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The purpose of the study: to study the clinical and epidemiological aspects of severe trauma (polytrauma), accompanied by shock and (or) coma, in military personnel in peacetime.Material and methods. During the period 2015–2021, 280 cases of severe trauma were studied in servicemen who were initially hospitalized in medical or military medical organizations of the zone of territorial medical responsibility of the Western Military District of the Russian Defense Ministry. Polytrauma (ISS≥18 points, “Berlin Definition”) was recorded in 137 cases (48.9%). 252 victims (90.0%) were subsequently evacuated to higher-level trauma centers for medical, tactical and organizational reasons. Statistical processing of information and analytical work were carried out with the help of the original trauma register.Results and discussion. In the structure of the causes of severe trauma (traumogenesis) military personnel in peacetime, as well as in the whole of the Russian Federation, were dominated by traffic accidents. The injury structure д. was dominated by injury without severe leading damage (max AIS=2 points). The most severe and unfavorable in prognostic terms were injuries of two or more anatomical areas; injuries with leading damage to soft tissues and breast organs. In general, compliance with the principles of primary routing of victims with mechanical injuries was noted, the proportion of victims with polytrauma taken to level 3 trauma centers is minimal. More than half of the victims (52.1%) are initially taken to trauma centers after hours, when their medical and diagnostic resources are limited. During the initial delivery to military medical organizations, military personnel are more often delivered to level 3 trauma centers. Victims with an ISS index of less than 18 points were taken to trauma centers of all levels in approximately equal proportions. The proportion of polytrauma victims taken to level 3 trauma centers was minimal. Inter-hospital transportation of victims from level 3 trauma centers was carried out on average 27 hours earlier than from level 2 trauma centers.Conclusions. Timely inter-hospital transportation of victims with polytrauma increased their chances of a favorable outcome. When studying the problem of severe trauma, the trauma register allows you to conduct high-quality analytical work. The problem of timeliness of inter-hospital transportation for medical and tactical indications is still relevant, especially in the central area of medical responsibility of the Western Military District.

INTRODUCTION. An increase of quality improvement program for severe polytrauma hypotensive patients is associated with new techniques of “endovascular resuscitation” of which resuscitative endovascular balloon occlusion of the aorta (REBOA) to be the most widespread and effective. OBJECTIVE. Treatment outcomes after damage control resuscitation and endovascular resuscitation strategies were evaluated in comparison between Russian and “foreign” cohorts. MATERIALS AND METHODS. A retrospective and propensity score matched analysis was performed to compare Russian (n = 24) and foreign (n = 241) cohorts of extremely severely injured trauma patients (in extremis) admitted to trauma centers during the period of 2013–2020. All hemodynamically unstable trauma patients admitted in shock, with signs of systemic hypoperfusion and non-compressible torso hemorrhage, were enrolled into the study. RESULTS. In average, REBOA was performed 22 minutes after admission in both groups. In most cases (65–75 %), occlusion of the thoracic aorta was performed, what resulted in a significant increase of blood pressure by 40–50 mm Hg from baseline and allowed temporary hemodynamic stabilization to initiate surgery and blood replacement therapy. Early fluid and blood replacement therapy was significantly different between groups. Total volume of fluid and blood replacement therapy was significantly higher in the foreign group (p = 0.001), mostly due to blood components: red packed blood cells and platelets (p < 0.05 before and after REBOA). No colloids were infused in the foreign group at all (p < 0.001). Early blood transfusion was found to improve survival until 50 % (95% CI, 43–56 %) (р = 0.002). CONCLUSIONS. REBOA seems to be an effective adjunct for temporary hemodynamic stabilization of extremely severe injured patients, but its effectiveness is likely to be defined by quality and quantity of infusion and transfusion strategy as well as by intensive care in whole.

Objective: substantiate the criteria for choosing a method for inter-hospital transportation of patients with severe trauma for the territorial system of medical support for the troops of the Western Military District.Materials and methods. We studied 121 cases of inter-hospital transportation of patients with severe trauma in the territorial system of medical support for the troops of the Western Military District for the period 2015–2020. The time of inter-hospital transportation of patients by an ambulance car of class C and by helicopter was studied at various distances between medical organizations: up to 70 km, from 70 to 200 km, more than 200 km.Results and discussion. At distances between medical organizations of more than 200 km, the average time of medical aviation evacuation of patients with severe injuries by helicopter was 176±35 minutes, and the average time of medical evacuation of patients in a class C ambulance was 290±43 minutes (p=0,04). When the distance between medical organizations is less than 200 km, the average time of medical aviation evacuation of patients with severe trauma by helicopter was 126±43 minutes, and the average time of medical evacuation of patients in a class C ambulance was 137±37 minutes (p=0,85).Conclusions. The main factor in choosing a method for carrying out inter-hospital transportation of patients with severe trauma in the territorial system of medical support for the troops of the Western Military District is the distance between medical organizations. It is advisable to plan medical aviation evacuation of patients with severe trauma by helicopter when the distance between medical organizations is more than 200 km.

The final reconstructive treatment of complex pelvic injury in a patient with combined trauma in the acute period of traumatic disease is presented. Indirect reposition, limited access, stable functional osteosynthesis were performed, which allowed to obtain a good anatomical and functional outcome.

The biography of colonel of Medical Corps, professor Georgiy Nicolaevich Tsibuliak (19322020) is presented. In 1956 G.N. Tsibuliak graduated from the Kirov Military Academy being awarded with gold medal. When being a cadet, he got actively engaged in research. In 1961 G.N. Tsibuliak defended candidates dissertation on the injury treatment in casualties damaged by ionizing radiation, took part in the study of multiple injuries occurring in atomic tests. After graduating from the medical residency he stayed in War Surgery department of the Academy, was eventually assigned as a senior lecturer, the head of the research laboratory carrying out the study of shock and terminal state. In1966 he defended a doctorate in pathogenesis, clinical findings and treatment of tetanus. G.N. Tsibuliak became one of the leading advocates for the concept of traumatic shock in individuals. This fact that at present emergency physicians and surgeons dealing with traumatic shock consider to be an axiom, is scientifically based, and was gained through hard routine work in treating severely injured casualties. From 1976 to 1982 Georgiy Nicolaevich was Surgeon-in-Chief in Group of Soviet Forces in Germany. In 19901993 he was in charge of research laboratory dealing with combat surgical trauma in the Academy. Since 1993 G.N. Tsibuliak had retired from active duty, holding the position of a professor at the War Surgery department. He is the author of more than 200 scientific papers, including 7 monographs. G.N. Tsibuliak was closest associate of A.N. Berkutov in studying traumatic shock in casualties, took an active part in formation of a new clinical specialty resuscitation.

On the 2nd of August, 2020 marked the 100th anniversary of the birth of the famous Russian surgeon, the Head of War Surgery department of the Academy, professor, Major-General of the Medical Corps Ilia Ivanovich Deriabin. I.I. Deriabin was the participant of the Great Patriotic War and the war against militarist Japan, the warfare in Afghanistan, the first postwar postgraduate fellow under professor S.I.Banaitis, a student and associate professor of A.N. Bercutov, an officer working many years at War Surgery department, Kirov Military Medical Academy. I.I. Deriabin was also the Head Surgeon to the Group of Soviet Forces in Germany, the founding principal of War Surgery department at the Military Medical faculty, Moscow Central Institute for Advanced Medical Education, Deputy Chief Surgeon of the Soviet Army. In the history of military medicine professor I.I. Deriabin will stay as a great scientist and organizer in the field of War Surgery, a founder of traumatic disease tactical treatment concept, the author of the idea of medical-transport immobilization (anticipating popular modern tactics Damage Control). He also came up with an idea of an improvised frame for unstable pelvic fracture immobilization, developed the technique of peritoneal dialysis (in cooperation with M.N. Lizanets and E.V. Chernov), devised (coauthored with A.C. Rozhkov) multicomponent anti-inflammatory local wound blockade for injury control and septic complications prevention.

Currently, explosive trauma is rare in peacetime injury surgery, but is of great importance in the work of surgeons. This is due to damage of a large number of anatomical areas, various damaging factors of the explosion and the simultaneous entering of several victims. The results of forensic medical examinations of 24 corpses of people who died as a result of terrorist acts in the subway of Minsk on 11/04/2011 and St. Petersburg on 03/04/2017 were analyzed. Incompatible with life injuries as the immediate cause of death were found only in 33,3% of cases. Profuse blood loss was the immediate cause of death in 66,7% of those killed. The most common (in 87,5% cases) cause of profuse blood loss was internal bleeding: in 7 (50%) cases - due to damage to organs and large vessels of the chest, in 6 (42,9%) cases - due to combined damage to the anatomical structures of the chest and abdomen, in 1 (7,1%) case - due to damage to the parenchymal organs of the abdominal cavity and retroperitoneal space. The leading role in thanatogenesis during the considered explosive peacetime injuries was occupied by blood loss, its specific gravity was 66,7%. Profuse blood loss in 87,5% of cases was due to damage to the organs of the chest and abdomen. Potentially salvable were 7 (29,2%) dead who received damage to the main vessels of the limbs, damage to internal organs without injuring the heart and large blood vessels. Thus, the development of new ways to stop intracavitary bleeding at the advanced stages of medical care for victims with explosive injuries and injuries is a priority aim.

Battlefield lethality remains the most underexplored problem from the surgical point of view. 540 battle­field fatalities during the military operation in the North Caucasus region of Russia (1994–1996) were ana­lyzed. It was found that 25.4% of all “Killed In Action” refer to the group of potentially survivable. Common causes of combat death in this group were prolonged hemorrhage (78.1%), tension pneumothorax (19.0%), and hemopneumothorax (2.9%). Reducing mortality can be attained due to introduction of new means of control for life-threatening consequences of injuries, improving tactical evacuation, as well as training mili­tary personnel in providing combat lifesaver care.

Traumatic shock is considered to be the most common clinical form of a severe patient’s condition (63%). Timely and adequate blood volume resuscitation is one of the most important procedures in providing medical care to critically injured casualties and patients at the forward medical evacuation stage. The key to this problem, especially when the infusion therapy is needed at the pre-hospital stage, is the development of alternative (extravascular) techniques of plasma volume expander administration. The article presents the results of testing of the first domestic medical devices for intraosseous infusion in critically injured casualties and patients. At present, on commission of the Russian Ministry of Defense and with the scientific support of Kirov Military Medical Academy, domestic enterprises developed test samples of medical devices to provide intraosseous infusions: a «Disposable device for intraosseous infusion of solutions if there is no intravenous access, which was designed on the basis of a spring drive» - the index «VKI-P», developed by limited liability company «Novoplast-М» and a set for intraosseous infusion using an electric drive - the index « VKI-E», developed by limited liability company «Research engineering company «Spetsproekt». Assessment of performance of test samples of the medical devices for intraosseous infusions «VKI-P» and «VKI-E» was carried out using pathophysiologic model of traumatic shock in 14 experimental animals (pigs) by creating artificial blood loss of medium severity, 25% of circulating blood volume (in average 440 ml), followed by its resuscitation with intraosseous infusion of 0,9% solution of NaCl. As a result of the performed tests it was found that the device «VKI-P» and the set «VKI-E» provide for NaCl infusion in major vessels (with an intraosseous infusion), 750 ml of volume during 45-50 min, and can be used as an alternative access to provide infusion as a part of anti-shock therapy, which solves the problem of volume resuscitation when giving care to severely injured casualties and patients at the forward medical evacuation stages. These samples may be recommended for inclusion into the medical service list of complete supplies and the Medical Corps supply support, the Armed Forces of the Russian Federation.

OBJECTIVE. Clinical efficacy of extraperitoneal pelvic packing for hemostasis was assessed in patients with unstable pelvic ring injuries and signs of unstable hemodynamics. MATERIAL AND METHODS. The results of treatment were analyzed in 19 patients with hemodynamically unstable pelvic ring injuries. Extraperitoneal pelvic packing was applied in order to stop bleeding after mechanical pelvic stabilization. The evaluation of hemostasis efficacy was performed by using computerized helical tomography with intravenous contrast. RESULTS. The extraperitoneal pelvic packing allowed doctors to achieve stop of bleeding in 14 (73,7 %) patients. CONCLUSIONS. Complex of mechanical stabilization and extraperitoneal pelvic packing of damaged pelvic ring could be actively used in cases of severe injuries for victims in critical conditions.

The tactics of blood transfusion therapy provides a significant impact on the course of wound disease but only in those with acute massive blood loss of the extremely severe degree. A proper use of blood transfusions in the post-shock period results in faster relief of the severity and reduces the risk to develop severe sepsis and acute respiratory distress syndrome. One of the most crucial organizational problems in blood transfusion is the issue of blood donation being especially critical in treatment of those with severe traumas since they often require blood transfusions including massive ones. The existing regulatory documents containing indicators and procedures for using blood transfusion media in those with severe traumas are often contradictory and require certain amendments.

The treatment of maxillofacial gunshot wounds in peacetime is an urgent and difficult problem. The emergence of new types of civilian weapons and relatively small current clinical experience does not allow generating recommendations for the treatment of this pathology. It presents a statistical analysis of injuries in St. Petersburg 2004-2014 restricted firearms destruction and experimental study of the harmful effect of these weapons on the fabric maxillofacial experimental animals (pigs). The features of the clinical picture, diagnosis and surgical treatment of wounds of the maxillofacial region, caused by a firearm -restricted lesions and wounds with extensive tissue damage maxillofacial caused a hunting weapon are considered.

The article presents a comparative characteristics of domestic and foreign approaches to the static analysis of losses of surgical profile in military conflicts. The ways of improvements of statistical materials on military losses for improvement of surgical aid delivery are mapped out. The authors proved the need to establish the register of combat trauma.

The authors underwent an analysis of doctrine changes of battle-field surgery. The terminology is specified, the ways of improvement of effectiveness and quality of medical care for the wounded, taking into account the new doctrine, are formulated. In accordance with Federal law No 323-FZ of 2011.11.21 the termreduced specialized care*is suggested for description of medical care at medical forward treatment unit instead of equalfied aid.

The article dedicated to the 85th anniversary of the establishment of the Kirov Military Medical Academy, the first independent department and clinic of field surgery. It describes the work of the department employees who were sent as medical advisers to the so-calledhot spotso in a variety of countries at different times (Kyuss LA., Dolinin V.A., Volikov A.A., Antipenko VS., Kornilov V.A., Felitsyn L.N., Zakurdaev V.E., Chernov E. V., Alekseev A. V and the others).

Use of the tacticts of multistage surgical treatment on the model of combined radiation-and-mechanic injury. The article provides information on the use of the tactics of multistage surgical treatment (MST), which allows increasing survival value in patients with polytrauma. There are no descriptions of possibility of the use of this tactics in case of combined radiation-and-mechanic injuries in available literature. During an experimental research underwent on 25 sheep it was found that in case of MST implementation there is a significant decrease of intraoperative and postoperative lethal outcome in comparison with traditional tactics. In animals, underwent MST, were defined more laudable course of radiation syndrome. Analysis of laboratory peripheral blood indexes allowed making conclusion, that conducting final surgical intervention (3'd stage of MST) during the first 24 hours after abbreviated surgical intervention allows finishing surgical treatment and intensive care before the beginning of acute radiation syndrome and doesn't counter classic recommendations concerning the treatment of combined radiation-and-mechanic injuries.

Pelvic ring stabilization is the basic emergency care measure in unstable pelvic injuries. The purpose of the work was to determine the efficacy of pelvic bandage in patients with unstable pelvic fractures and persistent intrapelvic hemorrhage. Thirty seven patients were divided into 2 groups. In study group (n=19) primary pelvic stabilization was performed using extempore pelvic bandage; in patients from control group (n=18) external fixation devices were applied. Duration of pelvic fixation procedure, hemodynamics and quality of reposition were assessed. Duration of pelvic bandage application was significantly lower than that required for pelvic external fixation - 2.4±0.8 min versus 29±3.2 min. That advantage enabled to use the bandage before the diagnosis was completed and other injuries were eliminated - in 6.0±2.1 min after patient’s admission while the time before the application of external fixation device made up 86.0±5.6 min ( p < 0.001). Application of pelvic bandage enabled to stabilize blood pressure in the course diagnostic and treatment measures. In some cases pelvic roentgenography revealed excessive internal rotation when bandage was applied. So, application of pelvic bandage is a simple, effective, rapid method for temporary pelvic fixation.

Pre-hospital care is one of the most important links in a chain of the military medical tenet. A survival of the most of severe casualties at the scene depends on a good quality and well-timed first aid and paramedic care. Based on the current state of medical equipment and training of the soldiers of the Russian and foreign armies, we summarized the data about the main medical products designed for pre-hospital care, briefly analyzed and compared their effectiveness to the foreign analogues. It is currently obvious, that fundamental changes in First aid kit modification and Medical Bags are warranted according to the reality and soldier's demands in combat operations. Proposals for modernization of military medical equipment were put forward.

The analysis of the frequency, structure and circumstances of the sacrum fractures in 148 patients, as well as evaluated the results of treatment 65 patients using conventional techniques and 83 with multiphase surgical tactic. The use during the first stage of external fixation devices, Ganz pelvic frame and active surgical treatment due to a quick stop the intrapelvic bleeding led to a decrease of the frequency of mortality by 2.6 times. The use of highly informative diagnostic methods and multi-stage surgical treatment in patients with concomitant pelvic injuries have reduced mortality by 1.4 times, the number of physical complications - by 1.6 times, local complications - by 2.4 times, the length of hospital stay - by 1.6 times, the frequency of permanent disablement - up to 28.9%, to restore the ability to work with 76.7% of patients within the first year.

A brief 140-years history of the Mikhailovsky clinical hospital ("Willie Hospital") of the Kirov Military Medical Academy is presented. Today the department of military surgery, integrated into the system of emergency medical care, locates in historical building of the Kirov Military Medical Academy, and considered as part of multi-field regional center for the treatment of severe combined injuries, and is the only one injury care center of the first level in the Ministry of Defence of the Russian Federation. The hospital admits on treatment more that one million of severe injured patients annually; many patients with severe injuries are transferred from other regional hospitals. Every year more than two thousands of surgical interventions are performed in the hospital. Next renovation of the building is planned in the near future; it should provide further development of new medical technologies in the Kirov Military Medical Academy.

Today self-expanding polymers are considered as the most promising as means for intracavitary hemostasis in case of continuing bleeding after trauma. Testing of domestic open-cell polyurethane foam composition "Locus" was carried out on the developed experimental model simulating liver trauma of V degree. After damaging 6 experimental rabbits were injected intraperitoneally with 80 ml of the composition. 5 experimental rabbits were included into to control group (haemostatic agent was not given). Estimated blood loss was 111-124 ml. The two-hour survival rate didn't differ significantly: 3 animals survived in the experimental group; 2 animal survived in the control. Despite the 3-4-fold widening of the foam, due to open cells it absorbed 72.6 +/- 8.3 g of blood. Thus, open-cell polyurethane foam intraperitoneal administration of the composition didn't provide a temporary intra-abdominal hemostasis in liver. In order to enhance the hemostatic effect it requires changing the formulation of the polyurethane composition. For a more accurate assessment of the results it is neccessary to perform additional researches on larger animals.

With the help of tests on 10 big biological objects (sheep) was studied a modern model of severe lateral damage (6 mm diameter) of femoral artery. Within 45 seconds blood loss was 432.5 +/- 258.2 ml. The usage of domestic local hemostatic agent--"Gemostop" based on zeolite and "Gemofleks" based on chitosan. The total three-hour mortality was 50%. Primary hemostasis was recorded only in 20% of biological objects, the final hemostasis in 60%. Thus, the model of standard 6-mm lateral damage of femoral artery with a free primary hemmorage during 45 seconds should be considered as. optimal for evaluating the effectiveness of modern hemostatic agents.

Rapid growth of medical technologies has led to implementation of endovascular methods of diagnosis and treatment into rapidly developing battlefield surgery. This work based on analysing all available current publications generalizes the data on using endovascular surgery in combat vascular injury. During the Korean war (1950-1953) American surgeons for the first time performed endovascular balloon occlusion of the aorta - the first intravascular intervention carried out in a zone of combat operations. Half a century thereafter, with the beginning of the war in Afghanistan (2001) and in Iraq (2003) surgeons of central hospitals of the USA Armed Forces began performing delayed endovascular operations to the wounded. The development of technologies, advent of mobile angiographs made it possible to later on implement high-tech endovascular interventions in a zone of combat operations. At first, more often they performed implantation of cava filters, somewhat afterward - angioembolization of damaged accessory vessels, stenting and endovascular repair of major arteries. The first in the theatre of war endovascular prosthetic repair of the thoracic aorta for severe closed injury was performed in 2008. Russian experience of using endovascular surgery in combat injuries is limited to diagnostic angiography and regional intraarterial perfusion. Despite the advent of stationary angiographs in large hospitals of the RF Ministry of Defence in the early 1990s, endovascular operations for combat vascular injury are casuistic. Foreign experience in active implementation of endovascular technologies to treatment of war-time injuries has substantiated feasibility of using intravascular interventions in tertiary care military hospitals. Carrying out basic training courses on endovascular surgery should become an organic part of preparing multimodality general battlefield surgeons rendering care on the theatre of combat operations.

Taken to supply in the Armed Forces of the Russian Federation and included in the modern regulating documents new sets and medical kits are a crucial element of the complete-standard-issue equipment. For the military unit of medical service provided 12 sets and medical kits united into 2 classification groups. They allow medical service to perform any surgical interventions and medical procedures in the military echelon in accordance with modern approaches to health care and treatment of the wounded in wartime, in armed conflict and the elimination of the health consequences of emergencies in peacetime.

The aim of the given study was development of surgical tactics in case of femoral artery injury, caused by medium-calibre bullet, on the basis acute experiment on large biological objects. Experimental animals were shot into mid third of the femora by a rifle cartridge in 7,62-mm calibre (AK-47 made in 1943). The analysis of microstructure, made in 5 cross-sections performed every 1-centimetre way from the wound canal, showed that there were no any damages of arterial wall. Authors came to conclusion that the surgical debridement of the gunshot wound, made by a rifle cartridge in 7,62-mm calibre of AK-47, should consist of exsection of devitalized section of artery.