A commercial junctional tourniquet will not always be available, and it is important to understand some additional procedures to supplement wound packing with hemostatic dressings and pressure bandages. An improvised junctional pressure delivery device (PDD) may be needed to apply additional, targeted, and sustained pressure to control junctional bleeding.

One of the difficulties in maintaining pressure on an inguinal wound is that the anatomy of the pelvic ring creates a challenge for pressure bandages to maintain the mechanical advantage they have when used on an extremity. Commercial tourniquets overcome this by using relative rigid retaining devices with pressure applied by inflated pads or pressure discs/pads that are tightened down. In their absence, medics involved in the recent conflicts in Iraq and Afghanistan developed some alternate options for maintaining pressure by making improvised PDD using materials that are readily available on the battlefield including limb tourniquets, water bottles, canteens, boots, shoes, etc.

An improvised PDD works by placing a solid object over the same pressure points that are used in commercial junctional tourniquets, and then applying pressure using limb tourniquets. The PDD is large enough that it sits above the pelvic ring to provide the necessary mechanical advantage, and the tourniquet allows for pressure that exceeds a normal pressure bandage to be applied. This combination creates pressure that can equal that of a commercial junctional tourniquet.

The PDD is placed in the inguinal gutter while continuously maintaining pressure on the hemostatic dressing or gauze packed wound. It is then secured using two limb tourniquets joined together around the casualty’s body and around the PDD (although in some casualties a single tourniquet may suffice). As the tourniquet’s windlass or ratchet is tightened, pressure is applied to the PDD over the wound until the bleeding is stopped and the distal pulse absent.