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FIGURE 17 Tourniquet placement. FIGURE 20 Placing the oropharyngeal cannula.

Needle Chest Decompression
Locate the second intercostal space and the middle clavicu-
lar line of the patient (Figure 21). If possible, clean the area,
and then insert a 10- to 14-gauge needle or catheter into the
inferior side of the upper rib in a 90° angle until the pleura is
penetrated and air escapes from the chest. Secure the needle to
the chest without occluding the end of the catheter. Monitor
closely for signs of recurring tension pneumothorax. In the
event of tension pneumothorax, repeat the procedure.
FIGURE 18 Use of combat gauze hemostatic dressing.
FIGURE 21 Needle chest decompression.

Sources and Recommended Lectures
American College of Surgeons. Advanced Trauma Life Support Stu-
dent Course Manual. 9th ed. Chicago, IL: American College of
Surgeons; 2012.
Center for Army Lessons Learned. Tactical Combat Casualty Care
Handbook. Version 5. May 2017. https://usacac.army.mil/sites
/default/files/publications/17493.pdf.
Savitsky E, Eastbridge B, eds. Combat Casualty Care: Lessons Learned
from OEF and OIF. Falls Church, VA: Office of the Surgeon Gen-
Nasopharyngeal Cannula eral, United States Army; 2012.
Before placing the cannula, check that there is no cerebrospi- Ministerio de Defensa de España. Manual de soporte vital avanzado.
nal fluid coming from the nose or ears. If there is no cerebro- December 2014. http://publicacionesoficiales.boe.es/.
spinal fluid, lubricate the cannula and place the patient’s head Confederation of Medical Reserve Officers (CIOMR). Combat Ca-
sualty Care Manual. Version 4.3. https://ciomr.org/mdocs-posts
in a neutral position (Figure 19). Insert the cannula in an angle /combat-casualty-care-zmanual/.
of 90° with respect to the patient’s head and push gently into Reyes-Baraona F, Rios J. Gas lacrimógeno: efectos mucocutáneos y
the nose until the flange rests against the nostril. enfrentamiento inicial. Rev Chil Dermatol. 2019;35(2):32–34.
Joint Trauma System. Critical Care Flight Paramedic Standard Med-
ical Operating Guidelines. FY18 Version published October 19,
FIGURE 19 Placing the nasopharyngeal cannula.
2017. https://mythcell.com/FY18_SMOG.pdf.
United States Army. Ranger Handbook SH 21-76. Ranger Training Bri-
gade United States Army Infantry School, Fort Benning, GA. April
2000. https://www.atu.edu/rotc/docs/3_21-76_ranger_hb.pdf.
United States Army. FM 90-10 Military Operations on Urbanized
Terrain (MOUT). https://archive.org/details/milmanual-fm-90-10
-military-operations-on-urban-terrain-mout/mode/2up.
Allen RC, ed. Pararescue Medication and Procedure Handbook.
2nd ed. 28 February 2001. http://www.operationalmedicine.org
/TextbookFiles/PJ.htm.
Joint Trauma System. The Department of Defense Center of Excel-
lence for Trauma. Clinical Practice Guidelines. https://jts.amedd
Oropharyngeal Cannula .army.mil/index.cfm/PI_CPGs/cpgs.
Place the patient’s head in a neutral position, open the mouth, Committee for Tactical Emergency Casualty Care. Tactical Emer-
and insert the cannula with the convexity in the caudal posi- gency Casualty Care (TECC) Guidelines. Current as of June 2015.
tion (Figure 20). After reaching the top half of the oral cavity, http://www.c-tecc.org/images/content/TECC_Guidelines_-_
JUNE_2015_update.pdf.
turn the cannula and push to the end. Do not use the cannula Warrior Publications. Warrior Crowd Control & Riot Manual.
in awake patients because doing so may stimulate the nausea Last word press. 2014. https://archive.org/details/WarriorCrowd
reflex. ControlRiotManual/page/n25/mode/2up.

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