STP 31-18D34-SM-TG

Perform a Needle Chest Decompression

081-833-3007

Conditions: You have a conscious, breathing casualty with chest trauma who requires needle chest
decompression. Given a field medical card, stethoscope, large bore needle (10 to 14 gauge), 35 to 60 cc
Luer-Lok syringe with 3-way stopcock, povidone-iodine swab, and sterile gloves.

Standards: Perform a needle chest decompression without causing unnecessary injury to the casualty.

Performance Steps
NOTE: Pneumothorax is defined as the presence of air within the pleural space. Air may enter the pleural
cavity either from the lungs through a rupture or laceration or from the outside through a sucking chest
wound. Trapped air in the pleural space compresses the lung beneath it. Unrelieved pressure will push
the contents of the mediastinum in the opposite direction, away from the side of the tension
pneumothorax. This pressure, in turn, will compromise venous return to the heart and interfere with
respiration.
1. Verify the presence of tension pneumothorax (Figure 1) by checking for indications of the condition.

Figure 1. Tension Pneumothorax

WARNING Correct assessment is essential. Insertion of a needle into the pleural space of a
nonaffected person will result in pneumothorax.
a. Question a conscious casualty about difficulty in breathing, pain on the affected side, or
coughing up blood.
b. Observe a bared anterior chest and upper abdomen for respiratory rate and depth.
c. Look for mediastinal shift manifested as a tracheal deviation and/or jugular distension.
d. Look and listen for gasping for air (dyspnea) and progressive respiratory distress.
NOTE: Dyspnea may be, but is not always, an indication of pneumothorax.
e. Look at and feel the patient’s chest for signs of subcutaneous emphysema.
f. Check for lack of chest excursion.
(1) Observe the rising and falling of the chest on respiration.
(2) Compare chest excursion bilaterally.
g. Look for unilateral distension.
(1) Place one hand on the affected side.
(2) Place the other hand on the unaffected side.
(3) Observe the height of each hand.

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Performance Steps
(4) Determine if the height of the hand on the affected side is greater during expiration than
the height of the hand on the unaffected side.
h. Use a stethoscope to listen to breath sounds.
(1) Compare the sides for equality.
(2) Auscultate both sides of the chest.
(3) If breath sounds are unequal, percuss both sides to determine the difference in tone.
NOTE: Breath sounds will be diminished or absent on the affected side.
i. Check for progressive distension of the abdomen that is not relieved by gastric aspiration and
endotracheal intubation.
j. Look for deep cyanosis.
k. Look for signs and symptoms of shock.
2. Locate the insertion site (Figure 2).
a. Locate the sternomanubrial junction (Angle of Louis).
b. From the sternomanubrial joint, follow the adjacent intercostal space to the midclavicular line.

Figure 2. Insertion Site of Chest Decompression

NOTE: The preferred entry site is the space between the second and third ribs approximately in line
with the nipple on the affected side of the patient’s chest.
3. Thoroughly clean a 3- to 4-inch area around the insertion site. Begin in the center and work
outward using a circular motion.
4. Insert a large bore (14 gauge) needle with attached syringe.
a. Place the needle tip, bevel up, on the insertion site, centered over the third rib.
b. Lower the proximal end of the needle to permit the tip to enter the skin just above the third rib
margin.
c. Firmly insert the needle into the skin over the third rib, until the pleura has been penetrated,
as evidenced by feeling a "pop" as the needle enters the pleural space.
WARNING Proper positioning of the needle is essential to avoid puncturing blood vessels and/or
nerves.

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Performance Steps
5. Decompress the affected side by aspirating as much air as is necessary to relieve the patient’s
acute symptoms.
NOTE: If using a catheter-over-needle, hold the needle still and push the catheter into the pleural space
until resistance is felt. Withdraw the needle along the angle of insertion while holding the catheter still.
NOTE: If a three-way stopcock (Figure 3) is used, additional air can be aspirated from the pleural cavity
by turning the stopcock lever to allow expulsion of the air from the syringe.
6. Initiate closed chest drainage with underwater seal, if available (Figure 4). Proceed to step 7 if
improvisation is required. The needle may be removed once chest tube thoracostomy has been
achieved.

Figure 3. Three-Way Stopcock

Figure 4. Drainage System

7. If underwater seal drainage is not available, use a commercial one-way flutter valve or improvise
one (Figure 5).
a. Cut a finger casing from a sterile glove.

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Performance Steps
b. Cut off the fingertip.
c. Tie or tape the finger casing to the needle hub.
d. Check the operation of the improvised flutter valve.

Figure 5. Improvised Flutter Valve

(1) Ensure air passes through the needle-valve assembly and improvised flutter valve on
expiration.
(2) Ensure the flutter valve collapses against itself on inspiration.
NOTE: This valve prevents air from entering the plural cavity.
8. Secure the needle or catheter to the chest.
9. Record the treatment on the field medical card.

Evaluation Preparation: Setup: For training and evaluation, use a mannequin or have another soldier
act as the casualty. Under no circumstances will the needle be inserted. Have the soldier demonstrate
and explain what he would do.

Brief Soldier: Tell the soldier to perform needle chest decompression.

Performance Measures GO NO GO
1. Verified the presence of tension pneumothorax. —— ——
2. Located the insertion site. —— ——
3. Thoroughly cleaned the area. —— ——
4. Inserted a large bore needle. —— ——
5. Decompressed the affected chest. —— ——
6. Initiated closed chest drainage or apply a flutter valve. —— ——
7. Secured the needle or catheter to the chest. —— ——
8. Recorded the treatment on the field medical card. —— ——

Evaluation Guidance: Score the soldier go if all steps are passed. Score the soldier no-go if any step is
failed. If the soldier fails any step, show what was done wrong and how to do it correctly.

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References
Required Related
STP 8-91B15-SM-TG

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