Ballistic thoracoabdominal injury: Analysis of recent military experience in Afghanistan

Background: Military surgery has seen the arrival of the critical care provision and cross-sectional imaging enjoyed by civilian trauma surgeons. Ballistic injury to the thoracoabdominal region is uncommon but potentially devastating. The aim of this study was to analyze recent military experience of managing this injury complex. Methods: The study is a retrospective analysis of patients, admitted over a 12-month period, to the British Military Hospital in Afghanistan with ballistic thoracoabdominal injuries. Results: In total, 27 patients sustained combined thoracoabdominal injury with a mean new injury severity score of 29 ± 12, revised trauma score of 5.94 ± 2.93 and predicted survival of 71.1% ± 39.1%. In all, 20 (74%) patients underwent immediate operation, and 7 (26%) were initially managed nonoperatively. Of those requiring surgery, 11 required laparotomy and tube thoracostomy, and 9 required thoraco-laparotomy. Of the seven casualties who were initially observed and/or further investigated, two required laparotomy following computed tomography scanning, and five were managed conservatively, two of whom required delayed surgery. There were nine fatalities, all within 16 days of being wounded. Four patients died from exsanguination, one from a traumatic brain injury, and four from multiorgan failure. Five patients presented with cardiac arrest, two of whom survived. Conclusions: Exploration remains the default treatment. Resuscitative thoracotomy may yield unexpected survivors, even if subsequent laparotomy is required. Nonoperative management appears to be feasible in a small proportion of patients but requires careful selection supported by cross-sectional imaging.