High-velocity gunshot chest trauma: tailoring patient care through insights from a mass casualty experience

This study describes the management strategies and clinical outcomes of a cohort of patients sustaining high-velocity military rifle gunshot wounds to the thorax during a mass casualty incident (MCI). The analysis focuses on damage control surgical techniques, the incidence and timeline of venous thromboembolism (VTE), regional pain management, and early psychiatric protocols.

A descriptive retrospective analysis was conducted on patients presenting with a single penetrating high-velocity ballistic wound to the thorax on October 7, 2023. Inclusion criteria were limited to patients with a projectile trajectory traversing the lung parenchyma, managed by the cardiothoracic surgery department. Injuries to immediately adjacent structures (subclavian vessels, brachial plexus, clavicle, and scapula) were recorded as associated injuries. Patients presenting with multi-system trauma involving entirely separate, distant anatomical regions were excluded.

The cohort comprised 11 male patients (age range: 19-49 years; 9 soldiers, 2 civilians) injured by 7.62 mm assault rifle rounds. Six patients (54.5%) required emergency thoracotomy, sternotomy, or VATS within the first 24 h due to ongoing hemorrhage; primary hemorrhage control consisted of deep parenchymal lung suturing (n = 5) and temporary chest packing (n = 1). Four patients (36.4%) underwent delayed, elective surgical stabilization of rib fractures. All patients survived to discharge and were successfully weaned from mechanical ventilation, with no cases of ARDS, pneumonia, or oxygen requirement at discharge. Venous thromboembolism occurred in 45.5% (n = 5), including deep vein thrombosis (n = 3) and pulmonary embolism (n = 2). Ipsilateral brachial plexus injury was present in 63.6% (n = 7), occurring exclusively in patients wearing ballistic protective vests. At 3-month follow-up, 4 patients had persistent upper limb neuropathy and 1 reported chronic post-thoracotomy pain. Mean hospital length of stay was 15.27 days (range: 2-41).

Lung-preserving, suture-based damage control strategies were effective for hemorrhage control during this mass casualty surge and supported rapid operative management in a resource-constrained setting. A high incidence of VTE (45.5%) was observed, including pulmonary embolism without documented lower-extremity deep vein thrombosis, supporting the need for early post-stabilization diagnostic surveillance. Brachial plexus injury was common among patients wearing ballistic protection and was associated with long-term functional impairment in this cohort.