ATP 4-02.11 Reference

CHEST INJURIES: OCCLUSIVE DRESSINGS & NEEDLE DECOMPRESSION

Source: ATP 4-02.11, Chapter 6 — Respiration and Breathing Control, 23 March 2026

Key Points

  • Respiration is the "R" in MARCH-PAWS
  • Chest wounds are NOT addressed during CUF — TFC only
  • Vented (3-sided) chest seal is preferred over unvented
  • NCD landmark: 2nd intercostal space, midclavicular line
  • Catheter size: 10-gauge or 14-gauge, at least 3.25 inches long
  • NCD is a Tier 2 (CLS) skill
  • Slow breathing (<6/min) or rapid (>20/min) = respiratory distress
  • Tension pneumothorax = deviated trachea, absent breath sounds on affected side

Common Mistakes

  • Applying chest seal during CUF (must wait for TFC)
  • Using unvented seal when vented is available
  • Wrong NCD site — must be 2nd ICS, midclavicular, NOT 5th ICS AAL for Tier 2
  • Failing to check for a second (exit) wound and sealing only one side
  • Not reassessing breathing rate and quality after applying chest seal

Respiratory Distress Signs

  • Difficulty breathing / struggling to get air in or out
  • Breathing too weak — <6 breaths/minute
  • Rapid breathing — >20 breaths/minute
  • Bruising, crepitus over chest/back/ribs
  • Visible deformity of chest wall
  • Sucking or bubbling sound from chest wound
Critical Principle

Airway and respiration are NOT addressed during CUF. They must be addressed in TFC. After establishing an open airway, evaluate respirations — this is the "R" of MARCH-PAWS. Respiratory failure kills; chest wounds and tension pneumothorax must be identified and treated immediately. (ATP 4-02.11, para 6-1)

Types of Chest Injuries

Open Pneumothorax (Sucking Chest Wound)

A penetrating chest wound creates a direct opening between the atmosphere and the pleural space. With each breath, air enters through the wound rather than through the trachea. The wound may produce a characteristic sucking or bubbling sound.

Treatment: Apply a vented (preferred) chest seal over the wound. The vent allows air to escape during exhalation but prevents air from entering during inhalation.

Tension Pneumothorax

When air accumulates in the pleural space with each breath but cannot escape (one-way valve effect), pressure builds up, collapsing the affected lung and eventually shifting the heart and mediastinum to the opposite side. This is rapidly fatal without intervention.

Signs and symptoms:

  • Severe respiratory distress; casualty cannot breathe
  • Absent or diminished breath sounds on the affected side
  • Tracheal deviation toward the unaffected side (late sign)
  • Hypotension; neck vein distension (late sign)
  • Rapidly deteriorating casualty with chest trauma

Treatment: Needle chest decompression (NCD) — immediate priority.

Chest Seal Application

The CoTCCC-recommended chest seal is a vented, self-adhering device. A vented seal is preferred over an unvented (3-sided) seal because it allows air to vent out during exhalation, reducing the risk of tension pneumothorax. (ATP 4-02.11, para 6-8)

  1. 1

    Expose the wound — expose the entire chest area. Check for both entry and exit wounds. Each wound requires its own seal.

  2. 2

    Dry the skin around the wound as much as possible — moisture prevents adhesion. Pack gauze around wound if needed to dry the area.

  3. 3

    Remove the backing from the chest seal. Center the vent over the wound opening.

  4. 4

    Press firmly around the edges to create an airtight seal. Ensure all edges are adhered, particularly at the inferior edge where blood may pool.

  5. 5

    Reassess breathing. If the casualty's condition worsens after applying the seal, consider lifting the lower edge briefly to allow trapped air to escape (burp the seal), or prepare for NCD if tension pneumothorax is suspected.

Needle Chest Decompression (NCD) — Tier 2 Skill

NCD is used to treat tension pneumothorax by releasing trapped air from the pleural space. The CoTCCC-recommended device is a 10-gauge or 14-gauge catheter-over-needle, at least 3.25 inches long. (ATP 4-02.11, para 6-10)

NCD Landmark

2nd intercostal space, midclavicular line on the affected side. Insert just above the 3rd rib to avoid the neurovascular bundle running below each rib. A rush of air confirms placement.

  1. 1

    Identify the 2nd intercostal space, midclavicular line on the side of the tension pneumothorax.

  2. 2

    Clean the insertion site if time allows. Remove the protective cap from the catheter.

  3. 3

    Insert the needle perpendicular to the chest wall, just above the 3rd rib (avoids neurovascular bundle on lower margin of 2nd rib), at 90 degrees.

  4. 4

    Advance the needle until a rush of air is felt or heard — this confirms penetration into the pleural space.

  5. 5

    Advance the catheter off the needle; withdraw the needle. Leave the catheter in place. Secure with tape if available.

  6. 6

    Reassess the casualty — breathing should improve. Note time of NCD on DD Form 1380.

ATP 4-02.11 Source

Chapter 6: Respiration and Breathing Control — Army Techniques Publication 4-02.11, Casualty Response, Tactical Combat Casualty Care, and First Aid. Headquarters, Department of the Army, 23 March 2026.

See It in Practice — ESB Tasks

These ESB Medical Lane tasks apply this doctrine directly:

M7: Occlusive Dressing / Needle Decompression
Airway Management Shock Recognition & Management