Unexploded Ordnance (UXO) Management

INTRODUCTION

The purpose of this Clinical Practice Guide (CPG) is to provide details on the procedures to safely remove Unexploded Ordnance (UXO) from combat patients, both loose and impaled, to minimize the risks to providers and the Medical Treatment Facility (MTF) while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Ordnance can be categorized in many ways. For the purposes of patient care, it can be considered “loose,” referring to items on the patient’s gear or stored in their pockets, or “impaled” when it penetrates into the body.1 While loose ordnance is fairly common among military patients and easy to address, embedded ordnance is rare and significantly increases the risk for the treatment team. Thirty-six reported cases of impaled ordnance from WWII through the Somalia conflict were discussed in a 1999 review article published in Military Medicine.2 While cases have occurred in other non-US combat zones, this is held as the best-documented report of impaled ordnance. Of these cases, four were moribund upon arrival to advanced care and died while the other 32 survived their initial surgery. Of note, none of the 36 impaled UXO devices detonated or injured those caring for their patients. Four cases in Afghanistan and two in Iraq since 2005, with another US case reported from Pakistan in 2012, indicate that the risk of similar events is still present.3 Prior planning, establishment of an standard operating procedure and realistic training are the best ways to prepare for managing these soldiers and avoid “on the fly” decision-making. However, if a patient arrives early on in the establishment of a MTF, expeditious and flexible management by medical leaders faced with the prospect of surgically removing UXO will have the greatest impact on patient and treating team survival. A discussion of steps to avoid accidental discharge of the ordnance and steps to mitigate risks to providers and the surgical facility follows. These protective principles may also be applied to the management of ordinance (e.g., suicide vest) found on non-military patients treated at medical facilities.