Lanny F. Littlejohn

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.

Review of New Topical Hemostatic Dressings for Combat Casualty Care

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third-generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

Application of Current Hemorrhage Control Techniques for Backcountry Care: Part Two, Hemostatic Dressings and Other Adjuncts ☆

Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Part one of this review covered the use of tourniquets on the extremities and the newer devices for use in junctional areas. Part two focuses on the use of hemostatic agents or dressings, pelvic binders, and tranexamic acid. Field applicable hemostatic dressings are safe and effective in controlling hemorrhage not amenable to extremity tourniquet application, and newer agents with increasing efficacy continue to be developed. Most of these agents are inexpensive and lightweight, making them ideal products for use in wilderness medicine. The use of pelvic binders to stabilize suspected pelvic fractures has gained new interest as these products are developed and refined, and the prehospital use of tranexamic acid, a potent antifibrinolytic, has been found to be life saving in patients at risk of death from severe hemorrhage. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Effects of training and simulated combat stress on leg tourniquet application accuracy, time, and effectiveness.

The lower extremity tourniquet failure rate remains significantly higher in combat than in preclinical testing, so we hypothesized that tourniquet placement accuracy, speed, and effectiveness would improve during training and decline during simulated combat. Navy Hospital Corpsman (N = 89), enrolled in a Tactical Combat Casualty Care training course in preparation for deployment, applied Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFT-T) on day 1 and day 4 of classroom training, then under simulated combat, wherein participants ran an obstacle course to apply a tourniquet while wearing full body armor and avoiding simulated small arms fire (paint balls). Application time and pulse elimination effectiveness improved day 1 to day 4 (p < 0.005). Under simulated combat, application time slowed significantly (p < 0.001), whereas accuracy and effectiveness declined slightly. Pulse elimination was poor for CAT (25% failure) and SOFT-T (60% failure) even in classroom conditions following training. CAT was more quickly applied (p < 0.005) and more effective (p < 0.002) than SOFT-T. Training fostered fast and effective application of leg tourniquets while performance declined under simulated combat. The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training in simulated combat scenarios.

Application of Current Hemorrhage Control Techniques for Backcountry Care: Part One, Tourniquets and Hemorrhage Control Adjuncts

Decade-long advancements in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Older methods such as limb elevation and pressure points are no longer recommended. Tourniquets have had a profound effect on lives saved without the commonly feared safety issues that have made them controversial. Unique tourniquet designs for inguinal and abdominal regions are now available for areas not amenable to current fielded extremity tourniquets. This article, the first of two parts, reviews the literature for advancements in prehospital hemorrhage control for any provider in the austere setting. It emphasizes the significant evidence-based advances in tourniquet use on the extremities that have occurred in battlefield trauma medicine since 2001 and reviews the newer junctional tourniquet devices. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Terlipressin with Limited Fluid Resuscitation in a Swine Model of Hemorrhage

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.

Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training

OBJECTIVE Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditional tourniquets accounts for one in five preventable battlefield exsanguination deaths. Products for treating these wounds are costly and require special training. However, chemically treated gauze products are inexpensive, potentially effective, and require only minimal training. This study was designed to assess the efficacy of three hemostatic gauze products following brief training, using a consensus swine groin injury model. METHODS After viewing a 15-minute PowerPoint presentation, without demonstration or practice, 24 U.S. Navy Corpsmen, most with little to no live tissue or hemostatic agent experience, applied one of three hemostatic agents: QuikClot Combat Gauze, Celox Trauma Gauze, or Hemcon ChitoGauze. Animals were resuscitated and monitored for 150 minutes to assess initial hemostasis, blood loss, rebleeding, and survival. Participants completed a survey before training and following testing. RESULTS Products were similar in initial hemostasis, blood loss, and rebleeding. Twenty-three swine survived (96%). Ease of use and perceived efficacy of training ratings were high. Comfort level with application improved following training. CONCLUSIONS Hemostatic gauze can potentially be effective for treating junctional wounds following minimal training, which has important implications for corpsmen, self-aid/buddy-aid, civilian providers, and Tactical Combat Casualty Care guidelines.

Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments

Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully treat. Traumatic open, pneumo-, and hemothoraces represent some of the most significant patterns for which advanced equipment and procedures may help leverage morbidity and mortality, particularly when evacuation is delayed and environmental conditions are extreme. This paper reviews the development of successful techniques for treating combat casualties with thoracic trauma, including the use of vented chest seals and the technique of needle thoracentesis. Recommendations are then given for applying this knowledge and skill set in the backcountry.