John J. Devlin

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

OBJECTIVES Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of the most challenging problems facing emergency medical professionals. Several hemostatic agents have emerged as effective adjuncts in controlling extremity hemorrhage. However, a review of the current literature indicates that none of these agents have proven superior under all conditions and in all wound types. This study compared several hemostatic agents in a lethal penetrating groin wound model where the bleeding site could not be visualized. METHODS A complex groin injury with a small penetrating wound, followed by transection of the femoral vessels and 45 seconds of uncontrolled hemorrhage, was created in 80 swine. The animals were then randomized to five treatment groups (16 animals each). Group 1 was Celox-A (CA), group 2 was combat gauze (CG), group 3 was Chitoflex (CF), group 4 was WoundStat (WS), and group 5 was standard gauze (SG) dressing. Each agent was applied with 5 minutes of manual pressure. Hetastarch (500 mL) was infused over 30 minutes. Hemodynamic parameters were recorded over 180 minutes. Primary endpoints were attainment of initial hemostasis and incidence of rebleeding. RESULTS Overall, no difference was found among the agents with respect to initial hemostasis, rebleeding, and survival. Localizing effects among the granular agents, with and without delivery mechanisms, revealed that WS performed more poorly in initial hemostasis and survival when compared to CA. CONCLUSIONS   In this swine model of uncontrolled penetrating hemorrhage, SG dressing performed similarly to the hemostatic agents tested. This supports the concept that proper wound packing and pressure may be more important than the use of a hemostatic agent in small penetrating wounds with severe vascular trauma.

Comparison of ChitoFlex®, CELOX™, and QuikClot® in control of hemorrhage.

BACKGROUND Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. STUDY OBJECTIVES To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS+™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. METHODS Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS+™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. RESULTS Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. CONCLUSION In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access.

Ink sick: Tattoo ink hypersensitivity vasculitis ☆ ☆☆ ★

This case describes a rare cause of vasculitis due to a hypersensitivity reaction to tattoo ink in a young man. This 21-year-old male sailor with no medical problems received a new tattoo on his right calf 2 weeks before presentation. He complained of a painful, pruritic rash on his legs for 1 week, most pronounced around the site of the tattoo. He also reported chills, arthralgias, and myalgias for the preceding 3 days. Despite treatment with loratadine and prednisone for presumed contact dermatitis by his primary care manager, the patient developed significant edema of his left hand and right ankle as well as rigors, prompting his presentation to the emergency department. The purpuric eruption was limited to his lower extremities (Figs. 1-3). His history and physical examination were unremarkable except where noted above. Although vasculitis is relatively common, tattoo ink hypersensitivity vasculitis is extremely rare. The most common complication of tattooing is cellulitis. Punch biopsy of this patient revealed leukocytoclastic vasculitis, which is consistent with previously published tattoo ink vasculidites [1,2]. The most common ink color precipitating cutaneous reactions to tattoos is red, as seen in this tattoo. Interestingly, the patient had previously received other less colorful tattoos without adverse effect. This presentation is similar to a case published by Hermida et al [3], which was the first of its kind. Our patient was admitted to the hospital and treated with systemic corticosteroids for 4 days. He was discharged with ☆ There was no financial support or grant for this paper. ☆☆ The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. ★ Government or non–copyright protected forum. I am a military service member. This work was prepared as part of my official duties. Title 17 USC 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 USC 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that persons official duties.—MJH 0735-6757/

Terlipressin with Limited Fluid Resuscitation in a Swine Model of Hemorrhage

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Scrotal pyocele: Uncommon urologic emergency

BACKGROUND Principles of damage control resuscitation include minimizing intravenous fluid (IVF) administration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advantage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. STUDY OBJECTIVE We evaluated three dosages of TP when combined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. METHODS Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend(®) (Hospira Inc, Lake Forest, IL) only, 3.75 μg/kg TP + Hextend, 7.5 μg/kg TP + Hextend, or 15 μg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min intervals were recorded and compared. RESULTS Subjects receiving 7.5 μg/kg TP had significantly higher MAPs at times t15 (p = 0.012), t20 (p = 0.004), t25 (p = 0.018), t30 (p = 0.032), t35 (p = 0.030), and t40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. CONCLUSION Subjects receiving 7.5 μg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resuscitation, TP doses between 3.75 and 15 μg/kg do not elevate lactate levels in hemorrhaged swine.

Development of a ballistic model of combat groin injury.

Sir, A scrotal pyocele is a rarely described urologic emergency that must be recognized and treated quickly to prevent testicular damage or Fournier’s gangrene. We present a 74 year-old man with four days of left-sided scrotal pain and swelling. Physical examination revealed edema, erythema, and tenderness on the left side of the scrotum extending onto his penis proximally. A scrotal ultrasound was obtained [Figure 1] demonstrating a large scrotal pyocele. Urology surgically drained the pyocele without performing an orchiectomy.

Primum non nocere: limitations of military-derived transfusion recommendations in civilian trauma.

Background: The current leading cause of death to troops in Operations Enduring Freedom results from improvised explosive devices. The need for accurate models of combat trauma in research is an ever present challenge and crucial to our efforts to save the lives of our injured troops. Current swine models of groin injury use a scalpel to create the wound, which provides for a controlled environment but limits the resemblance to real combat injuries. We sought to develop a reliable ballistic model of fragmentation injury that will allow for new research and training opportunities in the field of combat casualty care. Methods: A jet remote opening device was developed to inflict a fragmentation injury to the groin of 20 anesthetized swine. Laser positioning ensured alignment. After hemorrhage, subjects were treated with standard resuscitative measures and monitored for 180 minutes to determine survival. Results: Subject survival was 95% at 3 minutes postinjury and 75% at 180 minutes. Survival rates were similar to actual survival data collected from Operations Enduring Freedom (p = 0.993). Blood loss during initial hemorrhage averaged 15.4 (±6.0) mL/kg. No instances of peritoneal violation by the shrapnel fragments were revealed on necropsy. Conclusions: We developed a ballistic mechanism of injury in a model that replicates improvised explosive device-created wounds. The injury was reliably reproduced in each subject, with survival rates equating those of real casualties. We think that this model represents a true effectiveness model of injury that opens the doors for advanced research endeavors in combat casualty care.

Swine Models of Hemorrhagic Shock: To Splenectomize or Not to Splenectomize, That is the Question

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