The most ideal approach when choosing an IFAK pouch, bag, sack, container, or any type of ruck or pack, is to first decide the contents, what you are going to put in it, what you intend to carry based on your needs and capabilities. Only after you have done this should you start shopping for its container.
For an IFAK, which by definition will be a compact "individual" pack, you need to choose which wounds or emergencies you are anticipating overseeing and which you are definitely not.
Our thought process behind packing an IFAK is to have readily available that type of equipment that is quickly accessible and properly designed for the management of perilous wounds or a small number of manageable conditions that could if left untreated, be fatal. As such, we have identified several categories of items that will allow you to perform life-saving interventions (LSI). When preparing an IFAK, you should ask yourself, “does this item help me conduct an LSI?” A tourniquet is an obvious choice since that will address massive extremity hemorrhage, a Band-Aid, not so much, and those are best relegated to an adequate “boo-boo kit”. When faced with having to perform an LSI, you definitely do not want to waste time digging around your pouch or bag looking for the right item.
First, let us begin with some introductory academically historical and relevant data, data that serves as the justification for what it is we are trying to accomplish with the IFAK. The Wound Data and Munitions Effectiveness Team (WDMET) study completed in the early 1970s was the first dataset that clearly demonstrated the unique timing of battlefield deaths and emphasized the need for forward medical care. In the examination of a cohort of Vietnam era battlefield deaths, conclusions from WDMET showed that the greatest opportunity for lifesaving intervention on the battlefield is early on, at the point of injury. The study showed that 90% of the studied deaths on the battlefield occurred before designated medical care (field hospital or even from the combat medic) was able to be given to the injured: 42% immediately, 26% within five minutes and 16% within five to 20 minutes.
That means 84% of the fatalities on the battlefield died quickly, within 30 minutes of their injury. Let us be clear, 84% of all soldiers injured did not die in this period, but out of those who did in fact die, 84% died within those first 30 minutes.
Additionally, only 10% of the fatalities that were recorded in the registry were found to have received some type of medical care. Ninety % of the fatalities did not receive any medical care, so the natural assumption then is that those who received care were less likely to die. The summary results from the WDMET study echoed common sense conclusions, “The greatest benefit is achieved through a tactical configuration that puts the caregiver at the patient’s side within a few seconds to minutes of wounding.” This is where you and your IFAK come into play!
If you are a first responder, mainly police and fire, this conclusion does not endorse the outdated paradigm of “stage and wait until everything is safe.” Instead, the operational response must be adapted and configured to get the caregiver to the patient’s side within a few seconds to minutes of wounding.
All causes of battlefield deaths were reported to the registry, included devastating injuries such as surgically uncorrectable torso trauma, injury to the central nervous system, and blast/mutilating trauma. These injuries cause battlefield fatalities even immediate advanced medical care could not prevent.
However, included in the epidemiology of combat deaths were the 9% caused by exsanguination from an extremity wound. Also included were 1% from airway obstruction and another 5% from tension pneumothorax, both being relatively easy to diagnose and simple to manage in the acute setting. So, 15% of the combat fatalities from three etiologies (exsanguination from an extremity wound, tension pneumothorax and airway obstruction) were readily preventable with simple interventions if applied soon after wounding.
This last paragraph is convincing evidence that we refer to when preparing an IFAK, they should include the equipment necessary to address these causes of preventable deaths.
We can, therefore, conclude that the rapid application of simple, appropriate, stabilizing treatment at or near the site of wounding plus expedient evacuation to the closest appropriate medical facility, equals maximal survival rate for those injured. It is just common sense.
Let us discuss these “Life Saving Interventions”: The M-A-R-C-H algorithm.
LSIs managed with the IFAK components include massive junctional and extremity hemorrhage, furthest point drain, airway impediments, decompression of tension pneumothorax, and the prevention or management of hypothermia and its complications. Given that the IFAK is, by definition, small in size, other equipment such as IV access kits, cold packs, ointments, OPA’s, ETT’s, or CPR masks, require either too much space or ancillary gear for an IFAK .
Massive Hemorrhage: Tourniquets are the go-to tool of choice these days to manage extremity hemorrhage. There is, as of this writing, more than 18 years of evidence from the GWOT attesting to its safety and efficacy. The erroneous stigma previously associated with tourniquet use must be deleted from your thought process and replaced with current paradigms based on medical evidence. You should immediately raise your suspicions towards those not advocating the use of tourniquets, or those making baseless statements such as “you will lose the limb” These should be red flags such thinking is based on significantly outdated, disproven, and misleading information.
There are a number of suitable choices in this category, the CAT Gen 7 & SOF-T-W Gen 4, are a very popular choice, but there have been some excellent new tourniquets added to the Co-TCCC recommendation list. These are the SAM XT, the M2 & M3 Ratcheting TQ, and the Tactical Mechanical Tourniquet. We will not make any specific recommendation for this or any other item, we prefer you to make your choice on what would be best for you. However, the CAT seems to be a perennial favorite simply because of the abundance of research and evidence in its favor, and it is very easy to apply one-handed. The SOF-T-W is very popular as well due to its durability and the quick-detach strap, making it easy to put on and take off.
Once you figure out which TQ is best for you, go ahead and get two! Evidence suggests that one tourniquet placed high on a thigh may occlude blood flow only 70% of the time; you may need to have two accessible. This will increase the chances of success and improve survivability. It also makes good practice to have a spare in the event that you have more than one casualty. It is a great approach in any scenario.
In the event that two appropriately placed tourniquets next to the other cannot control the bleeding, you should then consider packing the injured site. Wounds to the junctional areas, neck, groin, axilla, and even some of the subclavian vessels cannot be managed with a tourniquet and will require the knowledge and skill of wound packing. Note: wound packing as an initial intervention is entirely appropriate in the absence of a tourniquet.
Packing an injury requires the use of either cotton or hemostatic gauze. A hemostatic dressing such as Combat Gauze has been proven to be beneficial in dealing with these wound patterns, but they can be of benefit to those that have less experience with managing these injuries. These are products impregnated with either Kaolin or Chitosan, substances that are proven to speed up the clotting process via two separate mechanisms. These gauzes do not necessarily work “better”, they simply work “faster”, and this can have some obvious benefits given the tactical situation and the experience of the user.
Combat Gauze is the choice of the military and many first responders simply because it has the most studies supporting its utilization, including ISR safety model. Whether you choose Combat Gauze, Celox, ChitoSAM, X-STAT, or another brand, they are all very sensible additions to your IFAK. There are a couple of good choices for non-hemostatic regular gauze. Rolls of Kerlix brand gauze make for excellent wound packing material and are useful in many other ways. If space is a concern, and it will be in a small IFAK, companies like North American Rescue or H&H Medical make some excellent compact vacuum-packed products. You should also try to maintain a 2:1 ratio of hemostatic gauze to cotton gauze. I.E. carrying two cotton gauze pouches for each Combat Gauze pack.
Packing a wound is not as easy or straightforward as usually portrayed on the internet, it does require quite a bit of material not only to pack the wound but also to make a proper bandage to secure the packed gauze in place. It makes no sense for you to have done a good job stopping the bleed if the packed gauze makes its way out of the wound channel and the casualty starts bleeding once again. You must consider this when preparing a kit and choose the right components.
WDMET information indicates that just over 1 % of preventable combat deaths are a result of airway issues, so this may not be a concern in most cases. Luckily, most of the cases you may see can be address by simple positioning of the airway using basic life support techniques such as the head-chin-tilt lift or the recovery position. You can drop a nasal pharyngeal airway on these patients and move on to another casualty or treat another injury on the same patient. The more complex cases likely are due to a direct injury or insult to the trachea or pharynx and will require a surgical airway. This is an advanced paramedic level skill and requires a set of tools not carried in an IFAK.
Respiratory Problems: The main killer in this category is a tension pneumothorax and requires the use of a needle for chest decompression. The needle makes a small puncture hole in the chest wall that allows trapped air to escape, improving breathing. The tool of choice here is a long 10-gauge catheter (at least 3.25”). The military used 14-gauge catheters for many years, but 10-gauge versions have recently been added to the Co-TCCC recommended gear list. Just like the surgical airway, NCD is also a paramedic level skill in many areas; however, it is a good idea to have it available in your kit in the event that a paramedic must perform the procedure on you.
Chest seals are another popular staple in IFAK’s; they are used to seal open chest wounds in order to prevent an open pneumothorax from becoming a tension pneumothorax, as in the case of sucking chest wounds. Having said that, there does not seem to be a good consensus as to whether an open pneumothorax needs to be sealed or not, given that air can freely flow in and out of the thoracic cavity. As such, carrying a chest seal may or may not be an absolute must, however, if space allows it, we say go for it!
Circulation Maintenance: Not much that we can do about that since equipment to start an IV or an IO is too bulky for an IFAK. The focus in maintaining good circulation must be keeping the "red stuff off the floor” by controlling hemorrhage.
Hypothermia Prevention: Often overlooked is the “Trauma Triad of Death”, not to be confused however with the three causes of preventable deaths. The combination of hypothermia, acidosis, and coagulopathy is a one-way ticket to whatever life awaits us on the other side. You need to be able to prevent the casualty’s core body temperature from dropping too much; a drop of core body temperature below 95 degrees F can have catastrophic effects.
The NAR HPMK or PerSys Blizzard Blanket are great tools for hypothermia management but are just too large for an IFAK. You will want to keep these in your ruck or vehicle kit. Since the size is a concern in a small IFAK, a quality "space blanket" is the best alternative. These blankets are very inexpensive and come in all kinds of colors such as black, coyote, olive drab and orange colors; there are alternatives other than the reflective silver types should your tactical situation require it.
This is completely up to the user but we recommend a certain level of uniformity should you decide to make several kits. It makes no sense to have three kits with the exact same components all packed differently. Have some consistency and pack items in the same spaces or order, it makes for much better muscle memory and reaction time in a crisis. It is perfectly reasonable and encouraged to have kits of various sizes distributed between your house, and vehicle, or in a rucksack or backpack, or even between family members, but keeping similar items in similar configurations always makes sense.
How big should your IFAK be?
This is the age-old question, and really only you can answer it. How big do you need it to be in order to address the LSI’s? If you have a limited skill set, you may be inclined to carry the bare essentials, while those with extensive medical training and improvisational skills can probably pack it a bit more.
Let us discuss some examples:
Police officers these days are starting to carry tourniquets for a host of good reasons, we are seeing these more and more each day becoming standard equipment such as handcuffs or radios. Besides some pairs of gloves, this may be the only LSI tool they carry and it is certainly better than carrying nothing.
Some are carrying small pouches on the belt specifically designed to address gunshot wounds. Some of these Downed Officer Kits or Individual Police Officer Kits can bring 3-4 items such as a compact bandage, some packing gauze, gloves, and a small chest seal. Other police officers carry larger IFAK’s on their body if they wear overt armor with outer pockets or perhaps a quickly attached leg rig. On this kit, they can carry tourniquets, an NPA, chest needle, a larger bandage such as the OLAES or PerSys T3, shears, 2-pack of chest seals, gloves, and even a casualty card.
An individual soldier can carry a very similar loadout as a police officer since they also have space and weight restrictions. A designated medic carries a slew of gear, which is a discussion for another day.
There is a kit known as a “Battle Pack” that military medics like to use. They keep several inside their pack and it includes all of the most common items to perform LSI’s inside a Ziploc bag. They can easily toss a pack or two to another provider to deliver faster care.
The Battle Pack includes:
- 1 Trauma dressing
- 1 6” ACE wrap
- 2 each compressed gauze
- 2 each cravats
- 2 each vented occlusive chest seals
- 2 each angiocatheters for NCD
- 1 Nasal Trumpet
- 2 CAT Tourniquets
- 1 each 3” silk tape
- 1 each Sharpie
- 1 pair of exam gloves
- 2 Mini Chemlights (red and green)
- 1 each TCCC Card
On the other hand, we have received unconfirmed reports that some East Coast Navy SEAL platoon members are carrying nothing more than a tourniquet an X-STAT sponge plunger device to handle penetrating injuries.
Someone with an advanced skill set can set up an IFAK as shown below, though this may be pushing the envelope of a body-worn kit, and would be best suited as a static kit for a vehicle or as a tear-away pack pouch:
- 2 each CAT tourniquets, removed from the packaging
- Several pairs of gloves
- Shears
- 2 each military safety pins for the military cravats
- NPAs in the universal size of 28 FR (or properly sized for individual family members)
- Lubricating Jelly for the NPA’s
- A portion of 100-MPH tape – flat folded if possible
- A vacuum-sealed pouch containing:
- 2 rolls of Kerlix 4.5 inches x 4.1 yards
- 2 each military cravats
- A military 4×7 Individual First Aid Dressing
- A 4 inch ETD/Israeli swathe
- A contingency windlass made out of wood or plastic (for improvisation)
- 2 packs of hemostatic gauze
- 2 each 10 gauge angiocatheters
- A prepackaged surgical airway kit such as the CRIC-KEY or:
- mosquito forceps
- tracheostomy tube or cut-down 6.5 mm ETT
- #10 scalpel
- Tape to secure the ETT
- A 10 cc syringe
- A space blanket
You have seen all these options, and we hope that you have seen the common components within them all. They are there for a reason, because they work, because they are evidence-based because they save lives!
We leave you to make an informed decision as to what is best for your mission and skill-set; we simply provide a starting point. That is all.
But wait! You forgot to include a…
A few people will ask why we may have left out such and such item even though so and so invented it and so and so endorses it. The reason is straightforward; the contents in these kits will allow you to address the components of the MARCH mnemonic on any casualty. An IFAK is not designed to address all first aid situations, it is not a mass casualty kit, it is not a survival kit for the woods, it isn’t even a “first aid” kit, it is a group of tools that when grouped together, will help you save lives!
