a. Assess for tension pneumothorax and treat as necessary.

NOTE:  If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest.

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.

b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

c. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

d. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

e.  If the casualty has impaired ventilation and uncorrectable hypoxia with decreasing oxygen saturation below 90%, consider insertion of a properly sized Nasopharyngeal Airway, and ventilate using a 1000ml resuscitator Bag-Valve-Mask.

f.  Use continuous EtCO2 and SpO2 monitoring to help assess airway patency.