In a modern combat or survival scenario, a medic is not typically the first line of response, but instead each member of the unit or team is trained on how to save their own lives and the lives of those operating around them. This is achieve by having a first response plan and following an initial assessment and management process known as the primary survey. But in order for this to work, an individual first aid kit (IFAK) is required, along with the knowledge and skills on how to use it. So who should carry an IFAK, and how do you use one in an attempt to save a life?

IFAK’s are compact medical kits issued to military soldiers when going into battle, and are swiftly becoming popular amongst civilians and preppers alike. The IFAK consists of medical tools that allow the user to conduct a primary survey, aiming to treat casualties and save lives as a first responder, particularly when operating in remote areas. The primary survey is the initial assessment and management of a trauma patient. It is conducted to detect and treat actual or imminent life threats and prevent complications from serious injuries. A systematic approach using DR CABC DE is used.

It is highly recommended to carry an IFAK, along with the knowledge and skills in how to properly use one, under the following circumstances:

• When hunting
• When at the firing range, or anywhere else that firearms are being used
• When preparing for active shooter situations
• If you live in rural or remote areas
• When dealing with heavy or dangerous machinery that may cause serious injury
• When preparing for disaster or survival scenarios
• When deploying on military operations or into high risk areas
• In your vehicle or bugout bag if you wish to do so

You can read exactly what contents should be carried in your IFAK under the following post: Contents of an Individual First Aid Kit: What Do You Really Need In Your IFAK?. If you have read the post, or if you are happy with the IFAK contents and their purpose, continue reading below and we’ll discuss how to use them as a first responder.

Warning: the information given in this article is intended for use by trained professionals. Always seek professional medical training before attempting any of the following techniques.

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The Primary Survey

The primary survey is the initial assessment and management of a casualty. It is conducted to detect and treat actual or imminent life threats, and prevent complications from these injuries.

When approaching a casualty to provide treatment, the colour coded card below summarises the steps in providing a thorough assessment and care towards the casualty. This card can be downloaded and saved to your mobile device, or printed and laminated for quick reference when needed.

During the primary survey, the following systematic approach using DR CABC DE is used.

DANGERS

• Your first step is to call or radio for help & assistance
• Ensure that the area is safe, clear and free from danger

RESPONSE

• Check AVPU (is the casualty Alert, Responsive to your Voice, Responsive to Pain, or Unresponsive?)

CATASTROPHIC HAEMORRHAGE CONTROL

• Conduct a thorough blood sweep (wearing gloves)
• Apply direct pressure, followed by a tourniquet or wound packing where necessary

AIRWAY

• Ensure the airway is clear, and clear the airway if necessary
• Insert a nasopharyngeal airway tube (if the casualty is not fully-responsive)
• Place the casualty in the lateral recovery position (unless you suspect a spinal injury)

BREATHING

• Assess breathing (look, listen and feel). Average rate should be 12 to 20 breaths per minute
• If not breathing, begin CPR (100 compressions per minute) or use an AED
• If difficulty breathing, assess for penetrating chest injuries and deal with any sucking chest wounds (apply a chest seal) or tension pneumothorax (requires needle decompression) where necessary

CIRCULATION

• Assess the casualty for signs of shock (conduct a second blood sweep), and apply gauze and bandages to stop any further bleeds
• Conduct a capillary refill test (should return after 2 seconds) and elevate injured limbs
• Assess pulse rate (normal adult resting heart rate is 60 to 100bpm)
• If shock is evident, administer fluids (IV drip or small sips of water) and keep warm

DISABILITY

• Assess the mental state of the casualty (AVPU once again) and splint where necessary

EXPOSURE & ENVIRONMENTAL CONTROL

• Remove wet clothing, and prevent hypothermia by keeping warm and giving fluids

Each life-saving step in this primary survey (haemorrhage control, airway, breathing and circulation) will be discussed on more detail below.

Tip: when approaching a casualty, always do so from the foot end. This avoids startling or further unsettling the casualty.

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1. Catastrophic Bleeding

Catastrophic Bleeding, otherwise known as a Catastrophic Haemorrhage, is defined as blood rapidly escaping from arteries, veins or capillaries.

Catastrophic Bleeding is the most frequent cause of preventable deaths on the battlefield. These preventable deaths are defined as deaths that could be avoided through public health and prevention interventions; proper first response in casualty care.

Click here to see an image of the body’s major arteries

1.1 Types of Haemorrhage

• Arterial: BRIGTH RED blood gushes out in spurts that are synchronised with the heartbeat. This bright red colour is a result of the high levels of oxygenation in the blood, and causes rapid loss of blood from the body
• Venous: blood flowing from a damaged vein is DARK RED (due to the lack of oxygen it transports) in colour and can be characterised by a steady, even flow. They can be life threatening depending on how much blood is being lost and how quickly
• Capillary: usually BRICK RED in colour, and oozes out slowly, although the flow may appear fast at first. Blood loss is usually slight and easy to control

• Extremity: bleeding from the arms, legs, hands, or feet
• Non-Extremity: bleeding from the head, neck, chest, back, abdomen, or pelvis

1.2 Our Blood Supply

The average human body holds around 5 litres of blood.

• Losing approximately one fifth (1 litre) would result in shock (lack of blood flow and oxygen deprivation in the blood)
• 30 to 40% of blood loss (1.5 to 2 litres) requires a transfusion, otherwise known as a blood donation
• Losing half of ones blood supply (2 and a half to 3 litres in the average body) will result in death

Depending on which artery is damaged and where, a bleed-out can take between 1 to 3 minutes. Immediate application of a tourniquet or blood-clotting agent (to the extremities) or direct pressure (to non-extremities) is therefore vital.

The following steps should be used when assessing for or dealing with a catastrophic bleed:

1.3 Applying Direct Pressure

Direct pressure is typically applied to severe non-extremity wounds, or to extremity wounds which are too high up to apply a tourniquet (the groin, armpit, etc). Direct pressure onto the wound constricts the blood vessels manually. 

1. First Pack the wound (use your fingers first with extreme pressure, and then gauze/ bandage or a clean cloth or piece of clothing). If the wound appears too large or won’t clot, use a homeostatic agent (see below)
2. Then apply direct pressure onto the wound for no less than 4 minutes, and then check to see if the bleeding has stopped
3. Secure the wound with a bandage/ dressing

To keep direct pressure onto the wound, use a piece of gauze and make a small pyramid/ mountain shape or use a second dressing made small & tight. This should sit directly beneath the bandage to apply constant pressure onto the wound. Alternatively you can use a pressure dressing which is designed to apply direct pressure onto the injured area.

Warning: do not pack chest & abdominal wounds. Bleeding in these areas are not compressible and wound packing won’t work. You’ll simply be wasting both time and medical supplies. In these instances, dress or cover the wound and get the patient into surgery as fast as possible. Also take care when packing a neck wound so that you don’t compromise the airway. And don’t wrap your bandage around the patient’s neck after packing; rather wrap it over the injured side of the neck and under/around the opposite armpit.

1.4 Dealing with a Pelvic Injury

A suspected shattered/ fractured pelvis must be stabilised by use of a pelvic splint. A pelvic fracture may include severe internal bleeding which, if untreated, may result in a bleed out. A pelvic splint therefore acts as a tourniquet to the pelvis.

1.5 Homeostatic (Clotting) Agents

Homeostatic agents are designed to promote rapid blood coagulation in the event of arterial bleeding by utilising the clotting properties of Kaolin. Common brands include:

• Combat Gauze
• Celox
• Quick Clot
• Hemcon

Kaolin works by activating a protein which assists in the initiation of the coagulation cascade – a protein chain reaction which promotes blood clotting as a result of trauma.

If a wound is too severe or too large, it may be difficult to stop the bleed without a clotting agent or tourniquet. Alternatively, you may wish to directly use a clotting agent in place of a tourniquet, as it provides a far greater chance of saving the casualties limb post-surgery. It is highly recommended to attach the packaging of the clotting agent to the casualties exterior. This lets the operating room know exactly what ingredients have been packed into the casualties wound, as some may require separation before surgery takes place.

1.6 The Combat Tourniquet

The combat tourniquet is used for severe bleeding to the extremities.

• A tourniquet must be applied to the extremities ONLY WHEN REQUIRED (during arterial or severe venous bleeds)
• If the patient is responsive, warn them that a tourniquet will be applied and that it will be extremely painful
• Place the tourniquet on top of clothing so that it remains visible for when paramedics arrive. But, ensure that there are no items beneath the tourniquet or inside of pockets that will prevent a tight seal
• Methods of application include high and tight (high up on the limb), 4 fingers above the wound or amputation, or above the joint of the wound or amputation 
• Once applied, the tourniquet must not be removed otherwise blood poisoning (septic shock/ septicaemia) is likely, resulting in death without immediate treatment
• Mark the time of application and inform the paramedic/ doctor that a tourniquet has been applied
• Place a “T” on the casualty’s forehead if possible; use blood or a marker pen
• In some cases, a second tourniquet may be required. This should be placed above the initial tourniquet

The risk of losing a limb below an applied tourniquet is likely after 3-hours, however this information is only to expand your knowledge and does not take away from the fact that a tourniquet must remain in place once applied, and is only to be removed by a trained professional.

Tip: store tourniquets ready for use, and ideally use spare tourniquets on a patient, saving your own tourniquets for yourself should you need them later on. Use a Makeshift Tourniquet when required; youtube provides some good makeshift ideas.

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2. Casualty Airway

The Airway consists of the Nose, Mouth, Throat, Voice Box and Wind Pipe. It is the canal through which air passes into the lungs, which are protected by the ribs. The lungs and heart draw oxygen into the blood cells, which require a constant supply of oxygen in order for our survival. The brain will die if the oxygen supply ceases for more than 4 to 6 minutes. Once these cells die, they are unable to regenerate, resulting in brain damage, paralysis or death. It is therefore vital to always ensure that your casualty has a clear airway.

The cycle of inhaling an exhaling is repeated 12 – 20 times per minute. This is breathing rate which we look out for assessing a casualties breathing. If breathing is less than 12 or more than 20 breaths per minute, then something is not right.

2.1 Identifying an Airway Emergency

Check for responsiveness of the casualty using the pneumonic: AVPU (Alert, Responsive to Voice, Responsive to Pain, or Unresponsive). Response to pain can be checked by either a Sternum Rub or pinch around the Brachial Artery (inside the tricep). If the casualty is alert or responds to your voice, then this is a good sign that the airway is clear, and if so, you can move past airway after a quick check.

A sternum rub is the application of painful stimulas with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli. The sternum rub is the most common painful stimulus practiced in the field by EMTs and paramedics.

EMS1.com

Common causes of an airway emergency are foreign body airway obstructions such as the tongue, broken teeth, vomit, or other foreign materials.

If the casualty is unresponsive, use the Jaw Thrust / Head Tilt / Trauma Chin Lift technique to open the airway and inspect, and remove any airway obstructions immediately.

Warning: always avoid placing your fingers into the casualty’s mouth where possible, as they can be bitten clean off and cause further complications. Instead, use Magill Forceps if you have them in your kit.

2.2 Insert a Nasopharyngeal Airway

The next step is to insert a Nasopharyngeal Airway Tube – this is a soft, latex device that is inserted through one of the nostrils and follows the natural pathway, bypassing any breathing problems caused by the tongue. If the casualty is fully responsive, there is no need, but if you feel that they may lose consciousness at any point, rather be safe and open up the airway by use of a NPA.

When selecting a NPA, choose one with a diameter smaller than the casualties nostril, and then measure from the casualty’s nose to earlobe for correct NPA sizing – this is important. Cut the NPA down with trauma shears if necessary.

Lubricate the NPA before inserting (use a water-based lubricant, vaseline, blood, etc).

The NPA works on both conscious & unconscious casualties, and does not disturb the gag-reflex unlike an Oropharyngeal Airway Tube, and is therefore the preferred method for keeping the airway open.

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3. Breathing

The first step in assessing your casualty’s breathing is to check for normal breathing, or to make sure that the casualty is breathing at all.

• Look, Listen & Feel – kneel down with your cheek and ear next to the casualty’s mouth and nose area, looking down the body towards the abdomen:
  • Look at the upper abdomen and chest to see if it is rising and falling
  • Listen to hear if they are either breathing, gasping, or not breathing
  • Feel for their breath on your cheek and look for the rise and fall of the chest with your hand on the diaphragm

• Monitor for 10 Seconds, and then multiply by 6 to give you total breaths per minute. Normal breathing is rhythmic (in & out) with 12 – 20 breaths per minute

Normal Breathing– if the casualty is breathing normally, place them into the recovery position and move onto Circulation. 

Not Breathing – if the casualty is not breathing, immediately begin chest compressions (CPR) at a rate of approximately 100 (to 120) compressions per minute, or use an AED (automated external defibrillator) if one is available. 

Breathing is Not Normal – if the casualty is breathing, but you are not certain that 12 – 20 rhythmic breaths are taking place per minute, assume that there is a problem with the casualty’s breathing and assess for penetrating chest injuries.

3.1 Cardiopulmonary Resuscitation (CPR)

CPR is is an emergency procedure consisting of chest compressions that aim to pump oxygenated blood around the body, allowing it to circulate to vital organs such as the brain and heart.

When performing chest compressions, interlock your fingers of both hands, lining your middle finger up with the mid-nipple line over the pectoral (above the heart), and the base of your palm sitting above the sternum.

Warning: while two hands are used to perform chest compressions on an adult, only one hand should be used on children, and only two fingers when performing chest compressions on an infant.

Do not stop giving CPR until the casualty begins breathing, or until medical assistance arrives, or until you physically cannot continue any longer. 

3.2 Assess for Penetrating Chest Injuries

Chest injuries are the second leading cause of trauma deaths each year, although the majority of all chest injuries (70 to 85%) can be managed without surgery.

Look, Listen & Feel for signs of penetrating chest injuries such as a Sucking Chest Wound or Tension Pneumothorax.

3.3 Sucking Chest Wound (or Open Chest Wound)

Penetrating Trauma (caused by a stabbing, gunshot, shrapnel, etc) to the chest can cause a collection of air or gas to enter the pleural space (the thin fluid-filled space between the two pulmonary pleurae of each lung) causing the lung to collapse. These wounds allow air to enter when the intrathoracic pressure is negative, and block the air’s release when the intrathoracic pressure is positive.

Signs & Symptoms:

• Chest wall trauma (bleeding & visible wounds)
• Shortness of breath & fast breathing
• Decreased chest wall motion (the chest not expanding to its full potential)
• Moist sucking or bubbling sounds coming from the chest wall

Treatment:

Assess for entry & exit wounds, and if discovered, cover them with an occlusive (air & watertight) dressing, such as a Chest Seal.

Note: wipe away blood, sweat, and other obstructions before applying the dressing or Chest Seal, and if necessary, use a surgical blade to remove excessive hair. 

Remember: it is very important to check the casualty’s back as well. While their may not be any penetrating chest injuries on his front, air can still enter the pleural space from the back. Remove clothing and body armour for a thorough inspection if you suspect a penetrating chest injury.

3.4 Tension Pneumothorax

If a sucking chest wound is not treated in time, pressure within the pleural space may increase, further collapsing the lung on the affected side and forcing the mediastinum (membranous partition between the lungs) to the opposite side. This can result in 2 serious consequences:

1. Breathing becomes increasingly difficult as the lungs get compressed by surrounding organs

2. The flow of blood into the heart becomes more difficult as the heart gets compressed by surrounding organs

Signs & Symptoms:

• Further Abnormal Breathing – unilateral (affecting only one side), absent, or diminished breath sounds, along with increased difficulty in breathing. The breathing rate may increasing as the heart rate increases
• Jugular Vein Distention (JVD) – the jugular vein bulges, making it most visible on the right side of the neck
• Tracheal Deviation – the windpipe is pushed to one side of the neck

Treatment:

• Treat chest injuries as you would a sucking chest wound
• Perform Needle Thoracentesis (or Needle Decompression)

Note: this should be performed on all casualties with penetrating chest trauma with an increase in breathing difficulty. Waiting for more signs and symptoms before performing this life saving technique can lead to death, as they are not always evident. The additional trauma caused by the needle would not be expected to significantly worsen the casualty’s condition should he not have had a Tension Pneumothorax. 

Needle Thoracentesis (Needle Decompression):

This is a procedure where a needle and catheter (typically a 14 gauge) are inserted through the chest wall and into the plural space, allowing for the release of accumulated pressure. This reduces pressure on the heart, lungs, and major vessels within the chest cavity. 

1. Identify the mid-clavicular line (just inside of the nipple) on the affected side of the casualty
2. Identify the 2nd intercostal space (between the 2nd & 3rd rib) on the affected side, approximately 3 finger widths below the clavicle
3. Cleanse the site with alcohol or betadine
4. Insert the needle (14 gauge) at a 90deg angle, immediately above the 3rd rib (do not insert beneath a rib, always go above; avoiding intercostal nerves and vessels)
5. Remove the needle, leaving the catheter in place, and listen for a rush of air
6. After pressure is released, remove the catheter and clean the puncture site
7. Prepare the needle & catheter for re-use
8. Repeat the process if needed

Note: the 5th intercostal space – approximately one hand’s width beneath the armpit, between the 5th & 6th rib – is commonly used as an alternate needle decompression site. Remember to insert the needle above the 6th rib and not beneath the 5th rib.

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4. Circulation

Circulation assessment in major trauma focuses on detecting and managing shock. The most common cause of shock in a casualty who has sustained major trauma is Hypovolaemic Shock (hypo=low + volemic=volume) due to blood loss. If blood volume gets too low, the body’s organs won’t be able to keep working; cells will die and organ failure will follow.

Blood loss may be external and visible, and therefore compressible, or internal and concealed and non-compressible (within the abdomen, brain, uterus, etc). Internal and non-compressible blood loss requires urgent surgery, as there is not much in terms of treatment that can be done as a first responder.

4.1 Assessing Circulation and Managing Shock

1. Conduct a second blood sweep of the entire body, applying gauze and bandages to stop further bleeds where necessary. Major bleeds should have been attended to during Haemorrhage control, so you can now deal with the minor bleeds and injuries
2. Elevate injured limbs to a level above that of the heart, in order to minimise swelling and help slow bleeding
3. Conduct a capillary refill test on finger and toe nails of injured limbs to ensure adequate circulation, and loosen bandages if required. Capillaries should return to normal in less than 2 seconds. Do not loosen tourniquets

Capillary Refill Test: hold the casualties hand higher than heart-level and press the soft pad of a finger or fingernail until it turns white, then take note of the time needed for the colour to return once pressure is released

4. Assess the casualty’s pulse rate by use of the radial, femoral, or carotid artery (do not use your thumb to check pulse, as it has its own large artery). Average resting heart rate/ pulse should be between 60 and 100 beats per minute
5. If signs of shock are evident, administer fluids to raise blood pressure quickly. This will assist in increasing the fluid volume within the blood vessel space. Intravenous (IV) fluids are recommended if this is an option

Signs & Symptoms of Shock:

• Increased heart rate/ pulse
• Low blood pressure and feeling weak and/or tired
• Fast, shallow breathing
• Confusion or wooziness, or loss of consciousness
• Cool, pale and clammy skin

Shock Class	Blood Loss	Heart Rate	Pulse Pressure	Breaths Per Min	Mental Status
1	15%	<100	Normal	12-20	Slightly Anxious
2	15-30%	100-120	Weak	20-30	Mildly Anxious
3	30-40%	120-140	Weak	30-40	Anxious, Confused
4	>40%	>140	Weak	>35	Confused, Lethargic

Warning: finally, it is highly important to keep the casualty warm otherwise hypothermia will develop, possibly resulting in death.

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Summary

The above information provides a guide on providing first aid and immediate response to casualties who have suffered severe combat related trauma. The information is in no way preparing or instructing readers to replace trained medical professionals and trained first responders, but rather to prepare you to provide life saving medical care if you happen to be the first responder on scene in a remote area.

Always seek help from a professional when you are dealing with a casualty, and remain concurrent in your ability to provide first aid should you be the first person on scene of an accident – this means regular training and refreshers in medical care.

And finally, don’t forget to regularly refer to the primary survey chart above – DR CABC DE.

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