An active shooter casualty is a patient wounded during an ongoing violent event, where the threat to rescuers shapes every step of care. Most preventable deaths come from bleeding, so care follows tactical emergency casualty care: stop massive bleeding first, then airway, breathing and circulation.
Key symptoms
- Gunshot or penetrating wounds, often more than one
- Heavy bleeding from limbs, groin, armpit or neck
- Shortness of breath or chest pain with chest wounds
- Confusion, anxiety or unresponsiveness from blood loss
What you find on exam
- Hot zone: only control massive limb bleeding, then move the patient to cover
- Warm zone: MARCH assessment, massive bleeding, airway, respiration, circulation, hypothermia
- Check for entry and exit wounds front and back, including armpits and groin
- Signs of tension pneumothorax: worsening breathing, absent breath sounds
- Mental status, skin color, pulse quality and radial pulse
Tests
- Rapid triage with START or SALT when there are many casualties
- Pulse oximetry, blood pressure and waveform capnography when safe
- At the trauma center: FAST ultrasound, blood type and crossmatch, CT
Treatment basics
- Tourniquet high and tight on bleeding limbs; pack and press junctional wounds
- Recovery position or airway adjuncts; vented chest seal on open chest wounds
- Needle decompression for tension pneumothorax
- Prevent hypothermia; tranexamic acid per protocol
- Rapid transport to a trauma center with early hospital notification
Red flags
- Ongoing threat to rescuers; do not enter until the scene is secured by police
- Uncontrolled bleeding or signs of shock
- Worsening breathing after a chest seal
Practice it in Making Synapses
Making Synapses cases
Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; National EMS Education Standards (2021); NREMT psychomotor skill sheets (EMT and Paramedic). Written by Making Synapses. Making Synapses is not affiliated with these organizations.