Guidelines and Key Points

## Basic Management Plan for Care Under Fire

1. Return fire and take cover.
2. Direct or expect casualty to remain engaged as a combatant if appropriate.
3. Direct casualty to move to cover and apply self-aid if able.
4. Try to keep the casualty from sustaining additional wounds.
5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
6. Stop life-threatening external hemorrhage if tactically feasible:
   - Direct casualty to control hemorrhage by self-aid if able.
   - Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
   - Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.
7. Airway management is generally best deferred until the Tactical Field Care phase.

#### Life-threatening bleeding can be identified by several characteristics

- There is pulsatile or steady bleeding from the wound.
- Blood is pooling on the ground.
- The overlying clothes are soaked with blood.
- Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood.
- There is a traumatic amputation of an arm or leg.
- There was prior bleeding, and the patient is now in shock (unconscious, confused, pale).

#### Applying the Tourniquet

Tighten the tourniquet until bleeding is controlled. If the first tourniquet fails to control the bleeding, apply a second tourniquet just above the first. Don’t put a tourniquet directly over the knee or elbow. Don’t put a tourniquet directly over a holster or a cargo pocket that contains bulky items.

#### Common Mistakes when Applying Tourniquets

- Not using one when you should, or waiting too long to put it on.
- Not pulling all the slack out before tightening.
- Using a tourniquet for minimal bleeding.
- Putting it on too proximally if the bleeding site is clearly visible.
- Not taking it off when indicated during TFC.
- Taking it off when the casualty is in shock or has only a short transport time to the hospital.
- Not making it tight enough – the tourniquet should both stop the bleeding AND eliminate the distal pulse.
- Not using a second tourniquet if needed.
- Periodically loosening the tourniquet to allow blood flow to the injured extremity​.