We are honored to share a guest write-up by Rob, @rob_o_medic, Senior 18D and instructor on the treatment of junctional injuries!
The hemorrhage that takes place when a main artery is divided is usually so rapid and so copious that the wounded man dies before help can reach him- Colonel H. M. Gray 1919
Hemorrhage in junctional areas, such as inguinal (groin), pelvic, and under the arms can take more time and expertise to control. These areas can and often should have junctional tourniquets added for additional hemorrhage control. Most medics should know or have heard of junctional tourniquets. However, improvised tourniquets of this nature may be unfamiliar to new medics or civilians who come across an injury that needs one, so we will lay out information as outlined through various reference materials available to service members and civilians alike.
As we all know hemorrhage is the leading cause of preventable death on the battle field. 90% of combat fatalities occur forward of a medical treatment facility. 75% of combat fatalities have non survivable injury and 25% have potentially survivable injury. Of those with potentially survivable wounds, 90% die from hemorrhage. Although bleeding is a main cause of death, the vast majority of wounds do not have life-threatening bleeding.
Massive hemorrhage tends to fall into two distinct categories:
Tourniquet use is great for extremities (compressible) wounds, but as IED's dominate the recent wars, an increasing percentage of casualties present with poly-trauma from blast related injuries rather than bullet or direct fire weapons. Recent statistics show a breakdown of casualties as: 60.5% from Boobytrap/IED and 19.2% from bullet. High junctional wounds (high femoral/pelvic and axillary wounds) do not allow the standard use of a tourniquet. So further considerations must be made to control blood loss to these areas.
Initial treatment should always be direct pressure and wound packing. There are various hemostatic agents available for use, such as Combat Gauze, Chito Gauze, Celox, and Nu-Stat. Its really shooter preference and what is readily available from your supply folks (what works better can be saved for another conversation). Remember to always find the SOURCE of the bleed and apply direct pressure.
Attempting Junctional TQ
A transition to a junctional TQ should be considered after manual pressure and wound packing has been attempted and successful. Due to the sometimes long and difficult set up of either deliberate or improved TQ's, the provider should make initial attempts at wound packing, manual pressure at identified pressure points, and if possible, clamping damaged vasculature when readily identified. Be sure to clamp proximal and distally to the damaged vasculature. Use of a Debakey peripheral vascular clamp preferable if you have access to one.
Managing Junctional Hemorrhage
Generally speaking if you arrive to find ongoing junctional hemorrhage and your patient is alive, you are already ahead of the power curve. We had an incident at Fob Shank in 2014. Some regular army platoon was training at the range. A young soldier got hot brass down his back. Being the undisciplined soldier he was, he freaked out, jerking his arm about with his weapon on fire. He shot his battle buddy in the hip right next to him. The soldier died before he made the 3 min drive to the FST located on base. The point of that story is if the major vasculature of the pelvis is hit, (iliac/femoral arteries) and there is complete dissection of those vessels, there is little you can do about it.
There are three major sources of pelvic bleeding: arterial, venous, and cancellous bone. 70% of the time, blunt pelvic trauma causing fracture is venous and may be controlled with pelvic stabilization.
Arriving at the patient:
(Pelvic and LE Junctional Bleeds/injuries)
I recommend applying pressure to high femoral with your fingers. It takes little to no pressure to achieve hemorrhage control this way. Medicine is generally not done in a vacuum, so utilize the people around you and replace your hands with theirs so you can control the chaos of treating the casualty.
Once hemorrhage control is confirmed, take a moment take a breath. Release some stress and think about what you are going to do next. Continue your blood sweeps of the patient and then begin exposing so you can visualize what you are dealing with. In training we generally don't make our patients completely trauma naked, but in actual trauma, you need to suspend modesty if it's the difference between life or death. This is important so you can identify what you need to pack or clamp etc...
Choose your hemostatic agent of preference. Pack as much as you can into the wound. Be sure to hold direct pressure for at least 3-5 minutes after application. This is often not done in training, yet is essential in a real life patient. (Training, especially at the school house, is often done on the clock so it creates bad habits).
Clamping- can be done and should if the major vasculature can be visualized.
Types of Junctional TQ's
SAM JTQ is my absolute favorite for a deliberate TQ.
I love the SAM for many reasons. It has so many uses and provides me with peace of mine that it will remain effective once applied, even after significant jostling of the patient. I am fortunate to have a giant patient population that we can try this on, and I have had the most success with the deliberate SAM. This will always be the one I carry until something else I find works better.
- Works as a pelvic binder
- Can be used bilaterally with both bulbs inflated over right and left femoral arteries
- The auto stop buckle ensures proper slack is taken out before application of bulbs
- Can be used for Axilla/subclavian injuries
- Has an auxiliary strap for additional support in pelvic use
- Extremely easy to use
- It's bulky- (I would hardly consider this a con as I am making sure I have room for this. But many people want to streamline their kits)
Go out and make sure you train with this device and become familiar with it. Common issues I see is applying this device to high. It must lie over the greater trochanter on both sides to effectively bind the pelvic and allow proper placement of the bulbs to gain hemorrhage control. You may need to tie the ankles with a cravat in internal rotation to provide further stabilization.
I have seen many types of improvised TQ's made with the SOFTT-W TQ's. I will lay out a few of them below. I will say these TQ's have a pretty high failure rate, at least from what I've seen in training at the school house. They do not provide me the piece of mind I once had when I first learned these years ago. Failures are commonly seen after patient movement due to it being improvised in nature. Be sure you have proper placement over high femoral area. Take out as much slack as possible and be sure to have the windless directly over where you are trying to provide direct downward pressure. With some of the larger implements used below, there is no pelvic instability, and if the patient permits, some external rotation of the LE may be needed to gain better purchase on the desired pressure point.
SOFT-W with a grenade pouch under the windless and a lacrosse ball secure inside. it provides pretty good direct pressure on the the high femoral area.
SOFT-W with a tightly rolled SAM splint preferably with all slack taken out and taped as to make it as rigid as possible
SOFT-W with a Nalgene bottle underneath
There are other ways to attempt JTQ's as well, such as using cravats! See pic below courtesy of the Special Operations Medical Coalition:
One last note. I am not a fan of placing a knee in pelvis for hem control. If you must and are a lone provider, a knee to the abdomen would be preferred over pelvis. We (the medical community) have also talked about using an AAJT (aortic TQ) as a very temporary stop gap so you can work through your procedures and then take it off. Most folks don't carry these and they are incredibly uncomfortable for the pt.
Axilla/ Subclavian vessel injuries
- I won't go into as much detail here as some of the same principals apply when managing this type of hemorrhage. As with above if you can visualize the bleeding utilize manual pressure to gain control of the bleeding. Pressure points are quite difficult in this area especially for the subclavian artery. You have the clavicle in the way of providing adequate pressure. I have seen it done but it takes an incredible amount of pressure and is extremely uncomfortable for the pt.
Wound packing- Same principals apply from above. If the wound is big enough, try to pack as much hemostatic gauze as possible and hold pressure for 3-5 minutes to achieve control. If there is no cervical involvement you can perform an X wrap around the body with a large 6in ACE wrap to provide external pressure to the injury.
Wound pack and take an additional roll of kerlex and place it in his armpit. Use the SAM TQ to secure his arm down to his side. With the added piece of kerlex you will provide adequate pressure to the Axilla to control any hemorrhage. More secure than just trying to use ACE wrap. It's difficult to provide direct pressure.
The SAM works great but you need to take an additional step. The SAM comes with this wedge device, and it's not ideal. Instead, take a golf ball sized roll of Coban and use that in place of the plastic wedge. Have the pt turn their head and you will see the notch/crease made by the proximal portion of the clavicle. Place the ball there underneath the balloon and you can achieve relatively comfortable hemcon of the subclavian vasculature.
Squashing a myth
-Subclavian tie off using IV tubing. This has been going around for a while and there are rumors it has been successfully done in the field. This is simply wishful thinking. With right-sided subclavian injuries a median sternotomy can be performed. For Left-sided injuries the use of a median sternotomy is inappropriate. The left subclavian vessels are posterior and cannot be reached through an incision alone. There is a procedure called a trapdoor incision or "book" thoracotomy. These procedures should be left to professionals. Utilize wound packing or a urinary catheter to gain hemorrhage control.
Don't cause more harm to a patient by attempting these procedures.
Pelvic Injury Notes:
If time permits, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and GU/GYN systems which may render FX open. Open injuries have a mortality rate of >50% due to hemorrhage and late sepsis.
Signs and Symptoms to look out for:
Length discrepancies, scrotal hematoma, and ecchymosis raise suspicion for pelvic ring injury. Bi-lateral lower leg amputations have a high association with clinically significant pelvic fracture and instability. Don't even waste time checking for stability. If the MOI correlates with associated injuries, go ahead and provide immediate pelvic stabilization.
Dropping a knee:
I am personally not a fan of dropping a knee into the pelvis. With the types of injuries we generally see that cause pelvic involvement, there is a high index of suspicion that there is pelvic instability. Dropping a knee into a patients pelvis is not good medicine. You are more than likely not actually getting any sort of occlusion to the underlying vasculature.
Use of X-Stat:
Lots of people ask about X-stat. Frankly I don't have any experience using this nor have I gotten much feedback in the positive about that device. I am not ruling it out, but as of right now its not finding a place in my aid bag.
My favorite- I think every medic should carry a Foley catheter in either their pocket or readily accessible on their med kit. you can use if for small wound tracks and stick it in directly into the wound. using saline flushes (preferred over air) fill the bulb to create a tamponade. Its important to clamp the proximal end of the catheter so as to not allow blood to flow through.
All treatment considerations come from an operator and instructors perspective. Supplementary information was gathered through Emergency War Surgery book as well as Joint Trauma Service CPG's.