2. Direct Threat Care (Hot Zone)

3. Direct Threat Care TERMINAL LEARNING OBJECTIVE Upon completion of this module, the participant will be able to determine when it is appropriate to apply life saving techniques in the Direct Threat Environment. ENABLING LEARNING OBJECTIVES 2.1describe and define the priorities in a Direct Threat environment 2.2describe and define the movement of wounded to cover and/or relative safety 2.3demonstrate proper management of external hemorrhage 2.4demonstrate the proper application and use of a tourniquet 2.5demonstrate the recovery position for airway management

4. Direct Threat Care Definition: The limited trauma interventions that may be considered for use in aiding a casualty while still engaged in mitigating a threat.

5. Direct Threat Care Engaged in ongoing direct threat ◦active fire fight ◦unstable building collapse ◦dynamic explosive scenario ◦etc. Security is Priority ◦Driving Force ◦Neutralize threat(s) Immediate Action Plan ◦Continue engaging threat? ◦Blocking force? ◦Move to cover? Medical ◦Communicate with casualty ◦Get Off the “X” ◦Self treatment ◦Life Saving Interventions only ◦Tourniquets ◦Recovery Position

6. Direct Threat Care Interventions DTC is primarily aimed at stopping the number 1 cause of Potentially Survivable Deaths, life threatening hemorrhage/bleeding with: Tourniquets DTC also addresses the second leading cause of PS deaths, airway obstruction with: Recovery Position

7. Intro to Tourniquets  No Longer a Last Resort  First line of defense against severe extremity bleeding  Primary adjunct for severe extremity bleeding  Use of Commercial Tourniquet is Recommended ◦Consult Medical Director and TQ Studies  TCCC Approved Tourniquets ◦Emergency & Military Tourniquet, E.M.T. by Dephi ◦Special Operations Forces Tactical Tourniquet-Wide, SOFTT-W ◦Combat Application Tourniquet, CAT

8. Vietnam Era Strap and Buckle Tourniquet

9. Del Phi E.M.T. Emergency Military Tourniquet

10. SOF Tactical Tourniquet

11. Combat Application Tourniquet CAT

12. DTC Tourniquet Application  Apply without delay if indicated. Both the casualty and the officer are in grave danger while a tourniquet is being applied in this phase – don’t use tourniquets for wounds with only minor bleeding. The decision regarding the relative risk of further injury versus that of bleeding to death must be made by the person rendering care.

13. DTC Tourniquet Application  Once the decision has been made to render care, if there is any question as to whether the bleeding is severe enough to warrant a tourniquet, use it.  Using a tourniquet when not needed is an acceptable mistake; not using a tourniquet when it is needed is a fatal mistake.

14. Tourniquet Application Guidelines  Go High or Die  20 Seconds to Apply  Applied Over Clothes  Determining Windlass Stopping Point  Mark Time  May Need More than One  Do not remove unless trained to do so

15. CAT Anatomy 3 1 2 4 5 6 1-friction buckle 2-windlass 3-circumfrencial band 4-windlass clip 5-windlass securing strap 6-self adhering band

16. CAT Storage Position Disassemble loop and unwind windlass Clean inner circumferential band in windlass clip area Fully extend inner circumferential band Insert tab of band into friction buckle (slit closest to windlass clip) While holding tourniquet by the windlass clip, pull tip of band to bottom of loop Mate Velcro of band below friction buckle Fold tourniquet in half, Velcro to Velcro Ensure windlass securing strap is Velcroed to one side of the windlass clip, not across the clip

17. TQ Application – One Handed Grab tourniquet by folded tab section Loop tourniquet over injured arm Pull tab midline (towards body) as tight as possible Mate Velcro on band from buckle to windlass clip Apply pressure with windlass until bleeding stops Secure Windlass in windlass clip Place free end of band through windlass clip Apply windlass securing strap Mark Time

18. TQ Application – Two Handed Grab CAT and remove band from friction buckle Route tourniquet around extremity and pass tab through inside slit of the friction buckle, pull band tight Pass the tab through the outside slit of the friction buckle, pull band tight and Velcro back onto itself Apply pressure with windlass and secure in windlass clip Apply securing strap over windlass clip Determine need for additional tourniquets (still bleeding) Note Time

19. RIGHT ARM! YOU’VE BEEN SHOT

20. No Tourniquet Victim Died

21. Tourniquets Save Lives a

22. Multiple Tourniquets Applied Lessons Learned

23. Murphy's Law Improvised TQ 2” pliable band Windlass/Stick Something to keep the windlass from unwinding Examples Band  Belt, Seat Belt, Strips of material Windlass  Stick, ammo magazine, flashlight Windlass Clip  Shoe string, zip tie, flex cuff Where is your tourniquet going to be?

24. Improvised Tourniquet

25. Amputation – Tourniquets?

26. LEFT ARM! You’ve Been Shot

27. Common Tourniquet Mistakes Waiting too long to use the tourniquet Not using one when you should Putting it on too high Not making it tight enough – eliminate the distal pulse Using a tourniquet for minimal bleeding Not using a second tourniquet if needed Periodically loosening the tourniquet Not taking it off when indicated during ITC Taking it off when the casualty is in shock Failing to Re-assess

28. “Well Aimed” Direct Pressure Effective in Controlling Compressible Hemorrhage Examples Fingers/Thumb Knee/Elbow Gauze with Pressure Bandage Uses Temporary control of bleeding while tourniquet is applied Control of severe bleeding not amenable to tourniquet application Control of minor to moderate bleeding

29. Pressure Points Success depends on Presentation not Pressure

30. YOU’VE BEEN SHOT Right Foot

31. Recovery Position  Protects the Airway  Placed on Left/Right Side  Injured side down  Used for semi/unconscious casualties  Aids in identification

32. Recovery Position

33. Questions?

34. BREAK