TB and the Ukraine War

Not only does the current Russia-Ukraine pose unique risks of regional and global military escalation, it is also creating historic levels of population displacement and military mobilization of convicts, in one of the world's foremost multi-drug-resistant tuberculosis hotspots.

TB, or "consumption" is an ancient disease, closely associated with malnutrition and overcrowding. It is the disease that killed Chekhov, Chopin, Emily Bronte, Orwell, Kafka, Keats, Thoreau, and many others at the height of their creative years.

TB is caused by the bacteria 'Mycobacterium tuberculosis'. Mycobacteria have evolved a waxy coating which allows them to survive and reproduce inside macrophages, thus evading our immune system's first line of defense. Tuberculosis can remain latent within the body for many years, becoming active once the immune system is sufficiently weakened by factors such as malnutrition, diabetes, HIV, or smoking. A patient with latent TB has a 5-10% lifetime chance of developing active TB. Classic symptoms of active pulmonary TB include night sweats, weight loss, and a cough that produces blood-tinged sputum. Untreated, pulmonary TB eventually destroys the lungs in a "swiss cheese" pattern, and leads to patient death. TB bacteria may also disseminate throughout the body, creating a variety of symptoms, such as cutaneous nodules, engorged lymph nodes (scrofula), meningitis, and an array of internal organ problems. 

TB is the world's top infectious disease killer, and fully 1/4 of the world population currently carries latent tuberculosis. Infection rates vary locally, ranging from as low as 3% in some developed countries, to 90%+ in parts of Africa. Only patients with active TB can pass the bacteria on to others, and may infect 15 other individuals per year. Conflict and other social disruption events can have a major impact on spread. Firstly, conflict subjects individuals to physical hardships, such as poor nutrition, inadequate housing, and exposure to other infectious diseases. Second, conflicts displace populations, and lead to overcrowding, poor sanitation, and breakdown of healthcare systems. Studies suggest that war increases annual TB incidence up by up to 20%. The 2022 Russian invasion of Ukraine has resulted in the fastest mass refugee migration since WWII. In 2022, the world-wide number of displaced persons hit a new record of over 100 million souls.

Social disruptions do not have to be conflict-based to facilitate the spread of TB. Russia and other former USSR members have the developed world's highest TB rates, due to social disruptions that occurred during the decade after the fall of the USSR. The 1990's reversed a huge amount of Soviet progress on TB control, which had been achieved via xray detection, isolation, and treatment in sanitariums. Infection rates in Russia fell from 1910 levels of 400/100,000, down to a rate of 17.3/100,000 (in men) and 1.9/100,000 (in women) in 1990. But post-Soviet poverty and healthcare system collapse caused Russian TB rates to double between 1991-1998. During the same time period, incarceration rates tripled in most post-Soviet states. By the late 1990's, TB had become a raging epidemic within the overcrowded Russian prison system, with prisoner infection rates averaging 4,000/100.0000, and in some regions reaching 7,000/100.000.

Mycobacterium tuberculosis's ability to hide from the immune system means that treatment regimes, even for cases that are susceptible to first-line antibiotics, are lengthy. If, due to treatment costs, disruptions in health services, or poor patient education, a patient stops treatment early, evolutionary forces favor the growth of antiobiotic-resistant bacteria within that patient's body. This resistant bacteria can then be passed on to others, garnering new opportunities, with each unsuccessful treatment course, to become resistant to additional medications. The result is multi-drug-resistant TB, or "MDR-TB"- one of today's major public health challenges. Treatment regimes for MDR-TB last up to two years, may cause uncomfortable side effects, and have a significant failure rate. To reduce risk of MDR-TB, DOTS, or Directly Observed Treatment, has become the gold standard for TB treatment worldwide.

However, in post-Soviet states, corruption and economic woes interfered with successful TB programs. Physicians opposed DOTs, feeling that it threatened their already precarious livelihoods. TB medications were re-purposed and sold in markets by crooked pharmacists, or traded for other items by prisoners in treatment programs. Until fairly recently, antibiotics were widely available without prescription at pharmacies in both Russia and Ukraine. It was quite common to self-prescribe an inappropriate course of antibiotics, for example, for a viral cold infection. By 1998 20% of Russian prison cases were MDR-TB. As prisoners were released mid-treatment, this trend spread into the general population. Eastern Europe now accounts for the largest MDR-TB burden in the world. 

In recent years Russia, along with many former Soviet states, has resumed making progress on TB control. Between 2010-2020, Russian TB mortality halved, and general population infection rates fell to 45-50/100,000 (48% MDR-TB). WHO estimated 2021 TB incidence in Ukraine to be 71/100,000 (31% MDR-TB in new cases and 45% in relapse cases). In contrast, average 2021 TB incidence in the EU was 8.4/100,000 (33% MDR-TB). Thus, TB infection in refugee populations moving from Eastern to Western Europe is a major public health concern.

Despite progress within prisons, as well as amongst the general population, TB remains a major problem in Russian prisons. Russia has one the world's highest incarceration rates, with overcrowding and poor living conditions extremely common. A 2017 study estimated that 1 in 10 Russian prisoners have active TB, and that the majority of remaining prisoners have latent infections. A 2019 study found that Russia had the world's second-highest number of new active TB cases amongst prisoners (~13,000 cases, second only to 15,000 cases in Brazil). A 2-3 yr prison sentence leads almost inevitably to TB infection. 48% of Russian prison cases are multi-drug-resistant. Russia also has one of the highest rates in the world of "extensively drug-resistant TB", which is even more difficult to treat than MDR-TB. Russia's heavy reliance on convicts as soldiers, low health standards for enlistment, difficult frontline living conditions, unreliability of medication supplies, potential for injury or capture, and inter-mixing with and displacement of civilian populations all create a major risk for wartime transmission of TB, MDR-TB, and XDR-TB.

In the Ukraine war, post-Soviet health challenges are potentiated by the melange of convict soldiers, frontline conditions, and mass displacement of civilians. The result is a myriad of spread opportunities for the world's new diseases of disruption: MDR-TB, MDR wound infections, and potentially also novel respiratory viruses (think a new wartime COVID variant or a 1918-style influenza). 

Spread of MDR-TB is not the only concern. TB comes in a variety of strains. Interestingly, the prevalent strain in Russia is the "Beijing" type. The Beijing TB strain, first described in 1995, has unique proteins. These potentially make it more infectious and more resistant to treatments. A 2020 literature review of studies involving 7,000 patients found strong support for correlation between the Beijing strain and more unfavorable treatment outcomes. Despite global implementation of DOTS, TB incidence seems to be declining at only 1-2%/yr- far slower than math models predict. The reasons for this include prevalence of HIV coinfection, diabetes, malnutrition, drug resistance, crowding, and poor control infrastructure. Arguably, another reason is the spread of Bejing subtypes- which will also likely be further facilitated by the disruptions of the Ukraine war.     

There is hope on the horizon for TB control. A currently approved vaccine, the BCG TB vaccine, does not prevent TB, but it does serve to lessen risk of some severe forms of disseminated disease in children. Several vaccines designed to prevent pulmonary TB in all ages are currently under development. The most promising is M72. M72 was dropped by its original creator due to low profit potentials, but has recently been picked up by the Gates Foundation and has entered Phase III trials. M72 may be able to prevent pulmonary disease in 54% of infected adults. And for a disease that can take years to treat, and becomes active in 5-10% of patients, who go on to infect 15 other people per year, 54% prevention be a game-changing statistic.

WHO TB page
WHO TB Surveillance and Monitoring in Europe, 2023
The 2020 clinical update by the Global Tuberculosis Network
2020 Stanford-China study: Mycobacterium tuberculosis Beijing genotype strains and unfavourable treatment outcomes: a systematic review and meta-analysis
2017 literature review: Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review
 

Ukraine: Bradley IFVs taking on T90 tanks

 

Several videos have emerged this week, showing Bradley Fighting Vehicles successfully taking on advanced Russian T-90 tanks.

From Special Kherson Cat on Twitter, video of Bradley IFV vs T-90 in Avdiivka

Ukraine: Types of Missiles that Russia Commonly Fires at Ukrainian Cities

 

 

     

S-300 / S-400 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. Image by By Tourbillon - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=6714828. 

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Kh-47 Kinzhal 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. Image from By kremlin.ru, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=68926303

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Kaliber 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, 

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Iskander 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.

Image 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

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Kh-101 / Kh-555 / Kh-55 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

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Kh-22 "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. Image by By Антон Бородин - Музей авиационной техники, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=10658517

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Kh-59 "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.

	Cost #USD	Warhead Size	Warhead Type	Missile Length, Speed	Engine	Range, Accuracy	Launch Platform
S300	1 million	up to  143 kg	19,000-36,000 metal frag,s	~25'		up to 250 nm	vehicle-based
Kinzhal	10 million	480kg	Conventional or nuclear	25' Mach 10	solid-fuel rocket	300nm	Tu-22 Mig-31
Kaliber	1 million	500kg	Conventional or nuclear	~25' Mach 3	solid-fuel rocket or turbojet	up to 1300nm	Air, ship, or sub launched
Iskander	3 million	480-700kg	Cluster, thermobaric, EMP, frag, bunker busting, nuclear	25' Mach 7	single-stage solid propellant	300nm 3' - 100'	vehicle
Kh-101	13 million	400mg	conventional or nuclear	24' Mach 0.7	turbofan jet	3500nm 20-33'	bomber aircraft
Kh-22	1 million	1,000 kg	RDX or thermo - nuclear	38' Mach 4.6	liquid - fueled rocket	320 nm             300-900'	Tu-22  Tu-95
Kh-59	500,000	320 kg	Cluster, Shape-Charge Frag	18' Mach 0.8	2-stage rocket	60-160nm	Sukhoi and Mig jets

Notes: "hypersonic" missile is somewhat of a misnomer; nearly all ballistic missiles reach hypersonic speeds at some point during flight

"Kh" and "X" are both transliteration options for the same Russian letter, (X)

Info from Jane's Air-Launched Missiles

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