Occasionally, casualties will not respond to fluid resuscitation, even when blood products are used, and shock will either persist or worsen. If this occurs, a thorough reassessment of the casualty must be performed to ensure that all sources of bleeding have been addressed. This includes reassessing all external hemorrhage control measures (tourniquets, wound packing, etc.), applying or repositioning a pelvic compression device, administering TXA if it has not already been done, and continuing with fluid resuscitation with blood products, if possible.

If these measures do not lead to improvement in the casualty status, consideration of an unrecognized tension pneumothorax should be suspected. Certainly, this would be supported by a decreased oxygen saturation (<90%) and absent breath sounds on one side or in a casualty who previously was treated successfully for a tension pneumothorax; but even without all of those symptoms, treatment with a needle decompression of the chest (NDC) should be considered. If not already done, treat indications with repeated Needle Decompression of the Chest (NDC), up to 2 times.

Also, depending on the mechanism of injury, signs, and if shock persists, consider decompressing the opposite side of the chest if indicated.