Code 3 Workshop

Paramedic Education
Home/All lessons/Trauma/Wound Packing & Junctional Bleed
Lesson

Wound Packing & Junctional Bleed

12 min Trauma Skip to quiz

Objective: Pack junctional bleeding you cannot stop with a tourniquet. Pack down to the source, then hold firm pressure. Do not pack the chest. If the patient is breathing on their own, an open chest wound gets a vented seal, not gauze. If you are bagging the patient or a tube is in place, leave the wound open.

Why this matters

A limb tourniquet does not reach the groin, the axilla, or the neck. Those are junctional sites, where the limb or the neck meets the trunk. They hide under clothing and can kill as fast as a femoral artery.

First, expose the wound and pack to the bleeding source, or use a junctional tourniquet if the site fits and you carry one. Check that the bleeding has stopped, and hold pressure for the full interval. Do not pack the chest. Do not lift your hand at 20 seconds to look.

Combat teaching is to pack hemostatic gauze into the wound, hold direct pressure for at least 3 minutes, then apply a pressure bandage. Hemostatic gauze is gauze that helps the blood clot. Some expanding-sponge devices have their own hold time. Follow the device you carry. If the junctional tourniquet is ready, do not wait to finish a neat pack. MARCH still applies. MARCH is massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury.

Key points
  • Expose the area. The wound is often under a belt or in the groin crease, not where the first glance lands.
  • If the patient is breathing on their own, an open chest wound gets a vented seal, not packing. If you are bagging the patient or a tube is in place, leave the wound open. Do not pack the chest the way you pack a groin.
  • Hold pressure for the full teaching interval, about 3 minutes with hemostatic gauze. If you look at 20 seconds, the bleeding can restart during transport.
Verbalize
  • This bleeding is junctional. A limb tourniquet on the torso will not stop it.
  • I will pack to the source. A loose piece of gauze on the surface is not packing.
  • I will hold pressure. I will not look at 20 seconds.
  • If they are breathing on their own, an open chest wound gets a vented seal, not a pack. If we are bagging, I leave the wound open.

Clinical sequence

  1. Bleeding at the groin, axilla, or neck is junctional. A limb tourniquet placed on the torso will not stop it. A mid-thigh artery is still a limb-tourniquet problem. Packing does not replace a tourniquet on an extremity you can tourniquet.
  2. Pack gauze down to the bleeding source, or to bone when that is the depth of the wound. Gauze sitting on the surface is not packing.
  3. Hold firm pressure. Do not lift your hand at 20 seconds to check.
  4. An open chest wound gets a vented seal if the patient is breathing on their own, not a roll of gauze. If you are bagging the patient or a tube is in place, leave the wound open. See open chest wounds.

How Packing Works

  1. Expose the wound. Remove only enough clot to find the source. You are not doing surgery.
  2. Feed gauze into the wound track with a finger, or with an instrument if that is how you were trained, until you reach the source. Keep packing until the space is full. One roll is often not enough.
  3. Hold firm pressure for about 3 minutes on hemostatic gauze. Do not lift your hand to check.
  4. Place a pressure bandage over the pack and reassess. If blood soaks through, add pressure or pack again as you were trained. Do not only stack dry gauze on top.

Hemostatic vs Plain

  • Use hemostatic gauze when you have it. Plain gauze, packed tightly and held with pressure, is still better than a loose dressing that does not reach the source.
  • Expanding-sponge devices are for deep, narrow tracks. Do not pull them out in the field. Know what you carry.
  • Do not pack the chest. An open chest wound gets a vented seal if the patient is breathing on their own, and you watch for tension. Three-sided dressings are no longer recommended. Do not seal a patient you are ventilating with a bag-valve mask, or who is intubated, as the default.

Neck

Packing a neck wound is a trained skill. The airway and an expanding hematoma are in the same small space. A hematoma is a growing collection of blood. Direct pressure that does not block both carotid arteries is the first move. Follow your protocol. Do not pack the whole neck with gauze if you have not been trained to do it.

Common errors

  • Placing a surface dressing on a deep wound track.
  • Packing an open chest wound the way you pack a junctional wound.
  • Looking every 15 seconds, so a clot never forms.

Practice

One-minute check

On a wound trainer, or a rolled towel with a cavity, pack until you cannot add more gauze. Then count 3 minutes of pressure out loud. Your partner names three sites: groin, chest, and mid-thigh. For each site, say pack, seal, or tourniquet.

Related: Tourniquets, Open Chest Wounds, Massive hemorrhage first.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Junctional hemorrhage (groin, axilla) is best framed as:
2. Pressure after hemostatic packing, as taught here, is:
3. An open chest wound should be:
4. A mid-thigh arterial spurt is still primarily a:
← Tourniquet Application Damage-Control Resuscitation →