An individual, sometimes called an immediate, first aid kit (IFAK) is one of the pieces of kit that you should have one you nearly all the time. You should never leave the house without it. If you carry a concealed weapon you should at least be carrying a tourniquet in your pocket. The IFAK is for you. In other words, not for your battle buddy, he should be carrying his own. This is why it’s important, if you are part of a group, that you all carry similar equipment, it makes training and treatment much easier.
There are a large number of companies that offer IFAK’s with a variety of options, including multiple brands of tourniquets, so what do you get?
Let’s look at the most critical and potentially lifesaving items first, tourniquets. Tourniquets have been around since the 1600’s and the use of a ‘constricting band’ was documented before that. Over the years the myth that tourniquets would result in limb amputations gained traction and so their use diminished as a ‘first line’ treatment to a ‘use of last resort.’ During the Gulf wars the military started using tourniquets as a ‘first line’ for treatment of arterial bleeding in extremities. In the battlefield environment not only did it stop the bleeding but, when applied quickly, there was decreased mental status due to blood loss, freed up the medic to do other things and, probably more importantly in the battlefield, could allow the soldier to stay in the fight longer (as he had a free hand that wasn’t trying to do direct pressure. Because of this, a large number of lives were saved, even if they were not able to save the limb in some cases.
In 1996 a Committee on Tactical Casualty Combat Care (CoTCCC) was formed consisting of trauma surgeons, emergency room physicians, military physicians, combat medics, corpsmen and para-jumpers, representing all branches of the military. They developed the guidelines for military combat care in the field, which was later adopted into the civilian emergency medical service. The CoTCCC recommends two specific tourniquets; the CAT® (Combat Application Tourniquet®) made by North American Rescue (NAR) and the SOF®TT (SOF Tactical Tourniquet) made by Tactical Medical Solutions.
Both the CAT® and SOF®TT sell for just under $30 on their respective manufacturers sites.
It is important to note that there is a company called Tactical Combat Casualty Care, formed about 10 years after the CoTCCC, who tried to trademark their name and sell other tourniquet’s labelled as “TCCC approved.” I’ve also just discovered another company sell what they call the C-A-T Resources tourniquet which also appears to be a copy. When buying a IFAK or tourniquet buy from a reputable company or the manufacturer. There are numerous copies flooding the market (just look on Amazon – copies of the CAT® for about $9). I mention this as personally, I’d only want to trust something that has been fully tested and proven in real situations.
Both the CAT® and the SOF®TT work the same way but have slight differences. The CAT® uses vercro to secure the tension initially whereas the SOF®TT has a ratchet system. The CAT® has an open “U” shaped area that the windlass (the tensioning bar) drops into. The SOF®TT has the triangle you have to manipulate over the end of the windlass. I’ve used both and I carry both in my trauma bags, and have taught over 400 people how to use them. When training civilians, who have a low probability of applying the tourniquet until they need to on themselves or a loved one (very high stress) I personally feel the “U” of the CAT® is going to be easier for them to manipulate the windlass into, especially as their hands are likely to be covered in blood. You also have to remember and consider that manual dexterity significantly decreases in high stress and shock situations.
In 2017, when the standards and guidelines for first aid and bleeding control were updated, tourniquets became the first line treatment for uncontrolled arterial bleeding and the use of hemostatic dressings where approved in instances where a tourniquet cannot be applied.
The latest CoTCCC (2017) guidelines can be found here. The civilian version by National Association of Emergency Medical Technicians (NAEMT) can be found here.
The TCCC quick reference guide can be found here. You should print this in a small notebook format and keep in a larger trauma kit if you are the team medic for your group.
The next item you should have in your IFAK for bleeding control is a hemostatic agent. A hemostatic agent is a chemical that will cause the blood to clot. There are two common brands on the market, Quick-Clot® and Celox®. They work differently (I’ll explain more on that below) but achieve the same result under most circumstances.
A hemostatic is used for arterial bleeding where you cannot use a tourniquet. Hemostatic commonly come in a gauze that is impregnated with the chemical, but there are some injectable hemostatic on the market as well for specific situations (more below). When applying a hemostatic you ‘fold’ the material into the wound, rather than apply the who ‘wad’ at once. The objective is to apply pressure directly where the artery is bleeding, then apply a piece of the gauze, then fold more on top while keeping one finger directly on the ‘hole’ at all times. You will be sticking your fingers in a wound, so non-latex gloves are a must in your IFAK. You can find manufacturers demonstration videos here
QuickClot® is the hemostatic of choice according to the CoTCCC and several other military related studies. QuickClot® contains kealin, which caused the body’s natural clotting mechanisms to activate.
Celox® is made by a UK company and is now approved by the CoTCCC. In a recent DoD comparative study Celox® had the least overall blood loss and highest survival rate of all the hemostatics. The granules are impregnated into the gauze, when they come into contact with blood they expand and stick together making a gel-like clot. They do not cause the body’s own clotting mechanism to activate. Any leftover material is absorbed by the body. This makes Celox® useful in hypothermia patients and those taking blood thinners, such as heparin.
Both QuickClot® and Celox® come in folded and rolled gauze packages of different sizes. QuickClot® was manufactured in regular 4×4” gauze, and some other sizes, but they discontinued manufacturing earlier this year as they weren’t selling enough. You can still find some available and it’s usually in white packages.
Celox-A® is an applicator with powdered Celox which can be injected into small wounds. This is useful for penetrating injuries which are too small to be able to put gauze, or your finger, in.
In all cases when applying the hemostat, including the Celox-A®, you must apply direct pressure for at least 3 minutes once applied. After that an elasticated wrap or trauma bandage is used to keep in in place.
I carry Celox® in my personal IFAK’s (yes I have more than one) and I carry all three products in a larger trauma bag.
If you do not have a hemostatic you can use normal gauze roll in the same manner, direct application over the injured artery, but apply direct pressure for 10 minutes.
A trauma dressing, such as an Israeli bandage, should also be in your IFAK. These are good where you can’t put a hemostatic in or large surface area injuries. As mentioned above, an elastic bandage is useful to have to keep the hemostatic in the wound. While a trauma bandage can be used for the same purpose you would be without it if there are additional injuries. If space is a problem you can get pouches to allow the tourniquet to be on the outside of the IFAK, this also allows for quicker access.
If you took a first aid class years ago you probably remember the A-B-C pneumonic for airway, breathing, circulation; the priority order for treatment. As you may have noticed we started talking about severe hemorrhaging, or bleeding, first. This is because of the realization that if you don’t ‘plug the hole’ a person will bleed out in 3 minutes and the other stuff doesn’t matter then!
The new order of treatment is massive hemorrhaging, airway, respirations, circulation and hypothermia. In other words:
M-A-R-C-H. See our Immediate Care under the medical section for more information on conducting an assessment.
Rescue Essentials makes a card so you can record the information to pass onto other medical personnel.
To help maintain an airway in a semi or unconscious patient you can use a nasopharyngeal airway (NPA). They are fairly simple to use, they go in the nose, with prior application of some water-soluble jel, and stop the tongue from falling back and blocking the airway. There are lots of videos on YouTube that show how to use these but nothing replaces in classroom practice on a mannequin. Either way you should carry one because the person treating YOU with YOUR IFAK might know how to use one.
Other items you should have in your IFAK is a chest seal. While they are fairly simplex to improvise the rapid application in the field makes them highly desirable. These are used for holes in the chest (or back) where the air is coming out of, or being sucked into, the chest cavity. These are called sucking chest wounds. Without going into the anatomy and physiology suffice it to say it’s not good and will cause great difficulty in breathing. There are a number of manufacturers of chest seals. In my IFAK I carry the Hyfin® as it will fit in the IFAK without being folder over (not a good idea). The one shown comes as a twin pack, one for the entry and one for the exit holes. I carry a variety in my larger trauma bag.
While it’s important to be able to seal a sucking chest wound, the ability to let the excess air out may also be needed. While this is a skill performed by medics, and requires certification to do in the civilian world, remember the IFAK is for treating you. Therefore, carrying a needle for chest decompression is also a good idea. Remember this requires specialized training and practice, DO NOT use one unless qualified to do so.
We mentioned gloves earlier, at least two pairs. And a good set of trauma scissors is always useful.
I also carry a couple of casualty cards and a small sharpie marker for jotting down patient information and treatment given.
FINAL THOUGHTS
As with all equipment, skills etc., you need to get training and do regular refreshers. Many places are now offering tourniquet training to the public, many for free, and it only takes a few minutes to learn how to apply one. If possible, you should look for a civilian version of the TCCC class. I teach an 8-hour version which includes the M-A-R-C-H assessment and includes doing the skills in sensory deprivation (darkness) and sensory overload (loud noises) situations. By practicing these skills by taking away one of your senses, like sight, your other senses significantly increase, this increases learning. I know of many lives that have been saved by the use of the techniques mentioned here, both military, law enforcement and civilian. I’ve had two of the folks who have taken my classes save lives, one was in a shooting situation (he was a bystander and he said he instinctively knew what to do and didn’t have to think about it), so training and regular practice cannot be over emphasized.
Get trained, practice regularly, carry always and stay frosty.
Remember – Fortune Favors the Prepared
