BACKGROUND The evolving warfare tactics used by near-peer adversaries are expected to increase the incidence of severe extremity injuries and delayed evacuations. Initial reports from combat in Ukraine suggest high complication rates associated with prolonged tourniquet use. This study aimed to evaluate the systemic effects of limb reperfusion following tourniquet application lasting 4 hours or more in patients with isolated extremity injuries. Patients were treated according to an evidence-based protocol designed to mitigate ischemia-reperfusion injuries. METHODS This retrospective review was conducted at a forward surgical facility in Ukraine during combat operations from May 2023 to February 2024. Patients with tourniquets in place for at least 4 hours were included, while those with contraindications to limb salvage or significant confounding injuries were excluded. Short-term outcomes assessed included limb salvage, organ failure, and survival rates. RESULTS Of the 1,945 casualties screened, 90 (4.6%) met the inclusion criteria. After excluding 16 patients, outcomes were analyzed for 74 males, with an average age of 41.6 ± 8.5 years and a mean tourniquet duration of 7.1 ± 2.9 hours. Among these, 19 patients (25.67%) had vascular injuries, and compartment syndrome was present in all cases. Hemodialysis was required for 58 patients (70.8%), while 27 (36.3%) needed a delayed limb amputation, and 5 patients (6.7%) died. Patients requiring dialysis underwent an average of 3 ± 2 sessions to recover kidney function. Longer tourniquet times increased the need for dialysis, which increased the likelihood of patient death. CONCLUSION We used a standardized ischemia-reperfusion algorithm to reduce the systemic effects of ischemia and reperfusion during attempts to salvage limbs following 4 hours or more of tourniquet time. Preliminary outcomes indicate that survival is probable, kidney function may improve with brief periods of dialysis, and limb salvage is possible in most cases. LEVEL OF EVIDENCE Retrospective Cohort Study; Level V. Export

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14–2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06–1.93), and decreased PaO₂/FiO₂ ratio (p = 0.001, OR = 0.56 95% CI 0.41–0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO₂/FiO₂ <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO₂/FiO₂, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

BACKGROUND. The era of coronavirus disease (COVID-19) set the such task for lung ultrasound (LUS): to identify the presence of COVID-pneumonia, its differential diagnosis with other conditions which characterized by interstitial edema, determining the severity of lung damage and its location, the dynamics of pulmonary changes tissue, the development of complications, as well as to assess the effectiveness of personalized therapy. OBJECTIVE. To develop a national LUS protocol for COVID-19 based on a balance of completeness of information with the optimal minimum of time and effort for medical staff, who often do not specialize in ultrasound using, with ultrasound equipment of basic and middle classes. MATERIALS AND METHODS. A total of 1576 patients with COVID-19 were examined. There were 810 women (51.4 %) and 766 men (48.6 %). The age of the examined patients was in the range of 18-83 years, the average age was 52.3±14.6 years. 4710 LUS were performed, of which 1572 were repeated and 3144 – in the dynamics. Polysystemic ultrasound was performed in 275 patients. Ultrasound devices of both domestic and foreign production were used: Soneus P7 (Ultrasine, Ukraine), HandyUsound (Ukraine), Xario, USAP-770A (Toshiba, Japan), GE Venue (General Electric, USA) and TE7 COVID (Mindray, China) with ultrasound probes of convex, linear and microconvex formats. RESULTS. Summarizing our own experience with patients with COVID-19 in 2020-2021, we have developed a version of the LUS-protocol, which has a convenient form of recording all stages of ultrasound with maximum coverage of the entire volume of both lungs according to a clear algorithm, a graphical form, clear ultrasound semiotics and diagnostic scoring criteria for the severity of lung damage. CONCLUSIONS. 1. Clinical data indicate the feasibility and effectiveness of using LUS for dynamic monitoring of patients with pneumonia caused by SARS-CoV-2, especially in oxygen-dependent patients at their bedside (POCUS principle). 2. Optimization of the use of radiological diagnostic methods due to ultrasound makes it possible to reduce the radiation dose of the patient.3. The use of LUS allows more adequate decision-making on the need for intensive and interventional therapy, leads to faster diagnosis, improved medical care, reduced length of stay of patients in ICU, as well as reducing the total cost of treatment.4. Ability to reduce the impact of SARS-CoV-2 on healthcare professionals by limiting physical contact with the patient. 5. The standardized Ukrainian protocol of LUS provides availability, efficiency and clear interpretation of the received data at its use by different doctors in different medical institutions. The integration of the protocol in to the ultrasound machine provides optimization of the workflow process.

Background: Combat-related lower extremity injuries frequently require prolonged tourniquet application to control life-threatening hemorrhage. Although effective for hemorrhage control, prolonged ischemia followed by reperfusion substantially increases the risk of rhabdomyolysis, acute kidney injury (AKI), limb loss, and mortality. The optimal timing of anti-rhabdomyolysis infusion therapy in relation to tourniquet release remains uncertain. Methods: This retrospective single-center cohort study analyzed 120 Ukrainian military casualties with combat-related lower extremity injuries requiring prolonged tourniquet application and subsequent surgical management, including fasciotomy and tourniquet release. Patients were divided into two groups based on infusion strategy: standard therapy initiated after tourniquet release and early anti-rhabdomyolysis infusion therapy initiated before tourniquet removal during the ischemic phase. Primary outcomes included dialysis-requiring AKI, limb amputation, and death. Multivariable logistic regression models were adjusted for baseline physiological severity, including shock index at admission and baseline acid–base status. Model performance was evaluated using the Akaike Information Criterion (AIC) and receiver operating characteristic (ROC) analysis. Propensity score–based inverse probability of treatment weighting (IPTW) was applied as a sensitivity analysis. Results: After adjustment, early infusion therapy was independently associated with lower rates of dialysis-requiring AKI (adjusted odds ratio [OR] 0.33; 95% confidence interval [CI] 0.13–0.84; p = 0.020), limb amputation (OR 0.32; 95% CI 0.11–0.95; p = 0.040), and mortality (OR 0.23; 95% CI 0.07–0.77; p = 0.017). Adjusted models demonstrated good discriminative ability, with areas under the ROC curve of 0.813 for AKI, 0.838 for amputation, and 0.823 for mortality. Sensitivity analyses using IPTW yielded consistent results. Conclusions: In combat-related lower extremity injuries requiring prolonged tourniquet application, early initiation of anti-rhabdomyolysis infusion therapy prior to reperfusion is associated with significantly reduced risks of severe AKI, limb loss, and death. These findings suggest that preventive renal-protective strategies initiated before tourniquet release may improve outcomes in high-risk military trauma settings and warrant further prospective investigation.

Background. Oral anticoagulants used in clinical practice in atrial fibrillation, deep vein thrombosis, pulmonary embolism (PE), as well as in heart valves protesis, heart thrombosis. Warfarin is the medicine with the largest evidence base and a long history of use more than 70 years. The optimal anticoagulant effect of warfarin is INR from 2,0-3,0 with 70% of measurements (TTR 70%). In one case there is a risk of ischemic stroke in non-compliance, in another - bleeding. Although cutaneous manifestations are rare, however, warfarin-induced skin necrosis is extremely dangerous. Present`s clinical case of progressive venous thromboembolism on the background of anticoagulant therapy in a 64-year-old woman with comorbid pathology. The described clinical, laboratory and instrumental data, that confirmed thrombotic and thromboembolic complications, which were ineffective in relation to the traditional anticoagulant strategy. Aim: to describe a clinical case and analyze the challenges in diagnosing and treatment of progressive venous thromboembolism in a patient with concomitant diabetus mellitus type 2, obese,cirrhosis of liver , ineffective anticoagulants and developing warfarin skin necrosis. Materials and methods. The article presents the clinical case of pulmonary embolism, progressive venous thromboembolism in a 64- year -old woman with concomitant diabetus mellitus type 2, obese,cirrhosis of liver that was observed in IUC in the Hospital” Medbud’. Results. A 64-year-old woman, was hospitalized in the therapeutic department of «Medbud» with a previous diagnosis of cirrhosis of the liver unknown etiology, Child-Pugh class A, hepatolienal syndrome, articular and hemorrhagic syndrome, de novo diabetus mellitus of type 2, paroxysmal atrial fibrillation tachisystolic variant. Preliminarily prescribed dabigatran without “bridge therapy”at a dose of 150 mg twice a day every other day on the recommendation of a gastroenterologist. Suspected pulmonary embolism made adjustments to treatment and anticoagulant therapy was switched from NOAC to UFH, then to LMWH with the addition of warfarin. There was progression of venous thromboembolism in the upper and lower limbs with the appearance of warfarin skin necrosis. Conclusion. Thus, cumulative influence of start therapy dabigatran without bridge heparin therapy, disturbance dabigatran regimes and drug interaction with glucocorticoids, postinjection phlebitis, liver disease, thrombocytopenia and hypothetical insufficiency antithrombin-III, protein C had influenced on progressive venous thromboembolism on background diabetus mellitus type 2, obese. Warfarin-induced skin necrosis is rare complication, but is often dangerous. In the absence of protein C, antithrombin – III, if possible, consider an alternative anticoagulant. The failures of anticoagulant therapy are not only associated with delays in its appointment, switching of anticoagulants, but also taking into account the drug interaction, concomitant pathology, the choice of the optimal drug and the prediction of its adverse effects.

Introduction and relevance: Penetrating neck trauma results in a 10% mortality rate for patients and management can be challenging, often requiring a multidisciplinary approach. Methods: This is a case report of a 33-year-old male patient who received a neck gunshot through the oral cavity during close combat on the south front of the Ukrainian-Russian war in January 2023. Clinical discussion: A CT scan revealed a foreign body in the neck on the right side, between the mastoid process and the right jaw angle. A CT scan with contrast revealed a foreign body in the neck – a bullet – and helped with observing relations to surrounding tissues and following the bullet’s trajectory. The multidisciplinary team performed surgery for foreign body removal. As a first step, carotid arteries and the internal jugular vein were dissected and looped to control potential bleeding. The bullet was 7.62 caliber. The patient recovered well with minimal postoperative complications, including hypoglossal and facial nerve neuropathy, which resolved in two weeks. Conclusion: The proximity gunshot resulted in unexpectedly moderate tissue injury, but regardless of the relatively low destruction of palate tissue, the location of the foreign body near carotid arteries made the surgery approach challenging.