BACKGROUND: Thoracic injuries are a leading cause of morbidity and mortality in military trauma. Tension pneumothorax (TPX) is a critical diagnosis that can lead to rapid hemodynamic and respiratory collapse if untreated. While timely intervention is essential, prehospital TPX diagnosis is challenging and may lead to unnecessary interventions. This study aimed to assess military prehospital chest injury management, including indications for chest decompression and clinical improvement post-intervention. STUDY DESIGN AND METHODS: Retrospective analysis of the Israel Defense Forces (IDF) Trauma Registry from January 2010 to August 2023 identifying patients who underwent needle or chest tube decompression. Data included demographics, injury mechanisms, vital signs, additional interventions, and prehospital mortality. Chart review evaluated decompression indications and outcomes, with the primary outcome being resolution of decreased oxygen saturation, tachycardia, or hypotension post-decompression. RESULTS: Overall, 224 patients were included, with a median age of 22 years. The most common injury mechanisms were gunshots (36.6%) and motor vehicle accidents (34.4%). Needle chest decompression was performed in 58.5% of cases, chest tubes in 12.5%, and both in 29.0%. Indications included traumatic cardiac arrest (53.1%), profound shock (17.9%), and SpO DISCUSSION: Chest decompression may be overutilized in prehospital military trauma. Future studies should refine criteria to optimize benefits while minimizing iatrogenic risks.