Efficacy of Three Topical Hemostatic Agents Applied by Medics in a Lethal Groin Injury Model

The evaluation of Hemoblast Bellows for arterial hemorrhage control in a swine model of vascular injury

Background

Uncontrolled hemorrhage remains the leading cause of preventable death on the battlefield. Hemostatic agents have increased in use and have been shown to improve survival. Combat Gauze (CG) is the most-used hemostatic gauze recommended by the Committee of Tactical Combat Casualty Care. Hemoblast Bellows (HB), a product FDA-approved for intraoperative hemorrhage, contains thrombin which differentiates it from CG and other kaolin-based hemostatic agents and has not been evaluated in the pre-hospital setting. This study aimed to compare HB to CG, in a standard swine arterial hemorrhage model.

Methods

Dilutional coagulopathy and hypothermia were induced in anesthetized Yorkshire-cross swine. The femoral artery was isolated and a 6 mm femoral arteriotomy was made. After a 30 s free bleed, randomly assigned hemostatic agent(s) from one of the three treatment groups: HB only, CG only, and HB + CG were applied and direct pressure was held for 3 min. At 30 min, the ipsilateral lower extremity was mobilized with a series of hip movements. Primary endpoints included blood loss, rebleeding, thromboelastogram (TEG) values, SPOT GRADE(TM) values, and mean arterial pressure (MAPs), which were monitored during the 150-min observation period.

Results

There were no significant differences between the treatment groups for blood loss, rebleeding, lactate, TEG values, SPOT GRADE, or MAPs for all time points examined.

Conclusions

We found no significant differences between the treatment groups for any of the included data points. These results suggest that arterial hemorrhage control with HB alone and HB + CG is not significantly different from hemorrhage control with CG only. These findings should not deter us from a continued investigation of hemostatic agents but should stimulate our search for superior hemorrhage control agents and novel delivery mechanisms. Continued innovation with such products may overcome the product limitations that we observed during testing and may prove to be a more relevant product for the point-of-injury.

Biomedical properties and hemostatic efficacy of polyvinyl alcohol (PVA) based hydrogel in experimental rat liver injury model

PURPOSE

Bleeding is a leading cause of mortality and morbidity in the trauma and surgery field, using effective hemostatic agents can help us reduce bleeding especially in parenchymal hemorrhage. Nowadays polyvinyl alcohol (PVA) is known as a safe candidate for wound dressing and maybe a hemostatic agent. PVA-based hydrogel is a popular biocompatible material in the biomedical field especially when it has high water absorption. In this study, we investigated the PVA hydrogel's mechanical and biological properties as well as its hemostatic potential in parenchymal bleeding.

METHODS

PVA hydrogel had made by the freeze-thawing approach, we used PVA hydrogel in comparison to standard treatment to investigate hemostatic potency. Also, we performed MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide) tests to survey PVA cellular toxicity. After an acute liver injury, two groups of 12 rats were treated with PVA hydrogel or standard treatment with sterile gauze. The results including the time and volume of bleeding, and the time and survival rate of the rats were measured and compared.

RESULTS

We saw that PVA hydrogel was safe with no cellular toxicity in the MTT assay. Regarding efficacy, PVA hydrogel increased rats' survival after bleeding from 75% to 91.7%, and decreased bleeding time (p: 0.015), and bleeding volume (p: 0.03) compared to the control group.

CONCLUSION

Polyvinyl alcohol is safe. It has good biological properties with no cellular toxicity and has a significant hemostatic effect and can be regarded in control of parenchymal hemorrhage.

The potential of chitosan-based haemostats for use in neurosurgical setting - Literature review

Haemorrhage is a major nuance in neurosurgery since blood can distort the surgeon's field of view and increase the risk of post-operative complications. Currently a variety of commercially available haemostats have been approved for use in neurosurgery, but they have caveats to their use in the brain, including, localised tissue compression, neural toxicity, induce immune reaction or form thrombus within the vessel. Thus, there is a need for haemostats that are efficacious and safe for application on brain and spinal tissue. Chitosan is a naturally occurring bio-polymer that is found on the exoskeleton of arthropods and the cell wall of fungi. Chitosan has been shown to accelerate haemostasis through a myriad of physiological pathways. These findings have led to the development of multiple chitosan-based haemostats, for use in peripheral human tissue. Although, clinical data regarding the use of chitosan-based haemostats in the brain is lacking, a range on in vivo studies have proven chitosan to be efficacious and safe in managing neurosurgical bleeds. Similarly, literature comparing chitosan-based haemostats with commercial haemostats used commonly in neurosurgery, have all demonstrated chitosan to be the superior agent. Additionally, clinical trials of chitosan-based haemostat used in peripheral tissue have all demonstrated chitosan to be safe for human use. The marriage of these findings indicates that the safety and superior efficacy of chitosan-based haemostat, makes it a potentially suitable haemostat for use in neurosurgical setting. However, further research pertaining to the clinical use of chitosan-based haemostat within the central nervous system needs to be conducted.

Effect of Celox® Powder on Initial Hemostasis After Cardiac Catheterization in Pediatric Patients with Congenital Heart Disease: A Prospective Study

Background: Ordinary pressure dressing for hemostasis after cardiac catheterization is time consuming and might cause some problems, such as pain or loss of blood, which has to be controlled, particularly in pediatric patient. Using Celox® (chitosan) powder dressing might cause quicker initial hemostasis. Methods: In this prospective study, we assessed Celox® powder among patients in hospitals affiliated with Shiraz University of Medical Sciences, from November 2017 to February 2018. The patients were stratified in two groups. The case group included patients for whom Celox® powder was used along with sterile gauze pressure at the puncture site to achieve hemostasis, and the control group those in whom hemostasis was achieved by standard sterile gauze pressure method. Results: Sixty patients under 16 years of age with congenital heart diseases were evaluated and underwent cardiac catheterization. We stratified the patients in two groups called case (30 patients) and control group (30 patients). Considering both arterial and venous initial hemostasis, in the case group, the minimum and maximum, median and mean coagulation time were less than those in the control group; however, the initial hemostasis was statistically significant only in venipuncture site. Also, the venous coagulation time was shorter among the patients weighing less than 10 kilograms in comparison to those with higher weight. In the case group, using Celox® stirred hemostasis toward the lower percentiles, but based on 50th percentile, the distribution in each group was identical. Conclusions: Celox® powder dressing in children led to reduced coagulation time in venipuncture site, and we might recommend utilizing this type of dressing for venous hemostasis in children after venipuncture.

Silver-decorated mesostructured cellular silica foams as excellent antibacterial hemostatic agents for rapid and effective treatment of hemorrhage

Uncontrolled bleeding, such as deep, narrow or irregular wound hemorrhage, has been a major cause of death in peacetime and wartime. Besides, traditional hemostatic agents are lack of antibacterial properties, which could not provide effective protection on open wound. In this paper, a novel antibacterial hemostatic agent composed of mesostructured cellular silica foams (MCF) decorated with silver ions (MCF-Ag) was synthesized by hydrothermal method. Hemorrhage wound infected with Escherichia coli was applied to evaluate its antibacterial and hemostatic performance both in vitro and in vivo. Both MCF and MCF-Ag showed excellent hemostasis in vitro and in vivo. The MCF-Ag demonstrated significant antibacterial effect. By contrast, no obvious antibacterial effect was observed from the MCF. The above results demonstrate that the MCF-Ag is an excellent antibacterial hemostatic agent with splendid water absorption and antibacterial capacity.

Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding

Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.

Design of New-Generation Usable Forms of Topical Haemostatic Agents Containing Chitosan

Designing usable forms of topical haemostatic agents is the most important activity during the design process, resulting in strengthened functional properties of the final medical devices. This study aimed to propose indications for a research programme based on risk management supporting the development of two usable forms of a topical haemostatic agent: chitosan/alginate lyophilized foam and chitosan/alginate impregnated gauze. Both of the usable forms of the topical haemostatic agent, being the main part of the modified combat gauze, were fabricated using the chitosan/alginate complex. Risk analysis is helpful in developing an appropriate research programme, significantly reducing the risk to an acceptable level.

Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: A prospective study of 66 cases

BACKGROUND

Uncontrolled haemorrhage is the leading cause of potentially preventable death in both civilian and military trauma patients. Animal studies and several case series have shown that hemostatic dressings reduce haemorrhage and might improve survival. One of these products is HemCon ChitoGauze(®). The objective of this study was to determine the effectiveness and safety of ChitoGauze in achieving hemostasis in massive traumatic bleeding in civilian emergency medical services.

METHODS

From June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with ChitoGauze. The dressing was used according to protocol; if conventional treatment (gauze dressing with manual pressure) failed to control external traumatic bleeding or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use.

RESULTS

A total of 66 patients were treated with ChitoGauze during the study period. Twenty-one patients were taking anticoagulants or suffered from a clotting disorder. The injuries were located in the extremities (n=29), the head and face (n=29), or the neck, thorax and groin (n=8). In 46/66 patients, the use of ChitoGauze resulted in cessation of haemorrhage. In 13/66 patients, Chitogauze application reduced haemorrhage. ChitoGauze failed to control haemorrhage in 7/66 patients, whereby user error was a contributing factor in 3 of these failures. No side effects have been observed during treatment or transport of the patients and no adverse effects have been reported in discharge letters.

CONCLUSION

This is the largest prospective study in civilian healthcare and the second largest case series with prehospital use of hemostatic dressings. It demonstrated that ChitoGauze is an effective and safe adjunct in the prehospital treatment of massive external traumatic haemorrhage.

A comparison of 2 devices for radial artery hemostasis after transradial coronary intervention

BACKGROUND AND OBJECTIVE

Transradial access is an attractive approach for angiography or percutaneous coronary intervention. Different devices have been used to apply pressure locally at the site of arterial entry for achieving hemostasis. The aim of this study was to evaluate the effect of 2 different hemostatic devices on radial artery outcomes after transradial coronary intervention.

SUBJECTS AND METHODS

This study included 600 patients who had undergone transradial coronary intervention who were randomized into 2 groups after the procedure: 300 were treated with a radial compression device (TR Band, Terumo Medical, Tokyo, Japan) (CD group) and the other 300 patients were treated using a chitosan-based pad (Anscare, Daxon, Taoyuan, Taiwan) (CS group). Compression time, major and minor access site bleeding complications, and incidence of radial artery occlusion were recorded.

RESULTS

There were no statistical differences in the baseline clinical characteristics of the patients between the 2 groups. Compression time in the CS group was significantly shorter than that in the CD group (P < .001). Although no major access site bleeding complications were observed in either group, 6 patients in each group experienced minor access site bleeding complications. At the same time, 61 patients in the CD group and 21 patients in the CS group experienced errhysis (20% vs 7%, respectively; P < .001). Early radial artery occlusion (24 hours) occurred in 11.7% of the patients in the CD group and 5.4% of the patients in the CS group (P < .05). Chronic radial artery occlusion (30 days) occurred in 10% of the patients in the CD group and 5% of the patients in the CS group (P < .05).

CONCLUSION

The application of the chitosan-based pad showed better hemostatic efficacy and a lower incidence of radial artery occlusion after transradial coronary intervention compared with the compression device.

Topical hemostatic agents and dressings in the prehospital setting

PURPOSE OF REVIEW

Death from exsanguinating hemorrhage remains a priority in the management of combat casualties and civilian trauma patients with truncal and junctional injuries. Appropriate use of hemostatic agents and dressings in the prehospital setting may allow for earlier control and an improved survival rate.

RECENT FINDINGS

Third-generation chitosan-based hemostatic agents and dressings appear to be equally efficacious to the dressing currently deployed by the US military forces in the management of hemorrhage not amenable to tourniquet placement. Unfortunately, a lack of clinical trials places a heavy reliance on anecdotal reports and laboratory studies in agent selection and application.

SUMMARY

Efficacy of currently available hemostatic agents and dressings appears to have plateaued in recent years although new agents and delivery mechanisms under development may improve control in cases of severe hemorrhage.

Current use of live tissue training in trauma: a descriptive systematic review

BACKGROUND

Growing public concern for animal welfare, advances in computerized simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation methods in trauma.

METHODS

We performed a systematic review of the literature considering observational studies and randomized controlled trials (RCTs) that examined LTT in trauma exclusively or compared with other simulation methods. Independently and in duplicate, we adjudicated studies for inclusion and data abstraction. We assessed the quality and risk of bias.

RESULTS

Twelve studies met our inclusion criteria: 2 RCTs and 10 prospective cohort studies. Eight and 4 studies were performed in the military and in the civilian settings, respectively. Anesthetized swine were used in 8 studies and goats in 1. The cohort studies involved LTT alone. Different adjunctive training modalities were included: mannequins in 6 studies, cadavers in 2, computer simulation in 1, video presentations in 2 and wound moulage scenarios in 1. The overall methodological quality was moderate as per the Newcastle-Ottawa score (mean 6.0 ± 0, possible range 1-9). The 2 RCTs did not demonstrate adequate random sequence generation and allocation concealment.

CONCLUSION

There is limited evidence that other types of simulation are better than LTT. Data on training effects of LTT versus other simulations on outcomes are lacking.

Surgical Materials: Current Challenges and Nano-enabled Solutions

Surgical adhesive biomaterials have emerged as substitutes to sutures and staples in many clinical applications. Nano-enabled materials containing nanoparticles or having a distinct nanotopography have been utilized for generation of a new class of surgical materials with enhanced functionality. In this review, the state of the art in the development of conventional surgical adhesive biomaterials is critically reviewed and their shortcomings are outlined. Recent advancements in generation of nano-enabled surgical materials with their potential future applications are discussed. This review will open new avenues for the innovative development of the next generation of tissue adhesives, hemostats, and sealants with enhanced functionality for various surgical applications.

Should chitosan and tranexamic acid be combined for improved hemostasis after sinus surgery?

Chitosan, a β-1,4-linked polymer of glucosamine with lesser amounts of N-acetylglucosamine, has well-recognized hemostatic properties. Chitosan is also able to open tight cellular junctions, facilitating paracellular drug transport and delivery. Chitosan, through topical application, facilitates the systemic delivery of analgesic drugs. Theoretically this ability could be used to enhance the local delivery of hemostatic drugs, such as tranexamic acid, improving chitosan's role as a topical dressing. Individually a chitosan-dextran gel and tranexamic acid have been shown to improve hemostasis after endoscopic sinus surgery. A combination of both should lead to improved hemostasis and better postsurgical outcomes. The use of a chitosan/tranexamic acid dressing could have a wide range of potential beneficial applications in a number of other clinical surgical settings. While the initial main application might be as an improved external hemostatic dressing, it should also be useful on a range of internal surgical wounds.

Preparation of N, O-Carboxymethyl Chitosan with Different Substitutional Degree and its Application for Hemostasis

We prepared N, O-carboxymethyl chitosans (CMCSs) with different substitutional degrees (SDs) to evaluate their effects of hemostasis, and provided experimental basis on biomedical materials. Chloroethanoic acid was used to synthesize CMCSs. The structure were characterized by Fourier transform infrared (FT-IR) and wide-angle X-ray diffraction (WXRD). Potentiometric titration and Ubbelohde viscometer were adopted to determine the SD and intrinsic viscosity of CMCSs. Contact angle measurements were investigated to determine surface wettability. Method of dynamic clotting time and coagulation test in vivo were used to evaluate their effects of hemostasis. SDs of CMCSs were from 50% to 110%. As the SD increased, molecular weight decreased. CMCS powder with SD 63% possessed excellent hemostasis both in vitro and in vivo. CMCS powder owned hemostatic capability prior to CS. CMCS powder with SD 63% (neither too high, nor too low) possessed excellent hemostasis both in vitro and in vivo.

Hemostasis in a noncompressible hemorrhage model: an end-user evaluation of hemostatic agents in a proximal arterial injury

OBJECTIVE

1. Evaluate hemostatic bandages by the end user using subjective and objective criteria. 2. Determine if user training and education level impact overall hemostatic outcomes. 3. Our hypothesis was that prior medical training would be directly linked to improved hemostatic outcomes in noncompressible hemorrhage indepen- dent of dressing used.

DESIGN

Military personnel were given standardized instruction on hemostatic dressings as part of a tactical combat casualty care course (TC3). Soldiers were randomized to a hemostatic dressing. Proximal arterial (femoral and axillary) injuries were created in extremities of live tissue models (goat or pig). Participants attempted hemostasis through standardized dressing application. Evaluation of hemostasis was performed at 2- and 4-minute intervals by physicians blinded to participants' training level.

SETTING

Military personnel that are due to deploy are given "refresher" instruction by their units as well as participating in the TC3 to further hone their medical skills prior to deployment. The TC3 is simulation training designed to simulate combat environments and real-life trauma scenarios.

PARTICIPANTS

Military personnel due to deploy, physicians (residents and board certified surgeons), animal care technicians, and veterinarian support.

RESULTS

Celox 42 (33%), ChitoGauze 11 (9%), Combat Gauze 45 (35%), and HemCon wafer 28 (22%) bandages were applied in 126 arterial injuries created in 45 animals in a standardized model of hemorrhage. Overall, no significant difference in hemostasis and volume of blood loss was seen between the 4 dressings at 2 or 4 minutes. Combat gauze was the most effective at controlling hemorrhage, achieving 83% hemostasis by 4 minutes. Combat gauze was also rated as the easiest dressing to use by the soldiers (p<0.05). When compared to nonmedical personnel, active duty soldiers with prior medical training improved hemostasis at 4 minutes by 20% (p = 0.05).

CONCLUSIONS

There is no significant difference in hemostasis between hemostatic bandages for proximal arterial hemorrhage. Hemostasis significantly improves between 2 and 4 minutes using direct pressure and hemostatic agents. Prior medical training leads to 20% greater efficacy when using hemostatic dressings.

Enhanced hemostatic performance of tranexamic acid-loaded chitosan/alginate composite microparticles

Novel microparticles based on chitosan and sodium alginate were prepared using emulsification and cross-linking technologies. The spherical microparticles had a porous surface and a diameter of 2 ~ 40 μm. In simulated body fluid, these microparticles quickly swelled but gradually degraded. The results of the MTT assay revealed that a slight inhibition of cell proliferation was observed on day 2 and then gradually decreased afterward. No cell morphology changes were observed. By loading tranexamic acid, the hemostatic performance of the microparticles was obviously improved. Using fast-acting styptic powder (Flashclot) as the control, the hemostatic efficiency was investigated in rabbits using a liver transection bleeding model. It was found that both Flashclot and the microparticles achieved hemostasis in 3.07 ± 0.84 min and 2.48 ± 0.88 min, respectively; however, the tranexamic acid-loaded microparticles stopped the bleeding in 1.90 ± 0.75 min (P < 0.05). Additionally, Flashclot resulted in heat injury to the experimental livers, while the microparticles did not. Thus, with their biodegradability, safety, and superior hemostatic efficiency, tranexamic acid-loaded microparticles might be a promising new powdered hemostatic agent with a wide range of potential applications.

QuikClot Combat Gauze Use for Hemorrhage Control in Military Trauma: January 2009 Israel Defense Force Experience in the Gaza Strip—A Preliminary Report of 14 Cases

Background:

Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009.

Methods:

QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation.

All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers.

Results:

Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported.

Conclusions:

This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.

Antibacterial hemostatic dressings with nanoporous bioglass containing silver

Nanoporous bioglass containing silver (n-BGS) was fabricated using the sol-gel method, with cetyltrimethyl ammonium bromide as template. The results showed that n-BGS with nanoporous structure had a surface area of 467 m²/g and a pore size of around 6 nm, and exhibited a significantly higher water absorption rate compared with BGS without nanopores. The n-BGS containing small amounts of silver (Ag) had a slight effect on its surface area. The n-BGS containing 0.02 wt% Ag, without cytotoxicity, had a good antibacterial effect on Escherichia coli, and its antibacterial rate reached 99% in 12 hours. The n-BGS’s clotting ability significantly decreased prothrombin time (PT) and activated partial thromboplastin time (APTT), indicating n-BGS with a higher surface area could significantly promote blood clotting (by decreasing clotting time) compared with BGS without nanopores. Effective hemostasis was achieved in skin injury models, and bleeding time was reduced. It is suggested that n-BGS could be a good dressing, with antibacterial and hemostatic properties, which might shorten wound bleeding time and control hemorrhage.

Intracorporeal use of advanced local hemostatics in a damage control swine model of grade IV liver injury

BACKGROUND

The purpose of this study was to evaluate the efficacy of zeolite- and chitosan-based local hemostatic agents for the control of intracorporeal bleeding in a damage control swine model of grade IV liver injury.

METHODS

Anesthetized pigs (weight, 40 kg) had a controlled 35% total blood volume bleed from the right jugular vein. A laparotomy was performed and the animals were cooled to 35°C. Ringer's lactate was titrated to achieve a three to one blood withdrawal resuscitation. The liver was injured with a standardized 10 cm × 3 cm avulsion. After 2 minutes of uncontrolled hemorrhage, the animals were randomized to application of gauze control (GC, n = 11), Celox (CX, n = 11) (5AM Medical, Newport, OR), or QuikClot ACS (QC, n = 11) (7-Medica, Wallington, CT) and packed in a standardized manner. At 10 minutes, the packs were removed to calculate amount of shed blood. The animals then underwent damage control closure with packing in place. Forty-eight hours after initial damage control packing, the animals were returned to the operating room for pack removal and killing. The need for repacking of the liver was assessed and tissue samples were collected from the liver edge and adjacent small bowel for histopathology.

RESULTS

There was no difference in the amount of uncontrolled bleeding at 2 minutes (GC: 4.0 mL/kg ± 0.4 mL/kg, CX: 3.5 mL/kg ± 0.5 mL/kg, QC: 4.0 mL/kg ± 0.6 mL/kg; one-way analysis of variance: p = 0.715). Compared with GCs, the blood loss at 10 minutes was significantly lower in the CX and QC arms (GC: 8.3 mL/kg ± 0.9 mL/kg, CX: 3.7 mL/kg ± 0.7 mL/kg, QC: 4.6 mL/kg ± 0.8 mL/kg; one-way analysis of variance: p = 0.001). A total of 27.3% of control animals died compared with 18.2% of CX and 0.0% of QC. All GC and QC animals required repacking, compared with one (9.1%) of those in the CX arm. There was no difference between groups in the extent of necrosis.

CONCLUSION

Celox and QuikClot ACS(+) are effective adjuncts to standard intracavitary damage control packing for the control of bleeding. Celox provided durable control allowing packing removal at the time of take-back laparotomy. Further evaluation of their long-term effects is warranted.

Pre-hospital haemostatic dressings: a systematic review

BACKGROUND

Uncontrolled haemorrhage is a leading cause of prehospital death after military and civilian trauma. Exsanguination from extremity wounds causes over half of preven military combat deaths and wounds to the anatomical junctional zones provide a particular challenge for first responders. Commercial products have been developed, which claim to outperform standard gauze bandages in establishing and maintaining non-surgical haemostasis. Since 2004, two advanced haemostatic dressing products, HemCon and QuikClot have been widely deployed in military operations. Newer products have since become available which aim to provide more efficient haemostasis than and thus supersede HemCon and QuikClot.

AIM

To conduct a systematic review of clinical and preclinical evidence to compare the relative efficacy and safety of available haemostatic products, which are of relevance to pre-hospital military and civilian emergency medical providers.

METHOD

An English language literature search was performed, using PubMed and Web of Knowledge Databases, with cross-referencing, focussed product searches and communication with product manufacturers. For studies employing animal models, the injury model was required to produce fatal haemorrhage. Products were categorised by primary mode of action as either factor concentrators,mucoadhesive agents or procoagulant supplementors.

RESULTS

From 60 articles collated, 6 clinical papers and 37 preclinical animal trials were eligible for inclusion in this review. Products have been tested in three different types of haemorrhage model: low pressure, high volume venous bleeding, high pressure arterial bleeding and mixed arterial-venous bleeding. The efficacy of products varies with the model adopted. Criteria for the 'ideal battle field haemostatic dressing' have previously been defined by Pusateri, but no product has yet attained suchstatus. Since 2004, HemCon (a mucoadhesive agent) and QuikClot (a factor concentrator) have been widely deployed by United States and United Kingdom Armed Forces; retrospective clinical data supports their efficacy. However, in some recent animal models of lethal haemorrhage, WoundStat(mucoadhesive), Celox (mucoadhesive) and CombatGauze (procoagulant supplementor) have all outperformed both HemCon and QuikClot products.

CONCLUSION

HemCon and QuikClot have augmented the haemostatic capabilities of the military first aid responder, but newer products demonstrate potential to be more effective and should be considered as replacements for current in service systems. These products could have utility for civilian pre-hospital care.

Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize

Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.