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EMS Junctional Hemorrhage Control

Editor: Annalee M. Baker Updated: 11/14/2023 3:03:23 PM


In the United States, trauma remains the leading cause of death in patients aged 46 and younger and the fourth leading cause of mortality across all age groups.[1] Trauma fatalities are mostly due to catastrophic hemorrhage and traumatic brain injury. Most hemorrhage-related traumatic deaths occur in the first 2 hours after injury, though around one-fourth of the cases are preventable.[2] Proper prehospital care, including swift medical or surgical hemorrhage control, can dramatically impact mortality and patient outcomes.[3]

The use of extremity tourniquets is perhaps the most well-known prehospital intervention for traumatic hemorrhage. Tourniquets control hemorrhage, occluding the injured artery by applying constant, firm circumferential pressure proximal to the bleeding site. As with other aspects of evidence-based trauma care, military data provided the earliest robust evidence for tourniquets' usefulness in controlling hemorrhage. The widespread application of extremity tourniquets in recent Iraq and Afghanistan wars successfully reduced hemorrhage-related mortality.

Subsequently, in 2015, a federal interagency workgroup launched a nationwide public health campaign called “Stop the Bleed.” The program translates combat medicine's hemorrhage control techniques to the civilian sphere by teaching basic bystander actions that stem life-threatening bleeding.[1][4] Additionally, tourniquets have become increasingly available to trained civilian EMS providers.[5]

After seeing the success of extremity tourniquets, the focus has now shifted to preventing battlefield deaths by exsanguination from sites not amenable to tourniquet use.[4] Traditional trauma education programs teach that 6 locations must be considered as sources of potentially fatal hemorrhage in a trauma patient:

  1. Chest cavity
  2. Abdominal cavity
  3. Retroperitoneum
  4. Pelvis
  5. Long bone fractures
  6. “Street” (scalp or other external sources)

While identifying the bleeding site is critical, determining whether or not it is manually compressible is also vital. Deep areas of internal bleeding, such as solid organ injury in the abdominal cavity, clearly cannot be easily controlled or recognized in the prehospital setting. However, hemorrhage from an extremity long bone fracture may be controlled by proper proximal tourniquet application. Scalp and other external wounds may respond to direct manual pressure, wound packing, or pressure dressings.  

Enemy use of Improvised Explosive Devices (IED) in recent wars led to an increase in pelvic fracture cases with associated groin or high leg injuries[6]. The term "junctional hemorrhage" was introduced in the literature in 2009, referring to hemorrhage in the junction between the torso and the neck or one or more extremities. That time was also marked by renewed efforts to develop techniques and devices for junctional hemorrhage control both on the battlefield and at home.

Sites involved in junctional hemorrhage include the groin, axilla, perineum, shoulder girdle, and base of the neck. Hemorrhage in these areas is potentially life-threatening and must not be missed during prehospital management.[4]

Junctional hemorrhage may or may not be manually compressible. However, it is generally not amenable to traditional tourniquets due to the injury's proximal location. Rapid exsanguination and death may result from uncontrolled junctional hemorrhage. Studies estimate that 19% of preventable Iraq and Afghanistan battlefield deaths between 2001 and 2011 involved junctional hemorrhage.[7] 

When compressible, junctional injuries often require constant, direct manual pressure against the site. This is often challenging to achieve due to the typically limited personnel and unpredictability of circumstances in prehospital settings. Wound packing, hemostatic agents and dressings, junctional tourniquet devices, and others may be necessary to control junctional hemorrhage in the field and increase survival rates. Emergency Medical Services (EMS) providers must be trained to properly and promptly recognize, assess, and manage junctional injuries. This article will review the considerations and most current management options for prehospital junctional hemorrhage control.


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Indications for treatment include traumatic hemorrhage from any of the following locations: 

  • Groin
  • Axilla 
  • Base of neck 
  • Perineum 
  • Shoulder girdle

Technique or Treatment

Early management of hemorrhagic shock relies on fast bleeding site identification, quick hemostasis, and immediate resuscitation. Traumatic hemorrhage may rapidly lead to the so-called "lethal triad" of coagulopathy, acidosis, and hypothermia. Preventing the onset of this chain reaction increases patient survival to definitive care. Priorities for prehospital care include minimizing further blood loss, limited volume resuscitation with crystalloid, hypothermia prevention, and rapid patient transport to a trauma center.[8]

This article will focus specifically on prehospital interventions that minimize blood loss in severe junctional hemorrhage cases.  

Manual Direct Pressure

Direct digital pressure on the wound should be first attempted to control junctional hemorrhage. Most external bleeding sites and some major arterial injuries respond to this measure.[9] Constant pressure should be applied with the body part supported by a firm surface. The pressure should not be released to check if bleeding persists. 

Wound Packing

Some wounds are not amenable to direct pressure alone. Filling the wound cavity with packing material aids in hemostasis by creating pressure and causing tamponade on the vessels. Using one hand to feed gauze and the other to keep it in place allows for continuous pressure on the wound. Foreign bodies and sharp bone fragments must be cleared during wound packing.

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

Packing material may absorb blood from the wound without controlling hemorrhage, causing the wicking effect. This must be prevented as it can lead to continued hidden hemorrhage. [10] 

Pressure Dressing

A well-made pressure dressing can effectively free the provider's hands from holding continuous pressure on the wound. A pressure dressing is created with a bulky sterile dressing material held in place by a tight circumferential band. Pressure dressings may be improvised using readily available wound care supplies. Roller bandages, gauze, or trauma pads can be used as bulky sterile dressing materials, while an elastic bandage, blood pressure cuff, or tourniquet can hold the dressing in place.

Commercially available pressure dressings are also available. Providers should read the manufacturer's instructions and be familiar with locally available commercial pressure dressings. Pressure dressings can be used alone, with manual pressure, or with wound packing and manual pressure. Additional pressure or dressing may be necessary if bleeding continues after pressure dressing application. 

Hemostatic Dressings

Research and development over the past two decades have led to the creation of various hemostatic products for use in prehospital care.[11] Hemostatic dressings are bio-engineered dressing materials impregnated with hemostatic agents. Combining hemostatic dressings and direct pressure has proven effective in controlling hemorrhage in a combat environment.[12] The American College of Surgeons Committee on Trauma (ACSCT), American Heart Association (AHA), American Red Cross, and CoTCCC recommend combining hemostatic dressings with direct pressure when an external major bleeding site cannot be controlled by direct pressure or traditional tourniquets.[13][14]

Hemostatic agents are classified into 3 groups based on their mechanism of action:[15]

  1. Factor concentrators: rapidly absorb water, increasing the concentration of clotting factors and platelets at the injury site
  2. Mucoadhesive agents: strongly adhere to injured tissue and physically seal the bleeding wound 
  3. Procoagulants: supplement hemostatic factors

Evidence does not support one type of hemostatic dressing over the others.[16] However, the following hemostatic dressings are recommended by the CoTCCC:

  • QuikClot Combat Gauze: The CoTCCC hemostatic dressing of choice. This kaolin-impregnated polyester-rayon dressing functions both as a factor concentrator and procoagulant.[11] Kaolin is an inorganic mineral and activator of the intrinsic clotting pathway, expediting clot formation.[17][18] It is the most widely studied hemostatic dressing and is known to have a good safety profile.[15] An Israel Defense Forces Medical Corps study involving 37 junctional hemorrhage cases found that QuikClot Combat gauze produced hemostasis in 88.6% of cases.[19] Combat gauze is currently the primary hemostatic dressing used by all US Operational Forces and NATO military organizations.[20] 
  • Celox Gauze and ChitoGauze: Chitosan-containing dressings serving as mucoadhesive agents. Chitosan is a positively charged, shrimp exoskeleton-derived polysaccharide. It binds to negatively charged red blood cells and forms a cross-linked barrier to seal the damaged vessel.[11] A 2015 randomized control trial of 160 patients with penetrating limb trauma found that Celox Gauze significantly reduced the time to hemostasis compared to standard pressure dressings.[21] Studies have shown both agents to be safe and effective for prehospital hemorrhage control.[22] 
  • XStat: A pre-loaded syringe-like applicator filled with small, chitosan-coated cellulose sponges. XStat is a mucoadhesive—it seals the wound and expands up to 12 times its volume, thus promoting internal compression and hemostasis.[11] The coated mini-sponges are not biodegradable and contain radiopaque markers that guide removal later. XStat can control hemorrhage in deep-tract and narrow-entrance wounds occurring in penetrating trauma, as in gunshot junctional area wounds. Research reveals that XStat can adequately control hemorrhage not amenable to tourniquet placement or other means, even in junctional injury cases.[23] However, XStat is more difficult and time-intensive to remove than simple gauze packing. The agent is contraindicated in severe intra-thoracic, intra-pelvic, and intra-abdominal injuries. 

Hemostatic wound packing is performed in the same manner as general wound packing. The CoTCCC recommends maintaining manual pressure for at least 3 minutes after applying the dressing. Most hemostatic dressings can be removed and replaced with a fresh one if the bleeding continues during prehospital care. XStat is the exception. If bleeding persists after XStat application, consider tourniquet placement and using more XStat or another hemostatic dressing type.  

Junctional Tourniquets 

Junctional tourniquets control junctional hemorrhage by creating proximal arterial compression. In 2013, the US Central Command and Department of Defense's joint trauma system called for more junctional tourniquet research, paving the way for the FDA approval of 4 junctional hemorrhage control devices.[12] The products are as follows:

  1. Combat Ready Clamp (CRoC): a vise-like compression disk that clamps down on the wound and promotes hemostasis. Unilateral inguinal and axillary bleeds are FDA-cleared indications. 
  2. Junctional Emergency Treatment Tool (JETT): a belt with 2 trapezoidal pressure pads that can be placed around the pelvis and tightened with 2 windlass mechanical T-handles. The JETT can be used to compress one or both femoral arteries. This product can be placed around the pelvis, though it is not FDA-cleared for pelvic stabilization.
  3. SAM Junctional Tourniquet (SJT): a belt with 2 pneumatic inflatable compression bladders indicated for bilateral inguinal hemorrhage, axillary hemorrhage, and pelvic stabilization. 
  4. Abdominal Aortic and Junction Tourniquet (AAJT): a wedge-shaped pneumatic belt FDA-approved for inguinal, axillary, and pelvic hemorrhage. It can be used to occlude the infrarenal abdominal aorta at the umbilical level in cases of bilateral inguinal or pelvic hemorrhage.[5]  

Presently, however, most civilian EMS agencies are not trained in using these products.

In 2014, the ACSCT Guideline for External Hemorrhage Control stated that evidence is insufficient to recommend the use of these novel junctional tourniquets. However, in 2021, the CoTCCC recommended junctional tourniquet use in amenable cases and must not be delayed even if hemostatic dressings are applied in the interim.

Note that studies on animals, healthy volunteers, and cadavers do not support the use of junctional tourniquet products. Furthermore, there is no clear evidence suggesting the superiority of any single product type over the others.

Tranexamic Acid

Tranexamic acid (TXA) is a synthetic lysine analog that stabilizes fibrin clots and blocks fibrinolysis.[24] The 2010 CRASH-2 trial demonstrated that intravenous TXA reduced mortality in trauma patients.[25] In 2012, data from the Military Application of TXA in Trauma Emergency Resuscitation (MATTERs) showed that intravenous TXA use in the combat setting reduced coagulopathy and improved survival.[26]

Various other trials later supported the mortality benefit of intravenous TXA administration in the prehospital setting.[24] The current CoTCCC guidelines recommend 2 g TXA in slow IV push within 3 hours of injury. Importantly, TXA administered more than 3 hours postinjury is less effective, even potentially harmful.[27] Studies have illustrated that TXA is a practical and economically sound option in the prehospital setting.[27]

Clinical Significance

Traumatic hemorrhage is the leading cause of preventable military death and the 2nd leading cause of death in civilian trauma patients.[5] A study evaluating U.S. combat casualties from 2001 to 2011 found that 19.2% of preventable prehospital deaths resulted from junctional hemorrhage.[7]

Massive hemorrhage is a time-dependent condition. Treatment options for ongoing hemorrhage in the prehospital setting have historically been limited. Hemostatic transfusion algorithms aid in emergency department resuscitation but are less useful in the prehospital environment, where access to blood products is rare. Prehospital interventions must focus on quickly finding and stopping the bleeding to facilitate rapid transport to definitive care.

The rising incidence of civilian mass shootings and bombings makes military medicine innovations increasingly relevant in the civilian sector. Advances in prehospital hemorrhage control may allow more time for definitive surgical management and yield a significant survival advantage. As discussed above, recognizing the possible consequences of massive junctional hemorrhage has led to numerous innovations in prehospital junctional hemorrhage control. Besides skillfully administering state-of-the-art medical and surgical interventions, EMS providers must be competent in managing hemorrhage.

Enhancing Healthcare Team Outcomes

Junctional hemorrhage management requires an interdisciplinary team composed of emergency medical technicians, paramedics, nurses, emergency medicine physicians, and trauma surgeons. Effective teamwork bridges the gaps between these disciplines, ensuring that each member contributes their expertise to the patient's care. Good communication, clearly defined roles, ample training, and prudent resource management are essential elements that facilitate collaboration among healthcare workers. Debriefing after severe hemorrhage cases helps refine team skills and enhances overall preparedness for future emergencies.



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