# Strategic Care of Ballistic Injuries: A Retrospective Observational Study at a Moroccan Military Hospital

## TL;DR

This study examines accidental gunshot injuries during military training in Morocco, highlighting the importance of early treatment and improved protocols in resource-limited settings.

## Contribution

The study provides insights into the management and outcomes of accidental ballistic trauma in military training, emphasizing triage and resuscitation strategies.

## Key findings

- Multiregional injuries were common, with limb trauma and abdominal injuries being most frequent.
- Unfavorable outcomes were linked to older age, comorbidities, and early hemodynamic instability.
- Favorable outcomes occurred in 62.5% of cases despite moderate-to-severe trauma in over a third of patients.

## Abstract

Background

Ballistic trauma from high-velocity projectiles causes severe multisystem injury and rapid physiological decline. While well-characterized in combat and civilian violence, accidental firearm injuries during military training remain understudied. These incidents typically affect young, unprotected individuals in settings with limited prehospital care factors that may influence injury patterns and outcomes. This study aims to describe the clinical features, injury profiles, and management of accidental ballistic trauma in a military training context, with implications for prevention, triage, and critical care in resource-limited settings.

Methods

We conducted a six-year retrospective observational study (2016-2021) at Hassan II Military Hospital, Morocco, including 32 consecutive male patients admitted to the intensive care unit (ICU) for accidental high-velocity ballistic trauma sustained during military training. Injuries were caused by North Atlantic Treaty Organization (NATO)-standard live ammunition (5.56 × 45 mm or 7.62 × 51 mm). No exclusions were applied. Data collected included demographics, injury characteristics, prehospital care, hemodynamic parameters at admission, surgeries, and outcomes. ICU admission followed institutional protocols based on hemodynamic instability, high trauma burden, or need for invasive support. Outcomes were classified as favorable (ICU discharge without major complications) or unfavorable (mortality, organ failure, or reoperation). The study received ethics approval from the Institutional Committee of Hassan II Military Hospital.

Results

The mean age was 30.7 years; half of the patients were aged 31-40. Multiregional injuries were frequent: limb trauma (50%), abdominal injury (37.5%), and neurological impairment (Glasgow Coma Scale (GCS): 9-13 in 37.5%). On ICU admission, tachypnea (62.5%), tachycardia (50%), and hypotension (37.5%) were common. Most patients (87.5%) underwent surgery (60% orthopedic and 40% abdominal), with a mean delay of 13.2 ± 7.3 hours, mainly due to prehospital transfer and imaging delays. Intensive monitoring was required in 62.5%. Injury Severity Score (ISS) ranged from 12 to 32, indicating moderate-to-severe trauma in over one-third of patients. Favorable outcomes were observed in 62.5%. Unfavorable outcomes (37.5%), including mortality and reoperation, were significantly associated with older age, comorbidities, hypotension, mean arterial pressure (MAP) < 65 mmHg, and oliguria (p < 0.05).

Conclusion

Accidental ballistic trauma during military training is associated with significant morbidity and mortality, particularly when early hemodynamic instability is present. Findings support early triage, aggressive resuscitation, and application of damage control principles at the point of injury ("damage control at ground zero") as critical strategies. Although limited by its retrospective, single-center design and small sample, this study provides foundational evidence to guide trauma protocols and improve care delivery in resource-limited military environments.