What is the immediate response for a paramedic or combat medic to a patient with two gunshot wounds (GSW) to the chest?

Immediate Management of Two Gunshot Wounds to the Chest

A paramedic or combat medic must immediately assess for and treat the three life-threatening chest injuries—tension pneumothorax, massive hemothorax, and open pneumothorax—while simultaneously controlling external hemorrhage and maintaining airway patency, then rapidly evacuate the casualty. 1

Primary Survey and Life-Threatening Injury Identification

Assess for tension pneumothorax by identifying progressive dyspnea, attenuated breath sounds on the affected side, and respiratory distress in a patient with chest trauma history. 2 Do not wait for tracheal deviation, jugular venous distension, or shock to develop before treating—these are late findings that indicate imminent death. 3, 4

Identify massive hemothorax through chest pain, shortness of breath, possible shock, attenuated or absent breath sounds on the injury side, and percussion dullness. 2 If portable ultrasound is available, use it to confirm hemothorax presence. 2

Recognize open pneumothorax by the presence of chest wall wounds with sucking or hissing sounds, foamed blood in the wound, difficulty breathing, and chest wall unable to rise normally during inhalation. 2

Immediate Interventions

For Tension Pneumothorax

Perform immediate needle decompression using a 14-gauge, 8.25 cm (3.25 inch) needle at either the second intercostal space at the midclavicular line OR the fifth intercostal space at the anterior axillary line. 2, 3, 4 Insert the needle perpendicular to the chest wall all the way to the hub, hold in place for 5-10 seconds to allow full decompression, then remove the needle while leaving the catheter in place. 4

Success indicators include: an audible hiss of air escaping, decreased respiratory distress, improved oxygen saturation, or improvement in shock signs. 4 If the first needle decompression fails, attempt a second decompression at the alternate site. 4 After two unsuccessful attempts, proceed to hemorrhage control and shock management rather than additional needle decompressions. 4

For Open Pneumothorax

Immediately apply a vented chest seal to close the wound. 2, 1 If a vented chest seal is unavailable, use a conventional occlusive dressing and monitor closely for development of tension pneumothorax. 2 If the patient develops progressive hypoxia, respiratory distress, or hypotension after applying an occlusive dressing, remove it or perform needle decompression. 2

For Massive Hemothorax

Prepare for tube thoracostomy at the fourth or fifth intercostal space in the midaxillary line if the patient has persistent shortness of breath without relief after needle thoracentesis. 2, 1 This requires advanced training and should be performed by qualified personnel when available. 4

Hemorrhage Control and Resuscitation

Control any external bleeding immediately, as penetrating chest wounds with hemorrhagic shock require urgent bleeding control. 2 Apply direct pressure or hemostatic dressings to external wounds.

Initiate limited fluid resuscitation with 100-200 mL/hour of crystalloids, targeting a systolic blood pressure of 80-100 mmHg (permissive hypotension) until definitive surgical care is available. 1, 5 Avoid excessive fluid administration that can worsen pulmonary contusion. 1

Airway and Breathing Management

Provide high-flow oxygen at minimum 10 L/min to all patients with chest gunshot wounds. 1 Maintain airway patency and prepare for potential airway compromise.

Monitor for respiratory failure requiring assisted ventilation, particularly in patients with flail chest or pulmonary contusion. 2

Pain Management

Administer adequate analgesia to prevent splinting and atelectasis using IV or oral acetaminophen as first-line, or low-dose ketamine as an alternative to opioids. 1 Effective pain control reduces the risk of respiratory failure. 2

Special Considerations for Behind-Armor Blunt Trauma

Remove body armor immediately to assess the chest wall for deformity, paradoxical movement, or underlying penetration, even if rounds did not visibly penetrate. 1 Behind-armor blunt trauma can cause severe internal injuries including pulmonary contusion, rib fractures, and cardiac injury without obvious external wounds. 1 Monitor for delayed tension pneumothorax development. 1

Evacuation Priorities

Initiate urgent evacuation (Priority 1) for patients with: 1

• Progressive hemorrhage despite interventions
• Suspected cardiac or great vessel injury
• Combined thoracoabdominal wounds
• Respiratory failure requiring mechanical ventilation
• Refractory shock after two needle decompressions

If shock persists after fluid resuscitation and two needle decompressions, consider untreated tension pneumothorax as the cause. 4 In this scenario, if trained and authorized, consider finger thoracostomy or chest tube placement only when the casualty is in refractory shock. 4

Critical Pitfalls to Avoid

Do not delay needle decompression waiting for radiographic confirmation or late signs like tracheal deviation—treat based on mechanism of injury and respiratory distress. 3, 4

Do not use needles shorter than 8.25 cm as they frequently fail to reach the pleural space, especially in larger patients. 3, 4

Do not perform routine spinal immobilization with rigid cervical collars or backboards in penetrating trauma—this increases mortality without benefit. 5

Do not administer excessive fluids that can worsen pulmonary contusion and cause abdominal compartment syndrome. 1, 5