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Chinese Journal of Traumatology logoLink to Chinese Journal of Traumatology
. 2023 Mar 11;26(3):125–130. doi: 10.1016/j.cjtee.2023.03.002

Wounding characteristics and treatment principles of ground anti-armored vehicle ammunition against armored crew

Yue Li a, Guang-Ming Yang b, Yong-Bo Zhao a, Bing-Cang Li b,∗
PMCID: PMC10244259  PMID: 36990837

Abstract

The wound mechanism, injury characteristics and treatment principles of anti-armored vehicle ammunition against armored crew in the past 20 years are summarized in this paper. Shock vibration, metal jet, depleted uranium aerosol and post armor breaking effect are the main factors for wounding armored crew. Their prominent characteristics are severe injury, high incidence of bone fracture, high rate of depleted uranium injury, and high incidence of multiple/combined injuries. During the treatment, attention must be paid on that the space of armored vehicle is limited, and the casualties should be moved outside of the cabin for comprehensive treatment. Especially, the management of depleted uranium injury and burn/inhalation injury are more important than other injuries for the armored wounds.

Keywords: Ammunition, Armored vehicles, Wound characteristics, Treatment principle

Introduction

Traditionally, ground anti-armored vehicle ammunition (AAVA) mainly includes armor-piercing projectile (APP), high-explosive anti-tank (HEAT), high-explosive plastic projectile (HEPP) and anti-tank mine (ATM). The improvised explosive device (IED), which firstly appeared on the battlefield in Afghanistan and Iraq, is often used to attack armored vehicles in addition to assaulting personnel. According to their combat purposes, armored vehicles can be divided into following categories: combat vehicles (tanks, infantry fighting vehicles, armored transport vehicles, etc.) and support vehicles (armored mine clearance vehicles, armored supply vehicles, armored ambulances, etc.). The armored vehicles have the characteristics of airtight cabin, narrow space and strong mobility, so the wound characteristics of the crew are different from those in an open space, and the treatment principle is also unique. Therefore, Chinese and English literatures about wound characteristics and treatment principle of armored crew injured by AAVA were retrieved since the Afghan war in 2001 from SinoMed and PubMed, with aim to summarize, for providing theoretical guidance and practical reference for its treatment and medical service support. The documents of air-to-ground and ground-to-ground anti-tank missiles are excluded.

Anti-armor ammunition

APP

With a large specific kinetic energy (the ratio of the kinetic energy to the cross section) and a large aspect ratio (the ratio of projectile length to diameter), APP is mainly made of tungsten steel and uranium alloy. Its warhead is thin and slender, and the kinetic energy for piercing armor is provided by its weight and velocity (muzzle velocity > 1350 m/s, large caliber APP can reach 1800 – 2000 m/s). High-strength projectile can pierce the armor as thick as 750 – 900 mm. The splashed armor fragments at high speed can kill and wound the crew, and destroy various equipment in the armored vehicle.1,2

HEAT

It is a chemical energy anti-armor weapon with hollow funnel shaped charge inside, also known as cone charge, shaped charge or hollow charge. The shaped charge effect that is caused by explosion when HEAT impacting the armor, makes the metal drug cover into a liquid metal jet, of which the speed is 8000 – 9000 m/s and temperature is about 30,000 °C. The metal jet can create a hole with a diameter of about 10 mm for the armor. After breaking the armor, the remaining metal jet together with the armor fragments and detonation products can wound the crew and destroy equipment inside the vehicle. The breaking thickness of the modern HEAT is usually more than 5 times the diameter of the cartridge cover, sometimes it can reach 1000 mm.1,3

HEPP

Loaded with plastic explosives, the shell of HEPP is made of carbon-free steel or copper, so it is soft and thin (about 2 – 4 mm) with a muzzle velocity of 470 – 750 m/s. When hitting the armor, it is easy to deform and break, causing plastic explosives to adhere to the surface. The shock wave from the impact acts directly on the armor in the form of impulse, producing stress spalling on the inner wall of the vehicle. This results in the formation of a dish-shaped fragment weighing about 2.5 – 5 kg, as well as many small fragments. At this time, although the armor is good in shape, the broken pieces that fly within the cabin at a speed of 200 – 350 m/s, that can kill the crew and destroy the equipment. At present, HEPP is less used as it only has a strong damage effect on regular armor, but composite armor is more frequently used now.4

ATM

ATM is loaded with trinitrotoluene (TNT) or hexogen explosives, with triggering force more than 180 kg. In accordance with acting targets, ATM can be divided into anti-track (pressure mine), anti-vehicle bottom (sensor initiation mine), full action (track and vehicle bottom), anti-side mine, and anti-top mine. The anti-vehicle bottom mine exerts a vertical force lasting 10 ms on human body, and makes armored floor to accelerate more than 100 g at moving speed >12 m/s. These data are much larger than that of car collision, which acceleration is 40 g and speed is about 2 – 6 m/s.5 The modern ATM is often loaded by shaped charge and developing toward to intelligence (automatically detect, identify, confirm and attack) and miniaturization (convenient for large area layout).6

IED

As IED is easy to make and its components are easy to get with low cost, it is a kind of homemade asymmetrical combat weapon with the characteristics of concealed lay out and multiple detonations.1 It has been extensively used by anti-American forces in Afghanistan (responsible for 63% of the casualties) and Iraq (responsible for 47% of casualties).7 The IED has caused a large amount of wounded (25,000 − 33,000) and deaths (> 3100) of the United States (US) troops in the Afghanistan/Iraq battlefields, also destroyed many combat vehicles.7,8

Killing factors

Fragments

The fragments can be the residuals after APP penetrating, also can be formed by armor itself during piercing, and fallen from the inner wall by HEPP. These fragments can cause open wound, or penetrating wound if the kinetic energy is high enough. The fragments are irregular in their shape called natural fragments, so as to making irregular wound. Although the velocity of APP is high, the falling fragments from the armor inner wall and the fragments formed by armor itself fly at a relatively low speed, hence the temporary cavity is not as typical as that of high-speed bullets.4,9

Blast wave

The anti-armored ammunition not only generates the overpressure in armored vehicle, but also forms a complex blast wave with a longer duration than that in an open space, due to the superposition of incident wave, reflected wave, diffraction wave and the convergence at the corner of the armored vehicle. The complex blast wave with a long duration can cause more serious injury to the hearing apparatus, lung and gastrointestinal tract and brain, so that blast injury in a confined space is much heavier than simple blast wave in the open space.10,11

Shock vibration

The explosive energy is transmitted to the armor in mode of stress waves, then forms shock vibration, which can make the armor wall to be accelerated at 100 − 1000 g within 0.5 – 1 ms. These forces result in increased axial stress of the limbs and spine that are in contact with the armor wall. Once the stress exceeds the threshold of the bone (the tibia, talus and calcaneus = 160 MPa,7 the axial impact force of 10% tibial fracture = 12.2 kN12 or 12.6 kN13), the fracture of limbs and spine occurs. The explosive energy can also make the armored vehicle displacement or throwing within 15 ms, further resulting in fractures and soft tissue injuries of armored crew due to the throwing and collision.7,14

Metal jet

It was demonstrated that if the metal jet directly hits the experimental animals, it can cause muscle necrosis, organ rupture, massive hemorrhage, and local tissue extensively destroyed, even makes animals to die immediately. Also, many fine metal particles are produced after the metal jet breaks the armor, which can cause prominent subcutaneous bleeding, but skin damage is not obvious. These fine particles are difficult to be removed by debridement and easy to cause tissue infection.15

Radioactive rays

The depleted uranium (DU) (uranium concentration < 0.2) is a by-product of uranium enrichment. It can produce α rays, but very few β and γ rays.15 Due to the depletion of 234U and 235U isotopes with abundance less than 0.71%, its radioactivity is 40% less than that of natural uranium, with specific activity about 14 Bq/mg (specific activity of natural uranium is about 25 Bq/mg). The US military requires that the weight of the 235U should be less than 0.3%, and the weight of 234U and 236U are 0.0006% and 0.003% in ammunition and armor, respectively. Typical DU ammunition and armor are consisted of 99.25% DU and 0.75% titanium alloy.16

Unlike tungsten projectile which becomes blunt rapidly during piercing armor, the adiabatic shear features of DU projectile can make it self-sharpening in the process of penetrating armored vehicle.17 The resulted metal particles may be rapidly oxidized in the air, then form oxide powder aerosols, which enter the human body by respiration, oral and wound contamination, even embedded in the human body.18, 19, 20, 21After DU absorbed through respiration and digestive tract, they will enter the circulation, then mainly deposited in the alveoli and bones. Uranium in body is mainly excreted by the kidney, with excretion rate more than 90% within 24 h, and completely eliminated within 340 days.18

High temperature

After explosion of anti-armored ammunition, the gas with high temperature (2000 °C − 60,000 °C), high pressure (1.1 − 2.5 MPa) and high speed (3000 − 4000 m/s) can be produced, which causes burning in armored vehicle. If the incendiary agents are added in the ammunition or more flammable materials are stacked in the cabin, the combustion is more violent with a longer duration, thus makeing severe burn injury to skin.22 Also, the inhaled injury can be produced if high temperature enters the respiratory tract. The previous animals study showed that incidence and degree of burn for armored crew was higher and more serious than that in an open space, with burn area up to 60%.9

Hypoxia

A lot of smoke and dust resulted from explosion of the ammunition are difficult to clear in the cabin, which together with oxygen consumption by burning lead the crew to asphyxia. Harmful gases generated by explosion and burning include CO, NO2, N2O3, SO2, H2S, NH3. These gases can strongly stimulate respiratory tract and aggravate suffocation of the crew. However, even the live animals can stay in the cabin for 0.5 h long, the asphyxiation phenomenon was still not evident, suggesting that there were species differences between humans and animals (unpublished data). After 10 min the kinetic energy of APP containing tungsten, nickel and cobalt penetrates the US Abrams tank, the concentration of metal particles in the tank is 6 – 12 g/m3, with diameter of 0.5 – 21 μm, which can aggravate the dyspnea of the crew.23

Wound characteristics

High incidence of blast injury and severe injury

The pressure of simple blast wave in open space rises quickly within a short time and decreases exponentially with the distance increasing. Contrarily, the pressure of complex blast wave in confined space rises slowly with a longer time and a slower attenuation. So, the blast wave in a confined space can cause a higher incidence of blast injury and more serious injury. For example, the overpressure resulting from the explosion of 3.0 kg spherical TNT at 2 m away from the detonation center was 702.8 kPa, with a duration of 0.442 ms in open space, which could make 60% of animals suffered severe blast injury on lung and gastrointestinal track, and 28.13% mortality rate. Similarly, explosion of 3.0 kg spherical TNT in a confined space at the same distance could produce 2 pressure peaks, in which the first peak resulted from incident wave with a pressure of 970 kPa, and the second peak from reflected wave with a pressure of 0.985 kPa, but their duration was extended to about 2 ms. This complex wave makes severer lung injury in 100% animals and gastrointestinal injury in 80% animals with a mortality of 70% (unpublished data).

High rate of the fracture, amputation and paraplegia

During the Iraq and Afghanistan wars, more than 70% of armored crew suffered limb fractures (lower limbs accounts for 45%) and amputation with a rate of 14.3%.22 The incidence of spinal cord injury was 43%, in which one-third was transversely injured.24 The above injuries were more caused by the explosion than twice of non-explosion.8 The oblique fractures often result from the blast, the comminuted fractures accompanying severe soft tissue wound mostly result from the fragments, but the throwing often results in the spiral fractures.22 Among 555 American soldiers wounded by under-vehicle explosions, 378 suffered foot and ankle fractures, and the lumbar fractures was 278.25 From January 2005 to December 2008 in field of Iraq and Afghanistan, 30 British soldiers were wounded in armored vehicle, among which 27 (90%) had the fractures of lower extremity. In this group, the rate of amputation was 45%, and delayed amputation was 10% due to chronic pain. The wound infection and disability were experienced in 38% and 76% of casualties, but only 6% of the wounded could return to their posts. The spinal fractures could be observed in 9 (30%) wounded (thoracic vertebrae 5 and lumbar vertebrae 4).14 From 2007 to 2010 in the US Army, 18 lower limb fractures, 12 pelvic fractures, and 65 thoracolumbar burst fractures (common at L1 - L3) were caused by IED attack.24 From 2010 to 2014, 553 (91.3%) of the 606 casualties in armored vehicles suffered fractures, among them heel and talus fractures accounting for 13%, tibia and fibula for 10%, lumbar for 7%, and thoracic for 6%.26 It was showed in another IED-wounded group that tibia and fibula fractures accounted for 45.8%, foot for 35.6%, femur for 10.1%, metacarpal for 3.4%, humerus for 3.3%, radial and ulnar for 1.7%, some cases with ankle dislocation, patella and knee ligament injuries.7 These fracture patterns are the same as those caused by naval mines during the evacuation of Dunkirk in 1940 and the Normandy landings in 1944.22

High ratio of DU damage

DU has both radiation and chemical (heavy metal) toxicity, in which chemical toxicity is a main injury factor to human,15 but the radiation toxicity can aggravate the chemical toxicity.19,27 In aerosols within the cabin, uranium content is related to explosive yield, armored vehicle type, ventilation, sampling time, technology, etc., so that the different data were reported such as 0.13 g/m3, 0.5 − 1.7 g/m3, 1.36 g/m3, 2.3 − 6.0 g/m3, 3.0 g/m3, 8.2 − 9.1 g/m3, 11 g/m,3 16 g/m3. The highest uranium concentration was found within 10 seconds after piercing armor, and decreased about 50% (about 0.23 g/m3) at 1 min. At 5 min, 30 min and 1 h after piercing, the uranium concentration was 0.047 g/m3, 0.11 − 0.13 g/m3, and 0.049 − 0.057 g/m3, separately.17 If sampling at 4 − 9 min outside the armored vehicle, the uranium concentration of aerosol was 7 – 17 mg/m3, about 9.6 mg/m3 around the turret, then decreased less than 1 mg/m3 within 10 min.18

During Gulf war in 1991, 6 Abrams tanks and 14 Bradley vehicles were mistakenly hit by DU shells, with 104 casualties survived. It showed that no significant changes in the functions of kidney, reproductive system and neurons cognitive ability by the clinical observation, indicating that low level DU (< 1%) did not have noticeable effect on the health.16 However, it was demonstrated that the incidence of some cancers was increased, such as lung cancer, lymphoma, bladder cancer, cervical cancer, breast cancer, rectal cancer, bone cancer, leukemia, testicular tumor, thyroid cancer by the observation about persons exposed to DU in wars of Gulf, Kosovo, Croatia, and Afghanistan-Iraq for more than 2 decades. Otherwise, bone density is decreased, but the toxicity for kidney, liver and nerve system is increased.20,28,29 Animal experiments also revealed that interstitial inflammation, fibrosis, edema, hemorrhage of the lung and emphysema can be induced by DU aerosol.27

High incidence of visceral injury

The visceral injury is mainly caused by the fragments and the collision with the armor wall. Among the 474 wounded in the vehicles during the wars in Iraq and Afghanistan, 88 (18.6%) had at least one visceral injury, in which liver, spleen, kidney, lung, mediastinum and heart were the most vulnerable organs. It was noted that among 157 cases of viscera injuries, lung injury accounted for 25.5% (40 cases), spleen injury for 18.5% (29 cases), mediastinum and heart injury for 17.8% (28 cases), liver injury for 6.4% (10 cases), kidney injury for 5% (8 cases). For 745 dead in the battle, 116 (15.6%) died of lung injury, 83 (11.1%) of liver injury, 81 (10.9%) of mediastinum and heart injury, 76 (10.2%) of spleen injury, and 53 (7.1%) of kidney injury, with incidence of 22.0% for brain contusion and 6.0% for penetrating brain injury.26 Also, cervical spinal cord injury was often encountered.26

High wound rate and fatality rate

Anti-armored ammunition attack is an important cause of casualties of American and British troops in the Afghanistan and Iraq wars.25 Among all wounded in armored crew, 79% were injured and 21% were killed.25,26 Totally, 2233 of 4895 American and British soldiers were killed by anti-tank mines and IEDs, accounting for 45.6%.22 In another set of 2019 casualties, 1887 (93.5%) were injured, and 132 (6.5%) were dead, with 90.2% of the deaths suffered at least one visceral injury.26 The common causes of death were severe injuries to head/face (84.0%), trunk/internal organs (78.0%), neck/cervical spine (52.0%), pelvis (51.0%), upper limbs (49.0%), thighs (44.0%), lower legs/knees (43.0%), feet/ankles (36.0%) and lumbar spine (30.0%).25

High incidence of multiple and combined injuries

A total of 3844 wounds were inflicted on 555 US armored crew in the Afghanistan and Iraq wars, averagely 4 wounds in each wounded case and 19 wounds in each death. The most common wounded sites were successively lumbar spine (35.0%), foot and ankle (33.0%), trunk and viscera (32.0%), shank and knee (28.0%), cervical spine (19.0%), upper limb (16.0%), head and face (16.0%), thigh (8.0%) and pelvis (8.0%).25

High incidence of burn and inhalation injuries

It is difficult to clear the heat and smoke in the armored vehicle, but they are easy to cause burn and inhalation injury. After the simulated tank was attacked by shaped energy ATM, the incidence of III and II burn on the animals' skin were 83% – 92% and 42%, separately, which area was 40% – 60% of the body surface. Specially, the incidence of inhalation injury was as high as 100%, expressed by the bleeding of the throat, trachea and bronchus mucosa, with large amount of foamy secretion and fluid containing dust particles in the trachea and bronchus. The incidence and severity of burns are related to the size of the cabin, ventilation, and the animal's posture (unpublished data). It was reported that the incidence of inhalation injury caused by anti-bottom mines was 4.5% in the Afghanistan and Iraq battlefields.28

It was reported previously that the metal aerosols produced by tungsten alloy kinetic APP in armored vehicle mainly contain iron (14.8 mg/m3), nickel (0.286 mg/m3) and tungsten (1.92 mg/m3), which can accelerate the death of cultured human alveolar epithelial cells.30

Treatment principles

Field treatment

With strong mobility and large range of activities, armored vehicles fight independently in the battlefield, hence it is difficult to find the wounded crew and treat them timely. Therefore, self and mutual medical aids are the key methods to the rescue on-field treatment.31 The armored crew should be trained to master 5 techniques for first aid: namely hemostasis, ventilation, bandaging, fixation and transport,32 in which hemostasis is the most important technique.9

Rapidly leaving and treatment outside

Since there are many harmful factors in the armor, the wounded should be quickly and safely transferred to the outside for first aid, or transferred to the next level treatment institution. However, the armored space is limited with a narrow exit, so it is very difficult to transfer the wounded to outside.33 For transferring, some researchers have developed small composed stretcher,34 lifting equipment weighted 3.8 kg for its dead-weight and 150 kg for its suspended load,35 transport pad,33 etc., but all of them require the cooperation of persons from inside and outside of the armor. During transportation, the secondary injury caused by the collision between the wounded and the vehicle wall should be avoided.35 In particular, when transferring the wounded with spine or spinal cord injury, the spine should be fixed properly and kept its normal physiological curve for preventing the secondary injury of the spinal cord.9

Fracture treatment

It should be noted that the free tiny bone pieces should be removed during debridement, but the larger free bone pieces attached to soft tissue or periosteum should be retained in situ, in case of bone defect, also serving as a scaffold for bone regeneration. In principle, the internal fixation is not necessary for gunshot fractures, and it can only be performed if the wounds are not heavily polluted or after the thorough debridement and effective anti-infection. The internal fixation is more conducive to the stability of the fracture end and fracture healing.6 All 40 casualties in the armored vehicle from battlefields of Afghanistan and Iraq were initially fixed externally, and the percutaneous wire fixation or plate internal fixation were performed only after evacuation to the United Kingdom by air.22

It is hard to keep the limbs with the comminuted and defective fractures, large area of soft tissue defect, and serious vascular or nerve injury. Under these conditions, it will be life threatening to keep limbs due to infection or shock, so that the amputation has to be performed. The amputation rate is 69.6% for the open fractures, and 11.8% for the closed fractures.22 Usually open amputation is used, and closed amputation is only performed under special situation. In the course of amputation, the fracture at the injured site should be properly fixed, and should not be removed at will. Even if they are very irregular in shape, the surviving skin and muscles beyond the amputation plane should be preserved as much as possible, for these tissues can be used to close the stump wound and repair soft tissue defect.6

Blast injury treatment

The armored crew may suffer blast injury of lung, abdomen, hearing apparatus, brain, eye and heart. The symptoms and treatment principles of the blast injury are different according to injured organs.36,37 Mild blast lung injury only has chest pain, chest tightness or short of breath, but symptoms such as cough, hemoptysis, dyspnea, etc., are presented for moderate injured cases, obvious dyspnea, cyanosis and bloody foamy fluid from the mouth and nose can be observed from severe cases. The severe lung blast injury is easy to develop into acute respiratory distress syndrome, and often combines with pneumothorax, hemopneumothorax and multiple rib fractures. In order to reduce the burden of heart and lung, the bed rest should be kept, and the airway should be kept open. If necessary, tracheotomy should be performed. When respiratory rate > 40 breathes/min, PaCO2 > 6.67 kPa, PaO2 < 8.0 kPa, intrapulmonary shunt > 15%, the mechanical assisted ventilation should be given. For preventing pulmonary edema and protecting cardiac function, dehydration, diuresis and cardiotonic drugs should be prescribed. The patients with pulmonary rupture and massive hemorrhage should be operated immediately, and the pulmonary fissure should be sutured or the lobectomy should be performed. The transfusion of blood and fluid should be performed for correcting the hemorrhagic shock, but the resistance of pulmonary circulatory is increased for these of lung blast injury, so it is better to use blood or colloid solution for the resuscitation, and crystalloid solution should be used less for reducing the burden of right heart.37 The symptoms such as abdominal pain, nausea, vomiting, internal hemorrhagic shock, peritoneal irritation, hematuria, and bloody stool can be experienced among the patients of abdominal blast injury. Food and drink should be prohibited for the patients with the peritoneal irritation. Continuous gastrointestinal decompression is required for paralytic intestinal obstruction. For patients with gastrointestinal perforation, surgical repair or resection should be performed as soon as possible. The surgical method depends on the injury extent, technical conditions and specific environment.37

Fragment injury treatment

In principle, the early surgical management of fragment injury should follow the rule of “early debridement (6 − 8 h after injury) and delayed suture”. The superficial fragments easy to excise should be removed during debridement, but these with deep position, small in size, and being harmful if removed (usually encountering in the brain injury) should be left for subsequent proper treatment. If soft tissue is defect in large scale, the muscular flap with vascular pedicle can be used to repair the defect at 5 days after thorough debridement, but the wound should be clean, fresh granulation, and without red, swollen, tenderness pain for wound edge. In case of acute bleeding from large vessels, it is necessary to use tourniquet, zeolite, and chitosan hemostatic device to control bleeding for preventing the hemorrhagic shock immediately. If shock occurred, it should be treated according to the principles of traumatic shock.6,22

Treatment of burn and inhalation injury

First, the air way must be kept open, and relieve airway obstruction timely by using methods of secretion removal, tracheal intubation and tracheotomy. Burn wound can be washed with cold water. It is recommended for patients with burn area less than 20% to drink the burn fluid (sodium chloride 0.3 g + sodium bicarbonate 0.15 g + phenobarbital 0.005 g/100 mL); if burn area more than 20%, colloid solution is suggested. For these suffered heart failure, strophanthin-k and cedilanid should be given intravenously to enhance cardiac function. If patients with high blood viscosity, low molecular dextran should be infused intravenously to dilute the blood. When pulmonary circulation resistance is increased, anisodamine should be used to dilate pulmonary vessels. For correcting hypoxemia and maintaining SpO2 > 92%, oxygen therapy, mechanical ventilation, and membrane oxygenator (if necessary) should be performed. Before the pathogen is identified, broad-spectrum anti-biotics should be used to prevent and treat pulmonary infection, but it is the most important to clean airway secretions and foreign matters to prevent and treat pulmonary infection.38

Treatment of DU injury

The washout and decontamination must be firstly finished timely. For those without wounds the whole body can be washed, if with wounds the injured sites should be cleaned according to the surgical principle, with paying a special attention to the oral cavity, nose, eyes, and external auditory. The next step is to promote excretion as early as possible to prevent further absorption of DU, those with respiratory contamination vasoconstrictor can be sprayed into nasopharynx or expectorants taken orally, even the lung lavage can be considered if necessary. While DU enters the digestive tract, vomiting, stomach lavage and cathartics can be used within 4 h for promoting excretion. DU fragments within wound should be removed to minimize the DU absorption. The traditional drugs for DU excretion are sodiumbicarbonate, diethyltriamine pentaacetic acid (chelating agent), catechol, alkylphosphonic acid, hydroxypyridinone, polyaminocarboxylic acid, polyphosphate, complexing and chelating agents such as calixarene. These drugs are mainly combined with DU in the body to form complexes with large solubility, small dissociation and strong diffusion for easy to be excreted through the kidney or hepatobiliary.27,39,40 At present, the drugs for promoting DU excretion have either toxicity and side-effects or unsatisfactory effects, and the better ones are still under developing.19

Summary and prospect

Nowadays, the various land-based and air-based anti-armor missiles are constantly developing and joining the combat sequence with stronger destructive capabilities besides traditional ones. In modern land warfare, armored vehicles are not only the main fight equipment, but also play an important role in the logistics, so they are still the focus target of attacking. The mechanisms and characteristics of armored crew injuries are significantly different from those in open space, it also has its uniqueness in the principle of treatment. Therefore, both basic researcher and clinical worker should master the wounding mechanisms and injury characteristics of anti-armored ammunition against the armored crew, also its treatment principles, so as to lay a broad and solid knowledge of medical service for winning the high-tech local wars in the future.

Funding

Nil.

Ethical statement

Not applicable.

Declaration of competing interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author contributions

Yue Li wrote the manuscript;

Guang-Ming Yang and Yong-Bo Zhao searched literature and edited the manuscript;

Bing-Cang Li contributed to the conception and revised the manuscript.

Footnotes

Peer review under responsibility of Chinese Medical Association.

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