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“As previously ordered, the three assault elements disregarded Netanyahu and stormed the building.”

“At this point in the operation, there wasn’t time to attend to the wounded.”

Raid on Entebbeby RADM Bill McRaven

Raid on Entebbeby RADM Bill McRaven

62

Do seconds really matter?

63

Ma’a lot Rescue Attemptby RADM Bill McRaven

Ma’a lot Rescue Attemptby RADM Bill McRaven

15 May 19743 PLO terrorists take 105 hostagesSchoolchildren and teachersWhen assault commenced, terrorists began killing hostages22 children killed, 56 woundedThe difference between a dramatic success and a disaster may be measured in seconds.

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NO IMMEDIATE MANAGEMENTof the airway should be anticipated at this point because of the need to move the casualty to cover as quickly as possible.

Care Under FireCare Under Fire

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Control of hemorrhage is the top priority.

Bleeding to death from extremity wounds is the number one cause of preventable death on the battlefield.

Cause of death in more than 2500 casualties in Vietnam who had no other injuries.

Care Under FireCare Under Fire

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Bloodborne PathogensBloodborne Pathogens

First Aiders may be exposed to infectious diseases when treating ill or injured persons.Blood or body fluid contact with: mouth, eyes, nose, or breaks in skinNeedle sticks (or other sharps)Sexual contact

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Bloodborne PathogensBloodborne Pathogens

Bodily fluids can transmit:HIVHepatitisTuberculosis…

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Universal PrecautionsUniversal Precautions

If you don’t already share bodily fluids with this person,

Now is not the time to start!

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Universal PrecautionsUniversal Precautions

GlovesEye and face protectionAirway barrier devicesHand washingContaminated clothingPotential exposure incidents

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Universal precautionsUniversal precautions

Bodily fluids can transmit HIV, hepatitis, tuberculosis,…Gloves

First choice: nitrileSecond choice: latex (allergy?)Avoid vinyl

Need for eye protection, mask?

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Is This Life Threatening Hemorrhage?

Is This Life Threatening Hemorrhage?

72

Extremity TraumaExtremity Trauma

Any penetrating extremity wound associated with a fracture is at serious risk for life

threatening hemorrhage.

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5.56mm Rifle Exit Wound

74

Questions/Comments?

75

How Do You Control Hemorrhage?How Do You Control Hemorrhage?

Direct Pressure / ElevationPressure pointPressure dressingTourniquetPacking

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Direct PressureDirect Pressure

Can you exert enough pressure?

Can you exert enough pressure at the site of bleeding?

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Direct PressureDirect Pressure

Use both handsGlovesGauze helps clottingBest method in a stable environmentElevate injured limb

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Direct PressureDirect Pressure

Works most of the time for external bleedingTwo handsGround or hard surface underneathLean into itDON’T LET UP TO CHECK WOUND!Hard to maintain on big bleeders during casualty carry

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Pressure PointPressure Point

Apply where artery can be trapped against boneUse two handsShould be use in conjunction with direct pressure or pressure dressing

80

Pressure DressingPressure Dressing

Used to replace direct (manual) pressure If direct pressure didn’t work a dressing WILL NOT be successful!A neat bandage (dressing) is a happy bandage

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Pressure DressingPressure Dressing

Probably less effective that direct pressureDirect pressure possible on top of dressingAssess your treatment: bleeding in the dressing is not effective

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83

Questions?

84

TourniquetsTourniquets

Discouraged by ATLS

Most reasonable initial choice to stop extremity bleeding in the Care Under Fire Phase

Direct pressure is hard to maintain during casualty transport under fire.

85

Tourniquets– from the front lineTourniquets

– from the front line

Tourniquets are not being placed correctly

Too liberal use on small oozing distal wounds.

They are not being tightened enoughVenous -vs- Arterial

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Leading Confederate GeneralKIA at Shiloh 7 April 1862Gen Johnston’s Surgeon - Dr. David Yandell - directed that tourniquets be issued During the battle, Gen Johnston sustained injury to popliteal artery - bled to deathTourniquet was in his pocket

The Death of General Albert Sidney Johnston

The Death of General Albert Sidney Johnston

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Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries.

Vietnam. Medical Evacuation. Marines of Company E, 2nd Battalion, 9th Marines, while under heavy firefight with NVAs within the DMZ on Operation Hickory III, are carrying one of their fellow Marines to the H-34. 07/29/1967

Extremity Hemorrhage Control

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OIF FatalityOIF Fatality

Marine shot in leg in IraqPulsatile femoral artery bleedingCorpsman arrived 10 minutes laterAttempted to use hemostatic materialFailedIV attempted – failedTourniquet finally appliedCasualty died

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Hemorrhage Control in COMBAT

Hemorrhage Control in COMBAT

The recommended means to control bleeding in a tactical environment while under fire is a rapidly applied tourniquet

COMBAT APPLICATION TOURNIQUET ®®

90

Journal of Special Operations Medicine, Volume 5, Edition 4 / Fall 05

91Cravat/Windlass

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Damage to the arm or leg is rare if the tourniquet is left on less than an hour.

Tourniquets often left in place for several hours during surgical procedures.

In the face of massive extremity hemorrhage, in any event, it is better to accept the small risk of damage to the limb than to have a casualty bleed to death.

TourniquetsTourniquets

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The Five Big Tourniquet Mistakes

The Five Big Tourniquet Mistakes

1. Not using one when you should

2. Using one when you shouldn’t

3. Putting it on too high above the wound

4. Not taking it off when you could

5. Not making it tight enough

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How long does it take to bleed to death from a complete femoral artery and vein disruption?

Answer:2-4 minutes

TourniquetsTourniquets