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Background Wartime injuries contribute to the global burden of mortality as a major public health threat. Early access to healthcare improves the quality of life of war-injured patients. The patterns of trauma care and its outcomes in war-injured patients have not been documented in conflict-affected regions of the Democratic Republic of Congo, where political crisis and civil unrest lasted more than two decades. This paper describes the pathway to care, referral patterns and treatment outcomes of war-injured patients treated at the Provincial Hospital of North Kivu (PHNK) during the January 2025 crisis in Goma. Methods This retrospective observational study identified 239 war-injured patients admitted at the PHNK between 25th January and 31st March 2025. The study gathered information on patient demographics (age, sex, marital status, and religion), time interval between trauma occurrence and hospital admission, mode of admission, injury patterns (mechanism, site, and type), first medical aid at the trauma site, severity of injury and outcomes (mortality, length of hospital stay, and postoperative infection). Descriptive analyses performed with Stata 15.0 were summarized as proportions, medians or means and standard deviation. Results Most war-injured patients admitted at the PHNK were male (82.3%), single (52.2%), and aged 18–49 years (76.3%). These patients were self-referred (87.1%), did not benefit from first medical aid at trauma sites (86.7%), and had a time interval ranging from 6 to 24 h between trauma occurrence and hospital admission (37.4%). Debridement was performed in 54.4% of cases. Tetanus immunization was administered to 15.9% of war-injured patients, whereas 13% benefited from physiotherapy. Only 7.1% of cases benefited from psychological management. The overall mortality rate was 4.4% (11 patients), with 9 deaths occurring within 48 h from admission. The mean length of hospital stay was 14 days, whereas 8% of war-injured patients had a postoperative infection. Conclusion These results show the delays in care, self-referral and mortality in war-injured patients in the context of limited resources and conflict. The results call for feasible interventions within a context of high violence such as that of the Democratic Republic of Congo, aiming at strengthening the health system and enhancing community-level capacities to improve the quality of life of war-wounded individuals in conflict zones. This study also shows that a robust health system can deliver an effective response to acute crises if it is equipped with sufficient technical capacity, well-trained staff, essential medicines, and strong organizational structures.

Combat casualty care has advanced significantly with the implementation of evidence-based protocols designed to lower combat-related mortality. Over the last decade, two major urban conflicts in southern Israel have challenged the evolving military trauma system. This study aimed to assess differences in prehospital care and compare the outcomes of aeromedically evacuated casualties from the 2014 and 2023 conflicts. This retrospective registry-based cohort study utilized records from the Military Airborne Combat Evacuation Unit (MACEU) and the Israeli National Trauma Registry. Eligible patients evacuated by MACEU between 07.17.14 and 08.16.14 and between 10.27.23 and 03.17.24 were compared. Ground-evacuated casualties were excluded. Demographics, prehospital interventions, and clinical outcomes were compared. During the 2014 conflict, 251 patients were evacuated alive, compared to 940 in 2023. Both conflicts involved mostly young males injured by explosions, with comparable injury distributions across body regions. The time from injury to hospital arrival decreased from 65 min (IQR 47–94) in 2014 to 60 min (IQR 47–180) in 2023 (d = 0.5, p < 0.001). The proportion of severely injured patients (ISS ≥ 16) increased from 18.3 % to 25.2 % (OR 1.5 [95 % CI 1.06–2.14], p = 0.03), and critically injured patients (ISS ≥ 25) from 7.6 % to 12.8 % (OR 1.79 [95 % CI 1.08–2.96], p = 0.03). Prehospital advanced airway interventions and tube thoracostomies decreased from 11.6 % to 6.0 % (OR 0.48 [95 % CI 0.30–0.76], p < 0.001) and from 7.0 % to 2.1 % (OR 0.28 [95 % CI 0.15–0.54], p < 0.001), respectively. Prehospital blood transfusions use increased from 6.6 % to 16.4 % (OR 2.78 [95 % CI 1.64–4.76], p < 0.001). In-hospital mortality rates remained stable (2.7 % vs. 2.5 %, OR 1.12 [95 % CI 0.44–2.81], p = 0.99). Although not statistically significant, lower mortality rates were recorded among the severely (13.0 % vs. 8.4 %, OR 0.61 [95 % CI 0.23–1.61, p = 0.48) and critically injured (26.3 % vs. 15.8 %, OR 0.53 [95 % CI 0.17–1.64], p = 0.32). Over the past decade, there has been a decline in prehospital airway interventions and thoracostomies, coupled with an increase in early blood transfusions. Despite greater injury severity, mortality rates have remained stable. Although not statistically significant, lower mortality rates were recorded among the severely and critically injured. These findings support the “less is more” approach in modern prehospital combat casualty care.

Background Haemorrhage remains the leading cause of preventable death in modern armed conflict, affecting both combatants and civilians. Recent conflicts—particularly the ongoing conflict in Ukraine— have highlighted the increasing complexity of battlefield injuries, characterised by hybrid warfare, disrupted evacuation chains, and delayed access to definitive surgical care. These realities challenge traditional trauma paradigms, such as the “Golden Hour” and demand adaptation of haemorrhage control and resuscitation strategies to austere environment. Content This narrative review synthesizes current practices and emerging innovations in the initial management of haemorrhagic shock in combat. Immediate haemorrhage control techniques—such as tourniquets, pelvic binders, direct vessel clamping, and external or endovascular aortic occlusion—are examined for their tactical relevance and impact on survival. The review underscores the role of haemostatic dressings and both topical and injectable haemostatic agents in controlling non-compressible bleeding. Damage control resuscitation centres on early administration of blood products in a 1:1:1 ratio or when available, low‑titer group O whole blood (LTOWB), combined with permissive hypotension and prevention of hypothermia. Whole blood and LTOWB are now routinely used by several armed forces, particularly the US and French armies, simplifying logistics and improving haemostatic efficacy during prehospital and tactical resuscitation. In cases of major haemorrhage, a transfusion protocol can be facilitated by novel products, such as leucocyte-depleted whole blood and freeze-dried blood products. Tranexamic acid, when administered within the first three hours after injury, halves mortality in massively transfused casualties, consistent with major international guidelines. Operational innovations address evacuation delays: forward damage-control surgery by lightweight Role 1/2 teams; drone delivery of blood components and medicines over distances from short range to>100 km, depending on platform capability and regulatory clearance; and prototype drone platforms for casualty evacuation (CASEVAC). Advanced technologies—such as closed-loop fluid systems, digital-twin physiology models, and AI-assisted triage—are poised to standardise care and reduce cognitive load for providers in austere settings. Conclusion The integration of haemorrhage control, targeted resuscitation, and logistical innovation defines the modern approach to managing war-related haemorrhagic shock. While challenges remain in evidence generation and field implementation, emerging practices—grounded in operational experience—are progressively improving survival. Ongoing investment in research, training, and technological adaptation will be essential to reducing preventable deaths on future battlefields.

Background In the complex landscape of modern warfare, understanding combat-related injuries leading to hospitalization is crucial for optimizing injury treatment. This study aims to compare combat casualty characteristics and outcomes during the major conflicts between Israel and Hamas in 2023 and 2014 as a basis for understanding the effectiveness of trauma care practices for wounded soldiers. Methods A cohort study of soldiers hospitalized due to combat injuries during two major wars between Israel and Hamas in 2023 and 2014, using data from the Israeli National Trauma Registry. This study did not include deaths before hospital arrival or casualties who were discharged from the Emergency Department. Results Of the 1,198 study subjects, 67.8% belonged to the 2023 cohort and 32.2% to the 2014 cohort. The percentage of casualties with severe and critical injuries (Injury Severity Score [ISS] 16–75) was higher among the 2023 cohort (18.6% vs. 13.7%, p  = 0.036), as was the percentage of casualties with multiple severe injuries (≥ 2 regions with Abbreviated Injury Score ≥ 3: 11.5% vs. 7.5%, p  = 0.035) and firearm injuries (19.6% vs. 14.5%, p  = 0.081). Injuries to the torso and extremities were more frequent among the 2023 cohort. Among the critically injured casualties (ISS 25–75), the mortality rates were 17.3% vs. 28.6%, respectively, for the 2023 and 2014 cohorts ( p  = 0.351); adjusted HR (95% CI): 0.56 (0.21–1.49). The 2023 cohort had higher rates for treatment in the trauma bay (61.5% vs. 47.9%, p  < 0.001), ICU utilization (admission: 16.3% vs 11.7%, p  = 0.036), surgical intervention (51.5% vs. 42.7%, p  = 0.005), longer duration from arrival to surgery (median [interquartile range]: 4.6 (1.2–18.5) vs. 2.6 (1.1–10.1) hours, p  = 0.037), and longer hospital stays (> 14 days: 15.5% vs. 8.8%, p  < 0.001). Conclusions Our data demonstrated that more casualties who survived to hospital arrival were severely and multiply injured in the 2023 Israel-Hamas war as compared to the 2014 war. Despite the increased severity, in-hospital survival did not worsen though there was an increase in hospital resource utilization.

The Lviv Military Medical Centre is the main hospital responsible for the management of wounded military personnel in Western Ukraine. Since the full-scale invasion of our country in 2022, we have had to rapidly adapt our department to managing a large influx of complex facial battle injuries. These wounds are generally from large explosive fragments such as from shells and commonly produce avulsive defects of the facial bones and overlying soft tissues. Using representative cases, we aim to discuss management of these extensive injuries and guide the future direction of our service, particularly in surgical training such as microvascular anastomosis.

Recent reclassification of the Klebsiella genus to include Klebsiella variicola , and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K . variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009–2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K . variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K . pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K . pneumoniae , 10 (4%) were K . variicola , and 6 (3%) were K . quasipneumoniae . Five K . variicola isolates were associated with infections. Compared to K . pneumoniae , infecting K . variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K . variicola isolates demonstrated the hypermucoviscosity phenotype. Although K . variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K . variicola and clarify its clinical significance in larger prospective studies.

Sally McCarthy, president of the International Federation for Emergency Medicine, stated the importance of reiterating the Founda-tion's condemnation of attacks against health-care workers during conflict “because recent experiences demonstrate less hesitancy in attacking healthcare workers”. Jarno Habicht, WHO representative in Ukraine and head of the WHO Country Office in Ukraine says that they have verified one incident of an attack on health-care facilities, on Feb 24, when a hospital came under heavy weapons attack, killing four people and injuring ten, including six health-care workers in Vuhledar, in the Donetska region. “Hospitals as well as health-care workers during a time of conflict are protected under the First Geneva Convention.

Patients with combat wounds and injuries, presented as extensive infected and purulent defects with antibiotic‐resistant microflora, were treated in a surgical inpatient setting. Closure of extensive soft tissue defects of the limbs is possible using methods of plastic and reconstructive surgery and requires preoperative infection control. The lack of effect from preoperative treatment for purulent limb defects with antibiotic‐resistant microflora leads to limb amputation. This clinical study proposes a method of treatment by hyperbaric oxygenation with an ozone‐containing steam–water mixture as an anti‐bacterial agent. Eighteen male patients, aged between 20 and 60 years, were categorised into three groups based on the time elapsed since the injury. All patients were treated using the proposed method. The high effectiveness of the proposed method was demonstrated in all groups and resulted in saving limbs from amputation, establishing suitable conditions for closing the soft tissue defects of the limbs and achieving significant progress in the recovery. Highlights The method of hyperbaric oxygenation using an ozone‐containing steam‐water mixture to treat combat wounds infected with resistant microflora showed promising results. Six 40‐60‐minute HO‐OM procedures totally stopped the growth of pathogenic microflora. The histological examination of biopsies revealed bundles of horizontally oriented fibroblasts, vascularized loose fibrous connective tissue, and the formation of collagen fibre bundles at the base of the wounds after the treatment course. The HO‐OM procedure proves to be an effective modality for preparing patients with large, infected limb defects for plastic and reconstructive surgeries, offering a viable alternative to amputation of wounded limbs.

Background Extremity vascular injuries are among the most challenging problems in military surgery. They are frequently accompanied by extensive soft tissue loss and heavy contamination, which increases the risk of infection and limb loss. Although negative pressure wound therapy (NPWT) is widely used in civilian practice, its role in combat vascular injuries remains unclear. The war in Ukraine provided an opportunity to evaluate NPWT as part of staged surgical care under modern battlefield conditions. Methods We retrospectively reviewed 85 service members with severe combat-related extremity vascular injuries admitted to a Role IV facility in 2022. Among these patients, 69/85 (81.2%) had extensive soft-tissue defects overlying vascular reconstructions and received NPWT; this subgroup constituted the analytic cohort. A standardised two-layer NPWT technique was used: an inner nonadherent barrier/PVA sponge directly over the reconstruction site and an outer polyurethane foam connected to continuous –70 to –80 mmHg. The dressing was changed every 3–4 days. The outcomes included infectious complications, erosion-related bleeding, arterial thrombosis, secondary amputation, the method of definitive wound closure, and the length of stay. Results The mechanisms of injury were mine blast (71%), gunshot (23%), and other explosive trauma (6%). Combined arterial–venous injuries occurred in 40% ( n  = 28/69), fractures in 42% ( n  = 29/69), and primary wound contamination in 57% ( n  = 39/69) of the patients. Definitive closure was achieved by primary approximation in 75.4% ( n  = 52/69), skin grafting in 17.4% ( n  = 12/69), and flap techniques in 4.3% ( n  = 3/69). Complications occurred in 27.5% ( n  = 19/69): erosion-related bleeding (13%, n  = 9/69), arterial thrombosis (8.7%, n  = 6/69), and infection (5.8%, n  = 4/69). Erosion-related bleeding clustered in two risk windows: days 7–10 and 18–30. Secondary amputation was required in 2.9% ( n  = 2/69); in-hospital mortality was 0%. Conclusions A two-layer NPWT protocol at –70 to –80 mmHg was a safe and effective adjunct in the staged management of combat-related extremity vascular injuries with extensive soft-tissue defects. This approach is associated with the preservation of vascular reconstructions and limbs, low infection and amputation rates, the mitigation of erosion-related bleeding, and timely wound closure. Prospective multicenter studies are needed to optimise and standardise NPWT protocols in this setting.

Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.