10.2 Hemostasis in Transport
Key Takeaways
- A tourniquet goes high and tight with the application time visible; do not loosen it in flight unless converting under a written protocol.
- Pack junctional wounds to bone with hemostatic gauze, hold pressure, and use a junctional device only if you are trained and equipped.
- A pelvic binder sits over the greater trochanters, not the iliac crests; scalp bleeding can empty the tank; impaled objects stay.
- Give tranexamic acid early (not after three hours), hang blood first, and treat resuscitative endovascular balloon occlusion of the aorta as a receiving-hospital intervention unless a rare program carries it.
- Confirm every tourniquet and pack before the door closes—you may not be able to reach them again in the cabin.
Hemostasis in transport is the job that cannot wait for a quiet trauma bay. Domain 3.A of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests hemostasis because a rotor-wing cabin gives you one chance to stop compressible bleeding and almost no chance to chase what you missed after the door closes. Blood is the fluid (Chapter 8). This section is the mechanical and pharmacologic stop.
Tourniquets: high, tight, timed
A commercial windlass tourniquet (TQ) goes high and tight on the bleeding extremity—as proximal as you can place it on bare skin—then is tightened until the bleeding stops and the distal pulse is gone. Write the time of application on the device and on the patient. That time is a receiving-team vital sign, not paperwork.
Do not loosen a TQ in flight to "check if they still need it." Reperfusion of a bleeding artery in a cramped cabin is how you convert a controlled scene into an unmanageable puddle. Convert a TQ to a pressure dressing only under a written conversion protocol, with blood hanging, a surgeon minutes away, and a plan if bleeding restarts. "The limb looks pale" is the TQ working, not a reason to ease the windlass.
Cabin access
After you package, you may not be able to reach a thigh TQ again. Confirm it is locked, the time is visible, and the dressing distal to it is not filling before the door slides. Recheck by feel and sight after loading, not by releasing pressure.
Packing, hemostatic gauze, and junctional devices
Wounds in the groin, axilla, neck base, or a wide soft-tissue crater are junctional—too proximal for a limb TQ. Pack them.
- Expose the hole.
- Pack hemostatic gauze (kaolin-impregnated Combat Gauze or a chitosan dressing, per program stock) all the way to bone or the vessel bed. Ordinary gauze is a second choice if that is what you have.
- Hold firm pressure for the full manufacturer interval, commonly about three minutes.
- Cap the pack with a tight pressure dressing. Do not peek every time the aircraft bumps.
A junctional tourniquet or similar device (for example a SAM Junctional Tourniquet or Junctional Emergency Treatment Tool (JETT)) is for trained crews who carry it. It compresses the groin or axilla when packing is not enough. It is not a neck device and not an excuse to invent resuscitative endovascular balloon occlusion of the aorta (REBOA) on the ramp.
REBOA is a receiving-hospital (or rare special-mission) intervention. If your aircraft does not carry a REBOA catheter and a written protocol, do not improvise with a central-line kit. Pack, bind, give blood and tranexamic acid (TXA), and fly to a center that can operate or place a balloon.
Pelvis, scalp, pressure, and what you must not pull
A pelvic binder sits over the greater trochanters, not the iliac crests. A binder that rides high on the wings of the ilium can increase pelvic volume and miss the ring you meant to close. Place it, then internally rotate the feet if protocol allows, and do not take it off to "have a look" in cruise. Bind on clinical suspicion: shock plus a compatible MVC, fall, or crush MOI. Do not wait for a pelvic x-ray you do not have.
Scalp bleeding is not cosmetic. The scalp is a high-flow, low-resistance circuit. In infants and older adults it can empty the tank. Hold pressure, use a snug dressing, and if trained and equipped, close the galea with staples, figure-of-eight sutures, or Raney clips. Do not treat a soaked head wrap as a nuisance dressing.
Pressure dressings work when they actually press. Elastic wrap over a bulky pack on a compressible site. They fail when they sit on a junctional hole you never packed.
Impaled objects stay. Stabilize the object with bulky dressings so it cannot lever in the wound. Cut the external length only if the remaining shaft will not fit through the aircraft door, and cut it with the object still stabilized—not by yanking. Removal belongs in an operating room unless the object arrests the airway and you have no other way to ventilate.
TXA, blood first, and the diamond
TXA is the antifibrinolytic you can give in a ditch. Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2 (CRASH-2) and current trauma teaching support 1 g early, typically over about ten minutes, often with a second gram if the receiving protocol uses that infusion. Give it inside the first three hours after injury. Starting TXA after three hours is associated with harm in that evidence base; a long flight is not a reason to give a late first dose.
Blood first. Crystalloid after the first bridging liters dilutes clot, drops temperature, and feeds acidosis—the trauma diamond you will prevent in section 10.3. Hang warmed product (Chapter 8). Calcium travels with massive transfusion protocol (MTP) blood because citrate binds ionized calcium.
Before lift, run a hemostasis checklist you can still reach:
| Device or drug | Pre-lift check | In-flight rule |
|---|---|---|
| Limb TQ | High, tight, timed, on skin | Do not loosen unless converting under protocol |
| Junctional pack | Packed to bone, pressure held, surface dry | Do not peek; add a second pack if it soaks |
| Pelvic binder | Over greater trochanters | Leave it on |
| Impaled object | Stabilized; will clear the door | Do not remove |
| TXA | Time from injury under 3 hours | Do not start a late first dose |
| Blood / cooler | Warmer ready, calcium available | Blood before more crystalloid |
A rotor-wing patient has a windlass tourniquet locked on the proximal thigh, application time written on the patient, and no distal pulse. The cabin is cramped and the wound is no longer spurting. What is the correct in-flight tourniquet plan?
A shocked motor-vehicle occupant has a suspected open-book pelvic fracture. Where should the pelvic binder sit?
A hypotensive scene patient has noncompressible junctional bleeding. The aircraft does not carry a resuscitative endovascular balloon occlusion of the aorta catheter. What is the correct hemostasis plan?