Hemostatic Control Agents, Update

[The Reaper]

Gents:

Not a medic, but I recently stayed at a Holiday Inn Express. I also watched the briefing at SOMA by the project officer for HCAs.

The Navy recently tested four HCAs, and Celox came out on top. It was among the best at stopping bleeding, is relatively inexpensive, does not create the exothermic burns that at least one other does, was relatively good at maintaining control during patient movement and handling, and finally, was the easiest to clean out of the wound during debridement and closure (rinse out with no ill-effects).

I believe that if long term studies were done including the post-incident recovery of patients after Quick Clot, it would be pulled from the market, or at least severaly limited in use. Anyone who opens a pack in a windy environment is going to create some problems as well. In a helicopter, it could be terminal. Users need to understand that it is a last resort, to be used only if other measures, like direct compression with packing for five minutes have failed.

I think that the Navy study is among the best, looking at the right primary factors (total blood loss and mortality) with few axes to grind or sponsors to protect.

Hope this is of value.

TR

[x SF med]

TR,
Condolences for staying at a Holiday Inn Express, I thought that was NDDs job. Did you remember to bring your own bed linens (poncho liner and plastic sheeting so the bedbugs don't get you)?

Otherwise, thanks for the post, great info.

[mugwump]

Thanks for this, very interesting. This stuff is cheap, $15 per packet retail as compared with $170 for the HemCon hemostatic bandage. Both use chitosan to control bleeding but the Celox looks even better for penetrating wounds. For $30 retail you can add a packet of this stuff and an Israeli bandage to a first aid kit.

When I Googled "chitosan" I found a zillion hits for its use as a dietary supplement for weight loss ("fat magnet"). It doesn't work, apparently, but it looks like the price of bulk chitosan has been driven down by the fad.

Any discussion about Hemopure, the blood substitute the Navy is backing? Now that PolyHeme has fallen out of bed it looks like the only game in town. I think if they are going to get Hemopure off the ground they are going to have to sponsor their own clinical studies.

[The Reaper]

Originally Posted by mugwump

Thanks for this, very interesting. This stuff is cheap, $15 per packet retail as compared with $170 for the HemCon hemostatic bandage. Both use chitosan to control bleeding but the Celox looks even better for penetrating wounds. For $30 retail you can add a packet of this stuff and an Israeli bandage to a first aid kit.

When I Googled "chitosan" I found a zillion hits for its use as a dietary supplement for weight loss ("fat magnet"). It doesn't work, apparently, but it looks like the price of bulk chitosan has been driven down by the fad.

Any discussion about Hemopure, the blood substitute the Navy is backing? Now that PolyHeme has fallen out of bed it looks like the only game in town. I think if they are going to get Hemopure off the ground they are going to have to sponsor their own clinical studies.

The HemCon is great for sealing clean lacerations, but in irregular wounds it periodically can (and does) fails catastrophically. The Celox can be dumped into the wound and packed with Kerlix gauze, working almost as well as the QuickClot, without cooking the meat.

Didn't see anything on the blood substitutes.

TR

[swatsurgeon]

This past year I attended a Trauma conference where Peter Rhee (Navy?) showed a video from the sand box...He's a surgeon and he clearly showed the hemcon 'pads' do not conform to an irregular wound, hence, lack of efficacy. The celox and new Arista (repackaged TraumaDex/Hemaderm by Medafor) are way ahead of the curve. We are using the Arista/TraumaDex in the operating room now and so far I'm happy. My next use will be into a bleeding bullet tract to see how it doed in the trauma resuscitation bay, then bring them to the operating room and check the results. This will as closely mimic the first responder pushing this stuff into a bad wound that you can't get 'direct 'pressure on but some sort of pressure and see what happens.
I'll post as soon as I have one...I'm on call for the next 4 days straight so maybe I'll get to use it this way.

ss

TR and company.....I agree with if NOTHING ELSE WORKS and all you have left is quikclot, well, then there is little to lose but it is at the VERY BOTTOM of my list of tricks for hemorrhage control.

[The Reaper]

Thanks, SS.

We have also had decent results with Fast Act, but for some reason, it has been spotty in previous tests.

Neatest thing is that it comes in a foam spray can, you can get it down deep into a wound.

mugwump, I agree wholeheartedly. These are all tools in the kit bag. The best solution is to have as many of them as possible available, and to choose the right one for the job. After hearing the Navy's results, I decided that Celox was going into my personal kit. As you noted, it is too inexpensive to pass up. The real scary expensive one is the Fibrin bandage from the Red Cross. Anyone else seem to think that they enjoy having a monopoly on the blood and blood products market?

TR

[swatsurgeon]

Well I knew sooner or later they would respond to the editorial we wrote about the ill effects of the exothermic reaction quikclot causes....I was just looking through my latest Journal of Trauma and what do I see but a new formulation of quikclot that only reaches 105 degrees. A significant improvement over the original formulation.
Once I read and get all of the info straight, I'll post my opinion on the 'new' formula and it's potential from my point of view.
NOTE: the views expressed are my own based on literature/experiments using the hog model that is published. The original video was edited to the point of non-validity.....stay tuned. My guess is that they will conform to improved safety standards and the product will be better accepted in both the civilian and military sectors.

It (a hemostatic agent) remains the last ditch effort to stop bleedining that does not respond to direct pressure, a tourniquet, or other maneuvers.
BTW, TraumaDex just got approval for intra-operative use for significant/uncontrolable bleeding. I will post my uses of this agent also. I have previously used it both in the field and in the OR and it worked very well without any ill effects to the patients unlike the original formula of quikclot.

I would appreciate any feedback from an 18D in the sandbox that has used any of the hemostatic agents recently...thanks

ss

[Eagle5US]

but since you asked...
most of the "kitty litter" quick clot has been removed from theater and replaced by the quick clot tea bag. I have not had any patients come in with the tea bag in place.

I was working in a level II and am now a sole provider at a combat outpost (level III) field aid station.

I have initiated use of the Chitosan dressing a half dozen times successfully...

-penetrating neck
-pelvis vs shrapnel
-missing shoulder / arm x 2
-bilat high amp of legs and associated butt cheek
-blown out perineum (entry anterior / exit perineum)

mixed results on other attempts....key issue was being able to sponge away as much active bleeding / retained clot and application directly on the bleeding source. In my environment - my focus is intermediate stabilization ... enough for them to survive the flight to the level I. Hypotensive rescusitation practices were also employed as well as Hespan for some of the above patients.

As an example: Two days ago I treated a soldier with a very high, (near complete) leg ampy where a TQ was ineffective...the chitosans (2 packed together) failed whether due to the volume, size of the wound, or number of active bleeding sources. I left the chitosans in place and packed with 5 rolls kerlex then utilized 6in aces for pressure-the bleeding appeared controlled by the time he was casevac'ed - I cannot help but think the chitosan dressing contributed to his survival.

Standing by-you all have a good New Year.

Eagle

[swatsurgeon]

Eagle,
Was the leg amp so high that a tourniquet didn't have enough tissue left to cinch down on and compress the vessels? (higher than the one in the picture?)
Also, depending on the injury, the vessels may be visible and clampable. The femoral vessels at this level ride in a sheath and if you follow the anatomy, you might (??) be able to reach up the sheath and pull them down and if not, pack the track of the vessels as tightly as you can with a kerlex, israeli bandage, gauze, etc which can compress the vein which is the usual suspect in continued bleeding...the artery generally will spasm and stop on its own. You are right that there are dozens of muscle bleeders, some of pretty good size that also have to be dealth with....
Best bandage I saw for a really high thigh amp was 2 israeli bandages wrapped around the opposite hip and back around the amp site so that is crosses over and around the other side to create as much pressure and compression to the amp site since a tourniquet could not be used.

ss

[Eagle5US]

Originally Posted by swatsurgeon

Eagle,
Was the leg amp so high that a tourniquet didn't have enough tissue left to cinch down on and compress the vessels? (higher than the one in the picture?)

ss

Correct...anterio/medially it extended to the inguinal fold, posteriorly a large portion of the gluteus was also gone. The proximal 1/3 of the femur had been taken away along with most of the flesh save for some posterior muscle bodies. He had additional significant injuries as well - Wish I had taken a photo.
You are correct in that we are using Isreali bandages CONSISTANTLY on numerous patients. Great peice of kit.
I will give a bit more effort in attempting to track bleeders-but I have thus far been unsuccessful. Be it time, environment, equipment # of patients, whatever-I never feel like I am doing it fast enough. and usually push back to basics to get them on the bird.

Eagle

[The Reaper]

Not a doc, but I have to agree that the combo of HCAs, TQs, and Israeli bandages, distributed at the individual soldier level, have saved a lot of lives.

A good bit of that is testimony to the efficacy of the body armor, which is minimizing thoracic trauma (which required intervention by surgeons) and allowing soldiers and lower level medical personnel to deal with the injuries to the extremities that they can more effectively manage. Despite ballistic improvements to helmets, head injuries continue to be bad news. I think that it is almost criminal for soldiers to deploy without a Level 3A (if not Level 4) helmet and upgraded suspension system, like the Oregon Areo. The OA provides significantly improved protection from blast and impact injuries, as well as comfort, causing the soldiers to wear the helmet longer and more often without degrading their duty performance. Anyone deploying with a PASGT, MICH, or ACH who does not have the OA system should order one for themselves ASAP.

The primary threat of IEDs and VBIEDs have caused the uparmored HMMWVs to be fielded in much larger numbers than were initially deployed, and this has helped save lives as well.

TCCC and the other med training is proving to be invaluable in immediate care of serious trauma. 18Ds, SF soldiers with med cross training, and SOF personnel who have attended Spec Ops Med Training are saving lives and limbs wherever they go. There are few other training programs that have paid off as handsomely as those from the SOMTF. I suspect that the Big Army medical personnel and facilities have also improved significantly during this conflict, and a better medical system is in place now than ever before.

I think that all of these innovations and training, as a whole, are synergistically contributing to a survival rate for injured soldiers which is much higher than would otherwise be expected. And that is some good news for a change.

TR