IaOz-WDbM4omVKLw5ssJ0y2xj_SQYdEzrGnIMjahrGXD37hE_7Y-22infzmPqafngv4aNzquzqJXW5s6chAgqueemBxuBtyZmN_dqglXtVqKRb0iOaevMVCD2ZG6wSMp6vBxV6IPRi88scQ44gpYoMGeIivv0qk_tvfjBzxg/s960/TCCC%20transfusion%20reactions.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><img border="0" data-original-height="540" data-original-width="960" height="361" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF3JTCEP1y2BmG2UU6t7c7IaOz-WDbM4omVKLw5ssJ0y2xj_SQYdEzrGnIMjahrGXD37hE_7Y-22infzmPqafngv4aNzquzqJXW5s6chAgqueemBxuBtyZmN_dqglXtVqKRb0iOaevMVCD2ZG6wSMp6vBxV6IPRi88scQ44gpYoMGeIivv0qk_tvfjBzxg/w640-h361/TCCC%20transfusion%20reactions.jpg" width="640" /></span></a></div><span style="font-family: georgia; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;">Monitor for reactions:</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;">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. </span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;">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.</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: georgia; font-size: medium;">Treatment measures for both anaphylactic and hemolytic reactions: immediately stop the transfusion, give normal saline, stabilize the patient, and try another blood product.</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUe15UR3Pf3JIYibZIYjKucHN1_cNHQq12hAcXm3HL58WctJs_9xU3yhzgy4_lz0q3ek_vxoab_IMFXRp_I_t0mPXsnQaYEK2J-ErRgj_1LF57gHzO6dCUJTMEwZnmTCueHyxwO7tOaNuQY7mBlv8L__DjLJKeMtvARYaqD24CHuOPw2s67rfmuGO8KZ0H/s960/TCCC%20FFP.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: georgia; font-size: medium;"><br /></span></a></div><span style="font-family: georgia; font-size: medium;"><br /></span><p><span style="background-color: #274e13; font-family: georgia; font-size: medium;"><br /></span></p><p><span style="background-color: #274e13; font-family: georgia; font-size: medium;"><br /></span></p><h1 itemprop="name" style="border: 0px; box-sizing: border-box; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-variant-alternates: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; font-variant-position: inherit; font-variation-settings: inherit; font-weight: 500; line-height: 1.25; margin: 10px 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: georgia; font-size: medium;"><a href="https://www.emra.org/emresident/article/group-o-whole-blood" style="background-color: #274e13;" target="_blank">The Use of Low Titer Group O Whole Blood in Emergency Medicine</a></span></h1><div class="col-md-8 no-padding-d" style="border: 0px; box-sizing: border-box; float: left; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-variant-alternates: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; font-variant-position: inherit; font-variation-settings: inherit; line-height: inherit; margin: 0px; min-height: 1px; padding: 0px; position: relative; vertical-align: baseline; width: 573.333px;"><span class="info" style="border: 0px; box-sizing: border-box; color: #676767; display: flow-root; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-variation-settings: inherit; font-weight: inherit; line-height: inherit; margin: 10px 0px 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: georgia; font-size: medium;"><a href="https://www.emra.org/emresident/article/group-o-whole-blood" style="background-color: #274e13;" target="_blank"><strong itemprop="datePublished" style="border: 0px; box-sizing: border-box; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-variation-settings: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">10/17/2018</strong> <strong style="border: 0px; box-sizing: border-box; color: #50ba70; cursor: pointer; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-variation-settings: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; text-decoration-line: none; vertical-align: baseline;">Christa A. L. Arefieva</strong></a></span></span><span class="info" style="border: 0px; box-sizing: border-box; color: #676767; display: flow-root; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-variation-settings: inherit; font-weight: inherit; line-height: inherit; margin: 10px 0px 0px; padding: 0px; vertical-align: baseline;"><span style="background-color: #274e13; font-family: georgia; font-size: medium;"><br /></span></span><span class="info" style="border: 0px; box-sizing: border-box; color: #676767; display: flow-root; font-feature-settings: inherit; font-kerning: inherit; font-optical-sizing: inherit; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-variation-settings: inherit; font-weight: inherit; line-height: inherit; margin: 10px 0px 0px; padding: 0px; vertical-align: baseline;"><div style="box-sizing: inherit; clear: both; color: #212121; line-height: 1.4; margin: 0px 0px 1.6rem; overflow-wrap: break-word; text-align: left;"><span style="font-family: georgia; font-size: medium;"><a href="https://pubmed.ncbi.nlm.nih.gov/29067429/" style="background-color: #274e13;" target="_blank">Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival</a></span></div></span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-86327411714762440682023-12-26T00:29:00.198+13:002024-01-04T03:25:43.626+13:00Mouse Fever- "Trench Nephritis"<p><span style="font-size: medium;">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).</span></p><p><span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;">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.</span></p><p><span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;"><br /></span></p><p><a href="https://www.cdc.gov/hantavirus/hfrs/index.html" target="_blank"><span style="font-size: medium;">CDC HFRS page https://www.cdc.gov/hantavirus/hfrs/index.html</span></a></p><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940369/" target="_blank"><span style="font-size: medium;">Article: Hemorrhagic Fever with Renal Syndrome</span></a></p><p><a href="https://link.springer.com/chapter/10.1007/978-3-642-56753-7_1" target="_blank"><span style="font-size: medium;">Hantaviruses: History and Overview</span></a></p><p><br /></p><p><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-77880883852089933532023-12-25T04:23:00.053+13:002024-01-04T03:19:45.765+13:00Christmas in Ukraine<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIbRCyClrhwVUMcDHT3eyHZT3jv3joRjS_QLAK8CgZYIZ3FmOgFbPFCdlq5pWU6F-INhJxYzJkBI9URxJO1wGf8MycUkp18Yq_X6mT_F55q1QHF1wjCC4ig0PPuIMH0JSlchQBnZRPUNj7ixYLpvIX9WQmHy9jFVclwQuIiW148ZtSTspKEyo7ex8cR4aO/s4032/IMG_2410.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIbRCyClrhwVUMcDHT3eyHZT3jv3joRjS_QLAK8CgZYIZ3FmOgFbPFCdlq5pWU6F-INhJxYzJkBI9URxJO1wGf8MycUkp18Yq_X6mT_F55q1QHF1wjCC4ig0PPuIMH0JSlchQBnZRPUNj7ixYLpvIX9WQmHy9jFVclwQuIiW148ZtSTspKEyo7ex8cR4aO/w238-h320/IMG_2410.JPG" width="238" /></a></div><div class="separator" style="clear: both; text-align: center;">Our Christmas Tree</div><div class="separator" style="clear: both; text-align: center;"><br /></div><span style="font-size: medium;"> The Christmas Eve shift in Ukraine was punctuated by the usual regular booms of outgoing (and occasionally incoming) artillery, along with a procession of concussions and minor blast injuries.</span><p></p><p><span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;">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).</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdkKAmsfyyY6p-ex4JO19yHsuyDz8pQxMd172DSu2d9nmhlcvn0Pc5_L2PgdooNtVt08qpS6Lf8Ni1QLMr6dggv4JFAfIZ6VQpPOFXQ3c9cAhB6hLeEhj1GYSHaUQzdSzpBufQKjROLIQW0ShnRSC_dQgsl4Cz3Q6MSAwLzTx5to7_415PaLhYZTw6OFrX/s1280/IMG_2278.jpeg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1280" data-original-width="853" height="671" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdkKAmsfyyY6p-ex4JO19yHsuyDz8pQxMd172DSu2d9nmhlcvn0Pc5_L2PgdooNtVt08qpS6Lf8Ni1QLMr6dggv4JFAfIZ6VQpPOFXQ3c9cAhB6hLeEhj1GYSHaUQzdSzpBufQKjROLIQW0ShnRSC_dQgsl4Cz3Q6MSAwLzTx5to7_415PaLhYZTw6OFrX/w446-h671/IMG_2278.jpeg" width="446" /></a></div><br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-38230888865144362642023-12-24T03:44:00.002+13:002024-01-01T07:53:39.906+13:00TCCC and Prolonged Field Care: more relevant than ever in Ukraine<p> <span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;">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. </span></p><p><span style="font-size: medium;">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. <a href="https://deployedmedicine.allogy.net/learner/collections/29/shelf/7621e88e-ad94-44a1-b041-d693a77cedff" target="_blank">Tactical Casualty Combat Care - Prolonged Casualty Care Guidelines are published by the US Military Joint Trauma System here.</a> In-depth podcasts on various prolonged field care topics can be found <a href="https://prolongedfieldcare.org/about-3/" target="_blank">here, on the Prolonged Field Care Collective website</a>, or on Spotify, and Youtube. </span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-83664372500542304832023-12-23T00:56:00.014+13:002023-12-25T08:00:10.005+13:00ISW Report; THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND<p><span style="background-color: #274e13; color: #d9ead3; font-family: arial; font-size: medium;"> "<span face="Arial, Helvetica, sans-serif" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">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. </span><strong style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">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. </strong><strong style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Russia will have manipulated America into abandoning its own interests in a fight it could and should have won. </strong><span face="Arial, Helvetica, sans-serif" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">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."</span></span></p><h1 class="title" id="page-title" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; line-height: 1.5385; margin: 0px; outline: 0px; padding: 0px; text-transform: uppercase; vertical-align: baseline;"><span style="background-color: #274e13; color: #3d85c6; font-family: arial; font-size: medium;"><br /></span></h1><h1 class="title" id="page-title" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; line-height: 1.5385; margin: 0px; outline: 0px; padding: 0px; text-transform: uppercase; vertical-align: baseline;"><span style="background-color: #274e13; color: #6fa8dc; font-family: arial; font-size: medium;">-THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND</span></h1><div class="region region-content" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><section class="block block-system" id="block-system-main" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px 0px 1.5385em; outline: 0px; padding: 0px; vertical-align: baseline;"><div class="content" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span class="submitted" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span content="2023-12-22T14:03:52-05:00" datatype="xsd:dateTime" property="dc:date dc:created" rel="sioc:has_creator" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; border: 0px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background-color: #274e13; color: #6fa8dc; font-family: arial; font-size: medium;">Dec 22, 2023 - <a about="/users/isw-press" class="username" datatype="" href="https://www.understandingwar.org/users/isw-press" property="foaf:name" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; margin: 0px; outline: none; padding: 0px; text-decoration-line: none; vertical-align: baseline;" title="View user profile." typeof="sioc:UserAccount" xml:lang="">ISW Press</a></span></span></span></div></section></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-26653702727031069482023-12-21T04:55:00.012+13:002023-12-22T05:24:18.714+13:00Ukraine War: Crush Injury Treatment<p><span style="font-family: arial; font-size: medium;">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.</span></p><p><span style="font-family: arial; font-size: medium;">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.</span></p><p><span style="font-family: arial; font-size: medium;"><b>Crush syndrome</b> 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.</span></p><p><span style="font-family: arial; font-size: medium;">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.</span></p><p><span style="font-family: arial; font-size: medium;"><span>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 (</span>from the Greek <i>rhabdos=</i>rod + <i>myo=</i>muscle + <i>lysis=</i>breakdown).<span>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. </span><span>Histamine and leukotriene release causes vasodilation and bronchoconstriction.</span><span> </span><span>General vasodilatory effects cause capillary bed leakage, which worsens edema, third spacing, and hypotension. </span><span>Ongoing enzymatic damage occurs in muscles, accompanied by tissue hypoperfusion and hypoxia.</span><span> Lactic acid from anaerobic respiration in damaged muscle tissue causes acidosis and dysrhythmias. </span><span>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. </span><span>Thromboplastic release can lead to DIC.</span></span></p><p><span style="font-family: arial; font-size: medium;"><span>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. </span><span>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.</span><span> </span><span>If extrication must be performed prior to IO/IV placement, consider short-term tourniquet placement.</span><span> For prolonged field care, urine output of 100-200mL/hour is the target. </span>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).</span></p><p><span style="font-family: arial; font-size: medium;"><span>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. </span>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).</span></p><p><span style="font-family: arial; font-size: medium;"><span>All crush injury patients should be observed, even if they appear well. </span><span>Significant toxin accumulation generally occurs after 4-6 hours of entrapment/tissue compression, but can occur in as little as 60 minutes. </span><span>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. </span></span></p><p><span style="font-family: arial; font-size: medium;">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. </span></p><p><span style="font-family: arial; font-size: medium;"><b>Compartment</b> <b>syndrome</b>- 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.</span></p><p><span style="font-family: arial; font-size: medium;"><br /></span></p><p><span style="font-family: arial; font-size: medium;"><span face="Barlow, Arial, Helvetica, sans-serif" style="background-color: #f7f7f7; color: #171717;">2004 study: <a href="https://pubmed.ncbi.nlm.nih.gov/15211124/" target="_blank">Brown C, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: Do bicarbonate and mannitol make a difference? </a></span><a href="https://pubmed.ncbi.nlm.nih.gov/15211124/" target="_blank"><i style="background-color: #f7f7f7; color: #171717;">J Trauma</i><span face="Barlow, Arial, Helvetica, sans-serif" style="background-color: #f7f7f7; color: #171717;">. 2004;56(6):1191—1196</span></a></span></p><p><span style="background-color: #f7f7f7; color: #171717; font-family: arial; font-size: medium;">2013 literature review: <a href="https://pubmed.ncbi.nlm.nih.gov/23324509/" target="_blank">Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: A systematic review. Ann Pharmacotherapy. 2013;47(1):90—105.</a></span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-29866247713050917992023-12-20T10:29:00.011+13:002023-12-21T10:32:59.815+13:00Ukraine: A Quiet Night at the Stabilization Point- with Kittens<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyp-PW5jVDGR2gKvNyHMzXp_O7jTHi_GnzQold_aG22g0qWbyHvfII3WS_3hFjwAKjJ1ECyeL3C_bO0NEf185CG4VBTTCCFxXfHc015_-bRXrZtJJ2eAWEn3MrBD0uXORryNo6aWY-eP4geQvymWabUQFd3R5LNlaDYl_uSNFNQDFvPma-JkuzdB2OH1eW/s998/clinic%20kittens.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="998" data-original-width="749" height="715" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyp-PW5jVDGR2gKvNyHMzXp_O7jTHi_GnzQold_aG22g0qWbyHvfII3WS_3hFjwAKjJ1ECyeL3C_bO0NEf185CG4VBTTCCFxXfHc015_-bRXrZtJJ2eAWEn3MrBD0uXORryNo6aWY-eP4geQvymWabUQFd3R5LNlaDYl_uSNFNQDFvPma-JkuzdB2OH1eW/w536-h715/clinic%20kittens.JPG" width="536" /></a></div><br /> <p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-483208660192016963.post-6754675464452535422023-12-19T10:24:00.018+13:002023-12-21T20:40:38.622+13:00TB and the Ukraine War<div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><span>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.</span></span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><span><br /></span></span><span><span>TB, or "consumption" is an ancient disease, closely associated with malnutrition and overcrowding. It is the disease that killed</span></span><span> Chekhov, Chopin, Emily Bronte, Orwell, Kafka, Keats, Thoreau, and many others at the height of their creative years.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span>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. </span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span>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. </span><span>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.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span>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.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span>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.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span style="background-color: #274e13;">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. </span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="background-color: #274e13; font-family: arial; font-size: medium;"><span><br /></span><span>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.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="background-color: #274e13; font-family: arial; font-size: medium;"><span><br /></span><span>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</span><span> 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 </span><span>inter-mixing with and displacement of civilian populations all</span><span> create a major risk for wartime transmission of TB, MDR-TB, and XDR-TB.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="background-color: #274e13; font-family: arial; font-size: medium;"><span><br /></span><span><span>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). </span></span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><span style="background-color: white;"><br /></span></span><span style="background-color: #274e13;"><span><span>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 </span></span><span>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. </span></span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span style="background-color: #274e13;">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.</span></span></div><div style="box-sizing: border-box; font-weight: 400; margin: 16px 0px; padding: 0px; text-align: left; word-break: break-word;"><span style="font-family: arial; font-size: medium;"><span><br /></span><span><span><a href="https://www.who.int/health-topics/tuberculosis#tab=tab_1" style="background-color: #274e13;" target="_blank">WHO TB page<br /></a></span></span><span><span><a href="chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ecdc.europa.eu/sites/default/files/documents/tuberculosis-surveillance-monitoring-2023.pdf" target="_blank"><span style="background-color: #274e13;">WHO TB Surveillance and Monitoring in Europe, 2023<br /></span></a></span></span><span><span><a href="https://www.ijidonline.com/article/S1201-9712(20)30045-X/fulltext#secsect0030" target="_blank">The 2020 clinical update by the Global Tuberculosis Network<br /></a></span></span><span><span class="title-text" style="box-sizing: border-box; margin: 0px; padding: 0px;"><span><a href="https://www.sciencedirect.com/science/article/pii/S1198743X19304057" target="_blank"><em style="box-sizing: border-box; margin: 0px; padding: 0px;">2020 S</em><span style="box-sizing: border-box; margin: 0px; padding: 0px;">tanford-China </span><span style="box-sizing: border-box; margin: 0px; padding: 0px;">study:</span><em style="box-sizing: border-box; margin: 0px; padding: 0px;"> Mycobacterium tuberculosis</em> Beijing genotype strains and unfavourable treatment outcomes: a systematic review and meta-analysis<br /></a></span></span></span><span><span><span class="title-text" style="box-sizing: border-box; margin: 0px; padding: 0px;"><span>2017 literature review: </span></span><span face=""Open Sans", Helvetica, Arial, sans-serif"><a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174373" target="_blank">Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review<br /></a></span></span></span><span><span class="title-text" style="box-sizing: border-box; margin: 0px; padding: 0px;"> </span></span></span></div>Unknownnoreply@blogger.com0