Gunshot wound field treatment

Uncontrolled hemorrhage kills in minutes. A person bleeding from a severed femoral artery has roughly two to three minutes before blood loss becomes unsurvivable. Field treatment of gunshot wounds is not surgery — it is a race to control bleeding, protect the airway, prevent the chest from collapsing, and keep the patient alive long enough to reach surgical care. These techniques follow the TCCC (Tactical Combat Casualty Care) framework, the most evidence-based prehospital trauma protocol available.

Educational use only

This page provides general educational information for emergency preparedness scenarios when professional medical care is unavailable. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider. Use this information at your own risk.

Scene safety first

You cannot help anyone if you become the second casualty. Before touching the patient:

Identify whether the threat is active. Do not approach until the threat is neutralized or suppressed.
If the patient must be moved under fire: grab the collar or drag by the clothing with one hand while staying low. Move cover-to-cover. Do not stand up.
Once at a safe position: put on gloves and perform a rapid visual scan — locate visible wounds before you commit your hands to one location.
Call for emergency services the moment it is safe to do so. Shout for bystanders to call while you treat.

Do not waste time on scene aesthetics. Your job is hemorrhage control, not wound photography.

TCCC care categories

TCCC divides care into three phases based on threat status. Understand which phase you are in — it determines what you do.

Phase	Situation	Goal
Care Under Fire (CUF)	Active threat, taking fire	Apply tourniquet, return fire or seek cover. Nothing else.
Tactical Field Care (TFC)	Threat suppressed, not evacuated	Full Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia (MARCH) assessment, wound packing, chest management
Tactical Evacuation Care (TACEVAC)	En route to definitive care	Reassessment, monitor vitals, prevent hypothermia

In civilian emergencies, you will almost always work in the TFC phase — threat suppressed, EMS not yet on scene.

MARCH protocol — apply in this order

MARCH is the TCCC priority sequence. It differs from civilian cardiopulmonary resuscitation (CPR) training because hemorrhage kills faster than airway obstruction in most trauma scenarios. Do not skip ahead.

M — Massive hemorrhage

Life-threatening bleeding is your first target. Locate all wounds before treating any of them. A single dramatic wound can distract you from a second fatal one.

Location classification — do this immediately:

Wound location	Treatment priority	Approach
Extremity (arm, leg)	TOURNIQUET — do not delay	Apply tourniquet first, then assess
Junctional (groin, axilla, neck base)	PACKING — tourniquet cannot reach	Pack, direct pressure
Truncal (chest, abdomen, back)	PACKING if accessible, then stabilize	No tourniquet possible; hemorrhage may be internal

See the detailed procedures for each location in the sections below.

A — Airway

Assess after hemorrhage is controlled.

Conscious patient speaking in full sentences: airway is patent. Move on.
Unconscious, not speaking: tilt head back (head-tilt/chin-lift). Listen for breath sounds at the mouth and nose for 5–10 seconds.
Gurgling or snoring sounds: material in the airway — use a finger sweep to clear visible obstruction. Do not do blind finger sweeps.
Persistent airway obstruction in an unconscious patient: jaw thrust, recovery position (on the side), or nasopharyngeal airway (NPA) if one is in your kit and you have been trained to use it.

Do not hyperextend the neck if a spinal injury is possible from the mechanism of injury.

R — Respiration

Assess breathing rate and quality.

Normal adult rate: 12–20 breaths per minute
Breathing > 30/min, labored, or one-sided chest movement: high suspicion for tension pneumothorax or sucking chest wound — see the chest section below
Check for a sucking chest wound: listen and watch for air moving through any chest wall or back wound with breathing

C — Circulation

With hemorrhage controlled and airway maintained:

Check pulse at the wrist (radial) and neck (carotid). Absent radial pulse with present carotid pulse = severe shock.
Monitor for shock signs: pale cool skin, confusion, rapid weak pulse, capillary refill > 2 seconds (press fingernail — color should return in under 2 seconds).
See the shock prevention section below.

H — Hypothermia and head injury

Cover the patient as soon as practical — wet, cold, or windy conditions accelerate coagulopathy (the blood's ability to clot).
Assess mental status with GCS: Eyes (1–4) + Verbal (1–5) + Motor (1–6). Note baseline score and trend.
Unequal pupils (one fixed and dilated) suggest increased intracranial pressure from a head wound.

Extremity GSW — tourniquet first

For any gunshot wound on an arm or leg with significant bleeding, a tourniquet is the first intervention — not a last resort.

Expose the limb. Cut or tear clothing away from the wound. You cannot assess or treat through fabric.
Confirm the wound is on an extremity (below the shoulder/hip joint). If the wound is in the axilla (armpit), groin, or neck junction, a tourniquet cannot reach — go to the junctional section below.
Select a commercial tourniquet: CAT (Combat Application Tourniquet), SOFTT-W, or equivalent. A windlass-style commercial tourniquet is the standard. Improvised tourniquets (belts, cloth strips) fail at a much higher rate.
Route the tourniquet around the limb 2–3 inches (5–7.5 cm) above the wound on bare skin. For very high wounds (mid-thigh, upper arm), place the tourniquet as high on the limb as possible.
Thread the strap through the buckle and pull all slack out. It should be firmly snug before the windlass is engaged.
Twist the windlass rod until bleeding stops completely — not slows, but stops. This typically requires 3–5 full rotations and causes significant pain. That pain is expected and necessary.
Lock the windlass into the retention clip.
Write the time of application directly on the patient — on the forehead or arm with a permanent marker, in 24-hour format. Write "TQ" and the time. This is the most important piece of documentation you will do. Without it, the surgical team cannot determine limb viability.
Do not cover the tourniquet. It must remain visible.
Reassess the wound every 10 minutes — if bleeding has restarted or the tourniquet is visibly loose, tighten further or apply a second tourniquet directly above the first.

Under-tightening kills

A tourniquet that slows but does not stop blood flow is worse than no tourniquet — it creates venous congestion without arterial occlusion. The only test is: is the wound dry? If not, tighten more.

Junctional GSW — groin, axilla, neck

Tourniquets cannot reach the groin (femoral triangle), armpit (axilla), neck base, or shoulder junction. These wounds require wound packing combined with sustained direct pressure.

Groin and axilla wound packing

Put on gloves.
Identify the deepest visible point of the wound.
If using hemostatic gauze (QuikClot, Combat Gauze, Celox): keep it as one continuous strip — do not cut pieces. Push the end into the deepest point of the wound with your finger.
Pack the gauze in firmly from the bottom upward, pushing each layer in with your finger. Fill the cavity until the gauze is level with or slightly above the skin surface.
Apply hard, immediate pressure with both hands on top of the packed wound — use your full body weight if needed.
Maintain continuous pressure for 3 minutes with hemostatic gauze, or 5 minutes with plain gauze. Do not release pressure during this window.
Do not remove the packing. Apply an additional pressure dressing over the top secured with an elastic wrap.
Write the packing time on the patient.

For groin wounds: lay the patient flat with the leg extended. Press the packed wound downward toward the femoral head to tamponade the femoral vessels. If a second rescuer is available, one person maintains pressure while the other stabilizes the patient.

For axilla wounds: after packing, have the patient lower their arm over the wound to add body-weight pressure against the pack.

Neck GSW

Neck wounds are extremely dangerous and technically complex.

Apply direct pressure only — do not pack a neck wound circumferentially (you will obstruct the airway and jugular veins).
Use flat, firm pressure with a gloved hand or a pressure dressing against the specific wound site.
Do not probe the wound. Do not remove impaled objects.
Watch the airway constantly — swelling and hematoma can obstruct breathing rapidly. If swelling progresses, position the patient sitting up or at 30 degrees.
Transport priority: neck GSW is among the highest-urgency GSW types.

Carotid and jugular injuries are rapidly fatal

A through-and-through neck wound with venous or arterial involvement can kill in 60 seconds from blood loss or in minutes from airway hematoma. Pressure, airway monitoring, and transport are the only field tools available.

Truncal / abdominal GSW

Tourniquets cannot be applied to the abdomen. Internal hemorrhage from an abdominal GSW cannot be controlled in the field — the only treatment is surgical. Field care limits damage, prevents additional injury, and optimizes the patient for surgery.

Do NOT probe the wound or attempt to remove embedded bullets, fragments, or objects. Moving them can release tamponade on vessels.
Do NOT irrigate the wound track.
Cover open abdominal wounds with a moist dressing — saline-moistened sterile gauze, or improvised with the cleanest available cloth dampened with clean water. This prevents bowel desiccation and reduces infection.
If bowel is visible or has protruded through the wound (evisceration): do not push it back in. Cover it gently with a moist dressing. A brief, gentle reduction attempt is acceptable in a wound with a large opening if contents slide back easily without force — do not spend more than 60 seconds on this. Cover and transport.
Keep the patient warm. Hypothermia accelerates coagulopathy — an abdominal GSW patient who is cold dies faster.
Keep the patient NPO (nothing by mouth). Abdominal surgery requires an empty stomach.
Monitor for progressive shock — abdominal hemorrhage is internal and will worsen without surgery.

Field note

An abdominal GSW casualty who is conscious and talking is not stable — they are losing blood into the abdominal cavity where you cannot see it. Their mental status is your most important monitor. Increasing confusion = worsening shock.

Chest GSW

Penetrating chest trauma is covered in depth on the chest injuries page. Key field actions for chest GSW:

Sucking chest wound (open pneumothorax)

Any penetrating chest wound with air movement = sucking chest wound. This requires an immediate seal.

Seal the wound with a vented chest seal (Hyfin Vent, Russell Chest Seal) as the preferred device. A vented seal allows air to escape from the pleural space while preventing air entry during inhalation.
If a vented chest seal is unavailable: improvise an occlusive dressing taped on three sides (leaving the bottom edge open to vent). This is inferior to a vented seal but better than a fully occlusive improvised dressing.
Apply the seal to both entry and exit wounds if both are present.
Reassess. If the patient's breathing worsens after sealing (increasing distress, tracheal deviation, unequal breath sounds): tension pneumothorax is developing. Burp the seal (briefly lift an edge) to release trapped pressure. If burping provides temporary relief, the patient needs needle decompression.

Needle decompression (tension pneumothorax)

Needle decompression is a life-saving procedure for tension pneumothorax. It is appropriate only when clinical signs are present: increasing respiratory distress, absent breath sounds on one side, tracheal deviation (late sign), and a known or suspected penetrating chest injury.

Use a 14-gauge or 10-gauge needle/catheter, at least 3.25 inches (8.3 cm) long — shorter needles fail in muscular or obese patients.
Site 1 (standard): 2nd intercostal space (ICS), midclavicular line (MCL) — find the angle of Louis (junction where the manubrium meets the sternum), trace to the 2nd rib, go one space below, stay on the midclavicular line.
Site 2 (preferred for muscular/obese patients): 4th–5th ICS, anterior axillary line (AAL) — lower and more lateral; shorter chest wall depth, lower failure rate in large patients.
Insert the needle perpendicular to the chest wall straight to the hub.
Hold in place for 5–10 seconds to allow full pleural decompression.
Remove the needle. Leave the catheter in place.
Listen and reassess: hissing air escaping during decompression confirms the diagnosis. Breathing should improve.

Hemothorax

Blood pooling in the pleural space (hemothorax) from a chest GSW cannot be drained in the field. Position the patient on the injured side to consolidate blood away from the functional lung. Treat for shock. Transport urgently — hemothorax requires a chest tube.

Head GSW

Do not remove impaled objects.
Control scalp bleeding with direct pressure. Scalp wounds bleed dramatically even in minor injuries — the vessel density is high. Hold firm, sustained pressure.
Protect the airway. An unconscious patient with a head wound should be placed in the recovery position (on their side) if no spinal injury concern — the risk of airway obstruction from blood or vomit is high.
Assess GCS every 5 minutes. Record baseline and trend.
Check pupils: asymmetric (one fixed and dilated) or bilaterally fixed = serious intracranial injury with raised ICP. This is not treatable in the field — note it and transport urgently.
Do not hyperextend the neck in a suspected spinal GSW.
Do not apply a tourniquet to the neck for head bleeding — use direct pressure only.

Head GSW evacuation is non-negotiable

There is no field treatment for traumatic brain injury from a gunshot. Scene stabilization and transport are the entire intervention. Do not delay transport to perform assessments that will not change your field management.

Shock prevention and monitoring

All GSW casualties should be treated for hemorrhagic shock until proven otherwise.

Lay the patient flat on their back.
Unless spinal, abdominal, or chest injury is suspected, elevate the legs 8–12 inches (20–30 cm) to shift blood volume to the core.
Cover the patient immediately — mylar emergency blanket, sleeping bag, coats, anything. Keep them warm.
Monitor mental status every 5 minutes. Increasing confusion or decreasing responsiveness = worsening shock.
Do not give fluids by mouth to an unconscious or semi-conscious patient (aspiration risk). For a conscious, alert patient in prolonged field care with no abdominal injury, small sips of water are appropriate.
Reassess every bleeding control intervention with each monitoring cycle — tourniquets can slip, packed wounds can restart.

For complete shock recognition and management, see shock.

Pain management

Conscious patient, minor wound: ibuprofen 400–800 mg (if no suspected internal bleeding — NSAIDs impair platelet function) or acetaminophen 500–1,000 mg.
Suspected internal hemorrhage: avoid all NSAIDs. Acetaminophen is safer.
Oral transmucosal fentanyl (OTFC) or ketamine: present in some advanced TCCC caches and military aid bags. Their use is beyond the scope of basic field first aid and requires training.
Do not administer opioids to a patient with a depressed level of consciousness.

Wound monitoring after stabilization

Once life threats are controlled, initiate ongoing monitoring at every 10-minute cycle:

Check	Action
Tourniquet tightness	Confirm windlass is locked; bleeding has not restarted
Packed wound	Check for breakthrough bleeding soaking through the dressing
Chest seal	Confirm seal is intact; assess for worsening respiratory distress
Temperature	Patient warm? Add insulation if not
Mental status	Note any change from baseline GCS
Pupils (head GSW)	Symmetry, reactivity

Infection risk begins at 6–8 hours for open wounds and is severe for abdominal GSW. If antibiotic prophylaxis is available (amoxicillin-clavulanate, doxycycline), initiation is appropriate for penetrating abdominal and significant soft tissue wounds with anticipated prolonged field care.

Evacuation priority

Field treatment is a bridge, not a cure. All GSW casualties require surgical evaluation.

Wound location	Evacuation urgency
Abdominal	IMMEDIATE — internal hemorrhage not controllable in field
Chest	IMMEDIATE — hemothorax, pneumothorax require procedural care
Head	IMMEDIATE — no field treatment for intracranial injury
Junctional (groin/axilla/neck)	URGENT — packing is temporizing; surgical control needed
Extremity (tourniquet applied)	URGENT — tourniquet time determines limb viability

Tourniquet time directly determines limb salvage. Under 2 hours: typically safe for healthy tissue. 2–4 hours: increasing nerve and muscle injury risk. Over 6 hours: amputation risk increases significantly. Do not delay transport because the patient appears stable — stability from tourniquet control does not mean stability from the wound.

GSW field kit checklist

The techniques on this page pair directly with bleeding control for hemorrhage fundamentals, chest injuries for the complete tension pneumothorax and hemothorax protocols, and shock for managing the deterioration that follows uncontrolled hemorrhage. Train these procedures before you need them — the psychological freeze in a real GSW emergency is only broken by muscle memory.