Pre-Hospital Care in Mass Casualty Shootings

You will likely recognize the above picture as a CAT tourniquet. As programs such as Stop The Bleed and others have focused on the use of tourniquets in the field, these have become a popular item for most to carry in our kits. This is for good reason too. Studies and data coming from military experience in Afghanistan and Iraq have shown, these devices are no longer to be considered the “last ditch” efforts we once thought. That being said, what does the data show about efficacy or applicability of this data in civilian shootings as we have recently seen in El Paso and Dayton?

This very question was addressed in the May/June 2019 edition of the Air Medical Journal. Three studies by Smith, Butler and de Jager were used to discuss differences between the battlefield and civilian injuries. Interestingly, military injuries tend to be to extremities. This is due to several reasons. First, many soldiers are injured by high explosive devices and the fragments coming off of them. Secondly, the battlefield and the highly armed nature of the two sides on the battlefield, tends to separate the combatants much further than what is seen in the civil setting. This separation makes shots to vital areas such as the torso, head and neck less likely. Finally, soldiers tend to wear body armor that covers vital areas. While not fool proof, especially against higher caliber and more powerful rounds, it can protect against many rounds, especially if shot from a distance.

What does this difference mean for civilian first responders in such scenarios? It means that chest, back and head shots are much more likely. These areas are, obviously, not amenable to tourniquet placement. So, while still important, we need to adjust training and prepare our first responders for what they are more likely to see. In particular, the authors advise focusing on chest wounds. While there are many who have survived head shots, the chest can be far more survivable. Focusing on pressure and hemostatic impregnated gauze as well as chest seals and decompression may be the next line in pre-Hospital treatment. Also, ensuring such first responders are well versed in all forms of artificial airways can be lifesaving.

Whether you are an EMT, Paramedic, nurse, doctor or private civilian, many of these techniques can be learned and practiced in courses offered throughout the country. Keep your tourniquets on hand but be ready with even more advanced skills should you be unfortunate enough to find yourself in a situation where you need to employ them.


1. Air Medical Journal, May/June 2019; p. 137-138.

2. Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Car Care Surg, 2016; 81:86-92.

3. Butler FK. Military history of increasing survival: the U.S. military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. Bull Am Coll Surg, 2015; 100: 60-64.

4. de Jager E, Goralnick E, McCarty JC, et al. Lethality of civilian active shooter incidents with and without semiautomatic rifles in the United States. JAMA. 2018; 320; 1034-1035.

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