If fluid resuscitation doesn't improve shock after hemorrhage control, suspect tension pneumothorax.

When you’ve done everything to stop the bleeding and you’ve given fluids, only to watch the patient stay in shock, a gut check is needed. In the field, you don’t have the luxury of time to chase every possible cause with a long, drawn-out workup. You rely on a few solid clues and decisive actions. Here’s the thing: if all hemorrhage control measures are in place and fluid resuscitation still doesn’t budge refractory shock, you should suspect tension pneumothorax.

What’s going on, exactly?

Think of the chest as a two-compartment system: the lungs and the heart. When air leaks into the pleural space and can’t escape, the space around the lung becomes pressurized. That pressure squashes the lung on that side and also squeezes the great vessels, cutting down venous return to the heart. The result? The heart doesn’t fill properly, the lungs don’t oxygenate well, and shock persists despite fluids and bleeding being controlled. In short, the problem isn’t just blood volume—it’s a mechanical problem inside the chest.

This is a classic trap you might encounter in tactical and austere environments. You may see a patient who looks pale or gray, with rapid breathing, a racing heartbeat, and developing confusion or agitation. You can still detect some signs that the story isn’t purely about blood loss.

How to tell tension pneumothorax from other shock culprits

• Anaphylactic shock (A): would usually show airway symptoms (swelling, wheeze, hives) and a response to epinephrine, not just a stubborn lack of perfusion after hemorrhage control.

• Tension pneumothorax (B): the clue is that breathing is compromised and circulation is faltering even when you’ve controlled bleeding and given fluids. It’s a pressure problem in the chest, not a simple shortage of fluid.

• Cardiogenic shock (C): the heart’s pumping problem could cause similar poor perfusion, but you’d expect signs pointing to a heart issue and you’d often be managing an underlying cardiogenic process, which is less common in the immediate post-trauma battlefield scenario.

• Hypovolemic shock (D): this is the classic blood-loss picture. Once you’ve controlled the bleeding and given adequate fluids, if shock lingers, you start thinking beyond volume loss—into intrathoracic problems like tension pneumothorax.

In the field, you’ll often rely on quick, practical indicators. Look for unilateral chest findings such as absent or diminished breath sounds on the affected side, hyperresonant percussion, and, when feasible, neck vein distension. The patient may appear visibly distressed, with sudden deterioration after initial stabilization. Remember: imaging is rarely available in austere settings, so your physical exam and sense of the scenario guide you.

Key signs to keep in mind (without getting lost in speculation)

• Rapid, shallow breathing or labored respiration on one side.

• Diminished or absent breath sounds on the suspected side.

• The chest on the affected side may feel unusually tender or tense to palpation.

• Tracheal deviation is a late and less reliable sign in a prehospital setting, but if you notice it, that’s a red flag.

• The patient remains hypotensive or shows signs of worsening perfusion despite fluids.

Put simply: when the “blood-only” story doesn’t resolve with fluids, you’re justified to look higher—toward the intrathoracic space.

Decompression: the decisive act that changes the story

If tension pneumothorax is suspected, decompression is the critical step that can restore circulation and oxygen delivery. In Tactical Combat Casualty Care, the goal is rapid relief of intrathoracic pressure to re-expand the lung and relax the vessels so venous return improves.

What you actually do depends on what you have at hand and your training level. In many field settings, needle decompression is the fastest option. Here’s a practical, straightforward approach you might use or adapt based on your protocol:

• Location and equipment: prepare for a chest decompression by accessing the second intercostal space at the midclavicular line (the classic “2nd ICS MCL” site) or the fifth intercostal space at the anterior axillary line as an alternative if the former isn’t accessible.

• Technique: insert a large-bore needle (often 14 to 18 gauge, depending on your kit) or a small chest catheter for rapid decompression. The needle goes through the chest wall into the pleural space to vent the trapped air.

• After decompression: expect an immediate improvement in breathing and, often, a stabilization of blood pressure. Oxygen remains essential—supplemental oxygen helps maximize the patient’s recovery once the lung re-expands.

• If symptoms recur or do not improve: that may indicate a persistent pneumothorax or a developing hemopneumothorax, and you should proceed with chest tube placement if the situation and your kit allow; transport for definitive care becomes urgent.

In practice, you won’t always have perfect visibility of anatomy in the heat of the moment. The emphasis is on speed and accuracy—pressure relief now, definitive care later. It’s a classic case of life over perfection, and in TCCC terms, that translates into decisive action and rapid evacuation.

Connecting the dots with the bigger picture

Why does this matter in tactical care? Because battlefield injuries teem with surprises. Bleeding is the most dramatic danger, but other hazards—air leaks, collapsed lungs, chest injuries—can stealthily derail your patient’s recovery. You’re training to think in systems: if you’ve controlled external bleeding and the patient isn’t responding to fluids, you should widen your lens to the chest.

This approach isn’t just for the doctors and medics in the field. It’s a mindset that bleeds into every strong prep and response plan. For teams operating in austere environments, that means carrying the right gear, rehearsing the decompression steps, and ensuring quick, orderly evacuation routes. The goal is resilience: a plan that keeps going when the obvious solution isn’t enough.

A few practical notes you’ll find useful

• Timing is everything. The faster you identify tension pneumothorax and relieve it, the better the odds your patient has to recover. Don’t wait for perfect diagnostic certainty when a quick maneuver can buy life.

• Don’t confuse this with simple pneumothorax. In tension pneumothorax, air doesn’t just accumulate—it builds pressure that actively squeezes the heart and great vessels.

• Always reassess after intervention. Vital signs, breathing, and mental status can change rapidly in the minutes after decompression. If you can, keep reassessing while you arrange evacuation.

• Balance with other injuries. Chest decompression doesn’t replace hemorrhage control or airway management. It complements them. You’re not choosing between one or the other—you’re stacking life-saving steps in a tight sequence.

• Training matters. In the chaos of a real operation, muscle memory from drills can be the difference between rapid, confident action and hesitation. Regular practice with your own kit, under realistic conditions, sharpens judgment.

A little story to anchor the idea

Let me explain with a quick scene. Imagine you’re part of a small rescue team moving through rugged terrain after an IED blast. You’ve already stopped external bleeding, applied tourniquets where needed, and started fluids. The patient looks pale, breathes fast, and you notice reduced breath sounds on one side. The clock is ticking. You act. You don the decompression needle, place it, and after a breath of relief, you see the chest rise more clearly and the pulse steadies a beat or two. The shock state doesn’t vanish instantly, but it begins to soften. That moment—where a decisive chest decompression shifts the balance—is why this maneuver belongs in every field toolkit.

Wrapping it up: what to remember for the next real scenario

• If hemorrhage control and fluids aren’t turning the tide, think tension pneumothorax.

• Look for respiratory distress with unilateral chest findings and signs of decreased oxygenation.

• Use rapid, field-appropriate decompression to relieve the pressure, then move toward definitive care.

• Remember that tension pneumothorax is a distinct animal from other shock etiologies; treating it quickly changes the odds.

The practical takeaway is simple, but powerful: when the story of shock doesn’t fit the bleeding narrative, you owe it to the patient to check the chest. In the austere, high-stakes world of tactical care, that small pivot can be the difference between a bleak prognosis and a path toward recovery. It’s not flashy, but it’s relentlessly effective.

If you’re building your mental toolkit for field care, this is one of those patterns you want to memorize and rehearse. The flow is familiar: stop the bleed, support with fluids as needed, then scan for chest trouble if the numbers don’t bend toward life. Tension pneumothorax doesn’t just sneak up on you—it announces itself with urgency. And when you hear that call, you’re ready to answer with a decisive decompression and a clear path to evacuation.