(Continued from Part 1. This concludes the article.)
Pressure points are areas where major arteries are closer to the surface of the skin than normal and utypically over hard/boney areas of the anatomy. Pressure points are areas of the body where arteries come close enough to the surface for pressure points to work. They are common areas where pulses are felt as well. You can practice locating them by feeling for the pulse on friends or family members, using your index and middle fingers together. I will be discussing the easiest points to identify and have labelled their general location with blue dots on the attached picture.
Working down the body, the first pressure point is where the brachial artery transits past the armpit (axilla) and down the arm over the humerus/biceps area. The pressure point is located on the inside of the arm over the area where the bicep muscle and humerus (upper arm bone) meet. The second point is also the brachial artery, but further down the arm. It is typically very visible in healthy, well hydrated individuals at the crease of the elbow, or antecubital area of the arm. This is the area that is commonly accessed for IV access.
The next point is the Radial artery, probably the most recognizable pressure point. The Radial pressure point is on the underside of the wrist on the thumb side, where the pulse is felt and measured most frequently. The next point down the body is the Femoral artery. The easiest way to identify Femoral Pressure Point is in the area where the leg meets abdomen close to the genitalia. To access the pressure point, you may need to cut away the clothing to expose the area to properly feel for the pressure point. This is where trauma shears would come in handy. When accessing the femoral pressure point, do not be shy. To reach the pressure point you will need to get close to the genitalia. I made sure to tell my sailors and Marines this, and in a life and death situation where there is a legitimate chance of bleeding out, the patient will not care.
The final pressure point to cover today is the Popliteal Pressure Point located behind the knee. This pressure point can be difficult to find due to the anatomy of the area. You will need to apply pressure with significant force to ascertain the location and to restrict blood flow to control bleeding. To control bleeding with a pressure point, you will need to apply significant enough force to slow or stop bleeding enough to apply further measures like applying gauze and pressure dressings. You will want to monitor bleeding while applying pressure as another responder applies and dressing and then slowly remove pressure and watch for bleeding through the dressing and add more as needed.
In a situation where EMS is not readily available, like possibly backcountry hiking or TEOTWAWKI  scenario, the procedure for applying a tourniquet is very specific to help save as much of the limb as possible. Again, I will reiterate this point, DO NOT use a tourniquet in any but the most emergent situations where there is a significant time before EMS will be able to reach you or there is no longer any Emergency Medical Services, WROL situation.
Of the many commercially available tourniquets available, I prefer tourniquets with a windlass to apply the pressure. With a windlass, you can adjust the tension on the tourniquet without needing to completely remove and reapply it. My other criteria I look for is a large enough surface area for adequate pressure to the large arteries to control bleeding. With these criteria in mind, my go to tourniquet is the tried and true Combat Application Tourniquet (CAT). There are plenty of others available, and I have put hands on most. The CAT is still my go to, but it is a bit bulky in a pouch. If storage space is an issue, my second choice would be the Rapid Application Tourniquet (RATs).
The CAT is currently on its seventh generation, but the design has not changed drastically since it was first fielded to me in the early 2000s. The changes of the generations have been improvements on the basic design to make them easier to use, especially for use by the injured personnel by themselves. These instructions should work for any of the generations. Slide the extremity through the loop of the hook and loop (Velcro type) band or wrap the hook and loop band around the extremity and re-route through friction adapter buckle. Position the CAT above the wound; leave at least 2-3 inches of uninjured skin between the CAT and the wound. This is will help leave enough tissue for the tourniquet to apply pressure to underlying arteries and not slide off as well as leave enough tissue for repair in the case of amputation.
To secure, pull the free running end of the hook and loop band tight and securely fasten it back on itself (if applying to an arm wound). Note: All the slack must be removed from the hook and loop band before tightening the Windlass Rod. Do not adhere the band past the Windlass Clip. If applying to a leg wound, the hook and loop band must be routed through both sides of the friction adapter buckle and fastened back on itself. This will prevent it from loosening when twisting the Windlass Clip. Twist the Windlass Rod until the bleeding stops. When the tactical situation permits insure the distal pulse is no longer palpable. Lock the rod in place with the Windlass Clip.
NOTE: For added security (and always before moving the casualty), secure the Windlass Rod with the Windlass Strap. For smaller extremities, continue to wind the hook and loop band across the Windlass Clip and secure it under the Windlass Strap. Grasp the Windlass Strap, pull it tight and adhere it to the hook and loop band on the Windlass Clip. Release and remove the tourniquet. Note that on a real casualty, the date and time the CAT was applied would be recorded when tactically feasible.
The RATs tourniquet has a metal cleat at one end and a long, elastic band attached to it. Start by holding the metal cleat in one hand. At the end with the cleat, the elastic band should be threaded through to form what they refer to as a three finger loop. Your limb does NOT go through the three finger loop. Place the cleat on the limb requiring a tourniquet and wrap the long length of rubber around the limb. Thread the long end of the rubber band through the three finger loop and pull until snug. Wrap the long length of rubber back on itself and continue wrapping the limb until the elastic is used up or the blood flow has stopped. With every wrap you should be stretching the rubber so that the band pulls tight and cuts off blood flow.
Do not pull the band as tight as it can go because it can cause permanent neurovascular damage if tightened too much. Hook the end of the rubber band into the cleat to secure the tourniquet in place. When using the RATs tourniquet, the elastic material is relatively thin when compared to the CAT, you will therefore need to make sure to wrap the elastic multiple times to adequately control blood flow as well as prevent nerve damage by using a thinner band. The band should be relatively close together, approximately half an inch between passes but not overlapping either. More practice will be required to be proficient with this tourniquet.
Once bleeding is controlled, finish dressing any wounds with gauze pads and ACE wrap as needed and ready to casualty for transport. Reassess casualty approximately every 5 minutes for increasing bleeding. With severe trauma and especially with traumatic amputation, the body will involuntarily contract muscles which will help constrict blood vessels. Over time, the muscles will relax and may cause an increase in bleeding once again. This may require tightening of the tourniquet. This is why I prefer a tourniquet that has a windlass to avoid either reapplying a tourniquet or having to add a second tourniquet above the first. With a windlass equipped tourniquet all that is required is to tighten the windlass and leave the tourniquet in place. Once the tourniquet is in place, it should not be removed until the casualty is in a place for definitive trauma intervention where physicians are present to preform any interventions as needed when the tourniquet is removed.
Bleeding is a pretty easy topic to conceptualize for the layperson. A sucking chest wound is not as obvious, but emergency treatment is a fairly simple process. A little bit of anatomy first, before delving in to treatment of sucking chest wounds. In an uninjured person, air has only one way in or out of the lungs, the trachea leading to the nose and mouth. As long as there is only one way in and out, breathing is an automatic behavior with the lungs filling and emptying as designed. If an extra hole is made into the lung, say by knife or bullet wound, it will make breathing very difficult and could lead to other issues. This wound is called a sucking chest wound. Symptoms of a sucking chest wound will include difficulty breathing or rapid/ shallow breathing, pain, and gurgling sounds possibly with frothy blood coming from the wound.
Note: Not every penetrating chest wound will cause a sucking chest wound. Treatment is based on symptoms and not the presence of a penetrating wound to the chest. A sucking chest wound will allow air into the chest in the area between the chest wall and the lining of the lungs which will in turn cause a pneumothorax: collapsed lung. Emergency treatment for a penetrating wound caused pneumothorax is a relatively simple process using a chest seal. A chest seal will likely be a thin, flat package. It is basically a sterile, thin plastic round or square shaped film with adhesive on one side. The seals will either have vents or not. A vent is not required to treat a penetrating chest wound/pneumothorax, but they do help the casualty breathe better by creating a one way valve that will allow blood to drain out as well of allow some air to escape without allowing air in.
Vents also allow air to escape through the wound and prevent it from collecting once again in the space between the lungs and chest wall. To use a chest seal, you will need to clean and dry the wounded area of any blood and debris to allow the seal to adhere properly. Once cleaned, simply apply the adhesive end of the chest seal to the wound and monitor the casualty. Do not forget to check for exit wounds and treat the same way. Some chest seals will come in packages of two for this reason. As with tourniquets, the chest seal should not be removed without physician supervision.
Now that you have had a good primer in how to use your IFAK, I recommend practicing with the items in your kit. You do not need to practice on a living person for risky procedures like tourniquet application, a small sandbag would suffice. Practicing finding pressure points is difficult to do on yourself because your pulse is the same in your fingers as well as at your pressure point, so I recommend using a partner to find them. Please do not wait to practice these skills until you are in a situation, it will be exceptionally difficult to complete with adrenalin pumping and distractions around.
God Bless and Semper Fi