Gunshot Wound to the Thorax: Lessons from a Landmark Case

Introduction

Penetrating chest wounds, particularly gunshot wounds, present a significant challenge to prehospital responders. Rapid response, early identification of immediate life threats, and implementation of advanced field procedures can make the difference between life and death for these critically ill patients. This article analyzes an emblematic case of prehospital management of a gunshot wound to the chest, highlighting crucial elements of the clinical approach, resuscitation strategies, and the importance of effective teamwork.

The clinical case

The case in question, taken from an educational video available on YouTube (viewable below), involves a patient with a penetrating gunshot wound to the left chest, managed by an experienced prehospital emergency team. Upon arrival on scene, the patient was in obvious hemorrhagic shock with a blood pressure of 85/62 mmHg . The team immediately noted the presence of subcutaneous crepitus in the left axilla, suggestive of pneumothorax , and identified a significant hemothorax .

I invite everyone to view and carefully study the video uploaded on the Dr channel.

https://www.youtube.com/@lmellick .

For those who don't understand oral English well, here's a detailed analysis of what happened.

Critical aspects of the intervention

Initial assessment and detection of immediate threats

The team's assessment immediately focused on identifying the lethal threats: hemorrhagic shock , respiratory compromise, and potential tension pneumothorax . The approach was geared toward recognizing the mechanism of injury ("the entry route of the projectile") and correlating it with the clinical signs observed. Identifying subcutaneous crepitus immediately alerted the team to the likely underlying lung injury.

The ability to perform a targeted assessment in seconds highlights the importance of a “threat-to-life first” approach in trauma patients. At this stage, systematic assessment must give way to rapid recognition of threats that can rapidly lead to traumatic cardiac arrest.

Management of hemorrhagic shock and resuscitation with blood products

One of the most significant aspects of this case was the immediate and aggressive use of warmed whole blood in the prehospital setting. Recent scientific literature strongly supports this approach:

• The Prehospital Air Medical Plasma Trial ( PAMPER ) study demonstrated a reduction in 30-day mortality in trauma patients who received prehospital plasma ( DOI: 10.1056/NEJMoa1802345 ).

• The PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial showed benefits in using balanced ratios of blood components (1:1:1 plasma, platelets, red blood cells) in patients with massive hemorrhage ( DOI: 10.1001/jama.2015.12 ).

• The study by Shackelford et al. documented significantly increased survival in patients with traumatic hemorrhagic shock who received prehospital transfusions ( DOI: 10.1001/jama.2017.15097 ).

• The work of Levy et al (2024) showed improved survival in severe trauma patients treated with whole blood in the prehospital setting ( DOI: 10.1002/emp2.13142 ).

In this case, the rate of infusion was impressive, as evidenced by the exclamation of one team member: " Holy crap... I'm watching this bag turn itself inside out. It's going so fast ." This observation underscores the severity of the hemorrhage and the need for rapid, massive infusion to counteract hemorrhagic shock.

Interestingly, there has been discussion of the use of tranexamic acid (TXA), an antifibrinolytic that may reduce mortality in patients with trauma and significant bleeding. The CRASH-2 study demonstrated a reduction in mortality in trauma patients treated with TXA ( DOI: 10.1016/S0140-6736(10)60835-5 ), while the STAAMP study specifically evaluated the use of TXA in the prehospital setting, showing potential benefits in specific subgroups of patients ( DOI: 10.1001/jamasurg.2020.4350 ).

Recognition and treatment of pneumothorax/hemothorax

The team identified a "significant left hemothorax" and proceeded rapidly to drainage. The modern approach to traumatic pneumothorax is to use finger thoracostomy rather than traditional needle decompression, which has a high failure rate (up to 60-80% in some studies). More and more advanced team guidelines (e.g. FPHC 2024) prefer it to needle, but it is not yet standard for all systems

Simple thoracostomy (without tube insertion) is now recommended as the method of choice for chest decompression in the prehospital setting by many international guidelines. This is because:

1. It's quicker to perform

2. It has a significantly higher success rate than needle decompression.

3. It allows a direct evaluation of the presence of blood in the pleural cavity

4. Facilitates subsequent insertion of a thoracostomy tube in a hospital setting

In the present case, the approach was quick and decisive: " Put your finger in there and just get it as wide, " indicating a correctly performed finger thoracostomy technique.

Preparation for advanced interventions: videolaryngoscopy and SALAD technique

Of particular note was the " resuscitate before intubate " approach. The team wisely recognized that premature intubation in a hypovolemic patient can precipitate cardiac arrest, and therefore decided to hemodynamically stabilize the patient before proceeding with advanced airway management .

I would like to underline how modern literature and numerous field testimonies now agree in stating that, in a critical patient and in peri-arrest, it is essential to stabilize him properly before proceeding with intubation via RSI or DSI .

Preparation for intubation included the use of a video laryngoscope and the SALAD ( Suction Assisted Laryngoscopy and Airway Decontamination ) technique. This technique represents a significant advancement in the management of airways contaminated with blood or secretions, particularly common in thoracic trauma.

The SALAD technique includes:

• Continuous use of suction (with DuCanto or Yankauer catheter) during laryngoscopy

• Strategic placement of the suction catheter to maintain a clear field of vision

• Coordinated manipulation of laryngeal structures during aspiration

This approach, combined with videolaryngoscopy, significantly increases the chances of success at the first intubation attempt, reducing the risk of complications.

The Crucial Role of Teamwork: Communication and Coordination

The effectiveness of the intervention described was amplified by excellent teamwork. The team demonstrated mastery of the principles of Crisis Resource Management ( CRM ):

1. Closed-loop communication : Every order was confirmed (“Sounds good”, “Got it”, “Perfect”), ensuring that no critical information was lost.

2. Clear but not authoritarian leadership : The brilliant D.ss Jenn Price's directives were precise but collaborative, fostering an environment where every member could contribute.

3. Effective distribution of tasks : Roles were clearly defined, with specific instructions given to different members ("Get your lines", "Can you come over this side", "You're driving").

4. Anticipating problems : The team anticipated potential complications and prepared accordingly ("his cardiac arrest will be from exsanguination...").

5. Situational communication : Constant updates on vital signs and response to therapies allowed for dynamic adaptation of the therapeutic approach.

These elements of effective communication are critical in high-stress situations where time is limited and decisions must be made quickly. Clear communication and effective coordination contributed significantly to the positive outcome of the case.

Transport and transition to definitive care

Transport planning was another key element of management. The team recognized the need for rapid transfer to a level one trauma center early, activating the air ambulance while continuing to stabilize the patient.

The mantra " right patient, right place, right time " was perfectly applied in this case. The patient was transported directly from the helicopter landing zone to the operating room, bypassing the emergency room and minimizing the precious time between the onset of the injury and definitive surgical treatment.

Continuity of care during transport was ensured by continuing the transfusion of warmed whole blood during the flight, highlighting the importance of maintaining life-saving therapies even during the transfer phase.

Outcome and conclusions: lessons from a success story

The final outcome of the case was extremely positive: the patient was discharged from the hospital on the ninth day . This result underlines the effectiveness of the integrated and timely approach in the management of gunshot wounds to the chest.

The video team deserves applause for demonstrating clinical excellence, effective communication, and decision-making under pressure. Their intervention truly sets the standard for what should be the optimal prehospital management of a critically ill patient with penetrating thoracic trauma.

Comparison with the Italian reality

It is important to contextualize this case with respect to the Italian reality, which presents significant epidemiological and organizational differences:

Epidemiological differences : In the United States, there are approximately 45,000 ( https://wonder.cdc.gov/ucd-icd10.html ) deaths per year from gunshot wounds, while in Italy there are approximately 400-500 ( https://esploradati.istat.it/ ), mostly due to suicides. According to ISTAT data, the incidence of gunshot wounds in Italy is approximately 90 times lower than in the USA. This enormous difference in case history inevitably affects the experience of the teams and the structuring of the protocols.

Comparison	Italy	USA
Gunshot wounds/year	~400-500	~45,000
Access to blood products	~3% of pre-hospital services	~17%
EMS Team Type	Doctor/Nurse	Paramedics (ALS/ILS)
Diffusion thoracostomy	Rare	Growing, recommended

Organization of emergency systems : The Italian system is characterized by advanced medicalization (doctor and/or nurse on the ambulance), while many US systems rely on paramedics with advanced training. Both models have strengths, but differ significantly in the approach and procedures available.

Availability of blood products : The use of whole blood in the prehospital setting is still rare in Italy, while it is more widespread in some American EMS systems. A 2022 survey found that only 3% ( SIAARTI's "Blood on Board" ) of Italian territorial emergency services have access to blood products, compared to 17% in the United States. Things are a little better in Italian HEMS bases where the figure reaches 7% ( DOI: 10.1016/j.amj.2023.11.007 )

Despite these differences, there are important lessons to be learned from the case analyzed that can also be implemented in the Italian context:

1. The Importance of Clear Protocols and Specific Training for Penetrating Thoracic Trauma

2. The need to develop systems to make blood products available in the pre-hospital setting.

3. The implementation of advanced airway management techniques such as videolaryngoscopy and SALAD.

4. Adopting CRM principles to improve team communication and coordination.

   
   

What do you think about the management of this scenario? Do you have any doubts, concerns? Write them in the comments!

Bibliography

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2. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. DOI: 10.1001/jama.2015.12

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