Page 269 - PJ MED OPS Handbook 8th Ed

5. Respiration/Breathing:
a. Assess for tension pneumothorax and treat as necessary.
i) Suspect a tension pneumothorax and treat when a casualty has significant torso trauma
or primary blast injury and one or more of the following:
1) Severe or progressive respiratory distress
2) Severe or progressive tachypnea
3) Absent or markedly decreased breath sounds on one side of the chest
4) Hemoglobin oxygen saturation <90% on pulse oximetry
5) Shock
6) 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.

ii) Initial treatment of suspected tension pneumothorax:
1) If the casualty has a chest seal in place, burp or remove the chest seal
2) Establish pulse oximetry monitoring
3) Place the casualty in the supine or recovery position unless he or she is conscious and
needs to sit up to help keep the airway clear as a result of maxillofacial trauma
4) Decompress the chest on the side of the injury with a 14-gauge or a 10-gauge, 3.25-
inch needle/catheter unit
5) If a casualty has significant torso trauma or primary blast injury and is in traumatic
cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs
of life), decompress both sides of the chest before discontinuing treatment

NOTE: Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS
in the mid-clavicular 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.

iii) The NDC should be considered successful if:
1) Respiratory distress improves, OR
2) There is an obvious hissing sound as air escapes from the chest when NDC is per-
formed (this may be difficult to appreciate in high-noise environments), OR
3) Hemoglobin oxygen saturation increases to 90% or greater (note that this may take
several minutes and may not happen at altitude), OR
4) A casualty with no vital signs has return of consciousness and/or radial pulse.
iv) If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected ten-
sion pneumothorax:
1) Perform a second NDC on the same side of the chest at whichever of the two recom-
mended sites was not previously used. Use a new needle/catheter unit for the second
attempt.

Appendix 1: TCCC Protocols n 267