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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]

Search Outcome

33 papers were found, with 3 being directly relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kozen 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
Kheirabadhi 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 et al 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	• Woundstat 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

Comment(s)

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.

Clinical 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

1. Kozen BG et al An Alternative Hemostatic Dressing: Comparision of CELOX, HemCon and Quickclot Academic Emergency Medicine 2008; 15:74–81
2. Kheirabadi, Bijan S et al Determination of Efficacy of New Hemostatic Dressings in a Model of Extremity Arterial Hemorrhage in Swine Journal of Trauma-Injury Infection & Critical Care: September 2009 - Volume 67 - Issue 3 - pp 450-460
3. Comparative Testing of New Hemostatic Agents in a Swine Model of Extremity Arterial and Venous Hemorrhage Clay JG Military Medicine Volume 175, Number 4, April 2010 , pp. 280-284(5)