Overview of EMS Junctional Hemorrhage Control
In the U.S., injuries or accidents (“trauma”) are the main cause of death for people under 46 years old. Also, they are the fourth leading cause of death in all age groups. The biggest reason people die from trauma is severe bleeding or severe brain injury. Most deaths from severe blood loss happen within 2 hours after the injury. However, around one-fourth of these cases could have been prevented with proper care quickly after the injury. This care often includes measures to stop the bleeding through medication or surgery, and can greatly improve a patient’s chances of survival.
One of the most common methods to stop bleeding after injury is the use of tourniquets. These are devices that put pressure on the area above the place that is bleeding in order to stop the blood flow. Evidence collected from military medicine has shown that tourniquets can be very useful in controlling bleeding. Recent wars in Iraq and Afghanistan have shown that wide use of tourniquets can greatly reduce death due to bleeding from injuries.
In 2015, a national public health initiative called “Stop the Bleed” was started. The goal of this project is to teach ordinary people how to stop severe bleeding and potentially save lives. Tourniquets have also become more commonly available to emergency medical service (EMS) providers who are not in the military.
Although tourniquets are effective, people are now looking at how to prevent deaths from “exsanguination” (blood loss) from injuries that are not good candidates for a tourniquet. Health care providers learn that in trauma patients, the following six areas are usually checked for potentially deadly bleeding:
– Chest
– Stomach area
– Back of the stomach area
– Pelvic area
– Bone fractures
– External bleeding (from the skin or scalp)
It’s important not only to figure out where the bleeding is coming from but also if it can be stopped through manual pressure. For example, internal injuries (like injuries to organs in the stomach) would not typically be controlled with pressure or detected without medical equipment. Nevertheless, bleeding from an injury to a long bone in your arm or leg might be stopped with a well-placed tourniquet. Wounds on the scalp or skin can usually be managed with direct pressure, or by packing the wound or using a pressure dressing.
The use of homemade bombs (“Improvised Explosive Devices” or IEDs) in recent wars has caused more pelvic injuries with accompanying injuries to the groin or upper leg. A term was introduced called “junctional hemorrhage,” which is bleeding occurring in the transition area between the torso and the neck or a limb. Efforts to manage this type of bleeding both on the battlefield and at home have increased.
“Bleeding junctions” may include the groin, armpit, genital area, shoulder, and base of the neck. Bleeding from these areas can be life-threatening and should not be overlooked during emergency care.
Bleeding from a “junction” may or may not be able to be controlled using manual pressure. However, tourniquets are often not an option because of the location of the injuries. Uncontrolled “junctional” bleeding can result in rapid blood loss and death. Reports suggest that 19% of preventable deaths on the battlefield from 2001 to 2011 were a result of “junctional” bleeding.
If pressure can be applied to a “junctional” injury, it often requires constant, direct pressure on the injured site. But this can be difficult to do in emergency situations due to lack of first-aid resources and unpredictable circumstances. Specialized tourniquets, wound packing, dressings and other methods may be needed to control “junctional” bleeding and improve chances of survival. It’s critical that EMS providers are trained to quickly and accurately identify, evaluate, and manage “junctional” injuries. The rest of this article reviews the latest strategies for controlling “junctional” bleeding during emergency care.
Why do People Need EMS Junctional Hemorrhage Control
Treatment might be needed if there is bleeding due to an injury or trauma in any of the following body areas:
- The groin, which is the area where your abdomen meets your thigh
- The axilla, more commonly known as the armpit
- The base of the neck, where the neck connects with the shoulders and chest
- The perineum, the area between the anus and the genitals
- The shoulder girdle, which includes the collarbones and shoulder blades
How is EMS Junctional Hemorrhage Control performed
If someone suffers a serious bleed, they could go into a state called hemorrhagic shock. This is very dangerous and can lead to a vicious cycle of worsening conditions known as the “lethal triad” – this includes having blood that doesn’t clot properly (coagulopathy), increased acidity in the blood (acidosis), and low body temperature (hypothermia). It’s really important to stop the bleeding quickly, keep the person warm and get them to a trauma center fast.
This article focuses on how to stop heavy bleeding, particularly in areas where large blood vessels are close to the surface of the skin (junctions).
Applying pressure with your hands
One of the first things to do is to apply pressure to the wound. This can stop bleeding in lots of cases, even in injuries to major blood vessels. If possible, the injured area should be placed against a firm surface while pressure is applied. It’s important to keep the pressure on and not let up to check the wound.
Packing the wound
If applying pressure isn’t enough, stuffing the wound with a material (like gauze) can help stop the bleeding. This works by putting pressure on the blood vessels and stopping the flow of blood. When filling the wound, one hand should be used to push the gauze in and the other to keep it in place. If there are any foreign objects or bone fragments in the wound, they need to be removed. Sometimes, the gauze might absorb the blood without stopping the bleeding. This can lead to hidden, ongoing bleeding, so it’s important to be aware of this.
Applying a pressure dressing
Sometimes, it’s not practical to keep pressure on a wound manually so dressing that applies pressure to the wound can be helpful. This usually involves a padding material, held in place by a tight band. Emergency care providers might use dressings that are readily available or use commercial ones. It may be necessary to apply more dressing or pressure if the wound continues to bleed.
Hemostatic Dressings
Over the past 20 years, dressings that help to stop bleeding (hemostatic dressings) have been developed. They work by encouraging the blood to clot (factor concentrators), sticking to the injured tissue to physically seal the wound (mucoadhesive agents), or providing additional substances to encourage clotting (procoagulants). Recommendations by different organizations suggest using these kinds of dressings when a major external bleed can’t be stopped by applying pressure or tourniquets.
There are a few different products available, including:
- QuikClot Combat Gauze: This dressing has a substance called kaolin which encourages clot formation.
- Celox Gauze and ChitoGauze: These dressings contain chitosan, a substance that binds to blood cells and forms a barrier to seal the damaged vessel.
- XStat: This product uses small, sponges that expand inside the wound effectively applying pressure and stopping the bleeding. However, XStat isn’t suitable for several types of injury.
When using these dressings, it’s important to keep pressure on the wound for at least 3 minutes and they can usually be replaced with a fresh one if the bleeding continues.
What Else Should I Know About EMS Junctional Hemorrhage Control?
Severe bleeding due to injuries is the top reason for preventable deaths in the military and the second leading cause of death in accidents among civilians. A study found that nearly 20% of avoidable deaths before reaching the hospital among combat casualties were due to bleeding from areas where the limbs connect to the body.
Bleeding heavily is a situation that requires immediate attention. While there are treatments available in the hospital to stop bleeding, resources for treating such conditions outside the hospital are often limited. Blood transfusion formulas can be used in hospitals but are less effective without access to proper blood supplies. So, it is crucial for first aid efforts to quickly locate the source of bleeding and try to stop it. This allows faster transport to a hospital where more extensive care can be provided.
Sadly, the rise in violent incidents involving mass shootings and bombings among civilians has meant that the methods used in military medicine to control heavy bleeding are increasingly necessary outside of the military. Better management of heavy bleeding before reaching a hospital can buy crucial time for definitive surgery and can significantly improve survival rates. Given the potential risks of severe bleeding, numerous new methods have been developed to control bleeding in the field. Furthermore, emergency medical service (EMS) providers need to be skilled not only in providing advanced medical and surgical treatments but also in handling emergencies involving heavy bleeding.