The use of explosive ordnance in conflict dates to the utilization of an early form of gunpowder in China during the 11th-century Song dynasty.Reference Andrade1 As civilizations have progressed, so too has the development of more efficient and destructive weapons (e.g., thermobaric and other high-energy explosives). Explosive ordnance inflicts devastating and longstanding consequences on individuals, populations, and societies from physical, psychological, and humanitarian perspectives.Reference Vogel and Dootz2–Reference Novik4 The volume of explosive ordnance used in modern conflicts illustrates the scale of this harm. Tens of thousands of explosive munitions were employed during Operation Iraqi Freedom and Operation Enduring Freedom.Reference Chamberlain5 Airpower statistics released by the US Combined Force Air Component Commander from 2008-2021 showed an annual average of 3672 weapons released.6, 7 Data recorded by Action on Armed Violence (AOAV) in 2021 and 2022 shows that at least 32 136 civilian casualties were reported in 71 countries and territories across the globe by explosive weapons.8 Such data are rarely available for less publicized conflicts in low-resource settings such as Myanmar, Sudan, and the Sahel.9 In addition, improvised explosive devices (IEDs) continue to be utilized routinely in armed conflicts globally.Reference Barker10, 11
One uncommon but potentially devastating consequence of explosive ordnance use is embedded unexploded ordnance (eUXO), when unexploded ordnance (UXO) or UXO components are embedded in the body of a patient.12 This rare event presents extraordinary risks for the patient, medical providers, and scarce health care infrastructure as routine procedures have the potential to initiate the item of eUXO. The management of eUXO even in an open environment (e.g., in situ in a field, road, or open land) under controlled circumstances with personnel trained in explosive ordnance disposal (EOD) is a complex, dangerous and a resource-intensive undertaking. When encountering eUXO during the provision of medical care, the complexity, danger, and required resources are dramatically increased. In many cases, the presence of eUXO cannot be detected in the field and may not be discovered until a patient is already receiving care at a medical facility.12, Reference Oh, Seery and Grabo13
The International Committee of the Red Cross (ICRC) “Removing Embedded Ordnance from Patients”12 and Joint Trauma System Clinical Practice Guideline (JTS) “Unexploded Ordnance Management”,Reference Oh, Seery and Grabo13 provide clinical, technical, and leadership guidance for the management of eUXO. However, to date a structured evaluation of the literature has not been conducted, including comparison of these guidelines to identify areas of concordance, discordance, and need for further research. As the global community struggles to contend with the direct and indirect long-term impacts of the use of explosive ordnance, understanding the scope and limitations of existing evidence on the diagnosis and management of eUXO is critical.
The application of translational science14 (T) can answer the T0 question, “What are trustworthyReference Graham, Mancher and Wolman15 clinical practice guidelines (CPG) to treat eUXO in low-resource environment complex settings, such as humanitarian events and conflict, low- and low-middle income countries, or prolonged transport times?” (Figure 1) The objective of this T1 scoping review is to synthesize available literature relating to the management of eUXO and to identify gaps between existing guidelines. Data extracted from sources obtained by this search can be utilized in the T2 creation of trustworthy clinical practice guidelines utilizing modified Delphi methodology.
Translational Science Framework.
Methods
Investigators used the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) methodology to conduct a scoping review of published peer-reviewed literature and non-peer-reviewed grey literature (e.g., governmental and non-governmental organizations (NGO) reports, conference papers, policy documents).Reference Tricco, Lillie and Zarin16 A pre-review protocol was archived in an open-access platform (Supplemental File 1).17
Search Strategy and Information
A strategy was developed querying databases including PUBMED, EMBASE/Elsevier, CINAHL/EBSCO, Global Index Medicus, Global Health/EBSCO, SCI Expanded/SSCI/AHCL/ESCI and Google Scholar as well as organizational websites of relevant stakeholders noted during the review of sources obtained (e.g., US Department of Defense, ICRC, Geneva International Center for Humanitarian Demining, United Nations Mine Action Service). Targeted keywords and database-specific search terms were used in Boolean search logic combinations. Search strings were developed utilizing structured index terms and database-specific language designed to capture records describing the diagnosis and treatment of eUXO in armed conflict and civilian use of explosive materials (e.g., “UXO”, “ordnance”, “munition”, “explosive”, “bombs”, “Improvised explosive device”, “Rocket Propelled Grenade”, “firework”, “pyrotechnic”) (Supplementary Table 1).
Eligibility Criteria
Investigators expected that the literature relevant to the topic would be limited. Therefore, inclusion criteria were designed to be intentionally broad to capture all potentially relevant evidence. Eligible records included peer-reviewed reports, conference papers, and grey literature that addressed the management of eUXO including all intervention types or outcomes related to this subject (e.g., type(s) of explosive ordnance, detection methods, mitigation strategies, injury patterns, morbidity, mortality). No restriction on publishing date was stipulated given the limited existing data on the topic. All geographic regions and languages were eligible for inclusion. Lastly, both civilian and military patient populations were eligible for inclusion. Peer-reviewed reports or grey literature without full-text availability and literature solely describing eUXO management from a technical EOD standpoint without patient care considerations were excluded.
Data Management
Eligible records identified through the search strategy and inclusion criteria were compiled into Covidence® (https://www.covidence.org). Duplicate records were removed. Each record was reviewed by 2 investigators during title and abstract screening. All potentially eligible full-text reports were reviewed by 2 investigators during full-text screening. Discordance was arbitrated by a senior investigator (HW). Covidence® was used to develop a standardized data extraction form to facilitate uniform data collection from eligible literature. Extracted data included bibliographic details, patient demographics, injury characteristics (e.g., mechanism, involved anatomy, injury severity scores), explosive ordnance specifics (if available), mitigation procedures, diagnostic and therapeutic procedures utilized, patient outcomes, and author recommendations. Existing guidelines (i.e., ICRC and JTS) were analyzed separately through qualitative comparison and narrative synthesis of topic areas covered and recommendations provided.
Results
Results were reported in accordance with PRISMA-ScR guidelines (Figure 2; PRISMA ScR checklist presented in Supplementary Figure 1). Database searches identified 4058 records with 13 additional records identified through grey literature searches and review of reference list of eligible reports. Duplicate records (643) were removed. The remaining 3428 records were screened for relevance of which 3410 were excluded. Of the remaining 18 reports, 5 did not meet eligibility criteria and were excluded (i.e., did not describe the patient population of interest). Therefore, 13 reports were analyzed, representing a total of 90 patients from conflicts ranging from World War II to the US-led wars in Iraq and Afghanistan (Table 1).14, Reference Afshar and Tabrizi18–Reference Waqas, Qasmi and Kiani29 Case reports (n = 10, 76.9%) accounted for the majority of reports included in analysis with one (7.7%) CPG, experimental model, brief report, and retrospective cohort review respectively accounting for the remainder of reports. Most reports (n = 11, 84.6%) presented data on patients treated at military medical facilities, with 3 reports (23.1%) presenting data on patients receiving care at local health facilities.
PRISMA-ScR Diagram.
Summary of peer-reviewed reports included in analysis
Abbreviations: eUXO – embedded unexploded ordnance; IED – improved explosive device; UXO – unexploded ordnance
Geographic Distribution of Included Reports
The US was the geographic location most frequently represented by included reports (n = 6, 46.2%) with all cases involving the use of commercial pyrotechnics. Four reports (30.8%) presented data from the Middle East and North Africa region, and the remaining 4 reports (30.8%) presented data from multiple countries or were not associated with a clearly defined geographic region (e.g., CPGs) (Figure 3).
Geographic distribution of reports included in analysis.
Patient and Injury Characteristics
Demographic reporting was inconsistent across included reports (Table 2). Seven reports (53.8%) provided demographic information (e.g., gender, age) of patients. All reported patients were male with a mean age of 29.7 years (Supplementary Table 2). Reports presenting data from outside the US (n = 8, 61.5%) all reported the involvement of a variety of eUXO. Types of eUXO included grenades, mortars, rockets, and anti-tank weapons. Anatomic regions of injury were presented by all but 1 report (n = 12, 92.3%) (Supplementary Figure 2). Multiple anatomic regions were frequently involved for each patient. The majority were of the injuries were upper extremity (n = 22, 40.7%) and chest injuries (n = 14, 25.9%). Head injuries were next (n = 7, 13.0%), followed by lower extremity injuries (n = 6, 11.1%), face (n = 3, 5.6%), neck (n = 1, 1.9%), and spine (n = 1, 1.9%). No recognized injury severity scores were presented.
Proportion of included peer-reviewed reports presenting data variables of interest
1 Unless otherwise specified.
2 N may be greater than 100% where multiple geographic locations or anatomic locations of injury specified.
Clinical and Other Outcomes
Mortality was reported in 3 reports (23.1% of reports).Reference Clark21, Reference Howell, Sontgerath and Simonet23, Reference Spencer27 Of these cases, 2 presented eUXO encountered during autopsy and the third presented eUXO in an expectant patient. All were deceased at time of eUXO identification. Complications following treatment were presented by 2 reports (15.4%),Reference Bartholomew, Evans and Ahmeti20, Reference Thaut, Murtha and Johnson28 including delay of care venous thromboembolism. Delays to care were associated with prolonged transport times and confusion over appropriate routing of patients with eUXO. For example, 1 patient was transported 244 minutes between a Level IV and Level I trauma center, increasing tourniquet time to 168 minutes.Reference Thaut, Murtha and Johnson28 Patient follow-up after discharge was presented by tw0 reports (15.4%).Reference High and Brywczynski22, Reference Pengelly, Moore and Burgess25 No reports described functional outcomes.
Recommendations
Reports included in the thematic and subthematic analysis generally provided convergent recommendations. Key recommendations included: i) an emphasis on preparedness and safety through training, establishment of standard operating procedures, and inclusion of multidisciplinary subject matter experts; ii) eliminating the use of electrically powered surgical, diagnostic, and other medical equipment when eUXO suspected or identified; and iii) surgeons should consider en bloc resection with eUXO until it is rendered safe (Table 3). All reports discussed safety of prehospital personnel and considerations during patient transport. The need for strategies to identify eUXO early was emphasized, given the complexity of management and need for preparation at the receiving health facility. Cooperation between EOD and surgical teams was also identified as essential for safe eUXO management.
Recommendations and quotes derived from peer-reviewed reports included in analysis
Abbreviations: EOD – explosive ordnance disposal; eUXO – embedded unexploded ordnance; IED – improved explosive device; UXO – unexploded ordnance
Guideline Comparison
The JTS and ICRC CPGs were evaluated for areas of concordance and discordance (Table 4). Areas of discordance were anticipated given the resource variation between a military trauma system with intact echelons of care and humanitarian surgical care in conflict and post-conflict settings or situations encountered by humanitarian demining teams. The ICRC guideline is exclusively directed towards health care professionals, while the JTS guideline is designed for both military and civilian personnel, focusing on the identification, handling, and disposal of eUXO. Safety of health care personnel and preservation of surgical resources and infrastructure is emphasized in both guidelines. ICRC guidance is predominantly focused on medical management of eUXO whereas the JTS provides a broader focus on the management of the entirety of the eUXO incident, including command structures and the engagement of EOD expertise. Clinical management of patients with eUXO ranging from preoperative considerations to surgical techniques is central to the ICRC guideline, which also includes psychological impacts to the patient.
Comparison of ICRC and JTS guidelines on management of embedded UXO
EOD – explosive ordnance disposal; eUXO – embedded unexploded ordnance; ICRC – International Committee of the Red Cross; JTS – Joint Trauma System; UXO – unexploded ordnance
Limitations
This review has several limitations. Limited data exist on the management of eUXO, the majority of which is derived from case reports and expert guidelines. This limited the strength of conclusions that could be drawn from available literature. Nonetheless, this review provides a structured synthesis on the literature regarding management of eUXO to inform further research. Second, data collection and reporting were highly variable, consistent with findings from previous reviews of civilian conflict casualties in low-resource settings.Reference Wild, Stewart and LeBoa30 No centralized trauma registry exists that can be accessed by civilian, military, and international health care providers to inform performance improvement surrounding eUXO incidents. Narrative synthesis was used to present the most robust findings possible within these limitations. This review did not evaluate the immediate or long-term psychological effects on patients and health care personnel associated with eUXO incidents, which fell outside the scope of this review’s objectives. Despite these limitations, the findings of this review may be used to inform further preparedness initiatives and research strengthening the evidence base for guidelines on the management of eUXO in low-resource settings.
Discussion
This review sought to synthesize the best evidence available regarding the management of eUXO to inform decision-making and the evidence base for CPGs on eUXO management in low-resource settings. Several “best practice” themes emerged in this review that discussed the importance of early eUXO identification, multidisciplinary involvement of EOD teams, safety of prehospital personnel, transport and surgical teams, and context-appropriate diagnostic and treatment modalities. Though rare, the potentially fatal consequences of eUXO management affecting both patient and surgical teams warrants dedicated attention. A coordinated approach from personnel representing a variety of clinical and non-clinical specialties is required to safely manage incidents involving eUXO.
Early Detection and Safety
The importance of early eUXO detection was emphasized by numerous reports given the range of technical expertise that must be mobilized to safely and effectively manage such situations.Reference Oh, Seery and Grabo13, Reference Barrow, Kachare and Kachare19, Reference High and Brywczynski22, Reference Howell, Sontgerath and Simonet23 Numerous barriers to early identification exist, particularly in low-resource settings, including lack of access to subject matter experts. In addition, the nature of the environment (e.g., active conflict or other impermissible environment) may not be amenable to early eUXO detection. In many instances, eUXO identification may be delayed until the patient reaches a health facility or trauma care stabilization point.Reference Salio, Pirisi and Bruni31 The delay of eUXO identification until reaching a medical facility effectively transfers the inherent hazard of eUXO to a location with increased risk to a greater number of people, including essential health care personnel, and scarce health care infrastructure. The complexity of these decisions is magnified in low-resource settings where the available health care staff, equipment, and infrastructure may be insufficient to implement existing CPGs. A safe location isolated from surgical facilities in which to manage the patient may not be available in many low-resource settings. Alternative algorithms for eUXO management in environments without established access to EOD teams or higher level of care are required.
Personal safety of prehospital and health facility-based personnel was discussed by all reports included in analysis. Two significant themes include removing all non-essential personnel away from the treatment area and altering or forgoing standard diagnostic and treatment modalities that hold potential to initiate eUXO. Multiple reports recommended establishing a pre-incident relationship with EOD assets to utilize their expertise in training medical, standard operating procedure development, and coordination of an eUXO incident. Based on the findings of this scoping review, the authors recommend having an EOD team as a planning partner when developing organizational response plans and treatment modalities utilizing command and control procedures. Adherence to a pre-determined command structure during eUXO incidents is critical to enable organizational leadership to make difficult and complex decisions. Video-assisted or telemedicine-based consultants spanning clinical treatment, EOD, and command and control are possible adjunct solutions if there is sufficient communication infrastructure and preparation of pre-selected experts to participate in the response.Reference Boyle, Ludy and Meguerdichian32–34
Diagnostic and Treatment Modalities
There was also broad concurrence regarding eliminating the use of powered equipment during the resuscitation and treatment of the patient.Reference Afshar and Tabrizi18, Reference Bartholomew, Evans and Ahmeti20, Reference High and Brywczynski22, Reference Lein, Holcomb, Brill, Hetz and McCrorey24, Reference Thaut, Murtha and Johnson28 Heat, vibration, or static, caused by medical equipment or movement of the patient has the potential to initiate an item of eUXO. This significantly limits the use of diagnostic (e.g., ultrasound, magnetic resonance imaging, computed axial tomography) and standard medical equipment (e.g., electrocautery). Roentgenography (i.e., fluoroscopy, X-ray) was the only diagnostic imaging modality presented by reports included in this review.Reference Oh, Seery and Grabo13 Further research is needed regarding the safety of ultrasound due to pressure application of the probe and CT in the setting of eUXO, though the utility of CT may be limited by artifact from the item of eUXO. Additional recommendations emerged including: i) repositioning the patient to obtain optimal imagining is discouraged due to the risk of accidental initiation,Reference Chamberlain5 and ii) en bloc surgical resection, including associated non-critical anatomic structures as appropriate, is the preferred means for excision and inspection of the device.Reference Howell, Sontgerath and Simonet23, Reference Lein, Holcomb, Brill, Hetz and McCrorey24 Although this method poses challenging ethical decisions for the treatment team and increases patient morbidity, it reduces the potential for accidental initiation from intraoperative disruption and minimizes risks to the surgical team and critical health care infrastructure.
ICRC12 versus JTSReference Oh, Seery and Grabo13 CPGs
The ICRC and JTS guidelines are foundational and provide valuable information for the management of eUXO incidents (Table 4). These resources are designed for different clinical settings with different resource constraints. Both CPGs are primarily applicable to conflict zones and humanitarian settings where the risk of encountering items of explosive ordnance is high and EOD expertise may not be immediately available. The ICRC CPG strikes a balance between prioritization of patient care and the avoidance of initiation. It provides specific recommendations for setting up a safe surgical environment and provides sample protocols for managing potential eUXO initiation. The ICRC CPG presents risk matrices for likelihood of eUXO initiation based on fuse type and explosive payload. However, in low-resource settings it is unclear that surgical personnel will have the capabilities to identify the type of eUXO with this degree of precision. JTS provides a comprehensive approach to the identification, risk assessment, containment, and disposal of eUXO including detailed procedures for a variety of explosive ordnance types. Emphasis is placed on coordination with EOD teams within existing military structures, but the guidance provided is applicable in scenarios ranging from active conflict zones to post-conflict demining efforts in low- to low-middle income countries.
Conclusion
The emergency management of a patient with eUXO is a complicated clinical and operational problem. The challenges of managing the injuries sustained from these incidents is exacerbated by the inherent risk of initiation and the inability to utilize standard diagnostic and surgical equipment. This review found that safe management of these incidents requires a high degree of preparation that includes pre-incident planning, staff training, resource allocation, and liaising with EOD teams and technical subject matter experts not customarily involved in surgical care. As limited data exist to inform the development of evidence-based CPGs, further research including a T2 Delphi study should be conducted to refine and strengthen guidance on eUXO management in low-resource settings.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.10081.
Acknowledgements
The authors acknowledge Taylor Jacoby for her contributions to extraction and record curation, and Teresa Jewell for her contributions to search string development.
Author contribution
DN wrote the first draft of the manuscript.
DN, CL, AG, DW conducted the search including screening and extraction.
CL was responsible for descriptive statistics, data management, and data visualization.
EW, HW provided supervision and developed the second draft of the manuscript.
EW, DN were joint first authors.
All authors provided input on the second draft of the manuscript, participated in revisions, and approved the final version.
Funding statement
HW is supported by the Global Health Equity Scholars Program NIH FIC and NIH OBSSR (D43TW010540). BTS is funded by the US Department of Defense Congressionally Mandated Military Burn Research Program (W81XWH2110364). The funders had no role in study conception, design, investigation, or manuscript development.
Competing interests
The authors have no competing interests to declare.
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