What was once considered non-compressible hemorrhage now has a solution. We used to solve the problem of truncal hemorrhage by driving faster, keeping the blood pressure low, and infusing blood products. The hope was that we maximize the time the patient is hemodynamically stable before the patient’s progression of shock outpaced our ability to maintain perfusion to the brain and the heart.
For quite some time hemorrhage control training has been largely centered around “compressible” hemorrhage or that which could be controlled by compressing the injured vessel or the next proximal branch that would stop the bleeding. What was created was a permissive environment for tourniquet (TQ) placement and wound packing. Which worked great for extremity and transitional area hemorrhage.
The question always lingered, “what do we do for chest and abdominal trauma?” What was in our bags was less than helpful (NCD needles and chest seals). The plan was to drive fast and keep the clots from becoming dislodged via permissive hypotension. The literature favored delayed resuscitation,1 and since we did not have a better idea, it stuck for quite some time.
But even in 2026, a significant percentage of trauma patients are still dying. This is even with the advent of prehospital blood transfusions, TXA, etc. I will start this part of the conversation by stating the well known fact that simply driving faster with lights and sirens has thus far proven to be of very little benefit. We know that it is not how fast they get to the hospital that makes a difference, but the care provided along the way.2
The Data Trail
In breaking down the numbers from the literature on the topic, this is what you would find:
20–22% – potentially preventable death from trauma. This is consistent across military and civilian data sets.3,4
47% of trauma deaths are from TBI, 80% of which are not survivable.5
23% of trauma deaths are from exsanguination. Which is interesting since we have all of these tourniquets and hemostatic dressings available to us.5
Of that 23% of death from exsanguination – 96% of it is truncal hemorrhage (we will call this NCTH): 25% thoracic, 41% abdominal, and 32% pelvic in origin.5,6
Truncal hemorrhage is fatal 44.6% of the time.6
At this point it may be easy to assume that this is all aortic injury from sudden deceleration mechanisms of injury which is nearly always fatal. But you would be wrong. A mere 1.5% of NCTH is from BTAI (blunt thoracic aorta injury). 45.3% involves the descending aorta, 43.7% involves the internal iliac artery in the pelvis, and 10.7% involves the renal artery.6,7
First Principles of Hemorrhage Control
Pressure. Pressure is the key and essential element of all hemorrhage control techniques in the prehospital setting. While volume replacement (with whole blood or blood products) is of paramount importance, if it is being administered to a patient with uncontrolled NCTH it is buying mere minutes of time back for the patient. At the same time, it likely is not having the impact on hemorrhage control one might hope.2,8,9 We have to stop the bleeding.
How do we generate compressible force to bleeding vessels in the trunk? We could just pack it with hemostatics, right? You would be wrong. Not only is doing this not published in any nationally accredited training, it is widely viewed by experts in the field as a poorly conceived idea for hemorrhage control and largely ineffective. Read: not recommended.
External compression of the aorta is not exactly a new concept. The fist was the original AAJT-S.10 A fist was used to provide direct compression of the aorta by a clinician by placing it at the umbilicus and leaning down and providing a compressive force to occlude the aorta.10 It seems like a no-brainer, but its effectiveness is limited by the transport environment and the human factor. The transport environment is rather unstable, making it difficult to maintain consistent pressure on the aorta (you need like 120lbs of consistent force). The human factor is one of fatigue and physics; holding 120lbs of force, consistently, can be a tall order.11
In 2013 the earliest version of the AAJT or Abdominal Aortic Junctional Tourniquet, was evaluated by the military and began to make its rounds in the literature.12 Worn like a WWF Championship wrestling belt, the device has an air bladder that once inflated compresses the abdomen and its contents against the abdominal aorta and then the spine, effectively occluding blood flow. Several studies have proven its equivalency with Zone 3 REBOA making it an attractive alternative to the procedure for prehospital teams.8,13
But does it work like we want it to?
Real World Applications
In civilian use, this comes from our friends in Sydney, Australia. They used the AAJT on 22 patients in traumatic cardiac arrest. They included eighteen of those cases in this study. Of the 18, 16 were in arrest at the time of the application which was around 16 minutes on average from loss of vitals to application of the device. They got 4 patients with ROSC. Three of those were sustained to the ED, but none of those patients survived the discharge. Of note, eleven of those patients had a positive rhythm change and six, as I said earlier, had a 24 point increase in their ETCO2.14
In the military literature, this one comes hot off the presses in 2025 from the Journal of Special Operations Medicine. This is a case series of six patients from the current conflict in Ukraine, 6 patients, 6 applications, all were included. Six patients arrested and all six had ROSC. Five of those patients survived the evacuation to the next level of care. One of those patients died of wounds at three hours. They couldn’t evacuate the patient as they were under an active artillery attack (which took out their evac platform) and they could not move the patient to the next higher level of care, which had damage control surgery capability. All had perfusion restored without the use of vasopressors.15
Of the five survivors, four of them survived the discharge. Three of them have been confirmed to be neuro intact. One of those patients died 10 days later, secondary to multiple organ dysfunction syndrome. He had liver and pancreas injuries that he ultimately succumbed to.15
Of note and what is interesting in this study. Was that all of these arrests were witnessed. The patients received blood, CPR and the AAJT. This is in contrast to the Australian paper where the crews worked through all of the other potentially reversible causes of traumatic cardiac arrest and then placed the AAJT. In the Australian study 16 of those 18 patients were in arrest prior to the flight teams arrival, so it doesn’t look like any of those were witnessed arrest. So they don’t know how long they were down prior to arrival.14-15
To be clear, this is not a pitch to purchase the AAJT-S, but rather to evaluate the problem of NCTH not as non-compressible anymore. The terminology and the mindsets to shift are made possible through many different technologies, A study in JSOM compared several different junctional tourniquets like the CRoC, JETT, SAM JT, and the AAJT. Read the study for yourself to decide which device works “best” and make a decision to implement it in your service from there.
Considerations
Implementing a new device for hemorrhage control is not a simple as buying it and putting it on the trucks after training the crews. The local trauma system needs to be brought in (maybe not to weigh in) to be oriented to what your service is using to combat the problem of NCTH. Trauma services don’t generally monitor EMS agencies for protocol and equipment changes, and this is one intervention that could create the perfect recipe for disaster if it surprises the trauma team.
Other considerations for these devices include things like occlusion time. Bowel ischemia is a known issue with the AAJT-S when it is in place for >60-90 minutes. It can also increase bleeding from sites distal to the device.16,17
Reflections
Instead of conclusions and summaries that offer no real benefit to the reader, I instead prefer reflection questions now. Take these back to your desk and your leadership and see what you come up with.
Can we make better clinical and operational decisions to improve the survivability in patients who are suffering from NCTH?
Is “diesel therapy” really working as well as we think?
Are the AAJT and its compatriots here to stay, or are they doomed to suffer the same fate as the MAST trousers?
For more, check this episode of the Alert Medic 1 podcast. This was presented at the R Adams Crowley Shock Trauma Center EMS Conference in Baltimore, MD.
References
Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109.
Qasim Z, Brenner M, Menaker J, Scalea T. Resuscitative endovascular balloon occlusion of the aorta (REBOA): updates on current practice and the expanding role in trauma. Shock. 2020;54(4):427-434.
Handford C, Parker PJ. Extremity vascular trauma and junctional hemorrhage: combat injury analysis. J R Army Med Corps. 2018;164(4):269-273.
Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J. 2007;24(8):584-587.
Callcut RA, Cotton BA, Muskat P, et al. Defining when to initiate whole blood and component therapy: the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. Ann Surg. 2016;264(3):475-481.
Zhang J, Liu H, Wang F. Management of non-compressible torso hemorrhage: an update. Chin J Traumatol. 2021;24(3):145-152.
Smith S, Teeter W, Patel M, et al. Injury patterns in non-compressible torso hemorrhage and vascular access considerations. J Trauma Acute Care Surg. 2017;82(6):1098-1105.
Bini R, Teeter W, Morrison JJ, et al. Non-invasive external aortic occlusion compared to resuscitative endovascular balloon occlusion of the aorta (REBOA) in severe truncal hemorrhage. J Trauma Acute Care Surg. 2019;86(5):812-820.
National Association of Emergency Medical Technicians (NAEMT). PHTLS: Prehospital Trauma Life Support. 9th ed. Jones & Bartlett Learning; 2019.
O’Dochartaigh D, Picard CT, Brindley PG, Douma MJ. Temporizing life-threatening non-compressible torso hemorrhage using external aortic compression. CJEM. 2020;22(5):717-720.
Douma MJ, Picard CT, O’Dochartaigh D, Brindley PG. External aortic compression in trauma: physical fatigue and force mechanics during simulated prehospital transport. Prehosp Emerg Care. 2021;25(4):534-541.
Taylor DM, Coleman M, Parker PJ. Evaluation of the Abdominal Aortic and Junctional Tourniquet for pelvic and inguinal hemorrhage control. Mil Med. 2013;178(11):1191-1196.
Stigall KS, Smith S, Sapsford M. Evaluation of the Abdominal Aortic and Junctional Tourniquet-Stabilized (AAJT-S) in comparison with Zone 3 REBOA for pelvic arterial hemorrhage. J Spec Oper Med. 2021;21(3):35-41.
Balian R, Burns B, Sweeny A, et al. Out-of-hospital application of the Abdominal Aortic and Junctional Tourniquet in traumatic cardiac arrest: a Sydney HEMS experience. Resuscitation. 2023;185:109740.
Androshchuk D, Verba A. Successful Management of Battlefield Traumatic Cardiac Arrest Using the Abdominal Aortic and Junctional Tourniquet (AAJT): A Case Series. J Spec Oper Med. 2025 Mar 18:7FEV-3ZRK. doi: 10.55460/7FEV-3ZRK. Epub ahead of print. PMID: 40063952.
Schwartz RB, Reynolds BZ, Adams KK. The Abdominal Aortic and Junctional Tourniquet: safety parameters, occlusion time, and physiological impact. J Spec Oper Med. 2017;17(3):42-47.
Bonanno FG. Noncompressible torso hemorrhage: updates on epidemiology, occlusion limits, and secondary reperfusion damage. Eur J Trauma Emerg Surg. 2020;46(4):755-766.
Editorial & AI Transparency Statement
This publication was researched and written by the author. Gemini AI was utilized solely for research assistance, literature synthesis organization, copyediting, and overall formatting. None of the clinical content, interpretations, data analyses, or conclusions were generated by AI.
