Combat Medic Management of Two Gunshot Wounds to the Chest

Initial Assessment and Intervention

The primary goal of immediate intervention is to prevent tension pneumothorax, manage massive hemorrhage, and maintain airway patency, regardless of armor type 1
The American College of Surgeons recommends assessing for the three immediate killers in chest GSW: tension pneumothorax, massive hemothorax, and open pneumothorax, characterized by progressive dyspnea, attenuated breath sounds, tracheal deviation, chest pain, shortness of breath, shock, percussion dullness, and sucking chest wounds with foamed blood and hissing sounds 1

Behind armor blunt trauma (BABT) is the primary concern even if rounds did not penetrate, and can cause severe internal injuries without penetration, including pulmonary contusion, rib fractures, and cardiac injury 2
The National Association of Emergency Medical Technicians recommends removing armor immediately to assess chest wall for deformity, paradoxical movement, or underlying penetration, and monitoring for delayed tension pneumothorax development even without obvious penetration 2

The Advanced Trauma Life Support (ATLS) guidelines recommend providing high-flow oxygen (minimum 10 L/min) and preparing for evacuation, as well as limited fluid resuscitation (100-200 mL/hour) to avoid worsening pulmonary contusion 3
The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend performing needle decompression at second intercostal space, midclavicular line using 14-gauge, 8.25 cm needle if tension pneumothorax develops, and anticipating hemopneumothorax requiring tube thoracostomy at fourth/fifth intercostal space, midaxillary line 1

The American Society of Anesthesiologists recommends providing adequate analgesia to prevent splinting and atelectasis, using a multimodal approach with IV/oral acetaminophen first-line, and low-dose ketamine as alternative to opioids 4
The Committee on Tactical Combat Casualty Care (TCCC) recommends urgent evacuation (Priority 1) for progressive hemorrhage despite interventions, suspected cardiac or great vessel injury, combined thoracoabdominal wounds, and respiratory failure requiring mechanical ventilation 5