One thing you figure out quickly in Army Special Forces is that if you get a bigger rucksack, you will always find things to put in it: Whether those things need to be there or not. The same thing happens if you buy a bag to use as an Individual First Aid Kit (IFAK) before planning what goes in it.
The best way to select an IFAK bag or any aid bag is to determine the packing list first, then find a bag that will fit the items on your very thoughtfully selected packing list.
For an IFAK, which by definition will be a small “personal” bag, you have to decide which injuries you are planning on managing and which you are not.
Our IFAK plan is for managing immediately life-threatening injuries that can be handled with minimal equipment during an ongoing dangerous event. That is the mission statement in our TC2 course.
Based on WDMET data, which drove the entire concept of TCCC, we plan on providing life-saving interventions (LSIs) only. Bandaids don’t go in an IFAK: They go in a “Boo Boo kit”. You don’t want somebody pulling things out of your IFAK looking for a band-aid. Note: Crisis Medicine does not receive financial compensation for any recommendations regarding gear or equipment.
Management of Life Saving Interventions: M-A-R-C-H
LSIs pertinent to an IFAK include the management of junctional and extremity hemorrhage, management of airway occlusion, decompression of tension pneumothorax, and prevention of hypothermia. Other more advanced interventions like iV access for shock require too much gear for an IFAK.
If you plan on managing massive hemorrhage from an extremity, you will be using tourniquets. In any study ever conducted on human thighs, verifying occlusion of arterial flow with Doppler ultrasound, the CAT always outperforms any competitors. [For reasons not to buy them on Amazon, see our blog post on counterfeits]. We only stock CAT tourniquets in our IFAKs. Admittedly, we are still using 6th generation CATS as they are the most proven. Unfortunately, their manufacture ceased in 2015. The 7th generation has now replaced them. There is literature to show it works, but not as much data as previous generations. We remain cautiously optimistic. Since one tourniquet high on a thigh may only occlude arterial flow 70% of the time, you need to have two available. That will bump the efficacy to at least 80% success. If you have more than one casualty, you can quickly run out of commercial tourniquets: Having a plan to improvise isn’t poor planning, it’s professional.
If two properly applied tourniquets placed side by side doesn’t control your massive extremity bleeding you will need to wound pack. Additionally, junctional hemorrhage, from necks, groins, armpits, and potentially subclavian vessels will not be amenable to tourniquet placement and also require skills and knowledge of wound packing.
The best way to pack a wound will be with gauze. In my Army Special Forces career, no advanced hemostatic type agents existed, and we routinely packed significant junctional wounds with cotton Kerlix gauze. Unfortunately, you can go through a lot of gauze packing a wound. Studies show plain old Kerlix gauze works just as well as the current hemostatic gauzes if you know what you are doing.
A hemostatic gauze with some scientific evidence it works may help less trained/experienced wound packers. Of the commercially available hemostatic gauzes, Combat Gauze has the most evidence supporting its use. If you can afford to add it to your IFAK, that seems reasonable.
Unless you plan on continuing to hold pressure on a tightly packed wound until the casualty is taken to definitive care, you will need to know how to make a wound packing bandage. The last thing you want is for the gauze in the tightly packed wound to work its way loose and have the person start bleeding to death all over again. Wound packing bandages require a lot of materials.
Airway intervention is not terribly likely in combat casualties based on the WDMET data, accounting for about 1.6% of deaths. Half will only require simple positioning, think head-tilt chin-lift and the recovery position. In this situation, a nasal pharyngeal airway can be helpful. The other half of airway interventions statistically will be for direct airway injuries. In that instance, a surgical airway will frequently be the answer and is a paramedic level skill.
The minimal equipment needed to decompress a tension pneumothorax is something sharp to make a hole in the chest wall to let out the air under tension. Although you can do this with a knife (which is basically a finger thoracotomy) having a large needle and catheter can make it easier. This too is a Paramedic level skill in most states. There is no good evidence that an open pneumothorax really needs to be sealed. Since we have limited space in an IFAK, we don’t have chest seals there.
More advanced interventions like iV/iO access require too much gear for an IFAK. Circulation management with an IFAK largely involves keeping the “red stuff in.” (By controlling hemorrhage).
Equipment for the prevention of hypothermia isn’t especially IFAK friendly. The NAR HPMK or PerSys Blizzard transport system are awesome options for a vehicle-mounted bag, but much too large for an IFAK. Having an inexpensive “space blanket” is the best option in a small kit.
Standardization of IFAKs
All of the IFAKS in my home, cars, and tactical gear are packed identically. They differ only in color. IFAKs are not location specific, they are casualty specific to deal with LSIs, so there is no reason to change what is in the IFAK. The plan for the IFAK remains consistent. Obviously, my medical skill set is more advanced than my wife or teenaged daughter, but the IFAK they may grab out of the car is loaded the same, in case I am there to use it.
How big is your IFAK?
The IFAK loadout below does make for a pretty big IFAK. With a smaller skill set or scope of practice, items can be omitted. My wife routinely carries a smaller IFAK in her purse that is primarily designed to deal with massive hemorrhage: 2 CAT tourniquets, two rolls of z-folded compressed gauze, a vacusealed pack containing a cravat, a 4×7 individual first aid dressing and 4” ETD, a windlass, shears, and gloves.
Based on the packing list I use, the only IFAK that is big enough to hold everything is the Condor Tear Away IFAK (model MA41). There are currently two sizes, and we use the larger. This IFAK bag is cheaply made, but also inexpensive. It seems to hold up fine and when it shows too much wear I replace the bag. We have students do all the casualty scenarios in our in-person Advanced class with this IFAK and a similar packing list (that class doesn’t cover surgical airways, so those materials aren’t included).
IFAK Load Out based on LSIs:
- (2) military safety pins from military cravats
- NPAs – although the “universal” size is 28 French, I have one sized for each family member
- A single serving packet of water soluble lubricating jelly for the NPAs – it just makes insertion easier
- (2) CAT tourniquets, taken out of the plastic wrap
- A very small roll of 100-MPH tape
- A vacusealed bag containing:
- (2) rolls of Kerlix 4.5 inches x 4.1 yards
- (2) military cravats
- A military 4×7 Individual First Aid Dressing
- A 4 inch ETD / Israeli bandage
- a preplanned wooden windlass
- (2) rolls military or LEO Combat Gauze
- (2) 10-14 gauze 3.25 inch angiocaths
- A surgical airway kit consisting of:
- mosquito forceps
- a cut down endotracheal tube, 6.5 mm
- a disposable #10 scalpel
- a length of gutted 550-cord to secure the ETT
- A 10 cc syringe
- A space blanket
But you left out the ####
Some people will say why don’t you carry [fill in their favorite medical gadget]. The reason is simple. These items allow me to run the MARCH mnemonic on any patient, especially my family. It’s not going to be enough for a mass casualty event because even local fire and ambulance services do not carry enough gear for a mass casualty event. Studies differ on how many casualties occur in active violent incidents. North American Rescue’s public access bleeding control kit comes as an 8-pack of sub-kits because they use data suggesting there are seven casualties per event. There is FBI data suggesting the number may be 4.
The final block of the Crisis Medicine Complete Tactical Casualty Care course is a 1-hour whiteboard discussion where we make a packing list for an IFAK, an aide bag, and a vehicle-mounted bag. Want to learn how to use everything on this packing list? Online classes available.