Under Pressure: Prehospital Junctional Tourniquets

By Frances Hall

One sunny afternoon your unit responds to a teenage boy who was deeply impaled with several pieces of jagged metal following a propane explosion.  In his pain and confusion, the patient yanked the shrapnel out of his inner thigh. Your partner packs gauze into his wound but the bleeding doesn’t slow at all.

Trauma remains a leading cause of death for healthy young adults who, save the one incident that put them into contact with EMS, probably would have enjoyed decades more of a healthy life. The statistic we hear quoted so often, that trauma is the leading cause of death of Americans under age 40, remains no less tragic and profound for the repetition.

Many of these patients die of a noncompressible hemorrhage: bleeding from an artery that typically cannot be accessed for manual compression by any means available to field providers. These scenarios can seem hopeless. However, with the correct education and appropriate training, we can control bleeding found at a “junction,” the groin or the armpit. This is done by occluding the arterial proximal to the bleeding through pressure on the patient’s torso.

The idea that enough pressure on an abdomen can successfully compress a subclavian or a descending aorta feels absurd. However, the research on the topic is indisputable: in 2019 six anesthetized were cut in half through their pelvises. They were separated into two groups: Three pigs had their wounds packed with hemostatic dressings, which are inundated with crystals and powders that encourage clotting. The other three had a junctional tourniquet applied around their abdomen. 

The results are dramatic: at sixty minutes, all of the pigs who had their wounds packed with hemostatic dressings were dead while all of the junctional tourniquet pigs were alive. The survivors also had a Mean Arterial Pressure (MAP) of 73 mmHg, within normal limits.

The puddle of blood has grown so much that now you’re kneeling in it. The clock is ticking, and the patient’s distraught father is looking to you for an answer. Your patient is starting to look sleepy and grey, clearly going into hemorrhagic shock.

In an ideal world, there would be a commercial junctional tourniquet available to you for these rare patients. However, if your service doesn’t carry them, or you find yourself in a situation where you do not have access to this tool, then what?

Fear not, brave adventurer, you can control the bleed and then make your very own device:

Ensure the patient is on a hard surface: As in CPR, this patient must be on a floor or backboard and not a mattress or cushion.

Select an appropriate smooth and rigid cylinder that can tolerate at least 200 pounds of pressure:  Some appropriate objects are radios, steel-toed boots, hose nozzles, axe handles, pickets, and durable “Nalgene-style” water bottles.  (We had the best results for the least effort with a Vindicator nozzle.)

Beyond those requirements, the only real limit is the ingenuity of the crew making the junctional tourniquet.

This object will be placed in one of two locations:

For limb injuries where the armpit is being occluded: 

• The official location to apply a rigid object under pressure for occlusion can be found directly below the far lateral clavicle, directly below the humeral head, and outside of the ribcage. 
  • In individual trials, the teams repeatedly had difficulty locating and applying enough pressure to that location, requiring multiple attempts and several minutes to occlude the artery.  
    • PRO TIP: Make your life easy. Lift the affected limb above the patient’s head and press a rigid cylinder like a hose nozzle across the armpit. Lifting the hand moves the subclavian artery more anterior and thins it, which is ideal if you are trying to compress this artery. An armpit is also much easier to locate than a specific, golf ball-sized section of the chest.

For a bleed from the groin, there are two options: 

• To rapidly, quick-and-dirty manage the bleed, or for a bilateral bleed or a bleed coming from beneath the belly button but above the groin just occlude the entire descending aorta: 
  • Place an ax handle or picket or baseball bat across the patient’s torso, just below the rib cage, perpendicular to the patient’s legs, and press down with at least 140 pounds of pressure.
• You can also just occlude the artery upstream of only the affected limb, either as initial management or for the junctional tourniquet you’ll be employing during transport.
  • For this use, the object goes right against the same place where we check the femoral pulse during a code: midway between the iliac crest and the groin, along the thigh crease.

Once the object is selected and placed in the correct location, the largest and heaviest provider must kneel on it while the other providers gather the rest of the material.

It takes a lot of force to occlude these arteries: a minimum of 120 lbs of pressure for the subclavian artery and 140 lbs. of pressure for the inguinal or descending aorta.

One study found that someone taking a knee casually can press down with about 55% of their weight and someone trying their absolute hardest to press down as hard as they can apply about 70%₃. Therefore, this should be done by a provider weighing 254 pounds or more. If you only have smaller providers available, have them hold or wear something heavy.  Or simply use two providers, having each kneel on either end of the cylinder until more units arrive.

They are on a hard surface, you are applying pressure, you’ve chosen your object, now what?

After selecting the object and placing it, the process becomes like improvising any other tourniquet. A wide band will be needed. This can be a commercial pelvis wrap, a rubber band-type tourniquet, a gait belt, strips of towel, or many other objects.

Taking extreme care not to displace the object, wrap the band over the object.

Use an improvised windlass to tighten it until the pressure is sufficient to stop the bleeding and the pulse distal to the device. The windlass can also be made from various objects: rigid stylet, wrench, chisel, or even a metal spatula. It needs to be rigid enough not to warp but short enough to twist and secure.

Note: For the armpit, it’s typical to need two straps running perpendicular across each other to secure it.

Use an incredible amount of tape to secure everything: the windlass to the strap, the strap to the tape, and the object to its position on the body.  Junctional tourniquets are very sensitive and must remain within millimeters of the exact position that they were placed in.

These patients must be moved very gently and The tourniquet itself needs to be treated like an endotracheal tube and rechecked after any moves. If you notice the bleed returning, check the position of the object. Tighten the strap further. Add another strap. Repeat until the bleeding stops.

The post-tourniquet management is the same as any other tourniquet: 

• Mark the patient clearly as having had a tourniquet applied.  
• Transport emergently.
• Keep the patient very warm to encourage clotting.
• Offer your patient as much pain management as their blood pressure can tolerate.
• Ensure the word “tourniquet” features in the first sentence of your hand-off report.

The wound in his groin from a large, jagged piece of backyard shrapnel continued to gush. The medic asks the father for his belt and one of the work boots he’s wearing. He lays the boot at approximately the level of the patient’s belly button and asks one of the bystanders, a 280-pound man, to kneel on it. Using one of the barbecue forks, he has an aortic tourniquet fastened in under five minutes.

An improvised junctional tourniquet is the epitome of a high-acuity, low-frequency skill. However, it can be educated on, trained, and drilled in a low-stress environment. This technique is reasonably new, even in combat theaters. In prehospital medicine, junctional tourniquets are typically not carried out or known. It is a skill that will be employed irregularly, if at all. Successful application, especially in an austere environment, may be a single skill that saves a person's life.

We all know how difficult it can be to do something so technical and fussy while your brain is fogged with adrenaline, to remember this one obscure and complicated skill in a moment that would be stressful to even the most seasoned provider. But the reward is a moment few people outside of our field ever get to experience, the reason each one of us works this of all jobs: to give a stranger the gift of a future, to do battle with physiology itself and win, to just barely wrench a human life away from death. It’s more than worth it.

(Author’s Note: If you find yourself in the unfortunate circumstance of having to do this skill or have discovered other successful materials or techniques, I would love to hear an HPI-redacted account of the event. Contact me at frances.hall@gffd17.org.)

Works Cited 

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