control bleeding - lesson plan final - c168w003 vr 1.1

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1 Control Bleeding C168W003 / Version 1.1 01 Jan 2010 SECTION I. ADMINISTRATIVE DATA All Courses Including This Lesson Course Number Version Course Title 300-68W10 2009 Health Care Specialist Task(s) Taught(*) or Supported Task Number Task Title INDIVIDUAL 081-833-0157 (*) PROVIDE BASIC EMERGENCY MEDICAL CARE FOR AN AMPUTATION 081-833-0210 (*) APPLY A TOURNIQUET TO CONTROL BLEEDING 081-833-0211 (*) APPLY A HEMOSTATIC DRESSING 081-833-0212 (*) APPLY A PRESSURE DRESSING TO AN OPEN WOUND 081-833-0229 (*) APPLY KERLIX TO AN OPEN WOUND Reinforced Task(s) Task Number Task Title 081-831-0011 MEASURE A PATIENT'S PULSE 081-831-0012 MEASURE A PATIENT'S BLOOD PRESSURE 081-833-0161 CONTROL BLEEDING 081-833-0213 PERFORM A TACTICAL CASUALTY ASSESSMENT Academic Hours The academic hours required to teach this lesson are as follows: Resident Hours/Methods 2 hrs 20 mins / Demonstration 1 hr 25 mins / Lecture 5 mins / Lecture 8 hrs / Practical Exercise (Hands-on) Test 0 hrs Test Review 0 hrs Total Hours: 12 hrs Test Lesson Number Hours Lesson No. Testing (to include test review) N/A Prerequisite Lesson(s) Lesson Number Lesson Title None Clearance Access Security Level: Unclassified Requirements: There are no clearance or access requirements for the lesson. Foreign Disclosure Restrictions FD6. This product/publication has been reviewed by the product developers in coordination with the USAMEDDC&S foreign disclosure authority. This product is releasable to students from foreign countries on a case-by-case basis.

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Page 1: Control Bleeding - Lesson Plan Final - C168W003 VR 1.1

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Control Bleeding C168W003 / Version 1.1

01 Jan 2010

SECTION I. ADMINISTRATIVE DATA

All Courses Including This Lesson

Course Number Version Course Title

300-68W10 2009 Health Care Specialist

Task(s) Taught(*) or Supported

Task Number Task Title

INDIVIDUAL

081-833-0157 (*) PROVIDE BASIC EMERGENCY MEDICAL CARE FOR AN AMPUTATION

081-833-0210 (*) APPLY A TOURNIQUET TO CONTROL BLEEDING

081-833-0211 (*) APPLY A HEMOSTATIC DRESSING

081-833-0212 (*) APPLY A PRESSURE DRESSING TO AN OPEN WOUND

081-833-0229 (*) APPLY KERLIX TO AN OPEN WOUND

Reinforced Task(s)

Task Number Task Title

081-831-0011 MEASURE A PATIENT'S PULSE 081-831-0012 MEASURE A PATIENT'S BLOOD PRESSURE 081-833-0161 CONTROL BLEEDING 081-833-0213 PERFORM A TACTICAL CASUALTY ASSESSMENT

Academic Hours

The academic hours required to teach this lesson are as follows:

Resident Hours/Methods 2 hrs 20 mins / Demonstration 1 hr 25 mins / Lecture 5 mins / Lecture 8 hrs / Practical Exercise (Hands-on) Test 0 hrs Test Review 0 hrs

Total Hours: 12 hrs

Test Lesson Number

Hours Lesson No.

Testing (to include test review) N/A

Prerequisite Lesson(s)

Lesson Number Lesson Title

None

Clearance Access

Security Level: Unclassified Requirements: There are no clearance or access requirements for the lesson.

Foreign Disclosure Restrictions

FD6. This product/publication has been reviewed by the product developers in coordination with the USAMEDDC&S foreign disclosure authority. This product is releasable to students from foreign countries on a case-by-case basis.

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References Number

Title

Date

Additional Information

0-323-03986-3 PHTLS: Prehospital Trauma Life Support, 6th Edition

01 Jan 2007

BUTLER, BOL. 161, AUG 199

Tactical Combat Casualty Care in Special Operations, Supplement to "Military Medicine"

NAVMEDPUB 5139 Operational Medicine 2000

01 Jan 2001 CD-ROM

Student Study Assignments

None

Instructor Requirements

One 68W instructor as per specified group

Additional Support

Name

Stu Ratio

Qty

Man Hours

Personnel Requirements

None

Equipment Required

Id Name

Stu Ratio

Instr Ratio

Spt

Qty

Exp

for Instruction 60MP00BK AID BAG (BLACK HAWK PRODUCTS GROUP 757-436-3101)

1:1 No 0 No

6510-00-058-3047 BANDAGE, GAUZE

1:44 No 0 Yes

6510-00-105-5806 BANDAGE, ELASTIC

1:18 No 0 Yes

6510-00-201-1755 BANDAGE, GAUZE

2:1 No 0 Yes

6510-00-201-7425 DRESSING, FIRST AID, FIELD

1:1 No 0 Yes

6510-00-201-7430 DRESSING, FIRST AID, FIELD

1:1 No 0 Yes

6510-00-926-8884 ADHESIVE TAPE, SURGICAL

1:2 No 0 Yes

6510-01-492-2275 BANDAGE KIT, ELASTIC

2:1 No 0 Yes

6515-00-324-5500 DEPRESSOR, TONGUE

1:6 No 0 Yes

6515-00-935-7138 SCISSORS, BANDAGE

1:1 No 0 No

6515-01-364-8553 GLOVE, PATIENT EXAMINING AND TREA

1:19 No 0 Yes

6515-01-364-8554 GLOVE, PATIENT EXAMINING AND TREA

1:111 No 0 Yes

6515-01-365-6183 GLOVE, PATIENT EXAMINING AND TREA

1:63 No 0 Yes

6515-01-530-7015 SOFT TOURNIQUETS

1:55 No 0 Yes

6545-01-530-0929 FIRST AID KIT, UNIVERSAL (IFAK)

1:1 No 0 Yes

6645-01-106-4302 STOPWATCH

1:6 No 0 Yes

6910-01-560-2972 Combat Application Tourniquet Trainer Blue

1:1 No 0 No

6910-01-C24-9225 Rescue Randy, Manikin

1:55 No 0 No

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7010-01-454-5951 Laptop/Notebook Computer (w/case & Windows OS)

1:1 No 0 No

COMPUTER-INSTRUCTOR COMPUTER (CPU) WITH KEYBOARD, INSTRUCTOR USE ONLY

1:60 No 0 No

MONITOR-INSTRUCTOR COMPUTER MONITOR

1:60 No 0 No

PART # 150 Quickclot Combat Gauze

2:1 No 0 Yes

PROJECTOR-INSTRUCTOR OVERHEAD PROJECTOR WITH COMPUTER INTERFACE

1:30 No 0 No

SCREEN-INSTRUCTOR SCREEN PROJECTOR, INSTRUCTOR USE

1:30 No 0 No

VCR-INSTRUCTOR VCR, CLASSROOM SUPPORT ITEM

1:60 No 0 No

* Before Id indicates a TADSS

Materials Required

Instructor Materials: Pre-Hospital Trauma Life Support (PHTLS), Military Edition, Revised 6th Edition Student Handout LP C168W003 Skills Sheets The AMEDD Virtual Library: https://medlinet.amedd.army.mil/

Classroom, Training Area, and Range Requirements

CLASSROOM, L1, 1881.81SF, 60PN (68W) MULTI-SKILLS, 1240.85SF, 48/8PN (68W)

Ammunition Requirements

Id Name

Exp

Stu Ratio

Instr Ratio

Spt Qty

None

Instructional Guidance

NOTE: Before presenting this lesson, instructors must thoroughly prepare by studying this

lesson and identified reference material.

Demonstrations - All demonstrations will be delivered by way of the "whole-part-whole" technique. The instructor demonstrates the skill three times in a row to students before students practice the directed task: 1. Whole. The instructor demonstrates the entire skill from beginning to end while briefly naming each action or step. If possible, the skill should be performed under the condition specified in standard. 2. Part. The instructor demonstrates the skill again step-by-step explaining each part in detail. It is important that the instructor select proper size "bites" of the skill. If the information is too specific, the learner can be overloaded with detail. Too broad and the learner may not be able to make the connection from step to step. 3. Whole. The instructor demonstrates the entire skill from beginning to end without interruption and usually without commentary. If possible, as the skill would normally be completed "on the job". Practical Exercises - All practical exercises associated with this block of instruction will be delivered in sessions with groups. Sessions: limitation Sessions Similar to "by-the-numbers". Group includes a Medic, an Evaluator w/manikin. Process: 1) Instructor reads a step in the task, 2) Medic performs it, 3) Instructor

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reads the next step, 4) This continues until the task is complete. Why? The first time a task must be completed correctly. Learn it right the first time. Manipulation Sessions Peer-guided training. Group includes Medic, Patient, Evaluator, Reader, Assistant Process: 1) Reader recites steps, 2) Medic & Assistant performs skill on patient, 3) Evaluator provides critique. Why? Exploits the group dynamic & develops “muscle memory”. Precision Sessions Peer-guided training. Group includes: Medic, Patient, Evaluator, Reader, Assistant Process: 1) Complexity is added, 2) Reader recites steps, 3) Medic & Assistant performs skill on patient, 4) Evaluator provides critique. Why? Develops “muscle memory” & Stress inoculates. Group Roles and Responsibilities Medic – primary skill performer, may be an individual or a team leader Patient – Portrays signs and symptoms according to the scenario provided. Evaluator – Uses a skill sheet and records steps as they are performed. Reader – verbalizes each step to the medic in Manipulation and Precision

Sessions CLS – performs care as directed by the Medic

Proponent Lesson Plan Approvals

Name

Hansen, Meredith

Rank

YC-02

Position

Chief, Curriculum Development

Date

01 Nov 2009

Walker, Barbara GS-12 ISS 01 Nov 2009

SECTION II. INTRODUCTION

Method of Instruction: Lecture Instructor to Student Ratio is: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction

Motivator

As a 68W Soldier medic, you will be providing medical care in a variety of situations; the methods you will use to control hemorrhage on your casualties will likely depend on the circumstances. Control of bleeding in a civilian environment is vastly different from the control of bleeding on the battlefield. This lesson will concentrate on the battlefield methods. Your ability to successfully control bleeding under extreme circumstances will result in more lives saved than any other medical intervention on the battlefield.

Terminal Learning Objective

NOTE: Inform the students of the following Terminal Learning Objective requirements.

At the completion of this lesson, you [the student] will:

Action:

Control bleeding

Conditions:

Given a simulated casualty with a severe bleeding injury in a combat environment

Standards:

IAW the concepts and principles of Tactical Combat Casualty Care (TC-3) and Prehospital Trauma Life Support Chapters 7, 20 and 21.

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Safety Requirements

None

Risk Assessment Level

Low - Use universal precautions.

Environmental Considerations

NOTE: It is the responsibility of all Soldiers and DA civilians to protect the environment from

damage.

Evaluation

Students will be given a one hour written examination covering information included in this Lesson Plan. Students will also demonstrate knowledge and skills during practical exercises.

Instructional Lead-In

Basic lifesaving steps for the 68W Soldier medic includes stopping the bleeding,

clearing the airway, restoring breathing, protecting the wound, and

treating/preventing shock. These are the HABC measures that apply to all injuries.

Certain types of wounds and burns will require special precautions and procedures

when applying these measures. This lesson provides specific information on

controlling bleeding. When properly applied these techniques will save soldier's

lives.

SECTION III. PRESENTATION

NOTE: Inform the students of the Enabling Learning Objective requirements.

A. ENABLING LEARNING OBJECTIVE

ACTION: Circulatory System and Hemorrhage Concepts - Review

CONDITIONS: Classroom Environment

STANDARDS: IAW Prehospital Trauma Life Support Chapter 7.

1. Learning Step / Activity 1. Review of the Circulatory System and Hemorrhage

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction a. Preventable death on the battlefield (1) Hemorrhage is and continues to be the leading cause of death of the battlefield. (2) Extremity hemorrhage is the leading cause of preventable battlefield deaths. b. Review of cardiovascular system. (1) Arteries & arterioles (a) Carry blood away from the heart, to the tissues. (b) Typically have higher pressure and bright red blood. (c) Bleeding tends to be pulsating, but may flow if from a deep artery. (d) Transected arteries may spasm and constrict, temporarily preventing hemorrhage.

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NOTE: An amputation with little or no bleeding requires an immediate tourniquet. (2) Veins & venules (a) Carry blood back to the heart (b) Have lower pressure compared to arteries and have darker, burgundy colored blood. (c) Bleeding tends to flow. WARNING: If enough blood is lost, whether from arterial or venous bleeding, it will still be life-threatening. (3) Capillaries (a) Small vessels where nutrient and waste exchange occur. (b) Bleeding oozes. c. Components of blood (1) Plasma (a) Watery fluid with proteins, other molecules and dissolved minerals. (b) Constitutes over half the blood volume. (c) Provides a fluid environment for other blood components and warmth to all tissues in the body. (d) Clotting factors are proteins dissolved in the blood. (2) Red blood cells (erythrocytes). (a) Primarily carry oxygen to the tissues (b) Provides blood's red color. (3) White blood cells (leukocytes). (a) Primarily fight infection and consume dead tissue. (b) Produce antibodies that help the body resist infection. (4) Platelets (thrombocytes). (a) Membrane-enclosed fragments of specialized cells. (b) When activated, they stick to the fibrin net to form clots over damaged vessels.

2. Learning Step / Activity 2. Blood Clotting and Hypothermia

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction a. Clotting Physiology (1) Injury to a blood vessel stimulates a series of chemical reactions in which clotting factors are activated and a fibrin net is formed over the injury of the vessel. The clotting cascade is a series of chemical reactions involving clotting factors.

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(2) Platelets and red blood cells stick to the fibrin net forming a clot. (3) Several factors can disrupt this process and contribute to coagulopathy (difficult clotting) (a) Hypothermia. 1) Chemical reactions of the clotting mechanisms are affected by the decrease in temperature and blood clotting will not occur. 2) Consider a casualty hypothermic when their core body temperature falls below 95º F. Clotting factors are usually not effected until the body temperature falls below 93 degrees. 3) Prevention of hypothermia should begin as soon as the casualty is identified, regardless of the ambient temperature. Hypothermia occurs with equal frequency in both cold and hot environments. a) As soon as the tactical situation permits, identify and treat all life-threatening injuries. b) If possible, remove wet clothing and replace with dry. c) Wrap/cover the casualty. (Blizzard Rescue Blankets and Ready-Heat Blankets) 4) When hypothermia is associated with significant injuries mortality rates increases dramatically. (b) Acidosis. 1) When the body suffers from shock (inadequate tissue perfusion) lactic acid builds up in tissues. 2) If not corrected, lactic acid builds up to change the pH level inside the body. 3) Normal clotting requires a normal pH. 4) Treatment: Assess and manage H - A - B - C. (c) Hemodilution. 1) This occurs when too much intravenous fluid has been given. 2) The clotting proteins, platelets and red blood cells have been “washed out” of the vascular space through ongoing hemorrhage and the addition of fluids that do not contain clotting factors. 3) Treatment: Provide only necessary fluid resuscitation (covered in an upcoming lesson). (d) Medications. 1) Some medications inhibit the formation of clots, such as aspirin, ibuprofen, naproxen, and Warfarin (Coumadin). 2) Treatment: Do not distribute these types of medications in Combat Zones. Educate your Soldiers as to the risks involved with using these types of medications. b. Blood pressure. (1) The higher the blood pressure inside of a damaged vessel, the faster it will bleed. Clotting requires time to form a fibrin clot.

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(2) All bleeding eventually stops (from hemorrhage control or death) (a) As bleeding continues and shock progresses, peripheral vessels constrict forcing blood towards the central circulation. This is called shunting. Shunting is designed to utilize the remaining blood to perfuse the important (vital) organs. (b) Shunting may slow or stop hemorrhage from peripheral vessels. As pressure decreases, hemorrhage slows and clots may form. NOTE: How does clotting work?

How does hypothermia affect clotting? How does acidosis affect clotting? How does blood pressure affect clotting? At what point should the Medic prevent or treat the casualty for hypothermia?

3. Learning Step / Activity 3. Compressible Vs Non-compressible Hemorrhage

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction a. Non-compressible Hemorrhage (1) Bleeding cannot be compressed with direct pressure (2) Includes the chest and abdomen and pelvis (the torso). (3) Signs and symptoms of non-compressible hemorrhage include (a) Abdominal rigidity and tenderness. Free blood in the abdomen irritates the peritoneum, causing the tenderness and the abdominal muscles to spasm. (b) Bruising (ecchymosis) (c) Coughing up blood (hemoptysis) – with pulmonary or airway injuries (d) Rectal bleeding – with large intestine injuries (e) Bloody vomiting (hematemesis) – with stomach or small intestine injuries. Resembles coffee grounds. (4) Significant sources of non-compressible hemorrhage (a) Heart (b) Lungs and pulmonary arteries & veins (c) Subclavian vessels (d) Mediastinal vessels (superior & inferior vena cava and aorta) (e) Intercostal vessels (up to 100ml per minute each) NOTE: A typical, adult casualty can bleed up to 1500 ml into each side of the chest.

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(f) Abdominal Organs and vessels NOTE: A typical, adult casualty can hemorrhage up to 10 liters of blood and IV fluid into the abdomen, even though he/she only has about 6 liters of blood circulating. (5) Casualties with non-compressible hemorrhage need appropriate shock management and urgent surgical evacuation and surgery. b. Compressible Hemorrhage (1) Can be compressed with direct pressure, wound packing and pressure bandages. (2) This includes the arms, legs, axilla, groin and neck and superficial injuries to the head and torso. (3) Key vessels include: (a) Carotid arteries. (b) Internal and external jugular veins. (c) Brachial arteries: in the upper arm to the elbow. (d) Radial and ulnar arteries: from the elbow to the wrist in the forearm. (e) Femoral arteries and veins: 1) The largest arteries of the lower extremities and are split into the superficial and deep femoral arteries. 2) The superficial femoral artery (SFA) is the most commonly injured artery in combat. NOTE: A typical adult casualty can bleed up to 1 liter into one thigh. (f) Posterior tibial artery: posterior aspect of the medial malleolus. (4) Casualties with compressible hemorrhage: (a) Initially need direct pressure to the wound. (b) Consideration should be given for tourniquet placement or the wound should be packed with either kerlix or hemostatic agents and with an emergency trauma bandage applied. NOTE: What is the difference between compressible and non-compressible bleeding?

Give specific example of each.

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B. ENABLING LEARNING OBJECTIVE

ACTION: Apply a Tourniquet to Control Life Threatening Hemorrhage

CONDITIONS: Given a simulated casualty

STANDARDS: IAW the principles of Tactical Combat Casualty Care and Prehospital Trauma Life Support Chapters 20 and 21.

1. Learning Step / Activity 1. Tourniquets

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 20 mins Media: Large Group Instruction NOTE: During the Vietnam conflict data demonstrated that 60% of all combat deaths were related to exsanguination from an extremity. a. Principles of Tourniquet Application (1) Compress the tissue around the vessel, which then compresses the vessel. The more tissue that must be compressed, the more pressure required to compress the blood vessels. (2) Tourniquets are the first tactical choice for life-threatening hemorrhage of an extremity in combat. They can be applied faster in dangerous situations and control bleeding more rapidly. NOTE: Many medical providers believe a tourniquet applied over the humerus or femur is more effective than one applied over the radius/ulna or tibia/fibula due to intraosseous circulation between the two bones of the distal extremities. COL Kragh’s study of tourniquet use in Iraq demonstrated the opposite; effectiveness was 92% for the forearm versus 81% for the upper arm and 100% for the lower leg versus 73% for the thigh. b. Types of Tourniquets (1) Improvised Tourniquets (a) Improvised tourniquets are applied with materials immediately available. (b) Improvised tourniquets should be used as a last resort IF no manufactured tourniquets are available. Studies have shown that improvised tourniquets are significantly less effective than manufactured tourniquets. Therefore, manufactured tourniquets are preferred. (c) The course standard for improvised tourniquet uses: 1) A cravat to wrap around the extremity 2) A windlass made of 8 tongue depressors taped together 3) Another cravat to keep the windlass from unwinding (2) Combat Application Tourniquet (CAT) (a) CAT is the standard tourniquet in the IFAK (b) All tourniquets are one time use only. NOTE: At DCMT use the blue CATs that are designed as trainers. Black CATs are carried in combat. (c) Uses a strap and windlass design. (3) Special Operations Forces Tactical Tourniquet (SOFTT)

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(a) Commonly used in theater (b) Also uses a strap and windlass design (4) Emergency Medical Tourniquet (EMT) (a) The most effective emergency department tourniquet (b) Uses a pneumatic design, which could rupture and deflate. NOTE: There are many tourniquets available on the market today. Some work well, some don’t work. The previous tourniquets were shown to stop arterial blood flow 100% of the time in both upper and lower extremities. c. Tourniquet use during Care under Fire (1) To maintain firepower supremacy, only extremity bleeding should warrant any intervention during Care under Fire. (a) Casualty blood sweeps are not recommended during this phase of care. The assessment takes a considerable amount of time to complete and leaves the care giver vulnerable to the enemy. (b) Visual inspection is not necessary until both the care provider and the casualty are behind cover. (c) When approaching the casualty, if blood is apparent on the shirt sleeve or the pant leg that is all of the proof necessary to warrant application of a tourniquet. (2) When the tactical situation dictates, no intervention should be employed unless and until: (a) The unit can afford to have the provider drop out of the fire fight long enough to intervene. (b) Efforts to direct the self-aid / buddy aid have failed. (3) Tourniquets are the only recommended treatment for extremity hemorrhage during this phase. (Remember: 30 seconds on the "X" is 25 seconds too many. Even if it take only a few seconds to apply a tourniquet, that is enough time for the enemy to take aim and fire on both you and the casualty.) (a) Intervention should take place under suitable cover or concealment. This may require that you initially move the casualty before placing a tourniquet. (b) The intervention should be tactically feasible as to avoid a circumstance where the care giver is an additional casualty. (c) For obvious life threatening extremity hemorrhage 1) You may not really know if hemorrhage is life threatening until Tactical Field Care phase when the wound can be exposed and evaluated. 2) The suspicion of life threatening hemorrhage is the only required criteria during Care under Fire. (4) All tourniquets placed during Care Under Fire should be Hasty Tourniquets. (a) Place over the clothing (b) As high on the extremity as possible (without capturing the shoulder or the buttock) 1) Rarely are combat wounds clean incisions perpendicular through the extremity.

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2) This placement is preferred during Care under Fire because of the inability to properly expose and assess the wound. 3) High application ensures the tourniquet is placed completely above any possible damaged/injured tissue. (c) As tightly as possible (due to the limitations during this phase of care, pulse checks are not required) (5) Hasty Tourniquets should be converted to an alternative form of hemorrhage control prior to evacuation, typically during the Tactical Field Care Phase. d. Tourniquet use during Tactical Field Care (1) Once fire superiority has been gained AND the tactical leader decides that medical treatment is appropriate AND the casualty has been moved behind cover and concealment, Tactical Field Care casualty assessment and treatment may begin. (2) Complete the first blood sweep for hemorrhage. (a) Assess only the neck, axillary area, upper extremities, inguinal area and lower extremities for signs of hemorrhage. (b) Tactical gear is not removed at this time unless removal is necessary for access and assessment of possible life threatening hemorrhage. 1) Hasty tourniquets should be evaluated to ensure hemorrhage is controlled. 2) Any new life threatening hemorrhage discovered in the neck, axillary and inguinal areas should be treated with direct pressure and hemostatic agents. 3) Newly discovered life threatening hemorrhage on the upper or lower extremities should be treated with a Deliberate Tourniquet. a) Applied directly to the skin b) 2-3 inches above (proximal to) the wound. c) Not over a joint d) Tightened until the bleeding has stopped and the distal pulse is absent. - If a distal pulse is still present, attempt to tighten the tourniquet more. - If this fails to eliminate the distal pulse a second tourniquet must be applied and tightened (side by side) just above the original tourniquet. NOTE: The second tourniquet actually makes the tourniquet wider. A wider tourniquet requires less pressure to compress the artery. This is the rational for using two tourniquets side by side. - It is possible for the bleeding to stop and still have a distal pulse. Tightening until the pulse is absent decreases the chances of developing a compartment syndrome later. Compartment syndrome can result in tissue death and loss of extremity or other disability. - In the case of amputations or mutilating extremity injuries, assessment of the distal pulse may not be practical. In these cases, the tourniquet should be tightened until the bleeding stops. NOTE: How do all tourniquets work?

What is the difference between a hasty and a deliberate tourniquet?

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Is one better than the other?

2. Learning Step / Activity 2. Improvised Tourniquet - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 15 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. See DCMT approved skill sheet for correct skill sequence.

3. Learning Step / Activity 3. Improvised Tourniquet - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 2 hrs Media: Large Group Instruction Scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student b. Manipulation Session - no less than three manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of two precision sessions must be completed per student. 1) Timed application competitions in a Care under Fire environment 2) Timed application competitions in a Tactical Field Care environment 3) Blind folded application in a Care under Fire environment 4) Blind folded application in a Tactical Field Care environment

4. Learning Step / Activity 4. Combat Application Tourniquet - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 15 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. See DCMT approved skill sheet for correct skill sequence.

5. Learning Step / Activity 5. Combat Application Tourniquet - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 1 hr Media: Large Group Instruction

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Scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student b. Manipulation Session - no less than three manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of two precision sessions must be completed per student. 1) Timed application competitions in a Care under Fire environment 2) Timed application competitions in a Tactical Field Care environment 3) Blind folded application in a Care under Fire environment 4) Blind folded application in a Tactical Field Care environment C. ENABLING LEARNING OBJECTIVE

ACTION: Pack a wound

CONDITIONS: Given a simulated casualty in a combat environment

STANDARDS: IAW Tactical Combat Casualty Care Principles and Prehospital Trauma Life Support Chapter 7 and 21.

1. Learning Step / Activity 1. Principles of Wound Packing

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 25 mins Media: Large Group Instruction a. Hemostatic Agents. (1) These have chemical properties that stimulate clotting when placed in wounds. (2) Hemostatic agents have undergone much research over the past 10 years resulting in changing recommendations. (3) Combat Gauze (made by QuikClot). (a) Combat Gauze is currently the only Army recommended hemostatic agent within the combat zone. (b) Comes as a roll of gauze impregnated with kaolin, a chemical which triggers the clotting cascade. (c) Per Army directive, every IFAK should have 1 roll of Combat Gauze. (4) Products you may see in the field, but are not recommended as first line hemostatic agents. (a) Woundstat (b) HemCon (c) QuikClot (original, Advanced Clotting Sponge [ACS], and ACS+) (d) Celox b. Gauze (compressed or roller) Packing.

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(1) Compressed or roller gauze is an effective method of hemorrhage control. (2) Gauze fills in wounds and puts focal pressure on the bleeding blood vessels to promote clotting by slowing the bleeding and giving clotting proteins and platelets more time to form a clot at the site of injury. (3) Follow the 4 “P’s” of Wound Packing (a) Peel the gauze off the roll (don’t stuff the whole roll in the wound). Remove the gauze from the center, if rolled. This will make the entire bandage easier to control. (b) Push the gauze into all cracks and crevices inside the wound. If the wound is large you may need an entire package of gauze and additional packages to fill and compress the wound. (c) Pile the gauze above the level of the skin 1 to 2 inches (to keep pressure in the wound) (d) Pressure dressing/bandage over the top of the wound (maintains pressure to the packing) c. Pressure Bandages (1) Elastic bandages wrapped tightly around a body part to put external pressure on the wounds. (2) Many products may be used as a pressure dressing. (a) Ace wrap / Elastic bandage 1) Most come with 2 silver colored metal clips 2) These clips should not be trusted to ensure pressure is maintained. 3) While applying the wrap, both ends should remain free. After application the free ends should be tied in a square not. (See Instructor Demonstration for more guidance.) (b) Emergency Trauma Dressing (c) Emergency Bandage (d) H Bandage (3) Indications: (a) May be used alone for superficial to moderate injuries. (b) May be used with hemostatic agents or gauze packing for large or deep wounds. This allows the agents to work better. (4) Anchor Points (a) Neck wounds may require an anchor point under the axilla opposite of the wound. (b) Axillary wounds may require an anchor point over the opposite shoulder against the neck (c) Inguinal wounds, depending on the direction of the wound, may require an anchor point using the casualty's thigh, buttocks or belt. d. Principles of Wound Packing (1) There is no one correct way to pack an open wound, there are many appropriate variables. (a) Location of the wound

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1) Hemostatic agents should be strongly considered with wounds of the neck, axillary area and inguinal area, especially if there is a presence of life threatening hemorrhage. 2) Wounds involving large vessels (veins or arteries) (b) Wound Depth 1) Moderate and deep wounds may require hemostatic agents and gauze packing 2) For superficial wounds, pressure bandages may be all that is necessary. (2) When tactically feasible, expose and visually inspect the wound. (a) If an approximate location of hemorrhage can be determined apply the appropriate material into that area in the wound (hemostatics, gauze packing, direct pressure, pressure dressing). (b) Monitor the wound and the casualty for signs of continued wound hemorrhage, which may include: 1) Blood visible and spreading on wound bandaging/dressing material 2) Signs your casualty is entering or progressing further into hemorrhagic shock. 3) Cessation of bleeding may be a clue to the proper wound packing. Always consider bleeding may still continue internally. NOTE: How to hemostatic agents work?

What is the hemostatic agent being used by the Army? What are anchor points, where are they and why are they important? What are the four "P" of wound packing? Explain each.

2. Learning Step / Activity 2. Emergency Trauma Bandage - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 15 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. Choose a single wound location to demonstrate the skill. Utilize the DCMT approved skills sheet to demonstrate the skill.

3. Learning Step / Activity 3. Emergency Trauma Bandage - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 1 hr Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized.

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a. Imitation Session - no less than one imitation session per student b. Manipulation Session - no less than two manipulations session per student. c. Precision Session - A minimum of one precision session should be completed per student.

4. Learning Step / Activity 4. Neck Wounds - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 20 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. Choose a single wound location to demonstrate the skill. Apply the following principles: 1) Expose and visually inspect the wound. 2) Determine what material is necessary based on wound location, size, depth and tissue involved. 3) Direct pressure to the bleeding site may be necessary while equipment is being accessed for treatment. 4) Apply hemostatics, gauze packing and/or pressure dressings/bandages. 5) When feasible, choose an anchor point under the opposite axillary area. 6) Ensure dressings/bandages are not obstructing the casualty's airway. 7) Secure intervention with tape. 8) Monitor the wound for continued bleeding. 9) Monitor the casualty for signs of hypovolemic shock.

5. Learning Step / Activity 5. Neck Wounds - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 1 hr Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student. Instructions should consider each

imitation session has a slightly different wound location while staying in the same area. b. Manipulation Session - no less than two manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of one precision session should be completed per student. 1) Wound packing for speed 2) Wound packing for durability

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6. Learning Step / Activity 6. Axillary Wounds - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 20 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. Choose a single wound location to demonstrate the skill. Apply the following principles: 1) Expose and visually inspect the wound. 2) Determine what material is necessary based on wound location, size, depth and tissue involved. 3) Direct pressure to the bleeding site may be necessary while equipment is being accessed for treatment. 4) Apply hemostatics, gauze packing and/or pressure dressings/bandages. 5) When feasible, choose an anchor point over the opposite shoulder, against the neck. 6) Ensure dressings/bandages are not obstructing the casualty's airway. 7) Secure intervention with tape. 8) Monitor the wound for continued bleeding. 9) Monitor the casualty for signs of hypovolemic shock.

7. Learning Step / Activity 7. Axillary Wounds - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 1 hr Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student. Instructions should consider each imitation session has a slightly different wound location while staying in the same area. b. Manipulation Session - no less than two manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of one precision session should be completed per student. 1) Wound packing for speed 2) Wound packing for durability

8. Learning Step / Activity 8. Inguinal Wounds - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 20 mins Media: Large Group Instruction

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The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. Choose a single wound location to demonstrate the skill. Apply the following principles: 1) Expose and visually inspect the wound. 2) Determine what material is necessary based on wound location, size, depth and tissue involved. 3) Direct pressure to the bleeding site may be necessary while equipment is being accessed for treatment. 4) Apply hemostatics, gauze packing and/or pressure dressings/bandages. 5) When feasible, choose an anchor point that may include the thigh, buttock or casualty's belt. 6) Secure intervention with tape. 7) Monitor the wound for continued bleeding. 8) Monitor the casualty for signs of hypovolemic shock.

9. Learning Step / Activity 9. Inguinal Wounds - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 1 hr Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student. Instructions should consider each

imitation session has a slightly different wound location while staying in the same area. b. Manipulation Session - no less than two manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of one precision session should be completed per student. 1) Wound packing for speed 2) Wound packing for durability D. ENABLING LEARNING OBJECTIVE

ACTION: Replace a Tourniquet Using Alternate Means of Hemorrhage Control

CONDITIONS: Given a simulated combat casualty

STANDARDS: IAW Tactical Combat Casualty Care Principles and Prehospital Trauma Life Support Chapter 21.

1. Learning Step / Activity 1. Hasty Tourniquet to Deliberate Tourniquet - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 5 mins Media: Large Group Instruction

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The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. a. If at all possible, Hasty Tourniquets should not be left in place for Tactical Casualty Evacuation. b. If a Hasty Tourniquet is placed during Care under Fire, at an appropriate time based on the tactical situation: (1) Expose and assess the wound for continued tourniquet need. (2) Apply and tighten a deliberate tourniquet 2-3 inches above the wound on the skin (3) Loosen the hasty tourniquet (DO NOT REMOVE) (4) Check distal pulse (a) If a distal pulse is present, attempt to further tighten the deliberate tourniquet. (b) If ineffective, place an additional tourniquet (side by side) directly above the deliberate tourniquet and tighten until the pulse disappears.

2. Learning Step / Activity 2. Hasty Tourniquet to Deliberate Tourniquet - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 25 mins Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than two imitation sessions per student. Instructions should consider each

imitation session has a slightly different wound location while staying in the same area. b. Manipulation Session - no less than two manipulation sessions per student. c. Precision Session - The following drills may be completed based on the time allotted. A minimum of

one precision session should be completed per student.

3. Learning Step / Activity 3. Principles of Tourniquet Conversion

Method of Instruction: Lecture Instructor to Student Ratio: 1:60 Time of Instruction: 10 mins Media: Large Group Instruction a. Principles of Tourniquet Conversion (1) Tourniquet conversion reduces unnecessary damage to an extremity. (a) If the evacuation to a definitive treatment facility is significantly delayed (hours), you can reduce tissue damage by changing to another method of hemorrhage control. (b) In certain cases, resulting in restored collateral circulation and blood flow to the extremity. (2) Tourniquets are left in place for 2 hours or more during orthopedic surgery without adverse

outcomes.

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(3) Tourniquets should not be loosened if: (a) The casualty will arrive at a surgical facility within 2 hours. NOTE: Complications of tourniquets do not usually occur within 2 hours of tourniquet placement. (b) The tourniquet has been in place for longer than 6 hours. Release of this tourniquet may cause death due to: 1) Release of micro-emboli resulting in respiratory failure. 2) Release of acidotic blood, metabolic waste, and toxins from non-perfused tissue back into the circulation. (c) Amputations. NOTE: Tourniquet conversion is not indicated for amputations since the purpose of conversion is to increase the likelihood of salvaging a limb. (d) Casualties in profound shock (altered mental status and absent radial pulse from blood loss) until after fluids have been administered. b. Tourniquets may be converted to alternate means of hemorrhage control if all the following are present: (1) The wound has been exposed and assessed (2) The tactical situation allows (3) There is enough time before evacuation to complete the intervention c. Based on wound need, tourniquets may be converted using any necessary combination of the

following: (1) Hemostatic agent (2) Kerlix, compressed gauze, roller gauze (3) Emergency bandage (4) Elastic Bandage

4. Learning Step / Activity 4. Tourniquet to Trauma Bandage - Demonstration

Method of Instruction: Demonstration Instructor to Student Ratio: 1:15 Time of Instruction: 10 mins Media: Large Group Instruction The class is broken down into 4 groups. One instructor will lead one group through demonstration of the task 3 times in a row using the "Whole-Part-Whole" method. Please refer the Instructor Guidance section for additional information. a. With the tourniquet in place, ensure all wounds on the affected extremity are dressed with either a hemostatic agent and/or packing with gauze and bandaged with an elastic bandage. b. Loosen the tourniquet. (DO NOT remove it from the extremity.) c. Assess for bleeding through the dressing & bandage.

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d. If bleeding recurs (1) Retighten the tourniquet (2) Do not reattempt tourniquet conversion. For Trauma Bandage Application see DCMT Approve Skill Sheet.

5. Learning Step / Activity 5. Tourniquet to Trauma Bandage - Practical Exercise

Method of Instruction: Practical Exercise (Hands-on) Instructor to Student Ratio: 1:6 Time of Instruction: 25 mins Media: Large Group Instruction Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized. a. Imitation Session - no less than one imitation session per student. Instructions should consider each imitation session has a slightly different wound location while staying in the same area. b. Manipulation Session - no less than one manipulation session per student.

6. Learning Step / Activity 6. Optional Student Homework

Method of Instruction: Study Assignment Instructor to Student Ratio: 1:445 Time of Instruction: 0 mins Media: Large Group Instruction

1. A soldier sustained wounds during a rocket attack at your base in Afghanistan. Because of the type on injuries, you know you must administer treatment to the soldier as soon as possible in order to save his life. What is the leading cause of preventable death on the battlefield?

a. Head injuries b. Amputations c. Internal bleeding d. Extremity hemorrhage

Page 1, 1 a 2. If the soldier in question one has an amputated foot but has little or no bleeding, how would you

treat his wound? a. Use an emergency trauma bandage b. Pack the wound with gauze and wrap with an ace wrap c. Immediately place a tourniquet on the casualty d. Immediately start an IV and administer hextend

Page 1, Note 3. Even though it is about 90 degrees on your base in Afghanistan, you notice that the trauma

patient you are treating is shivering. Why should you to be concerned? a. When hypothermia is associated with significant injuries, mortality rates increase

dramatically b. You should not be concerned because hypothermia will slow down the patient’s

metabolism which should slow down any bleeding that he may have c. You should not be concerned because it is too warm for your patient to have hypothermia d. Chemical reactions in the body are affected by the decrease in temperature and

excessive blood clotting will occur Page 2, (a) 4)

4. You suspect that your patient may have internal bleeding. What are some of the signs and symptoms that point to internal bleeding?

a. Abdomen swollen with excessive bowel sounds

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b. Abdominal rigidity, and tenderness c. Signs of hypervolemic shock d. Open fracture of the left femur

Page 4, a (3) (a) 5. You suspect that your patient may have internal bleeding into his abdomen. How many liters of

blood and IV solution can a typical adult casualty hemorrhage into the abdomen? a. Up to 6 liters b. Up to 4 liters c. Up to 10 liters d. Up to 8 liters

Page 4, Second Note SECTION IV. SUMMARY

Method of Instruction: Lecture Instructor to Student Ratio is: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction

Check on Learning

Explain how hemorrhage is controlled in care under fire. Explain how hemorrhage is controlled in tactical field care. What are some of the tools Medics have available to control hemorrhage? Give an example of a realistic combat casualty scenario where each hemorrhage control tool could be used. Give examples of when tourniquets should NOT be removed. Why do we convert tourniquets to: Hasty to deliberate? Tourniquets to hemostatics or pressure bandages?

Review / Summarize Lesson

As a Soldier medic, knowledge of the principles and techniques of controlling hemorrhage by direct pressure, hemostatic agents, wound packing and the use of tourniquets WILL save lives.