What is the best field care for a patient with two gunshot wounds (GSW) to the shoulder and one to the chest, with no pneumothorax or cardiac involvement, who has been bleeding for approximately ten minutes?

Field Care for Multiple Gunshot Wounds with Active Bleeding

Apply direct manual pressure immediately to all bleeding wounds, prioritizing the chest wound, and prepare for rapid evacuation to definitive surgical care—penetrating gunshot wounds with ongoing hemorrhage for 10 minutes indicate Class II-III hemorrhagic shock requiring urgent operative bleeding control. 1, 2

Immediate Hemorrhage Control

Direct manual pressure is the first-line intervention for all external bleeding wounds. 1 Apply firm, continuous pressure directly over each wound site using whatever clean material is available (gauze, cloth, or bare hands if necessary). 1

• Prioritize the chest wound first, as thoracic gunshot wounds carry the highest risk of rapid exsanguination from major vessel or cardiac injury, even without visible pneumothorax. 2, 3
• Apply hemostatic dressings if available as adjunctive therapy to improve effectiveness of direct pressure—these are specifically useful when multiple wounds require simultaneous control. 1
• Once bleeding slows, apply pressure dressings to maintain hemorrhage control while preparing for evacuation. 1
• Do NOT use tourniquets for shoulder or chest wounds—tourniquets are only effective for extremity hemorrhage when applied proximal to the wound. 1

Assess Hemorrhage Severity

After 10 minutes of bleeding, you are likely in Class II hemorrhage (750-1,500 ml blood loss) with potential progression to Class III (1,500-2,000 ml). 1, 2 Monitor for these signs:

• Class II indicators: Heart rate >100 bpm, normal blood pressure initially, mild anxiety, respiratory rate 20-30/min 1, 2
• Class III indicators: Heart rate >120 bpm, decreased systolic blood pressure, anxious/confused mental status, respiratory rate 30-40/min 1, 2, 4
• Class IV indicators: Heart rate >140 bpm, severely decreased blood pressure, lethargic mental status, respiratory rate >40/min 1, 2, 4

Critical Field Management Principles

All gunshot wound patients with signs of hemorrhagic shock require immediate transfer to operating room for surgical bleeding control—this is non-negotiable for penetrating trauma with ongoing hemorrhage. 1, 2

• Do NOT attempt spinal immobilization—rigid cervical collars and spinal boards in penetrating trauma are associated with increased mortality without neurological benefit. 5, 2, 4
• Keep the patient as still as possible during evacuation, but prioritize rapid transport over immobilization techniques. 5
• Do NOT hyperventilate if providing rescue breathing—hyperventilation in trauma patients increases mortality. 2, 4

Evacuation Priority

The 60-minute emergency department time limit for hemorrhagic shock significantly decreases mortality—every minute counts. 2 Your field care goals are:

1. Control external bleeding with direct pressure 1
2. Maintain pressure during transport 1
3. Activate emergency medical services immediately if not already done 1
4. Communicate clearly: "Multiple gunshot wounds, chest and shoulder, active bleeding for 10 minutes, patient needs immediate surgery" 2

Common Pitfalls to Avoid

• Do NOT pack wounds deeply or probe them—this can worsen bleeding and introduce contamination. 6
• Do NOT give oral fluids—the patient will require emergency surgery and must remain NPO. 2
• Do NOT delay evacuation for "better" hemorrhage control—once direct pressure is applied and maintained, immediate transport is the priority. 2
• Do NOT assume hemodynamic stability means safety—even stable-appearing gunshot wound patients can harbor life-threatening injuries requiring urgent operative intervention. 4, 7

What to Expect at Hospital

The patient will require:

• Immediate surgical exploration for bleeding control, as all patients arriving in shock from gunshot wounds require rapid transfer to operating room. 1, 4
• Massive transfusion protocol with blood products for Class III/IV hemorrhage. 2
• 48-72 hours of antibiotics (first-generation cephalosporin ± aminoglycoside) for high-velocity gunshot wounds. 5, 2, 4

Your field care success is measured by maintaining direct pressure and achieving rapid evacuation—definitive hemorrhage control requires operative intervention that only a hospital can provide. 1, 2