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Unstable pelvic fractures can bleed massively. Applying a pelvic binder over the greater trochanters reduces pelvic volume and controls venous bleeding. Oral fluids are unsafe. Upright positioning worsens hemodynamics and binder effectiveness. Binder removal risks re-bleeding. Maintain binder, minimize movement, administer TXA if indicated, and pursue balanced resuscitation with blood products when possible. Evacuation to definitive surgical control (angioembolization, external fixation) is essential. Early binder use is one of the most impactful prehospital interventions for pelvic trauma.

Once in a secure environment, the goal is to minimize ischemic injury while maintaining hemorrhage control. If anatomically feasible and evacuation is delayed, tourniquet conversion to wound packing with hemostatic gauze and a pressure dressing is appropriate. Tourniquet loosening without hemostatic control risks catastrophic rebleeding. Reassessment is continuous: if bleeding recurs or conditions are unsafe, leave the tourniquet in place. Tourniquet conversion is a deliberate, controlled process, documented carefully, and always balanced against tactical realities.

Under threat, casualty movement must preserve security and tempo. A four-person litter team (two primary carriers, two assist/relief) allows rapid, stable movement over obstacles while maintaining 360° security with additional team members. This configuration reduces fatigue, permits bounding, and keeps weapons up. Two-person carries overexpose both rescuers and strain endurance. A solo drag is acceptable for hasty extraction from immediate danger but not for prolonged movement through complex terrain. Comprehensive exams are deferred until the warm zone/CCP; while moving, reassess only life-threatening changes. Pre-briefed routes, rally points, and hand signals minimize confusion and comms load. Litter straps should be pre-rigged; weapons discipline and fields of fire must be assigned. Integrate with overall scheme of maneuver so medical evacuation does not create a vulnerability. This approach balances casualty care, survivability, and mission continuation.

Junctional hemorrhage (axilla, groin, neck) cannot be controlled with standard circumferential limb tourniquets because there is no compressible long bone to occlude. The recommended immediate intervention is aggressive wound packing with a hemostatic dressing (e.g., chitosan or kaolin-based), applied directly at the source of bleeding, followed by sustained manual pressure for several minutes and a secure pressure dressing. Junctional tourniquet devices may be used if available and trained, but in most field contexts, expert wound packing is the fastest, most accessible solution. Needle thoracostomy addresses tension pneumothorax, not hemorrhage. Direct pressure without packing may be insufficient for deep, high-flow junctional wounds. Attempting a “high-and-tight” limb tourniquet above the pelvis is anatomically ineffective. After initial control, monitor for rebleeding, consider pelvic stabilization if pelvic injury suspected, and expedite evacuation.

Penetrating abdominal trauma often involves uncontrolled hemorrhage. Permissive hypotension (SBP ~80–90 mmHg if no TBI) balances perfusion with reduced bleeding. Whole blood or balanced blood products are preferred; TXA given within 3 hours improves survival. Hypothermia prevention is essential. Aggressive crystalloid resuscitation dilutes clotting factors, exacerbates acidosis, and worsens hypothermia. Oral fluids and upright positioning are unsafe. Field resuscitation must focus on damage-control principles until surgical control is possible.