The trauma system in Iraq has evolved to deliver advanced pre-hospital care, rapid road or aero-medical evacuation (AME), early initial wound (damage control) surgery at a forward operating base and then secondary assessment, further resuscitation more specialised damage control surgery at the major field hospital. This is a Level 1 Trauma Centre and includes computed tomography (CT) scan, intensive care unit (ICU) and the full complement of surgical specialists including a head and neck team and consultant radiologists. When stabilized, the patients are transported with ongoing intensive care to Germany and then to the US. The mortality of battle injuries has reduced progressively since World War II (WWII) and is now approximately 10% in the Iraq war which is at the lowest level ever recorded; a remarkable achievement considering the severity of blast injuries. The reason for the reduction in mortality will be discussed. The management of severe blast injuries and mass casualties within the military hospital in Iraq is presented. Blast injury results in polytrauma with penetration from metal fragments and other foreign bodies, blast wave injury to internal organs and extremities and burns including respiratory burns. Blast lung injury is very common following blast exposure and increases the complexity of management in the operating room and ICU environment. This severe multiple trauma produces gross physiological compromise and requires trauma care of the highest order in order to save lives and reduce morbidity. These problems are infrequently encountered in the civilian sector. There are many lessons in how these casualties are managed in a military hospital which inform the management of blast injury and severe multi-trauma casualties in the civilian sector.