The IFAK Explained.

FAK = Individual First Aid Kit - 

The Individual First Aid kit (misnamed in the NPR article on silent chaos as "infantry first aid kit") is the mature form of the military first aid kit.  The contents of the IFAK are all included because of key discoveries in military medicine.  IFAK's come in several varieties but all contain similar products.  One key assumption behind the IFAK is "the threat is still active"  These kits came out of the world of military combat.  These kits were designed to be carried all the time, and used by an injured individual who could not reach the medic before they lost too much blood.  They were designed to be used by the individual who carries it, for themselves.  The treatments they contain are for emergency conditions that will kill a person within minutes.  They are not intended to be the only medical solution for everything. 

A typical IFAK can include at least one Tourniquet, one compressive dressing, one hemostatic bandage, one wound seal, one nasal airway and one pair of medical gloves.   Additional products are placed in the kit for a variety of different reasons. Let's look at each one briefly.

 The Tourniquet

The tourniquet goes way back, at least as far as Napolean's army.  Boy Scouts and most wilderness first aid training includes some discussion of tourniquets.  Mainstream first aid classes don't include tourniquets because its use had fallen out of favor in the last century.  However, in the last 20 years, military experience showed us the need to have a quickly applied, rugged, and simple device to stop bleeding from wounds to the arms and legs.  There are several current models to choose from.  Each has its own strengths.  The U.S. military forces equip their soldiers with either the Combat Application Tourniquet (CAT) or the Special Operations Forces Tactical Tourniquet (SOFT-T).  Other devices exist but are not easily applied with one hand only (assumes the other arm is the injured arm).    

Tourniquets can stop bleeding from arm or leg wounds when they are applied above the site of injury (between the heart and the injury).   They work by compressing the blood vessels in the limb.  They must be applied tight enough to stop arterial flow (tighter than the pressure in the vessel - systolic blood pressure).   If they are not tight enough, they can slightly increase blood loss by blocking only the draining veins and causing a back up of blood in the limb.  This also accounts for the concern civilian docs have about their use. After prolonged blockage of blood flow, the limb can sustain damage.  This is not usually a concern in the U.S. civilian EMS world as most seriously injured trauma patients can be transported to advanced care in less than 2 hours.  We promote the use of the SOFT-T because it is very simple and hasn't had the problem of cheap knock-offs that fail.  

Compressive Dressings 

Unlike tourniquets, which are not placed directly on the wound, Compressive Bandages are designed to be placed directly on the bleeding wound.  First aid training always emphasizes the need to apply direct pressure to any bleeding wound.  Direct pressure provides local compression of the arteries and veins feeding the wound. This allows the blood flow to slow and the normal clotting systems of the body to act and stop the bleeding.  Compressive bandages work well on moderate bleeding and allow the rescuer to apply the dressing and then move to another care task.  Modern compressive dressings are often strong enough to create a tourniquet effect so care needs to be used in applying them. They should not be left in place beyond the end of the emergency to avoid damage to the limb.   Most modern compressive bandages are long enough to be applied to the torso as well as arms and legs. Tourniquets are only used on arms and legs.   

Hemostatic Bandages

The word Hemostatic translates to "Blood Stop".  Hemostatic Bandages should be considered a major discovery linked to the high cost of the wars over the last 20 years.  These bandages, along with tourniquets have saved hundreds of lives in combat.  The current technology in hemostatic dressings come directly from the military's need to stop bleeding quickly and simply without surgery.  Most current hemostatic bandage technology is based on the concept that normal blood will clot when it comes into contact with a substance that is not normally in contact with blood.  That sounds funny but in the body, blood is always undergoing clotting (coagulation) and clot breakdown (fibrinolysis).  Anytime blood comes into contact with anything not normally present inside a blood vessel, it starts to clot (think heart attacks or stroke).   Some substances prevent clots but we will ignore this now.  All hemostatic bandages are based on a common concept, they are usually gauze products coated or made from a substance that accelerates the clotting process.  One popular product uses Kaolin, a component of clay or sand.  Others use forms of silica, cellulose, or chitosan. These compounds all interact with the clotting system to accelerate clotting.  In most cases these products accelerate clotting many times the normal rate.  This allows even severe bleeding to be controlled when direct pressure is applied along with the special hemostatic dressing.  I have my preference for chitosan products since it seems to work better than the others and also has antimicrobial effects.

Hemostatic dressings can stop severe bleeding from anywhere on the body.  Tourniquets and compressive dressings work best on limbs where they can be wrapped tightly.  Hemostatic bandages allow bleeding to be controlled even in areas that are difficult to compress such as the scalp, neck, chest, abdomen and groin.   In fact, military training often includes the use of tourniquets for arm and leg wounds and direct pressure with a hemostatic bandage to anywhere else.   Keep in mind that direct pressure on the neck can collapse the airway so care must be taken to allow the patient to breath.  Its always bad when the patient can't breath. That brings us to the next item....

Nasal Airway.

The nasal airway or "nasal trumpet" is designed to allow air to pass through the nose and past the tongue.  They are at best a temporary and minimalist solution for airway control.  My personal opinion is that Nasal airways are of limited use as most awake patients will naturally protect their own airway and find a body position that allows some breathing.  The use of a nasal airway requires specific training and is very uncomfortable to insert (both for the patient and the rescuer).  Before I use nasal airways, I always attempt to position the patient in the sniffing position or perform a chin lift to improve airflow.  If a nasal airway is necessary for survival in the minutes following a crisis, then the patient is usually a candidate for a more advanced airway device or procedure.  IF your kit has a nasal airway, be prepared to use it by seeking the proper training.  In some states you have to be a licensed medical provider to use one.  

Wound Seal

Wound seals or "chest seals" are basically occlusive dressings (impervious to air at least). Most commercial wound seals are medical grade sticky patches.  Imagine a plastic or rubberized film coated with stuff as sticky as those live catch sticky mouse or rat traps.  They are intended to seal up a wound to the chest.  Some "chest seals" actually have valves in them that supposedly make them safer to use on a sucking chest wound.  The valve is supposed to allow pressurized air from inside the chest to escape, preventing a "tension Pneumothorax- a deadly condition).  Examples of chest seals with valves include the Aschermann Chest Seal and the Bolin Chest Seal. Simpler wound seals don't have valves but also stick to the skin tightly and prevent air and fluid from moving past them.   

Here's the deal with penetrating chest wounds.  The hole on the outside is not nearly as much of a problem as the possibility of having additional holes on the inside of the chest.  Once the chest wall is open to the outside lung function is compromised.  If the lung is also damaged, then air can accumulate inside the chest and compress the lungs and big blood vessels, leading to a "tension pneumothorax" which can kill the person.  Tension pneumothorax leads to rapid deep breathing, shortness of breath and eventually death.  Treatment of a tension pneumothorax involves making another hole that stays open and prevents the pressure from building up in the chest.  Trauma teams and medics often use large needles pushed through the chest in a specific location to vent the pressure.  The classic "sucking chest wound", albeit dramatic, is full of pitfalls.  Remember this, just because the sucking sound is stopped does not mean the patient is getting better. They could develop a tension pneumothorax faster BECAUSE the hole was sealed on the outside. 

Other inside holes that are bad to have include holes to the big blood vessels of the chest, the airway and the heart.  If those holes exist, patching the ones on the outside is not likely to be very helpful. That being said, wound seals can also work okay on bleeding wounds by containing the blood and allowing clotting to take place.   

Trauma Shears, Gloves, tape, cravats, backboards and the kitchen sink.

Trauma shears are heavy scissors used to cut away clothes.  Do this if you have the time. However, If you have a severely bleeding wound to the lower leg and the bad guy is still shooting, get to cover and then apply the tourniquet near the upper thigh on the same leg.  Its like I always quote, "Don't just do something, stand there".  Just because you can doesn't mean you should. 

Gloves = Personal Protective Equipment - don't touch a patient without them - ever.  Enough said. 

The IFAK is not a full service first aid kit. It is a "survive the next 10 minutes kit".  

The last two items are meant to be silly.  Backboards are too long to put in a little bag and no one carries a kitchen sink in their first aid kit right?  i have yet to see an IFAK with a kitchen sink, but I have seen "first aid kits" that look a lot like an ambulance in a backpack.  The IFAK came out of a very practical need to save lives during combat.  The IFAK needs to be small enough that each soldier would carry it everywhere and still address the life threats that occur in the few short minutes after a body is hit by things that make holes.  IFAK's aren't meant to treat heart attacks, or splint a fracture.  They aren't any good for asthma or bee stings unless you put the right medicines in them.  The technology in an IFAK represents a major advancement in first aid. Countless lives will be saved in the future through the use of these simple items.  Get your own IFAk and keep it handy.  As our world continues to breed violence, the need for IFAKs will continue to grow.  Get yours today and become part of the solution!

Dr. Matt Evenhouse (doc1@medsecintl.com)