Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war.

BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city.

BACKGROUND: The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes. METHODS: We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes. RESULTS: Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome. CONCLUSION: The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.

Lung sealing using the tissue-welding technology in spontaneous pneumothorax.

OBJECTIVE: Welding of lung tissue is a new radio-frequency surgical method that allows sealing pulmonary tissue without overheating and damaging the tissue. The objective of the research was to study the results of sealing the lung tissue in a non-resectional procedure for spontaneous pneumothorax comprising ablation of bullae via video-assisted thoracoscopic surgery (VATS). METHODS: We present a series of 133 consecutive patients with primary spontaneous pneumothorax, who were operated on during the past 3 years. Among 133 patients, 123 were men and 10 were women, with an average age of 26 years (from 14 to 59 years). Indications for surgery were pneumothorax recurrence (59 patients), contralateral occurrence (13), bilateral pneumothorax (one) and haemopneumothorax (two). Prolonged air leakage for more than 2 days was observed in 58 patients. We used the tissue-welding technology and an original bipolar hand-piece for bullae electroablation and lung sealing. Conventional apical pleural abrasion was carried out in all cases. Chest tubes were removed 48 h postoperatively by protocol. RESULTS: Intra-operatively, emphysema-like changes and blebs under 1cm were seen in 29 patients (22%) and bullae of 1-2 cm in 48 patients (36%); in 56 cases (42%) the size of bullae exceeded 2 cm. In all cases, lung sealing was achieved by tissue welding alone, without using staplers, sutures, glues and sealants. The operating time depended on the presence of adhesions and the number of bullae, but did not exceed 65 min. Postoperative air leakage for 1-6 days was observed in six patients. Neither mortality nor major morbidity was observed. There were seven recurrences (5.2%). CONCLUSIONS: The tissue-welding procedure is easy to perform through VATS and is efficient for ablation of bullae of any size. Leak-proof sealing is achieved, allowing us to repair the pulmonary-pleural fistula, thus being a non-resectional alternative to wedge resection. No conventional wound-closing devices are needed.