Ukraine: Drones and Dogwalking

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. 

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. 

And, as we see in the video, drones are not just good for war. They are also great for dog-walking.

Ukrainian Army Recruiting Posters

 Recruiting for the 3rd Storming Brigade

Aug 2023: 'The Spectator' Article on military medicine in Ukraine

From The Spectator, 23 Aug 2023: 'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'

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,

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. 

The Telegraph Ukraine reporting and daily hour-long Ukraine podcast

From The Spectator, 23 Aug 2023: 'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'

Video of hospital in Pokrovsk, Ukraine, at moment of bomb impact

 

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.

Ukraine: Air Raid!

 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".

13:57     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.        - 39,000 views

14:02    Air alarm for Dnipropetrovsk Oblast!    - 38,000 views

14:02     Air alarm for Zaporizhya Oblast!        - 37,800 views

14:06    X-59 threat for areas where the Alarm is        - 38,900 views

14:18    X-59 headed towards Dnipro                - 38.600 views

14:19    Dnipro: take shelter!        - 39,100 views

14:19    Zaporizhya: take shelter!    - 39,600 views

14:19    X-59 Rocket approaching Dnipro Region    - 39.800 views

14:21    Dnipro: Explosions        - 41,000 views

14:24    The rocket has been destroyed! (by air defense)    -41,000 views

Combat Medicine: Pelvic Fractures

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.

Pelvic fractures are generally caused by severe blunt force or blast trauma. Signs and symptoms include:

Pelvic pain and/or crepitus

Deformed or unstable pelvis, unequal leg lengths, or outward rotation of legs (open-book fracture)

Bruising at bony prominences of pelvic ring, anal/vaginal/urethral bruising or bleeding

Neurological deficits in lower extremities

Major lower limb amputation or near amputation

Unconsciousness

Shock

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. One assessment at a major UK trauma center found that 41% of pelvic binders were placed too high.  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. 

An Assessment of Pelvic Binder Placement at a Major UK Trauma Center

TCCC

1996 CAPT Frank Butler formalized 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. 

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 “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.” 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. 

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:

1) DOD Trauma Registry Management

2) Defense Committee on Trauma

3) Performance Improvement

4) Combatant Command Trauma System Management

5) Joint Trauma Education and Training

6) Defense Medical Readiness Institute

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. 

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.

ASM All Service Members

CLS Combat Lifesaver

CMC Combat Medic/Corpsman

CPP Combat Provider Paramedic

The latest version of TCCC was released in 2020 and can be found here.

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

TCCC Tactical Casualty Care, full Combat Medic/ Corpsman Course, Prolonged Field Care, and other resources at tcc.org English and Ukrainian versions available 

Tourniquet Conversion

 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. 

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.

The process for converting a tourniquet is:

1) pack the wound and apply pressure for 3 minutes

2) apply pressure dressing

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.

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.

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.

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

Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review

Ukraine: Combat TBIs

TBIs and their sequelae have long been associated with wars. 

Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects: Chapter 2: Combat TBI History, Epidemiology, and Injury Modes* 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.  

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 New York Times investigation examined TBI rates amongst US artillery companies 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 military-ordered study of Fox battery, 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 "Warfighter Brain Health Initiative". 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.

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.

 Manpower shortages mean a lack 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.

In his book, Ralph G. DePalma writes: "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 (Johnson, 2010). Viscoelastic dynamic rippling of the skull secondary to the blast has been postulated based on modeling (Moss et al., 2009). 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 (Armonda et al., 2006), and diffuse axonal injury (DAI) with disruption across attentional networks (Vakhtin et al., 2013)... Kucherov et al. (2012b) 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 (Kucherov, 2012a). 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."

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. 

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.

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. 

A 2017 study published in the Annals of Emergency Medicine found 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.

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.   

Opiate pain medications and benzodiazepines may cause blood pressure to drop suddenly in patients with compensated shock, and should be used with extreme caution. 

Link to Health.mil fillable MACE 2 evaluation pdf

Link to University of Arizona EPIC 2.0 program

War in Ukraine: a neurosurgical perspective Daniel Dubinski and Volodymyr Kolesnyk

US DOD's TCC/Combat Medic Online Module on Head Trauma

Ukraine: Great PFC Podcast episode

 Ukrainian medic Henri talks with the Prolonged Field Care Collective about conditions in Ukraine: most common injury patterns, weather and exposure, access difficulties, Russian drone attacks on medics, trench foot, dressing complex wounds, penetrating pelvic trauma, prevalence of pneumo-hemothorax over tension pneumothorax, body armor selection factors, and more.

Blood Loss and the Lethal Triad

Symptoms of blood loss:

500 mL - well tolerated, may produce slight tachycardia, equivalent to a typical                       blood donation volume.

1000 mL - tachycardia over 100

1500 mL - changes in mental status, weak radial pulse, persistant tachycardia,                         tachypnea

2000 mL - confusion, lethargy, weak radial, tachycardia over 120, tachypnea over                     35, might be fatal if not managed properly

2500 mL - unconsciousness, no palpable radial pulse, tachycardia over 140,                             tachypnea over 35, fatal without intervention

 In patients with blood loss, the "Lethal triad"- is a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy.

Acidosis: Reduced circulating blood volume leads to shunting of blood from the periphery to vital organs in the core. Peripheral tissues resort to anaerobic metabolism, which creates lactic acid as a byproduct. This can be worsened by administration of large volumes of non-oxygen-carrying, acidic fluids, such as normal saline (pH 5.5).  

Hypothermia: Develops easily and rapidly in trauma patents, even in warm conditions. Anaerobic metabolism, immobility, and other physiological responses to blood loss reduce heat production. Evidence shows that even small drops in body temperature (to 36C / 96.8F) can significantly increase mortality in trauma and burn patients. At core temperatures below 30C / 86F, patients stop shivering and cannot warm up without application of external heat, even if they are well-insulated. It is far easier to prevent hypothermia than to correct it. 

Coagulopathy: Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Loss of clotting factors due to bleeding, acidosis, and hypothermia all produce coagulopathy, which in turn further exacerbates blood loss, acidosis, and hypothermia. 

Preventing the Lethal Triad cycle is crucial; once established, it is difficult to interrupt. Field treatment of patients with significant blood loss should include oxygen, insulation from the ground, covering with blankets/space blankets/ready-heat systems, and placement in a heated environment if possible.

Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy Create a Deadly Cycle for Trauma Patients

 

Antibiotics in trauma

Evidence from historical US conflicts makes it clear that early administration of antibiotics in the field improves outcomes for battlefield casualties. Safety profiles are good for field antibiotics used in US combat medicine, and adverse reactions are rare. Currently, moxifloxacin (4th generation flouroquinolone) is the US military oral antibiotic of choice. Ertapenem (a carbapenem) is the parenteral antibiotic of choice. Together, these drugs cover a wide spectrum of potential infectious microbes. 

The US Combat Wound Medication Pack contains 400mg moxifloxacin, along with 15mg meloxicam and 500mg acetominophen. The Ukrainian medication pack contains a similar assemblage of pills. 

TCCC Combat Medic/Corpsman Antiobiotics Administration, TCCC.org  https://tccc.org.ua/en/guide/module-16-antibiotics-administration-cmc

Duration of extremity tourniquet application profoundly impacts soft-tissue antibiotic exposure in a rat model of ischemia-reperfusion injury

Good new Video: Ukraine’s SBU SpecOps Medics

 

SBU Special operations of victory. Combat medics. Death will wait.

 https://m.youtube.com/watch?v=PnCgATphvLs&pp=QACIAgHKBUJTQlUgU3BlY2lhbCBvcGVyYXRpb25zIG9mIHZpY3RvcnkuIENvbWJhdCBtZWRpY3MuIERlYXRoIHdpbGwgd2FpdC4%3D&rco=1

 . 

Giving Blood in the Field: current TCCC recommendations

Due to occasional severe transfusion reactions, whole blood fell out of favor after WWII. Separating blood into components, such as plasma, red blood cells (RBCs), and platelets allowed for a longer shelf life, easier transport and storage logistics, and reduced risk of disease and transfusion reactions. Separate blood components are needed for many medical interventions. An exception, however, is trauma with massive blood transfusion needed. Recent evidence suggests that, for trauma patients in hypovolemic shock, whole blood produces better outcomes. 

TCCC recommendations have evolved through combat experience gained in Iraq and Afghanistan during the recent "Global War on Terror" (GWOT). Before the US invasion of Iraq, most forward resuscitation efforts for blood loss centered on providing non-blood products such as Hextend and PLASMA-LYTE. In 2003, TCCC recommended that blood be carried on casevac units if possible. In 2006, this recommendation was updated to specify low-titer type O blood. As ongoing studies demonstrated increased coagulopathy and reduced survival with non-blood product use, in 2014 TCCC moved blood products to the forefront of care for hemorrhagic shock. 2020 TCCC guidelines list whole blood as the "fluid of choice", with crystalloids, Hextend, and PLASMA-LYTE recommended only if blood products are unavailable.

Whole blood for trauma has a number of advantages. It contains clotting factors that are missing from individually packaged blood components, and has a reduced amount of artificial anti-clotting agents (which can lead to coagulopathy). Whole blood is faster and simpler to administer than individual blood products. This can be important during times of high demand on patient caregivers, reducing workload and opportunities for errors. In general, the sooner blood is given, the better the outcomes. A retrospective study of 502 US military combat casualties in Afghanistan between 2012 and 2015 showed that time to initial blood product transfusion was associated with a reduced 24-hour and 30-day mortality. 

Non-blood products such as crystalloids, Hextend, and PLASMA-LYTE come with several negative side-effects. They may contribute to the "Lethal triad"- a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy which is hard to interrupt once it sets in. Expanding blood volume without adding RBCs does not increase oxygen-carrying capacity, leading to ongoing lactic acid production via anaerobic metabolism in oxygen-deprived tissues. Normal saline is acidic (pH 5.5) and infusing large volumes can cause acidosis. Lactated ringers is less acidic (pH 6.5), but is slightly hypotonic and some experts believe it may worsen swelling in TBI patients. Even isotonic crystalloids may seep into damaged tissues, rather than stay in the vascular compartment, due to osmotic differences. High-volume unwarmed fluids contribute to hypothermia, which develops easily and rapidly in trauma patients, due to reduced heat generation during anaerobic metabolism, reduced circulating blood volume, immobility, and physiologic responses to blood loss. Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Acidosis and hypothermia both produce coagulopathy, which in turn further exacerbates acidosis and hypothermia. Once established, the lethal triad cycle is difficult to interrupt.

The current TCCC-preferred fluid for blood loss replacement in trauma victims is "LTOWB": cold-stored, low-titer O-negative whole blood. The "ABO" blood groups refer to the presence of A-type and B-type antigens on the surface of red blood cells. Most antibodies are only produced after an exposure to an antigen ("sensitization"). For instance, someone with a severe allergy to bees only experiences an allergic reaction after their second bee sting- the first sting merely introduces foreign material that the body that incites antibody production. But, in the case of antibodies that act against A-type and B-type antigens, this is not true. Each person is born with innate A and/or B antibodies, with no foreign blood exposure required. If a patient with type-A blood is given a transfusion of type-B blood, each of the patient's anti-B antibodies will adhere to several type-B antigens in the donor blood. This causes the donor RBCs to clump together ("agglutination"). These clumps block small blood vessels throughout the body. As the cells of clumps break down ("hemolysis"), they release hemoglobin, which can clog the kidneys and result in kidney failure. 

Image shows agglutination in a rapid blood-type test.

Those with blood type A innately have A antigens and anti-B antibodies. Those with blood type B have B antigens, and anti-A antibodies. Those with type O blood have no antigens, and both anti-A and anti-B antibodies. Therefore, type-O blood will not produce reactions in people with type A or B blood. 

A second transfusion consideration is presence or absence of Rh factor. 85% of Americans are Rh-positive; they have Rh antigens, and therefore will not produce anti-Rh antibodies. Only Rh-negative individuals can produce anti-Rh antibodies, and they only do so after sensitization. Sensitization can occur via pregnancy with an Rh-positive fetus, or via an Rh-mismatched transfusion. In the case of pregnancy, Rh+ cells rarely cross the placenta; exposure may occur during childbirth, and may become an issue if a second pregnancy with an Rh+ fetus occurs. Similarly, a first transfusion with Rh-mismatched blood is not a problem, however a second transfusion or Rh+ pregnancy might cause a reaction.

Low-titer O blood refers to low levels of anti-A and anti-B antibodies in the type-O donor's blood. Titers below <256 are very unlikely to cause transfusion reactions in blood recipients. For massive transfusion purposes, low A/B antibody titers are more important than presence or absence of Rhesus factors (i.e. whether the blood is "O-positive" or O-negative". Because rhesus-negative patients don't develop sensitivity to Rh-positive products until several weeks after exposure, Rh+ blood can be given to Rh- acute trauma patients without significant risk of a transfusion reaction. So, while ABO-mismatched transfusion reactions can be severe, Rh-mismatch is less concerning in acute trauma situations. For acute trauma, low-titer O blood is best. For general medical transfusion applications, O-negative blood is most useful. Generally, people with type-O-negative blood are 'universal donors', and those with type AB-positive are 'universal recipients'. 

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.

TCCC Blood Products Order of Preference:

1) "LTOWB" Cold stored low-titer O negative whole blood. This product has had disease testing performed (HIV, HBV, HCV, West Nile, syphilis, HTLV, Chagas), anti-A/B antibody titer <256, and leukocyte reduction. Shelf life is 21-35 days.

2) "FWB" Pre-screened low-titer O fresh whole blood. 16ga IV should be used to collect from the donor; placement of an 18ga in the recipient is sufficient, safe, and encouraged. Shelf life 6-8 hours. 

3) Plasma, RBCs, and platelets in 1:1:1 ratio

4) Plasma and RBCs in a 1:1 ratio. Shelf life 1 yr for plasma, 42 days for RBCs.

5) Plasma or RBCs alone. Some countries (including France, Germany, and South Africa) use freeze-dried plasma (FDP) for austere ops; FDP contains fibrinogen and other hemostatic factors.

Care should be used to prevent hypothermia; warm chilled blood before administration and use a filter to remove small clots. Citrate preservative used in blood collection bags binds with the patient's calcium, therefore 1g calcium should be given after administration of the first unit of blood (either 30mL 10% calcium gluconate or 10 mL 10% calcium chloride daily). Give blood until mental status improves, radial becomes palpable, or BP rises above 100. 

Monitor for reactions:

1) Anaphylaxis: wheezing, stridor, shortness of breath, hypotension, hives. Give 0.3mg epi + 25mg benadryl and monitor airway. Optionally give 10-40mg methylprednisolone slow IVP. 

2) Acute hemolytic reactions: rupture of RBCs and leakage of contents, generally due to blood mismatch. Symptoms include fever, flank pain, and red/brown urine. All 3 are rarely observed together in field, Pain may alternately occur in an arm, chest, or back, DIC may occur. Nausea may preceed other symptoms. Give 25mg benadryl via slow IV push.

Treatment measures for both anaphylactic and hemolytic reactions: immediately stop the transfusion, give normal saline, stabilize the patient, and try another blood product.

The Use of Low Titer Group O Whole Blood in Emergency Medicine

10/17/2018  Christa A. L. Arefieva

Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival

Mouse Fever- "Trench Nephritis"

During December of 2023, reports of Russian soldiers falling ill with fever, back and abdominal pain, red eyes, and kidney problems began to emerge from the trenches of Eastern Ukraine. Ukraine's Military Intelligence Directorate (GUR), has blamed the reports on "mouse fever", or Hemorrhagic Fever with Renal Syndrome (HFRS).

Although HFRS is poorly researched, it is likely this hemorrhagic viral disease accompanied many wars of the past. HFRS (aka Korean Hemorrhagic Fever, Epidemic Hemorrhagic Fever, or Nephropathia Epidemica), is a rodent-borne group of hantaviruses, of the family Bunyaviridae. Strains, which differ in their symptoms and epidemiology, include Hantaan, Dobrava (found in the Balkans), Saaremaa, Seoul (found worldwide), and Puumala (in Scandinavia, Russia, and W Europe). Poor wartime living conditions for soldiers and displaced populations contribute to both increases in rodent populations, and increased exposure to virus shed in the rodents' urine and feces. In Ukraine this year, warm fall weather and unharvested crops in fallow fields have led to a large winter rodent population. Life in the trenches increases soldiers' exposure to rodents. HFRS is spread by striped and yellow-necked field mice, norway rats, and bank voles, amongst others. 

Unlike New World hantaviruses, which cause pulmonary disease with mortality rates of 40-50%, Old World hantaviruses tend to create generalized hemorrhagic symptoms and kidney problems. They are more likely to spread as epidemics and have lower case fatality rates (CFR 2-20%). Reports of wartime HFRS-like diseases have cropped up in many wars throughout history, often referred to as "trench nephritis", or mis-diagnosed as other conditions. 

The first known written mention of HFRS was likely made in a Chinese medical book in AD 960. Mentions of "trench nephritis" during the US Civil War may be attributable to a kidney-targeting hantavirus, such as the Seoul strain. "Mouse Fever" appeared in a 1913 Vladivostok hospital record. "Field nephritis" affected both Allied and German troops in Flanders in WWI. During WWII, 10,000 Japanese soldiers fell victim to a HFRS-like illness in Manchuria, as did several hundred Russian soldiers in the Far East. More than 1,000 Finnish and German soldiers contracted what was probably the Puumala strain in Finland. 3,200 cases of HFRS were diagnosed amongst UN soldiers during the Korean War; these experienced a mortality rate of 15-20%. Numerous soldiers fell ill with HFRS symptoms during the Balkans war. Currently, an estimated 100,000 cases of HFRS occur each year worldwide. In Ukraine, one study found that 1.6% of healthy individuals have antibodies to hantaviruses.

HFRS is contracted by inhaling dried rodent urine, droppings, or saliva, or by touching mucous membranes after touching surfaces contaminated with rodent excrement. After a 1-2 week incubation, patients experience a sudden onset of flu-like symptoms. These can include severe headache, abdominal pain, nausea, vomiting, back pain, fever, chills, back pain, flushed face, red eyes, and blurred vision. In severe cases, the disease may progress to kidney failure, fluid overload, vascular leakage, hypotension, and possibly death. Hantaan and Dobrova strains are more like to cause severe illness; other strains tend to be more moderate. Ribavirin, if given very early, may help. Otherwise, supportive care focuses on maintaining fluid and electrolyte balance. Dialysis may be required. CFR ranges from 5-20% for Hantaan to <1% for Puumala virus. Complete recovery can take weeks or months. A vaccine for the Hantaan strain exists in Korea, but is little-used. 

CDC HFRS page https://www.cdc.gov/hantavirus/hfrs/index.html

Article: Hemorrhagic Fever with Renal Syndrome

Hantaviruses: History and Overview

Christmas in Ukraine

Our Christmas Tree

 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.

Most people in Ukraine have shifted to celebrating Christmas Day on 25 December, instead of the Russian Orthodox tradition of 7 January. Thus, Christmas fell on our day off. We visited an old church, which was used as a sports hall during Soviet times, and has since been restored by donors. 

We had a fairly simple Christmas repast. However, for many Ukrainians, old traditions have become more popular, such as caroling, serving 12 traditional dishes, and setting out a "dedukh" (rye sheath that symbolizes ancestral spirits).

TCCC and Prolonged Field Care: more relevant than ever in Ukraine

 For US medics in Afghanistan and Iraq, air superiority more often than not allowed for relatively quick evacuation of injured soldiers in need of advanced surgical care. In contrast, medics in Ukraine commonly are forced to provide prolonged care to patients at or near the frontlines. 4-12 hours, or more, may pass before conditions are safe enough for ground evacuation of patients. Air evacuation is generally impossible due to high risks from Russian air defense platforms, and to a lesser extent, Russian aircraft. Additionally, due to heavy use of artillery, patients often come in clusters. Attrition amongst experienced frontline medics has the potential to burden inexperienced replacement medics with multiple severely injured patients at once, who are in need of prolonged patient management under very austere circumstances. 

Similar conditions might well prevail during a hypothetical ground war involving the US and either China, or a similarly strong alliance of powers. Under such conditions, ability to provide advanced prolonged care techniques in the field would be an important tool to improve patient outcomes. 

US military working groups have made great progress on developing evidence-based prolonged field care guidelines, mostly based on experience in Iraq and Afghanistan over the past two decades. These guidelines are also applicable to traumatic injuries in many non-combat austere medical situations, such as maritime and wilderness environments. Tactical Casualty Combat Care - Prolonged Casualty Care Guidelines are published by the US Military Joint Trauma System here. In-depth podcasts on various prolonged field care topics can be found here, on the Prolonged Field Care Collective website, or on Spotify, and Youtube.