Written by: Ade Akhetuamhen, MD (NUEM PGY-2) Edited by: Spenser Lang, MD (NUEM Alum ‘18) Expert commentary by: Matthew Levine, MD
Expert Commentary
Dr Akhetuamhen has provided a nice quick reference for topical hemostatic agents (THAs). These agents have become more relevant in recent years, particularly in prehospital care, as the prehospital emphasis has shifted from resuscitating hemorrhage more towards hemorrhage control. Much of our knowledge of these dressings come from battlefield studies of major hemorrhage. Their use has been formally endorsed by the American College of Surgeons Committee on Trauma in 2014, particularly for junctional site hemorrhaging. Dr Akhetuamhen has listed the properties of the ideal THA. No current product fulfills all of these criteria.
Much of what we know about these agents comes from military studies. There are limitations to these studies. There are fewer human studies, and these tend to be retrospective, observational, and based on questionnaires. The possibility of reporting bias exists in these studies and study design made it impossible to control for the type of wound. There are far more animal studies. Animal studies allow for the ability to control for wound type, but are more difficult to simulate real life wounds from missiles or shrapnel.
Hemcon and Quickclot products were the earliest products studied by the military and became the early THA gold standards after they were determined to be more effective than standard gauze. An earlier concern for Quickclot was exothermic reactions from the activated products that caused burns to patients. As Quickclot transitioned its active ingredient from zeolite to kaolin, this concern diminished. Quickclot is available in a roll called Combat Gauze that is favored by the military and available in our trauma bay.
Finally, there are some important practical tips for using these products. THAs are not a substitute for proper wound packing and direct pressure. Most topical hemostatic agent failures in studies were from user failure! THAs must come into contact with the bleeding vessel to work. Simply applying the THA over the bleeding areas does not mean it is contacting the bleeding vessel. The product may need to be trimmed, packed, shaped or molded in order to achieve this. Otherwise it is simply collecting blood. After it is properly applied, pile gauze on top of it and give firm direct pressure for several minutes before checking for effectiveness.
See what THA(s) you have available in your trauma bay, it is nice to know ahead of time before presented with a hemorrhaging patient what you have and in what form (a roll, sponge, wafer, etc). Find out how the product is removed. It may not be relevant to the patient’s ED stay but at some point the dressing needs to come off. Some are left to fall off on their own. The chitosan products are removed by soaking them. When soaked, the chitosan turns slimy and can be slid off atraumatically.
Matthew Levine, MD
Assistant Professor of Emergency Medicine
Northwestern Medicine
How to Cite this Blog
[Peer-Reviewed, Web Publication] Akhetuamhen A, Lang S (2018, October 29). Bad Blood. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/bad-blood
