Page 116 - Journal of Special Operations Medicine - Spring 2016

the active assailant incident. https://www.mfri.org/lms/mgmt (a) Unique, austere, and different than the conven-
155/story_content/external_files/Maryland%20Active%20 tional environment of care in which EMS medi-
Assailant%20Guidance%20Final.docx. Accessed 13 Febru- cine is usually rendered AND
ary 2016. (b) The application of standard prehospital emer-
10. Maryland Institute for Emergency Medical Services Systems. gency practices could unnecessarily jeopardize
2015 Maryland medical protocols for emergency medical the safety of the patient and/or medical provider.
services providers. http://miemss.org/home/LinkClick.aspx? 3. An active assailant incident or Potentially Volatile
fileticket=Y1KRCqTYkpc%3d&tabid=118&portalid=0&
mid=742. Accessed 13 February 2016. Environments with Life-Sustaining Interventions
(PVE/LSI) protocol is declared.
PROTOCOL d. CONTRAINDICATIONS
1. Absent the presence of perceived or actual threat,
28. POTENTIALLY VOLATILE ENVIRONMENTS WITH standard general patient care practices should be
LIFE-SUSTAINING INTERVENTIONS followed.
a. BACKGROUND e. ZONES OF CARE/OPERATIONS
1. A review of past active assailant incidents has 1. The zones described below are intended to stan-
shown that the conventional prehospital practice dardize the terminology used by responding
of not entering the scene until it is deemed safe by emergency medical providers in Maryland and to
law enforcement (LE) has been associated with ad- establish a common understanding of the interven-
ditional loss of life. tions to be performed within each zone.
2. This protocol is designed to be all-hazards in na- 2. Hot Zone (Direct Threat): (Integrated Tactical
ture. It is meant to provide a clinical concept of op- EMS) Operational area with a direct and immedi-
erations that empowers trained and equipped, but ate threat to personal safety or health
not necessarily tactical, EMS prehospital providers, (a) The overarching priority in the Hot Zone is
to access casualties and expedite life-sustaining in- mitigation of active threat. Medical care is a
terventions closer to the point and time of injury. secondary function to threat mitigation.
For active assailant and other LE-related incidents, (b) Medical providers must be an integrated tac-
EMS providers shall be under LE escort. EMS pro- tical medic (i.e., TEMS) to operate in this en-
viders shall use appropriate personal protective vironment. Medical priorities are to prevent
equipment as defined by local jurisdiction. casualties and responders from sustaining ad-
(a) Examples of such potentially volatile environ- ditional injuries and include prompt evacuation
ments include, but are not limited to: to a more secure zone.
(i) Active assailant (active shooter/IED) (i) If at all possible, casualties should self-
situations evacuate.
(ii) Post-blast detonations (ii) Goals of care include keeping the response
(iii) Intentional release of a chemical agent team engaged in neutralizing the threat,
(iv) Industrial accident/explosion minimizing public harm, and controlling
(v) Hazardous materials incident life-threatening extremity hemorrhage.
(vi) Structural collapse/urban search and res- a. Control of severe hemorrhage in the
cue situations direct threat environment is best ac-
(vii) Transportation mishaps with limited scene complished with commercially avail-
access able tourniquets.
(viii) In the immediate aftermath of a natural b. Tourniquet should be placed as high
disaster such as a tornado up on the limb as possible without tak-
b. INTRODUCTION ing the time to expose the area.
1. This protocol provides guidelines for the type of in- c. For full or partial amputation, imme-
tervention and care that should be rendered at vari- diately place a tourniquet if possible.
ous proximities to a threat in a potentially volatile d. Cardiopulmonary resuscitation (CPR)
environment. is not indicated in this environment.
2. By definition, potentially volatile environments are (iii) In circumstances of chemical agent expo-
dynamic in nature. Scene conditions may change sure, administration of Nerve Agent An-
and emergent evacuation of responders and pa- tidote Kits (NAAK/MARK-1) might be
tients may interfere with the delivery of interven- warranted if available.
tions described in this protocol. 3. Warm Zone (Indirect Threat): (Limited LSI) Area
c. INDICATIONS with a potential threat to personal safety or health
1. This protocol does not replace or supersede the gen- (a) Evacuation of patients to a completely safe area
eral patient care practices in The Maryland Medical is the primary objective of care in this area.
Protocols for EMS Providers, which are still to be The following care guidance is dependent on
followed once the concern of active threat has been the availability of equipment, supplies, and the
mitigated. appropriate level providers. Extrication should
2. Use of this protocol is an acknowledgement by the NOT be delayed to provide advanced or in-
EMS provider that the situation is: volved treatment measures.

100 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016