EMS Junctional Hemorrhage Control

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. 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. Proper prehospital care, including swift medical or surgical hemorrhage control, can dramatically impact mortality and patient outcomes. 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. Additionally, tourniquets have become increasingly available to trained civilian EMS providers. 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. 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. 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. 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.  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.