Haemostatic dressings in prehospital care

Abstract

Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans.

Topical hemostatics for bleeding control in pre-hospital setting: Then and now

“…[6,8,9] Although very successful in achieving bleeding control, smectite is outdated because of its potential for tissue damage and inability to wipe it off the tissue. [15,27] Chitosan seems relatively safe; the only concern regarding its use may be shellfish allergy of the individual. [14,15] Kaolin is also safe but needs more time for achieving hemostasis and an intact coagulation system in the individual.…”

“…[15,27] Chitosan seems relatively safe; the only concern regarding its use may be shellfish allergy of the individual. [14,15] Kaolin is also safe but needs more time for achieving hemostasis and an intact coagulation system in the individual. [8] Dry fibrin sealants are expensive and fragile for battlefield environment.…”

“…[12,13] Chitosan's positively charged surface successfully attracts erythrocytes and mechanically seals the bleeding site, and its chemical structure causes vasoconstriction, which enhances its hemostatic effect. [14,15] HemCon Bandage ® , Celox ® , and ChitoGauze ® are the best known commercial products containing chitosan as an active ingredient. Preclinical studies are the mainstay of using chitosan-based materials on the battlefield.…”

Control of Traumatic Extremity Hemorrhage

“…In addition, kaolin activates the XII factor of the coagulation cascade 19 and is dependent upon an adequately functioning coagulation cascade. 20 However, small, ongoing animal research studies have demonstrated QuikClot's effi cacy with both hypothermia and dilutional coagulopathy. 21,22 Because of its mechanism of action, QuikClot may not provide immediate hemostasis and may cause more initial blood loss.…”

Use of local pro-coagulant haemostatic agents for intra-cavity control of haemorrhage after trauma

“…As well as efficacy and safety, these include ease of administration and stability of the product. There is a growing body of literature which describe the relative merits and disadvantages of products such as QuikClot Ò Combat Gauze (a Zeolite mineral based compound), WoundStat Ò (a granular combination of a smectite mineral and a polymer), Celox Ò (a chitosan product) and HemCon Ò (a complex polysaccharide-chitosan) as adjuncts to pressure control in peripheral injuries (reviewed in detail by Granville-Chapman et al [8] and Smith et al [9]). However, these products are primarily for external application and may not be licensed for intra-cavity use.…”