Page 211 - 2026 SMOG

NEEDLE THORACOSTOMY
Clinical Indication
Suspect a tension pneumothorax and treat when a casualty has significant torso trauma or
primary blast injury and one or more of the following:
• Severe or progressive respiratory distress or tachypnea, absent or markedly decreased breath
sounds on one side of the chest, chest pain, distended neck vessels, hemoglobin oxygen
saturation <90% on pulse oximetry, shock, traumatic cardiac arrest without obviously
fatal wounds
*NOTE: If not treated promptly, tension pneumothorax may progress from respiratory
distress to shock and traumatic cardiac arrest
Procedure
**NOTE: This intervention is a BRIEF stopgap utilized in order to buy time for a definitive
tube thoracostomy. It is not a solution unto itself.**
• Decompress the chest on the side of the injury with a 14G or a 10G, 3.25-inch needle/catheter
• If a casualty has significant torso trauma or primary blast injury and is in traumatic cardiac
arrest, decompress both sides of the chest before discontinuing treatment. Clean the area if
possible with betadine/alcohol, but do not delay treatment for this step
• **NOTE: Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd
ICS in the midclavicular line (MCL) may be used for needle decompression (NDC). If the
anterior (MCL) site is used, do not insert the needle medial to the nipple line.
• The needle/catheter unit should be inserted at an angle perpendicular to the chest wall and just
over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way to
the hub and hold it in place for 5–10 seconds to allow decompression to occur.
• After the NDC has been performed, remove the needle and leave the catheter in place.
• The NDC should be considered successful if:
˚ Respiratory distress improves; there is an obvious hissing sound as air escapes from the chest
when NDC is performed (this may be difficult to appreciate in high-noise environments);
hemoglobin oxygen saturation increases to 90% or greater (note that this may take several
minutes and may not happen at altitude); the casualty with no vital signs has return of
consciousness and/or radial pulse.
• If the initial NDC was successful, but symptoms later recur:
˚ Perform another NDC at the same site that was used previously. Use a new needle/catheter
unit for the repeat NDC.
• If the second NDC is also not successful:
˚ Fix appropriate circulation issues and consider finger/tube thoracostomy
**Document procedure, results, and vital signs.**

2026 Standard Medical Operating Guidelines (SMOG) • 203