Diagnosis and treatment of combat-related mine-explosive chest trauma at the forefront of medical evacuation in a civilian hospital: a single-center retrospective observational study

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BACKGROUND

In contemporary armed conflict, blast injury has increasingly become prevalent not only in active combat zones but also far from them, and represents the leading cause of combat casualties, substantially exceeding the incidence of injuries from small arms [1]. Mine-blast wounds result from the combined effects of several injurious mechanisms: the primary blast wave, jets of flame and hot gases, secondary fragmentation (shrapnel), and fluctuations in atmospheric pressure and acoustic waves (barotrauma) [2]. Chest injuries constitute a substantial proportion of all combat trauma and carry a mortality rate classified as “preventable” or “potentially preventable,” wherein the casualty’s survival is directly contingent upon the speed and quality of medical care delivered. For this reason, the management of combat chest trauma has been the subject of extensive investigation, and the actions of military medical personnel are strictly regulated in many armies worldwide (Fig.1). The nature of combat operations directly influences the pattern and severity of wounds, which may vary considerably across time and location [3–4].

 

Fig. 1. Critical exposure zones (“critical windows”) in body armor and illustrative examples of associated thoracic and abdominal injuries. a, the dotted arrows indicate the probable directions of the trajectories of shrapnel wounds; b, the entrance wound of a thoracoabdominal wound with a rupture of the diaphragm and translocation of the stomach into the left hemithorax; c, a tangential wound from a shell fragment fired from a tank that passed under the body armor of a soldier who was lying on the ground; d, a «typical» entrance wound of a shrapnel wound located along the anterior axillary line. This illustration reflects the authors’ clinical experience in treating wounded patients; it was produced with the aid of AI-based visualization tools.

 

Military operations in Kursk Oblast in 2024 were characterized by the intensive deployment by the opposing force of a broad arsenal of modern heavy-fire rocket and artillery systems of NATO-member state manufacture. Significant casualties were inflicted by silent lightweight 60 mm mortars, whose absence of audible warning precluded personnel from seeking cover in time. The use of unmanned aerial vehicles and artillery complicated the timely evacuation of the wounded to medical facilities. Under these conditions, the capacity to deliver early specialized surgical care in civilian hospitals located in close proximity to the line of contact assumed particular importance.

The consolidated FMBA detachment commenced delivery of specialized surgical care at Medical Unit No. 125 in Kurchatov within the first hours of the opposing force’s incursion into Kursk Oblast. A substantial proportion of the detachment comprised specialists from the Federal Scientific and Clinical Center (FSCC) of the FMBA of Russia. In the present study, we analyzed our institutional experience in managing modern combat chest trauma at forward stages of medical evacuation within a civilian hospital setting.

Aim: To characterize, through retrospective analysis, a cohort of patients sustaining combat chest trauma from modern weaponry, and to compare the immediate outcomes of two surgical management strategies—comprehensive care (Early Total Care) and minimally sufficient surgical care (Early Appropriate Care)—in a civilian hospital in close proximity to the line of engagement.

METHODS

Study Design

A retrospective analysis was performed of approaches to the management of patients with mine-blast chest wounds, based on data from the consolidated detachment of the Federal Scientific and Clinical Center of the FMBA of Russia that participated in the care of casualties at Medical Unit No. 125 of the FMBA of Russia (Kurchatov, Kursk Oblast)

Eligibility Criteria

Inclusion criteria. The study included 304 military personnel of the Russian Federation who sustained mine blast chest trauma and were hospitalized at Medical Unit No. 125 in Kurchatov.

Exclusion criteria. The study excluded military personnel who sustained gunshot wounds (which constituted a small proportion of cases) or chest injuries of other origins; those with minor concussive lung injuries (without a consolidated lesion); and patients for whom medical documentation lacked information sufficient to assess the nature of the injury.

Intervention

Triage of casualties was performed by the most experienced medical team in the emergency department of Medical Unit No. 125, based on information regarding prior care (including care delivered at the forward medical group level), physical examination findings, results of expert-level diagnostic imaging, and laboratory investigations.

Patient routing within the medical facility was standardized and implemented following an initial assessment of injury severity and identification of the primary lesion. Indications for multi-slice computed tomography (MSCT) included direct or indirect evidence of blast wave exposure and the presence of shrapnel entry wounds in the trunk region. The study was performed using a 64-slice GE «REVOLUTION EVO» computed tomography scanner (USA).

Anesthetic Management

All operative procedures were performed under total intravenous anesthesia with multimodal analgesia (intravenous ketoprofen, dexamethasone, and lidocaine). Induction and maintenance of anesthesia employed combinations of intravenous agents selected according to hemodynamic status: ketamine or propofol in combination with fentanyl and rocuronium. In patients with complicated chest trauma (pneumothorax, hemothorax), mechanical ventilation was conducted according to a “lung-protective” strategy (Table 1). Double-lumen endotracheal intubation was used for thoracotomy procedures.

 

Table 1

Parameters of Lung-Protective Mechanical Ventilation

Parameter	Target Value	Rationale
Tidal volume (VT)	4–6 ml/kg IBW	Reduction of volutrauma and barotrauma
Peak inspiratory pressure (PIP)	<25–30 cmH2O	Reduction of barotrauma
Plateau pressure (Pplat)	<27 cmH2O	—
PEEP	Individualized titration	Prevention of atelectasis
FiO2	Minimum to achieve SpO2 90–94%	—
Permissive hypercapnia	PaCO2 45–55 mmHg	—
Respiratory rate	14–18 breaths/min	Titrated to CO2 level

Note. PEEP, positive end-expiratory pressure; IBW, ideal body weight; SpO₂, oxygen saturation; PaCO₂, partial pressure of carbon dioxide in arterial blood; VT, tidal volume; «—» not applicable.

 

Norepinephrine was used as a vasopressor, initiated at 0.05 µg/kg/min. Prior to receipt of complete blood count results obtained at admission, an infusion of crystalloid-colloid combination was administered with monitoring of acid–base status. Following receipt of laboratory results, transfusion of packed red blood cells and fresh frozen plasma was indicated in patients with hemodynamic instability, massive blood loss (>30% of circulating blood volume), or hemoglobin level below 70 g/L, taking into account estimated blood loss.

Surgical Strategy

During the first six weeks of operation, indications for thoracotomy included massive pulmonary destruction on CT imaging accompanied by pneumohemothorax. Subsequently, management of all penetrating lung injuries was initiated with large-bore silicone tube drainage, and thoracotomy was reserved for patients with an initial drain output ≥1500 mL, or ongoing hemorrhage at a rate of ≥250 mL/hour for two consecutive hours.

Pleural drainage was performed in the 4th or 5th intercostal space along the anterior or mid-axillary line, using a silicone drain with an internal diameter of no less than 8 mm/24 Fr (for pneumothorax) or 9.3 mm/28 Fr (for hemothorax), connected to a Bülau underwater seal drainage system (with active suction as required) or to a Heimlich one-way valve in cases of small-volume hemothorax or hemopneumothorax (up to 500 mL). Where MSCT evidence indicated inadequate drain function, replacement drainage was performed. The drainage output was monitored over time, with assessment of both the volume and the nature of the drained fluid.

When thoracotomy was indicated, the operating team invariably comprised an anesthesiologist-intensivist, thoracic surgeon, general surgeon, scrub nurse, and anesthetic nurse. Anterolateral thoracotomy was performed through the 5th intercostal space. For parenchymal bleeding from a small-caliber defect, the lung parenchyma was sutured with Vicryl 2-0; for peripheral (“mantle”) wounds in the absence of a major bleeding vessel at the wound base, atypical (wedge) resection was performed using a linear cutting stapler. For wounds at the hilum or involving major lobar vessels or bronchi, a “fissure-less” lobectomy was performed: the hilar structures were divided first—vessels using a linear cutting stapler (or double-ligated with Nylon and Prolene 2-0 suture in the absence of a stapler), and the bronchus was divided with a linear cutting stapler (or closed by the Overholt technique with Prolene 3-0 in the absence of a stapler). The integrity of parenchymal and bronchial suture lines was verified by “bubble test” following reconnection of the non-ventilated lung with elevation of peak pressure to 35 mmHg. The procedure was concluded upon achievement of complete hemostasis and aerostasis.

Pleural cavity drainage was performed according to the following technique: an 8-mm silicone drain was inserted into the 7th or 8th intercostal space along the anterior or mid-axillary line, passing through the costodiaphragmatic recess into the pleural cupula. The drain was secured to the skin with a size 1 nylon suture and connected to a glass drainage bottle.

Wound closure was carried out in layers: the ribs were approximated using 3–4 looped PDS 1 sutures; the muscles were closed with a continuous suture using Vicryl 1; the subcutaneous fat was closed with a continuous Vicryl 0 or 2-0 suture; and the skin was closed with interrupted simple sutures using 3-0 nylon. An aseptic dressing impregnated with iodopiron solution was applied.

Surgical interventions to address concomitant injuries were performed as clinically indicated by trauma and orthopedic surgeons, abdominal surgeons, neurosurgeons, and urologists.

After completion of the surgery at the L4–L6 level, an epidural catheter was placed by the anesthesiologist, with administration of 200 mL of 0.2% ropivacaine via an infusion pump.

Given the specifics of total intravenous anesthesia, patients remained on mechanical ventilation and were transferred to the intensive care unit under the supervision of the anesthesiologist and thoracic surgeon for subsequent emergence from anesthesia.

All patients received antibiotic prophylaxis with third- or fourth-generation cephalosporins. In cases of penetrating wounds, tetanus prophylaxis was administered (0.5 mL tetanus toxoid).

It should be noted that all surgical procedures were performed under conditions of simultaneous mass influx of casualties. Given the availability of multiple operating rooms and surgical teams, no delays in performing the interventions occurred. Intraoperative photographs were not obtained due to the lack of available personnel capable of taking them.

Statistical Analysis

Categorical data are presented as absolute frequencies and proportions; continuous data are presented as means with standard deviations. Comparison of categorical parameters was performed using the chi-squared test; continuous variables were compared using the Mann–Whitney U test (SPSS version 26.0). Statistical significance was defined as p ≤0.05.

RESULTS

Sample Characteristics

Over the five-month study period, 6,571 patients were admitted for all causes (combat wounds, burns and frostbite, non-combat injuries, and diseases.). Gunshot wounds (from small arms) to the chest occurred in only 3 patients (0.045%). Combat mine-blast chest trauma was diagnosed in 304 patients (4.6% of all admissions): 187 (2.8%) sustained penetrating mine-blast chest wounds; 117 sustained non-penetrating mine-blast chest trauma with pulmonary contusion. Patients with penetrating injuries were divided into two subgroups: the first subgroup (n=88) received full-scale surgical management in accordance with the Early Total Care (ETC) principle; the second subgroup (n=99) was managed using the minimally sufficient surgical approach, Early Appropriate Care (EAC) (Supplement 1).

Performance of multi-slice CT for diagnostic purposes. In patients with entry wounds in the trunk region, combined chest and abdominal injuries were always suspected, and multislice computed tomography (MSCT) of the chest, abdomen, and pelvis was performed. If esophageal or laryngeal trauma was suspected, an endoscopic examination was carried out. MSCT verification of shrapnel injuries to the lung was usually straightforward (Fig. 2).

 

Fig. 2. MSCT-image of penetrating mine-explosive wounds of the lung. a, b, wound channels are clearly visible, the area of pulmonary contusion around the channel develops over time (begins to increase after 6 hours) and will depend on the duration of the injury (see discussion); c, traumatic avulsion of the right upper limb with destruction of tissues of the anterior chest wall. The figure is prepared by the authors using their own data.

 

MSCT imaging in patients with lung contusion demonstrated the following key patterns: сonfluent consolidation, typically located in the peripheral lung zones; ground-glass opacities, appearing as diffuse, heterogeneous areas of increased attenuation; these correspond to interstitial edema and hemorrhage; а “bat-wing” or “butterfly” configuration, characterized by symmetrical centripetal spread with relative sparing of the perihilar regions; аssociated pleural abnormalities, including hemothorax (fluid density of 30–70 HU) and/or pneumothorax (Fig. 3).

 

Fig. 3. Blast injury of the lung. a, b, unilateral pulmonary contusion in a patient with traumatic avulsion of the right upper limb; c, d, bilateral contusion, behind armor blunt trauma (BABT) of the lung—“bat wing” / “butterfly”.

 

All penetrating chest injuries were accompanied by pulmonary contusion, however, the severity of the contusion depended on the time elapsed since the injury and was maximal 24–48 hours after trauma. In contrast, changes were less clearly visualized within the first 6 hours post-injury.

In the initial 5-week period of the FMBA team’s deployment, emergency thoracotomy was indicated for penetrating shrapnel injuries of the lung when associated with a substantial hemothorax (>700–800 mL) and marked destructive lung changes on MSCT.

The management strategy was later modified: thoracotomy was then performed if MSCT revealed hemothorax >1500 mL or if there was persistent intrapleural hemorrhage, defined as a chest tube output exceeding 250 mL/h for 2 consecutive hours.

Figs. 4–6 illustrate selected cases with commentary on the scope of surgical intervention.

 

Fig. 4. Thoracoabdominal shrapnel wound, accompanied by a wound to the lower lobe of the left lung, rupture of the diaphragm, wound to the spleen, wound to the stomach with its translocation into the cavity of the left hemithorax. The figure is prepared by the authors using their own data. The chest CT included sagittal reconstruction (a), axial view (b), and 3D reconstruction (c). Key findings were: (1) the projectile’s trajectory with development of pulmonary contusion; (2) translocation of the stomach into the thorax through a diaphragmatic defect; and (3) a shrapnel fragment measuring up to 2 cm, situated directly over the spleen. The patient underwent extensive combined surgery: laparotomy with splenectomy, repair of the diaphragmatic defect, and closure of a gastric wound in the middle third of the stomach, followed by left anterolateral thoracotomy, pleural debridement, and left lower lobectomy. Notably, under the revised protocol applied in the second operational phase of the FMBA team, such a clinical and imaging pattern would have warranted only abdominal intervention and pleural drainage, without resection of the lung.

 

Fig. 5. Computed tomography of a patient with bilateral lung damage. MSCT of the thoracic organs. a, axial image; b, coronal CT image. In the parenchyma of the upper lobe of the left lung, there is a track with hemorrhagic impregnation and areas of rupture. In the pleural cavity, there are up to 1700 ml of blood and free gas. In the right pleural cavity, there is a small pneumothorax, with a volume of up to 130 ml. In the parenchyma of the upper lobe of the right lung, there is a contusion zone along the wound channel, which passes through the entire thickness of the lobe from front to back to a fragment in the posterior segment of the 8th rib on the right. There is air in the soft tissues of the left half of the chest and neck. The following operation was performed: lateral thoracotomy on the right and left, evacuation of hemothorax on the right and left, suturing of wounds of the lower lobe of the right lung and the upper lobe of the left lung, suturing of the wound of the hemiazygos vein, stopping of intrapleural bleeding, drainage of the right and left pleural cavities; During the second phase of the combined team’s work, the right thoracotomy would have been abandoned, limiting itself to drainage of the right pleural cavity. A left thoracotomy would have been performed in any case.

 

Fig. 6. Computed tomography of a patient with a right lung injury requiring thoracotomy. MSCT of the thoracic organs. a, axial view; b, coronal reconstruction. Right-sided hemopneumothorax, volume up to 1800 mL. The right lung is collapsed. Surgical intervention: right lateral thoracotomy; suturing of wounds in the upper and lower lobes of the right lung; control of intrapleural hemorrhage; debridement and drainage of the right pleural cavity.

 

Among the study cohort, 57 patients (30.4%) with penetrating chest trauma had undergone chest drainage at earlier stages of management. Redrainage was necessary in 26 of these patients (45.6%), primarily due to suboptimal drainage efficacy. Key contributing factors included the use of undersized drainage tubes (diameter <8–9 mm) and the adaptation of intravenous-system connectors to extend narrow tubes—both of which predisposed to clot-induced occlusion.

Additional technical issues arose from excessive insertion depth: the drain would kink and impinge on the left hemidiaphragm, resulting in loss of function (Fig. 7).

 

Fig. 7. An example of drainage being installed at an excessive depth, as a result of which the drainage did not function adequately. Drainage is indicated by arrows.

 

Primary outcomes

The two subgroups of patients with penetrating chest wounds were statistically comparable with respect to injury severity and hemothorax volume (p=0.55). No resuscitative thoracotomies were performed.

In Subgroup I, 36 thoracotomies (41%) were performed: in 7 cases (7.9% of patients; 19% of thoracotomies), strict indications were present (immediate drain output >1500 mL, or drain output ≥250 mL/hour for 2 hours); in the remaining 29 cases (33% of patients; 81% of thoracotomies), the indication was extensive CT-demonstrated pulmonary destruction. Among these, parenchymal suture repair was performed in 9 patients (25% of thoracotomies), atypical resection in 13 (36%), and lobectomy in 13 (36%). In one patient, no pulmonary procedure was required; intraoperative exploration revealed an azygos vein injury, which was repaired by vascular suture.

In Subgroup II, only 3 thoracotomies (3%) were performed, all on strict indications: parenchymal suture repair in 2 patients, atypical resection in 1. No lobectomies were performed.

Thoracotomy performed according to strict criteria was more frequent in the first subgroup, although the observed difference did not reach statistical significance (7.9% versus 3%, p=0.123).

Thoracotomy was a time-consuming procedure, with an average duration of 160–200 minutes. This is notably longer compared to surgeries on other body regions, which typically last no more than 90 minutes.

Rethoracotomy due to ongoing bleeding was required in one patient (2.7%) in the first subgroup; no cases of rethoracotomy were observed in the second subgroup.

A satisfactory clinical outcome was achieved in all patients. This included maintenance of adequate oxygen saturation without respiratory support, stable hemodynamics with no evidence of persistent bleeding, complete lung re-expansion, and absence of mediastinal shift on control chest X-ray. Patients were transferred to the next care level while in stable condition. Notably, the average time to evacuation differed between subgroups: it was 28.1±2.5 hours in the first group versus 22.4±1.2 hours in the second, a difference that reached statistical significance (p=0.03).

Importantly, there were no in-hospital deaths in either subgroup.

DISCUSSION

Combat chest trauma represents one of the leading causes of death among military personnel in contemporary armed conflict [1, 5]. While military surgeons devote considerable attention to optimizing surgical management strategies for chest injuries, civilian physicians—even thoracic surgeons—are generally unfamiliar with the specific features of this pathology. A team of authors from the Main Military Clinical Hospital of the National Guard Troops [6], having reviewed the literature available as of 2025, concluded that the mortality rate in combat chest trauma remains at a relatively high level. This underscores the need to improve diagnostic and treatment approaches. Our team also encountered the challenges associated with the diagnosis and treatment of combat chest trauma. In the very first hours after the emergency situation arose in the Kursk Region in August 2024, a medical team comprising physicians and nurses from the Federal State Budgetary Institution “Federal Research and Clinical Center” of the FMBA of Russia was deployed to provide specialized care to the wounded and injured at the Medical Unit No. 125 in Kurchatov. The surgeons encountered combat surgical trauma, which they had never faced in their routine clinical practice. Severe changes observed on MSCT in cases of penetrating mine-blast chest injuries, coupled with the imperative to avoid diagnostic errors and not overlook critically important injuries, naturally led to a more aggressive management approach. Initially, it seemed intuitive that the optimal scope of care provided by a qualified thoracic surgeon in a well-equipped hospital would be a single-stage surgical correction of all injuries.

The concept of immediate comprehensive care— Early Total Care (ETC)—was previously widely used. However, experience gained in major trauma centers during peacetime has demonstrated the existence of three peaks of mortality (the “trimodal mortality curve”): the first two occur within the earliest hours and days after injury, whereas the third peak emerges at 3–4 weeks post-trauma and is associated with multiple organ failure and sepsis [7–8]. A combat injury is not merely a local tissue injury but the onset of a systemic pathological process affecting all organs and systems of the body—a condition referred to as traumatic disease [9]. Within the first minutes after injury, there is a release of a complex of endogenous molecules— damage-associated molecular patterns (DAMPs) [10–11]. A sterile systemic inflammation develops, accompanied by the emergence of two syndromes: the systemic inflammatory response syndrome (SIRS) and the compensatory anti-inflammatory response syndrome (CARS) [12]. Activation of the sympathoadrenal and hypothalamic-pituitary-adrenal systems occurs, along with the development of acidosis and acute traumatic coagulopathy [13–14]. If the patient survives the early phase, the processes initiated in the body evolve into the persistent inflammation, immunosuppression, and catabolism syndrome (PICS) [15]. The pathogenetic basis of multiple organ dysfunction following trauma—the leading cause of late mortality—is explained by the “two-hit” concept. The first hit is the injury itself; the second hit comprises surgical intervention and uncorrected complications [16]. All of the above formed the basis for the key concept of modern military field surgery: Damage Control Surgery (DCS). This approach implies that only a very limited range of surgical interventions is feasible during the early stages of care. The abbreviated form of treatment has both advantages and disadvantages. For example, experience from previous conflicts has shown that increasing the number of treatment stages is associated with a higher incidence of complications [17–18]. Recent advances in resuscitation and intensive care have made it possible to achieve stabilization of the patient’s condition at the initial stage of traumatic disease. This allows for a reevaluation of the traditionally adopted abbreviated treatment approach and the development of new protocols based on the concept of Early Appropriate Care [19].

Damage Control Surgery (DCS) for chest injuries is less well studied compared to its application in abdominal trauma [20–22]. It is evident that peacetime trauma differs from combat trauma. Furthermore, the nature of the injury is determined by the type of weapon used. No army in the world possesses experience in providing medical care for injuries caused by modern high-energy artillery fire. To better understand the underlying mechanisms of such trauma, we will focus in greater detail on wound ballistics. There are two main damaging factors: the blast wave and primary fragments. Initially, the shock wave from the explosion acts on the body, causing rupture of the alveolar septa and triggering a prolonged inflammatory process. Hemorrhagic consolidation of the most severely affected lung areas develops no earlier than 6 hours post-injury, while the peak of diffuse alveolar damage is observed at 48 hours [23–25]. Subsequently, damage to the microcirculatory bed develops, and, together with the emergence of local infection, this leads to post-traumatic pneumonia. The pathogenesis scheme of mine-blast chest trauma (lung contusion) in armed conflicts involving modern high-energy weapons is presented in Supplement 2.

Following the impact of the blast wave, primary fragments from the artillery shell cause injury. These fragments have an irregular shape and a greater relative drag area compared to a bullet, although they rarely exceed 20 mm in size and, in 40% of cases, measure up to 8 mm. Nevertheless, even these small projectiles carry substantial kinetic energy, which they transfer to the tissues at the wound site, generating a large temporary cavitation cavity. This cavity, under pressure, draws in dirt and other contaminating particles. A fragment with a maximum diameter of up to 8 mm can damage tissues within a radius of 100–125 mm. However, direct destruction of anatomical structures occurs only along the fragment’s immediate trajectory, which accounts for the high incidence of tangential and punctate wounds that are clinically “silent”.

Meanwhile, tissue damage caused by the fragment’s shock wave (microtears, various forms of cell death, and capillary disruption) becomes macroscopically evident only over time [26] (Supplement 3).

Thus, a distinctive feature of modern mine-blast chest injury is the large area of affected tissue. The bulk of this tissue remains in a state of active inflammation and sustains all the key syndromes of traumatic disease, which hypothetically should significantly influence the patient’s overall outcome. This raises one of the key dilemmas: is lung resection justified in cases of severe contusion accompanied by tissue destruction and contamination with foreign particles?

One of the key arguments is the theoretical risk of developing post-traumatic necrotizing pneumonia and suppurative complications, which are traditionally associated with high mortality. However, this concern is not supported by the available literature data [27].

According to Levchuk A. L. et al., the group of patients who underwent thoracotomy was the most severely affected: thoracotomy not only failed to prevent the development of suppurative complications but also exacerbated them. In contrast, better outcomes were observed in wounded patients who received sanitation thoracoscopy at the forward treatment stages [28]. Nevertheless, the authors’ experience is too limited to draw definitive conclusions.

The American Tactical Combat Casualty Care Guidelines (TCCCG) stipulate that treatment should begin with chest tube placement. Thoracotomy is indicated in patients with hemothorax and bleeding exceeding 1500 mL or 200 mL/h over a 2-hour period [29]. According to the National Guidelines for Military Field Surgery of the Russian Federation, finger thoracostomy and pleural cavity drainage in the 5th intercostal space along the anterior axillary line are performed in cases of tension pneumothorax. In open pneumothorax, the wound is closed with a double-row suture without suturing the skin, followed by application of an occlusive ointment dressing. Indications for emergency thoracotomy in hemodynamically unstable patients include ongoing intrapleural bleeding. The main signs of such bleeding are: immediate drainage of 1200 mL of blood from the pleural cavity, blood output exceeding 250 mL/h over a 2-hour period, and cardiac tamponade [30].

The transition from one tactical paradigm to another in our study was not associated with a deterioration in short-term outcomes. In the vast majority of cases (97%), pleural cavity drainage was sufficient to stabilize the patient’s condition and prepare them for further evacuation.It is evident that patients undergoing thoracotomy require a longer period of in-hospital observation at the facility where the surgical intervention was performed. Early evacuation in such cases may lead to clinical deterioration. Notably, the delayed evacuation in the first group was also related to the more challenging operational environment in the region during the first month of the study.

Another significant problem in combat chest trauma is blast-induced lung contusion. In patients with combined injuries, if no complications such as pneumothorax or hemothorax were present and respiratory function remained normal, surgery was performed under general anesthesia according to standard protocols. Our analysis revealed that these wounded individuals subsequently required prolonged oxygen support, which delayed their evacuation. These findings correspond to the classical pattern of blast lung injury, in which the peak of respiratory dysfunction occurs at 48 hours. It is difficult to determine whether such a delay in evacuation could have been prevented, as we did not have a control group. Moreover, blunt chest trauma was typically observed in the most severely injured patients, who also had traumatic brain injury, traumatic amputations of the extremities, injuries to the major limb vessels, and penetrating abdominal wounds. However, the likelihood of additional ventilator-induced lung injury appears to be quite real [31]. We did not encounter cases of the most dangerous variant of this complication—air embolism—but this potential complication should be kept in mind. For extremity injuries, regional anesthesia techniques should be preferred. If mechanical ventilation is unavoidable, it should be delivered in a “protective” mode, as we previously described in the “Methods” section.

As a result of the study, we have optimized the algorithm for providing care to wounded patients with combat chest trauma (Supplement 4). This algorithm is based on our own clinical experience, in which the majority of casualties were delivered more than 6 hours after the injury. This timing influences the structure of the incoming flow of wounded patients: in the absence of critical injuries, the effects of blast trauma and the course of traumatic disease are already evident. The patients’ condition tends to be more severe but relatively stable compared to the first hours after injury.

The algorithm is based on three key vectors: 1—assessment of the patient’s hemodynamic stability or instability; 2—evaluation of the presence of complications associated with combat chest trauma (pneumothorax, hemothorax, or their combination), 3—exclusion of a thoracoabdominal injury pattern in cases of penetrating chest wounds.

The most common types of thoracic injuries are pneumohemothorax and pulmonary contusion. In our analyzed material, there were no or virtually no casualties with thoracic injury variants associated with the highest mortality rates: cardiac tamponade, major vessel injury, esophageal perforation, tracheobronchial injuries, and flail chest. Since we lack experience in managing such injuries, they were not included in the final algorithm. It is likely that casualties with such injuries are unable to tolerate an evacuation period exceeding 6 hours, which in fact served as the main criterion for patient selection in the present study. Management of this most severely injured group remains the responsibility of forward medical teams, who operate under exceptional conditions, with minimal equipment, and at direct personal risk [32]. At the same time, we consider it essential to include resuscitative thoracotomy in our algorithm as a last-resort measure for moribund casualties with extremely unstable hemodynamics and/or cardiac arrest (although we did not encounter such patients in our cohort).

Most studies evaluating abbreviated surgical care at early stages have been conducted in patients with civilian trauma or low-energy combat mine-blast injuries, demonstrating considerable heterogeneity of outcomes [22, 33, 34]. The value of our study lies in the analysis of immediate treatment outcomes in military personnel who sustained combat mine-blast injuries caused by modern high-energy weapons.

Study Limitations

The principal limitation of this study is the absence of outcome data beyond hospital discharge, owing to patient evacuation; accordingly, postoperative complication rates and in-hospital mortality beyond the forward stage could not be calculated. In the absence of long-term outcome data, the primary question of how surgical strategy selection affects clinical outcome and delayed mortality remains unresolved.

CONCLUSIONS

A minimally sufficient surgical strategy for modern mine-blast chest trauma—consisting of initial pleural drainage and thoracotomy reserved for strict indications—does not result in deterioration of immediate outcomes at the forward care stage, but does enable a significant reduction in time spent in the front-line hospital. Deferring thoracotomy reduces the operational burden on the operating theater and intensive care unit.

Additional information

Supplement 1. Characteristics of injuries in patients with combat chest trauma, volumes of interventions performed and indications for surgical interventions.

doi: 10.17816/clinpract713711-4418933

Supplement 2. Algorithm for providing medical care to wounded with combat chest trauma at the stage of qualified/specialized surgical care in a civilian medical facility near the combat area.

doi: 10.17816/clinpract713711-4418935

Supplement 3. Pathogenesis of mine-explosive lung contusion.

doi: 10.17816/clinpract713711-4418937

Supplement 4. Wound ballistics of high-energy fragmentation wounds.

doi: 10.17816/clinpract713711-4418938

Author contributions: A.V. Smirnov, general concept, collection and analysis of material, writing the article, preparing illustrations, editing, direct treatment of the wounded; A.A. Keshvedinova, collection and analysis of material, writing the article, discussion of the material, editing; V.Yu. Gritsun, E.A. Epifantsev, I.L. Anyushin, treatment of the wounded and participation in the collection and discussion of material; E.A. Velichko, participation in the analysis of material, editing; V.N. Lesnyak, T.V. Klypa, analysis and discussion of material; N.A. Soloviev, Yu.V. Ivanov, A.V. Troitsky, general supervision and participation in the discussion of the material. All authors approved the manuscript (the version for publication), and also agreed to be accountable for all aspects of the work, ensuring proper consideration and resolution of questions related to the accuracy and integrity of any part of it.

Acknowledgments: The authors express deep gratitude to the entire team and seconded staff of the Medical and Sanitary Unit No. 125 for their crucial role in providing care to the wounded. We especially wish to thank R.N. Dolgikh for his exceptional support in organizing and coordinating surgical services. Special thanks are also due to M.V. Khruslov for his significant organizational contribution and assistance with data collection; and to the physicians of the consolidated FMBA of Russia team — A.A. Ilyin, M.N. Kukaev, M.S. Shidakov, An.V. Smirnov, S.N. Svetikov, P.V. Konyukhov, and Yu.A. Rakovskaya — for their assistance in caring for the injured.

Ethics approval: The authors declare that ethics committee approval was not required, as the study involved analysis of anonymized medical records (archival data) and did not include direct participation of human subjects.

Funding source: State Assignment of the Federal Medical and Biological Agency of Russia (FMBA of Russia).

Disclosure of interests: The authors declare no conflicts of interest related to this publication.

Statement of originality: When conducting the research and creating this article, the authors did not use previously obtained and published information.

Data availability statement: The authors report that all data is presented in the article and/or its appendices.

Generative AI: During manuscript preparation, the authors employed generative AI for the preparation of Supplement 2–4 and for editing the English translation of the article. Following use of this tool, the authors reviewed and revised both the figures and the manuscript text, and assume full responsibility for its content.

About the authors

Alexander V. Smirnov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Author for correspondence.
Email: smirnov.av@fnkc-fmba.ru
ORCID iD: 0000-0003-3897-8306
SPIN-code: 5619-1151

MD, PhD, Assistant Professor

Russian Federation, Moscow

Aishe A. Keshvedinova

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: aishe1998@mail.ru
ORCID iD: 0000-0002-0045-2715
SPIN-code: 1577-0901

MD

Russian Federation, Moscow

Ivan L. Anyushin

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: Myneo@yandex.ru
ORCID iD: 0009-0001-9109-1440
SPIN-code: 4108-9305

MD

Russian Federation, Moscow

Vladimir Yu. Gritsun

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: ords1313@gmail.com
ORCID iD: 0000-0001-7647-9853
SPIN-code: 7007-2611
Russian Federation, Moscow

Evgeny A. Epifantsev

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: Epifantsev.e@gmail.com
ORCID iD: 0000-0001-9768-7440
SPIN-code: 1820-2153

MD, PhD

Russian Federation, Moscow

Evgeny A. Velichko

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: velichko_eugen@mail.ru
ORCID iD: 0000-0002-0297-8155
SPIN-code: 9817-2850

MD, PhD, Assistant Professor

Russian Federation, Moscow

Viktor N. Lesnyak

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: lesnyak_kb83@mail.ru
ORCID iD: 0000-0002-2739-0649
SPIN-code: 5483-3113

MD, PhD

Russian Federation, Moscow

Iraida A. Demina

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: ir7demi@yandex.ru
ORCID iD: 0009-0004-7637-7899
Russian Federation, Moscow

Tatiana V. Klypa

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: tvklypa@gmail.com
ORCID iD: 0000-0002-2732-967X
SPIN-code: 2349-8980

MD, PhD, Assistant Professor

Russian Federation, Moscow

Nikolay A. Soloviev

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: my_docs@mail.ru
ORCID iD: 0000-0001-9760-289X
SPIN-code: 8024-7220

MD, PhD

Russian Federation, Moscow

Yury V. Ivanov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: ivanovkb83@yandex.ru
ORCID iD: 0000-0001-6209-4194
SPIN-code: 3240-4335

MD, PhD, Professor

Russian Federation, Moscow

Aleksandr V. Troitskiy

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: dr.troitskiy@gmail.com
ORCID iD: 0000-0003-2143-8696
SPIN-code: 2670-6662

MD, PhD, Professor

Russian Federation, Moscow

References

Supplementary files