Celox Hemostatic Gauze: Application for Massive Junctional Hemorrhage
Where a tourniquet has nowhere to grip, correct wound packing decides the outcome.
The third installment of the Micro-Interventions series covers applying Celox hemostatic gauze for massive external hemorrhage from a junctional zone — the places where a standard limb tourniquet simply has nowhere to grip.
Why a tourniquet doesn’t work in junctional zones
Junctional zones — the groin, axilla, and neck — are where a limb or the neck joins the torso. The vessels here are larger than in the limbs, but there is no way to wrap a tourniquet around them that would effectively compress the bleeding source without crossing onto the torso. Bleeding from these areas is still compressible — it can be stopped with direct pressure — it just requires a different tool than a tourniquet. This is where combining hemostatic wound packing with sustained direct pressure comes in, ideally followed by a junctional tourniquet where anatomically appropriate and available.
Dispatched to a young man with a penetrating groin injury following an assault. Active pulsatile bleeding, soaked clothing, pale and tachycardic. A limb tourniquet cannot be applied — the wound sits too proximally, in the junctional zone.
Decision: the only immediately available option is direct pressure followed by wound packing with hemostatic gauze.
Clinical indication
Massive external hemorrhage from a site where a limb tourniquet cannot be applied (groin, axilla, neck) — most commonly penetrating injuries, gunshot wounds, and deep lacerations.
Contraindications and limitations
Hemostatic gauze is not packed into chest wounds (risk of forcing material into the pleural cavity). Where a junctional tourniquet is available, apply it without delay after packing — packing alone is only a first step. A known shellfish allergy is not treated as a contraindication in practice — the allergenic proteins are largely removed during chitosan purification.
Step-by-step procedure
Junctional hemorrhage control sits within the MARCH/C-ABC algorithm immediately after recognizing massive hemorrhage and applying manual compression. The sequence is: manual compression → wound packing with a hemostatic agent while maintaining pressure → junctional tourniquet application (SAM Junctional, CRoC, JETT) where anatomically appropriate and available → consideration of systemic measures (e.g. tranexamic acid) per local protocol. Junctional hemorrhage must never be managed with delay.
Comparison of hemostatic agents
First-line agent per current TCCC guidelines.
Works independently of the coagulation cascade — relevant in anticoagulated patients.
Designed for deep, narrow junctional tracts. Not removed in the field.
Physiological background
Chitosan promotes clot formation through a mechanism independent of the classic coagulation cascade — it attracts and aggregates red blood cells into a gel-like matrix on contact with blood. This has practical relevance in patients with impaired coagulation, in whom cascade-dependent hemostatics may fail. Current evidence, however, does not demonstrate clear superiority of chitosan over kaolin — agent selection should never be delayed to work out a patient’s medication history.
Common field mistakes
| Mistake | Consequence |
|---|---|
| Insufficiently deep wound packing | no contact with source |
| Releasing pressure before 3 minutes | re-bleeding |
| Lifting the dressing to check during the hold | same effect as releasing early |
| Packing gauze into a chest wound | risk of pleural forcing |
| Delaying junctional tourniquet after packing | unnecessary delay |
Documenting the procedure
“Packed it, it stopped bleeding.”
“Stab wound to the right groin, packed with Celox hemostatic gauze from the deepest point outward, direct pressure held for 3 minutes. Bleeding controlled, secured with a pressure bandage. No re-bleeding en route to receiving facility.”
“Didn’t work, so we did it again.”
“After 3 minutes of direct pressure bleeding persists — dressing removed, wound repacked with emphasis on greater packing depth. Junctional tourniquet considered but anatomically unsuitable for wound location. Rapid transport to a surgical facility prioritized.”
Practical takeaways for the responder
1. In junctional zones a tourniquet won’t work — the answer is wound packing with hemostatic gauze plus sustained pressure.
2. Pack from the deepest point outward, hold pressure without interruption for at least 3 minutes.
3. Once packed, consider a junctional tourniquet if available and anatomically appropriate.
4. Never pack hemostatic gauze into a chest wound.
- REVERT Maneuver for Paroxysmal SVT
- Intraosseous Access with EZ-IO
- Celox Hemostatic Gauze for Junctional Hemorrhage (this article)
- Needle Decompression of Tension Pneumothorax
- Airway-Opening Maneuvers
- Nasopharyngeal Airway
- Applying the CAT Tourniquet
- Manual In-Line Cervical Spine Stabilization During Extrication
- Head and Cervical Spine Fixation on a Vacuum Mattress
- Peripheral IV Cannulation in the Centralized Patient
- Applying a Chest Seal for Open Pneumothorax
- Module 06: Massive Hemorrhage Control in TFC. TCCC.org.ua / Deployed Medicine.
- TCCC Guidelines, 25 JAN 2024. Committee on Tactical Combat Casualty Care.
- Hemostatic Gauze — Medical-Grade Hemostatic Dressings. Rescue Essentials.
- Junctional Hemorrhage Control: Recognition, Packing, and Junctional Tourniquet Application. MED-TAC International / Deployed Medicine.