DIRECT THREAT CARE (DTC) /
HOT ZONE Guidelines:
1.
Mitigate
any threat and move to a safer position (e.g. Return fire, utilize less lethal
technology, assume an overwhelming force posture, etc.).
a.
Recognize
that threats are dynamic and may be ongoing, requiring continuous threat
assessments.
2.
Direct the
law enforcement/first responder casualty to stay engaged in tactical operation
if able and appropriate.
3. Extract casualty to a safer position:
a. Instruct the casualty to move to a safer position and apply self-‐aid
if capable.
b. If the casualty is responsive but cannot move, a
rescue plan should be devised and implemented.
c.
If a
casualty is unresponsive, weigh the risks and benefits of an immediate rescue
attempt in terms of manpower and likelihood of success. Remote
medical assessment techniques for survivability should be considered.
4.
Stop life
threatening external hemorrhage if present and reasonable depending on the
immediate threat, severity of the bleeding and the extraction distance to
safety. Consider moving to safety prior to application of the tourniquet if the
situation warrants.
a.
Direct
casualty to apply direct pressure to wound and/or own effective tourniquet if
able.
b.
Tourniquet application:
i.
Apply the
tourniquet as high on the limb as possible, including over the clothing if
present.
ii. Tighten until cessation of bleeding and move to safety.
5. Consider quickly placing unresponsive casualty in recovery position to
protect airway.
INDIRECT THREAT CARE (ITC) /
WARM ZONE Guidelines:
1.
Any
casualty with a weapon should have that weapon made safe and secured once the
threat is neutralized and/or if mental status is altered.
2. Bleeding:
a. Assess for and control any unrecognized major bleeding:
i.
Use a tourniquet
or an appropriate pressure dressing with deep wound packing (either plain gauze
or, if available, hemostatic dressing to control life-‐ threatening bleeding
in an extremity or a junctional area:
- Apply
the tourniquet over the clothing as proximal-‐-‐ high on the limb-‐-‐ as possible, or if able to fully
expose and evaluate the wound, apply directly to the skin at least 2-‐3 inches
above wound (DO NOT APPLY OVER THE JOINT).
- For any
traumatic total or partial amputation, a tourniquet should be applied as high on the
extremity as possible regardless of bleeding.
b. If available, immediately apply a junctional
tourniquet device for anatomic junctional areas where bleeding cannot be easily
controlled by direct pressure and hemostatics/dressings.
c.
Reassess all
tourniquets that were hastily applied during Direct Threat/Hot Zone Care.
i.
Evaluate
the wound for continued bleeding or a distal pulse in the extremity. - If there is continued bleeding
or a distal pulse is still present, either
tighten the existing tourniquet further or apply a
second tourniquet, side-‐ by-‐side and, if possible, proximal to the first,
to eliminate the distal pulse.
d. If possible, mark all tourniquet sites with the time of tourniquet
application.
3. Airway Management:
a. If the casualty is unconscious or is conscious but unable to follow
commands:
i.
Clear mouth of any foreign
bodies (vomit, food, teeth, gum, etc).
ii.
Apply basic chin lift or jaw
thrust maneuver to open airway.
iii.
Consider placing a
nasopharyngeal airway.
iv.
Place casualty in the
recovery position to maintain the open airway.
b. If the casualty is conscious and able to follow commands:
i.
Allow
casualty to assume position of comfort, including sitting up. Do not
force to lie down.
a.
All open
and/or sucking torso wounds should be treated by immediately applying a vented
or non-‐vented occlusive seal to cover the defect.
b. Monitor any casualty with penetrating torso trauma for
the potential development of a tension pneumothorax. Most common presentation
will be penetrating chest injury with subsequent increasing shortness of breath
and difficulty breathing and/or increasing anxiety/agitation.
i.
If tension
pneumothorax appears to be developing, removing the occlusive dressing and/or “burp”
the chest seal.
ii.
Casualties
with concern for developing tension pneumothorax should be prioritized for
evacuation to higher level of care.
5.
Shock
Management/Resuscitation:
a.
Assess for hemorrhagic shock
i.
Altered
mental status (in the absence of head injury) and weak or absent peripheral
pulses are the best field indicators of shock.
b.
If not in shock:
i.
Casualty may
drink if conscious, can swallow, and there is a confirmed delay in evacuation
to care.
c.
If in shock:
i.
Prioritize
for rapid evacuation any patient, especially those with penetrating torso injury,
displaying signs of shock.
6.
Prevention of hypothermia:
a. Minimize casualty’s exposure and subsequent heat loss.
i.
Keep protective gear on or
with law enforcement casualty if feasible.
ii.
Keep casualty warm and dry:
- Place the casualty onto an
insulated surface to reduce conductive heat loss as soon as possible.
- Minimize exposure to
the elements.
- Replace wet clothing
with dry if possible.
- Cover
casualty with commercial warming device, blankets, poncho liners, sleeping bags, or anything
that will retain heat and keep the casualty dry.
7.
Reassess casualty:
a.
Perform a
rapid blood sweep, front and back, checking for additional injuries. Tearing,
cutting, or otherwise exposing the wound may be necessary.
8.
Burns:
a.
Stop the burning process.
b. Cover burns with loose dry dressings if available.
c.
Large area
burns and signs of significant airway burns or smoke inhalation (e.g. singed
facial hair, soot/burns/swelling around the nose or mouth) should be
prioritized for rapid evacuation.
d. Burn patients are more susceptible to hypothermia – minimize heat loss
as above.
9.
Prepare casualty for
movement:
a. Consider operational and environmental factors for safe and expeditious
evacuation.
b. Secure casualty to a movement assist device when available.
c. If vertical extraction required, ensure casualty secured appropriately.
10. Communicate
with the casualty if possible. a. Encourage, reassure and explain
care.
11.
Cardiopulmonary
resuscitation:
a.
CPR within
this phase of care for victims of blast or penetrating trauma who have no pulse,
no ventilations, and no other signs of life will likely not be successful and
should not be attempted.
b. In other circumstances, performing CPR may be of benefit and may be considered
in the context of the operational situation.
12.
Documentation of Care:
a.
Communication
of assessments and treatments rendered should be passed along with the casualty
to the next level of care. This should be documented on a simple standardized
casualty care card with the casualty to the next level of care.
EVACUATION CARE (EVAC) /
COLD ZONE Guidelines:
1. Reassess all interventions applied in previous phases of care.
2.
If multiple
wounded, perform primary triage for priority and destination of evacuation to a
higher level of care.
3. Airway Management:
a.
The
principles of airway management in Evacuation Care / Cold Zone are similar to
that in ITC / Warm Zone.
b. If the casualty is unconscious or is conscious but unable to follow
commands:
i.
Clear mouth of any foreign
bodies (vomit, food, teeth, gum, etc).
ii.
Apply basic chin lift or jaw
thrust maneuver to open airway.
iii.
Consider placing a
nasopharyngeal airway.
iv.
Place casualty in the recovery
position to maintain the open airway.
c. If the casualty is conscious and able to follow commands:
i.
Allow
casualty to assume position of comfort, including sitting up. Do not force
to lie down.
4.
Breathing:
a.
All open
and/or sucking chest wounds should be treated immediately by applying a vented
or non-‐vented occlusive seal to cover the defect. Monitor the casualty for
the potential development of a subsequent tension pneumothorax.
b. Reassess casualties who have had chest seals applied.
Any developing tension pneumothorax should be treated as described in ITC /
Warm Zone.
c.
If
available, administration of oxygen may be of benefit for all traumatically
injured patients, especially for the following types of casualties:
- Chest injuries
- Torso injuries associated with shortness of breath - Unconscious or altered mental
status
- Post-‐blast injuries -
Casualty in shock - Casualty at altitude
5.
Bleeding:
a. Fully expose wounds to reassess for and control any unrecognized major
bleeding:
i.
Use a
tourniquet or an appropriate pressure dressing with deep wound packing (either
plain gauze or, if available, hemostatic gauze) to control life-‐
threatening bleeding in an extremity or a
junctional area:
- Apply the tourniquet over the clothing as
proximal-‐-‐ high on the limb-‐-‐ as possible, or if able to fully expose
and evaluate the wound, apply directly to the skin 2-‐3 inches above wound (DO
NOT APPLY OVER THE JOINT).
- For any traumatic total or partial amputation, a
tourniquet should be applied regardless of bleeding.
b. If available, immediately apply a junctional
tourniquet device for anatomic junctional areas where bleeding cannot be easily
controlled by direct pressure and hemostatics/dressings.
c. Reassess all tourniquets that were hastily applied during prior phases
of care.
i.
Evaluate
the wound for continued bleeding or a distal pulse in the extremity. - If there is continued bleeding
or a distal pulse is still present, either
tighten the existing tourniquet further or apply a
second tourniquet, side-‐ by-‐side and, if possible, proximal to the first,
to eliminate the distal pulse.
d. Clearly mark all tourniquet sites with the time of tourniquet
application.
6.
Shock
Management/Resuscitation:
a. Re-‐assess for developing hemorrhagic shock
i.
Altered
mental status (in the absence of head injury) and weak or absent peripheral
pulses are the best field indicators of shock.
ii.
Utilize
additional medical assessment and monitoring equipment that may be available in
this phase.
b.
If not in shock:
i.
Casualty may
drink if conscious, can swallow, and there is a confirmed delay in evacuation
to care.
ii.
Allow casualty to assume
position of comfort.
c.
If in shock:
i.
Prioritize
for rapid evacuation any penetrating torso injury patient displaying signs of
shock.
ii.
Consider
alternative methods of transportation to definitive medical care if traditional
methods delayed or unavailable. Ensure coordination of patient distribution to
avoid overwhelming any one medical receiving facility.
d. If altered mental status due to suspected TBI and
casualty not in shock, position the casualty supine and raise the casualty’s
head to 30 degrees.
7. Prevention of hypothermia:
a. Minimize casualty’s exposure and subsequent heat loss.
i.
Keep protective gear on or
with law enforcement casualty if feasible.
ii.
Keep casualty warm and dry:
-‐ Place the casualty onto an insulated surface to reduce conductive heat
loss
as soon as possible.
-‐ Minimize
exposure to the elements.
-‐ Replace
wet clothing with dry if possible.
-‐ Cover
casualty with commercial warming device, blankets, poncho liners,
sleeping bags, or anything that will retain heat and keep the casualty
dry.
iii.
Move into a vehicle or
warmed structure if possible.
8. Reassess casualty:
a.
Complete
full front and back re-‐assessment checking for additional injuries. Inspect and
dress known wounds that were previously deferred.
b. Frequently re-‐check the casualty for any changes in
condition. Worsening status at any point should prompt priority evacuation.
Consider alternative methods of transportation to definitive medical care if
traditional methods delayed or unavailable. Ensure coordination of patient
distribution to avoid overwhelming any one medical receiving facility.
9.
Burns:
a.
Stop the burning process.
b. Cover burns with loose dry dressings if available.
Clean, dry sheets are effective for casualties with large area burns.
c.
Large area
burns and signs of significant airway burns or smoke inhalation (e.g. singed
facial hair, soot/burns/swelling around the nose or mouth) should be
prioritized for rapid evacuation. Consider alternative methods of
transportation to definitive medical care if traditional methods delayed or
unavailable. Ensure coordination of patient distribution to avoid overwhelming
any one medical receiving facility.
d. Burn patients are more susceptible to hypothermia – minimize heat loss
as above.
10. Prepare casualty for movement:
a. Consider environmental factors for safe and expeditious evacuation.
b. Secure casualty to a movement assist device when available.
c. If vertical extraction required, ensure casualty secured appropriately.
11. Communicate with the casualty if possible, and with the
operational medical provider or medical
facility assuming care of the casualty.
a.
Encourage,
reassure and explain care and expectations to patient, family and/or
caregivers.
b. Notify receiving provider or facility of wounds,
patient condition, and treatments applied.
12. Cardiopulmonary resuscitation
a.
CPR may have
a larger role during the evacuation
phase especially for patients with electrocution, hypothermia, non-‐traumatic
arrest or near drowning.
13. Documentation of Care:
a.
Continue or
initiate documentation of clinical assessments, treatments rendered, and
changes in the casualty’s status in accordance with local protocol.
b. Forward this information with the casualty to the next level of care.
GOALS, PRINCIPLES, SKILL SETS
Care
provided within the TECC guidelines is inherent upon individual first responder
training, available equipment, local medical protocols, and medical director
approval.
I. Direct Threat Care
(DTC)/Hot Zone
Primary Goals:
1. Accomplish the mission with minimal additional casualties.
2. Prevent any casualty from sustaining additional injuries.
3.
Keep
response team maximally engaged in neutralizing the existing threat (e.g.
active shooter, barricade, high threat warrant etc.).
4.
Minimize public harm.
Operational Principles:
1.
Establish tactical supremacy and defer in-‐depth
medical interventions if engaged in ongoing
direct threat mitigation (e.g. active fire fight, dynamic explosive
scenario, etc.).
2.
Threat mitigation techniques will minimize risk to casualties and the providers. These should include techniques and tools for
rapid casualty access and egress.
3.
Triage
should be deferred to a later phase of care. Prioritization for extraction is
based on resources available and the tactical situation.
4. Minimal trauma interventions are warranted during this phase.
5.
Consider bleeding control.
a. Tourniquet application is the primary “medical” intervention to be considered.
b. For response personnel, tourniquet should be readily
available and accessible with either hand.
DTC/Hot Zone Required Skill
Set (applied per approved SOP/protocol only):
1. Direct pressure and hasty tourniquet application
a. Consider PACE Methodology-‐ Primary, Alternative, Contingency,
Emergency
b.
Commercially available tourniquets
c.
Field expedient tourniquets
2.
Tactical casualty extraction
3.
Rapid placement in recovery position
II.
Indirect Threat Care (ITC) / Warm Zone
Primary Goals:
1. Goals 1-‐4 as above with DTC / Hot Zone care
2.
Stabilize
the casualty as required to permit safe extraction to dedicated treatment
sector or medical evacuation assets.
Operational Principles:
1. Maintain tactical supremacy
and complete the overall mission.
2.
As
applicable, ensure safety of both first responders and casualties by rendering weapons safe and/or rendering any adjunct tactical gear safe for
handling (flash bangs, gas canisters,
etc).
3.
Conduct dedicated patient assessment and
initiate appropriate life-‐saving interventions as outlined in the ITC / Warm
Zone guidelines. DO NOT DELAY casualty extraction/evacuation for non
life-‐saving interventions.
4. Consider establishing a casualty collection
point if multiple casualties are encountered.
5.
Unless in a
fixed casualty collection point, triage in this phase of care should be limited
to the following categories:
a. Uninjured and/or capable of ambulation or self-‐extraction
b.
Deceased / expectant
c.
All others
6.
Establish communication with the tactical and/or
unified command and request or verify initiation of casualty
extraction/evacuation.
7.
Prepare
casualties for extraction and document care rendered for continuity of care
purposes.
ITC/Warm Zone Required Skill
Set (applied per approved SOP/protocol only):
1.
Hemorrhage Control:
a.
Application of direct pressure
b.
Application of tourniquet
i.
Consider PACE Methodology-‐
Primary, Alternative, Contingency, Emergency
ii.
Commercially available tourniquets
iii.
Field expedient tourniquets
c. Perform wound packing with gauze or hemostatic agent
d.
Application of pressure dressing
2.
Airway:
a. Perform Manual Maneuvers (chin lift, jaw thrust, recovery position)
b.
Insert nasal pharyngeal airway
3.
Breathing:
a. Application of effective occlusive chest seal
b.
Apply oxygen
c. Recognize the symptoms of tension pneumothorax
d.
“Burp” occlusive dressing
4.
Circulation:
a. Recognize the symptoms of hemorrhagic shock
5.
Hypothermia prevention:
a. Apply available materials to prevent heat loss
6.
Wound management:
a.
Initiate basic burn treatment
7.
Casualty evacuation:
a. Move casualty (drags, carries, lifts)
b.
Secure casualty to litter
8.
Other Skills:
a.
Monitor casualty
b. Recognize need and requirements for, and establish Casualty Collection
Point.
III.
Evacuation Care (Evac)/Cold Zone
Primary Goals:
1. Maintain any lifesaving interventions applied during DTC and ITC phases.
2. Provide rapid and secure evacuation to an appropriate medical receiving
facility.
3.
Provide
good communication and patient care data between field medical providers and
fixed receiving facility.
4. Avoid additional preventable causes of death.
Operational Principles:
1. Reassess the casualty or casualties for efficacy of all applied medical
interventions.
2.
Utilize a
triage system/criteria per local policy that considers priority AND destination
to ensure proper distribution of patients.
3. Utilize additional available resources to maximize advanced care.
4.
Avoid hypothermia.
5.
Communication
is critical, especially between tactical elements and non-‐tactical EMS teams.
6. Maintain situational awareness: in dynamic events, there are NO threat
free areas.
Evac/Cold Zone Required
Skill Set (applied per approved SOP/protocol only):
1.
Same as ITC/Warm Zone
2.
Apply triage prioritization of casualties
3. Communicate effectively between non-‐medical, pre-‐hospital and
hospital medical assets