Understanding the Anatomy of Junctional Bleeding
Junctional haemorrhage is bleeding that occurs from a serious injury at the 'junctions' of the body. These critical anatomical areas include the groin, axilla (armpit), and the base of the neck where major arteries and veins travel close to the skin's surface before entering the limbs. Unlike bleeding from a lower arm or leg, these locations are not easily compressed with a standard circumferential tourniquet, posing a unique and life-threatening challenge for trauma care providers.
Where does junctional haemorrhage occur?
- Groin/Inguinal Area: The femoral artery and vein, which supply blood to the legs, can be severed or injured here.
- Axilla/Armpit Area: The subclavian and axillary arteries, which supply blood to the arms, are vulnerable.
- Base of the Neck/Shoulder: This area contains vital vessels like the carotid, subclavian, and jugular, injuries to which can be catastrophic.
Causes and Risk Factors
Junctional haemorrhage can result from a variety of traumatic incidents. The severity of the bleeding is directly related to the size of the injured blood vessel and the mechanism of injury. It can happen to anyone, but certain scenarios increase the risk.
Common causes of junctional bleeding include:
- High-Energy Trauma: Incidents like motor vehicle accidents, high-impact sports injuries, or falls from a significant height.
- Penetrating Injuries: Gunshot wounds, shrapnel, or stabbings that occur in the junctional regions are a primary cause.
- Industrial Accidents: Crushing injuries from heavy machinery or equipment.
Recognizing and Assessing the Injury
Rapid recognition is key to saving a life. Any major trauma to a junctional area with external bleeding should be considered a junctional haemorrhage until proven otherwise. Signs can include visible spurting or gushing of blood, blood-soaked clothing, or a patient who is losing consciousness due to blood loss (exsanguination).
Steps for initial assessment:
- Survey the Scene: Ensure safety for yourself and the patient before approaching.
- Assess the Bleeding: Identify the source of the bleeding and estimate the volume. Look for major blood vessels. In severe cases, the blood loss can be massive and immediate.
- Check for Other Injuries: In many high-trauma situations, multiple injuries may be present. Prioritize the most life-threatening bleeding first.
The Critical Challenge of Control
Controlling haemorrhage is the primary goal, but the irregular shape and location of junctional areas complicate this. Standard limb tourniquets are not designed for these areas and are ineffective. This is why specialized equipment and techniques have been developed.
Hemorrhage Control Techniques
Effective control of junctional bleeding requires specific interventions. These techniques can be applied by trained first responders and emergency medical services (EMS) providers.
- Direct Pressure and Wound Packing: This is the most immediate and accessible method. The wound should be packed with hemostatic gauze (specialized gauze that promotes clotting) and firm, direct pressure should be applied for at least three minutes. This is often a temporizing measure until a mechanical device can be applied or the patient reaches definitive medical care.
- Junctional Tourniquets: These are specialized devices designed to apply pressure to junctional areas. They typically consist of a belt or strap with an inflatable bladder or mechanical pressure device to target the specific blood vessel. Examples include the Combat Ready Clamp (CRoC), the Junctional Emergency Treatment Tool (JETT), and the SAM Junctional Tourniquet (SJT).
- Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): This is a more advanced technique used primarily in hospital settings or by highly-trained teams. A balloon catheter is inserted into a major artery (usually in the leg) and advanced to the aorta, where it is inflated to temporarily block blood flow to the lower body and pelvis.
Comparison of Haemorrhage Control Methods
| Method | Applicability | Pros | Cons |
|---|---|---|---|
| Direct Pressure/Wound Packing | Pre-hospital (first aid) | Widely available, quick to implement | Requires continuous manual pressure, may not be sufficient for severe bleeding |
| Junctional Tourniquets | Pre-hospital (trained personnel) | Specifically designed for junctions, frees up rescuer's hands | Specialized equipment required, training is necessary |
| REBOA | Hospital/Advanced Pre-hospital | Highly effective for pelvic/lower torso bleeding | Highly invasive, requires advanced training and equipment, carries risks |
Training and Response
Given the severity and rapid progression of junctional haemorrhage, effective training is crucial for both first responders and civilian personnel. Initiatives like 'Stop the Bleed' have increased public awareness of how to control massive bleeding, but specific training for junctional injuries remains critical for professionals.
What untrained individuals can do in an emergency:
- Call emergency services immediately.
- Apply firm, direct pressure to the wound with a clean cloth or their hands.
- Elevate the injured area if possible, though this is difficult for junctional sites.
- Keep the patient warm to prevent hypothermia, which can worsen bleeding.
Conclusion: The Importance of Preparedness
Junctional haemorrhage represents a profound threat due to its location and the potential for rapid blood loss. Understanding what is junctional haemorrhage is the first step toward effective management. The application of trauma care knowledge from various contexts to civilian settings highlights the importance of specialized equipment and training. With the right knowledge and tools, it is possible to control this life-threatening bleeding and significantly improve patient outcomes.
For more information on the latest techniques for controlling massive haemorrhage, including junctional injuries, authoritative sources like the StatPearls - NCBI Bookshelf offer comprehensive insights into management protocols.
