Atirc PDF

Active Threat
Integrated Response
Course
Participant Guide
Version 2.0
Copyright Information
Active Threat Integrated Response Course (ATIRC)
© Advanced Law Enforcement Rapid Response Training Center, Texas State University 2015
All Rights Reserved. First Edition 2015

This Printing: December 2015
Printed in the United States of America.
Reproduction of this document, in whole, or in part, in any form or by any means—graphic,

electronic, or mechanical, including photocopying, digital copying, recording, taping, or Web
distribution or information storage and retrieval systems—is strictly prohibited.
This project was supported by Cooperative Agreement Number EMW-2013-CA-K00109-S01

administered by the US Department of Homeland Security. Points of view or opinions in this
document are those of the author and do not necessarily represent the official position or
policies of the US Department of Homeland Security.
Department of Homeland Security reserves a royalty-free, non-exclusive, and irrevocable

license to reproduce, publish, or otherwise use, and authorize others to use, for federal
government purposes: (1) the copyright in any work developed under an award or sub-award;
and (2) any rights of copyright to which a recipient or sub-recipient purchases ownership with
federal support.
FEMA’s National Training and Education Division (NTED) offers a full catalog of courses at no-
cost to help build critical skills that responders need to function effectively in mass-consequence
events. Course subjects range from weapons of mass destruction (WMD) terrorism, cyber
security, and agro terrorism to citizen preparedness and public works. NTED courses include
multiple delivery methods: instructor-led (direct deliveries), train-the-trainer (indirect deliveries),
customized (conferences and seminars), and web-based. Instructor-led courses are offered in
residence (at a training facility) or through mobile programs, in which courses are brought to
state and local jurisdictions that request the training. A full list of NTED courses can be found at
http://www.firstrespondertraining.gov.
Active Threat Integrated Response Course Participant Guide
(ATIRC)
Table of Contents
Course Introduction ................................................................................................................... iii
Module 1: Course Introduction and Administration ............................................................. 1-1
Module 2: Incident Command and Integrated Active Shooter Incident Management
Checklist ................................................................................................................................... 2-1
Module 3: Staging Procedures and Resource Management................................................ 3-1
Module 4: Direct Threat Care .................................................................................................. 4-1
Module 5: Indirect Threat Care ............................................................................................... 5-1
Module 6: Tactical Response Considerations and Rescue Task Force Integration .......... 6-1
Module 7: EMS Advanced Skills ............................................................................................. 7-1
Module 8: Practical Exercises ................................................................................................ 8-1
Module 9: Course Wrap-Up, Post-Test, and Course Evaluation.......................................... 9-1
Appendix A: Glossary ............................................................................................................ A-1

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Course Introduction
In the past two decades, horrific mass shootings have been thrust into public consciousness.
Mitigating the effects of these sudden incidents is the responsibility of those that serve in our
communities’ public safety organizations. The public expects an effective and swift response to
these threats and the sequence of events that follow them.
The perpetrators of these crimes are not constrained by moral boundaries. Their motives
include anger, revenge, notoriety, and attempts to further political ideals. Because of the
unpredictable nature of active shooter events, response involves all public safety disciplines:
law enforcement, fire, and emergency medical services (EMS). Local response agencies must
be able to quickly interface with state and federal authorities.
The Active Threat Integrated Response Course (ATIRC) is a three-day, 24-hour performance-
level direct delivery course designed to improve integration between law enforcement, fire, and
EMS during active threat events. The course provides law enforcement officers with key medical
skills based on tactical emergency casualty care (TECC) guidelines which can be used at the
point of injury to increase survivability of victims in active shooter events. The course also
provides a model framework for law enforcement, fire, and EMS to integrate responses during
an active threat event through the rescue task force concept using the Active Shooter Incident
Management Checklist.
Version 2.0 iii

Active Threat Integrated Response Course Instructor Guide
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Version 2.0 iv
Active Threat
Integrated Response
Course
Module 1: Course Introduction and Administration
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This Page Intentionally Left Blank

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Module 1: Course Introduction and Administration
Slide 1-0. Title
Duration
1 hour
Scope Statement
In this module, participants will receive an overview and schedule of the three-day, 24-hour
ATIRC course. Participants will introduce themselves and complete administrative requirements
including, registration, waivers, and training rosters. Participants will also complete a pre-test to
assess their base knowledge of course materials.
Terminal Learning Objective

Participants will recognize the course goal, enabling objectives, course schedule, and course
performance requirements.
Version 2.0 PART 1-1

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Enabling Learning Objectives
Slide 1-1. Enabling Learning Objectives
At the conclusion of this module, participants will be able to
1-1 state the goal and summarize the objectives for the course,
1-2 describe the course schedule and complete administrative requirements,
1-3 describe how participant performance will be evaluated,
1-4 assess their knowledge of course material by taking a pre-test,
1-5 recognize the need for medical training for law enforcement officers, and
1-6 recognize the need for integrated response between police, fire, and emergency medical
services (EMS) during an active shooter or mass shooting incident.
Resources
 Instructor Guide
 Module 1 presentation slides
 Audiovisual kit
 Projection screen
 Attendance sheets
 Pre-test answer key
 One per participant of the following items:
 Participant Guide
 Pen
 Registration form
 Pre-Test

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Instructor to Participant Ratio

1:40
Reference List
Al-Shahi, S., Kawahara, T., Morris, Z., Perel, P., Prieto-Merino, D., Sandercock, P., and
Wardlaw, J. 2010. CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant
Haemorrhage) Intracranial Bleeding Study: The Effect of Tranexamic Acid in Traumatic
Brain Injury--a Nested Randomised, Placebo-Controlled Trial. London School of Hygiene
and Tropical Medicine, London, UK.
DHS (Department of Homeland Security). 2005. Weapons of Mass Destruction Tactical

Operations Course. Louisiana State University Academy of Counter-Terrorist Education.
DuBose, J., Midwinter, M., Morrison, J., and Rasmussen, T. 2011. Military Application of
Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.
Fabbri, W. 2014. “FBI's View to Improving Survival in Active Shooter Events.” October. Journal
of Emergency Medical Services. http://www.jems.com/articles/2014/09/fbi-s-view-
improving-survival-active-sho.html
Godfrey, W., Agan, D., Otterbacher, R., and Fender, D. 2013. 4 Best Practices for Active
Shooter Incident Management: Lessons Learned from 10 Active Shooter Exercises with
the University of North Florida. C3 Pathways, Inc.
http://www.c3pathways.com/whitepaper/White_Paper_4_Best_Practices_Active_Shoote
r
Godfrey, W., Agan, D., Otterbacher, R., and Fender, D. 2014. Active Shooter Incident
Management Checklist. Retrieved from C3 Pathways, Inc.:
http://www.c3pathways.com/asc/
Management Checklist Help Guide. Retrieved from C3 Pathways, Inc:
http://www.c3pathways.com/asc/Active_Shooter_Checklist_Help_Guide.pdf
Howe, P. 2005. Advanced Hostage Rescue Course. Nacogdoches, TX: Combat Shooting and
Tactics (CSAT). http://www.combatshootingandtactics.com/
IAFF. (International Association of Fire Fighters). n.d. “Active Shooter Events.” Washington.
http://www.iaff.org/Comm/PDFs/IAFF_Active_Shooter_Position_Statement.pdf
IAFF. n.d.. Rescue Task Force Training. Washington: International Association of Fire Fighters.
http://www.iaff.org/Comm/PDFs/IAFF_RTF_Training_Position_Statement.pdf

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Jacobs, L. D., McSwain, N. D., Rotondo, M. D., Wade, D. D., Fabbri, W. D., Eastman, A. D., and
Sinclair, J. 2013. Improving Survival from Active Shooter Events: The Hartford
Consensus. Clinton: National Association of Emergency Medical Technicians.
Metropolitan Police Department Washington, D.C. 2014. After Action Report Washington Navy
Yard September 16, 2013. Washington, D.C.: Metropolitan Police Department.
National Tactical Police Officers Association. 2002. High Risk Patrol and Patrol Rifle Instructor
Course. Houston TX: National Tactical Police Officers Association.
Smith, E. R., and Delaney, J. 2013. “Major Incidents; Supporting Paradigm Change in EMS'
Operational Medical Response to Active Shooter Events.” Journal of Emergency Medical
Services. http://www.jems.com/article/supporting-paradigm-change-ems-operation
Texas State University-Advanced Law Enforcement Rapid Response Training (ALERRT)

Center. 2014. Active Shooter Level II Training Manual: Vol. 2.0. San Marcos, Texas:
Texas State University-Advanced Law Enforcement Rapid Response Training
(ALERRT) Center.

Center. 2014. Active Shooter Train-the-Trainer Manual: Vol. 5.0. San Marcos, Texas:
(ALERRT) Center.
Texas Tactical Police Officer’s Association. n.d. Self-Aid/Buddy-Aid Course.
TriData Division, System Planning Corporation. 2014. After Action Report Aurora Century 16
Theater Shooting. April.
https://www.courts.state.co.us/Media/Opinion_Docs/14CV31595%20After%20Action%2
0Review%20Report%20Redacted.pdf
United States Military. (n.d.) Tactical Combat Casualty Care.
Vandervreen, C and Hansen, C. 2013. “After Aurora: A 9News Special Report.” July 23.
Multimedia Holdings Corporation. https://www.youtube.com/watch?v=R2zuvOfVc8Y
Wallentine, K. 2007. North Carolina’s (ISAAC) Information Bulletin. March 7. Utah Police
Academy.
Practical Exercise Statement

Not applicable


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Assessment Strategy
 Observing participant behavior in the classroom
 Administering a pre-test to assess participants’ base knowledge of course materials
 Questioning participants to ensure that they understand how their performance will
be evaluated
Icon Map
Key Point: Essential learning concept and discussion
Participant Note: Additional information for participants
Resource: Reference to books, websites, articles and Insert QR

other external information sources with QR code code here

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Welcome
Slide 1-2. Introductions and Welcome
Slide 1-3. Safety Brief

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Introductions Activity
Slide 1-4. Introductions Activity
Participants should introduce themselves. In their introductions, participants should share their
names, agency names, something they want to learn from this course, and something they
know about the training topic.
Registration Form
Slide 1-5. Registration

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Participants should follow the instructor’s directions and complete a registration form. An
example of a completed form is included on the slide.
Participants are required to have a FEMA student identification (SID) number to take this
training; this number must be entered on the registration form.
When completing the registration form, participants should

 write in upper case letters,
 write one character per block,
 include an e-mail address where the electronic certificate should be sent,
 spell out titles, agencies, and cities,
 bubble in one circle for level of government, and
 bubble in one circle for student discipline.
Testing
Slide 1-6. Testing
To pass the course, participants must complete the pre-test and achieve a 70% score on the
post-test. These tests assess how well participants have mastered the learning objectives. The
course’s evaluation strategy compares post-test scores with pre-test scores to measure learning
that has taken place during the course. Instructors may administer retests onsite, if needed.

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Pre-Test
Slide 1-7. Pre-Test
Participants will take the pre-test at this time. When taking the pre-test, participants should
indicate their answers by circling the most appropriate answer on the test. Participants have
approximately 15 minutes to complete the test.
Instructors will collect and grade the pre-tests. The pre-tests will be returned to participants for
review on the first break.

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Course Overview
Course Goal
Slide 1-8. Course Goal
To increase the survivability of victims and casualties, law enforcement first responders must be
able to provide key life-saving medical interventions at the point of injury. Additionally, a
coordinated integrated response between police, fire, and EMS is critical to the efficient
evacuation of these causalities to higher levels of medical care. This can be accomplished
through implementation of the Incident Command System (ICS) very early in the incident.
The goal of this course is to merge these concepts by providing medical training to law
enforcement first responders while providing an active shooter incident management structure
that can be used from the first officer arriving on scene to a large Unified Command structure.

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Disclaimers
Slide 1-9. Disclaimer: Graphic Content
Some of the medical content in this course includes photographs, videos, simulations, and
illustrations of traumatic injuries. The use of this content is not for shock value; it is used to
address a specific learning objective. Any participant experiencing a problem with this should
notify an instructor.
Slide 1-10. Disclaimer: Medical Procedures

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The medical procedures described and instructed in this course are designed for use on
yourself, your partners, your family, and during mass casualty incidents (MCI) such as an active
shooter incident or threat. All medical procedures and adjuncts in the course are in accordance
with national standards and established best practices including the Committee for Tactical
Emergency Casualty Care (C-TECC) and the Committee on Tactical Combat Casualty Care
(CoTCCC). Additionally, these procedures and adjuncts are reviewed and approved by the
Advanced Law Enforcement Rapid Response Training Center (ALERRT) medical director.
The medical procedures and adjuncts discussed are not for use during routine events. Use of
these medical procedures or adjuncts outside the scope of this training environment requires
written policy within your agency.
Additionally, a medical director within your jurisdiction may be required to authorize and support
the application of these procedures and the use of the adjuncts discussed during this course.
Continued training within your jurisdiction is highly recommended and may be required.
Texas State University, their employees, or contractors are not liable for improper use or
application of these medical procedures or adjuncts outside the scope of application as
instructed during this course.
Challenges
Active shooter events pose significant challenges to all emergency responders. Several past
events will be examined during this course to identify these challenges. The first case will be the
July 20, 2012 shooting in Aurora, Colorado, which demonstrates challenges of achieving an
active threat integrated response. Responders must understand these challenges to solve them.
Slide 1-11. Aurora Video

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The incident on July 20, 2012 in Aurora, Colorado at the Century 16 Theater identified response
and preparedness gaps faced by first responders across the United States. While law
enforcement has been training and exercising for active shooter response for many years post-
Columbine, little work has been done on the national level to intergrate the response between
police, fire, and EMS.
The Aurora incident demonstrated gaps in the nation’s overall response protocols to an active
shooter incident. This event and its response challenges could have occurred in almost any city
in the United States.
Resource: To access the Aurora Century 16 Theater

Shooting After Action Report, scan the QR code or visit
https://www.courts.state.co.us/Media/Opinion_Docs/
14CV31595%20After%20Action%20Review%20Report%20R
edacted.pdf
Resource: After Aurora is a 50 minute video that examines

the response to the Century 16 shooting. To view the
YouTube video, scan the QR code or visit
https://www.youtube.com/watch?v=R2zuvOfVc8Y
Slide 1-12. Challenges
An active shooter or threat event like Aurora poses numerous challenges to even well-prepared,
well-equipped agencies. This course will focus on addressing the following challenges:

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Stopping the Threat

Stopping an ongoing threat to public safety is the first priority when responding to an active
shooter or threat event. This course will provide law enforcement first responders with a review
of tactical considerations to be used when responding to an ongoing threat. This includes a
model framework to use post-engagement to facilitate rapid medical care to casualties and
evacuation from the scene.
Integrating the Response

Incident management must be employed to facilitate an organized response for quickly stopping
a threat and providing medical care. This starts with the first officer on the scene and builds from
the bottom up. This course will provide an active shooter incident management checklist that all
emergency responders can use to facilitate integration of police, fire, and EMS.
Staging
Staging is a critical function often neglected by law enforcement during large-scale response
events such as an active shooter incident. Everyone on the scene must have a task and
purpose. With the exception of the first few arriving officers who are quickly moving to stop an
ongoing threat, all resources must be organized in staging. This will save time throughout the
incident and enable Incident Commanders to deploy resources efficiently and effectively.
Medical Care
In an active shooter or threat event, law enforcement will be the first emergency responders to
reach casualties at the point of injury. Law enforcement must have key medical training to
address the most common types of preventable trauma deaths, including hemorrhage control
and airway management. This course is not designed to make police officers into paramedics. It
is intended to provide key life-saving skills that have saved lives in the United States and on
battlefields in Iraq and Afghanistan.
Evacuation and Transport of the Injured

To increase the survivability of injured victims, rapid evacuation and transport to higher levels of
medical care are paramount. This takes a significant amount of coordination between law
enforcement, fire, and EMS to be done safely and effectively. A model framework for integration
helps agencies work together to save lives.

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Slide 1-13. Threat Zone Matrix
Key Point: In an active shooter or active threat environment, the

overarching mission of law enforcement first responders is to stop
the killing. This is considered the driving force for decisions,
tactics, and resource deployment.
Hot Zone
The area where shots are being fired is considered the hot zone. The only medical interventions
that would be considered in the hot zone are known as direct threat care, which will be
discussed in Module 3. The only emergency responders operating in the hot zone should be law
enforcement contact teams actively searching for the threat.
Warm Zone
The area with no active gunfire, but that has not been systematically searched and cleared by
law enforcement, is considered the warm zone. For casualties in this area, which could include
a casualty collection point (CCP), medical interventions include indirect threat care, which will
be discussed in Module 4. Law enforcement and rescue task forces (RTF) work within the warm
zone. An ambulance exchange or loading point may also be created in the warm zone.
Cold Zone
The cold zone is an area that is considered safe with no known threat. This includes the location
of the Command Post, staging, and potentially a traditional mass casualty triaging area. The
medical care provided in this area consists of evacuation care, which will also be discussed in
Module 4. All emergency responders may work in the cold zone.

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Scope of Course
Slide 1-14. Schedule
Module 1: Course Overview

Participants will identify the course goal, enabling objectives, course schedule, and course
performance requirements.
Module 2: Incident Command and Active Shooter Incident Management Checklist

Participants will be able to use the Active Shooter Incident Management Checklist in managing
an integrated response to active shooter events.
Module 3: Staging Procedures and Resource Management

Participants will identify the concepts of staging and how to function as a Staging Area Manager
in an active threat integrated response.
Module 4: Direct Threat Care

Participants will be able to identify appropriate lifesaving techniques that can be used in a direct
threat environment.
Module 5: Indirect Threat Care

Participants will be able to identify appropriate lifesaving techniques that can be used in an
indirect threat care environment.

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Module 6: Tactical Response Considerations and Rescue Task Force Integration

Participants will be able to discuss the initial response priorities and tactical considerations for a
swift response by law enforcement, fire, and EMS responders. Participants will also be able to
demonstrate the security, immediate action planning, and medical (SIM) model from their
respective discipline (police, fire, or EMS). Participants will also be able to discuss the role and
demonstrate the formation and deployment of integrated rescue task force teams.

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Module 7: EMS Advanced Skills

Certified medical provider participants (only) will be able to identify and demonstrate advanced
medical skills based on C-TECC and Co-TCCC guidelines.
Module 8: Practical Exercises

Participants will be able to respond to a simulated active shooter incident and successfully
integrate the response between law enforcement, fire, and EMS services to quickly mitigate the
threat while increasing the survivability of injured persons.

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Module 9: Course Wrap-Up, Post-Test, Course Evaluation

Participants will complete a comprehensive written post-test and complete a course evaluation
form.
Summary
Slide 1-18. Summary
Participants learned how instructors evaluate their performance and they completed a pre-test.
The pre-test provided participants with an idea of their strengths and weaknesses regarding the
course subject matter. Instructors reviewed the course goal, structure, and agenda so
participants were aware of the course goals and had a general understanding of what to expect
over the next few days
Participant Note: The next module discusses Incident Command

and the Integrated Active Shooter Incident Management Checklist.


Active Threat
Integrated Response
Course
Module 2: Incident Command and Integrated
Active Shooter Incident Management Checklist
Version 2.0


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Module 2: Incident Command and Integrated Active Shooter

Incident Management Checklist
Slide 2- 0. Title
Duration
2.5 hours (1.5 hours lecture, 1 hour practical exercise)
Scope Statement
In this module, instructors will provide participants with characteristics of an active shooter
event, components of an integrated response, a detailed overview of the National Incident
Management System (NIMS) Incident Command theory, span of control principles, and effective
scene management using a validated checklist.

At the end of this module, participants will be able to use the Active Shooter Incident
Management Checklist in managing an integrated response to active shooter events.

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During this module, participants will be able to:

2-1 examine the profile of an active shooter and characteristics of an active shooter
event;
2-2 describe the importance of an integrated response in an active shooter event,
2-3 describe and define casualty collection points,
2-4 describe and define triage,
2-5 describe and define ambulance exchange point and evacuation care,

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2-6 identify span of control and recommendations,

2-7 discuss NIMS Incident Command organizational structures,
2-8 describe the Incident Command System (ICS) organizational chart of the Active
Shooter Incident Management Checklist,
2-9 discuss the position responsibilities of the Active Shooter Incident Management
Checklist, and
2-10 demonstrate use of the Active Shooter Incident Management Checklist.
Resources
 Audio visual kit
 Pen
 Active Shooter Incident Management Checklist
 Active Shooter Counterstrike tabletop exercise (two complete sets)

1:40

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Reference List
Blair, J. Pete, interview by William M. Godfrey. 2014. Active Shooter Event Data Clarification
October 20.
Blair, J. Pete, and Schweit, Katherine W. 2014. A Study of Active Shooter Incidents, 2000 -
2013. Texas State University and Federal Bureau of Investigation, US Department of
Justice, Washington, DC.
Blair, J. Pete, Martaindale, M. Hunter, and Nichols, Terry. 2014. "Active Shooter Events from
2000 to 2012." FBI Law Enforcement Bulletin.
DHS (Department of Homeland Security). n.d. Active Shooter Event Quick Reference Guide.
Washington, DC. http://www.dhs.gov/sites/default/files/publications/active-shooter-
pamphlet-508.pdf
DHS, FEMA. 2004. IS 200 - Applying ICS. Washington DC: U.S. Government Printing Office.
DHS, FEMA. Emergency Management Institute. 2014. National Incident Management System
Independent Study Program. July 25. http://www.training.fema.gov/is/nims.aspx
DHS, FEMA. 2006. Task Book: Employee Job Aid: Staging Area Manager. Washington DC:
U.S. Government Printing Office.
Godfrey, W.M., Agan, D., Otterbacher, R., Fender, D. 2013. 4 Best Practices for Active Shooter
Incident Management: Lessons Learned from 10 Active Shooter Exercises with the
University of North Florida. Orlando, FL: C3 Pathways, Inc.
r.pdf
Godfrey, W.M., Agan, D., Otterbacher, R., Fender, D. 2014. Active Shooter Incident
Management Checklist. Orlando, FL: C3 Pathways, Inc.
Godfrey, W.M., Agan, D., Otterbacher, R., Fender, D. 2014. Active Shooter Incident
Management Checklist Help Guide. Orlando, FL: C3 Pathways, Inc.
Metropolitan Police Department Washington, DC. 2014. After Action Report Washington Navy
Yard. July. Washington, DC: Metropolitan Police Department.
http://mpdc.dc.gov/sites/default/files/dc/sites/mpdc/publication/attachments/MPD%20AA
R_Navy%20Yard_Posting_07-2014.pdf
World Health Organization (2007). Mass Casualty Management Systems: Strategies and
Guidelines for Building Health Sector Capacity. Geneva, Switzerland.
http://www.who.int/hac/techguidance/MCM_guidelines_inside_final.pdf

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Participants will engage in tabletop exercises performing incident management procedures and
functions using the Active Shooter Incident Management Checklist for a simulated event.
Assessment Strategy
 Observing participant behavior during practical exercises (tabletop exercises)
 Questioning participants to ensure that they understand each objective
 Soliciting input from participants to explain actions during each objective
Icon Map
Definition: Key term that is often field-specific and may be

unfamiliar
Example: Descriptive illustration to show or explain a course

concept

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Resource: Reference to books, websites, articles and

other external information sources.

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Introduction
This module examines the importance of an integrated response in an active shooter incident.
During an active shooter event, the first priority is to stop the killing. The second priority is to
stop the dying. The killing stops when a solo officer, a contact team, or multiple contact teams
neutralize the threat. Stopping the dying means administering tactical emergency casualty care
(TECC) to victims, not simply waiting for fire and EMS to arrive down range.
This module examines ICS and the Active Shooter Incident Management Checklist as they
relate to improving response during an active shooter incident.
Characteristics of an Active Shooter Event
Defining Active Shooter
Definition: Active shooter as defined by the US Department of

Homeland Security (DHS) is an individual actively engaged in
killing or attempting to kill people in a confined and populated area;
in most cases, active shooters use firearms and there is no pattern
or method to their selection of victims.
For the purpose of research, if an event begins with an individual that actively engages or
attempts to kill people in a confined and populated area, then it is included in active shooter
research.
The tactical definition of active shooter is used for the purpose of guiding the actions of
responders. From a tactical perspective, arriving officers should consider a situation to be an
active shooter incident if the following conditions are present:
 Audible gunfire
 Intelligence indicating there is active killing or an armed person present
 Direct observation of hostile attack
The absence of these conditions may indicate a static, hostage, or barricade incident that
requires a more deliberate response and deployment of resources.

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Active Shooter Event Resolution
Slide 2-3. Active Shooter Event Resolution
Slide 2-3 shows active shooter event resolutions. The diagram divides resolutions into two
categories: those resolved prior to the arrival of law enforcement and those resolved after the
arrival of law enforcement.
Key Point: A common misconception regarding active shooter

incidents is that they usually end with the shooter committing
suicide; however, this occurs in less than half of events.
A study of 179 active shooter incidents from 2000 - 2014 revealed that 40% of incidents ended
with the shooter’s suicide and 12% with the shooter stopping on their own. The shooter has to
be stopped in 48% of incidents – nearly half. (C3 Pathways 2015)
Resolution Prior to Law Enforcement’s Arrival

In 55% of the cases, the attack ends before law enforcement arrives. These resolutions include
the shooter commiting suicide, the shooter leaving the scene, or victims stopping the attack. In
33 of the 179 incidents victims subdued the attacker, and in six incidents victims shot the
attacker prior to the arrival of law enforcment. (C3 Pathways 2015)
Resolution Following Law Enforcement’s Arrival

Once law enforcement arrives, the attacker may still stop on their own, either by committing
suicide or by surrendering. If law enforcement arrives while the attack is occurring, 2 out of 3
times they will have to stop the attacker. Refer to the diagram and notice that, of the incidents

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that were ongoing upon law enforcement’s arrival, 53 out of 80 required officers to subdue or
shoot the attacker. (C3 Pathways 2015)
Active Shooter Profile
Slide 2-4. Active Shooter Profile
Based on case research, 99% of active shooter incidents involve only one shooter. Multiple
locations are involved 21% of the time. The use of body armor is not common; however, it is
used by the attacker in 5% of incidents. The use of improvised explosive devices (IEDs) is also
rare but on the rise, accounting for about 3% of active shooter events. This data includes IEDs
that have been used at the scene and those planted at secondary scenes. (Blair et al 2014)
Locations of Active Shooter Events

Nearly half — 52% of active shooter events take place at a business. Schools account for 24%
of active shooter event locations. (Blair et al 2014)
Weapons
In 57% of active shooter incidents, the most powerful weapon used by the attacker is a pistol.
Various types of rifles are used 25% of the time. (Blair et al 2014)

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Median Number of Casualties
Slide 2-5. Active Shooter Profile
Participant Note: Median number is different from average. While

most active shooter incidents involve a relatively small number of
casualties, there are statistical outliers such as the Aurora theater
shooting. Because of a few incidents with high casualty counts, the
average is misleading. Organizing incidents from fewest to most
casualties, median is the data point in the middle, e.g. 4 is the
median in 1, 2, 2, 4, 5, 8, 70. The average is 13, which is not
“typical” of this example data set. This is the case with Active
Shooter Events.
The median number of casualties is four shot — two of which die from their injuries. This is an
important statistic to keep in mind because fire and EMS are often conditioned to believe that
active shooter events are mass casualty incidents. Statistically, however, they are not often
mass casualty incidents (MCI).
Fire and EMS agencies go into mass casualty mode because there is an overwhelming number
of casualties and insufficient personnel and equipment to handle the casualties. Mass casualty
mode is efficient with a large number of victims; however, it can unnecessarily delay transport in
incidents with a smaller number of casualties. Transport will always be faster when patients are
loaded into an ambulance and proceed directly to a hospital as opposed to a shuttle operation
from a warm zone to the cold zone where patients are unloaded, sorted, and re-loaded into
waiting ambulances.

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Definition: Mass Casualty Incident: An incident which generates

more patients at one time than locally available resources can
manage using routine procedures. It requires exceptional
emergency arrangements and additional or extraordinary
assistance.
An incident involving fewer than five patients is not considered an MCI by most jurisdictions, but
this can vary and is a locally policy issue. Many agencies have established MCI procedures that
dictate response levels and notifications based on estimated casualty counts.
Why Casualty Counts Matter
Slide 2-6. Why Casualty Counts Matter
Participant Note: The concept of MCI relates to casualty counts

and triggers the appropriate resource response. Agencies should
consider establishing preset MCI Alarm levels and notifications. An
Alarm Level is a preset package of equipment to be dispatched.
For example, 11-20 casualties might be a Level 2 MCI Alarm that
when declared causes the automatic dispatch of 10 ambulances, 5
engine companies, 2 chiefs, and notification to all area hospitals.
The specific resources and actions assigned are a local policy
matter, but all agencies are encouraged to establish MCI Alarms.

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MCI Resources
Slide 2-7. Why Casualty Counts Matter: Non-MCI Response
Although it varies, fire and EMS across the country commonly have some methodology of
dispatching packages of resources to meet a perceived or actual need at an emergency scene.
As it relates to MCI, these are typically grouped into MCI Alarm Levels.
For the typical active shooter response, a common response would include one engine
company (manpower), two transport-capable units, and a chief officer. This provides the ability
to immediately treat and transport four to six casualties. The number of casualties that warrant a
mass casualty response varies; however, most fire and EMS agencies can manage between
seven and ten injured people without depleting their resources.

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MCI Level 2
Slide 2-8. Why Casualty Counts Matter: MCI Level 2
Slide 2-8 illustrates an example MCI Level 2 response based on 11 to 20 casualties.
Participant Note: Rank and Staffing

Rank and unit staffing differ by discipline. The following notes are
general guidance and will vary by locale.
Most law enforcement agencies staff one officer per patrol vehicle.
The most common first level supervisor is a Sergeant. The ranking
supervisor in charge of a shift is commonly a Lieutenant or
Captain.
Most Ambulances are staffed with two medical personnel, which

may be Basic Life Support (BLS, e.g. 2 EMTs) or Advanced Life
Support (ALS, e.g. Paramedic and EMT). The most common first
level supervisor is an EMS Supervisor, but Lieutenant or Captain is
also common. EMS agencies operating separately from the fire
department commonly have a ranking shift supervisor, though
titles vary.
Fire departments have the most variation in staffing. An engine

company may have 1-5 personnel assigned, with 3 being the most
common. Usually, at least one person is a supervisor, e.g. a
company officer, commonly a Lieutenant or Captain. The same is
true for ladder and truck companies. The most common next level

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supervisor is a Battalion Chief, who may also be the ranking shift

supervisor depending on the size of the jurisdiction.
There are many Chief titles in the fire service, which can be
confusing for non-fire service disciplines. Generally speaking, a
person with Chief in their title is not riding on a fire truck; they are a
supervisor equivalent in rank to a law enforcement Lieutenant,
Captain, or higher.
MCI Level 3
Slide 2-9. Why Casualty Counts Matter: MCI Level 3
Slide 2-9 illustrates an example MCI Level 3 response based on 21 to 100 casualties.
A response to this type of incident involves 63 personnel. Fire and EMS can deliver these
resources to a scene in most areas of the United States; however, rural areas may have
difficulty bringing in this level of response even with the help of neighboring jurisdictions and
regional assistance. Most jurisdictions across this country could deliver this level of resources in
20 or 30 minutes. The main concern with this timeframe is recognizing the need to declare the
MCI Alarm Level as early into the response as possible. Otherwise, there may not be enough
ambulances at the scene to transport casualties as they are evacuated and ready for transport.

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Law Enforcement Casulaties
Slide 2-10. Law Enforcement Casualties
Data from 2000 to 2013 involving 160 incidents documented law enforcement casualties. In
these active shooter events, law enforcement was involved in gunfight 45 times, or 28%, of the
time. Of those 45 incidents, 28 law enforcement officers were wounded in a total of 15 incidents.
Nine officers were killed during a total of five incidents. (Blair and Schweit 2014)
Key Point: It is important for law enforcement to have a mental

picture of what they are walking into -- be aware of the fact that
you may be engaged in gunfire with the attacker and aware of the
fact you may be shot. If gunfire is still ringing out when law
enforcement arrives (In Progress):
 2 out of 3 times the shooting will not stop until LE stops it.
 1 out of 2 times -- half the time -- LE will get in a gunfight
with the shooter.
 1 out of 4 times a law enforcement office will get shot.

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Solo Officer Entry
Slide 2-11. Law Enforcement Casualties
Of the 18 solo officer entries studied, 13 incidents were still in progress. Of these 13 incidents,
the solo law enforcement officer stopped 12 of them. In three of these incidents, law
enforcement officers were wounded.
CAUTION is warranted from drawing conclusions from this small data set where only 18 solo
officer entries were clearly documented, especially the wounding rate.
When compared as a percentage of “In Progress” incidents, data indicates the wounding rate
for solo officer entry is nearly the same as it is for a contact team entry. One statistic that does
appear to differ dramatically is the stop rate. Solo officer entries in these “In Progress” incidents
resulted in stopping the attack 92% of the time!

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Active Shooter Event Duration
Slide 2-12. Active Shooter Event Duration from FBI report 2000-2013
According to the Federal Bureau of Investigation (FBI), 65% of active shooter events last five
minutes or less (2014).
Duration 85th Percentile
Slide 2-13. Active Shooter Event Duration 2000-2014
85% of active shooter events last 10 minutes or less (Blair et al 2015).

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Duration 90th Percentile
Slide 2-14. Active Shooter Event Duration 2000-2014
Ninety percent of active shooter events last 15 minutes or less. Outliers beyond this 90% are
often complex incidents with extenuating circumstances. Statistically, active shooter events are
almost all 15 minutes or less. (Blair et al 2015)

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Duration Example Response
Slide 2-15. Duration and Fire / EMS Response
Slide 2-15 illustrates a typical fire and EMS response timeline to understand where it falls
against the duration of Active Shooter Events. As this example demonstrates, it is difficult for fire
and EMS to have medical crews ready to deploy down range prior to most active threats being
over. Keep in mind much of the illustration also applies to law enforcement, though their
response time is typically shorter. Law enforcement will likely arrive first, but will only be minutes
ahead of fire and EMS responders.
Firefighters and trained from day one that every minute that goes by, a fire becomes more and
more dangerous. This is exactly the opposite with Active Shooter Events. Statistically, every
minute that goes by, an Active Shooter Event becomes safer and safer.

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Complex Coordinated Attack
Slide 2-16. Complex Coordinated Attack
Active Shooter Event Comparison
Slide 2-16 is a map depicting the individual sites attacked in the 2015 Paris terror attack.
Discussion of Complex Coordinated Attack (CCA) such as Paris is beyond the scope of this
class. However, the response methods and concepts taught in this class are appropriate to
apply at each individual site attacked in a CCA.
Definition: Complex Coordinated Attack (CCA)

Killing or threatening to kill multiple unrelated individuals where
there are [a] three or more attackers, or [b] simultaneous attack of
two or more sites, or [c] an act of terrorism* which overwhelms the
local jurisdiction and initiates a regional/statewide response.
*Title VIII, Section 802 of the USA PATRIOT Act: [An] act of terrorism means any activity that (A) involves a
violent act or an act dangerous to human life that is a violation of the criminal laws of the United States or any
State, or that would be a criminal violation if committed within the jurisdiction of the United States or of any
State; and (B) appears to be intended (i) to intimidate or coerce a civilian population; (ii) to influence the policy
of a government by intimidation or coercion; or (iii) to affect the conduct of a government by assassination or
kidnapping.

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Integrated Response
Achieving an integrated response of law enforcement, fire, and EMS requires many elements to
work together seamlessly. This course will present these organizational and functional concepts
by first starting with the big picture of how things fit together and then move to the functional
elements.
Slide 2- 17. Integrated Response Priorities
The goal of integrated response to an Active Shooter Event is to Stop the Killing, and Stop the
Dying. Based on the statistical profile of an Active Shooter Event already presented, an
integrated response system and methodology is presented.

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Organizing with a Task and Purpose
Slide 2- 18. Organize with a Task and Purpose
Basic organization of the scene is essential to execute timely and effective operations. Every
responder is a valuable resource at the scene. Resources must be put on task where needed
exactly when needed. Without a specific task and purpose, resources are not used effectively –
or worse, resources are wasted. US Army Major (Ret.) James McGinnis makes this explicitly
clear, “Everyone should have a task and purpose on the scene, or they don’t need to be
there…”

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Incident Command Structure
Slide 2-19. Command
This course utilizes the National Incident Management System (NIMS) Incident Command
System (ICS) for the management of Active Shooter Events. A specific structure and
methodology is recommended based on the Active Shooter Profile discussed previously, and it
is NIMS compliant.

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ICS Isn’t New
Slide 2-20. Incident Command Structure
Slide 2-20 depicts the ICS organizational structure used by this course. The process will take
participants step-by-step through building this structure from the first arriving law enforcement
officer.

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Hot Zones, Warm Zones, and Cold Zones
Slide 2- 21. Identifying Zones of Threat
Stopping the attacker from killing requires responders to enter the hot zone, an area under
direct threat in the inner perimeter. Stopping the dying occurs in the warm zone and cold zone.
The warm zone is also in the inner perimeter of the scene; however, security measures are in
place allowing responders with a security escort to render medical care. The cold zone is
outside of the inner perimeter but inside the outer perimeter where no threat is reasonably
expected.
Key Point: The warm zone may not be a contiguous area. The
warm zone may resemble more amoeba-like blobs dotting the hot
zone. In other words, law enforcement may secure pockets (e.g.
rooms, hallways, etc.) of small areas that are warm but may still
reside inside the hot zone. One Warm Zone pocket may not be
connected to the next Warm Zone pocket.

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Why Staging Matters
Slide 2- 22. Staging
Of significant importance is staging. Fire and EMS have used staging for years; however, law
enforcement generally does not. During this course and its scenarios, staging will be discussed
as it relates to law enforcement. Staging does not involve the initial few law enforcement officers
arriving on the scene; however, it does apply to additional law enforcement, fire, and EMS
resources that arrive as the active shooter event unfolds.

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Washington Navy Yard Timeline
Slide 2-23. Why Staging Matters
On September 16, 2013, an active shooter event occurred at the Washington Navy Yard in
Washington, DC. The single-shooter attack began at 8:16 a.m. and ended 69 minutes later at
9:25 a.m. The shooter killed 10 of the total 12 dead in the first six minutes of the attack, before
law enforcement arrived. The shooter killed the 12th and final fatality 16 minutes later. The
shooter roamed for 36 minutes, shot a police officer, and was finally stopped 11 minutes later
when he attempted to ambush searching officers.
This attack is an outlier because of the length of time it took responders to neutralize the
shooter. In this case, the building was large and had multiple floors. During the attack, 117
officers were inside the building and despite this, it took 69 minutes to neutralize the attacker.
Lack of coordination hindered the response. Responders did not know who was checking what
floor, where fellow officers were going, and who was locking down stairwells. The attacker had
the ability to move almost unrestricted through floors, up and down stairwells, and around the
building.

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Washington Navy Yard After Action Report
Slide 2-24. Navy Yard After-Action Report
Following this attack, the Washington DC agencies that responded to the attack developed an
honest and constructive after-action report (AAR) that included 35 observations and 76
recommendations. The AAR demonstrates the importance of staging.
One important observation was that the street next to the building quickly became obstructed.
According to the AAR, self-dispatch caused scene congestion and made personnel tracking
challenging. Another AAR observation notes that there was no single staging area. Multiple
staging areas made tracking and managing resources very difficult.
AAR recommendations included establishing staging and check-in for responding agencies and
establishing check in for law enforcement.
Key Point: All law enforcement agencies should have clear

policies to check in at staging.

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Resource: Read the complete Washington Navy

Yard AAR online at
http://mpdc.dc.gov/sites/default/files/dc/sites/mpdc/p
ublication/attachments/MPD%20AAR_Navy%20Yar
d_Posting_07-2014.pdf
One of the challenges of the this incident was that even after command and staging had been
established, some agencies refused to check in at staging and proceeded straight into the
incident. Response is derailed quickly with this lack of structure.
After the first officers arrive and proceed to the threat, subsequent responders must stop
flooding into the scene and organize themselves. This organization occurs when officers check
into the staging area, receive their assignment, and execute their assignment.
Staging Task and Purpose
Slide 2-25. Staging
Major James McGinnis was quoted as saying “everyone should have a task and purpose on the
scene or they don't need to be there" at an Active Shooter Summit held in Washington, DC. This
is a key point in active shooter response.

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Radio ID
Slide 2-26. Radio ID
Radio IDs are another important component of integrated response to an active shooter
incident. Historically, law enforcement has used their unit ID on the radio even while in
command. For example, in the Aurora theater video from Module 1, Lincoln 23 can be heard on
the radio saying, “Where are my ambulances at?” Lincoln 23 was the Incident Commander, but
continued to use his “Lincoln 23” call sign on the radio instead of “Command.”
When responders are assigned a position in a command structure, those positions become their
radio ID. This is an important part of responders’ ability to interoperate with other agencies.
Example: Under typical circumstances, you might be a supervisor;

however, if you are in command, your radio handle is Command. If
you are Unit 111, but are assigned to take staging, you are no
longer 111 on the radio, you are Staging.

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Span of Control
Slide 2-27. Span of Control
Recall that according to the NIMS, ideal span of control involves between three and seven
people working under one person, with five supposedly optimum. A responder’s effective span
of control can vary dramatically depending on the experience level of the individual and the
severity and pace of the event.
Key Point: In a fast-paced situation, an Incident Commander with

little Incident Command experience may have an effective span of
control of three or four and may feel overloaded beyond that. The
NIMS span of control recommendation is a guide; however,
effective span of control depends greatly on experience levels and
how quickly the incident is moving.
Span of control affects the volume of radio traffic at an incident. Most every responder has
experienced an incident where radio traffic is so heavy they couldn’t key up to transmit. This is a
sign of inadequate span of control. Supervisors should react to overloaded radio traffic quickly
by evaluating and addressing any excessive span of control issues. Adequate span of control
should enable some responders to communicate face-to-face and alleviate radio traffic.

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Active Shooter Incident Management Checklist
Slide 2-28. Active Shooter Incident Management Checklist
The Active Shooter Incident Management Checklist is one approach; however, it is not the only
approach to managing an active shooter event. There are several ways that an active shooter
incident can be managed, provided that responders are properly trained, and everyone is on the
same page. The checklist provides responder tasks in a logical order and a detailed help guide
is available that explains each task and how the tasks fit together.
Example: In the pilot world, there are two types of checklists.

There is one in which the copilot calls out a command, such as
"set flaps.” The pilot reaches down, sets the flap levers, says,
"flaps set," and the copilot checks the task off of the list. This is a
“call-do” checklist.
Another type is a “do-check” where items on this checklist
comprise a process that is executed by memory, and when
possible reviewed to ensure no task has been forgotten when
possible.
The Active Shooter Incident Management Checklist is a “do-check”
type of checklist.

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Law Enforcement First Arriving Officer
Slide 2-29. LE First Arriving
Size Up Report
The first arriving law enforcement officer must perform a size up of the situation. This is a
mental exercise that is taught and practiced by most agencies. Officers must be aware of what
to say, how to say it, and what information is critical. Conveying this information clearly and
accurately in a stressful environmental requires practice. Information overload is common during
the size up.
Identify Hot Zone

Responders must immediately identify the area of threat to reduce exposure to danger. This
information must be clearly stated over radio to inform subsequent responders. The
communications center must rebroadcast this information. For the safety of responders, hot
zone boundaries may start large and be scaled back as the situation permits.
Establish Mobile Command

Command is the single term that clearly identifies to all responders that there is a person “in
charge”. Even if multiple units arrive simultaneously, only one unit may take the role of
command, even if only for a short time. A “Mobile Command” simply means that the first arriving
officer who establishes Command is mobile.

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Key Point: The first arriving law enforcement officer will remain in
Command until he or she is relieved by another officer.
If Command is not immediately established, situational awareness

and control will be lost and risk will significantly increase.
Engage
The ultimate goal in an active shooter event is to Stop The Killing. Departmental policies and
training will guide the officers’ actions and will be based on their size up assessment. Entrance
into the hot zone should be determined by the risk assessment of the situation, operational
necessity, and officer safety.
ICS Organizational Chart
Slide 2-30. LE First Arriving
ICS and NIMS are applied beginning with the first law enforcement officer arriving on scene.
Example: The following is an example of a first responding

officer’s communication:
“101 is arriving on scene in front of the school. Kids are running

out. I can hear shots fired from the campus. The entire campus is

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going to be the hot zone. 101 has command. I'm making entry to
try to make contact with the shooter.”
Law Enforcement Second through Fourth Arriving Officers
Slide 2-31. LE 2nd-4th arriving
Communicate with Command

The 2nd – 4th arriving officer should communicate directly with “Command” and request where
he/she is needed. Communicating with command insures that arriving resources are directed
where they are needed, ensures that everyone knows who is making decisions, where that
person is, and what the next immediate priorities are.
Link-Up
Link-up is dictated by local policy.
Example: Link-up could be communicated in the following

manner: “102 to command, on scene. Your location?”
Command would reply and give directions such as; “Command to

102, enter thru the front entrance, turn left at the first hallway, link
up with me”.
The following units would report “on scene” directly to command

and request instructions.

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Contact Team
Contact Teams should also be directed according to local policy. A typical Contact Team is an
ad-hoc formation of 2-4 officers that move in a coordinated effort. Once the Link Up is
completed, this joining of officers constitutes a Contact Team.
Law Enforcement Fifth Officer
Slide 2-32. LE “5th Officer”
Briefing
The fifth officer should obtain verbal briefing either face-to-face or by radio. This should be
concise and communicate;
Example: The arriving fifth officer’s communication could be:
"105 is on scene. 105 to command. What is going on?”
“Command to 105- shots being fired, we have 4 persons down in
the front office, I have a team of 4 and we are moving towards
last gunfire, need a second contact team to enter through the
front and link up with us in the hallway on Side C, need medical
to the 4 injured in the front office.”
Participant Note: Providing a clear and concise briefing while

under stress takes practice. One of the many formats that can
help in these situation is a CAN report. It is easily remembered
and paints a consistent situational picture.

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Example:
C - Conditions: such as “shots being fired”
A - Actions: such as “I have a team of 4 and we are moving
towards last gunfire”
N – Needs: such as “need a second contact team to enter
through the front and link up with us in the hallway on Side
C, need medical to the 4 injured in the front office.”
Assume Command
The fifth officer should assume command after receiving the briefing and clearly announce that
he or she has assumed command. The fifth officer should designate the relieved commander
as the team leader of Contact 1. This should also be clearly announced over the radio and the
communications/dispatch center should repeat this announcement.
Example: After receiving the briefing, the fifth officer’s

communication could be: "105 to all units, I have command, I’m
located at the north parking lot entrance, 101 you are now Contact
1.”
“101 to command, copy, I’m Contact 1”
Communications transmission could sound like: “ All units - 105
has command, 101 is Contact 1. Command is located at the north
parking lot entrance”
Set Staging Location

The fifth officer should set and announce the staging location. Setting the location of the staging
area this early in an event may be a new concept for law enforcement agencies; however, it is
critical to the effective deployment of resources. In setting the location, responding units should
alter their trajectory to the designated staging location and should hold at that location until they
are pulled for a specific task and purpose. Command should direct all units to report to that
location and specifically request resources to fulfill specific tasks and purposes.
Get Situational Awareness

If unclear at this point, situational awareness becomes an immediate priority. Determine location
of all Contact Teams, on scene personnel, and confirm clear understanding of the hot zone
boundaries. Command (the fifth officer) must obtain an understanding of conditions, current
actions, planned actions, and resource needs.
Situational awareness could include the following information:

 Type of facility or building
 Size of the building
 Layout of the building its surroundings

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 Number of people involves

 Tactical scenario details
 Consider any intelligence that may be at hand
Assign More Contact Teams
Staging becomes even more important in the formation of the next contact teams. Command
might direct the sixth officer to form Contact Team 2. The sixth arriving officer will report to the
staging location and will wait for the next few officers to arrive. When they arrive at the scene,
these officers will gather their gear, med kits, and additional weapons and ammunition and
obtain orders for deployment directly from Command.
Participant Note: Having additional units at a staging location

affords the Incident Commander the ability to deploy resources
where needed with a specific task and purpose. This may be an
additional contact team to clear the second floor of a multi-story
building or lockdown a stairwell.
Slide 2-33. LE 5th Officer

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First Arriving Law Enforcement Supervisor
Slide 2-34. First LE Supervisor
This position is dictated by local policy which could be and could be Corporal, Sergeant, or
higher. This step builds on the root command structure and divides the intense workload in
efforts to reduce the fog of war and improve situational awareness.
Briefing
This is a verbal briefing that may be face-to-face between Command (the fifth officer) and the
first arriving law enforcement supervisor. Content should be somewhat more detailed that the
previous briefing, but should still be quick and concise. The conditions-actions-needs (CAN)
format assists with obtaining that information that is quick yet actionable.

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Slide 2-35. First LE Supervisor
Assume Command
After being briefed, the first arriving law enforcement supervisor should assume command. The
newly established command should clearly state over the radio that he or she has assumed that
position and should provide the physical location of the Command Post. The
communications/dispatch center should repeat this announcement.
Designate Tactical Group

Command (the first LE supervisor) should designate the fifth officer as Tactical Group and
clearly announce this over the radio.
Assign Staging Manager

After designating the Tactical Group, command should identify a unit that has arrived at the
staging location and assign that unit as the staging manager. Command will rely upon this
person to provide requested resources. This person will manage, organize, and document what
units and types are in staging and keep the Incident Commander aware of the resource pool.
Assign Perimeter Group

Once staging manager has been assigned, Command should order the Staging Manager to
assign a unit as the Perimeter Group Supervisor and assign resources to him as they are
available. The Staging Manager should inform Command that the assignment has been given
with the ID of the Perimeter Group Supervisor.

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Assign Medical Branch to EMS

If fire and EMS are not on scene, request the first arriving fire and EMS supervisor to report to
the Command Post for assignment as the Medical Branch. When the fire or EMS supervisor
checks in at the Command Post, they should request this assignment following a briefing.
First Arriving Fire Department or EMS Supervisor
Slide 2-36. First Fire or EMS Supervisor
Check In
The first arriving fire or EMS supervisor should check in at the Command Post. It is important for
the first arriving fire or EMS supervisor to make contact with the Incident Commander if the
Command Post is in a relatively safe location.
Briefing
The fire or EMS supervisor should obtain a verbal briefing and determine the following:
 Conditions
 Hot zone boundaries
 No-go areas
 Estimated number of injured
Request Medical Branch Assignment

In the event that the fire or EMS Supervisor arrives at the Command Post before the Incident
Commander has or is developing their situational awareness, then specifically requesting to be
assigned as Medical Branch will assist the IC with organizing their command staff.

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Medical Branch
Slide 2-37. Medical Branch
Briefing
Obtain a briefing from the Incident Commander and assume the Medical Branch Manager
assignment.
Co-Locate with Law Enforcement Branch Manager

This is critical to ensure situational awareness of the status of downrange teams within the hot
zone, to receive updates to casualty locations and status, and gain access permission control
for deployment of RTFs.
Separate Radio Channel

Fire and EMS traditionally operate on a separate radio channels from Law Enforcement. This
separate radio channel will provide redundant communication for the movement and
management of RTFs and transport units.
Declare MCI Level

Per local policy, the Medical Branch may declare the level of MCI response to ensure an
adequate number of resources to meet the patient care and transport demand. If possible,
obtain the estimate of injuries during the briefing from Command or Law Enforcement Branch.

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Assign Triage Group

The Medical Branch must contact the Staging Area Manager and request resource assignment
to perform Triage Group functions. The Medical Branch must give directions to assemble
resources to create appropriate number of RTFs as a high priority.
Assign Transport Group

The Medical Branch must contact the Staging Area Manager and request resource assignment
to perform Transport Group functions. The Medical Branch must give directions to determine
group location and assemble transport resources for number of expected injuries.
Treatment Group
Consider the establishment of a Treatment Group if the situation presents movement challenges
based on number of patients, resource limitations, geography constraints, or other
circumstances that inhibit rapid distribution of patients from the incident.
Slide 2-38. Medical Branch

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Triage Group
Slide 2-39. Triage Group
Briefing
The Triage Group Supervisor must obtain a verbal briefing and situational awareness from the
Medical Branch Manager.
Co-Locate with Tactical Group

The Triage Group Supervisor should co-locate with the Tactical Group Supervisor. This is
critical to ensure situational awareness of the status of downrange teams within the hot zone
and warm zone, to receive updates on casualty locations and status, and gain access
permission control for deployment of RTF.
Participant Note: Ideally, the Tactical Group Supervisor (the fifth

officer), is set up in a position of relative safety so that the Triage
Group Supervisor can co-locate with them. These are difficult jobs
and communication is improved if these two responders are
physically located next to each other during the response.
Get Operable Areas, Routes, and CCP Locations

The Triage Group is tasked with determining operable areas, routes, CCP locations, and if an
ambulance exchange point has been set up. They should obtain hot zone and warm zone
boundaries and ingress and egress routes as soon as available from Medical Branch Director or
Tactical Group Supervisor.

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Establish Rescue Task Force(s)

A Rescue Task Force (RTF) makeup will be determined by local policy. The Triage Group
Supervisor should assemble teams of a minimum of four personnel consisting of at least two
law enforcement officers as the security element and team leader with two medically trained
personnel to provide medical care element of the team. The medical element of the RTF may
be comprised of medically trained Fire, EMS or Law Enforcement personnel depending on local
policy
The security element will communicate directly to the Tactical Group Supervisor on the Law
Enforcement radio channel. The medical element should communicate directly with the Triage
Group Supervisor on the medical channel. Triage and Tactical should be co-located to work
together.
The medical element of the RTF should be equipped to treat airways, hemorrhaging, and the
ability to effectively move at least one patient.
RTF assets should be requested as soon as possible so that teams can form up quickly. The
Triage Group Supervisor must update the Medical Branch Director regarding status and
capabilities as they are acquired.
Key Point: The Triage Group Supervisor must quickly organize at

least one RTF so that when one is requested by the Tactical
Group Supervisor, they are prepared and ready to deploy.
Participant Note: Remember that RTF staffing will be dictated by

local policy and may vary by jurisdiction.
Rescue Task Force

Briefing
Obtain briefing, including situational awareness from the Triage Group Supervisor, and
coordinate communications with law enforcement team members.

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Gather Equipment
Gather equipment to treat and stabilize airways, control hemorrhage from penetrating trauma,
and move at least one non-ambulatory patient. RTF members should only take what they can
carry and run with.
Get Permission to Enter Inner Perimeter from Tactical Group

Obtain permission from the Tactical Group Supervisor to enter the inner perimeter. Law
enforcement RTF members should monitor law enforcement operations and fire and EMS
members should monitor the Medical Branch communications channel.
Rapidly Assess Casualties

Rapidly assess casualties and triage with emphasis on hemorrhage control and rapid
evacuation from the warm zone and inner perimeter.
Report Counts to Triage Group

Report counts to Triage Group Supervisor and periodically provide updates Triage Group
Supervisor on casualty counts, triage level/severity and locations.
Coordinate Casualty Evacuation to Ambulance Exchange Point(s)

Coordinate casualty evacuation to an ambulance exchange point.
Participant Note: It is important for law enforcement to make sure

that all RTF members are aware of how to operate in the tactical
environment. While in the staging area, quickly state who will do
what. Let fire and EMS know what the roles of the officers will be
and make sure everyone understand the rules of engagement.
Once the RTF has instructions to deploy, the security element of the RTF must confirm from the
Tactical Group Supervisor that they have permission to enter the inner perimeter. The Tactical
Group Supervisor controls the tactical picture of the inner perimeter.
Once in the inner perimeter, the medical element of the RTF must rapidly assess casualties and
report counts to the Triage Group Supervisor. The medical element on the team should radio
the Triage Group with the number of casualties, the severity of casualties by triage color, and
their locations.
After assessing casualties, the medical element of the RTF discusses where the ambulance
exchange points will be set up, how casualties will be evacuated, where the closest exits are,
and location of access points with the security element of their RTF. The security element of the
RTF will communicate with the Tactical Group Supervisor, who will jointly coordinate this task
(face to face) with the Triage Group Supervisor. The Triage Group Supervisor along with the

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Transport Officer will be involved with task accomplishment; however, the decision-making
process must begin at the RTF level in the CCP.
Moving casualties to a CCP can improve security and EMS access to casualties. Depending on
the situation, more than one CCP may be set up. In a multi-story building, CCPs may be
established on each floor. The size of the incident may require more than one CCP or because
of security concerns, there may be one inside of the site and one outside behind cover.
Flexibility and precision in reporting CCP locations is imperative.
Slide 2-40. Triage and RTF

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Second Law Enforcement Supervisor
Slide 2-41. Second LE Supervisor
Briefing
The second law enforcement supervisor should obtain a face-to-face briefing from command.
Optimally, a somewhat stabilized command and Command Post will be established upon the
arrival of the second law enforcement supervisor. The content should be more detailed than the
first arriving supervisor’s briefing.
Assume Command
After obtaining a briefing, the second law enforcement supervisor should assume command.
This should be clearly stated over the radio with confirmation of the physical location of the
Command Post.
Designate First Law Enforcement Supervisor as Law Enforcement Branch

The second arriving law enforcement supervisor, now Command, should designate the first
arriving supervisor as the Law Enforcement Branch. This assignment should be clearly
communicated. The first arriving supervisor remains at the Command Post as the LE Branch
Director—this supervisor still possesses the most recent and best situational awareness, is the
point of contact for all of the units currently deployed, and is best prepared to focus on the
ongoing tactical and strategic plans.
Assign Intelligence Section

Next, Command (second LE Supervisor) assigns an Intelligence Section. He or she should
identify a resource qualified to begin the functions of Section Chief, co-locate this position in the
Command Post, and provide the checklist for this activity as part of the command staff.

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It is strongly recommended that the Intelligence Section is established as early as possible in an

active shooter incident because of the flood of information that will occur. Information will be
coming from internally and externally from the scene. This flood of information should be
gathered, screened and evaluated by the Intelligence Section Chief actionable intelligence. In
most agencies, intelligence and organization of information is the responsibility of a detective or
investigator; however, in the beginning, this assignment can be any resources available to the
Incident Commander until more qualified or experienced personnel arrive at the command post.
Under the Intelligence Section is the position of Reunification Group Supervisor. Circumstances
involving large crowds, educational facilities, or social events have a high probability of involving
separated family members. These types of incidents will attract rapid public notification via all
types of communication streams such as social media, television, and 24-hour news outlets.
This will prompt a rapid mass influx of people to the scene. Quickly assigning a responder to
this task can serve to control this situation by providing a location for family members to go
instead of approaching or challenging the scene’s outer perimeter. See the Checklist Help
Guide for additional information.
Slide 2-42. Second LE Supervisor

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Unified Command
Slide 2-43. Unified Command
Building from the bottom up creates the base from which to seamlessly transition to a Unified
Command. At this point, the Incident Commander—the second arriving law enforcement
supervisor, becomes the Operations Section Chief. The Operations Sections Chief will brief fire,
police, and EMS chiefs as they arrive on scene. This creates an organized, orderly, and
seamless transition to Unified Command.

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Additional Information
Improvised Explosive Devices is outside the scope of this course, but the following is provided
to participants to explain some key concepts of the Checklist for IED encounters. Participants
are CAUTIONED to read the entire IED section of the Active Shooter Incident Management
Checklist Help Guide AND to consult with their local Explosive Ordinance Demotion (EOD,
a.k.a. bomb squad) experts BEFORE employing the concepts.
Improvised Explosive Devices (IEDs)
Participant Note: Participants are CAUTIONED to read the entire

IED section of the Active Shooter Incident Management Checklist
Help Guide AND to consult with their local Explosive Ordinance
Demotion (EOD, a.k.a. bomb squad) experts BEFORE employing
the concepts.
The Active Shooter Incident Management Checklist contains an IED checklist. It provides
guidance for non-explosive ordnance disposal (EOD) first responders encountering a suspected
IED during an active shooter event. The guidance is based largely on military procedures for
encountering an IED on the battlefield and civilian procedures adjusted for the context of an
active shooter event, most notably that the IED is likely to be less than 50 lbs and inside a
building or other confined area. Use of IEDs in active shooter events has increased domestically
and has increased significantly internationally.
Discovery or Detonation
The following steps provide guidelines for responders who have encountered and IED during an
active threat incident:
Announce the IED

Announce the IED to the team by yelling to the team that you have found a device and
communicate the location of the device, for example: "Everyone stop! Improvised explosive
device ahead in front of that door, on the left side." If you are too close to the device, move clear
of it.
Secondary Threat Scan

Quickly conduct a secondary threat scan. Note what the device looks like—are there wires,
batteries, a proximity sensor, or a motion detector? Note the size of the device.
Scan the area around the device as follows:

 Look within a five-foot radius of the device for other devices, wires, or sensors. The
attacker may have placed trip wires or secondary sensors within this five-foot radius.

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 Conduct the same visual scan for a 25-foot radius. Look primarily for other devices, but
also for secondary sensors and trip wires.
A contact team should divide these duties up. One team member should act as security, one
should scan the device, another should scan the five-foot radius, and another should scan the
25-foot radius.
Contact Teams and RTF’s

Consider Threat to Life and Alternate Route
If a moving contact team or RTF encounters an IED, they should first consider the threat to life,
including the risk to the team and the risk to nearby victims and casualties. They should also
consider alternate routes around the device. If a quick alternate route is available, the team
should take it. If alternate routes would cost too much time, consider how this prolonged
response could affect lives.
Mark and Bypass

If possible, the team should mark and bypass the IED. IEDs should be marked at a distance that
safely warns others that something is wrong. Some agencies will mark it with glow sticks or light
markers. Many officers do not carry this type of equipment on them and will have to improvise
using items on them or items from the scene. The goal is to catch the attention of other
responders and provide them with an indication that they need to be aware of their
surroundings. For example, a team member could place a chair sideways in the middle of the
hallway or place a pair of hand cuffs on the floor in the middle of the hallway.
Provide a Security Element if Possible

If the team is large enough, one or more officers could act as a security element to ensure that
following responders are aware of the device.
Exposed Victim Rescue

Direct Victim Movement Explicitly
Officers should provide victims with detailed instructions on how to move about the scene.
Keeping in mind that there may be trip wires and sensors that victims cannot see, officers
should indicate how they should move, when they should move, and where they should go.
A narrow cordon into and out of the device threat area should be established. After determining
a successful path, officers should continue to direct victims through that path.
View Area for Secondary Threats

Scan from floor to waist along perimeters (e.g. walls) first, then interior. Repeat scan from waist
to ceiling paying attention to tops of furniture/ cabinets. Look for unordinary things (wire,

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antenna, watch or timer, cell phone, remote control device, handheld radio, passive infrared
(PIR) or motion sensor, chemicals, powder, liquid, batteries, etc.), unusual chemical smells, and
proximity of any hazards (e.g. flammable liquid/gas, chemicals, etc.). If post detonation, look for
structural damage or collapse threat.
Provide Direct Threat Care Only

This is a direct threat care environment. If within range of detonation of an IED, responders may
only administer direct threat care.
Evacuate to Standoff / Isolate / Barricade

Lastly, responders should evacuate to the appropriate standoff distance. The checklist contains
minimum and preferred standoff distances for various types of devices. Injury is likely to occur at
the minimum standoff distances. For example, a five-pound pipe bomb has a minimum standoff
distance of 70 feet. At this minimum distance, it would be important to have cover, such as a
concrete wall, around a corner, or through a doorway. The preferred standoff distance for a pipe
bomb is 1,200 feet. Suicide bombers typically carry a 20-pound device. In this instance,
responders must seek cover and a minimum standoff distance of 110 feet. The preferred
standoff distance is 1,700 feet.
From Radio Safe Distance

(300ft or standoff) - Public safety radios should be kept on, but responders should avoid
transmitting until at least 300 feet from an IED or at a safe standoff distance. Radio devices (e.g.
public safety radios, cell phones, etc.) transmitting in close proximity to a radio command
controlled IED might cause detonation. Modern public safety radios and cell phones transmit
small data packets in very short bursts at regular intervals, but detonation risk from these
automatic transmissions is considered to be very low.
Report IED Location, Description, Size

Report the location, brief description, and estimated size in pounds of suspected IED. Report
any indication of CBRN (Chemical, Biological, Radiological, and Nuclear) in detail. Note CBRN
threats are outside the scope of this document.
Report Action Taken

Report actions taken related to the suspected IED.
Request Bomb Squad

Request local EOD/Bomb Squad response.

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No Victims Threatened
View area for secondary threats

Scan from floor to waist along perimeters (e.g. walls) first, then interior. Repeat scan from waist
to ceiling paying attention to tops of furniture/ cabinets. Look for unordinary things (wire,
antenna, watch or timer, cell phone, remote control device, handheld radio, passive infrared
(PIR) or motion sensor, chemicals, powder, liquid, batteries, etc.), unusual chemical smells, and
proximity of any hazards (e.g. flammable liquid/gas, chemicals, etc). If post detonation, look for
structural damage or collapse threat.
Reposition personnel to safe standoff

Evacuate personnel to standoff distance (see chart) as soon as possible.
Report impact to assignment and priority

Report impact to previous assignment caused by suspected IED and communicate the priority
of mitigating the suspected IED.
Cordon off 360° device kill zone

Cordon off a 360 degree radius around the suspected IED utilizing the standoff chart as a guide.
Control cordon security awaiting Bomb Squad

Secure the 360 degree cordon perimeter while awaiting EOD/ Bomb Squad response. Monitor
the entire area and maintain eyes on the suspected IED if possible.

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Active Shooter Incident Management Checklist Help Guide
Slide 2-44. Checklist Help Guide
Resource: For additional information regarding the

checklist, refer to the free detailed help guide at
http://c3.cm/asc
The Active Shooter Incident Management Checklist and some descriptive content in this section
are the ©Copyrighted work of C3 Pathways and is used with permission.

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Task and Purpose

Saving lives is everyone’s job. It is essential to work together across disciplines. It is equally
important to work outside traditional lanes of responsibility when and where necessary.
Slide 2- 45. Saving Lives
Common Tasks
Slide 2- 46. Everyone’s Job

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There are common tasks that apply to all responders in an Active Shooter Event. They are
incident priorities, medical care, and triage.
Incident Priorities
Slide 2- 47. Incident Priorities
Recall there are three standard NIMS ICS priorities: life safety, incident stabilization, and
property conservation. While applicable to an Active Shooter Event, more specific incident
priorities are needed to guide responders on prioritization of assignments and resource
utilization.
The three standard priorities for an Active Shooter Event are:

1. Active Threat
2. Rescue
3. Clear
Priority 1. Active Threat

The primary focus must be to stop the active threat, the very thing that is causing injuries and
loss of life. This priority is uniquely a law enforcement issue, and officers are expected to
aggressively move toward and neutralize the active threat. It is very important to note the word
“active” in the phrase active threat, meaning actively attempting to kill victims.

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Priority 2. Rescue
The second priority is rescue of the casualties, the injured victims. This priority involves all
disciplines, but is especially important for law enforcement. Outdated response models called
for law enforcement to clear the entire area and insure it was secure prior to fire and EMS
moving down range to render medical care. Unfortunately, casualties may bleed to death or
succumb to their injuries because of delays due to clearing, which can take a long time to
complete – even hours.
It is important to note that law enforcement has a dual role in the rescue priority. Law
enforcement must directly render medical care to casualties and also provide security to support
the rescue operation of fire and EMS. This takes training and coordination among responders
that crosses disciplines and jurisdictions.
It is also important to note the first two priorities may be executed simultaneously if resources
and the environment make it possible. In other words, if the active threat is in another building or
area away from some casualties, some law enforcement resources may be assigned to
neutralize the active threat while at the same time other law enforcement resources are
assigned to support rescue of casualties -- provided there are sufficient law enforcement
resources to do both. If not, the first priority to neutralize the active threat takes precedence.
Priority 3. Clear
The third priority is to clear and secure the area where the attack took place. Clearing
operations should NOT occur until all casualties have been treated and evacuated from the
scene unless sufficient law enforcement resources are available to support both rescue and
clearing operations simultaneously.
One possible exception to clearing operations being the third priority is when the building or
area is small enough to rapidly clear the area and declare it safe, e.g. a Cold Zone. If the entire
scene is a Cold Zone, fire and EMS can move up in mass and without restriction to rescue
casualties. It is important to note the ability to rapidly (e.g. 5 minutes or less) render the entire
scene a Cold Zone is extremely rare.
Medical Care
In terms of the type of care rendered, medical response is divided into direct threat care, which
occurs in the hot zone, indirect threat care, which occurs in the warm zone, and evacuation
care, which occurs in the cold zone.

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Direct Threat Care
Slide 2-48. Hot Zone: Direct Threat Care
Direct threat care occurs in the Hot Zone and includes the following types of treatment:
 Direct pressure
 Tourniquet application
 Recovery position
All of these will be covered thoroughly in later modules.
Indirect Threat Care

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Slide 2-49. Warm Zone: Indirect Threat Care
Indirect threat care occurs in the Warm Zone and includes the following types of treatment:
 Wound packing
 Hemostatic gauze
 Airway management
 Needle decompression
 Intravenous (IV) and interosseous (IO) infusion
 Dressings
 Splints
Evac Care
Slide 2-50. Cold Zone: Evac Care
Evacuation care takes place in the cold zone and during the transport phase and includes all
medical procedures.
Triage
Triage means to sort or prioritize. It is an essential and critical function in Active Shooter Events
that is everyone’s responsibility. Unfortunately, the term has several different meanings during
emergency response that can be confusing.

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Terminology: Victims and Casualties

Responders should be aware of their use of the terms victims and casualties. Law enforcement
considers everyone involved in the crime to be a victim that must be processed, interviewed,
and documented. A casualty is a person who has been injured.
Key Point: All involved are victims, but not all victims are
casualties. Law enforcement should call injured people casualties,
patients, or injured. If law enforcement escorts 100 students from
the scene of a school shooting for screening, they consider it to be
an event with 100 victims.
Fire and EMS responders have a different understanding of the term victim. These agencies
consider victims to be people who are injured or require medical treatment. If a Medical Branch
staffed by a fire chief asks how many victims are at a scene, response from a Law Enforcement
Branch on scene could be that there are 100 victims, even if there are only five injuries. Given
this information, the Medical Branch may order too many ambulances.
Definition: Victim (as used in this course)

A non-perpetrator person involved in an Active Shooter Event.
Definition: Casualty (as used in this course)

An injured person involved in an Active Shooter Event.

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The Act of Triage
Slide 2- 51. Triage: Act
The first and most common use of triage is as an act, meaning the act of triaging (sorting)
casualties at the scene. This is where responders will conduct some medical assessment and
assign a priority to the casualty. Priorities vary by locality, but the most common is Green,
Yellow, Red, or Black, with Green theoretically being the least injured and Black a fatality.
A Location to Triage Evacuated Casualties
Slide 2- 52. Triage: Physical Location

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Another usage of the word triage is a physical location, e.g. a triage area, setup in the Cold
Zone where casualties are evacuated to be triaged (e.g. the act of triage). A triage location is
common in traditional mass casualty incident training where casualties are commonly not
located in an unsafe area. Obviously, this is not the case in an Active Shooter Event. A separate
triage area in the Cold Zone is generally not necessary in an Active Shooter Event. Exceptions
would include a large number of casualties that self-evacuate from the Hot Zone and need
treatment, or if a shuttle operation is setup with law enforcement to evacuate casualties from the
Hot Zone.
The Triage Officer
Slide 2- 53. Triage: ICS Position
The third use of the term triage is the Triage Group Supervisor, or the triage officer responsible
for overseeing the act of triage. This is a position that is used during an Active Shooter Event,
and is key to integrating the response and saving lives. In the case of an Active Shooter Event,
the Triage position is responsible for collecting the triage information from Rescue Task Forces
down range and coordinating with the Transport officer and Medical Branch.

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Triage Counts
Slide 2- 54. Triage: Counts
The count of the total number of casualties involved in an Active Shooter Event is extremely
critical. The number of injured casualties drives the numbers of resources needed to provide
medical care and transportation.
When a contact team is deployed and discovers casualties, it is important to attach a number
and location in the report back to command. Descriptions should provide actual numbers or
estimated numbers of casualties so that EMS can efficiently deliver appropriate resources.
Even an estimate is important because it can provide three important, actionable responses:
 What resources will be required for the casualties
 Where the largest number of casualties are concentrated
 Whether there are adequate resources at the scene or inbound
Example: Be precise in the descriptions you are reporting to

command. Avoid phrases such as “we have multiple victims down”
or “we have a lot wounded.” Provide a count of the casualties you
encounter.
For example, when encountering the first casualties at a scene,

state “Contact one, we have five casualties” or “Contact one, we
have 20 casualties in the cafeteria.”

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Key Point: Responders should not attempt to keep a cumulative

tally of casualties after the initial casualty report to command. For
example, use a format such as “Contact Two, plus 3 casualties
front lobby,” or “Contact One, plus 12 casualties room 104.” It is
the role of dispatch and command to keep a cumulative total of the
casualties.
Simple Triage for Law Enforcement
Slide 2- 55. Triage: Law Enforcement
Law enforcement personnel can perform a simple triage which aids in security and effectively
sorts casualties and victims.
With the use of simple commands, officers can direct all persons in a room to move to a specific
wall if they are able to do so. Persons who remain and are unable to walk or follow simple
commands are categorized as Red, a.k.a. an Immediate casualty. Of the group of victims now
against the wall, officers need to separate the injured from uninjured. This can be done several
ways, for example asking the injured to identify themselves (raise hand, say something, etc.),
directing the uninjured to move to another wall, etc. Persons who are injured AND walking are
categorized as Green, a.k.a. a Minor casualty or walking wounded. Uninjured victims are NOT
assigned a color category – they are simply uninjured victims.

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During this simple triage, all casualties will be categorized as either Green or Red, including any
injured suspect(s). Additional assessment and treatment options will be covered in more detail
in an upcoming module.
It is important for law enforcement personnel to note fire and EMS personnel will re-assess all
casualties and triage in accordance with their local protocols, for example using Green, Yellow,
Red, and Black.
Reporting Severity
Providing information regarding severity is very helpful. One emergency medical technician
(EMT) or paramedic can take care of between four and eight green casualties, but it takes three
to four EMTs or paramedics to take care of one red casualty. This information affects the
response provided, the resources delivered, and the overall level of care.
The best way to quickly convey severity is to report casualties as; “Contact one, I have 5 green,
2 red in room 101”.
Fire / EMS Triage
Slide 2- 56. Triage: Fire and EMS
Fire and EMS responders should triage all casualties in accordance with their local protocol,
which will vary from jurisdiction to jurisdiction.
There are many different triage systems in use in the United States (more than a dozen). The
most common system used is START. Like many others, START is not a validated triage

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system and suffers from over-triage and under-triage. In other words, casualties with minor
injuries are sometimes triaged more seriously, and casualties with serious injuries are
sometimes triaged as minor.
Within the START system and many others, responders are cautioned not to think Green
casualties can be ignored. It is important to remember a casualty self-elects to be categorized
Green by walking and following commands. Casualties can have very serious injuries and still
walk – at least for a while. Likewise, a relatively minor casualty can elect not to walk and
become categorized Yellow.
Field Triage Score
Slide 2- 57. Triage: Field Triage Score
The Field Triage Score (FTS) is a validated triage methodology, which demonstrated
substantially equivalent sensitivity to more complex triage systems. It is used by the military for
its simplicity and accuracy. The Field Triage Score is recommended for civilian use over START
because of its validation and simplicity.
There are only two components to the FTS. The first is radial pulse. Score 1 for a normal radial
pulse pressure, or score 0 for weak or absent pulse pressure. The second component is
Glasgow Coma Scale Motor response. Score 1 for a normal motor response where the patient
obeys commands for purposeful movement, or score 0 for any abnormal movement or absence
of movement.

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Add the two component scores together. It is only possible to score 0, 1, or 2. A casualty with a
score of 0 is critical and should be considered an Immediate or Red. A casualty with a score of
1 is considered serious and should be considered a Delayed or Yellow. A casualty with a score
of 2 should be considered Minor or Green.

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Contact Team
Slide 2-58. Contact Teams
Recall incident priorities are as follows:

1. Active threat
2. Rescue
3. Clear
The top priority is to stop the killing by stopping the attacker. The second priority is to stop the
dying by rescuing casualties, and for law enforcement this means directly providing medical
care and providing security to support the rescue operation. Clearing the building is the third
priority. Recall the previous discussion about simultaneously addressing priorities if sufficient
resources are present to fully execute the higher priority with additional resources to execute the
next priority simultaneously.

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Contact Team Zone of Operation
Slide 2-59. Contact Team Zones of Operation
A Contact Team is the organizational unit for law enforcement that (mostly) executes security
tasks. Contact Teams are the only component that should be operating in a Hot Zone. Contact
Teams will also operate in Warm Zones and Cold Zones, executing security tasks.
Contact Team Staffing
Slide 2-60. Contact Team Staffing

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These priorities are accomplished using Contact teams typically made up of two to five officers.
It is important to note specific staffing and formations are a local policy decision.
Contact Team Stimulus
Slide 2-61. Contact Team Driving Force
The stimulus for the Contact Teams is gunfire, victims streaming out of the building indicating
the location of the shooter, seeing the shooter, or any combination of things that indicate an
active threat.

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Contact Team Sim
Slide 2-62. Contact Team SIM
After the gunfire stops, law enforcement should switch to SIM—security, immediate action plan,
and medical. Security is the top priority. Once the attacker has been neutralized or the active
threat has stopped, officers should secure and gain control of the area in which they are
working. Once this has been accomplished, the Contact Team should develop an immediate
action plan to make sure that all team members understand their roles and coordinate their
actions, e.g. get everyone on the same page. Finally, officers should begin administering
medical treatment to casualties. Generally, one or two team members will maintain security
while the remaining team members care for casualties.

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Casualty Collection Point (CCP)
Slide 2-63. Casualty Collection Point (CCP)
A Contact Team will have first contact with casualties well before fire and EMS responders
move down range. It is normally the Contact Team that will establish a Casualty Collection Point
for the consolidation and security of casualties.

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CCP Definition
Slide 2-64. Casualty Collection Point Definition
Definition: A casualty collection point (CCP) is a specific warm

zone location with security measures to assemble nearby
casualties and provide indirect threat care.
.
A CCP is located in the warm zone. In the CCP, security measures are established so
responders can administer indirect threat care.

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CCP Zone of Operation
Slide 2-65. CCP Zone of Operation
A Casualty Collection Point is a Warm Zone function. It should have security as a component
when established.
CCP Functions
Slide 2-66. CCP

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The location for a Casualty Collection Point is important. They are situated close to casualties,
in a defensible space that is large enough to accommodate medical treatment. They are
established early in the response. When establishing CCPs, responders should consider how
they will evacuate the casualties, e.g. nearby exits points, corridors, and location of the
ambulance exchange point.
Security within the CCP consists of addressing any threats, controlling the location by securing
doors and using overwatch. Responders should separate victims from casualties and should
consider removing uninjured persons. If necessary, consider using uninjured to move casualties
and assist with immediate life-saving aid such as stopping significant bleeding.
If not accomplished by a Contact Team, a Rescue Task Force may establish a CCP.
Key Point: It may be necessary to have more the one Casualty

Collection Point. Examples would include a multi-floor building with
casualties and multiple floors, clusters of casualties spread out
physical far apart, casualties in separate buildings, etc. It is critical
to name each CCP uniquely if more than one CCP will be used.
Naming can be as simple as numbering, e.g. “CCP 1, CCP 2,” etc.,
or the naming might include a location reference such as “Lobby
CCP, Warehouse CCP,” etc.
CCP Example
Slide 2-67. CCP Example

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Slide 2-67 shows an example CCP layout with Red casualties physically separated from Green
casualties, which are placed against a wall. Uninjured victims (not shown) should be placed on
a separate wall.
In October 2015, the White House launched the “Stop the Bleed” campaign to provide
bystanders’ of emergency situations with the tools and knowledge to stop life threatening
bleeding. The government, in cooperation with the private sector and nonprofit organizations
will be putting knowledge gained by first responders and the military in the hands of the public to
help save lives. Responders should be aware there may be uninjured victims who have training
that may be able to help render aid prior to an RTF arriving at the CCP.
Resource: To access more information on the “Stop

the Bleed” campaign, scan the QR Code or visit
http://www.dhs.gov/stopthebleed

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Rescue Task Force (RTF)
Slide 2-68. Rescue Task Force
The term rescue task force has been used across the country by different agencies in different
ways. How these function in one part of the country may not be how they function in another
part of the country. RTF staffing depends on the jurisdiction. This is a local policy issue that may
also be driven by the type of incident and the tactical requirements of the response.

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RTF Zone of Operation
Slide 2-69. Rescue Task Force Zone of Operation
Rescue Task Force is a Warm Zone function.
Participant Note: The level of care provided in the warm zone is

known as indirect threat care. This will be discussed in greater
detail in Module 5.

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RTF Staffing
Slide 2-70. Rescue Task Force Staffing
A RTF has a task and a purpose. It is an ad hoc team typically comprised of four to six people,
although depending on the jurisdiction, it could include more or fewer team members.
Regardless of how it is staffed, the RTF involves the following three elements:
 Team leader
 Security element
 Medical element

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Medical Element
Slide 2-71. RTF Medical Care
The medical team focuses on all medical details and is responsible for carrying medical
equipment. Medical care consists of the following:
 Patient assessment
 Treatment for life-threatening conditions
 Triage
 Treatment
 Evacuation coordination with the ambulance exchange point
Casualties should be rapidly transported to an ambulance exchange point through a secured

exit path. The road leading to the CCP should be secured and the ambulance should be waiting
for casualties when they are brought to the ambulance exchange point.
RTF medical personnel must communicate to the Triage Group casualty numbers and severity.
RTF medical and RTF security must communicate regarding the ambulance exchange point
location and the casualty movement plan.
RTF security must communicate to the Tactical Group the ambulance exchange point location
and path of movement. The RTF medical group must communicate to the Triage Group the
location of the ambulance exchange point and when they are ready for ambulances to arrive.

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RTF Zone of Operation
Slide 2-72. RTF Zone of Operation
The group's job, task, and purpose is to operate in the warm zone, preferably along cleared
corridors. These areas may have already been cleared by the contact team and controlled by
law enforcement. RTFs have their own security element, however, so they may also move
through warm zones that have not been cleared. In some instances, a contact team may have
cleared an area and left, so the RTF may not know if the area is still clear.
Rescue Task Force security formations and movements are covered in a later module. While
this course teaches a few standard methods, it should be noted formation and movement
methods are a local policy decision.
Key Point: Remember that law enforcement’s responsibility in an

RTF is to secure the team, not to neutralize the attacker. This is a
protection job. Even if shots are fired, focus on keeping the team
safe. The security element never, EVER leaves their medical
element.

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Ambulance Exchange Point
Slide 2-73. Ambulance Exchange Point
The Rescue Task Force is in the best position to identify and coordinate the Ambulance
Exchange Point for evacuation of casualties from the CCP.
AEP Definition
Slide 2-74. Ambulance Exchange Point Definition

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Definition: An ambulance exchange point is a specific location

where an ambulance is sent to pick up evacuated casualties from
a team operating in the warm zone.
AEP Zone of Operation
Slide 2-75. Ambulance Exchange Point Zone of Operation
An Ambulance Exchange Point is typically a Warm Zone function.

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AEP Details
Slide 2-76. Ambulance Exchange Point
An ambulance exchange point involves the RTF and law enforcement. It is located in an area
with drivable access, near casualties and an exit point. It must be in a defensible space with
cover, concealment, and limited exposure to threats. The exchange point goes into effect when
casualties are ready for evacuation and when security measures are in place. Security
measures include an exterior cordon for vehicle movement and an interior cordon for movement
of responders and victims.
There may be some scenes in which the tactical environment is too risky to establish an
ambulance exchange point. In such cases, an armored vehicle may be used to load casualties
and rapidly shuttle them into a safe area in the cold zone. Ambulance exchange points must be
coordinated with the Tactical Group, Triage Group, and Transport Group.
The loading target for direct transportation to a hospital is three per ambulance, including one
cot for red patients, one bench for yellow patients, and one seat for green patients. When
shuttling patients to the cold zone, the loading target is as many as possible. Patients will either
be transported to the triage or treatment area or to the transport loading zone.
If possible, ambulances should transport patients to a hospital after loading them at the
exchange point. Ambulance exchange points are setup by the RTF in a secure, cordoned area
close to casualties.

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Traditional Mass Casualty Incident Functions
Slide 2-77. Cold Zone: Traditional MCI Functions
Slide 2-77 summarizes overall response functions categorized by zone.
Summary
Slide 2-78. Summary

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This module described the profile and characteristics of an active shooter event. Participants
also discussed CCPs, triage, ambulance exchange points, and evacuation care. It also gave
participants an opportunity to examine the Active Shooter Incident Management Checklist and
discuss how ICS concepts can be applied to an active shooter event.
Participant Note: The next module discusses Staging and

Resource Management.
Practical Exercise: Active Shooter Counterstrike Tabletop

Exercise
Slide 2-79. Practical Exercise Active Shooter Counterstrike
Introduction
This exercise will provide participants with the opportunity to respond to and manage an active
shooter attack through a tabletop exercise. The exercise design enables emergency responders
to exercise strategy, decision making, command and control, communication, and other skills in
responding to highly variable and dynamic active shooter attack scenarios.

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Exercise
Participants will be assigned to one of two mixed-discipline groups. At each station, instructors
will present the scenario and provide directions for the exercise. Following each round,
instructors will facilitate discussion on issues related to response and management of an active
shooter attack and provide feedback on participants’ performance. Instructors will coach
participants as they work collaboratively to establish priorities and develop a plan for effective
and efficient response and management of the incident.
Active Shooter Counterstrike Tabletop Exercise

Active Shooter Counterstrike is a turn-based exercise comprised of two groups, attackers and
responders. The object is for attackers to inflict heavy casualties on civilians and responders,
while responders try to confront and stop the attackers, establish command and control,
evacuate and transport casualties, and secure the area. Participants deploy and manage
resources under their control, with confrontation outcomes determined by dice rolls.
Strategy
The basic strategy for Active Shooter Counterstrike is first to stop the threat and then render aid
to casualties. This may sound simple, but there is surprising complexity in simultaneous action
of priorities. Responders should:
 Aggressively move to neutralize the attacker threat
 Establish command and control
 Deploy RTFs forward to casualties
 Establish a perimeter
 Secure ingress and egress for ambulances
 Evacuate casualties
 Clear the crisis area by occupying all cells on the game board with at least one law
enforcement responder
Responder are expected to use the ICS during the exercise by using the Active Shooter Incident
Management Checklist as a guide. The responder group is expected to conduct their team
discussions, communications, decisions, and actions within the command context. In other
words, someone is in charge and a clear hierarchy is established and used.
Equipment and Design

Exercise boards are maps depicting selected target hazards, with an appropriate zoom level to
show the area of interest (typically a few to several city block-sized area). The board is divided
into rectangular cells that participants may occupy.
Red cells depict the outer perimeter

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Green cells depict drivable areas
Blue cells depict non-drivable (foot traffic only) areas
Yellow-striping in a cell depicts exposure to attack from adjacent cells
Labeled tokens are placed on the board to represent Attacker and Responder resources
deployed to a specific location. Resource tokens are colored chips with identifying labels as
follows:
Vehicle People
Law Enforcement Patrol Blue Officers (LEO) White w/ blue stripe
Fire Department Engine Red Firefighters White w/ red stripe
EMS Ambulance Green EMT/Paramedics White w/ green stripe
Victims Victims and Casualties White w/ gray stripe
Attackers Bad Guy Black w/ yellow stripe
Additional tokens are used to depict organizational elements using colored chips with identifying
labels as follows:
Organizational Chip Color Example Label

Contact Team Purple Contact 1, Contact 2, …
Rescue Task Force Orange RTF 1, RTF 2, …
Specialty Unit Yellow Bomb Squad, SWAT, Sniper, Hazmat, …
Tokens are moved around the board by Attackers and Responders on their respective turns.
Specific rules govern the movement of resources.
Several sets of dice are used to control resource allocation and attack outcomes. Resource
allocation for responders is controlled by a colored die for each discipline:
 Blue for law enforcement
 Red for fire
 Green for EMS

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Attackers use black dice, while responders use white dice for confrontations. An ICS
organizational chart and checklist cards help players keep track of assignments during the
exercise.
Instructors will evaluate participants based on their individual performance within the group and
evaluate the group based on its performance as a whole. Following the exercise, instructors will
conduct an after-action discussion (hot wash) on the exercise and provide participants with
feedback on their performance.
Evaluation Criteria
Participants will be evaluated on their ability to:
 effectively communicate critical information;
 coordinate response among multiple disciplines, jurisdictions, and agencies;
 effectively identify, coordinate, and use available resources, including personnel,
equipment, and materials;
 overcome challenges with communication;
 solve challenges by using creative thinking and improvisation; and
 anticipate and plan for possible future attacks.

Active Threat
Integrated Response
Course
Module 3: Staging and Resource Management
Version 2.0


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Module 3: Staging and Resource Management
Slide 3-0. Staging and Resource Management
Duration
1 hour (lecture)
Scope Statement
In this module, instructors will provide participants with staging procedures and techniques in
resource management, functions and responsibilities of the Staging Area Manager and how
staging can support successful completion of incident objectives.

Participants will be familiar with staging and how to function as a Staging Area Manager in an
active threat integrated response.

At the conclusion of this module, participants will be able to:

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3-1 articulate the importance of the staging function,

3-2 describe the purpose and function of staging,
3-3 manage resources through check-in and check-out procedures,
3-4 discuss the role of the Staging Area Manager, and
3-5 articulate the use of staging within the Active Shooter Incident Command Checklist.
Resources
 Audiovisual kit
 Pen

1:40 (lecture)
Reference List
DHS (Department of Homeland Security), FEMA. 2004. IS 200 - Applying ICS. Washington DC:
U.S. Government Printing Office.

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DHS. 2014. National Incident Management System Independent Study Program. July 25.
FEMA, Emergency Management Institute. http://www.training.fema.gov/IS/NIMS.aspx
Godfrey, W.M., Agan, D., Otterbacher, R., Fender, D. 2013. 4 Best Practices for Active Shooter
Incident Management: Lesssons Learned from 10 Active Shooter Exercises with the
University of North Florida. Orlando, FL: C3 Pathways, Inc.
r.pdf
Godfrey, W.M., Agan, D., Otterbacher, and R., Fender, D. 2014. Active Shooter Incident
Management Checklist. Orlando, FL: C3 Pathways, Inc.
Godfrey, W.M., Agan, D., Otterbacher, R., and Fender, D. 2014. Active Shooter Incident
Management Checklist Help Guide. Orlando, FL: C3 Pathways, Inc.
Metropolitan Police Department Washington, D.C. 2014. After ActionReport Washington Navy
Yard September 16, 2013. Washington, D.C.: Metropolitan Police Department.
U.S. Department of Homeland Security, FEMA. (2006). Task Book: Employee Job Aid: Staging
Area Manager. Washington DC: U.S. Government Printing Office.

Not applicable

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Assessment Strategy
 Observing participant behavior during practical exercises
Icon Map

unfamiliar

concept
Resource: Reference to books, websites, articles and Insert QR

other external information sources with QR code code here

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Introduction
Slide 3-2. Why Staging Matters
Recall from Module 2 that on September 16, 2013, an active shooter event occurred at the
Washington Navy Yard in Washington, DC. The single-shooter attack began at 8:16 a.m. and
ended 69 minutes later at 9:25 a.m.
As discussed in Module 2, an active shooter event lasting 69 minutes is very uncommon. Active
shooter research has documented that 90% of incidents last no more than 15 minutes.
Lack of immediate law enforcement resources was not a factor in the duration of this active
shooter event. During the initial search for the gunman, 117 law enforcement officers were
inside actively searching for the shooter. Some were part of contact teams, and some operated
alone. They were not using a common tactical radio channel to coordinate the search. There
was no organized search plan or strategy. This resulted from an all-call, flood-the-scene, and
over-convergence approach from multiple local, state, and federal law enforcement officers.
The Importance of Staging

Key Point: The primary goal of first responding law enforcement
to an active shooter event is to stop the ongoing threat. Although
the initial deployment of these first responders depends upon
training and local policy, the staging function is critical for the
follow-on and secondary responders from all disciplines.

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The use of staging does not automatically ensure a seamless operation in a dynamic situation
like an active shooter event. It is an important part of the overall effort to reduce or stop
confusion resulting from over convergence and self-deployment of resources.
Additionally, staging intentionally controls the flow of resources into the hot and warm zones.
This immediately reduces confusion and allows the incident commander to assess the scene
and gain situational awareness.
The absence of staging at the crisis site increases confusion and creates a fog-of-war
environment that hinders effective response and increases risks to civilians and responders.
Key Point: A security element, or force protection, must be

assigned to the staging location. Although staging should be
established in the cold zone, always keep in mind the possibility of
secondary attacks. Staging locations can be an attractive target for
terrorists desiring to harm first responders and delay response.
Staging Functions
Slide 3-3. Staging Functions
Staging serves three primary functions: resource utilization, accountability, and ingress and
egress.
Resource Utilization
A properly managed staging point ensures effective and efficient use of resources. Emergency
response resources are limited and expensive. Additionally, it is very difficult for Incident

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Commanders to develop strategic plans to address the emergency if they do not know the
resources available to them.
Resources should be used effectively and efficiently. The right resource must be assigned to the
appropriate job and location.
Key Point: Keep in mind the quote from US Army Major James
McGinnis: “Everyone should have a task and purpose on the
scene, or they don’t need to be there.”
Accountability
The ability to track and account for the well-being of every responder on a scene is of
paramount importance at all emergency scenes, especially active shooter events.
Scene accountability starts with checking in at staging and receiving a specific assignment. The
Staging Area Manager should record the following information:
 Unit identifier
 Type of resource
 To whom the resource is being assigned within the Incident Command System (ICS),
 Where the resource is being sent
 The task, if known
 Assigned radio channel
 Time of the assignment
Ingress and Egress

The staging function controls physical access to the scene to ensure that resources, such as
ambulances, can readily move into and out of the scene. It also prevents responders from
endangering themselves by unknowingly entering the hot zone.
While the fire service has used staging for decades, it is not common within law enforcement. If
not managed quickly, responding officers are likely to park as physically close to the incident
site as they can get—often blocking roadways and interfering with ingress and egress. Staging
ensures that the mass of responding resources does not obstruct ingress and egress and often
allows resources to form teams and consolidate vehicles for an assigned task. This could
include a contact team of four police officers deploying to search for the threat or an integrated
rescue task force (RTF) comprised of law enforcement and fire and EMS personnel.

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Role of the Staging Manager

The Staging Area Manager is responsible for checking in resources and making assignments as
requested by command. When making assignments, the Staging Area Manager should inform
the resource of the assigned task, if known; the radio call-sign to be used; to whom they should
report; where to report; and the assigned radio channel. The Staging Area Manager should log
everything in an organized manner so that they may answer questions regarding locations,
assignments, and accountability.
Participant Note: Public safety responders are driven

professionals. Often, if they are on the scene without an
assignment, they will find something to do. This is referred to as
freelancing which is counterproductive to the overall mission. A
freelancing resource is not being used effectively, has no
accountability within the ICS, may endanger other responders, or
compromise the overarching incident response objectives.
Staging Log
Slide 3-4. Staging Log
All that is required to create a staging log is a pen and a pad of paper. A pen and paper log
should begin with the initiation of staging; however, a temporary log, such as a white board may
be used in the beginning. Responders should photograph or transcribe a temporary log onto
paper as soon as possible to ensure that information is not lost.
As soon as practical and when transitioning into defined operational periods, an ICS Form 214
(Activity Log) should be used.

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Setting Up Log
Slide 3-5. Setting Up Log
A legal pad is best, but any pad or blank piece of paper can be used as a staging log.
Responders should first organize the page.
Start by writing the title “Staging Mgr” and adding the proper unit identifier, such as the unit
number of the person serving as Staging Area Manager. To keep track of page numbering, write

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“Pg 1” in the upper right hand corner. Repeat the page number in the upper right corner for each
subsequent page.
Next, write the title “Radio” and draw blank lines to record the radio channels in use at the
scene. Common channels are “Command,” “Tactical,” and “Medical.” In large incidents, there
may be additional channels assigned and they should be recorded here.

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To track law enforcement resources, write “LE” and draw a line vertically to the bottom of the
page. Draw a short horizontal line at every second or third rule mark on the pad. As law
enforcement resources arrive and check in, they will be recorded on each of these lines.
To track fire resources, write “Fire” and draw a line vertically to the bottom of the page. Draw a
short horizontal line at every second or third rule mark on the pad. This is where all fire and non-
transport EMS assets will be recorded as they check in.

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Finally, write “Amb” for ambulances. Draw a short horizontal line at every second or third rule
mark on the pad. This is where ambulances and other transport-capable resources will be
checked in.
Key Point: Ambulances are kept separate to ensure that when

resources are needed for RTFs or other medical assignments,
transport ambulances are not deployed for non-transport functions.
Radio Channels
Slide 3-11. Radio Channels
Communications are critical in high stress, dynamic, and potentially lethal environments. In most
after-action reports for large-scale events, including many high-profile active shooter attacks,
communications were identified as a significant response gap. Although it is challenging to
address hardware-related communication issues, such as lack of radios or interoperability
issues during the initial stages of an active shooter response, staging ensures that responders
are on the correct radio channel for the proper function. Staging allows all personnel operating
within the crisis site to communicate with the proper chain of command.
As the Staging Area Manager becomes aware of radio channel assignments, they should write
the name of the channel on the appropriate line.

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Slide 3-12. Radio Channels
The common radio channel assignments used at an active shooter event are “Command,”
“Tactical,” and “Medical.” Other functions that may be assigned channels include “Staging,”
“Perimeter,” “Aviation,” and others.
Before any team or resource departs staging to begin a task, the Staging Area Manager should
make sure personnel have the capability to communicate with their chain of command and have
selected the correct radio channel.
Key Point: Ensure that group leaders, team leaders, or single

units have direct communication capabilities on the correct radio
channel before allowing them to deploy downrange.

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Adding Resources
Slide 3-13. Adding Resources
As new resources arrive and check in, write each unit ID on a line below the corresponding
discipline. Do not be concerned with the order at this point. It is important that every unit is
logged in to know what is available and that there are enough resources to meet the demand.
Once each unit has checked in, responders should stand away from Staging Area Manager to
allow others to report and be accounted for. It is important to note that all resources should
maintain a state of readiness to rapidly deploy.
Participant Note: Law enforcement officers should prep all gear,

including long guns, go-bags, medical equipment, and breaching
tools. While prepping their gear, officers should also coordinate
with fire personnel to obtain forcible breaching tools from fire
trucks if necessary.
Responders should also prepare patrol vehicles to carry teams of

officers or RTF personnel. This could include cleaning out
passenger compartments and trunks and removing backseat
cushions.

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When checking in fire and non-transport EMS resources, write each unit ID on one line as
shown.
Key Point: Most fire and EMS resources typically have multiple
personnel assigned per unit. It may be helpful later to know how
many personnel are assigned to each unit. Record this information
by writing a small number next to the unit ID and circling the
number of personnel.

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When checking in ambulances operating only as transport capable resources, write each unit ID
on one line as shown. Designate the level of care that can be provided by each transport unit.
Resource: Additional information on ambulance resource

typing and capabilities can be found at
https://rtlt.preptoolkit.org/Public/Combined?q=ambulance or
by scanning the QR code.

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Making Assignments
Slide 3-16. Making Assignments
When making assignments, start by drawing a bracket next to the individual unit being assigned
to the task. On this slide, the first four law enforcement officers are being tasked for a contact
team assignment.

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Write the assigned radio call-sign for this assignment. In this example, there is already a
Contact Team 1, so this group will use call sign “Contact 2” on the radio. This can be notated by
“Contact 2” or abbreviated it as “CT 2.”
It is important to note to whom each resource will report—who their boss will be in the ICS. In
this example, “Contact 2” reports to “Tactical Group.” Notate this under the call-sign.

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Next, write where this resource is to report for the assignment. In some cases the resource may
be told to report to the supervisor for further instructions. In this case, it is the Tactical Group
Leader. In other cases, the resource may be sent directly to their task location. In this example,
“Contact 2” is reporting to the “Front of the bldg” to meet with “Contact 1.”
Write the radio channel the resource should use for the task. In this example, “Contact 2” is
talking to “Contact 1” on “LE TAC 2.” This is the channel assigned to the Tactical Group.

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Write the time the resource is assigned to the task. In this example, “Contact 2” is assigned at
“1205 hrs.”
Lastly, draw a single line through the resources assigned to the task after the Staging Area
Manager has made the assignment. This denotes that the resource is no longer under the
control of the Staging Area Manager and is no longer available.

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Key Point: Do not erase, scribble-through, or obliterate what was

written on the staging log. It is important to be able to read what
was written later.
Participant Note: When assembling a RTF comprised of a law

enforcement security element and medical personnel, it is
important to know which discipline is providing the medical
component. If possible, staff the RTF with medically-trained
personnel from non-transport units, such as EMTs or paramedics
assigned to fire apparatus. This keeps the ambulance and casualty
transport units staffed and ready to take patients to the hospital.
If the EMS discipline is the only source of medical personnel, the

Staging Area Manager must quickly ensure that there are enough
EMS transport units with personnel intact to receive and transport
casualties.
Requesting Resources
Slide 3-23. Requesting Resources
The Staging Area Manager may need to request additional resources from the local jurisdiction
or neighboring communities. As the Staging Area Manager orders resources, they should write
the letter identifying the resource type in the appropriate column.

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The Staging Area Manager must track the use of resources and be aware of when they are
running low. The Staging Area Manager should alert the Incident Commander when a resource
is running low.
Key Point: The Staging Area Manager can greatly assist the
Incident Commander by requesting orders to maintain a minimum
number of resources in the staging area.
With a properly functioning staging process, the Incident Commander no longer has to focus on
backfilling resources as they are used; that is now the responsibility of the Staging Area
Manager.
Example: For example, an Incident Commander might order

staging to keep 10 law enforcement, three fire, and four
ambulances in staging at all times. When the Staging Area
Manager runs below the ordered levels, he or she makes a direct
request to the communications center to dispatch additional
resources to maintain the ordered levels.
Using this example, assume the Staging Area Manager has four
ambulances in staging. The Incident Commander orders three
ambulances to move up for casualty evacuation. The Staging Area
Manager would then make the assignments and immediately call
the communications center to have additional ambulances
dispatched.
Resource requests are guided by:

 the size of the incident;
 the stage of the incident—early, middle, or late;
 the speed at which the incident is unfolding; and
 the length of time required for additional resources to deploy to the staging location.

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In the example shown, three additional ambulances are requested. The Staging Area Manager
would write “A” on three lines.
The Staging Area Manager should note the time of each resource request. This provides an
estimate of when resources will arrive and serves as a reminder to follow up on the request if
resources do not arrive in a timely manner.

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Participant Note: During critical incidents, it is not uncommon for

resource requests to be made multiple times, acknowledged, and
not dispatched. Overwhelmed communications personnel, fog of
war, and communication breakdowns occur; however, the simple
act of logging the request time lessens delays from these types of
oversights.
When the requested resources arrive in staging, write the unit ID next to the appropriate letter.
In the example shown, Ambulance 3 has arrived in staging and the Staging Area Manager
writes a “3” next to the first “A.”

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Activity: Creating a Staging Log

Participants will use the information presented on the slides to create a staging log during a
simulated integrated response event. Use the following blank pages to create and maintain the
log.
Slide 3-27. Activity
Activity Review
Slide 3-28. Activity Review

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Use the example example shown to check the staging log you created. An organized and
effective staging log enables subsequent responders to have a full understanding of available
and deployed resources.
Summary
Slide 3-29. Summary
This module examined the role of staging and the Staging Area Manager in an active shooter
event. The purpose and importance of staging was discussed along with a method of creating a
staging log. Participants created a staging log to practice this skill while recognizing the
importance of maintaining available resources at staging.
Participant Note: The next module discusses Direct Threat Care.

Active Threat
Integrated Response
Course
Version 2.0


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Slide 4-0. Title
Duration
45 minutes
Scope Statement
In this module, participants will be introduced to direct threat care and the priorities for the
potential care giver and casualty during this phase. Specific critical lifesaving interventions that
can be used while both the care giver and casualty are under hostile fire is also addressed.

Participants will be able to identify appropriate life saving techniques that can be used in a direct
threat environment.

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4-1 describe and define the priorities in a direct threat environment,
4-2 describe and define the movement of wounded to cover or relative safety,
4-3 demonstrate proper management of external hemorrhage,
4-4 demonstrate the proper application and use of a tourniquet, and
4-5 demonstrate the recovery position for airway management.
Resources
 Audio visual kit
 Training/demo tourniquet
 Pen
 Training tourniquet

1:40

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Reference List
Haemorrhage) intracranial bleeding study: The Effect of Tranexamic Acid in Traumatic
Blackbourne, L., Butler, F., Cantrell, J., Champion, J., Eastridge, B., Holcomb, J., Kotwal, R.,
Lawnick, M., Mabry, R., Mallett, O., Moores, L., Oetjen-Gerdes, L., Rasmussen, T.,
Seguin, P., Tops, T., Uribe, P., Wade, C., and Zubko, T. 2011. Death on the Battlefield
(2001-2011): Implications for the Future of Combat Casualty Care.
Committee for Tactical Emergency Casualty Care. 2013. Resources-Tactical Emergency

Casualty Care (TECC) Guidelines. http://c-tecc.org/
Smith, E. R., and Delaney, J. 2013. “Supporting Paradigm Change in EMS' Operational Medical
Response to Active Shooter Events.” Journal of Emergency Medical Services.
http://www.jems.com/article/supporting-paradigm-change-ems-operation
Wall, P. L., Welander, J.D., Singh, A., Sidwell, R.A., and Buising, C. M. 2012. Stretch and Wrap
Style Tourniquet Effectiveness With Minimal Training. Military Medicine, 177, 11:1366.

During this module, participants will be issued a tourniquet and will be directed at pre-
determined times to apply a tourniquet to themselves or another participant on one or more
extremities.
Assessment Strategy

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Icon Map

unfamiliar

concept

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Introduction
Slide 4-2. Medical Skills and Concepts
The medical skills and concepts discussed in this course are based on the guidelines developed
by the Committee on Tactical Emergency Casualty Care.
Tactical Combat Casualty Care (TCCC)

The evolution of tactical combat casualty care occurred as a result of the lessons learned from
centuries of battlefield health care and a landmark article that appeared in a 1996 issue of
Military Medicine.
This publication was heavily influenced by the Battle of the Black Sea which took place in
Mogadishu, Somalia in October 1993. Previously, military guidelines for trauma management
mirrored tactics used in the civilian sector. Initiated by elements of the Special Operations
Command, the new strategies outlined in 1996 were collectively referred to as technical combat
casualty care (TCCC).
The Committee on TCCC (CoTCCC) launched a total reassessment of practices with one
overarching goal: decrease preventable combat death at the point of wounding.
Tactical Emergency Casualty Care (TECC)

TCCC strategies based on historical wounding patterns in combat are especially relevant to law
enforcement officers who share many operational parallels with their military counterparts.

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Slide 4-3. Tactical Combat Casualty Care
The TECC guidelines are based upon the principles of TCCC but account for the differences in
the civilian environment, resources allocation, patient population, and scope of practice. They
are guidelines for a set of best practices recommendations for casualty management during
high threat civilian tactical and rescue operations.
Prevent Further Casualties

The TECC concept includes preventing further casualties by eliminating the shooter even prior
to providing medical aid to a partner or fellow responder. This is because the rescuer is likely to
become a victim if the shooter has not been isolated, distracted, or neutralized before aid is
rendered.
Treat the Casualties

Once the threat has been mitigated, the priority shifts to immediate life-saving intervention. If the
casualty is you, get off the X, seek cover or concealment, administer self-aid, and prepare to
defend yourself.
Participant Note: The term get off the X refers to moving away
from the location where the injury occurred since it is a known
danger area.

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Complete the Mission

The greater good of completing the mission, especially in a terrorism mass casualty incident, is
more important than any one individual. The repercussions of a successful Beslan- or Mumbai-
style terrorist attack will result in an increase of such attacks. American law enforcement must
demonstrate that what is perceived as a soft target is not. Like our military counterparts,
responders must demonstrate that they are willing to face unprecedented perils in order to deny
attackers any appearance of victory. Furthermore, to be most effective, the mission must be
accomplished without significant loss.
TECC Guidelines and Phases of Care

The TECC guidelines take into account that wounding patterns and mechanisms of injury may
be similar in civilian incidents involving ballistic and explosive wounding. Accordingly, TECC
recommends treatment modalities based on the tactical situation and available assets. The
primary TCCC tenets of placing far forward timely medical care, and doing the right thing at the
right time, are also paramount in the TECC guidelines.
Applying NIMS Terminology to Improve Interoperability

The TECC guidelines are being established nationally as the tactical medicine standard for the
civilian tactical emergency medical support (TEMS) community; however, many providers have
previously received TCCC training in either the military or civilian communities. The use of
accepted NIMS terminology—hot zone, warm zone, and cold zone, to describe the phases of
care bridges the language gap between TEMS personnel trained in TECC and enhances
interoperability. It also facilitates the learning process for personnel undergoing training by
associating tactical casualty care principles and phases of care with standard, well-established
NIMS threat zone terms.
Potentially Survivable Deaths

Using the concept of TECC, this course focuses on developing skills to address severe injuries
identified as being potentially survivable. The following are the top three potentially preventable
causes of deaths seen in combat-like casualties:
1. Hemorrhage
2. Tension pneumothorax
3. Airway obstruction

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Slide 4-4. Potentially Survivable Deaths
According to an evaluation of 983 casualties, hemorrhage was the leading cause of potentially
survivable death in Operation Iraqi Freedom and Operation Enduring Freedom (Kelly at al
2008).

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Priorities in the Direct Threat Care Environment

The priorities of direct threat care are mitigating the threat, moving the wounded to cover or an
area of relative safety, and managing external hemorrhages, particularly through the use of
tourniquets. Rapid positional airway management should be considered if tactically feasible.
Slide 4-5. Direct Threat Care
Definition: Direct threat care refers to the limited trauma

interventions that may be considered for use in aiding a casualty
while still actively engaged in mitigating a threat.
Threat mitigation will always take priority; however, these limited interventions may be applied if
adequate security is established.

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Direct Threat Care
Slide 4-6. Direct Threat Care Guidelines
Direct threat care is care rendered at the scene of the injury while both the medic and the
casualty are under hostile fire. Medical equipment is limited to what is carried by each
responder.
The following is a basic management plan for care under fire or direct threat care:
 Return fire and take cover. Remember that fast is fine, but accuracy is final.
 Direct or expect the casualty to remain engaged as a combatant if appropriate and they
are able.
 Direct the casualty to move to cover and apply self-aid, if able.
 Try to keep the casualty from sustaining additional wounds.
 Get yourself and the casualty off the X.
 Stop life-threatening external bleeding if tactically feasible:
 Direct casualty to control bleeding using self-aid, if able
 Apply a tourniquet on the upper portion of the affected extremity, regardless of where
the wound is, over the uniform, tighten the tourniquet, and move the casualty to
cover once the threat has been isolated, distracted, or neutralized

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Slide 4-7. Direct Threat Care Guidelines

.
In a direct threat environment, superior firepower is the best way to neutralize the attacker.
Pausing to administering medical treatment can result in poor tactics—neutralizing the attacker
is always the top priority. Responders should never provide care on the X. Communication is
important in assessing the injured person’s ability to administer self-aid and in directing the
injured person to move to a safer location.
Key Point: Be decisive in a direct threat environment!

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Direct Threat Care Interventions
Slide 4-8. Direct Threat Care Interventions
The first US casualty to die in the current conflicts from enemy fire was a Special Forces
Soldier, SFC Nathan Chapman. He died during medical air evacuation on January 4, 2002 from
isolated limb exsanguination without tourniquet use. A Central Intelligence Agency officer
sustained a chest wound alongside SFC Chapman. The officer’s chest wound was triaged as
more serious than Chapman’s femoral artery injury; however, Chapman’s artery was severed,
resulting in severe blood loss and death before the helicopter landed.
The loss of SFC Chapman underscored the need for a reliable tourniquet for all soldiers. The
hallmark tragedy of this story in hindsight is not surprising given what we know now about
tourniquets. In contrast to SFC Chapman’s tragedy, during the March 2002 Operation Anaconda
SFC Cory Lamoreaux, a Special Operations Forces flight medic, successfully used a tourniquet
during care under fire for over 16 hours. SFC Lamoreaux kept his limb and, after rehabilitation,
returned to pilot duty.
The Army Rangers have achieved the lowest preventable death rate ever reported in a major
conflict. They did it by training everyone in TCCC before the start of the current conflicts. The
75th Ranger Regiment reported that the incidence of preventable deaths in 419 battle injury
casualties sustained by that unit, was found to be 3%. This is significantly less than a study that
indicated a 15% – 28% percent rate of preventable deaths in which combatants had not had
TCCC training. (Kelly et al 2008)

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Slide 4-9. Hemorrhage Video
Responders must be prepared to control bleeds like the one shown on Slide 4-9.
“The hemorrhage that takes place when a main artery is divided is usually so rapid and so
copious that the wounded man dies before help can reach him.”
Col. H.M. Gray, 1919

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Bleeding to Death
Slide 4-10. Bleeding to Death
The human body can survive the loss of 2000cc or two liters of blood. Mindset plays a
significant role in how a person responds to blood loss. Use tactical performance imagery to
prepare yourself for being shot at, being hit, and continuing the fight. Some first responders will
shut down physically at the first sign of bleeding. Responders must condition themselves to
expect to bleed.
Key Point: Mentally prepare yourself for being shot. Fill a two-liter
bottle with liquid. On a flat, hard surface, slowly pour the liquid onto
the ground. Take note of what two liters of fluid looks like on the
ground. Reflect back to this image if you have been shot and are
bleeding.

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Tourniquet Use and Application
Training Considerations and Participation Exclusions
Slide 4-11. Tourniquet Training Exclusions
There are potential health concerns with the application of a tourniquet to the lower extremity of
anyone who has certain pre-existing health conditions. During the ATIRC Practical Exercises
and classroom activities, any participant who meets one or more of the following exclusionary
criteria should not apply or allow application of a tourniquet on their legs beyond simple (loose)
placement of the tourniquet in the proper location:
 Clotting or circulation abnormalities

 Blood pressure problems
 Pain syndromes
 Peripheral neuropathies
 Over the age of 50
* Participants can self-apply or allow application of the tourniquet strap around their lower
extremity but the windlass will not be utilized to apply pressure to the limb.
Key Point: During the training course, participants should not

apply a tourniquet to their leg or allow the application of a
tourniquet if any of the criteria above are met. Participants should
err on the side of caution when determining whether or not they
should apply a tourniquet to their leg during training based on their
personal health history.

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Slide 4-12. Intro to Tourniquets
Tourniquets are a fast and effective tool to stop major extremity bleeding when used properly.
Risks associated with tourniquets are generally a result of improper use, lack of training, or
prolonged use. (C-TECC) They are no longer considered a treatment of last resort.
History of Military Use of Tourniquets

Tourniquets have been used in the field with varying success since the Battle of Flanders in
1674. For over 300 years, tourniquets have been shown to be effective in stopping arterial
extremity bleeding. The variations in the material used to create the tourniquet and lack of
training led to very sporadic success and a great deal of complications. Tourniquets became
synonymous with limb loss following the Civil War and those images have prevailed for nearly
150 years. The military continued to issue tourniquets with the understanding that although they
were seen as a last resort, they were frequently the only hope for controlling severe arterial
extremity bleeding. They were often applied too late, resulting in significant blood loss and
shock. Unfortunately the canvas and buckle tourniquets issued by the military throughout the
Vietnam War and into the late 1990s were ineffective largely because they had no mechanical
advantage, or a windlass, for applying pressure.
In the late 1990s, research started in earnest to develop a reliable tourniquet. The Army studied
several hundred casualty reports involving tourniquet application and concluded overwhelmingly
in favor of the early use of tourniquets to stop severe extremity hemorrhage. They also
concluded that a simple, effective, easy to apply tourniquet needed to be developed.

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Slide 4-13. Vietnam-Era Strap and Buckle Tourniquet
Slide 4-13 shows an example of an obsolete canvas belt and friction buckle tourniquet that had
been used by the US military for six decades. Its National Stock Number was removed in 2008.
Today’s Use of Tourniquets by First Responders

Agencies should consult tourniquet studies and their medical directors prior to selecting any
device, and should not necessarily rely on recommendations or endorsements of devices used
by the military. Studies have shown that improvised tourniquets are ineffective in 40% of
applications. TECC recommends a commercially-produced tourniquet as the first choice.
Guidelines developed by TECC show providers how to use tourniquets correctly and lessen the
chance of complications. These guidelines are based on existing evidence, best practices, and
military recommendations and experiences. TECC guidelines take into account differences in
civilian populations and operating parameters, and does not recommend or endorse a particular
device.
CoTCCC Approved Tourniquets

Following extensive tourniquet testing conducted by the US Army Institute of Surgical Research,
the CoTCCC has approved three tourniquets for use by US military forces: the Delfi Emergency
and Military Tourniquet (EMT), SOF Tactical Tourniquet Wide, and the Combat Application
Tourniquet (CAT).
Because the Delfi EMT is pneumatic and cost prohibitive, it is not used as a front line field
tourniquet. The SOF Tactical Tourniquet Wide and CAT proved 100 percent effective in
stopping severe extremity arterial bleeds. The floating circumferential band design of the CAT

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allows for bleeding control with less pressure than other field tourniquets and therefore reduces
the possibility of long term damage due to tourniquet use. For this reason, it is the primary
tourniquet issued to US military forces.
Delfi EMT
Slide 4-14. Delfi EMT
This tourniquet is effective; however, it is not typically used in the field due to its size and cost—
approximately $300. It is also pneumatic and could leak air with field use.

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SOF Tactical Tourniquet Wide
Slide 4-15. SOF Tactical Tourniquet Wide
The SOF Tactical Tourniquet Wide is one of the top performing tourniquets available. It is the
tourniquet of choice for many of the world's elite and experienced warriors because of its ability
to control severe bleeding, reliability, and ease of application. While some military units have
replaced their issue tourniquets with the SOF Tactical Tourniquet Wide, others military units
have implemented standard operating procedures stating that the SOF Tactical Tourniquet
Wide is to be used on all lower extremity bleeds. It is the tourniquet that is trusted to control the
most severe extremity hemorrhage on the battlefield.
The key to successful implementation of a device to be used in a high stress environment is

training and ease of use. For law enforcement officers, application of this tourniquet is similar to
the use of a hobble. This existing level of familiarity reduces training time and aids in the
effectiveness of the device.

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Combat Application Tourniquet (CAT)
Slide 4-16. Combat Application Tourniquet (CAT)
The CAT is a one-handed tourniquet proven to be 100% effective by the US Army Institute of
Surgical Research. It is the tourniquet of choice for the US military. Tests prove that the CAT
completely occluds blood flow of an extremity in the event of a traumatic wound with significant
hemorrhage.
The CAT uses a durable windlass system with a free-moving internal band providing true
circumferential pressure to the extremity. A self-adhering band allows for easy one-handed
application with little reliance on fine motor skills.
The internal, free-floating circumferential band design enables this tourniquet to apply equal
pressure around the limb as the windlass is turned. This results in effective bleeding control with
the least amount of pressure, decreased pain, and decreased possibility of long-term nerve
damage.
Participant Note: This course uses the CAT for the reasons
described above; however, tourniquet selection varies by agency.
Some agencies prefer the SOF Tactical Tourniquet Wide because
of its ease of application in leg wounds.

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Direct Threat Care Tourniquet Application
Slide 4-17. Direct Threat Care Tourniquet Application
Tourniquets are the primary adjunct used to control severe extremity bleeding. When tactically
feasible, they should be applied without delay. During direct threat care, both the casualty and
the officer are in grave danger while the tourniquet is being applied. The decision regarding the
relative risk from the threat versus that of bleeding to death must be made by the officer
rendering care.

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Slide 4-18. Direct Threat Care Tourniquet Application
Once the decision has been made to render care, use a tourniquet if there is any question
regarding severity of bleeding. Using a tourniquet when not needed is an acceptable mistake;
not using a tourniquet when it is needed is a fatal mistake.
Applying well-aimed direct pressure while acquiring the tourniquet can aid in reducing the
amount of blood loss if a responder is trained and has experience in these procedures. The best
approach is to use the victim’s tourniquet; the second option is for a responder to use their own
tourniquet.
Key Point: Applying pressure while acquiring the tourniquet adds

seconds to application.Your goal during direct threat care is to
apply the tourniquet without delay and get back in the fight. You
must decide if you have the training and experience to apply direct
pressure or a pressure point without delaying the application of the
tourniquet.

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Tourniquet Application Guidelines
Slide 4-19. Tourniquet Application Guidelines
Go High or Die
During direct threat care, a tourniquet should always be applied as high on the arm or leg as
possible, even if the hand or foot is injured. Go high or die is the default approach during any
phase of care.
The national standard is to apply the tourniquet two inches above the knee or elbow or two
inches above the wound, whichever is higher. This standard assumes you have time to expose
and perform a thorough assessment of the injured limb.
Key Point: The threat is your primary concern. Any medical care
must be performed quickly; you will not have time to examine the
wound. Going high ensures exit wounds or multiple wounds in the
same extremity are addressed with one tourniquet.
20 Seconds to Apply
With proper training, responders should be able to self-apply a tourniquet with their non-
dominate hand in under 20 seconds. Responders should purchase a tourniquet to use for
practice. Tourniquet drills should be part of law enforcement’s firearms training. It is a perishable
skill and needs to be practiced often.

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Apply Directly Over Clothes

To ensure rapid application, the initial tourniquet should be applied high and directly over the
clothing. Quickly check for and remove any object, such as holsters or pocket knives, that could
interfere with tourniquet application.
Determining Windlass Stopping Point

During direct threat care, the windlass of the tourniquet should be turned until the bleeding
stops. During indirect or evacuation care, the windlass should be turned until there is no distal—
or below-the-wound pulse present. The goal is to stop all distal circulation. This can be verified
by checking the distal pulse, typically at the wrist or ankle. Checking the pulse is ideal; however,
it is not practical during direct threat care.
Once casualties have been moved to cover, tourniquets must be reassessed for effective
bleeding control. The initial tourniquet may be tightened and additional tourniquets may be
applied if bleeding resumes or a distal pulse is present.
Marking the Casualty

Noting the time that the tourniquet was applied is important for follow-up medical personnel.
Simply marking the time on the patient’s forehead or directly on the tourniquet will suffice. The
tourniquet can be left in place for several hours with no long term implications. There are
several documented cases in which tourniquets were left on for 6 – 10 hours with little or no
permanent damage.
Number of Tourniquets
It is not uncommon to use two or three tourniquets on one leg to stop bleeding. The leg is dense
with muscle mass and often requires additional pressure applied to a greater surface area to
completely collapse the artery.
Additional tourniquets should be applied directly adjacent to the last tourniquet applied. They
should be placed as close as possible without overlapping.
Once casualites have been moved to cover, an additional tourniquet should be added to
exposed skin for wounds that have been treated with a tourniquet over the clothes. A tourniquet
applied over the clothes is likely to move and loosen during patient movement. Applying a
second tourniquet should not delay evacuation as long as the initial tourniquet is still effective.
Do Not Remove Tourniquet

Non-medically trained persons should not remove a tourniquet once it has been applied.

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CAT Anatomy and Storage
Slide 4-20. CAT Anatomy
Slide 4-20 shows the six components of the CAT:

1. Friction buckle
2. Windlass
3. Circumferential band
4. Windlass clip
5. Windlass securing strap
6. Self-adhering band

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Slide 4-21. CAT Storage Position
The storage configuation for the CAT, as recommended by the manufacturer, is as follows:
1. Disassemble loop and undwind windlass
2. Clean inner circumfrential band in windlass clip area
3. Fully extend inner circumfrential bank
4. Insert tab of band into friction buckle using the slit closest to the windlass clip
5. Pull the tip of the band to the bottom of the loop while holding the tourniquet by the
windlass clip
6. Mate Velcro of band below friction buckle
7. Fold tourniquet in half, matching Velcro to Velcro
8. Ensure windlass securing strap is affixed to one side of the windlass clip, not across the
clip
The user should be very familiar with the storage configuration and location of the tourniquet so
that it can be accessed and applied quickly and efficiently. Officers should be certain that they
can deploy their tourniquet rapidly, with one hand, and with the tab pointing inward when placed
on a limb.
Participant Note: Using operational tourniquets for training is not
recommended. Excessive use can stretch and weaken the nylon
and degrade the Velcro adhering strength. Errors can also be
made when re-configuring the tourniquet for storage. This could
cause delays during operational application.
Nylon is degraded by extended exposure to sunlight and chemicals. Avoid storing your
tourniquet in an area exposed to direct sunlight or chemicals, such as the front or rear dash of a
vehicle, or in a trunk or compartment where oil or gas is stored.

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Participant Note: For the purpose of this course, instructors will

show you how to carry the tourniquet for rapid deployment;
however, this technique may vary depending on the invididual and
how and where they choose to carry the tourniquet.
Key Point: The objective is to be able to retrieve the tourniquet

with either hand, place it on your injured limb, and have the tab
moving midline when tightening the band.
It is important to develop a deployment method that works for you

and has been committed to muscle memory. This will ensure you
can successfully apply your tourniquet under stress with one hand.
One- and Two-Handed Tourniquet Application

In training, using more than three turns of the windlass to properly apply the tourniquet is a fail
point. During actual application, if more than three turns are required to tighten the tourniquet,
continue turning the windlass as much as necessary. Be prepared to apply a second tourniquet
since this is sign that the tourniquet may be ineffective.
One-Handed Application
Slide 4-22. One-Handed Application
Use the following steps for one-handed tourniquet application:

 Grab tourniquet by folded tab section
 Loop tourniquet over injured arm

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 Pull tab midline, towards body, as tight as possible

 Mate Velcro on band from buckle to windlass clip
 Apply pressure with windlass until bleeding stops
 Secure windlass in windlass clip
 Place free end of band through windlass clip
 Apply windlass securing strap
 Mark time
Two-Handed Tourniquet Application
Slide 4-23. Two-Handed Application
Use the following steps for two-handed tourniquet application:

 Grab CAT and remove band from friction buckle
 Route tourniquet around extremity and pass tab through inside slip of the friction buckle,
pull band tight
 Pass the tab through the outside slip of the friction buckle, pull band tight and Velcro
back onto itself
 Apply pressure with windlass and secure in windlass clip
 Apply securing strap over windlass clip
 Determine need for additional tourniquets
 Mark time

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Slide 4-24. No Tourniquet Victim Died
Key Point: Your teammate cannot wait for a medic to arrive. You
have to act quickly.
Slide 4-25. Tourniquets Save Lives

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Slide 4-26. Tourniquets Save Lives
Discussion: Identifying the need for additional tourniquets is

critical. Can you identify the number of tourniquets? Based on
photos, do you think the tourniquets worked?
Slide 4-27. Multiple Tourniquets Applied
Slide 4-27 provides and example of improper tourniquet application. The person in this photo
did not survive his injuries. The initial tourniquet was placed too low, allowing bleeding to
continue. Subsequent tourniquets were placed above the first tourniquet with gaps between

(ATIRC)
them. Because the first tourniquet was placed low on the limb, it blocked superficial arterial flow
causing swelling, which hampered effectiveness of subsequent tourniquets.
In this case, improvised tourniquets were used. A CAT or SOF Tactical Tourniquet Wide in the
hands of a trained responder could have prevented this death.
Slide 4-28. Improvised Tourniquets
Discussion: Prepare for instances in which you do not have your

tourniquet—you may not have it on you, or you may have already
used it for another casualty.
Consider how you could use your surroundings to solve the

problem. What items on yourself, in your vehicle, or from your
surroundings could you use to create an improvised tourniquet?
Remain calm and apply direct pressure to buy yourself time to

locate and apply the improvised tourniquet. If the item you initially
find is too narrow to use as a band, keep it to use for securing the
windlass.
Improvised Tourniquet Examples

2 inch pliable band Belt, seat belt, material strips
Windlass Stick, ammo magazine, baton, flashlight
Windlass clip Shoe strings, zip ties, flex cuffs

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Slide 4-29. Improvised Tourniquet
When applying an improvised tourniquet, wrap the material completely around the limb before
securing the windlass to the tourniquet. The windlass should not be under the material directly
against the skin.
Responders should be aware that an improvised tourniquet does not often provide the same
results as an approved commercial tourniquet. It also takes more time to locate and apply an
improvised tourniquet. Improvsed tourniquets fail to control bleeding 40% – 60% of the time.
Slide 4-30. Amputations: Tourniquets?

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Tourniquets must always be applied to complete amputations even though this type of injury
may not initially bleed due to the body’s response mechanism.
It is important to be proactive in applying additional tourniquets to leg amputations. The

effectiveness of the tourniquet will be difficult to determine because the leg may not initially
bleed.
Common Tourniquet Mistakes
Slide 4-31. Common Tourniquet Mistakes
The most common mistake in tourniquet application is waiting too long to use the tourniquet.
This is possibly a result of people still assuming the tourniquet is a last resort. A tourniquet
should be used immediately in casualties involving severe extremity bleeding. Responders
should not spend time trying to control the bleeding by other means. Any attempt at direct
pressure or pressure point application should be for the sole purpose of slowing the bleeding
while the tourniquet is applied.
Another common mistake is placing the tourniquet too high. In an effort to follow the go-high-or-
die guideline, the tourniquet is sometimes placed so high that it goes over part of the shoulder
or buttocks, making if difficult or impossible to adequately tighten.
Another common mistake is not tightening the tourniquet enough. When the tourniquet is only
tightened enough to block venous bleeding, it ultimately leads to worse bleeding. If the
tourniquet is tightened enough to stop the bleeding but not eliminate the distal pulse, the
possibility of long term damage is greatly increased.

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The tourniquet should never be loosened. At one time, this was thought to decrease damage to
the limb; however, this practice was shown to increase blood loss and potential for shock.
Law enforcement first responders should never attempt to remove a tourniquet. The best course
of action for law enforcment is to continually reassess tourniquets to ensure the distal pulse is
eliminated and to apply additional tourniquets as needed.
Removing the tourniquet at the wrong time or when the casualty is in shock are common
mistakes made by medical personnel. This will be discussed further in the advanced medical
module.
Airway Management
Slide 4-32. Recovery Position
The recovery position helps to maintain an open airway in a semi-conscious or unconscious

casualty. This position helps the injured person breathe by keeping the tongue forward and
permitting fluids to drain from the nose and throat so they are not inhaled. Placing the casualty
on the injured side facilitates expansion of the uninjured lung.
The recovery position is only used for semi-conscious or unconscious casualties. Responders
should not force conscious casualties into the recovery position, but should allow them to
assume a comfortable position that allows them to breathe. Conscious casualties with airway
problems will generally naturally get into the position that best facilitates their breathing, but if
they are unable to move freely due to other injuries, the responder may need to assist them.

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The recovery position also functions as an identifier to follow-on responders signifying that the
casualty has been assessed by another team. This minimizes duplicate assessments and
facilitates smooth movement as follow-on teams transition into the area.
Slide 4-33. Recovery Position
Slide 4-33 shows an example of a recovery position. This position maintains an open airway for
semi-conscious or unconscious casualties, keeps the tongue forward, and allows fluids to drain
from the nose and mouth.
To place a casualty in the recovery position as shown in the slide, follow these steps:
1. Kneel next to the victim on her injured side.
2. Extend the casualty’s lower arm over her head, letting it rest on the floor.
3. Lift the casualty’s knee farthest from you, placing the leg into a bent position. This knee
will act as a stopper when you roll the casualty onto her side, preventing the casualty
from rolling completely over onto her stomach.
4. Place one hand under the casualty’s shoulder farthest from you, with your other hand,
grasp the casualty’s bent leg at the knee. Pull the casualty towards you. Her head
should now lay on her extended arm. Place the foot of the bent leg behind the knee of
the straight leg.
5. Bend the casualty’s upper arm at the elbow and place the hand, palm down, between
the casualty’s head and shoulder. This will provide added support for the head.
6. Tilt the victim's head up slightly to open the airway and facilitate breathing and drainage
of fluids. The victim is now in the recovery position.
7. In indirect threat or evacuation care, consider hypothermia prevention. If possible,
insulate casualty top and bottom.

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Summary
Slide 4-37. Summary
Participants examined direct threat care and the priorities for the potential care giver and
casualty during this phase. The module addressed specific critical lifesaving interventions that
can be used while both the caregiver and casualty are under hostile fire.
Participant Note: The next module discusses indirect threat care.

Active Threat
Integrated Response
Course
Version 2.0


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Slide 5-0. Title
Duration
5:30 hours (2:30 hours lecture, 3:00 hour practical exercise)
Scope Statement
In this module, instructors will provide participants with medical skills to render lifesaving
medical care once a casualty in no longer under direct hostile fire but potential threats remain.
Upon completion of this module, participants will be able to determine when it is appropriate to
apply lifesaving techniques in the indirect threat environment and apply appropriate medical
care.

Participants will be able to identify appropriate lifesaving techniques that can be used in an
indirect threat environment.

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Slide 5-1 Enabling Learning Objectives
5-1 describe and define indirect threat environment;

5-2 describe the difference between life-threatening and non-life-threatening injuries;
5-3 demonstrate the proper application and use of a tourniquet;

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5-4 demonstrate the recovery position for airway management;

5-5 demonstrate proper patient assessment techniques for life-threatening and non-life
threatening injuries;
5-6 demonstrate proper wound packing techniques;
5-7 demonstrate the application of occlusive dressings;
5-8 demonstrate bandaging methods;

5-9 demonstrate proper lifts, drags, and carries; and
5-10 describe non-trauma victim care and blast injury considerations.

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Resources
 Audiovisual kit
 Pen
Day 1 Exercise Resources

1. Wound packing station
a. Required equipment
 4 instructors
 4 tables
 4 Z-Medica Hemorrhage Control Training Kits with Lenovo S5000-F
Tablets
 40 rolls of gauze
 1 can of spray silicone
2. Pressure point station

 2 instructors
 An open area large enough for participants to lie flat on the floor
 3 handheld vascular doppler instruments and lube
 1 roll of paper towels
Day 2 Exercise Resources

1. Bandaging station
 2 instructors
 45 Olaes bandages
2. Improvised tourniquets and Module 4 review station
 1 instructor
 3 tables
 2 Z-Medica Hemorrhage Control Training Kits with Lenovo S5000-F
Tablets
 1 can of spray silicon
 20 CAT Training Tourniquets
 1 SOFT-T Tourniquet
 10 SOFTT-W Tourniquets

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 2 SWAT-T Tourniquets
 5 triangle bandages
 3’ of seatbelt material
 Improvised windlass tools: flashlight and scissors
3. Patient management station

 4 instructors
 2 moulage blankets
 2 pairs wound packing moulage station training pants
 2 groin gunshot wound moulage sets (M055)
 2 chest gunshot wound moulage
 1 bottle blood powder
 1 mixing bottle
 1 gallon of water
 2 Techline bags
 2 Techline clips
 2 squeeze bulbs
 4 tubes
 2 tube reducers
 4 tube valves
 2 rolls of paper towels
 1 box gloves
 4 Olaes bandages
4. Lifts, drags, and carries station
 2 instructors
 Pole-less litter
 22’ webbing
 Blanket

6:40
Reference List

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Bulter, FK, Giebner S., McSwain N., Pons P, eds. 2014. Prehospital Trauma Life Support
Manual 7th Edition (Military). Tactical Field Care. Jones and Bartlett Learning.

Eastridge, BJ, RL Mabry, P Sequin, J. Cantrell, T. Tops, P. Uribe, O. Mallett, T. Zubko, L.

Oetjen-Gerdes, TE Rasmussen, FK Butler, RS Kotwol, JB Holcomb, C. Wade, H.
Champion, M. Lawnick., L. Moores, and LH Blackbourne. 2012. “Death on the Battlefield
(2001 – 2011): Implications for the Future of Combat Casualty Care.” December. Journal
of Trauma and Acute Care Surgery. http://www.ncbi.nlm.nih.gov/pubmed/23192066
Smith, E. R., and Delaney, J. 2013. “Supporting Paradigm Change in EMS' Operational Medical
Response to Active Shooter Events.” Journal of Emergency Medical Services:
http://www.jems.com/article/supporting-paradigm-change-ems-operation

Module 5 has practical exercises on day 1 and day 2 of the course. Participants will be divided
into two groups and will remain in the two groups for rotation through the Module 5 exercises as
well as the table top exercise for Module 2 on day 2.
Day 1
Two stations run concurrently with half of the participants in each station and rotating stations
after 30 minutes
 Wound packing station
 Pressure point station
Day 2
Participants will be divided into two groups to run concurrently with half the participants in the
improvised tourniquets application review station and half in the bandaging, lifts, drags, carries
station. Participants will be pulled out in pairs from the improvised tourniquet station to conduct

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the patient management station exercise. The two groups will rotate stations once each
participant has completed the station (2 hours total).
 Patient management station
 Improvised tourniquets and application review
 Bandaging, lifts, drags, and carries
Instructors will provide constructive critique and feedback to participants during the practical
exercises to ensure competency.
Assessment Strategy

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Icon Map

unfamiliar

concept
Resource: Reference to books, websites, articles and other

external information sources

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Introduction
In direct threat care, if wounded responders are conscious, they are encouraged to return fire,
move off the X, and self-apply a tourniquet. Responders rapidly assist injured teammates who
are unable to administer self-aid if the size of their team is sufficient and circumstances allow.
Unlike the direct threat care environment, in which the main priority was engaging the threat,
indirect threat care occurs once the threat has been mitigated.
The Indirect Threat Care Environment
Slide 5-4. Indirect Threat Care
Indirect threat care begins once the threat is neutralized, isolated, or distracted. Casualties are
first moved to an area of cover and then security, immediate action plan, and medical, or SIM, is
addressed. Security is the priority; an immediate action plan is developed, including
communication with command and link-ups; and medical treatment is rendered.
When rendering medical treatment, the first priority is to complete a rapid bleeding, airway,
tension pneumothorax, hypothermia (BATH) assessment on each casualty to locate and treat
life-threatening injuries. After this, responders should determine the need for and their ability to
establish a casualty collection point (CCP). Responders may need to establish more than one
CCP. Casualties are then triaged inside the CCP.
Casualties should be reassessed after patient movement to ensure treatment is still in place and
working properly. If immediate evacuation is not possible, all casualties should be reassessed
from head to toe.

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Key Point: With the supplies available, prepare each casualty for
evacuation. Bandage all open wounds and splint all injured limbs
to the extent possible. Do not render secondary care if it will delay
evacuation.
Indirect Threat Care Goals

The following are goals of indirect threat care:
 Accomplish the mission with minimal casualties
 Prevent casualty from sustaining additional injuries
 Keep response team maximally engaged in neutralizing any existing threat, such as
active shooter, unstable building, confined space, or HazMat
 Minimize public harm
 Stabilize the casualty to permit safe extraction to dedicated treatment sector or
medical evacuation assets
Slide 5-5. Indirect Threat Care Warm Zone
Indirect threat care is rendered once the threat has been isolated, distracted, or neutralized and
the casualty has been moved to cover. Medical equipment is still limited to that carried into the
site by first responders and improvised from within the environment. The time known threats
have been neutralized to evacuation may range from a few minutes to many hours. In a mass
casualty situation, emergency services will be quickly overwhelmed and evacuation of
casualties may be delayed considerably.

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Key Point: During indirect threat care, keep in mind the following
basic management concepts:
 Security is the first priority.
 Immediately disarm injured persons who are unconscious
or whose mental state is altered.
 Indirect threat care allows for an assessment and more
thorough treatment of casualties.
 When rendering medical care, your weapon should be in its
holster or sling and you should use contact cover principles
as necessary.
 Your weapon should be in your hand when you are not
rendering medical care.
Slide 5-6. Indirect Threat Care Warm Zone
While in an indirect threat care environment, responders should constantly reassess injured
persons by performing quick head-to-toe physical examinations. The assessment should
include the casualty’s legs, arms, head, neck, chest, abdomen, pelvis, and back. It should
include a check for unrecognized hemorrhage and continued control of all sources of bleeding.
In this environment, responders should also establish a CCP, establish a safety cordon for
evacuation, facilitate evacuation of the injured, and return with logistical support.

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Assessment and Treatment of Life-Threatening Injuries
Slide 5-7. Initial Contact with Casualty
The indirect threat care medical priority is to assess and treat life-threatening injuries identified
as treatable in the field by first responders. This is accomplished by first performing a systematic
rapid BATH assessment.
Using BATH, responders identify and treat life-threatening bleeding, maintain an open airway,
monitor for signs of tension pneumothorax, and attempt to maintain the casualty’s body
temperature to prevent hypothermia.
Participant Note: The BATH acronym was developed by ALERRT

with the help of the US Marine Corps. The Marines use the
acronym BAT, which stands for bleeding, airway, and tension
pneumothorax. All medically trained Marines use this as a guide to
ensure that major treatable wounds are discovered.
The letter H was added to address the effects of hypothermia in

the trauma patient.
BATH is a change from the traditional airway, breathing, circulation (ABC) approach because it
focuses on blood loss, the number one injury during combat-like trauma.

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BATH: B, Bleeding
Slide 5-8. Bleeding
Stopping severe bleeding is the first priority. Responders should assess for obvious and
unrecognized hemorrhage and control all sources of significant compressible bleeding. This is
accomplished by using a medical director-recommended tourniquet on extremities or by using
wound packing and pressure dressing techniques on other areas of the body.
Participant Note: A tourniquet may have been applied during

direct threat care. If so, quickly assess its effectiveness and tighten
or apply additional tourniquets as needed.
To identify and treat severe bleeding, a rapid bleeding assessment must be performed. Focus
should be on compressible bleeds or areas of the body in which life-threatening bleeding can be
controlled. Responders must sweep the injured person’s body with their hands to detect
penetrating trauma. The initial bleeding sweep is performed while the casualty is clothed.
Wounds identified during the sweep are quickly exposed.

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Key Point: During your sweep, keep your fingers together.

Spreading your fingers allows gaps that could cause you to miss a
small entrance wound.
Blind sweeps only work well with clean gloves and adequate
lighting. When assessing a bleeding casualty, your gloves will
quickly become bloody. Do not rely on blind sweeps.
The assessment begins at the legs so that responders will immediately focus on the femoral
arteries. The initial sweep includes the front of the legs from the groin to the feet, rear of legs
from buttocks to feet, neck, focusing only on the sides of the neck in the area of the carotid
arteries and jugular veins, and arms from armpits and shooting pockets, or lateral subclavian
areas, to the hands.
Any severe bleeding found during the sweep of the legs, neck, and arms must be immediately
controlled with direct pressure or tourniquets. After severe bleeding has been controlled,
responders should sweep the chest, abdomen, and back for penetrating trauma.
All open or sucking chest, back, or abdominal wounds should be treated by immediately
applying an occlusive material to cover the wound and securing it in place. Monitor the casualty
for the potential development of tension pneumothorax.
Responders must also sweep the head for severe bleeding and apply appropriate direct
pressure to bleeds. Normal application of well-aimed direct pressure can be applied to head
wounds that do not compromise the integrity of the skull. Direct pressure should not be applied
to a wound that has broken or penetrated the skull. If the skull has been broken or penetrated,
the responder should control severe bleeding by locating the bleed and pinching the inner and
outer layers of the scalp between his or her finger and thumb. Pressure must be maintained for
five minutes or for three minutes if a hemostatic agent is used to aid in controlling the bleed.
Key Point: Remember the plus 1 rule when you find penetrating
trauma. Assume there is an exit wound until ruled out. Never
assume the exit wound will be directly opposite the entrance
wound.

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Bleeding Sweep Sequence
Slide 5-9. Bleeding Sweep Sequence
The bleeding sweep is intended to rapidly locate, within 30 seconds, all life-threatening bleeding
that can be controlled in the field and all torso wounds that compromise breathing. This includes
all severe bleeding located in a part of the body that is responsive to compression and all
penetrating trauma to the chest, back, or abdomen.
The following sequence is one way to quickly and methodically assess the casualty, with focus
on the areas most prone to exsanguination:
1. Place casualty on his or her back.
2. Approach from the feet of the casualty.
3. Kneel next to the casualty and look at and sweep the front of the legs from groin to feet.
4. Roll the patient towards you and look at and sweep the back of the legs from buttocks to
feet.
5. Roll the patient back to a flat position.
6. Look at and sweep the sides of the neck.
7. Look at and sweep the arms from armpits to hands and from shooting pocket to hands.
8. Immediately treat identified life-threatening bleeding as it is found with tourniquet
application or direct pressure.
9. Look at and sweep the chest and abdomen. If the casualty is wearing armor, loosen and
lift the armor to perform the sweep.
10. Roll the patient towards you and look at and sweep the back. If the casualty is wearing
armor, loosen and lift the armor to perform the sweep.
11. Apply occlusive dressing to penetrating wounds.
12. Look at and sweep the head.

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If the first responder is alone, the standard practice is as follows:

1. Complete the initial sweep of the legs, neck, and arms.
2. Immediately treat any severe bleeds by applying tourniquets or direct pressure.
3. Sweep the chest, abdomen, and back and apply occlusive dressings to penetrating
trauma.
4. Pack wounds that are being controlled by direct pressure and pressure points.
5. Sweep the head and treat bleeding.
If additional manpower is available, the responder performing the sweep will direct other
responders to apply tourniquets or direct pressure as wounds are found.
BATH: A, Airway
Slide 5-10. Airway

The chest, abdomen, and back were assessed for penetrating injuries during the bleeding
assessment. During the airway assessment, responders assess the casualty’s respiratory
function and work to maintain an open airway.
Signs of Respiratory Distress

Immediate medical attention is warranted if the responder suspects that a casualty is suffering
from breathing problems.
Appearance
Appearance is the general impression of the casualty. Often, responders can assess casualties
for signs of respiratory distress from a distance. The exception is if the casualty is not breathing
or minimally breathing; this requires hands-on assessment by the responder.

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A casualty’s appearance provides an indication of their overall condition, for example:

 Pale skin indicates lack of blood and oxygen to the tissue. Look for inadequate
breathing and bleeding.
 Blue skin indicates lack of oxygen to the tissue. Look for inadequate breathing and
bleeding.
 Fast breathing indicates lack of oxygen, similar to what occurs after running or due to
blood loss. It could also indicate hyperventilation or a psychotic state. Keep the
casualty calm and check for blood loss.
 Slow breathing could indicate that the casualty’s condition is quickly deteriorating
and immediate medical support is necessary.
 Irregular breathing indicates possible brain injury and requires immediate medical
support.
Breathing Effort
Immediate medical attention is necessary if
 the casualty is working very hard to breath,
 their neck muscles are sticking out,
 they are sitting upright with their hands on their knees in a tripod position, or
 they are using their abdominal muscles to breath.
Incomplete Sentences
A casualty speaking in incomplete sentences is an indication of breathing problems. Normally,
people speak in complete sentences without taking a breath. Responders should be concerned
if an injured person is not able to complete a sentence without taking a breath. If a person
cannot complete a sentence, responders should evaluate why this is occurring—were they just
running? Are they hysterical? Are they experiencing blood loss?
Audible Noises
Does the victim make unusual sounds when breathing? High pitched sounds, gurgling sounds,
raspy sounds, or coughing sounds indicate that the victim is in need of immediate medical
support.
Airway Treatment and Management

Because of the limited treatment options available to law enforcement first responders,
casualties exhibiting respiratory difficulty must be reported as a red patient. A rescue task force
(RTF) or extraction should be requested as soon as tactically feasible.

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Slide 5-11. Airway Treatment
Semi-Conscious or Unconscious Casualties

If a casualty is semi-conscious or unconscious, responders should use a modified jaw thrust
maneuver to open the airway and look for objects that may become obstructions. Remove
objects in the airway if they can be easily moved without pushing the object down the airway.
Responders trained in the nasopharyngeal airway (NPA) technique may employ that method if
approved by their medical director.
Following treatment, responders should place casualties in the recovery position.

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Slide 5-12. Modified Jaw Thrust
To perform the modified jaw thrust, grasp the angles of the lower jaw and lift with both hands,
one on each side, moving the jaw forward. If the casualty’s lips are closed, responders should
use their thumbs to push open the lower jaw.
Conscious Casualties
If a casualty is conscious, the responder should allow them to assume the position that best
protects their airway, including sitting up. Conscious casualties should be monitored and placed
in the recovery position if they become unconscious.
Participant Note: Instructors will address airway problems

resulting from tension pneumothorax during the discussion on the
T portion of the BATH assessment.

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Slide 5-13. Nasopharyngeal Airway
The NPA, also known as a nose hose or trumpet, has been successful in the war on terrorism. It
is well-tolerated by conscious patients. When inserting the device, take the following steps:
 Lubricate before inserting
 Insert at 90 degree angle to the face, not along the axis of the external nose
 Tape it in
 Do not use an oropharyngeal airway, or J tube
 Will cause conscious casualties to gag
 Easily dislodged

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Slide 5-14. Nasal Airway System
Slide 5-14 provides a diagram of the nasal airway system.
Slide 5-15. What is Wrong with this NPA Insertion?

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Discussion: What is wrong with this NPA insertion?
Slide 5-16. He is Awake and Alert. What do You Do?
Discussion: This patient is awake and alert. What do you do?

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Recovery Position for Airway Management
Slide 5-17. Indirect Threat Care Recovery Position
The positioning for indirect threat care is the same as it is for direct threat care. The difference
lies in the airway assessment performed before rolling the casualty into the recovery position. In
direct threat care, recall that responders simply roll any semi-conscious or unconscious casualty
into the recovery position and resume threat mitigation. In indirect threat care, responders have
time to open the airway, assess the casualty's breathing, insert an NPA if trained to do so, and
remove obstructions before rolling them into the recovery position.

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Slide 5-18. Moscow Theater Crisis
Example: On October 23, 2002, a group of heavily armed Muslim

extremists from the Russian province of Chechnya burst into a
Moscow theater during a performance and took more than 800
people hostage. A 57-hour standoff followed.
A total of 129 hostages died—two executed by terrorists and the

remainder from choking on vomit or swallowing their tongues. This
occurred because hostages, unconscious from the effects of
fentanyl gas, were carried out of the theater and placed with their
heads rolled back, face-up in the rain.

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BATH: T, Tension Pneumothorax
Slide 5-19. Tension Pneumothorax
Tension pneumothorax is the second leading cause of preventable death encountered by

responders. Causes of tension pneumothorax include the following:
 Open chest wound that closes due to clotting or flaps of tissue resulting in trapped air
 Blunt force trauma that causes lung laceration
 Open chest wound covered by an occlusive dressing resulting in trapped air

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Slide 5-20. Pneumothorax
Definition: Pneumothorax or air in the chest cavity is a condition

in which air has entered the chest cavity outside the normal
respiratory tract.
Air is normally contained in the lungs, but chest trauma may cause damage to the lung. This
results in air leaking out of the lung and into the surrounding chest cavity, or thorax. As air
continues to fill this space, the damaged lung will collapse.
Participant Note: For the purpose of this course, pneumothorax

tension pertains to blunt or penetrating trauma.

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As air leaks and pressure builds, the casualty will begin to exhibit signs of respiratory distress,
primarily shortness of breath. Soon the air outside the lung will completely fill the affected side
of the chest and begin to exert pressure on the heart and opposite lung creating the condition
known as tension pneumothorax.
Definition: A tension pneumothorax exists when pressure goes

uncorrected and begins to apply tension on the heart, great
vessels, and opposite lung, ultimately leading to death.
In penetrating trauma, air can enter the chest cavity outside the damaged lung from one or two
sources: air exiting the damaged lung and the hole in the chest wall. Responders can
temporarily fix a hole in the chest wall with an occlusive dressing, but they cannot correct
damage to the lung. An occlusive dressing helps; however, tension pneumothorax is still likely
to occur because of air entering the cavity from the damaged lung.
Participant Note: It is possible to develop a tension

pneumothorax in the presence of a penetrating chest wound
without the application of a chest seal. In some cases, the tissue
surrounding the injury will act as a one way flap, allowing air in but
blocking its exit.
In blunt trauma, air enters the chest cavity outside the lungs from only one source, the damaged
lung. The lung can become damaged as a result of blunt force trauma that breaks ribs and

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lacerates the lung or from blast trauma popping a lung. This causes air to enter the chest cavity,
possibly developing into a life-threatening tension pneumothorax.
Slide 5-22. Tension Pneumothorax Demonstration
Tension pneumothorax is not a condition that is normally present during a responder’s initial
assessment. This is because tension has not developed to a level that results in severe
shortness of breath. Responders must understand the mechanisms that can lead to a tension
pneumothorax and recognize casualties that are likely to develop one. Consider a tension

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pneumothorax in any casualty involving respiratory distress, hypotension, and known or

suspected torso trauma.
With penetrating trauma, the treatment, an occlusive dressing, can lead to a tension
pneumothorax. This is because the hole, if making an audible sucking sound on inhalation, is
allowing air to enter the chest cavity and allowing air to exit the chest cavity on exhalation. The
occlusive dressing will close the hole and trap the air inside the chest wall. This, however, is not
a reason to withhold an occlusive dressing.
Without the occlusive dressing, airflow to the uninjured lung is compromised. Air travels the path
of least resistance, so if air is entering through the open chest wound, it is not entering through
the trachea. With a sucking chest wound, as the chest expands on inhalation, air enters the
penetrating injury, not the trachea and lungs. While the occlusive dressing may lead to tension,
it is necessary to restore normal respiratory function to the uninjured lung.
Key Point: Once an occlusive dressing is applied, remember to

constantly monitor the casualty because tension build up is likely.
When assessing your patient for tension pneumothorax, consider the mechanism of injury. Does
the patient have an injury that could lead to a tension pneumothorax, such as penetrating
trauma to the chest, back, or abdomen or blunt trauma to the chest or back? Penetrating trauma
to the abdomen could penetrate the diaphragm and allow air to enter the chest cavity.
The best indication of increasing tension is the patient’s breathing ability. A conscious patient
will become increasingly short of breath, anxious, and ultimately panicked. An unconscious
patient who initially appears to have normal respirations will develop rapid, shallow respirations.
Other signs may include the following:

 Pale skin and bluish lips
 Absent breath sounds over the affected area because the lung has collapsed and air
cannot be heard entering the lung
 Jugular vein distention
 As the tension increases, heart function is inhibited, resulting in blood flow backing
up into the jugular veins.
 Tracheal deviation
 The tension or pressure has built to the point where the heart and lungs are being
displaced towards the uninjured lung. The trachea extends into the mediastinum and
attaches to the lungs via the bronchi. As pressure builds, the trachea is also pushed
towards the uninjured side, deviating from its normal midline position.
 This is a very late sign.

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The goal in treating a tension pneumothorax in the field is to release the buildup of air pressure
or tension. This is a temporary fix in the field that may have to be repeated several times before
a patient can be delivered to definitive care.
The first option, and currently the only option for responders not trained in needle
decompression, is to burp the occlusive dressing. This involves pulling back the occlusive
dressing from the open chest wound. The hope is that a clot has not formed and that pressure
will vent through the open hole. If the wound has clotted, the clot may be disrupted when the
occlusive dressing is pulled back. It is also possible that the clot will not be disrupted and the
pressure will not vent. In this case, immediate needle decompression or chest tube placement is
necessary.
Needle decompression involves inserting a 3 ¼-inch, 14 gauge catheter into the chest wall to
relieve built up pressure. This technique requires additional training and medical director
approval.
Chest tube placement is an advanced skill that requires certification at the paramedic level or
above and medical director approval.
Key Point: Tension pneumothorax patients are red patients.

Remember that any patient with torso trauma may also have non-
compressible bleeding.

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BATH: H, Hypothermia
Slide 5-25. Hypothermia
Based on extensive research of casualties from the war on terror over the last decade, it has
been documented that hypothermia plays a significant role in victim recovery and survivability.
Hypothermia significantly increases the time required for the clotting cascade to stop bleeding
and in severe cases, the clotting cascade is completely blocked. By preventing hypothermia in
the field, responders greatly increase the chance of survival and decrease recovery time. (Butler
et al 2014)
Hypothermia prevention is especially important for casualties with non-compressible bleeding.
Definitions: Hypothermia is defined as low body temperature

which is any temperature below normal, 98.6°F.
Significant hypothermia is defined as a body temperature below

95°F and severe hypothermia is defined as a temperature below
90°F.
Clotting cascade is the formation of a clot to stop bleeding.
If a patient’s body temperature falls below 95°F, clotting is significantly prolonged. If it falls
below 92°F, natural clotting cannot occur. This is significant because as a patient loses blood
they also begin losing the ability to produce heat and regulate body temperature. Moderate to
severe blood loss can quickly lead to hypothermia. A patient with internal non-compressible

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bleeding who becomes hypothermic loses their primary defense against blood loss—forming a
clot.
Responders should attempt to prevent loss of body heat by actively warming hemorrhage
patients to maintain a body temperature near 98.6°F.
Passive and Active Warming
Slide 5-26. Hypothermia Treatment
Preventing and treating hypothermia involves taking actions to maintain the patient’s body
temperature at or near 98.6°F. This includes passive and active warming.
The following is a list of ways to implement passive warming:

 Minimize casualty’s exposure to the elements. Clothing and protective gear removed
during assessment and treatment should be put back on as soon as possible.
 Replace wet clothing with dry, if possible.
 Cover the casualty with anything that will help maintain body temperature, including
blankets, jackets, curtains, or towels.
 Place the casualty on an insulated surface or place insulating material such as
blankets between the ground and the casualty as soon as possible. Avoid leaving the
casualty on concrete due to the rapid conduction of heat away from the body.
 Cover the head and neck, as significant amounts of heat are lost from these areas.
 Use commercially-available heat reflective devices, such as survival blankets.

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The following is a list of ways to implement active warming:

 Use commercial hypothermia warming devices such as the Hypothermia Prevention
and Management Kit (HPMK) recommended in the tactical combat casualty care
(TCCC) guidelines.
 Sustains six hours of continuous dry heat to 106ºF with oxygen-activated, self-
heating liner
 No external power supply required
 Heat reflective shell with built-in hood
 Self-heating shell liner
 Plastic vacuum bag
 Packaged HPMK: H 6.75 in. x W 10.5 in. x D 5.5
 Turn on the heat in the room or vehicle where the casualties are located.
 Apply heat packs to the groin, armpits, and back of neck.
Examples of Active and Passive Warming
This slide shows a casualty using a heat reflective blanket. Is this an example of passive or
active warming?

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Slide 5-28 Hypothermia Treatment
This slide shows the use of heat packs on the neck, armpit, and groin. Is this an example of
passive or active warming?
This slide shows a casualty using an HPMK. Is this an example of passive or active warming?

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BATH Summary
Slide 5-30. BATH Summary
Bleeding
 Sweep for life-threatening, compressible hemorrhages and apply tourniquets, direct
pressure or pressure points to control severe bleeding.
 Sweep the torso for open wounds and cover them with occlusive dressings.
 Treat life-threatening hemorrhages not amenable to tourniquet application with
wound packing.
Airway
 Open the airway.
 Place unconscious persons in the recovery position.
 Place conscious persons in the position in which they are most comfortable.
Tension Pneumothorax
 Suspect tension with all torso injuries.
 Burp the chest seal if breathing worsens.
Hypothermia
 Provide passive and active warming to critical patients.

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Slide 5-31. BATH Assessment
Slide 5-32. BATH Activity

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Lifesaving Interventions
Slide 5-33. Lifesaving Interventions
Based on the BATH approach, this portion of the module will focus on the lifesaving
interventions that are performed to treat injuries identified in the assessment, including:
 Tourniquets
 Direct pressure and pressure points
 Wound packing and junctional tourniquets
 Airway positioning
 Tension pneumothorax decompression
 Hypothermia prevention
Establishing SIM is the first priority in performing lifesaving interventions in indirect threat care
environments. Security must be established prior to assessing wounds. An immediate action
plan should be established in conjunction with security and medical assessment. Medical
assessment and treatment can be conducted after the threat is isolated, distracted, or
neutralized.

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Interventions for Controlling Bleeding
Slide 5-34. Controlling Bleeding
The leading cause of preventable death in combat is blood loss from compressible bleeds. For
this reason, this course focuses heavily on controlling severe compressible bleeding. In both the
direct and indirect threat care environments, tourniquets are the number one defense against
exsanguination from severe extremity bleeding. The guidelines for direct threat care tourniquet
application are the same during indirect threat care for initial casualty contact.
How should first responders treat severe compressible bleeding in an area not amenable to
tourniquet application? These types of wounds are typically referred to as junctional wounds
because they are located at the junction of an extremity and the torso. In these instances, direct
pressure or pressure points may help to temporarily slow the bleeding. Without specialized
adjuncts for junctional wounds, stopping the bleeding requires wound packing.

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Direct Pressure
Slide 5-35. Well Aimed Direct Pressure
Effective direct pressure at the point of injury or applicable pressure point is the quickest way to
control compressible bleeding. This approach does not require adjuncts. When possible, a team
approach to bleeding management is best. One person applies direct pressure at the point of
injury or using a pressure point while the second person applies a tourniquet or packs the
wound.
Direct pressure can be effective in controlling compressible bleeding but only if well-aimed at
the point of bleeding.
Temporary direct pressure can be accomplished with your fingers, thumb, or knee. Longer term
direct pressure can be applied to a wound with gauze and a pressure bandage.
Direct pressure has very limited application during direct threat care but can be extensively used
in indirect threat care and evacuation care. Direct pressure use during direct threat care is
limited to temporary control of bleeding while a tourniquet is applied. Direct pressure use during
indirect threat care or evacuation care includes temporary control of bleeding during tourniquet
application, control of minor or moderate bleeding not requiring a tourniquet, and control of
severe bleeding not amenable to tourniquet application.
Direct pressure is administered by applying firm pressure directly above the wound in the
direction of the underlying bone. If the wound is deep, the responder will need to insert one or
more fingers into the wound channel to locate the severed artery and apply firm pressure in the
direction of the underlying bone. Minor bleeding can be controlled with the application of a
pressure bandage.

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Key Point: Moderate wounds may require wound packing. Severe

wounds will require wound packing.
Clot Formation: Mother Nature’s Response to Bleeding

A clot is a plug that fills a hole. An initial weak clot can form in as little as five minutes. A strong
plug will form after at least 30 minutes of wound pressure. After 45 minutes of wound pressure,
the plug will be at maximum strength. Responders should exercise care when transporting a
casualty. If moving the casualty, it is important to immobilize limbs using a splint. Rough
handling of the clot, movement of the limb, or joint flexion or extension may cause disruption of
the clot.
Types of Bleeding Wounds
Slide 5-36. Types of Bleeding Wounds
Responders encounter two types of wounds: compressible and non-compressible.

Compressible wounds are treatable with well-aimed direct pressure. Direct pressure cannot be
used to treat non-compressible wounds.

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Compressible Wounds
Slide 5-37. Compressible Wounds
Compressible wounds are treatable with well-aimed direct pressure and tourniquets. They are
located on the arms, legs, neck, groin, buttocks, armpits, and lateral subclavian areas, known as
shooting pockets.
When treating compressible wounds, responders should expose and observe the wound by
removing the patient’s clothing and protective equipment. Removing obstructions ensures that
direct pressure will be effective and that wound dressing will be conducted properly. Once the
wound has been treated, protective equipment can be put back on the victim.
Key Point: It is important that only one side of the neck is

compressed at a time. Also, never compress the front of the neck
because you will crush the wind pipe.

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Non-Compressible Wounds
Slide 5-38. Non-Compressible Wounds
Non-compressible wounds are those wounds that cannot be controlled using well-aimed direct
pressure or tourniquets. These wounds are typically penetrating trauma to the torso. Non-
compressible wounds are located inside the head, chest, and abdomen. Patients with these
types of wounds will require surgery and must be transported to a medical facility as quickly as
possible.
A head injury that involves a skull fracture or penetrating trauma is a non-compressible wound.
Superficial cuts and lacerations to the face and head without a skull fracture or penetrating
trauma can be treated as a compressible wound.
The chest and abdomen are non-compressible wound sites. This is because direct pressure
cannot be applied and because vital organ function would be adversely affected if wound
packing was attempted. These wounds are life-threatening. It is imperative that responders
recognize a non-compressible wound and remove that casualty as soon as possible.

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Pressure Points
Slide 5-39. Pressure Points
Pressure points may be useful in controlling severe bleeding until a tourniquet can be applied or
wound packing can be performed. The key to successful pressure point use is the presentation
of the artery, not the amount of pressure applied. While pressure is important, if the artery is not
exposed to the pressure, bleeding will not be effectively controlled.
Key Point: Proper placement, not excessive force, is the key to

successful direct pressure at a pressure point. Force cannot
overcome application of pressure in the wrong location.
This course focuses on two main pressure points: the brachial and the femoral. The brachial
artery can be occluded with knee pressure or finger pressure using a c-clamp grip. The femoral
artery is most commonly occluded using knee pressure; however, depending on the size of the
patient versus the size of the officer, adequate pressure may be achievable with the palm.
How to Apply Pressure

To apply knee pressure, face the victim and straddle the victim’s extremity, use your inside knee
to apply the pressure. For injuries to the victim’s right extremities, use your right knee, for
injuries to the victim’s left extremities, use your left knee.
The key to effective pressure point application is to expose the artery. The femoral and brachial
arteries run along the inside surface of the extremity. To expose the artery, place the patient on
his or her back and rotate the limb outward.

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Brachial Artery
To expose the brachial artery, rotate the palm up to expose the inner surface of the bicep. Place
your four fingers at the base of the inner bicep where the muscle meets the bone, up high near
the armpit. Using your thumb on the opposite side of the bicep, apply pressure in a c-clamp
fashion. A good landmark for the brachial artery is just below the junction of the pectoralis
(chest) muscle and the bicep.
To aide in locating the correct position when using knee pressure, begin with the knee on the
bicep up high near the armpit then slide your knee downward until you see the bleeding stop.
The artery runs along the bone where the bicep muscle and bone meet.
Femoral Artery
For the femoral artery, rotate the foot outward so you can access the inner surface of the thigh.
To further expose the inner surface of the thigh, bend the knee at about a 45 degree angle while
turning the foot outward. This presents you with a large flat surface where you can place your
shin bone perpendicular to the surface of the thigh and quickly occlude the femoral artery.
Begin by placing your knee on the thigh muscle and moving it down towards the bone until
bleeding stops. Femoral artery pressure should be applied about halfway down the width of the
inner thigh where the thigh muscle meets the bone and close to the junction of the leg and
pelvis.

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Exsanguination
Slide 5-40. Exsanguination
Because blood loss is the leading cause of preventable battlefield death, it is helpful to identify
specific treatments that first responders can perform to treat such injuries. Exsanguination
injuries are categorized as truncal, junctional, or extremity.
Prior to Operation Iraqi Freedom and Operation Enduring Freedom, the leading cause of
potentially survivable death was extremity exsanguination. With the widespread use of
improvised explosive devices by our enemies over the last decade, junctional injuries have
become the new leading cause of potentially survivable death for non-medic first responders.
Many torso or truncal injuries can now be successfully treated in the field. (Eastridge et al 2012)
Emphasis on TCCC training and the widespread dissemination of commercial tourniquets to all
deploying Soldiers, Sailors, Airmen, and Marines have had a positive effect on battlefield
injuries. Since the focus on early tourniquet application in the field, deaths due to extremity
exsanguination have been reduced by 70%.
The 75th Ranger Regiment has had even greater success in reducing the occurrence of deaths
from potentially survivable wounds. They have demonstrated what can be done when science,
technology, and training combine. The science confirmed the need for early tourniquet
application, technology allowed for the development of effective tourniquets, and the Rangers
implemented an aggressive TCCC training program for every Ranger. Because of this
aggressive approach, the Army Rangers have nearly eliminated deaths on the battlefield from
extremity exsanguination.

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Today, the focus is on improving the survival rate for the more severe, difficult to control
junctional hemorrhages. Junctional injuries involve compressible bleeding that cannot be
stopped with a standard tourniquet but can be controlled by the non-medic first responder.
Junctional Hemorrhage
Slide 5-41. Junctional Hemorrhage
Definition: For the purpose of this course, junctional hemorrhage

is defined as a compressible bleed that occurs at the junction of an
extremity and the torso at an anatomic location that precludes the
effective use of an extremity tourniquet to control the bleeding.
Junctional hemorrhages include bleeding from the

 groin;
 buttocks, gluteal and pelvic areas, and perineum;
 axilla, shoulder girdle, and the base of the neck; and
 sites too high on a limb for effective use of extremity tourniquets.
Junctional hemorrhages are compressible hemorrhages. Compressible hemorrhage can be

controlled in the field. Several devices have been developed that have proven effective in
controlling junctional hemorrhage; however, it is unlikely that front line law enforcement officers
will have access to these devices. It is imperative that each officer participates in hands-on
wound packing training.
Specialized teams may find it beneficial to purchase a junctional tourniquet for their team.

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Slide 5-42. Junctional Arteries
Knowing the location of the femoral artery is useful when trying to find a pulse or place a
junctional tourniquet. It can also be used to apply digital pressure in an attempt to stop bleeding
when other methods have failed.
Slide 5-43. Vascular Anatomy of the Abdomen and Groin
The aorta and femoral arteries are especially vulnerable to blood loss because the upper thigh
and groin are not covered by body armor. The aorta can be compressed near the umbilicus
(belly button). The femoral arteries can be compressed in the groin.

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Slide 5-44. Junctional Arteries
Slide 5-44 shows a diagram of junctional artieries.
Slide 5-45. Junctional Wound
Slide 5-45 contains a photo of a junctional wound.

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Slide 5-46. Junctional Tourniquets
Slide 5-46 shows four types of junctional tourniquets.

1. AAT – Abdominal Aortic Tourniquet
2. SJT – SAM Junctional Tourniquet
3. JETT – Junctional Emergency Treatment Tool
4. CRoC – Combat Ready Clamp

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Slide 5-47. Legacy Tourniquet
Slide 5-47 shows the legacy tourniquet. Modern junctional tourniquets are similar to surgeons’
tourniquets used in the Civil War.
Wound Packing
Slide 5-48. Wound Packing
Indication for Wound Packing

Wound packing is performed during the indirect threat care phase. It is used to control severe
bleeding that is compressible but not amenable to tourniquet application, such as junctional

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bleeds. These bleeds should be identified and treated during the BATH assessment. Wound
packing can also be used by field medical personnel when attempting to remove tourniquets.
How it Works
Wound packing is performed by applying well-aimed direct pressure to an artery from inside the
wound. As the wound cavity is filled with tightly-packed gauze; direct pressure is placed on the
artery.
Danger Areas and Non-Compressible Bleeding

Wound packing should not be performed on the following areas:
 Chest
 Filling the chest cavity with gauze will compromise the function of the heart and
lungs.
 Abdomen and back
 The objective of wound packing is to apply well-aimed direct pressure from the inside
out. It is not possible to identify the point of bleeding in an abdominal or back wound.
Blindly filling the abdomen with gauze will harm vital organs.
 Head
 Attempting to pack gauze into the skull will compromise the brain.
Methods for Effective Wound Packing
Slide 5-49. Effective Wound Packing
The goal of wound packing is to fill the wound cavity tightly with gauze and to apply pressure
against the damaged artery. When a bullet enters the body, the circumference of the internal
damage is typically significantly greater than the circumference of the entrance wound.
Responders must remember to pack the wound so that gauze fills the inner wound channel.

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Responders should pack the entrance wound and the exit wound, if one exists, to gain control of
bleeding.
Wound packing can be accomplished with standard gauze; however, hemostatic agents have
been proven to be an effective adjunct in controlling junctional hemorrhage. If available, TECC
recommends the use of a hemostatic agent with wound packing. With or without a hemostatic
agent, the goal is to apply gauze to the point of bleeding and pack the wound tightly.
Slide 5-50. Video: Quikclot
Wound Packing Steps
Slide 5-51. Pack the Wound

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Step 1
Expose the wound and insert your fingers into the wound to apply direct pressure at the point of
bleeding. Use caution when inserting fingers into the wound due to the possibility of bone
fragments. Cautiously but quickly feel for bone fragments and move your fingers over them to
the point of bleeding.
Step 2
Next sweep away pooled blood from the cavity and look to see if blood re-enters the void. If it
does not, move on to next step, inserting gauze. If blood pools in the void, move your fingers
further up into the wound, apply pressure, and perform another blood sweep. To apply more
surface area pressure with your fingers at the point of bleeding, advance them up into the
wound and then turn your fingers at approximately a 45 degree angle to the bone as you apply
pressure. Once you have gained control of the bleeding and blood is no longer pooling in the
injury cavity, maintain control and constant pressure at the point of bleeding.
Step 3
Pack the wound by inserting bites of gauze all the way to the point of bleeding. Insert two to
three bites of gauze and then stop to re-assess your control of the bleeding. If you have
maintained control, continue packing the wound. Bites of gauze should be wrapped over the
front of your fingers to ensure it is inserted to the point of bleeding.
After the initial two or three bites of gauze have been inserted and re-assessment reveals
reoccurrence of bleeding, the two or three bites of gauze will be pushed further up into the
wound cavity to regain control of the bleeding. Bleeding control will again be assessed by
sweeping the pooled blood away. Once controlled, packing will resume.
Step 4
Pack the entire void until gauze is protruding from the wound. This may require several rolls of
gauze.
Step 5
Apply a minimum of 3 – 5 minutes of direct pressure (3 minutes if using hemostatic gauze and 5
minutes if using standard gauze) before attempting to apply a pressure bandage.
Step 6
Apply a pressure bandage.
If you are unable to quickly gain control of the bleeding in step 1, begin blind wound packing.
Blind wound packing is used when the direct control method is unsuccessful. Spend no more
than 15 seconds attempting primary method before moving to blind packing. The blind packing
technique involves completely filling the void with gauze tightly and quickly followed by three to
five minutes of direct pressure. The groin is the most common area to require the blind packing
technique.

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During the first 30 – 45 minutes following wound packing, any movement can dislodge the
packing from the artery. If possible, these casualties should be carefully placed on a backboard
or similar device for extraction.
Hemostatic Agents
Slide 5-52. CoTCCC-Recommended Hemostatic Agents
Hemostatic agents have been proven to be an effective adjunct in controlling severe bleeding in
compressible wounds. Their use is recommended by TECC and TCCC. There are many
hemostatic agents on the market today. The three listed in this course were selected by TECC
and TCCC because they are Food and Drug Administration-approved; have been extensively
researched; including by the US Army Institute of Surgical Research, and have been proven
effective on the battlefields of Afghanistan. Combat Gauze remains the mainstay of the US
military.
The difference lies in the mechanism of action of the agent impregnated into the gauze. There
are three mechanisms:
 Concentrators absorb water from the blood and concentrate the clotting factors.
 Pro-coagulants activate the clotting cascade or provide clotting factors such as
fibrinogen and thrombin.
 Mucoadhesives cross link cellular blood components to form a mucoadhesive
barrier.
Combat Gauze is impregnated with Kaolin, a non-organic mineral which acts as a concentrator
and pro-coagulant by absorbing water and aiding in activating the casualty’s own clotting

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factors. It has been studied extensively by the civilian and military medical communities and has
been proven effective in battlefield trauma application.
Celox and ChitoGauze are impregnated with chitosan, an organic component derived from the
shells of crustaceans, which forms a mucoadhesive barrier independent of the casualty’s own
clotting mechanism. These have been studied extensively by the civilian medical community
and have been proven effective in battlefield trauma application.
Celox and ChitoGauze where added as approved hemostatic agents by the US military and
have been selected for frontline use by many US civilian hospitals and the British military.
Earlier versions of chitosan-based products had a significant occurrence of severe allergic
reaction, which limited their use. Technological advances have eliminated this threat and
rendered these products safe.
Combat Gauze has proven effective in quickly aiding in clot formation; however, its
effectiveness is severely degraded in the absence of the casualty’s own clotting factor.
Chitosan-based products work in the absence of the casualty’s clotting factor and therefore
have been shown to be more effective in treating casualties with degraded clotting ability. This
could be due to hypothermia, significant blood loss, or casualties who have taken blood thinners
or aspirin. Many medical directors have selected these products because they accommodate a
diverse patient population.
To date, there is no single hemostatic agent that has all the ideal characteristics for battlefield
trauma; however, these three products have been proven to be safe and effective in aiding in
the control of severe hemorrhage.
Key Point: Use the hemostatic agent approved by your medical

director.

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Slide 5-53. Hemostatic Agents
Hemostatic agent research continues to advance. First generation agents proved effective in
controlling bleeding but had severe side effects. They created excessive heat on contact with
the blood causing burns. They had the potential for severe allergic reaction. They were granular
and therefore created the potential for embolism. Improper use could lead to diffuse burns when
poured into a wound.
Today’s hemostatic agents have addressed these shortfalls. They are normothermic, meaning
that they do not change the temperature of the surrounding area when applied and are non-
allergenic and non-granular.
Research continues in an effort to improve the effectiveness of hemostatic agents and their
application method. There is promising research into effectively introducing the naturally
occurring clotting agents, fibrinogen and thrombin, directly to the injury site.
NuStat is a new hemostatic agent that has recently been developed. It is a proprietary blend of
biocompatible regenerated cellulose- and silica-based fibers with inherent hemostatic
properties. The specialty fibers are knitted together into a flexible dressing that can provide
compression to restrict blood flow while allowing the patient’s clotting factors to contact NuStat's
hemostasis enhancing fibers.

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Slide 5-54. Practical Exercise
Chest Wound Types
Slide 5-55. Chest Wound Types
Chest trauma is often lethal and is difficult to treat in the field. The best course of action is to
prevent trauma by wearing body armor.

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Definitions: Open chest wounds are injuries to the torso area that
are caused by penetrating trauma, such as bullet, knife, or spear
injuries.
Closed chest wounds are injuries to the torso that are caused by
blunt force and do not penetrate the torso. These injuries can be
caused by objects such as baseball bats, clubs, 2”x4” boards, and
steering wheels.
Sucking Chest Wounds
Slide 5-56. Sucking Chest Wound
A sucking, or open chest wound is caused by penetrating trauma. A foreign object enters the
chest wall and punctures the lung, allowing air to enter the space between the injured lung and
inner chest wall by escaping through the puncture into the chest cavity or entering through the
hole in the chest wall. As the victim inhales, air can be drawn in through the hole in the chest
wall causing the classic sucking sound. Treatment is the same whether or not this sound is
audible.
It takes a hole in the chest about the size of a nickel or bigger for this to occur. Air travels the
path of least resistance. When the casualty inhales, there are now two pathways open for the air
to enter: the injury site and the trachea. If the hole in the chest is the size of a nickel of bigger,
the path of least resistance becomes the hole in the chest. In this instance, air flow to the
unaffected lung is degraded. A sucking chest wound must be covered to restore the negative
pressure gradient created with inspiration to improve air flow into the uninjured lung. The
immediate effect of sealing the sucking chest wound will be improved ventilation; however, air
escaping from the injured lung can result in a tension pneumothorax.

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Sucking Chest Wound Treatment
Slide 5-57. Open Chest Wound Treatment
Open or sucking chest wounds should be treated by immediately applying an occlusive material
to cover the injury and taping it to the chest on all sides. Initially, responders may use their hand
to cover the injury. An occlusive dressing can be anything that will stop air from entering the
opening, including plastic from a bandage wrapper, aluminum foil, petroleum gauze, or
commercial chest seal. If an occlusive dressing is not readily available, use gauze or other
material to cover the wound and block air passage.
Unconscious patients should be placed in the recovery position on their affected side. This
allows easy expansion of the unaffected lung. Conscious patients should be allowed to assume
any position they feel best aides their breathing.
Responders should assume that sucking chest wound patients also have internal bleeding and
should treat them passively and actively for hypothermia to the extent the situation and
resources allow.
Any patient with chest or back trauma must be constantly monitored for the development of a
tension pneumothorax. These are considered red patients.

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Participant Note: If your department is going to purchase

commercial chest seals, be aware that TECC and TCCC
recommends the use of a vented chest seal to reduce the
likelihood of developing a tension pneumothorax.
If your department already has chest seals that are not vented,
TECC advocates their continued use. C-TECC concluded that it is
not often that an officer would be in a situation in which medical
support is not readily available. Therefore, by the time tension
could occur, medics would be available to assist.
Slide 5-58. Sucking Chest Wound
Slide 5-58 shows a photo of a sucking chest wound, also known as an open chest wound.

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Closed Chest Injury Treatment
Slide 5-59. Closed Chest Injury Treatment
Responders must assume that a casualty with significant blunt chest or back trauma has
internal bleeding and should categorize such casualties as red. Damage to the lungs through
contusion or puncture, from injuries such as broken ribs or over pressure, will result in breathing
difficulty. Medical care involves airway support, hypothermia prevention, and priority evacuation.
For unconscious patients with obvious blunt chest trauma, responders must open the airway
using the modified jaw thrust maneuver and observe for easily removable objects. Patients
should then be placed in the recovery position on their affected side. Responders should assist
conscious patients into a position of comfort.
Patients should be kept warm to prevent hypothermia and should be monitored for difficulty
breathing, which is a sign of tension pneumothorax. When monitoring unconscious patients for
tension pneumothorax, responders should watch for increasingly rapid, shallow respirations. For
closed chest wounds, responder action for addressing tension pneumothorax is limited to
notifying command of the need for immediate medical intervention.

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Special Considerations in Indirect Threat Care
Slide 5-60. Special Considerations
Tourniquets
In direct and indirect threat care, tourniquets are applied quickly with the goal of stopping
bleeding. During indirect threat care, after all life-threatening injuries have been addressed,
tourniquets should be re-assessed for effectiveness in blocking distal circulation.
Participant Note: Recall that distal circulation means blood flow

below the tourniquet.
This is done by feeling for a radial or pedal pulse. Distal pulse checks are used to determine if
the tourniquet is appropriately applied and is cutting off all circulation below the level of the
tourniquet. Distal pulse checks are normally performed at the radial pulse in the wrist for the
upper extremities and the posterior tibial artery or dorsalis pedis artery in the lower extremities.
If you are unfamiliar locating pulses particularly the pulses in the lower extremities, simply
perform a capillary refill check by grasping a fingernail or toenail on the affecting limb and
squeeze until the nailbed becomes pale in color. Release the nailbed and observe for 5 to 10
seconds. If the nailbed remains pale the tourniquet is properly applied. If the nailbed returns to
a reddish color blood is still getting past the tourniquet
If the pulse is still present, tighten the existing tourniquet or apply a second tourniquet. It is
possible to stop the bleeding without cutting off all blood flow to the extremity, which is
determined by checking for a distal pulse. If this is left uncorrected, the possibility of long-term
extremity damage secondary to the tourniquet is greatly increased.

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Slide 5-61. Distal Pulse Checks
After all casualties have been assessed and treated for life-threatening injuries, time and
manpower permitting, responders should expose extremity wounds treated with tourniquets
applied over clothing and apply an additional tourniquet directly over the skin. This improves
tourniquet security and function during patient movement. Additional tourniquets should be
applied according to standard protocol: close to the first tourniquet without overlapping.
If the BATH assessment reveals severe swelling in the thigh or a closed fracture of the femur,
responders should apply a tourniquet following the direct threat care guidelines. Closed femur
fractures can lacerate arteries resulting in severe bleeding inside the upper leg. It is possible to
lose a third of blood volume from a femur fracture without any external bleeding.
Occlusive Dressings
Occlusive dressings are used to prevent air from entering a wound. They are primarily used to
cover chest or back wounds but are also used to cover abdominal and neck wounds.
Key Point: The boundaries for using an occlusive dressing are

from the chin to the navel.
Any wound found from the chin to the navel should be sealed with an occlusive dressing. As
with a chest or back wound, neck and abdomen wounds also require occlusive dressing to
prevent air entry. Without knowing the exact trajectory and travel of a penetrating object that
enters the abdomen, diaphragm damage cannot be ruled out. If the diaphragm is damaged, air
entering the abdomen can make its way into the chest cavity and result in a tension

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pneumothorax. Neck wounds also require an occlusive dressing because air entering the large
neck veins or arteries could result in an embolism.
Slide 5-62. Occlusive Dressings
Evisceration
Evisceration is a wound characterized by bowels protruding from the abdomen. Treatment for
these wounds involves carefully containing the eviscerated bowel without puncturing it. The
bowels should be covered with a wet dressing followed by an occlusive material and lightly
bandaged in place. The goal is to contain the bowel and keep it moist. First responders may not
have the resources to accomplish this, but should notify command and attempt to contain the
bowel without causing further damage.
Burns
The first priority for this type of casualty is to stop the burning. Burn casualties are in danger of
going into shock, developing airway problems, and becoming hypothermic. Responders should
use their best judgment to determine if this is a delayed or immediate patient using these
guidelines:
 Any casualty with burns to the face is in danger of losing their airway and is an
immediate patient
 Any casualty with burns greater than 20% of the body surface area is an immediate
patient
 1% is about the size of the casualty’s palm, 20% is about the area of the chest and
abdomen or the area of the back
 Any patient with circumferential burns to the chest and back is an immediate patient
Responders should place unconscious and semi-conscious patients in the recovery position and
cover burns with material such as a dry sheet and prevent hypothermia.

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Participant Note: Treating severe burn patients for hypothermia

may seem counterintuitive; however, these patients lose the ability
to regulate their temperature and can quickly become hypothermic.
Reassessment and Secondary Assessent
Slide 5-63. Reassessment

Reassessment is an ongoing priority. Tourniquets, wound packing, and occlusive dressings may
be disrupted each time a patient is moved. Responders should reassess patient status and
treatments as follows after movement and every five minutes:
 Perform a BATH assessment and check for life-threatening conditions.
 Check tourniquets for effectiveness and tighten or apply additional tourniquets as
necessary.
 Check wound packing to ensure bandaging is still applying adequate pressure to
block the distal pulse.
 Check occlusive dressings for effectiveness in sealing the wound.
 Open the airway and place patient in the recovery position or position of comfort.
 Evaluate the patient for signs of tension pneumothorax and treat as necessary.
Consider hypothermia and maintain body temperature near normal.

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Slide 5-64. Secondary Assessment and Treatment
The secondary assessment is used to find and treat any non-life-threatening injuries that were
not addressed during the rapid BATH assessment. This includes bandaging wounds, splinting,
and packaging patients for movement during evacuation.
The secondary assessment is the methodical head-to-toe evaluation of the casualty for
unidentified wounds. To perform this evaluation, responders should
 begin at the head and work down the front of the patient feeling and looking for
bleeding or deformity;
 if the patient is conscious, elicit a pain response as you feel each part of the body;
 check the front of the patient, moving from the head, to the neck, chest, abdomen,
pelvis, legs, and arms; and
 roll the patient to check the back, buttocks, and rear of the legs.
Key Point: Do not delay evacuation to complete a secondary

assessment.

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Bandaging
Slide 5-65. Bandaging
Bandaging non-life-threatening wounds will be accomplished only after all casualties have been
assessed and treated for life-threatening injuries. Bandaging non-life-threatening wounds should
not delay evacuation. If there is a time delay between completing treatment of all life-threatening
injuries and evacuation, begin secondary assessments; treat non-life-threatening injuries, splint
wounds, and package patients for evacuation.
General guidelines for bandaging include:

 Secondary bandaging is performed during indirect threat care and evacuation care
phases only.
 Remove all clothing in, on, and around the wound.
 Do not remove impaled objects. If a patient has been impaled, bandage around the
object to prevent movement.
 Avoid contaminating the dressing (white part) of the bandage.
 Apply dressing directly to the wound (exception—occlusive dressing first).
 Apply pressure bar directly over the wound.
 Wrap the wound with the bandage, but do not overwrap; the elastic will continue to
squeeze.
 Bandages applied to non-life-threatening bleeds should not become tourniquets;
ensure that fingers and toes still have blood flow, check capillary refill after bandage
has been applied and adjust as necessary.

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Participant Note: Checking for capillary refill is performed by

squeezing the patient’s finger or toe. Squeeze the nail bed until it
turns white, then release. The pink or red color should return in
about two to four seconds. If the color has not returned in four
seconds, the bandage is too tight and should be loosened.
 Cover the entire dressing with the bandage and try to ensure that no white is
showing. This is a general guideline and may not be possible. Covering the entire
white dressing is ideal because the dressing may absorb contaminants into the
wound.
 If bleeding comes through the bandage; do not remove it. Add an additional bandage
on top of the original.
Splinting
Slide 5-66. Splinting
Splinting is effective in stabilizing broken bones and limiting movement of wounds. Any steps
that can be taken to immobilize broken bones or wounds before moving the casualties will help
prevent further damage and bleeding. Broken bones allowed to move freely during evacuation
could cause extensive additional damage by slicing arteries, veins, or nerves.
Wound packing may become dislodged, resulting in severe bleeding. Rapid evacuation is
important, but responders should avoid harming the patient during the process. RTF medical
personnel may bring limited splinting supplies. Consider having evacuation teams bring
backboards and litters into the CCP for evacuation to the transport vehicles. Limit the use of ad
hoc lifts, drags, and carries to casualty movement for the purpose of moving to cover and the
CCP.

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Packaging
Slide 5-67. Packaging
Packaging means preparing casualties for extraction from the warm zone or CCP. When
possible, red or immediate casualties should be evacuated using stretchers, backboards, or
other devices capable of limiting casualty movement. Care must be taken to protect the
lifesaving interventions applied during indirect threat care.

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Non-Trauma Victims on Scene
Slide 5-68. Non-Truama Victims
In a chaotic, active shooter situation, responders should be prepared to manage non-trauma

casualties including:
 Heart attack
 Strokes
 Breathing problems
 Seizures
 Mental health conditions
Heart Attack
High stress situations can cause a person to have a heart attack. Signs and symptoms of a
heart attack are:
 Crushing chest pain, patients often report extreme heaviness on their chest
 Shortness of breath
 Referred pain
 Victims will usually have pain in their jaw or left arm
 Pale, sweaty skin; victim will appear ghostly white and will be cool and clammy to the
touch
Victims that exhibit signs of a heart attack need immediate transport by EMS. EMS must be
made aware that the victim is having a heart attack. The victim should not walk. Responders
should be calm and resassuring. Excitement will increase the victim’s heart rate and increase
muscle damage.

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Strokes
An obstructed or ruptured blood vessel in the brain causes a stroke. The lack of blood to the
affected area of the brain causes it to die. Strokes can be caused by extreme excitement or
stress. Signs and symptoms of a stroke include:
 Sudden head pain, often described as the worst headache ever experienced
 Drooping on one side of the face
 Single-sided paralysis
Victims that exhibit signs of a stroke need immediate transport by EMS. Responders should
notify EMS of stroke victims. The victim should not walk. Responders should be calm and
resassuring.
Respiratory Complications
Asthma is typically the leading diagnosed respiratory disease in the United States. Most cases
are minor and require only rest or an albuterol inhaler. Serious asthma patients will exhibit loud
wheezing and typically convey their history of asthma to responders. These patients need EMS
as soon as possible.
Seizures
Grand mal, or full body, seizures are common. During a seizure, the victim stops breathing.
Seizures usually do not last more than 1–2 minutes. One seizure is usually not a critical
situation. The victim will start breathing again and recover fully within the next 10–15 minutes.
The situation becomes critical when a victim has multiple seizures without a recovery period.
The brain does not have time to re-oxygenate before the next seizure. This is an immediate
medical concern and the victim needs EMS as soon as possible. If a victim has a single
episode, move the victim to the CCP or a location where a willing bystander can watch them. If
there are no further seizures, the victim is put in the delayed category.
Participant Note: If multiple persons are having seizures at the

same time, get out immediately. Seizures are a common symptom
of chemical weapon exposure.
Mental Health
Some victims will not be capable of mentally handling what they have experienced. Some
victims will appear calm, distant, and non-responsive and others will be out of control. Victims
who are out of control need to be contained and quickly removed. Responders may also
encounter victims with developmental disabilities or pre-existing mental health conditions. These
victims require additional time to contain and remove.

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First responders must understand that people will exhibit a variety of responses. Responders
must judge people for their responses, reactions, or lack of reactions. Both victims and
responders may have difficulty managing high stress situations and they may not know it until
they are put into the situation.
Treating Victims of Chemical, Biological, Radiological, Nuclear, and

Explosive (CBRNE) Weapons
Slide 5-69. Treating CBRNE Casualties
When treating victims of CBRNE, responders should follow normal triage and employ immediate
lifesaving interventions including tourniquet application and airway management. Refer to fire
and HazMat responders for decontamination requirements.
Participant Note: Significant training and equipment is required

for all emergency services (police, fire and EMS) as it relates to
working in a CBRNE enviornment. The medical treatment
discussed is for consideration of emergency service personnel
who may find themselves unknowingly working providing indirect
threat care in a CBRNE environment or working post-detonation of
an explosive device.

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Blast Injuries
Slide 5-70. Blast Injuries
For blast injuries, responders should treat external wounds using traditional interventions:
tourniquets, bandages, and prevention. Casualties are at high risk for internal injuries. Organs
are susceptible to damage from overpressure. Blast injury casualties are considered priority
patients.
This slide depicts the four types of blast injuries. Blast injuries are divided into the following four
categories:

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 Primary: caused solely by the direct effect of blast overpressure on tissue

 Secondary: caused by flying objects that strike people
 Tertiary: caused by high-energy explosions; occurs when people fly through the air
and strike other objects
 Quaternary: encompasses all other injuries caused by explosions, such as burns and
smoke inhalation
Summary
Slide 5-73. Summary

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During this module, participants discussed the medical interventions that are applied in an
indirect threat care setting. Participants examined lifesaving interventions used to treat injuries
that commonly occur in an active shooter event.
Participant Note: Day 2 of the course will begin with practical

exercises for Module 5 and Module 2.
Law enforcement officers should secure their weapons before
class begins on day 2. Weapons will not be allowed in the training
course for the remainder of the course.


Active Threat
Integrated Response
Course
Module 6: Tactical Response Considerations and
Rescue Task Force Integration
Version 2.0


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Module 6: Tactical Response Considerations and Rescue

Task Force Integration
Duration
5 hours (practical exercise)
Scope Statement
In this module, participants will receive instruction on rapid response to a known threat location
and the priorities of actions by law enforcement to mitigate an ongoing threat. Module 6
addresses security, immediate action planning, and the medical treatment (SIM) and evacuation
of casualties. Instruction for link-up procedures with follow-on responders and establishment of
casualty collection points (CCP) are addressed. Additionally, tactical and casualty care
considerations for the formation and deployment of integrated rescue task force teams are
addressed along with ambulance exchange points (AEP).
Terminal Learning Objectives

Participants will be able to discuss the initial response priorities to an active shooter event and
tactical considerations for a swift response by law enforcement, fire, and emergency medical
services (EMS).

6-1 identify the priority of life scale as it relates to an active shooter scene (all
participants);
6-2 discuss (fire and EMS participants) and demonstrate (law enforcement participants)
basic first responder tactics used during an active shooter response;
6-3 discuss the importance of securing the immediate crisis point quickly and effectively
using any and all reasonable and necessary force options (all participants);
6-4 identify and demonstrate the role and formation of integrated rescue task force
teams (all participants);
6-5 identify and demonstrate approach tactics to a crisis site as an integrated rescue
task force (all participants);
6-6 identify and demonstrate interior movement tactics as an integrated rescue task
force (all participants);
6-7 identify and discuss the creation of a casualty collection point (CCP) within a crisis
site (all participants);
6-8 identify indirect threat care which can be provided once security has been
established (all participants);

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6-9 identify and discuss the roles and responsibilities of law enforcement, fire, and EMS
personnel in a CCP (all participants);
6-10 identify and demonstrate creating cordons for casualty evacuation (all participants);
6-11 identify and demonstrate establishing command of the scene (law enforcement
participants);
6-12 identify and demonstrate creating ambulance exchange points (AEP) (all
participants);
6-13 identify and demonstrate link-up procedures between initial responders and follow-on
responders (law enforcement participants).
Resources
 25 blue training handguns
 25 blue and 15 red training vests

7:40
Reference List
Godfrey, W., Agan, D., Otterbacher, R., and Fender, D. 2013. 4 Best Practices for Active
Shooter Incident Management: Lessons Learned from 10 Active Shooter Exercises with
the University of North Florida.
r
Management Checklist. http://www.c3pathways.com/asc/
Management Checklist Help Guide.
Howe, P. 2005. Advanced Hostage Rescue Course. Nacogdoches, TX: Combat Shooting and
Tactics (CSAT). http://www.combatshootingandtactics.com/

Center. (2014). Active Shooter Level II Training Manual (Vol. 2.0). San Marcos, Texas:

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(ALERRT) Center.

Center. 2014. Active Shooter Train-the-Trainer Manual (Vol. 5.0). San Marcos, Texas:
(ALERRT) Center.

During the practical exercise portions of this module, instructors will demonstrate and have
participants perform all practical techniques. Law enforcement participants (only) will conduct
the first 2:45 hours of the practical exercise. During this time, the fire/EMS participants will
conduct Module 7 for 2:45 hours. At the conclusion of Module 7, the fire/EMS participants will
join the law enforcement participants and complete the remaining 2:15 hours of Module 6.
Practical exercises for this module consist of eight activities:
 Approaches and Breaching considerations – 30 minutes (law enforcement participants)
 Threshold Evaluation, Team Movement Techniques, and Setting Up for Entry – 60
minutes (law enforcement participants)
 Room Entry, Security/Immediate Action/Medical (SIM) Principles, and Link Ups – 50
minutes (law enforcement participants)
 Casualty Collection Points (CCP), Safety Cordons, and Ambulance Exchange Points
(AEP) – 20 minutes (law enforcement participants)
 Rescue Task Force (RTF) exterior movement techniques - 20 minutes (all participants)
 RTF interior movement techniques – 35 minutes (all participants)
 Casualty collection points (CCP) and Ambulance exchange points (AEP) – 40 minutes
(all participants)
 Practical application exercises – 40 minutes (all participants)
Assessment Strategy
 Observing participant behavior during lecture

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Icon Map

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Introduction
All first responders to the active shooter scene, especially law enforcement, will usually be
required to place themselves in harm’s way and display uncommon acts of courage to save the
innocent. Law enforcement first responders must understand and accept the role of protector
and be prepared to meet violence with controlled aggression.
Initial actions set the stage for the success of the overall response. In addition to the primary
goal of stopping the killing, the first officer on scene must remain cognizant that a much larger
incident response has been triggered. A very large, comprehensive command structure will be
built from the foundation created by the first officer.
Priority of Life Scale

Innocent civilians are at the top of the priority of life scale. This scale is used to guide first
responders during the critical decision making process that is required to effectively neutralize
threats and save lives.
1. Innocent civilians
2. First responders
3. Actors and suspects
4. Property
First responders, using effective tactics and situational awareness, must isolate, distract, and
neutralize attackers while mitigating the loss of innocent life.
The pre-1999 priority of life scale likely looked significantly different from today’s. Many may
have placed the first responder at the top with the rationale that if responders go down, they
cannot help others. While technically accurate, this argument leads to an obvious question: if
responders place themselves at the top, then why would they go to the scene at all?
Law enforcement has the tools, protective equipment, training, and a moral and legal duty to put
themselves between a threat and the innocent population.
Fire and EMS responders have also reconciled this need to protect themselves with the larger
mission to save lives. The fire services adage of “risk a little to save a little, risk a lot to save a
lot” is especially appropriate here because responders must be prepared to risk a lot to save
what is most important—innocent lives.

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Law Enforcement First Responder Response Considerations

Law enforcement first responders must begin thinking about the tactical approach to a crisis site
long before they arrive.
Parking and Staging

A major consideration when arriving on scene is parking. There are numerous examples from
across the nation of law enforcement officers parking and unintentionally blocking roadways
when responding to active shooter events. This slows response by preventing fire, EMS, and
tactical assets from being able to reach the scene.
Parking decisions and approach tactics should take into consideration actionable intelligence, if
present. If no actionable intelligence exists, first responders should consider the ease and
speed of approach and tactical considerations including:
 Location of the crisis site in relation to terrain, including tree lines, nearby buildings, and
natural cover
 Construction of the building, including window tinting, doors, structural avenues of
approach, elevated firing positions, positions of advantage, and effective ranges of
different types of weapons
 Availability of cover for approaching and follow-on responders, including natural cover,
vehicles, natural or manmade obstacles
Initial staging considerations have to be balanced with the need to close distance to the entry
point. Identification of the hot zone by initial first responders is paramount as additional
resources arrive. It is safer to declare a much larger hot zone than necessary during the initial
response than it is to pull resources out of a hot zone after they have arrived.
Equipment
Law enforcement first responders will typically only have the tools and resources that they carry
on their persons when responding to an active shooter event. Pre-event training and preparation
should be driven by the reality that first responders must have the resources and capability to
perform the following:
 Make a tactically-sound approach to the entry point
 Force entry into the crisis site, using breaching tools if necessary
 Isolate, distract, and neutralize the threat to stop the killing and be equipped with extra
ammunition in the event of a protracted incident
 Provide immediate life-saving intervention with appropriate medical equipment
 Communicate with follow-on responders and outside resources using radios and a
communications plan
A healthy liaison with fire and EMS prior to an event can facilitate on scene access to breaching
tools, tactical equipment and training, and medical equipment and training.

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Tactical Concepts and Principles

These tactical concepts and principles are focused on inserting an ad hoc team (2 or more
officers generally) into an active shooter event with limited actionable information directing the
team to the exact location of the shooter or shooters. The team must insert into the building and
move past uncleared areas while protecting themselves from attack.
Contact Team Principles

Ideally, four to five first responders will form a single contact team on scene. Realistically, the
first contact teams to enter the structure and address an active shooter will consist of two or
three first responders. Although it should not be a typical response, in some situations a single
first responder may enter the scene. Officers entering by themselves must understand the
increased risk they face when entering alone.
Solo Officer Entry

The solo entry is a concept based on the reality that every second a first responder waits for
backup could mean death and serious injury to innocent victims trapped inside. Time is critical.
The first officer on the scene must have good situational awareness and make the decision to
enter or to hold and wait for backup based on what is known at the time.
The decision to make a solo entry is based on the availability of actionable information. The
general location of the gunman inside the structure, number of actors, the delay until backup
arrives, and your ability to communicate with follow-on responders are important in this
decision-making process. Responders should not make entry into a situation if they feel they will
exacerbate the problem instead of bringing it to a successful resolution. A responder’s decisions
should be consistent with departmental policy.
Bypass Wounded
The primary function of the contact team is to locate and stop the threat. Generally, the contact
team will bypass the wounded in search of the threat. If time allows, the contact team can
conduct a quick assessment of the casualty’s bleeding and airway if there is no driving force,
gunfire, or information indicating where the shooter is located. If the victim has no pulse and is
not breathing, do not call a follow-on team for evacuation. The scene will eventually transition
into a crime scene and lifesaving resources should not be consumed for body recovery. If in
doubt, responders should direct lifesaving resources to the victim’s location.
Direct Victims to Safety

This principle is situation-dependent. First responders should try to give accurate information to
those trying to escape the scene. If the gunman is in an elevated position in a multi-story
building, first responders might not want to send victims outside into a possible kill zone. It might
be more effective to have them barricade themselves inside the structure with orders to not
allow anyone inside unless they can positively identify themselves as friendly by, for example,
slipping a business card under the door. In addition, first responders can ask victims for
actionable information including suspect descriptions, weapons, and direction of travel.

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Direct Follow-On Responders

Contact teams should direct follow-on responders to assist in quickly locating and stopping the
threat. Additionally, contact teams should identify and communicate the location of wounded
persons to follow-on responders and the Incident Commander. If there is no active threat near
the wounded victims, follow-on responders may work as part of an integrated rescue task force
with fire and EMS to evacuate these victims. Contact teams should provide link-up protocols to
be used between themselves and follow-on responders.
Contact Team Priorities

Stop the Killing
Move toward the sounds of gunfire to isolate, distract, and neutralize the threat. While operating
in this phase, contact teams will bypass wounded and uncleared areas to approach and engage
the threat. The only medical intervention consideration at this time would be direct threat care.
Stop the Dying

Contact teams will transition to providing lifesaving intervention—primarily indirect threat care,
consisting of hemorrhage control and respiratory assistance. CCPs will be identified and used
as necessary.
Conduct Casualty Evacuation

Law enforcement will partner with fire and EMS to enter into a warm zone or cold zone as a
combined rescue task force to evacuate casualties from the crisis site.
Tactical Response Strategies and the SIM Model

Law enforcment must employ sound tactics to quickly and efficiently stop an ongoing active
shooter threat. The following are proven tactical concepts and principles for working in ad hoc
first responder teams.
Stay Together
Staying together as much as possible provides the team with three key advantages: maximizing
communication between team members, maximizing threat area coverage, and maximizing
firepower from the team on a known threat.
540 Degree Coverage

This allows the team to bypass uncleared areas when actionable information calls for them to
move directly to a threat. In a structure with numerous unknown persons, responders will not be
able to stop and investigate every person with whom they come in contact or every location that
could possibly conceal a threat. This dome of protection around the team allows the team to
enter and go deep inside the threat area to quickly neutralize a known threat.

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Communicate
This is the most critical aspect of teamwork. Effective communication ensures that, regardless
of size, the team acts as one. Ineffective communication will turn a team into a group of
individuals.
Cover the Angles

The urban environment is full of hard angles that responders must constantly identify and cover.
When moving, either inside a building or on a city street, first responders are constantly
exposed to opening and closing angles along the route. In most settings, first responders will
not be capable of covering every angle of exposure at all times. First responders must learn to
prioritize which angles are covered more thoroughly than others. For example, when first
responders are moving down a hallway, they should prioritize angles by distance from the team.
As a team passes an open door in a long hallway, they should cover the angles of exposure
through the open door. This will mean that the first responder will have to drop observation of
angles at a distance down the hallway in order to cover the angle that is closest to the team.
Threshold Evaluation
Also known as slicing the pie, threshold evaluation is a technique used to search the majority of
a room prior to entry. This technique can aid the first responder in gathering critical information
that is normally lacking during a rapid response. This technique also helps first responders, who
may have never worked or trained with each other prior to the incident, by giving them time to
observe, orient themselves, and decide upon a course of action more.
The threshold evaluation technique can be conducted at any pace from extremely slow if no
actionable information is driving the first responders, to an extremely fast, dynamic pace if shots
are heard coming from inside the room.
Speed of Movement
The dynamic nature of the response can often overwhelm the senses of the first responder.
Teams must respond quickly to the sounds of gunfire, but not so fast that they cannot process
critical information and effectively understand it in the context of the situation.
Do not move faster than you can accurately shoot and think. Shooting is a motor skill that, when
properly trained into muscle memory, can be done very quickly and accurately. Thinking in a
dynamic life or death scene can quickly overwhelm the best target shooter.
Room Entries
Law enforcement will conduct room entries and secure an environment that will enable RTFs to
safely operate in the warm zone. There are many different methods of clearing rooms and
conducting room entries. When working within an ad hoc team of first responders using the
concepts and principles listed above, the following methods have been found to be effective.
If the door is on the right, the right cover will move up to the doorway and post on it, covering
the deep corner in the direction the officer is holding. The rear guard will go back-to-back with

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the right cover and continue to protect the rear of the team. The left cover will take long cover
responsibilities and protect the point as he slices the pie across the threshold, making sure not
to telegraph past where the point is able to clear. As the point completes the clear across the
threshold, the point and the left cover will end up back-to-back. Figure 6.1 shows the
movements and positioning for setting up for room entry.
Figure 6.1
Physical contact between team members throughout this process is critical for keeping a tight
formation and maintaining coverage without having to look away to check on the pace of the
other first responders. At this point, the doorway is split between two, two-person teams. The
two first responders outside the formation, left cover and rear guard, will now cover front and
rear while the two first responders inside the formation cover the threshold and evaluate the
room prior to entry.
These steps are also applicable for closed doors except that the threshold evaluation will take
place after the door has been opened. The setup will likely be much quicker; however, some
doors may have windows, which the team should be attentive to.
Once the team has set up for room entry, the point and either the left or right cover position
(depending on the location of the threshold) will use hand and arm signals to communicate who
will be first to make entry, with the other first responder entering second. Usually, the first
person to enter will be the position that has seen more of the room (point) but occasionally a
floor plan will dictate that the left or right cover enters first. Remember, it takes a minimum of
two first responders to clear a room. Since the buttonhook can be a somewhat clumsy entry
method and may take more time to dominate the room, first responders should use the
crisscross method of room entry, also known as going to the known.

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Figure 6.2
Once the point and left or right cover make entry into the room, the long cover and rear guard
slowly move back into the area of the threshold. This is done for the following reasons:
 To maintain communication among the team
 To limit exposure in the hallway while maintaining hallway security
 To provide immediate support inside the room
Figure 6.3
Two-Person Entry
If there are only two first responders who enter and find that there is no actionable information
directing them to the shooter’s location, they can bend the team around the doorway and make
entry into a room and clear it. This may give responders critical intelligence from occupants
inside the room. By moving out of the hallway, responders will minimize their target signature in
the hallway and give them a secured base of operation from which to marshal additional
resources and gather operational intelligence.

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To perform this entry technique, the point will communicate the intent of conducting a threshold
evaluation and entry into a room. This will signal the rear guard to start covering the entire
hallway and all threat areas as the point assesses the room from beyond the threshold. Once
the point has seen as much of the room as possible, he uses his support elbow to signal the
rear guard to turn and prepare for room entry. Once the rear guard feels the tap from the point
man, he then turns around and conducts a squeeze-tap on the shoulder of the point. Using a
squeeze-tap reduces the confusion of an accidental tap. The point pauses for one second after
feeling the squeeze-tap to allow the rear guard to get both hands back on his weapon system
prior to entry. The point then moves through the threshold in one direction and the rear guard
moves in the opposite direction to their points of domination in the room.
Figure 6.4
Three-Person Entry
Three responders can also adhere to the concepts and principles of setting up to make room
entry. The left or right cover position communicates the team’s intent. This alerts the rear guard
to take on multiple roles (long and rear cover) as the responder opposite the door begins
threshold evaluation. The responder on the door side takes up a position holding security on the
unknown corner of the room as other team members perform threshold evaluation.
Once opposite each other, the left and right covers communicate using hand and arm signals
and make room entry. The rear guard will feel the indexed responder move to make entry
through touch indexing. Once the rear guard feels the room entry being made, he can elect to
turn and make entry into the number 3 position or back slowly into the threshold while scanning
the entire hallway. The rear guard should, at a minimum, scan into the room where his partners
have entered prior to backing into the threshold.

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Figure 6.5
Room Entries and the SIM Model

Security
The security of the team is the primary focus of the concepts and principles taught throughout
this course. After entering a structure, first responders should attempt to close the distance on
the shooter and, if possible, engage using the threshold evaluation technique. First responders
should attempt to communicate with victims or unknowns inside the room prior to making entry.
The information gained through this communication may lessen the possibility of an ad hoc
entry team rushing into an ambush inside the room. If attempts to communicate with persons
inside the room fail, first responders must attempt to assess the reason for the failure. The
victims could be frozen in fear or there could be another shooter inside the room preventing
communication.
Upon entry, all members of the contact team should enter the room. An exception to this tactic
is if the team needs to cover a threat outside the room.
As soon as practical, one team member should communicate that they are covering the door
and then move into a position of cover, as depicted by officer 4 in Error! Reference source not
found.. If it is necessary for all first responders to stay focused on the room, one tactic may be
to close the door leading into the hallway. This will help reduce both the visual and auditory
target signature presented by the team working in the room.

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Figure 6.6
Figure 6.7
First responders must immediately gain control over everyone in the room and should not make
assumptions regarding who is and is not a threat. Everyone should be treated as unknown until
they have been thoroughly searched or vetted. Four or five first responders in a room with
fifteen, twenty, thirty, or more unknowns can be easily overwhelmed if they do not exert control
quickly and effectively.
First responders should attempt to secure known shooters quickly without giving up security.
Suspects should be thoroughly searched for weapons and intelligence information including
radios, phones, and maps which could indicate additional suspects or target locations.
Unknowns should be moved to positions of disadvantage using verbal commands before
moving into areas of the room where responders are vulnerable to attack.

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Responders will not have enough restraints, such as hand cuffs or flex ties, to restrain dozens of
unknowns. To evaluate unknown persons, officers should move them against a wall, called the
dirty wall, inside the room. They should command unknown persons to assume a position of
disadvantage until the team restrains the known suspects. First responders must then begin
cleaning the unknown persons inside the room by searching them to ensure that they do not
pose a threat to the victims or first responders. One method first responders can use to expedite
this cleaning process is for first responders to clean two of the unknowns and then, once found
to not be a threat, enlist them to assist the first responders by identifying others that are known
to them to not be threats. Anyone they are not sure of should be cleared by first responders.
The success of this approach varies depending on the scene.
Closing Down A Room

With the unknowns moved against the dirty wall and placed in a position of disadvantage, the
first responders in the center of the room should act as cover while the first responders on the
perimeter of the room should act as contact, or hands-on. If there are four first responders in a
room, the two on the left side can work as a contact/cover team and the two on the right can do
the same. If there are only three first responders in the room, the first responder in the center
will act as cover and the outside two first responders will operate as contact, as shown in Figure
6.8.
Figure 6.8
First responders must communicate and identify which team member will serve as hands-on
and who will serve as cover. The hands-on first responder should immediately put his weapon
back into a ready position after securing the hostile or unknown.
Immediate Action Plan

After the team neutralizes all known threats inside the room and gains positive control over the
room’s occupants, they should formulate an immediate action plan as quickly as possible.

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If the number four officer assesses the room and determines that he or she should turn and
provide cover through the doorway, he should also communicate the team’s status, including
their location, casualties, and fatalities, via radio to the Command Post or other responders.
Once the status update is complete, someone on the team must decide upon a course of action
in the event that more gunfire erupts and the team needs to move to another location to defend
innocent lives.
The immediate action plan should be simple, easy to understand, and based on a when/then
model such as, “When <this event> happens, then <team member name> will stay here and
<team member name> will move to the threat.” This should be the first phase of the immediate
action plan and should be developed as soon as practical.
The immediate action plan helps to minimize confusion among teammates if the situation
dictates that the team must suspend what they are doing and move to another location to stop
an attacker. The KISS principle—keep it simple, stupid, applies here. There is no need to
develop a complicated plan. A simple statement like, “When shots are fired, you stay, we will
go” works best.
An immediate action plan should take into account the totality of the circumstances as they are
perceived at the time. For example, if there are known to be five other contact teams moving
inside the crisis site, first responders may not want to leave the location they are working. They
may elect to set up a blocking position in a hallway and allow another team to move to the
second crisis point.
Medical
First responders should address medical issues as soon as they establish security and
formulate the immediate action plan.
Link-Up Procedure
First responders must recognize the danger of bringing two armed elements, a contact team
and a secondary responder team, into contact with each other during a chaotic and dynamic
active shooter event.
Teams must establish positive communication before coming together. Secondary responders,
including RTFs, should not enter into the immediate area controlled by the contact team until
they establish communication with the contact team. Link-up protocols must be established and
understood before the secondary responders enter.
Contact team members should attempt to mark their exact location inside the crisis site. They
can accomplish this by using a statement like “we are inside the third room on the right once
you enter the doorway, room 212.” Another method is for the contact team to use a mechanical

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device to mark their location. This could be done with a ChemLight or small battery operated
strobe light. If none of these devices are available, first responders can use items found at the
site to mark their location, such as chairs stacked on top of each other outside the doorway or
trashcans in the center of the hallway.
As depicted in Figure 6.9, contact team members should not be in the hallway when the
secondary responder team is given permission to enter. This prevents a crossfire situation with
a threat coming out of a room between members of the secondary responder team and contact
team.
Figure 6.9
If for some reason this does occur, it is important to remember that the moving team has priority
of fire. This is almost always the secondary responder team. Members of the contact team
should evacuate the hallway or make themselves small to avoid being hit by friendly fire.
Key Point: It is imperative for law enforcement to train and

practice these perishable skills. Additionally, it is important for area
law enforcement agencies’ tactics and response strategies to be
aligned before a tragedy occurs.

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Rescue Task Force (RTF) Team Considerations

“Coordinated active shooter responses by police, fire/rescue and EMS are complex and don’t
lend themselves to a cookie cutter approach. To be effective they must be tailored to the
resources and level of risk tolerance of a given community.”
Dr. William Fabbri, FBI
The RTF concept involves law enforcement teaming up with fire and EMS personnel to escort
them into a warm zone. Law enforcement personnel serve as a force protection element
working with the medical providers. The ultimate goal is to quickly evacuate wounded victims to
higher levels of care.
Key Point: Law enforcement’s role in an RTF is to provide

protection for fire and EMS personnel.
Additionally, law enforcement personnel are responsible for coordinating the movement of the
RTF into and out of the warm zone.
There are various RTF models in use throughout the country. Some considerations for
deployment of RTF include:
 Available law enforcement, fire, and EMS resources
 The security situation at the crisis site
 The number and type of causalities
RTFs may be used to conduct several functions during an active shooter situation, including one
or more of the following:
 RTF enters warm zone and evacuates casualties. This is also known as a grab and go.
Casualties may be evacuated at the point of injury or from a CCP.
 RTF enters warm zone, provides indirect threat care, and evacuates casualties.
 RTF enters warm zone and manages a CCP already established by law enforcement.
This includes providing indirect threat care, initial triaging, and coordinating evacuation.
 RTF posts at entry point and evacuates casualties brought to them by law enforcement.
Key Point: Local emergency responders from all discplines should

plan, train, and exercise together to build capacity for intergrated
RTF.

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Fire and EMS Equipment Considerations

RTF concepts require different fire and EMS equipment considerations than a traditional
response. Indirect threat care is the only type of medical intervention that will be performed in
the warm zone; therefore, medical equipment should be limited to providing that level of care.
This includes a trauma bag with tourniquets, hemorrhage control adjuncts, airway management
equipment, and a portable litter. These items need to be easily transported and must allow for
the RTF team to move rapidly. Responders should evaluate the need to carry cumbersome
items such as large medical tackle boxes and backboards.
Participant Note: There is significant national discussion

regarding the need for RTF fire and EMS personnel to have
ballistic protection. Federal grant funds have been made available
to fire departments to purchase body armor. While it is advisable
for all emergency responders entering a warm zone to wear body
armor to protect from potential gunfire, this should not be the
deciding factor regarding fire and EMS participation in an RTF
team.
Some fire and EMS agencies across the country, Clark County,
NV and Arlington, VA, for example, have made significant capital
investments in body armor and helmets for RTF personnel. Other
agencies, San Marcos, TX and Charlotte, NC, for example, have
RTF programs that do not currently include body armor for fire and
EMS personnel. Referring back to Dr. Fabbri’s quote, the
requirement for fire and EMS personnel to use body armor when
working as part of a RTF should be based on local resources and
level of acceptable risk.
RTF Team Formation Considerations

While there are no specific rules regarding how many personnel from each discipline should
make up an RTF, the team must be able to move quickly and efficiently. There should be a
minimum of two law enforcement officers providing force protection for any deployed RTF.
There could be anywhere between one and four fire and EMS personnel assigned to an RTF.
The exact number depends on the specific mission assigned to the RTF.

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Figure 6.10
Pointman Rear Guard
LE FD FD LE
Direction of Travel
Figure 6.11
Pointman Rear Guard
LE
FD
LE FD LE
FD
LE
RTF Team Approach Tactics
Once requested and cleared to deploy, an RTF team will generally move from a staging point or
forward rally point. There may be a secure cold zone route from the rally point into the crisis
site. However, if the team must move through a non-secure warm zone, a tactical movement will
be used to approach and enter the crisis site. In this case, two tactical approaches may be
used.

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Wedge Formation
The wedge formation, shown in Figure 6.12, is used when crossing an open area in which the
team has no cover or concealment. In this case, law enforcement works in front of the fire and
EMS personnel, providing protection from threats that may appear in doors and windows.
Figure 6.12
FD
FD

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Bounding Overwatch
The bounding overwatch formation, shown in Figures 6.13 – 6.16, is used when crossing open
areas that provide some cover and concealment. This could include a parking lot with cars or an
open field with trees.
Figure 6.13
FD
FD

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Figure 6.14
FD
FD
Figure 6.15
FD
FD

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Figure 6.16
FD
FD
When the team can break into sub-elements, the bounding overwatch can be a very effective
method to close in on the entry point and provide cover for all responders, especially in a
parking lot or other locations that provide ample points of cover.
Communication is critical when working in this formation. While one team provides cover on the
threat areas, the other team advances. The team providing cover is watching the threat areas
and because they are stationary, they can place more precise fire on threats. The cover team
can also use the barriers for stabilization.
The team that is advancing should quickly move past the cover team to the next available point
of cover. The advancing team should not move too far in front of the cover team because the
cover team may not be able to cover them effectively. When the advancing team establishes a
position from which to take cover, the elements switch roles. This process continues until the
team reaches the entry point.
Open Air Casualty Extraction

The wedge and bounding overwatch formations can be used to approach and extract a casualty
in a warm zone outside of a structure. Law enforcement should set up blocking positons
between the threat area and the casualty while fire and EMS quickly evacuate the casualty.
Responders should evacuate the casualty to a position of cover before performing indirect
threat care interventions.

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RTF Interior Movements

There are two conditions in an interior warm zone in which an RTF may operate. The first is a
warm zone in which law enforcement has not established a safety cordon. An example would be
moving an RTF to extract casualties in hallways or to move into an established CCP. In this
case, the speed of movement of the team is the primary substitute for a security cordon. The
speed of movement is key to reducing angles of exposure to the team. Fire and EMS personnel
must stay within the bubble of law enforcement protection and not engage in independent
movement. Communication is key to moving quickly and efficiently within the warm zone.
The law enforcement officers assigned to the RTF must remain vigilant and understand that
their role is not to move toward the sound of gunfire, but to provide protection to the RTF at all
times. They must also link up with existing contact teams to coordinate movement and identify
casualties that need to be extracted or directed to the CCP.
It may become necessary for an RTF team to quickly evacuate a hallway or area. This could be
because law enforcement identifies a threat or because the contact team movement takes
priority over RTF movement. In this case, the law enforcement members of the RTF will direct
fire and EMS personnel where and when to move. Fire and EMS personnel must carefully follow
direction from law enforcement.
The second condition an RTF team would encounter inside the crisis site is working within a
safety cordon. In this case, law enforcement already in the crisis site has established a safe
zone for the RTF to either evacuate casualties or manage an established CCP. Even within a
safety cordon, law enforcement on the RTF must provide protection to the RTF at all times. It is
important to note that safety cordons may exist in one part of the structure but not others. The
law enforcement members of the RTF will need to coordinate all movement with interior contact
teams and recognize the status of security anywhere the RTF moves.
Establishing and Managing a CCP

A CCP is an area in a warm zone with cover and security measures in place to assemble
casualities and provide indirect threat care. A warm zone may contain one or more CCPs. The
CCP provides a location to:
 consolidate causalities,
 consolidate logistics,
 provide indirect threat care,
 conduct hasty triaging of causalities, and
 prepare causalities for evacuation.
A CCP will typically be created by law enforcement before RTF teams enter the warm zone. A
CCP may be naturally created if all of the casualities were in one place upon arrival. Contact
teams may consolidate casualities after establishing security to facilitate treatment and
evacuation.

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Establishing a CCP using the SIM Model

The SIM model explains law enforcement’s priority of work in determining when to establish a
CCP.
Security
Security is top priority. The ongoing threat must be stopped before law enforcement can
consider moving casualties and starting medical intervention other than direct threat care.
Immediate Action Plan

Officers must always think “what if?” Law enforcement must make contingency plans and
communicate them to all members of the contact team. Plans must be continually evaluated as
more resources arrive and the situation changes.
Medical
Officers should first direct the wounded to help themselves if possible. When security has been
established in the immediate area and there is no ongoing threat or shots being fired, officers
can provide indirect threat care.
CCP Management
It is important that someone is in charge of the CCP (CCP Manager) until relieved by a trained
medical first responder. If one room is being used as the CCP, casualties should be separated
into two distinct groups: immediate and delayed. This will aid medical personnel in their
assessment and ensure that the most critical causalities receive attention first. This can be done
by writing “immediate” on one wall of a room and “delayed” on an opposing wall. As casualties
are brought into the CCP, the person in charge of the room will inquire as to the category of the
casualty and direct them to the appropriate area. If multiple rooms are used, mark one of the
rooms as “immediate” and the other “delayed” and have patients placed into the rooms
according to their condition.
Key Point: Immediate and delayed casualties in the CCP should

be constantly reassessed until they are evacuated to a higher level
of medical care. All first responders should recheck tourniquets
and bandages to ensure they are still properly positioned.
Once an RTF arrives at the CCP, law enforcement’s role is to provide security while planning
and coordinating evacuation routes, safety cordons, and ambulance exchange points. This
includes establishing security outside of the structure for the ambulance exchange point.

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Indirect Threat Care in a CCP
Key Point: When an RTF reaches causalities or an established

CCP, they become responsible for the medical care.
The CCP will most likely be within the warm zone. Medical interventions within the warm zone
are limited to indirect threat care as discussed in Module 5. Prior to the arrival of an RTF, law
enforcement is responsible for providing medical care, but only if security has been established.
Law enforcement can also ask uninjured victims within the crisis site to assist with medical care.
After an RTF has arrived, fire and EMS will assume primary responsibility for providing indirect
threat care and triaging beyond what has already been done by law enforcement.
Cordons and Casualty Evacuation

A safety cordon is a secure area or route to a safe place or extraction point that is enveloped by
officers serving as sentinel or overwatch. This allows for the safe passage of an RTF in and out
of the CCP to the point of transportation.
Officers should take care not to disrupt casualties’ medical interventions when moving them
from the CCP to an ambulance or other transportation. Proper use of lifts, drags, and carry
techniques affect survival. Responders should consider using improvised litters such as chairs,
tables, or other items to aid in moving casualties.
Key Point: Remember to constantly reassess casualties and the

effectiveness of medical adjuncts and bandages. They may
become ineffective during movement.
When determining the location of an exit point, responders should consider exits other than the
initial breach point and beyond the closest windows or doors. The tactical considerations
responders take into account on the initial approach should be considered equally during
extraction.
When determining where to establish an ambulance exchange point, law enforcement

responders should consider the following factors:
 The availability to provide adequate security within the crisis site and outside of the crisis
site
 The number of causalities requiring evacuation
 Whether the area is large enough for ambulances or other transport vehicles to quickly
arrive, load, and depart

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Responders must minimize the amount of time ambulances wait in the warm zone prior to
loading patients and should avoid staging multiple ambulances in the warm zone waiting for
patients. Causalities should not be moved from the CCP to the ambulance exchange point
unless there is an ambulance ready to receive them. Good communication, coordination, and
use of the staging function will help minimize the time that ambulances wait for patients and the
amount of time that patients wait for ambulances.
Law enforcement is responsible for security at the exchange point until the ambulance or
transport vehicle is out of the area. Once loaded and departing the exchange point, officers
should monitor the vehicle to ensure their departure from the warm zone.
Summary
In this module, participants discussed and practiced rapid response to a known threat location
and examined the priorities of actions and tactics by law enforcement to mitigate an ongoing
threat. Module 6 introduced the creation of casualty collection points (CCP) and the role of the
CCP manager. Instruction for link-up procedures with follow-on responders were also
addressed. Additionally, tactical considerations for the formation and deployment of integrated
rescue task force teams as well as ambulance exchange points were discussed and
demonstrated.
Participant Note: The next module will consist of practical

exercise scenarios.

Active Threat
Integrated Response
Course
Module 7: EMS Advanced Skills
Version 2.0


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Module 7: Emergency Medical Services (EMS) Advanced

Skills
Slide 7-0. EMS Advanced Skills
Duration
2:45 hours (45 minutes lecture, 2 hours practical exercise)
Scope Statement
In this module, instructors will provide certified medical providers (EMT-B or higher) participants
specific medical techniques to augment existing skills to match the demands of responding to
an active shooter event.
Terminal Learning Objectives

At the conclusion of this module, certified medical provider participants will be able to discuss
and demonstrate advanced medical skills based on Tactical Emergency Casualty Care (TECC)
and Tactical Combat Casualty Care (TCCC) guidelines.

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7-1 identify principles of damage control resuscitation,
7-2 describe an advanced technique for pre-hospital treatment for junctional
hemorrhage,
7-3 describe an advanced technique for pre-hospital treatment for tension
pneumothorax,

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7-4 describe an advanced technique for pre-hospital treatment for traumatic brain injury,
7-5 describe an advanced technique for pre-hospital treatment for internal hemorrhage,
7-6 describe an advanced technique for and administration of interosseous (IO) infusion,
7-7 demonstrate proper technique for pre-hospital interosseous needle insertion,

7-8 describe assessment of failed airway considerations that may require cricothyrotomy
procedure,
7-9 demonstrate proper technique for pre-hospital cricothyrotomy,
7-10 demonstrate proper application of a junctional tourniquet,

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7-11 demonstrate proper technique for needle decompression of the chest, and
7-12 discuss pediatric patient concerns.
Resources
 Audiovisual kit
 Pen
 2 blood pressure cuff bladders
 4 chest decompression needles
 2 SAM junctional tourniquets
 Abdominal aortic tourniquet
 1 JETT Tourniquet
 2 cric-key knives
 2 cric hook
 2 EZ intraosseous infusion (IO) drills
 4 EZ IO needles
 4 scalpels
 4 10cc syringes
 4 18 gauge needles
 4 6.0 ET tubes
 4 1.25” 18ga Catheters
 1 IV Tubing – 30”
 2 Bougie ET introducers

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 8 absorbent pads
 2 Porcine trachea cric stands
 2 chamois cloths
 Box of 1.34” push pins
 Dozen store-bought uncooked chicken eggs
 2 pounds store-bought uncooked beef ribs
 20 Porcine tracheas
 Nasco Cricothyrotomy Trainer
 10 Nasco Cricothyrotomy Trainer skin inserts
 2 sharps container
 Box latex gloves
 Roll of paper towels

5:15 (1:15 lecture, 5:15 practical exercise)
Reference List
Al-Shahi, S., Kawahara, T., Morris, Z., Perel, P., Prieto-Merino, D., Sandercock, P., & Wardlaw,
J. 2010. CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant

Glassberg, E, Lipsky, A., Lending, G., Sergeev, I. Elbaz, A., Morose, A., Katzenell, U., and Ash,
N. 2013 “Blood glucose levels as an adjunct in prehospital triage,” American Journal of
Emergency Medicine. March 4. 31(3):556-61.
Holzrichter, D., Meiss, L., Behrens, S., and Mickley, V. 1987. “The Rise of Blood Sugar as an
Additional Parameter in Traumatic Shock.” February. Archives of Orthopaedic and
Traumatic Surgery. 106(5): 319-322.

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Jacobs, L. D., McSwain, N. D., Rotondo, M. D., Wade, D. D., Fabbri, W. D., Eastman, A. D.,
Kotwal R.S., O’Connor, K.C., Johnson, T.R., Mosely, D.S. and Holcomb, J.B. 2004. “Novel Pain
Management Strategy for Combat Casualty Care.” Annals of Emergency Medicine:
August. 44:121-127.
Sirbaugh, P., and Shah, M.I. 2014 “Pediatric Considerations in Prehospital Care.” UpToDate.
http://www.uptodate.com/contents/pediatric-considerations-in-prehospital-care
Smith, E. R., and Delaney, J. 2013. “Major Incidents; Supporting Paradigm Change in EMS'
Operational Medical Response to Active Shooter Events.” Journal of Emergency Medical
Services. http://www.jems.com/article/supporting-paradigm-change-ems-operation

During the practical exercise portions of this module, instructors will demonstrate and have
participants perform all practical techniques covered during the lecture portion of the module.
Instructors will provide constructive critique and feedback to participants during the practical
exercises to ensure competency.
Participants will be divided into four groups and rotated among the following four practical
exercise stations at 30 minute intervals.
 Needle decompression
 IO insertion
 Junctional tourniquet application
 Surgical cricothyrotomy
Assessment Strategy

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Icon Map

concept
Resource: Reference to books, websites, articles and other

external information sources

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Introduction
Injuries sustained during active shooter events are very similar to those seen on the battlefields
around the world. Gunshot wounds and injuries inflicted by improvised explosive devices (IED)
are often not routinely seen by many first responder medical providers in the US. As
demonstrated in earlier modules, many lessons regarding the treatment of these types of
injuries have been learned from the battlefields.
This module is designed to provide, or update, current medical providers with lessons learned
and improvements in the skills and protocols for the pre-hospital treatment of the seriously
injured patient. As stated at the beginning of the course, the procedures and protocols
discussed, demonstrated and practiced in this module may require approval from your medical
director. Participants are reminded to follow local policies and consult their medical director
before implementing or performing the procedures or protocols.

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How to Save Lives and Advanced EMS Concepts
Slide 7-5. Top three killers in combat
Tactical EMS and law enforcement support is exceedingly similar to battlefield medicine, of 976
potentially survivable deaths on the battlefield from 2001-2011, 91% died of hemorrhage, 8%
died of failed airway, and 1% died of tension pneumothorax (Eastridge et al 2012).

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The Lethal Triad
Slide 7-6. Lethal Triad of Traumatic Death
One of the greatest challenges in treating patients with multisystem injuries is a group of
interrelated symptoms, collectively known as the lethal triad. The conditions that make up the
triad—hypothermia, coagulopathy, and acidosis, compound one another, creating an escalating
chain of events. If left untreated, this results in irreversible tissue damage and death.

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Damage Control Resuscitation
Slide 7-7. How to Save
The goal of EMS is to deliver the patient to the surgical team in the best physiological state to
increase the odds of surgical success. This is accomplished by
 stopping the bleeding—hemostasis,
 making the air go in and out—ventilation management, and
 patient warming—holding the lethal triad at bay or reversing it.
Participant Note: Damage control resuscitation is not damage

control surgery, a very specific set of interventions performed by
trained surgeons.

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Slide 7-8. How to Save Lives
The following chart shows the top three killers in a prehospital setting and their interventions:
Condition Intervention
Hemorrhage Tourniquets and tranexamic acid (TXA)
Failed airway Cricothyrotomy
Tension pneumothorax Needle decompression
Hemorrhage
In trauma, severe hemorrhage control is a responder’s first priority. This module explores
beyond the basic extremity tourniquet to hemorrhage treatment in junctional and non-
compressible areas of the body.

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Slide 7-9. Hemorrhage
The medic’s typical approach to severe hemorrhage control during indirect threat care and
evacuation care is to apply well-aimed direct pressure, an extremity tourniquet, and wound
packing.
Slide 7-10. What if You Cannot Apply a Tourniquet?
If a tourniquet cannot be applied, responders should restrict blood flow with one or a
combination of the following:

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 Direct pressure
 Wound packing with standard gauze or hemostatic gauze
 Junctional tourniquet
 TXA
The following junctional tourniquets are Food and Drug Administration (FDA) approved and
have been successfully used to control severe junctional hemorrhage:
 SAM Junctional Tourniquet
 CRoC Combat Ready Clamp
 Junctional Emergency Treatment Tool (JETT)
 Abdominal Aortic and Junctional Tourniquet (AAJT)
The AAJT and the CRoC have both been approved by the FDA for use in pelvic bleeding.
Participant Note: Junctional tourniquets have proven to be

effective in controlling junctional bleeding, but as with any
tourniquet, responders must apply direct pressure at the site while
the device is being readied.
Slide 7-11. Advanced Concepts TXA
Example: You are the lead medic of the rescue task force charged
with entering and manning the casualty collection point. After
overseeing the assessment and treatment of all casualties, you
note that all but one is stable—a 34 year old male with a single
gunshot wound to the abdomen. His blood pressure is 80/40

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mmHg, his heart rate is 132 beats per minute, and his respirations
are 24. He is pale and only responds to verbal stimulus. You
consider permissive hypotensive resuscitation; however, you only
have lactated ringers (LR) available. You begin warm IV therapy
with your thermal angel and assess the need for ventilation
support.
Right now your care is limited to hypotensive resuscitation, patient

warming, and ventilation support. Despite your best efforts, he
continues to decline. You need something to temporarily control
the internal hemorrhage until he arrives at the hospital.
In this case, TXA may sustain the patient until he arrives at the
hospital.
Slide 7-12. What is TXA?
TXA is an anti-fibrinolytic that stabilizes clots by blocking their natural breakdown
Participant Note: You have likely heard of fibrinolytics, which are

used to breakdown clots in stroke and heart attack patients. TXA is
the reverse of fibrinolytics.

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Two major TXA studies have been completed:

 Clinical Randomization of an Anti-fibrinolytic in Significant Hemorrhage 2 (CRASH-2)
involving more than 20,000 adult patients
 Military Application of Tranexamic Acid in Trauma Emergency Resuscitation
(MATTERs).
As a result of these studies, TXA is a Class I recommendation in the TECC guidelines and in
the military TCCC guidelines.
Participant Note: TXA is not a new drug. It has been used for
more than 40 years to decrease bleeding in hemophilia and
prolonged uterine bleeding. While it is known that TXA helps to
stem the flow of internal bleeding, it also has long-term benefits
that are not fully understood. TXA may have a potent anti-
inflammatory property providing improved long-term mortality
rates.
Slide 7-13. TXA Dosage
TXA is administered by IV or IO. One gram is added to 100cc of normal saline or lactated
ringers and administered over 10 minutes.
Failed Airway
A failed airway exists when a medic is unable to affect gas exchange in a patient that cannot do
so on their own. A good algorithm stresses basic airway maneuvers, while simultaneously
addressing the need to move rapidly through the algorithm to maintain adequate patient
ventilation.

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Slide 7-14. Failed Airway
Responders may not be able to adequately ventilate a patient using basic maneuvers including
positioning, nasopharyngeal airway (NPA), or a bag valve mask (BVM). Responders must be
able to determine the appropriate next step for their patient. If basic maneuvers fail to ventilate,
medics may intubate or administer a supraglottic airway (SGA) or surgical cricothyrotomy.
Sometimes, due to facial trauma, moving directly to surgical cricothyrotomy is warranted.
Agencies must develop protocols for determining the appropriate airway tools for each scenario.
Responders must have an excellent understanding of the tools available to them.

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Endotracheal Intubation
Slide 7-15. Endotracheal Intubation
Endotracheal intubation is considered the gold standard for securing an airway (US National
Library of Medicine National Institute of Health); however, it may not be appropriate for every
trauma patient. If a patient is semi-conscious or conscious, he may have a gag reflex. Without
rapid sequence intubation (RSI) drugs, a responder most likely will not be able to successfully
intubate patients. Data shows that if a responder is able to successfully intubate a trauma
patient without RSI, it is because brain stem function had already ceased and, therefore, a gag
reflex was not stimulated.
Key Point: If the patient’s gag reflex is intact, you will harm your
patient attempting to pass the tube.

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Slide 7-16. Survival of Field Intubated Trauma Patients
A study on the survival of trauma patients who have prehospital tracheal intubation without
anesthesia or muscle relaxants, shows that of 492 patients intubated without medication, only
one patient survived. The patient who survived had a cardiac arrest after a penetrating chest
trauma and underwent a thoracotomy on the scene. (Lockey 2001)
Equipment Constraints
Slide 7-17. Equipment Constraints

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Equipment constraints are a factor when considering airway management options during an
active shooter event. Tactical medics and medics assigned to rescue task forces will be limited
to what they carry on their backs. Medics will not likely have oxygen, suction, refrigeration, or
advanced tools, such as the King Vision or GlideScope in the casualty collection point.
Slide 7-18. SGAs
Outcomes from using an SGA are generally the same as intubation without RSI. Medics risk
stimulation of the gag reflex by introducing the SGA. This device was initially developed as a
rescue airway for cardiac arrest, in which the gag reflex is not a concern.

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Slide 7-19. Surgical Cricothyrotomy
Basic life support (BLS) airway maneuvers can be quite effective. Often, BLS skills, like applying
a tourniquet, appear simple on the surface and are therefore rarely practiced. Little practice
leads to poor results. The poor results are often interpreted as an indictment of the procedure
instead of a failure to train.
Responders should consider moving straight to surgical cricothyrotomy if adequate ventilation

cannot be achieved or maintained with BLS maneuvers.

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Slide 7-20. Airway Algorithm
This slide shows a suggested algorithm for airway management for trauma patients. This is
meant for providers in critical environments without RSI capability. (Mabry 2015)

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To successfully perform a surgical cricothyrotomy the medic must be very familiar with the
anatomy. Responders will need to be able to quickly identify the thyroid cartilage, the cricoid
cartilage, and the cricothyroid membrane. Once identified, grasp the thyroid cartilage with your
non-dominant hand between the thumb and middle finger. Use the index finger of your non-
dominant hand to identify landmarks. Similar to the old carpenter adage “measure twice, cut
once,” identify your landmarks, confirm your landmarks, and maintain positive control
throughout the procedure. Always use your dominant hand when using the scalpel.

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Slide 7-26. Multiple Tools Available
Surgical cricothyrotomy may be performed using one of many types of manufactured devices or
using improvised methods.
Key Point: Responders should choose one type of surgical

cricothyrotomy device and become very proficient in its use.

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Slide 7-27. Pre-Hospital Surgical Cricothyrotomy
According to a review of 72 cricothyrotomies performed in Operation Iraqi Freedom and

Operation Enduring Freedom, a 30% failure rate occurred among well-trained medics
performing a surgical airway in the field. The failures were linked to incorrect anatomic
placement, excessive bleeding, air leak, and main stem placement. (Mabry)
CRIC Criteria
Slide 7-28. Improving Surgical Cricothyrotomy Success

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Responders should know their equipment. The cricothyrotomy kit should be simple, easy to use,
and dedicated to its purpose. Often, responders attempt to downsize their kits by assigning
multiple uses to items. This normally requires some improvisation to adapt the item to a specific
use. A surgical cricothyrotomy is a critical, invasive procedure that warrants a dedicated tool.
Your department or team should have a standardized technique for using the cricothyrotomy kit.
Training should be as realistic as possible. Responders must know how to confirm placement in
low light and noisy settings. Failed cricothyrotomy often results from the tube being inserted into
the soft tissue alongside the trachea even though the medic had successfully punctured
trachea.
Procedures should not be complicated or comprised of multiple steps and equipment should be
simple and not include wires, dilators, trochars, or trach tubes.
Slide 7-29. Improving Surgical Cricothyrotomy Success
The Control-Cric is an example of a device that incorporates all the above criteria. The cric-knife
incorporates a scalpel blade and cric hook into one device for cutting and hooking the
cricothyroid membrane. The Control-Cric key incorporates a coude tipped introducer, similar to
the bougie endotracheal introducer, which allows the medic to detect the trachea rings
confirming proper placement as the tube is inserted.

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Slide 7-30. Comparison
This study compared the Army medic’s standard surgical cricothyrotomy technique to the
Control-Cric technique using cadaver models. Fifteen Army medic volunteers performed the two
skills in random order. All 15 medics successfully placed the Control-Cric on the first attempt.
Only 10 of 15 medics successfully placed the standard cric on the first attempt. The Control-Cric
was also placed in about half the time of the standard cric. (Mabry et al 2013)

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Tension Pneumothorax
Of the three leading causes of preventable deaths, tension pneumothorax may appear to be the
easiest to correct in the field. This is not always the case. Once tension develops, it is an
emergent life-threatening condition that responders must recognize and immediately treat.
For the medic in the field, tension pneumothorax is a clinical diagnosis. Without the use of an X-
ray or a CT, responders must rely on their understanding of torso trauma and the subsequent
changes that are seen in a patient’s signs and symptoms. In some cases, this will be relatively
easy to diagnosis. A conscious patient with a gunshot wound to the chest that has been sealed
with an occlusive dressing develops shortness of breath and indicates that he cannot breathe is
likely is developing tension and needs decompression.
Rescue task force medics may enter a casualty collection point to find a patient unconscious
with a weak radial pulse, shallow rapid respirations, and no obvious bleeding. Responders
should consider ahead of time how they will determine when a patient has a tension
pneumothorax that needs to be decompressed. This includes performing a BATH assessment
to see if there are wounds that were missed by the initial first responder. Medics must also
determine the mechanism of injury for their patient—penetrating trauma, blunt force trauma, or
blast trauma.

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Needle Decompression
Slide 7-32. Needle Decompression
In the field, tension pneumothorax is treated with burping, needle decompression, and in some
instances, chest tubes. Needle decompression is the most common treatment performed by the
field medic. The most widely used location for needle insertion is the second or third intercostal
space along the midclavicular line. This location presents several problems. Muscle makes
finding landmarks difficult, there is a large variance in tissue thickness, and vital structures can
be punctured if the needle is inserted too medial. The fourth or fifth intercostal space along the
anterior axillary line is a good alternative site because there is less tissue to penetrate and it is
less likely vital structures will be punctured. TECC guidelines recommend both locations as
acceptable positions.

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Slide 7-33. NCD Landmarks
One barrier to being able to effectively perform needle decompression is hands-on training and
anatomy knowledge. In many instances, medics are not performing the procedure correctly.
Medics must know land marks; for example, the second rib comes off the angle of Louis, the
bottom of the body of the sternum is at the level of the fifth rib. Most importantly, the
midclavicular line is not half the width of the left or right side of the chest. Because the clavicle
extends out to the shoulder, the midclavicular line is significantly lateral to the midpoint of the
left or right half of the chest. TECC guidelines state to insert the needle into the second or third
intercostal space lateral to the nipple line. It is important to note how extremely lateral this line is
and the small window available for correct needle placement.

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Slide 7-34. Chest Anatomy Video
Insertion technique is also critical. In a postmortem review of 23 attempted needle

decompressions, only 10 were found to be successful. Success or failure could not be positively
determined in six of the attempts. So, out of 17 attempts, only 10 were successful. Of the 17
attempts, 13 were inserted in the anterior chest wall and four in the lateral chest wall. Only six of
the anterior chest wall insertions were successful while all four lateral insertions were
successful. Of the six anterior chest wall insertions, only two were placed along or lateral to the
midclavicular line. Five of the seven failures were directly linked to kinked catheters. Care must
be taken to ensure the needle and catheter are advanced as one unit into the chest cavity.
Medics should attempt to make the insertion over the rib to avoid the nerve, artery, and vein
bundle located along the posterior aspect of each rib.
Pain Control
Pain control is a topic often neglected in tactical field care training; however, it is a critical
component of patient care in the field.
Early and effective pain control at the point of injury significantly reduces patient recovery time.
It also facilitates treatment because of the pain patients experience during tourniquet application
and wound packing. There are also patient management concerns, including pain control in
hypotensive patients and monitoring patients who have received opioids.

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Analgesia
Slide 7-35. Advanced Concepts: Analgesia in the Field
Oral pain medications are an excellent option for conscious and alert casualties with moderate
pain. Avoid the use of non-steroidal anti-inflammatory medications (NSAIDs) in trauma patients
since these medications interfere with platelet function and may worsen bleeding. This limits
choices since it excludes common medication such as aspirin, ibuprofen, naproxen, and
ketorolac. The military carries Tylenol and Mobic. Although Mobic is classified as an NSAID, it is
COX-2 enzyme-specific and, therefore, does not inhibit platelet function.
Pain management specialists often recommend attacking pain from different aspects. In an alert
patient, a combination of acetaminophen and meloxicam may work best. This will inhibit both
COX-3 and COX-2 enzymes, providing multiple avenues of attack for pain and inflammation
control.
Key Point: Work with your medical director to determine the best
medications for your department. Much research is being done in
this area; it is imperative that you and your organization are aware
of current best practices.
Participant Note: The enzymes that produce prostaglandins are

called cyclooxygenase (COX). There are two types of COX
enzymes, COX-1 and COX-2. Both enzymes produce
prostaglandins that promote inflammation, pain, and fever;
however, only COX-1 produces prostaglandins that activate

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platelets and protect the stomach and intestinal lining.
COX-2 inhibitors are a subclass of NSAIDs. NSAIDs work by

reducing the production of prostaglandins, chemicals that promote
inflammation, pain, and fever. Prostaglandins also protect the
lining of the stomach and intestines from the damaging effects of
acid, promote blood clotting by activating platelets, and affect
kidney function.
NSAIDs block the COX enzymes and reduce production of

prostaglandins. Therefore, inflammation, pain, and fever are
reduced by all COX inhibitors. Since the prostaglandins that
protect the stomach and promote blood clotting also are reduced,
NSAIDs can cause ulcers in the stomach and intestines, and
increase the risk of bleeding. Unlike older NSAIDs that block both
COX-1 and COX-2, newer COX-2 inhibitors only block the COX-2
enzyme. Since COX-2 inhibitors do not block COX-1, which
primarily produces prostaglandins that protect the stomach and
promote blood clotting, they do not cause ulcers or increase the
risk of bleeding as much as older NSAIDs. COX-2 inhibitors are as
effective as the older NSAIDs for treating inflammation, pain and
fever.
Much less is known about the actions of acetaminophen but it is

believed that in inhibits COX-3 enzymes in the cerebral cortex.

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Slide 7-36. Analgesia in the Field
Oral transmucosal fentanyl citrate (OTFC) lozenges are a good option for an alert casualty in
moderate to severe pain if they are not at risk of going into shock or exhibiting respiratory
distress (Kotwal et al 2004).
OTFC should be administered as follows:

 Tape lozenge on a stick to casualty’s finger as an added safety measure or use a safety
pin and rubber band to attach the lozenge to the patient’s uniform or plate carrier
 Reassess in 15 minutes and add second lozenge in other cheek as necessary to control
severe pain
 Monitor for respiratory distress
If IV is accessible, IV morphine is an alternative to OTFC and should be administered as

follows:
 5 mg IV or IO
 Reassess in 10 minutes
 Repeat dose every 10 minutes as necessary to control severe pain
 Monitor for respiratory depression
Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.
One possible treatment plan is to administer oral Tylenol and Mobic along with the OTFC
lozenge. The OTFC is fast-acting but has a short duration while the Tylenol and Mobic have a
much slower onset but longer duration of action. This could reduce the need for repeat dosing of
the OTFC or opioid.

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Both ketamine and OTFC could worsen severe traumatic brain injury. The medic must consider
this when making a decision regarding analgesia. If the casualty is able to complain of pain,
then the traumatic brain injury is likely not severe enough to preclude the use of ketamine or
OTFC.
Eye injury also does not preclude the use of ketamine. The risk of additional damage to the eye
from using ketamine is low and maximizing the casualty’s chance for survival takes precedence
if the casualty is at risk of shock or respiratory distress.
Ketamine may be a useful adjunct to reduce the amount of opioids required for effective pain
relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC.
The following guidelines apply to the use of ketamine:

 IV ketamine should be given over one minute.
 If respirations are reduced after using opioids or ketamine, provide ventilatory support
with a bag valve mask or mouth-to-mask ventilations.
 Promethazine, 25 mg IV, IM, or IO every six hours may be given as needed for nausea
or vomiting.
 Continually reassess the casualty.

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The goal of pain management in the trauma patient is to reduce the pain to a tolerable level.
This is not cardiac pain management in which the goal is zero pain.
End points of analgesia in the field are control of pain, development of nystagmus, and a
change in end tidal CO2 capnography waveform.
Key Point: Always remember to frequently reassess the patient.

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Advanced Concepts
Traumatic Brain Injury (TBI)
Slide 7-39. Advanced Concepts: Traumatic Brain Injury
When treating a casualty with a traumatic brain injury, the goal is to prevent secondary injury.
The mortality and morbidity rate significantly increase if a patient experiences hypothermia or an
episode of hypoxia or hypotension. (Davids et al 2014)

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Slide 7-40. Traumatic Brain Injury
Hypotension and hypoxia in a brain injury patient results in irreversible brain damage. To
properly care for these patients, medics must constantly monitor blood pressure, PCO2, and
SPO2. Normally, hypotension means a systolic blood pressure below 90; however, in a brain
injury casualty, the greater concern is adequate cerebral perfusion pressure (CPP). CPP or
intracranial pressure (ICP) cannot be monitored in the field, so medics must rely on mean
arterial pressure (MAP) to estimate CPP.
Participant Note: Normal CPP is considered to be between 70

and 80mmHg. Since normal ICP is around 10mmHg, the MAP
must be around 80 to 90mmHg in an adult to maintain normal CPP
(CPP = MAP – ICP). A MAP less than 80 indicates inadequate
CPP.
In traumatic brain injury, medics are concerned with increases in ICP, so the typical 10mmHg
ICP will be increasing thus requiring a higher MAP to offset the increased ICP and provide
adequate CPP. If there is no indication of decreased level of consciousness, then CPP is
adequate at the current MAP. This number can be used as a baseline for determining future
care.
Medics’ care involves constant monitoring; ventilatory support to maintain end tidal CO2 in the
low end of normal, 35-40; and hypothermia management. Assisted ventilation should be
provided at the normal 10 to 12 breaths per minute.
Medics should not hyperventilate the casualty unless signs of impending herniation are present:
decrease in level of consciousness, dilation of pupils, or posturing. Casualties may be

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hyperventilated with oxygen using the bag valve mask technique to reverse the signs of
herniation. Once signs are reversed, the normal ventilator rate should be resumed.
Other traumatic brain injury considerations include the following:

 Per agency protocols, a hypertonic solution, such as 3% saline may be administered to
counter tissue swelling.
 Establish an IV line and be prepared to treat seizures.
 Assume that spinal and neck injuries are present and treat them appropriately; however,
consider stabilizing the head and neck without the use of a rigid c-collar. The rigid c-
collar can restrict the outflow of blood from the head through the jugular veins and
increase ICP.
Tourniquet Conversion Protocol
Slide 7-41. Advanced Concepts: Tourniquet Conversion Protocol
Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure

dressings as soon as possible if three criteria are met:
1. The casualty is not is shock.
2. It is possible to monitor the wound closely for bleeding.
3. The tourniquet is not being used to control bleeding from an amputated extremity.
(TCCC 2014)

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Slide 7-42. Tourniquet Conversion Protocol
Every effort should be made to convert tourniquets in less than two hours if bleeding can be
controlled with other means. If a tourniquet has been in place more than two hours, but less
than six, medics should consider conversion if all three criteria are met and if monitoring and
sodium bicarbonate are available. Tourniquets that have been in place for more than six hours
should not be removed until close monitoring and lab capability are available. (TCCC 2014)

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Prioritizing Transport
Slide 7-43. Advanced Concepts: Prioritizing Transport at CCP
One Israeli Defense Force Study of more than 700 patients seems to indicate that checking
blood sugars of immediate patients makes a difference in transporting the sickest trauma
patients to definitive care first (Glassberg et al 2013).
The study indicates that seriously injured patients will, as a last resort, dump their glucose
stores in an attempt to maintain some level of homeostasis.
Key Point: This science can make a huge difference if it translates

directly into field applications. Based on a quick d-stick of five
immediates, responders could transport them in order of blood
sugar elevation.

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Field Triage
Slide 7-44. Advanced Concepts: Field Triage
The Revised Trauma Score (RTS) is the standard pre-hospital triage score recommended by
Prehospital Trauma Life Support and the American College of Surgeons Committee on Trauma;
however, it is complex and difficult to calculate in the field. The Field Triage Score (FTS) is a
simplified system that is effective in predicting patient survival. FTS is derived by assigning a
component value of 0 for weak or absent pulse or abnormal Glasgow Coma Scale motor scale
(GCS-M) status and a component value of 1 for either a normal pulse or normal GCS-M status.
Adding the scores result in an aggregate FTS value of 0, 1, or 2.
A comparative study was completed using 869,401 patient records from the National Trauma
Data Bank. An FTS and RTS were assigned to each patient with a variation of less than 0.001
in patient categorization.
The FTS has been successfully used by combat medics on the battlefield and has been
validated by the US Army Institute of Surgical Research, and the data from the National Trauma
Data Bank.
Civilian pre-hospital trauma systems may consider using this simple, practical, and effective
triage tool.
Key Point: Participants are encouraged to practice and use the
FTS during the practical exercises on Day 3 of the course to
become familiar with the system.

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Pediatrics
Slide 7-45. Advanced Concepts: Prehospital Pediatrics
Medics must plan and train for pediatric trauma patients. Specific medical direction regarding
pediatric patients should be developed in anticipation of an incident involving children. The skills
used on adults are often ineffective, and in some cases, harmful to pediatric patients.
Resource: The Emergency Medical Services for Children National

Resource Center is a federally-funded program focusing on pre-
hospital and hospital readiness for pediatric emergencies.

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Slide 7-46. Prehospital Pediatrics
A length-based treatment approach using Broselow Tape guides decision-making in pediatric

patients. Medics must be prepared with the proper equipment for treating pediatric patients,
including smaller IVs, IOs, endotracheal tubes, and laryngoscopes.
Medics should not perform a cricothyrotomy on patients under the age of eight (Sirbaugh and
Shah 2014).
Key Point: Remember to always carry proper equipment. You

must be fully-trained and comfortable with equipment and
procedures specific to pediatric casualties.

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Slide 7-47. Prehospital Pediatrics
Just as with IO flow rates in the adult patient, tibia flow rates in the pediatric patient are minimal.
These flow rates are typically adequate for the standard medical call, but are not always
adequate for trauma resuscitation. The proximal tibia provides minimal flow and the medullary
space is an extremely small target. With the recent FDA approval of the distal femur as an
alternate site, the tibia may not be the right place for IO insertion in the pediatric trauma patient.
Key Point: Medical research is continually leading to better ways

to care for the injured. Review research and be involved in your
protocol development.

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Slide 7-48. IO Infusion Flow Rates
A study completed in 2012 by University Health System in San Antonio determined humeral
head IO flow rates to be more in line with the needs of a trauma patient than that of the typical
tibia IO.
This data shows that to get any perceivable flow through a tibia IO, medics will need a pressure
infuser. To administer a 500cc bolus (PRBC, hextend, LR) with a 300mmHg pressure infuser via
the tibia, it would take approximately 30 minutes. The same amount of fluid could be
administered by a humeral IO in less than six minutes. This correlates closely to the difference
in flow rates between a 1¼ inch 21ga catheter (15cc per minute) and a 1¼ inch 16ga catheter
(83cc per minute).
A humeral head IO is also typically half as painful as a tibia IO, and therefore easier to control
with a 2% lidocaine bolus.

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Slide 7-49. Infant IO Site Comparative
The site most commonly used for IO insertion for adult and pediatric patients is the proximal
tibia. As demonstrated on the previous slide, this site is not the optimal site for fluid
resuscitation in the trauma patient. In addition, this comparison also demonstrates that the most
difficult site to insert an IO needle into is the proximal tibia. Current research suggests that we
look critically at our current IO protocols and avoid staying with a practice that is proven to be
less effective just because it is familiar to us. The distal femur in the infant has a better flow rate
and provides a larger target increasing success of insertion. The humeral head in the adult
patient is a large target area and has a flow rate equal to a central line. Both sites are currently
approved for use by the FDA.
The purpose of these images is to offer a side by side comparative of the published, commonly
accepted IO insertion sites for infants.
Resource: Additional anatomical studies have been

completed for toddlers and adults. For more information,
scan the QR code or visit http://www.vidacare.com/
This comparative provides an opportunity to directly visualize and appreciate compact and
medullary bone densities, target bone size, relative depth, adjacent muscle structures and the
relationship between the catheter and the bone. It is our collective desire that these images be
seen and duplicated with the expressed intent that they help to eliminate intraosseous access
difficulties in our smallest patients.

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Slide 7-55. Resources
Resources: The following is a list of helpful resources for

additional information on EMS advanced skills:
 TECC Guidelines at www.c-tecc.org
 Journal of Special Operations Medicine:
www.jsomonline.org/

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 Journal of Emergency Medical Services: www.jems.com

 TCCC Guidelines: www.naemt.org
 Emergency Medical Service for Children: www.emscnrc.org
Summary
Slide 7-56. Summary
This module provided certified medical provider participants with specific medical techniques to
augment existing skills to match the demands of an active shooter response.
Participant Note: Certified medical provider participants will now

conduct the practical exercise portion of Module 7.

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Slide 7-57. Practical Exercise


Active Threat
Integrated Response
Course
Version 2.0


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Duration
6.5 hours (practical exercises)
Scope Statement
In this module, instructors will observe and evaluate participants as they perform the procedures
instructed in this course in simulated real world practical exercises.

Participants will be able to respond to a simulated active shooter incident and successfully
integrate the response between law enforcement, fire, and emergency medical services (EMS)
to quickly mitigate the threat while increasing the survivability of injured persons.

8-1 recognize an active shooter threat and successfully mitigate an ongoing deadly force
threat (law enforcement participants);
8-2 demonstrate the concepts and use the Active Shooter Incident Management
Checklist;
8-3 provide direct and indirect threat care to injured victims;
8-4 establish and manage casualty collection points (CCPs);
8-5 integrate fire and EMS into warm zones using rescue task force (RTF) concepts;
8-6 demonstrate advanced medical skills (certified medical personnel) in an indirect
threat care and evacuation care environment;
8-7 evacuate injured victims from the crisis site using RTF concepts and principles; and
8-8 participate in an after-action debrief of the practical exercises.
Resources
Host-Provided
 2 ambulances
 Water or water coolers
 2 dispatchers
 White board or easel pad with markers

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Instructors
 Instructor vests
 Radio with earpiece
 Participant assignment roster
 Active Shooter Incident Management Checklist
 1 blank gun and box of 50 blanks
 Ear protection
Participants
 Duty gear, including holster, body armor, and flashlight, for law enforcement participants
 Litters and trauma kits with training supplies, if available, for fire and EMS participants
 Radios, if available
ALERRT-Provided
 Inert blue training guns (1 per law enforcement participant and 1 per suspect role player)
 Ear protection (1 set per participant and role player)
 45 responder or ICS position vests
 45 radios (if needed)
 2 pole-less litters (if needed)
 15 go bags
 1 CAT Tourniquet
 1 Olaes bandage
 2 ChemLights
 1 roll colored survey tape
 4 EMS rescue bags
 8 CAT Tourniquets
 8 Olaes bandages
 20 triage cards with pens
 Clothing for role players
 4 short sleeve shirts
 2 pants
 1 long sleeve shirt
 1 security or law enforcement shirt
 4 moulage blankets
 3 large blood puddle simulators
 Mixing bottle
 2 bottles of blood powder
 Red grease paint
 20 patient condition cards
 Moulage
 M001 – Thigh Laceration
 M005 – Evisceration
 M008 – Compound Fracture

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 M010 – GSW to Leg

 M051 – Partial Arm Amputation
 M072 – Leg Amputation
 M908 – Gunshot Wound Bicep
 Gunshot wound chest
 2 moulage wax
 2 lacerations
 Moulage set up equipment
o 4 Techline bags
o 4 Techline clips
o 4 squeeze balls
o 8 tubes
o 4 tube reducer
o 12 tube valves
o 2 red tubes with reducers
o 3 carry pouches
o 2 one-gallon Zip Lock bags
 SAM Junctional Tourniquet
 Cricothyrotomy station
 3 porcine tracheas
 Porcine trachea cric stand
 Chamois cloth
 Box of 1 ¾” push pins
 Cric-key knife
 Cric hook
 Scalpel
 6.0 ET tube
 Bougie ET introducer
 10cc syringe with 18 gauge needle
 3 absorbent pads

8:40
Reference List
Not applicable

During the practical exercises in this module, instructors will guide participants as they perform
scripted, scenario-based exercises. Instructors shall provide constructive critique and feedback
to participants during the practical exercises to ensure competency.

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A roster will be created, separating participants by discipline (police, fire, and EMS). During the
functional exercise scenarios, participants will rotate through different response positions
ranging from first responders to Incident Command staff positions based on rank. Dedicated
role players provided by the host will be used during the scenarios. All course participants will
take part in each of the functional exercise scenarios.
Four scenario-based exercises will be conducted. Instructors will conduct a thorough safety
inspection of all participants prior to practical exercises. Once participants are in a secure, safe
training site, instructors will provide a detailed safety briefing and issue equipment.
Assessment Strategy
Icon Map

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Introduction
During this module, participants will work collaboratively during scripted, scenario-based
exercises involving active shooter attacks. Participants will have the opportunity to demonstrate
decision making, tactics, medical care, resource allocation, integration, command organization,
and problem solving. Exercises will begin with a dispatch call for service and will end when all
casualties have been evacuated from the scene. Designated role players will be used as
victims, casualties, bystanders, and suspects.
Class participants will be divided by discipline (police, fire, and EMS). For each scenario,
participants rotate through different assignments ranging from first responder to Incident
Command staff positions based on rank.
Exercise
Participants will be given a response assignment and role for each scenario. Instructors will
issue the appropriate equipment required for each assignment and role. Participants will be
radio dispatched to the scenario by a dispatcher and respond accordingly. Through the
functional scenarios, participants will interact with one another as needed to respond to the
threat, mitigate the threat, establish command, provide medical care, provide security, integrate
disciplines, and evacuate casualties. Following each scenario, instructors will conduct an after-
action debrief, or hot wash, regarding the scenario and will provide participants with feedback
on their performance.
Evaluation Criteria
Participants will be evaluated on their ability to:
 Effectively mitigate an ongoing threat
 Establish command and control
 Effectively use staging
 Provide medical care to casualties
 Coordinate and integrate response among different disciplines
 Effectively evacuate casualties to higher levels of care
Equipment and Dress

Participants are encouraged to wear uniforms and dress suitably for the practical exercises.
Bunker gear is not required nor advised for fire participants. Individual gear and equipment,
such as body armor, duty belts, and flashlights, may be used. Agency equipment and gear,
such as litters and trauma bags (training) may be used with instructor approval.

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Safety Brief
The safety of all participants during practical exercises is paramount. Participants and role
players must follow a specific set of safety protocols when conducting training. Participants and
role players must follow directions provided by instructors.
Although force-on-force weapons are not used, instructors and participants must make sure no
live weapons or ammunition are in the training environment.
Participant Note: No weapons of any type are allowed in the

training location during practical exercises!
The following items are not allowed in the training location:

 Live weapons
 Tasers
 Large fixed blade knives
 Live ammunition
 Ammunition magazines
 Chemical dispersion devices
 Flashbangs or sound diversionary devices
 Impact weapons
 Any other item determined by the instructors to be unsafe
Participants should conduct a self-search to ensure no weapons or prohibited items are in the
training location. Participants are responsible for safely securing and storing weapons not
allowed in the training environment. Instructors may conduct a physical search of participants
and role players for weapons before starting the exercises. If participants leave the secure
training location during or between scenarios, they may be searched again for weapons.
An instructor will fire a dedicated blank gun to simulate gunfire. Participants and role players
should not handle the blank gun at any time. Participants and role players who will be near the
blank gun will be directed by instructors to wear ear protection.
Participants should use care when handling any role player. Some role players will play the role
of suspects while others will have simulated injuries requiring medical interventions. Participants
should take care not to injure or abuse role players. Additionally, participants should use good
judgement when performing BATH assessments and applying medical adjuncts on role players
of the opposite sex. Handcuffs will not be used during the exercises. Participants may inform an
instructor that a suspect should be handcuffed and simulate handcuffing of suspect role players.

(ATIRC)
Participant Note: Participants should be aware and cautious

when applying tourniquets to the legs of role players. The
instructors will select role players who are not excluded from the
placement of tourniquets on the legs, however caution should be
used. If in doubt, do not tighten a tourniquet on the leg of a role
player without first consulting an instructor.
While instructors will try to be near participants while they are handling role players, participants
must use good judgement when carrying or moving role players. Specific care should be taken
when carrying and evacuating role players up or down steps, stairwells, and through doorways.
Participant Note: To avoid injuries, participants must use good

judgement when deciding when and how to carry or move role
players.
Exercise Location
Instructors will identify three distinct areas to be used for practical exercises.
Rally and Briefing Location and Incident Command

This is the location where the participants will receive scenario briefings and from where they
will prepare to deploy. This could be the classroom used throughout the course, a nearby
building, or a parking lot. This is also where Incident Command and dispatch will be established
for each scenario. This will be the semi-safe zone.
Staging
This is the location where participants will report once they have been dispatched from the rally
location. After initial law enforcement responders arrive on scene to begin the scenario, all other
responders will report to the staging location and await assignment and deployment.
Safe Zone and Scenario Area

This is the location where the scenario takes place. This could be an entire structure, such as a
school or office building. It could also be a portion of a school or office such as a wing or specific
floor. When using large structures, instructors will identify two or three primary entry and
evacuation points for participants to use during the exercises. No persons other than instructors,
participants, role players, and approved observers will be allowed in the safe zone and scenario
area.

(ATIRC)
Mishap Procedure
Any participant, instructor, or role player can stop an exercise at any time for a significant safety
concern. If anyone witnesses a significant safety concern, they should loudly yell “cease fire,
cease fire, cease fire” while waving their hand in front of their face with their palm out. If this
command is heard or given, all participants and role players should immediately stop where
they are and wait for direction from an instructor.
Participant Note: A cease-fire could be called due to a real world

injury to a participant or role player. It could also be called if
uninvolved persons enter the training site during a scenario.
After-Action Debrief and Equipment Recovery

At the conclusion of each scenario, instructors will gather participants and facilitate an after-
action debrief. After the after-action debrief, instructors will direct participants to turn in
equipment and supplies. Participants should inform an instructor of damaged or missing
equipment.

Active Threat
Integrated Response
Course
Module 9: Course Wrap-Up, Post-Test, and Course
Evaluation
Version 2.0


(ATIRC)
Module 9: Course Wrap-Up, Post-Test, and Course

Evaluation
Slide 9-0. Title
Duration
1 hour
Scope Statement
In this module participants will turn in all equipment issued during the course and complete a
post-test covering the objectives of the course. Participants will also complete a course
evaluation form.

At the end of this module, participants will complete a comprehensive written post-test and
course evaluation.

(ATIRC)
At the end of this module, participants will be able to:
9-1 discuss learning objectives and overall course content,

9-2 provide feedback by completing a course evaluation form, and
9-3 complete a comprehensive post-test successfully.
Resources
 Audiovisual kit
 Post-test answer sheet
 Post-test
 DHS Student Assessment of Course and Instructors evaluation form
 Black pens

1:40

(ATIRC)
Reference List
None

Not applicable
Assessment Strategy
 Instructor administration of a post-test to assess knowledge participants gained from
each module
 Completion of a course evaluation form

(ATIRC)
Introduction
This module provides participants with an opportunity to demonstrate mastery of the course
goal and terminal learning objectives, as well as to provide feedback on the quality of
instruction, content, and materials. As the final module of the course, it also provides an
opportunity for instructors to conclude the course and to make final remarks.
Course Wrap-Up
Slide 9-2. Course Wrap-Up
During the course, participants examined characteristics of active shooter scenarios. They also
examined the Active Shooter Incident Management Checklist, how it relates to the Incident
Command System, and how it can be used to improve integration between law enforcement,
fire, and EMS responders. Participants also discussed rescue task forces and how staging can
be used to for a more organized and efficient response.
Participants discussed and practiced direct and indirect threat care. All participants had the
opportunity to practice what they learned using practical exercises and realistic scenarios.
This final module has provided an opportunity for participants to review the course and apply the
knowledge they have gained by completing a comprehensive post-test. Participants were able
to provide their thoughts and feedback on the course content and were encouraged to comment
on the quality of the instruction and course materials.

(ATIRC)
Equipment Recovery
Slide 9-3. Equipment Recovery
ALERRT instructors will collect all equipment and supplies. Participants should check their
personal equipment to ensure that they have returned all course-issued equipment.
Post-Test
Slide 9-4. Post-Test

(ATIRC)
The post-test provides participants with an opportunity to demonstrate mastery of the terminal
learning objectives. The post-test is similar in design and content to the pre-test that participants
completed at the beginning of the course. Participants’ pre-test and post-test scores will be used
to measure the course’s benefit and to identify the knowledge and skills participants have
gained from their attendance. Retests may be administered onsite if needed.
Course Evaluation
DHS and ALERRT would like to obtain participant feedback about this course. Both
organizations recognize the importance of participant suggestions and observations to
sustaining high-quality instruction and identifying areas for improvement. For this reason, DHS
and ALERRT ask each participant to complete a course evaluation form.
Besides obtaining participant feedback from the course evaluation forms, ALERRT also
conducts outcome studies. In the future, participants may receive an email or phone call from a
member of ALERRT inquiring as to how they have used the knowledge, skills, and abilities they
have gained from this class.
Slide 9-5. Course Evaluation
Participants should complete both sides of the form. On the front, enter the class number
provided by instructors and today’s date. On the back, please provide honest feedback for each
question prompt.

Active Threat
Integrated Response
Course
Appendix A: Acronym List
Version 2.0


Active Threat Integrated Response Course Particpant Guide
(ATIRC)
Appendix A: Glossary
A
AAJT Abdominal Aortic and Junctional Tourniquet
AAR after-action report
ABC airway, breathing, circulation
Active shooter an individual actively engaged in killing or attempting to kill
people in a confined and populated area; in most cases, active
shooters use firearms and there is no pattern or method to their
selection of victims (DHS)
AED automated external defibrillator
ALERRT Advanced Law Enforcement Rapid Response Training
Ambulance exchange a specific location where an ambulance is sent to pick up
point evacuated casualties from a team operating in the warm zone.
ATIRC Active Threat Integrated Response Course
B
BATH bleeding, airway, tension pneumothorax, hypothermia
BLS basic life support
BVM bag valve mask
C
CAN conditions, actions, needs
CAT Combat Application Tourniquet
CBRNE chemical, biological, radiological, nuclear, and explosive
CCP casualty collection point
a specific warm zone location with security measures to
assemble nearby casualties and provide indirect threat care
CCA complex coordinated attack
killing or threatening to kill multiple unrelated individuals where
there are [a] three or more attackers, or [b] simultaneous attack
of two or more sites, or [c] an act of terrorism* which overwhelms
the local jurisdiction and initiates a regional/statewide response
Version 2.0 PART A-1

(ATIRC)
Closed chest wound injuries to the torso area that are caused by blunt force and do
not penetrate the torso
Clotting cascade the formation of a clot to stop bleeding
CoTCCC Committee on Tactical Combat Casualty Care
C-TECC Committee on Tactical Emergency Casualty Care
COX cyclooxygenase
CPP cerebral perfusion pressure
D
DHS Department of Homeland Security
Direct threat care the limited trauma interventions that may be considered for use
in aiding a casualty while still actively engaged in mitigating a
threat
E
ELO enabling learning objective
EMS emergency medical services
EMT emergency medical technician
EOD explosive ordnance disposal
F
FBI Federal Bureau of Investigation
FDA US Food and Drug Administration
FEMA Federal Emergency Management Agency
FTS field trauma score
G
GCS-M Glasgow Coma Scale-motor

(ATIRC)
H
HPMK hypothermia prevention and management kit
Hypothermia low body temperature; any temperature below normal, 98.6°F
I
ICP intracranial pressure
ICS Incident Command System
IED improvised explosive device
IO intraosseous
IV intravenous
J
JETT Junctional Emergency Treatment Tool
Junctional hemorrhage a compressible bleed that occurs at the junction of an extremity
and the torso at an anatomic location that precludes the effective
use of an extremity tourniquet to control bleeding
L
LE law enforcement
LR lactated ringers
M
MAP mean arterial pressure
MCI mass casualty incident
N
NIMS National Incident Management System
NPA nasopharyngeal airway
NSAID non-steroidal anti-inflammatory medications

(ATIRC)
O
Open chest wound injuries to the torso area that are caused by penetrating trauma,
such as bullet, knife, or spear injuries
OTFC oral transmucosal fentanyl citrate
P
PACE planning primary, alternate, contingency, and emergency plan
Pneumothorax air in the chest cavity
POI point of injury
R
RSI rapid sequence intubation
RTF rescue task force
RTS revised trauma score
S
SGA supraglottic airway
SID student identification number
SIM security, immediate action planning, and medical
T
TCCC tactical combat casualty care
TECC tactical emergency casualty care
TEMS tactical emergency medical support
Tension pneumothorax a condition in which air outside of the lung fills the chest and
exerts pressure on the heart and opposite lung
TXA tranexamic acid

(ATIRC)
Reference List
DHS (Department of Homeland Security). n.d. Active Shooter Event Quick Reference Guide.
Washington, DC. http://www.dhs.gov/sites/default/files/publications/active-shooter-
pamphlet-508.pdf.

For more information on the ALERRT program, please visit our web site at
www.ALERRT.org
The Advanced Law Enforcement Rapid Response Training program (ALERRT) is a partnership
between Texas State University, the San Marcos, Texas, Police Department, and the Hays
County, Texas, Sheriff’s Office.
Version 2.0—December 2015
Texas State University is part of the Texas State University System.

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What is the purpose of the Active Threat Integrated Response Course?

What is the purpose of the Active Threat Integrated Response Course?

What topics are covered in the course modules?

What topics are covered in the course modules?

Active Threat

Active Threat Integrated Response Course (ATIRC)

All Rights Reserved. First Edition 2015

Reproduction of this document, in whole, or in part, in any form or by any means—graphic,

This project was supported by Cooperative Agreement Number EMW-2013-CA-K00109-S01

Department of Homeland Security reserves a royalty-free, non-exclusive, and irrevocable

Version 2.0 iii

This Page Intentionally Left Blank

Module 1: Course Introduction and Administration

Slide 1-0. Title

Terminal Learning Objective

Version 2.0 PART 1-1

Enabling Learning Objectives

Slide 1-1. Enabling Learning Objectives

At the conclusion of this module, participants will be able to

Version 2.0 PART 1-2

Instructor to Participant Ratio

DHS (Department of Homeland Security). 2005. Weapons of Mass Destruction Tactical

Version 2.0 PART 1-3

Texas State University-Advanced Law Enforcement Rapid Response Training (ALERRT)

Texas State University-Advanced Law Enforcement Rapid Response Training (ALERRT)

Texas Tactical Police Officer’s Association. n.d. Self-Aid/Buddy-Aid Course.

Practical Exercise Statement

Version 2.0 PART 1-4

Key Point: Essential learning concept and discussion

Participant Note: Additional information for participants

Resource: Reference to books, websites, articles and Insert QR

Version 2.0 PART 1-5

Slide 1-2. Introductions and Welcome

Slide 1-3. Safety Brief

Version 2.0 PART 1-6

Slide 1-4. Introductions Activity

Slide 1-5. Registration

Version 2.0 PART 1-7

When completing the registration form, participants should

Slide 1-6. Testing

Version 2.0 PART 1-8

Slide 1-7. Pre-Test

Version 2.0 PART 1-9

Slide 1-8. Course Goal

Version 2.0 PART 1-10

Slide 1-9. Disclaimer: Graphic Content

Slide 1-10. Disclaimer: Medical Procedures

Version 2.0 PART 1-11

Slide 1-11. Aurora Video

Version 2.0 PART 1-12

Resource: To access the Aurora Century 16 Theater

Resource: After Aurora is a 50 minute video that examines

Slide 1-12. Challenges

Version 2.0 PART 1-13

Stopping the Threat

Integrating the Response

Evacuation and Transport of the Injured

Version 2.0 PART 1-14

Slide 1-13. Threat Zone Matrix