A brief guide to Haemostatic Agents

Haemostatics are applications designed to stem blood-flow through the accelerated promotion of clotting.  As with all treatments it is important to understand their roles, applications and the differences between them.

Both Tourniquets and Haemostatics are demonstrated and applied on our First Person on Scene course, and we advocate their use but only when appropriate.  This is why:

Considerations

  • Haemostatics are not the first line treatment for serious bleeds.  Always start with direct pressure before considering haemostatics.
  • They are used with direct pressure – not instead of.
  • Every haemostatic agent (brand and type) is different and familiarisation training should be sought.
  • They are applied to the source of the bleed – the damaged blood vessel – not somewhere near it.
  • The packaging should be retained and handed-over to the EMS with the instruction that it goes with them to hospital to enable their wound to be managed effectively.  Do not assume the hospital will know how to deal with the haemostatic you have applied.

 

Application

Uncontrolled haemorrhage is the leading cause of preventable death on the battlefield (1-3) and the second leading cause of trauma related death in a civilian setting (4) with most being penetrating injury or predominantly affecting the limbs (1,2)

The tourniquet is an effective means of haemorrhage control but junctional zones, such as the groin, armpit, neck, as well as head and abdomen present their own difficulties in trying to stop serious blood loss (5), being unsuitable wounds for tourniquet application and difficult to maintain effective compression.

In simple terms Haemostatic agents work in a variety of ways to stem the flow of blood but their use, as with all advanced interventions, requires training and understanding.

The primary treatment for all serious bleeds is direct pressure; all haemostatics are designed to be used with direct pressure at the site of the bleed – directly onto the bleeding artery, deep within the wound if necessary.  They are not a ‘magic powder’ that can be casually applied somewhere near the wound and left to work.

Most brands are available as either a loose, granular powder, impregnated onto a bandage or retained inside a porous bag.   Loose powders present issue when trying to apply them accurately into the wound site and can be blown around by the wind. 

Powders cannot be applied against gravity – for example packing a wound underneath a casualty – nor can they be applied against very fast flowing blood.  Haemostatic bandages, gauzes and ‘sponges’ are often easier and more practical to apply.  These dressings are also easier to remove and clean in theatre, once the casualty gets to hospital.  For these reasons this article does not discuss the various granular forms and neither is their use recommended on our courses.

Finally, Haemostatic agents should never be allowed to enter:

  • The eyes
  • The airway
  • The chest
  • Head injuries with exposed brain tissue or meninges

 

Types of Haemostatic Agents

Factor concentrators

These agents work through rapid absorption of the water content of blood concentrating the cellular and protein components of the blood encouraging clot formation.

One of the most common ‘myths’ you will hear of Haemostatics is that they cause burns.  One particular brand Quikclot used Zeolite, an inert volcanic mineral which rapidly absorbs water but creates an exothermic reaction.   Quikclot’s first generation products created heat of up to 72oC (6,7), the 2nd generation products had been seen to generate heat up to 42oC. (8)  

This product was replaced in 2009 and is no longer available.  Current generations of Quikclot product do not cause burns.

 

Mucoadhesive agents

These agents create a strong adherence to tissues and physically seal bleeding wounds. Three common products –Celox, SAM Chito Hemcon - all use chitosan, a naturally occurring, bio-compatible polysaccharide derived from shellfish, and work in this fashion.

On contact with anionic erythrocytes, the chitosan salts rapidly ‘cross-link’, adhering strongly with the wound surface.  This adhesive process is thought to be the primary mechanism of action; independent of platelets or clotting factors. (9)

Chitosan is extracted from shrimp shells so there have been inevitable questions about whether it could trigger shellfish allergies:  There are no cases on record of allergic reaction to chitosan based haemostatics, even in those with a known seafood allergy.(10, 11)

Celox Gauze and Chito-SAM

Celox Guaze is a fibrous bandages coated in chitosan powder.  Chito-SAM is made from woven chitosan filament.  This is easier to handle and apply than granules and is also easier to clean in theatre, usually with normal saline.  Chitosan is naturally broken down by the body’s natural enzymes unlike Kaolin or other minerals used in haemostatics which will remain in the body indefinitely unless removed.

As haemostatic bandages need to be packed into the wound, the user is limited by the length of their finger; the Celox Applicator is a unique design which allows the chitosan to be applied into deep wounds making it ideal for gunshot and penetrating wounds.

Celox Gauze

Celox Gauze

Chito-SAM

Chito-SAM

Celox Applicator

Celox Applicator

HemCon

HemCon products are also chitosan-based haemostatic and works on the same adhesive principle as CeloxHemcon is a mucoadhesive pad which is intended to seal the wound (like a puncture repair) but, being a fairly stiff and brittle pad, it is not efficient as efficient at dealing with deeper wounds.  Hemcon pads have been known to break apart during use (12).  Recently Hemcon have introduced Hemocon Chitoflex which is a coated bandage similar to Celox and Chito-SAM which can be packed into the wound.

HemCon Bandage

HemCon Bandage

HemCon Chitoflex

HemCon Chitoflex


Procoagulant supplimentors

A third class of agents function by delivering procoagulant factors to the bleeding wound. 

Current 3rd and 4th Generation Quikclot utilise Kaolin, a white aluminosilicate nano-particulate which has been shown to accelerate the body’s natural coagulation cascade.

3rd Generation products are dispensed in a ‘tea bag’ like sachet which is applied directly to the wound.  This removes the problems associated with handling loose granules and enables a large area to be covered, deep wounds to be filled and direct pressure to be effectively applied.  This method of application also facilitates the quick and easy removal of the product in theatre.  Conversely, this method is not ideal for treating small, deep puncture wounds or incisions. 

4th Generation Quikclot Combat Gauze is fibrous gauze impregnated with Kaolin.  The bandage is packed deep inside the wounds as with other haemostatic bandages. 

Quikclot Combat Gauze

Quikclot Combat Gauze

Quikclot ACE 'Sponge'

Quikclot ACE 'Sponge'

 

Which is best?

There are a number of independent studies which have examined the efficacy of these products but there is not absolute consistency.  Quikclot Combat Gauze is repeatedly cited as the haemostatic agent of choice for the whole of the US Armed Forces (13)  based on early clinical trials.  Since then other, newer products have emerged with equal efficacy; general consensus is that in terms of stopping bleeding, they are all as good as each other.(14, 15)

Rather than worrying about the biochemical effectiveness of each mechanism a more appropriate discussion would be about ease of use.   Desirable qualities include ease of application, ease of removal, non-exothermic, robust packaging which is easy to open, small pack size and Cost. (16, 17)

  • The Hemcon patch has the smallest pack size but is exorbitantly expensive (circa £100 each compared to £30-40 for each other available product) and also has limitations in its application mentioned above.
     
  • 3rd Generation Quiklot sachets are similarly limited to larger wounds due to their bulk.
     
  • It is widely known that the hypovolaemic casualty is more susceptible to hypothermia and that below 35oC, coagulation is inhibited due to the inefficacy of the bio-chemical clotting cascade at lower temperatures(18) which would imply that the ideal haemostatic should work independently of the body’s natural clotting factors, ruling out Quikclot Combat Gauze.

This would leave any of the Chitosan based gauze haemostatics as indistinguishable in terms of application or efficacy.

The unique design of the Celox Applicator make it a desirable addition if space in your kit and budget allows for a second option.

 

But...what about just normal gauze?

Comparisons of Quikclot Combat Gauze, Celox and Kerlix (a standard, unmediated, gauze bandage) that standard gauze was faster to pack with no difference in haemostatic success or blood loss (19, 20)

Haemostatics should not be left in place for more than 24 hours.  If the casualty cannot be evacuated to definitive care within this time, their use is not appropriate.  This might limit their use in extremely remote environments.

A casualty with a catastrophic haemorrhage is very poorly.  Evidence suggest that this may account for 50% of trauma related fatalities, more to the point, these fatalities typically occur within one hour of the causing incident.   Whilst the haemostatic should not be left for more than 24 hours, can you evacuate your casualty to definitive care within one hour?


Conclusion

  • Let’s not be precious about brand but considers a gauze style haemostatic for ease of use.
  • There may be merit in a chitosan based haemostatic over Combat Gauze for the critically ill casualty.
  • If you do not have a haemostatic dressing any sterile gauze will do to pack the wound if a) direct pressure is not effective and b) a tourniquet is not appropriate.
  • Communicate your treatment in your initial call for help – the use of a haemostatic has made your casualty time-critical.
  • Some people will die.   Not because of you, your actions or which brand of haemostatic you were or were not using.  That’s’ why it is call “Catastrophic” bleeding.


References

  1. Bellamy RF.  The causes of death in conventional land warfare–implications for combat casualty care research.  Military Medicine 1984;149(2):55–62.
     
  2. 2.Champion HR, Bellamy RF, Roberts CP, Leppaniemi A.  (2003)  “A profile of combat injury.  Journal of Trauma – Injury Infection and Critical Care 2003;54(5):S13–9.
     
  3. Eastridge BJ1, Hardin M et al  (2011)  “Died of wounds on the battlefield: causation and implications for improving combat casualty care.”  Journal of Trauma. Jul;71(1 Suppl):S4-8.
     
  4. Sauaia A, Moore FA, Moore EE, et al.  (1995)  “Epidemiology of trauma deaths – a reassessment.” Journal of Trauma – Injury Infection and Critical Care 1995;38 (2):185–93.
     
  5. Mabry RL, Holcomb JB, Baker AM, et al. (2000)  “United States army rangers in Somalia:  an analysis of combat casualties on an urban battlefield.”  Journal of Trauma - Injury Infection and Critical Care.  49(3):515–28.
     
  6. M A A Khan, R Jose, C Taylor, H Malick, W Jaffe (2010) "An iatrogenic burn from the use of a topical haemostatic agent”.  Emergency Medical Journal.  27:950-951
     
  7. Rhee P1, Brown C, Martin M, Salim A, Plurad D, Green D, Chambers L, Demetriades D, Velmahos G, Alam H. (2008) “QuikClot use in trauma for hemorrhage control: case series of 103 documented uses”.  Journal of Trauma.  Apr;64(4):1093-9
     
  8. Arnaud F, Tomori T, Carr W, McKeague A, Teranishi K, Prusaczyk K, McCarron R. (2008)  “Exothermic reaction in zeolite hemostatic dressings: QuikClot ACS and ACS+”, Annals of Biomedical Engineering.  Oct;36(10):1708-13
     
  9. Burkatovskaya M, Tegos GP, Swietlik E, et al.  (2006)  “Use of chitosan bandage to prevent fatal infections developing from highly contaminated wounds in mice.  Biomaterials  27(22):4157–64.
     
  10. Waibel KH, Haney B, Moore M, Whisman B, Gomez R.  (2001)  “Safety of chitosan bandages in shellfish allergic patients.”  Military Medicine.  Oct;176(10):1153-6.
     
  11. KozenB, Kircher S, Heanao J, et al.  (2007)  “An alternative field hemostatic Agent?  Comparison of a new chitosan granule dressing to existing chitosan wafer, zeolite and standard dressings, in a lethal hemorrhagic groin injury.”  Annals of Emergency Medicine 2007;50(3):S60–1.
     
  12. Stuke LE.  (2013)  “Prehospital topical hemostatic agents – A review of the current literature”.  PHTLS Executive Committee.
     
  13. "Tactical Combat Casualty Care Guidelines", 28 October 2013,  http://www.naemt.org/Files/TCCC/041114/TCCC%20Guidelines_131028.pdf
     
  14. Rall JM, Cox JM, Songer AG, Cestero RF, Ross JD.  (2013)  “Comparison of novel hemostatic dressings with QuikClot combat gauze in a standardized swine model of uncontrolled hemorrhage.”  The Journal of Trauma and Acute Care Surgery.  Aug;75(2 Suppl 2):S150-6.
     
  15. Granville-Chapman J, Jacobs N, Midwinter MJ (2011)  “Pre-hospital haemostatic dressings: A systematic review."  Injury  42(5): 447-459
     
  16. Granville-Chapman J, Jacobs N, Midwinter MJ. (2011)  “Pre-hospital haemostatic dressings: a systematic review”, Injury, May;42(5):447-59.
     
  17. Kheirabadi BS1, Scherer MR, Estep JS, Dubick MA, Holcomb JB. (2009)  “Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine”, Journal of Trauma,  Sep;67(3):450-9
     
  18. Tsuei BJ, Kearney PA.  (2004)  “Hypothermia in the trauma patient.”  Injury.  Jan; 35(1):7–15
     
  19. Watters JM, Van PY, Hamilton GJ, et al. (2011)  “Advanced Hemostatic Dressings Are Not Superior to Gauze for Care Under Fire Scenarios.” Journal of Trauma. 70:1413-1419.
     
  20. Littlejohn LF, Devlin JJ, Kircher SS, et al. (2011)  “Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma.”  Academic Emergency Medicine.  18(4);340-350.

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