EMS Junctional Hemorrhage Control

Indications

Indications for treatment include traumatic hemorrhage from the groin, axilla, base of the neck, perineum, and shoulder girdle. These anatomic sites represent classic junctional regions where standard extremity tourniquets are ineffective.

Technique or Treatment

Early management of hemorrhagic shock relies on rapid identification of the bleeding site, prompt hemostasis, and immediate resuscitation. Traumatic hemorrhage may rapidly progress to the “lethal triad” of coagulopathy, acidosis, and hypothermia. Prevention of this cascade improves survival to definitive care. Prehospital priorities include minimization of further blood loss, limited-volume crystalloid resuscitation, prevention of hypothermia, and rapid transport to a trauma center.[8] This activity focuses specifically on prehospital interventions that reduce blood loss in severe junctional hemorrhage cases.

Manual Direct Pressure

Direct digital pressure applied to the wound should be the initial attempt for control of junctional hemorrhage. Most external bleeding sites and selected major arterial injuries respond to this intervention.[9] Constant pressure should be maintained with the affected body part supported on a firm surface. Pressure should not be intermittently released to assess for ongoing bleeding.

Wound Packing

Some wounds are not amenable to direct pressure alone. Wound cavity packing supports hemostasis by creating localized pressure and vascular tamponade. One hand should advance the gauze into the wound, while the other maintains the packing material's position to sustain continuous pressure. Foreign bodies and sharp bone fragments must be removed during wound packing.

The Committee on Tactical Combat Casualty Care (CoTCCC) recommends hemostatic dressings, when available, for wound packing in accordance with manufacturer recommendations. Hemostatic agents are discussed in further detail below.

Packing material may absorb blood without achieving hemorrhage control, resulting in a wicking effect. This phenomenon must be prevented due to the risk of ongoing concealed hemorrhage.[10]

Pressure Dressing

A well-constructed pressure dressing may eliminate the need for continuous manual pressure by the provider. A pressure dressing consists of a bulky sterile dressing secured in place with a tight circumferential band. Pressure dressings may be improvised using readily available wound care supplies. Roller bandages, gauze, or trauma pads may serve as bulky sterile dressing material, while elastic bandages, blood pressure cuffs, or tourniquets may be used to secure the dressing.

Commercially available pressure dressings are also available. Manufacturer instructions should be reviewed, and familiarity with locally available commercial pressure dressings is required. Pressure dressings may be used alone, in combination with manual pressure, or in conjunction with wound packing and manual pressure. Additional pressure or reinforcement of the dressing may be required if bleeding persists after application.

Hemostatic Dressings

Research and development over the past 2 decades have led to the development of various hemostatic products for prehospital use.[11] Hemostatic dressings are bioengineered dressing materials impregnated with hemostatic agents. Combining hemostatic dressings with direct pressure has been shown to be effective in hemorrhage control in combat environments.[12] The American College of Surgeons Committee on Trauma, American Heart Association, American Red Cross, and CoTCCC recommend the use of hemostatic dressings in combination with direct pressure when external major bleeding cannot be controlled with direct pressure or conventional tourniquets.[13][14]

Hemostatic agents are classified into 3 groups based on the mechanism of action:

• Factor concentrators: absorb water rapidly, increasing local concentrations of clotting factors and platelets at the injury site
• Mucoadhesive agents: adhere strongly to injured tissue and seal the bleeding wound mechanically
• Procoagulants: supplement or activate components of the hemostatic cascade

Current evidence does not substantiate the superiority of one hemostatic category over another.[15][16][17] However, the following hemostatic dressings are recommended by the CoTCCC:

• QuikClot Combat Gauze: The CoTCCC's hemostatic dressing of choice. Kaolin-impregnated polyester-rayon dressing functions as both a factor concentrator and procoagulant. Kaolin, an inorganic mineral, activates the intrinsic coagulation pathway and accelerates clot formation.[18][19] Extensive studies support the safety profile of this hemostatic dressing.[20] An Israel Defense Forces Medical Corps study involving 37 cases of junctional hemorrhage demonstrated hemostasis in 88.6% of cases following QuikClot Combat Gauze use.[21] Combat gauze remains the primary hemostatic dressing utilized by US Operational Forces and NATO (North Atlantic Treaty Organization) military organizations.[22]
• Celox Gauze and ChitoGauze: Chitosan-based dressings functioning as mucoadhesive agents. Chitosan is a positively charged polysaccharide derived from shrimp exoskeleton. Binding occurs between chitosan and negatively charged red blood cells, producing a cross-linked mechanical barrier that seals the injured vessel. A 2015 randomized controlled trial involving 160 patients with penetrating limb trauma demonstrated significantly reduced time to hemostasis with Celox Gauze compared with standard pressure dressings.[23] Available studies support the safety and effectiveness of both agents for prehospital hemorrhage control.[24]
• XStat: Preloaded syringe-like applicator containing small chitosan-coated cellulose sponges. XStat functions as a mucoadhesive hemostatic agent, sealing the wound and expanding to up to 12 times its original volume, thereby promoting internal compression and hemostasis. The coated minisponges are nonbiodegradable and contain radiopaque markers to facilitate later retrieval. XStat is indicated for control of hemorrhage in deep-tract and narrow-entrance wounds associated with penetrating trauma, including junctional injuries such as gunshot wounds. Evidence demonstrates effective hemorrhage control in scenarios, including junctional injuries, that are not amenable to conventional measures, such as tourniquet application.[25] Removal is more difficult and time-consuming than standard gauze packing. Contraindications include severe intrathoracic, intrapelvic, and intra-abdominal injuries.

Hemostatic wound packing is performed similarly to standard wound packing. The CoTCCC recommends maintaining manual pressure for at least 3 minutes after applying a hemostatic dressing. Most hemostatic dressings may be removed and replaced with fresh material if bleeding persists during prehospital care. XStat represents an exception to this approach. Persistence of hemorrhage following XStat placement warrants consideration of tourniquet placement and additional XStat placement or an alternative hemostatic dressing.

Junctional Tourniquets 

Junctional tourniquets control junctional hemorrhage through proximal arterial compression. In 2013, US Central Command and the Department of Defense Joint Trauma System called for increased research on junctional tourniquets, leading to US Food and Drug Administration (FDA) clearance of 4 junctional hemorrhage-control devices. The products are as follows:

• Combat Ready Clamp (CRoC): Vise-like compression device that applies focused pressure to the wound to promote hemostasis. FDA-cleared indications include unilateral inguinal and axillary hemorrhage.
• Junctional Emergency Treatment Tool (JETT): Belt-based system with 2 trapezoidal pressure pads applied around the pelvis and tightened using 2 windlass T-handles. Compression capability includes unilateral or bilateral control of the femoral artery. Device placement is applicable around the pelvis. However, FDA clearance does not include pelvic stabilization.
• SAM Junctional Tourniquet (SJT): Belt system with 2 pneumatic inflatable compression bladders. FDA-cleared indications include bilateral inguinal hemorrhage, axillary hemorrhage, and pelvic stabilization.
• Abdominal Aortic and Junctional Tourniquet (AAJT): Wedge-shaped pneumatic belt with FDA clearance for inguinal, axillary, and pelvic hemorrhage control. Capability includes occlusion of the infrarenal abdominal aorta at the umbilical level in cases of bilateral inguinal or pelvic hemorrhage.

Most civilian EMS agencies are not currently trained to use these devices. In 2014, the American College of Surgeons Committee on Trauma guideline for external hemorrhage control stated that evidence was insufficient to recommend the use of novel junctional tourniquets. In 2021, the CoTCCC recommended the use of a junctional tourniquet in appropriate cases, with application not delayed even when hemostatic dressings are used in the interim.

Studies involving animal models, healthy volunteers, and cadaveric subjects do not provide consistent support for junctional tourniquet use. In addition, no clear evidence demonstrates the superiority of any single junctional tourniquet device over others.

Tranexamic Acid

Tranexamic acid (TXA) is a synthetic lysine analog that stabilizes fibrin clots and inhibits fibrinolysis. The 2010 CRASH-2 (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2) trial demonstrated reduced mortality in trauma patients following intravenous TXA administration.[26] In 2012, data from the MATTERs (Military Application of TXA in Trauma Emergency Resuscitation) study demonstrated that intravenous TXA use in the combat setting reduced coagulopathy and improved survival.[27]

Subsequent trials have further supported a mortality benefit associated with prehospital intravenous TXA administration.[28] Current CoTCCC guidelines recommend administering 2 g of TXA via slow intravenous push within 3 hours of injury. Administration beyond 3 hours postinjury is less effective and may be harmful. Studies have demonstrated TXA as a practical and cost-effective option in the prehospital setting.[29]

Clinical Significance

Traumatic hemorrhage is the leading cause of preventable military death and the 2nd leading cause of death in civilian trauma patients. A study evaluating US combat casualties from 2001 to 2011 found that 19.2% of preventable prehospital deaths were attributable to junctional hemorrhage. Analysis of the Department of Defense Trauma Registry for casualties with documented junctional tourniquet application from 2007 to 2023 identified 48,301 encounters, with junctional tourniquet placement documented in only 39 cases.[30] This finding highlights a discrepancy between the recognized burden of junctional hemorrhage and the infrequent use of junctional tourniquets in practice, suggesting potential underutilization or barriers to implementation in trauma care.

Massive hemorrhage is a time-dependent condition. Treatment options for ongoing hemorrhage in the prehospital setting have historically been limited. Hemostatic transfusion algorithms assist in emergency department resuscitation but are less applicable in the prehospital environment, where access to blood products remains limited. Prehospital interventions must prioritize the rapid identification and control of bleeding to facilitate prompt transport to definitive care.

The increasing incidence of civilian mass shootings and bombings has increased the relevance of military medical innovations in civilian practice. Advances in prehospital hemorrhage control may extend the time window for definitive surgical management and provide a significant survival advantage. As mentioned, recognition of the consequences of massive junctional hemorrhage has driven multiple innovations in prehospital junctional hemorrhage control. In addition to the application of advanced medical and surgical interventions, EMS providers require competency in hemorrhage management.

Enhancing Healthcare Team Outcomes

Junctional hemorrhage management requires an interprofessional team composed of emergency medical technicians, paramedics, nurses, emergency medicine physicians, and trauma surgeons. Effective teamwork bridges gaps between disciplines and ensures appropriate application of individual expertise in patient care. Good communication, clearly defined roles, structured training, and prudent resource management are essential elements supporting collaboration among healthcare personnel. Debriefing after severe hemorrhage cases facilitates refinement of team performance and improves preparedness for future emergencies.