What's the best course of treatment for a fellow soldier with two gunshot wounds (GSW) to the chest, considering varying levels of body armor (Tier 1, Tier 3, or no armor)?

Combat Medic Management of Two Gunshot Wounds to the Chest

Immediately control life-threatening chest injuries through systematic assessment and intervention, with the primary goal of preventing tension pneumothorax, managing massive hemorrhage, and maintaining airway patency—regardless of armor type, though the specific injury pattern and severity will differ based on armor protection. 1

Initial Assessment Priorities (All Armor Variants)

Assess for the three immediate killers in chest GSW:

• Tension pneumothorax: Progressive dyspnea, attenuated breath sounds, tracheal deviation 1
• Massive hemothorax: Chest pain, shortness of breath, shock, percussion dullness 1
• Open pneumothorax: Sucking chest wounds with foamed blood, hissing sounds 1

Variant 1: Tier 3 Armor (Hard Plate Protection)

Behind armor blunt trauma (BABT) is the primary concern even if rounds did not penetrate. 1

• Energy transfer through armor can cause severe internal injuries without penetration, including pulmonary contusion, rib fractures, and cardiac injury 1
• Remove armor immediately to assess chest wall for deformity, paradoxical movement, or underlying penetration 1
• If flail chest is present (paradoxical chest wall movement with rapid breathing): Apply immediate chest wall stabilization using pressure dressing with pads or multi-head chest strap 2
• Monitor for delayed tension pneumothorax development even without obvious penetration 1
• Provide high-flow oxygen (minimum 10 L/min) and prepare for evacuation 2

Variant 2: Tier 1 Armor (Soft Armor/Kevlar)

Expect partial penetration with combined blunt and penetrating trauma. 1

• Rounds may penetrate soft tissue but with reduced velocity, creating intermediate wound patterns 3
• Remove armor and assess for entry wounds—two GSW to chest likely means bilateral injuries 1
• If sucking chest wounds present: Immediately apply vented chest seals to both wounds; if unavailable, use conventional chest seals and monitor closely for tension pneumothorax 1
• If tension pneumothorax develops: Perform needle decompression at second intercostal space, midclavicular line using 14-gauge, 8.25 cm needle 1
• Anticipate hemopneumothorax requiring tube thoracostomy at fourth/fifth intercostal space, midaxillary line 1

Variant 3: No Armor (Full Penetration)

Assume high-velocity penetrating trauma with maximum tissue destruction and high mortality risk. 3, 4

Immediate Life-Saving Interventions:

Step 1: Airway and Breathing

• Maintain airway patency and provide high-flow oxygen 1
• Seal any open chest wounds immediately with vented chest seals (or conventional seals with close monitoring) 1
• If progressive dyspnea after sealing wounds: Remove seal or perform needle decompression for tension pneumothorax 1

Step 2: Identify Injury Pattern

• Two GSW to chest creates high probability of:
  • Bilateral hemopneumothorax (most common) 5
  • Cardiac injury if wounds near precordial area (look for tachycardia, enlarged heart shadow, ST-segment elevation) 1
  • Great vessel injury if progressive hemorrhage despite interventions 1
  • Combined thoracoabdominal injury if lower chest wounds (rapid pulse, hypotension, abdominal rigidity) 1

Step 3: Hemorrhage Control

• If massive hemothorax suspected (shortness of breath not relieved by needle decompression, shock): Perform tube thoracostomy bilaterally if both sides affected 1
• Limited fluid resuscitation (100-200 mL/hour) to avoid worsening pulmonary contusion 2
• Initiate damage control resuscitation if available (massive transfusion protocol) 4

Step 4: Cardiac Injury Recognition

• If tachycardia with hypotension persists despite chest decompression: Suspect cardiac tamponade or direct cardiac injury 1
• Pericardial ultrasound if available can confirm diagnosis 1
• These casualties require immediate surgical evacuation—survival depends on rapid thoracotomy 1

Critical Decision Points for All Variants

Indications for Urgent Evacuation (Priority 1):

• Progressive hemorrhage despite interventions 1
• Suspected cardiac or great vessel injury 1
• Combined thoracoabdominal wounds 1
• Respiratory failure requiring mechanical ventilation 1

Acceptable Field Stabilization:

• Isolated hemopneumothorax responding to chest tube drainage 5
• Stable vital signs after initial interventions 5
• No signs of ongoing hemorrhage 5

Common Pitfalls to Avoid

• Do not delay needle decompression while searching for chest seals—tension pneumothorax kills in minutes 1
• Do not assume armor prevented injury—BABT can cause lethal internal damage without penetration 1
• Do not overlook combined thoracoabdominal injury (10-35% incidence in warfare)—lower chest GSW frequently involves abdominal organs 1
• Do not provide excessive fluid resuscitation—this worsens pulmonary contusion and increases mortality 2
• Do not miss cardiac injury—precordial GSW with persistent tachycardia requires immediate surgical evacuation 1

Pain Management During Stabilization

• Provide adequate analgesia to prevent splinting and atelectasis 1
• Multimodal approach: IV/oral acetaminophen first-line, low-dose ketamine as alternative to opioids 6
• Inadequate pain control leads to respiratory complications (40% incidence) 2

The mortality rate for penetrating chest GSW in warfare is 2-5.6% with appropriate treatment, but rises dramatically with delayed intervention or missed injuries. 5, 3