Which haemostatic agent most effectively controls catastrophic external haemorrhage?
Date First Published:
January 30, 2012
Last Updated:
June 4, 2012
Report by:
Carl McQueen, HEMS doctor (Warwickshire and Northamptonshire Air Ambulance)
Search checked by:
David Roberts, Warwickshire and Northamptonshire Air Ambulance
Three-Part Question:
In [catastrophic external haemorrhage] which of the available [haemostatic agents] provide the [most effective control of bleeding]?
Clinical Scenario:
You are part of a HEMS crew tasked to a 50 year old farmer who has trapped his arm in a machine on his farm. The patient has sustained a traumatic amputation of the right arm at the level of the mid humerus and there is catastrophic blood loss. Bleeding has not been controlled with simple elevation, compression or a combat application tourniquet (C-A-T). You wounder which of the available haemostatic agents will best control this man's life threatening haemorrhage.
Search Strategy:
OVID Medline (1946 to May Week3 2012) [Hemcon AND Quikclot AND Celox]
Outcome:
33 papers were found, with 3 being directly relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| An Alternative Hemostatic Dressing: Comparision of CELOX, HemCon and Quickclot Kozen BG et al 2008 USA | 48 anaesthetised swine | Randomised control trial (unblinded) comparing HemCon/Quickclot/Celox and standard dressing on the management of incisional wound to the groin | All haemostatic agents were better than standard dressings at reducing rates of re-bleeding and survival from injury to 3 hours. | Celox reduced rebleeding to 0% | •Porcine study •Small sample size •3 minutes from wounding to dressing application |
| Determination of Efficacy of New Hemostatic Dressings in a Model of Extremity Arterial Hemorrhage in Swine Kheirabadi, Bijan S et al 2009 USA | 46 anaesthetised swine | Comparative Study comparing the efficacy of Celox/Trauma Stat/Combat Gauze/standard dressings on the management of incisional wounds to the groin in anaesthetised swine |
Combat gauze provided better initial haemostasis than all other dressings | Combat gauze shown to be more effective than other dressings (including Celox) in primary haemostatis/overall blood loss/survival and preservation of MAP | •Porcine study •Small sample size •45 seconds from wounding to dressing application |
| Clay JG Comparative Testing of New Hemostatic Agents in a Swine Model of Extremity Arterial and Venous Hemorrhage 2010 USA | 30 Swine | RCT (unblinded)comparing Woundstat/Celox/HemCon/Quickclot/Army field dressing in the management of incisional wounds to the groin in anaesthetised swine |
Overall survival to 120 minutes better for all haemostatic agents compared to field dressing | •tWoundstat was shown to be the most effective haemostatic agent in all areas but only statistically different to Quickclot | •Porcine study •Small sample size •45 seconds from wounding to dressing application |
Author Commentary:
Haemostatic agents have been shown to be more effective than standard dressings in the management of catastrophic haemorrhage in swine models. The studies that are available however are limited by small sample size. Celox has been shown to be more effective than older agents such as HemCon and Quickclot in terms of survival and re-bleeding rates. Newer agents such as Woundstat and Combat gauze have since been shown to be more effective than Celox.
The major limitation of all of the studies reviewed in this analysis however is the extremely short length of time from wounding to the application of a dressing. The authors of each of the papers reviewed stated that they wished to replicate the time frames encountered on the battlefield, where rapid emergency care from other soldiers is the norm. In civilian practice it is extremely rare that immediate care will be available in these timeframes and hence the type of injuries inflicted on the animals in these studies will likely prove to be fatal. There is currently no evidence evaluating the use of haemostatic agents in models that better reflect civilian practice.
The major limitation of all of the studies reviewed in this analysis however is the extremely short length of time from wounding to the application of a dressing. The authors of each of the papers reviewed stated that they wished to replicate the time frames encountered on the battlefield, where rapid emergency care from other soldiers is the norm. In civilian practice it is extremely rare that immediate care will be available in these timeframes and hence the type of injuries inflicted on the animals in these studies will likely prove to be fatal. There is currently no evidence evaluating the use of haemostatic agents in models that better reflect civilian practice.
Bottom Line:
Haemostatic agents have been shown to be more effective in the management of catastrophic haemorrhage than simple dressings. Agents such as Celox are more effective than older dressings such as Quickclot and Hemcon, with fewer side effects, but may eventually be superseded by newer products. Further research is required into the use of haemostatic agents in models that are more relevant to civilian practice.
References:
- Kozen BG et al. An Alternative Hemostatic Dressing: Comparision of CELOX, HemCon and Quickclot
- Kheirabadi, Bijan S et al. Determination of Efficacy of New Hemostatic Dressings in a Model of Extremity Arterial Hemorrhage in Swine
- Comparative Testing of New Hemostatic Agents in a Swine Model of Extremity Arterial and Venous Hemorrhage. Clay JG