A brief guide to Haemostatic Agents

Revised 22nd May 2019

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Haemostatics are applications designed to stem blood-flow through the promotion of accelerated 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 Responder course, and we advocate their use but only when appropriate.  This is why:

Considerations

  • 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 the 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 Phokus Wound Cube.

The Phokus Wound Cube.

Practicing wound packing technique.

Practicing wound packing technique.

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)


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. 

 

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 was the haemostatic agent of choice for the whole of the US Armed Forces (13)  based on early clinical trials.  Currently Celox is the recommended haemostatic agent for both the UK and US military. 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 -16)

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.


But...what about just normal gauze?

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

Further research (21 – 23) reveals that while haemostatics have been shown to reduce blood loss “the difference is not significant”.

What stops deep junction or abdominal bleeding which cannot be arrested with direct pressure is not the magic moon-dust thermostatic agents are made from, it is the mechanical process of wound packing which:

  1. Applies pressure to the damaged vessel or organ and

  2. Fills the void with material to reduce available space to bleed into.

Haemostatic agents have, however, demonstrated significant benefit in the propagation of a more stable clot that is less prone to rupture during moment of the casualty (24).


Conclusion

  • Let’s not be precious about brand but consider 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. 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 BJ, 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. Khan MAA, Jose R, Taylor C, Malick H, Jaffe W. (2010) "An iatrogenic burn from the use of a topical haemostatic agent”. Emergency Medical Journal. 27:950-951

  7. Rhee P, 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. Welch M, Barratt J, Peters A, et al (2019)Systematic review of prehospital haemostatic dressings”. Journal of the Royal Army Medical Corps.  Published Online First: 02 February 2019. doi: 10.1136/jramc-2018-0010669

  16. Granville-Chapman J, Jacobs N, Midwinter MJ. (2011) “Pre-hospital haemostatic dressings: a systematic review”, Injury, May;42(5):447-59.

  17. Kheirabadi BS, 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.

  21. Kheirabadi BS, Scherer MR, Estep JS, et al. (2009)  “Determination of efficacy of new hemostatic dressings in a model of extremity arterial haemorrhage in swine”.  Journal of Trauma-Injury Infection Critical Care.  67(3):450-459.

  22. Kheirabadi BS, Mace JE, Terrazas IB, et al.  (2010)  “Safety evaluation of new hemostatic agents, smectite granules, and kaolin-coated gauze in a vascular injury wound model in swine”.  Journal of Trauma.  68(2):269-278.

  23. Kunio N, Riha GM, Watson KM, Differding JA, Schreiber MA, Watters JM (2013)  Chitosan based hemostatic dressing is associated with decreased blood loss in a swine uncontrolled hemorrhage model”. Americal Journal of Surgery  205(5): 505–10.

  24. Gegel B, Burgert J, Gasko J, et al.  (2012)  “The effects of QuikClot Combat Gauze and movement on hemorrhage control in a porcine model”.  Military Medicine.  177(12):1543–1547.

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