Elsevier

Injury

Volume 42, Issue 5, May 2011, Pages 447-459
Injury

Review
Pre-hospital haemostatic dressings: A systematic review

https://doi.org/10.1016/j.injury.2010.09.037Get rights and content

Abstract

Background

Uncontrolled haemorrhage is a leading cause of prehospital death after military and civilian trauma. Exsanguination from extremity wounds causes over half of preven military combat deaths and wounds to the anatomical junctional zones provide a particular challenge for first responders. Commercial products have been developed, which claim to outperform standard gauze bandages in establishing and maintaining non-surgical haemostasis. Since 2004, two advanced haemostatic dressing products, HemCon and QuikClot have been widely deployed in military operations. Newer products have since become available which aim to provide more efficient haemostasis than and thus supersede HemCon and QuikClot.

Aim

To conduct a systematic review of clinical and preclinical evidence to compare the relative efficacy and safety of available haemostatic products, which are of relevance to pre-hospital military and civilian emergency medical providers.

Method

An English language literature search was performed, using PubMed® and Web of Knowledge® Databases, with cross-referencing, focussed product searches and communication with product manufacturers. For studies employing animal models, the injury model was required to produce fatal haemorrhage. Products were categorised by primary mode of action as either factor concentrators, mucoadhesive agents or procoagulant supplementors.

Results

From 60 articles collated, 6 clinical papers and 37 preclinical animal trials were eligible for inclusion in this review. Products have been tested in three different types of haemorrhage model: low pressure, high volume venous bleeding, high pressure arterial bleeding and mixed arterial-venous bleeding. The efficacy of products varies with the model adopted. Criteria for the ‘ideal battlefield haemostatic dressing’ have previously been defined by Pusateri, but no product has yet attained such status. Since 2004, HemCon (a mucoadhesive agent) and QuikClot (a factor concentrator) have been widely deployed by United States and United Kingdom Armed Forces; retrospective clinical data supports their efficacy. However, in some recent animal models of lethal haemorrhage, WoundStat (mucoadhesive), Celox (mucoadhesive) and CombatGauze (procoagulant supplementor) have all outperformed both HemCon and QuikClot products.

Conclusion

HemCon and QuikClot have augmented the haemostatic capabilities of the military first aid responder, but newer products demonstrate potential to be more effective and should be considered as replacements for current in service systems. These products could have utility for civilian pre-hospital care.

Introduction

Uncontrolled haemorrhage is the leading cause of death on the battlefield 11, 16 and the second leading cause after civilian trauma.51 In modern combat, most injuries are penetrating and affect predominantly the limbs11, 16: exsanguination from extremity wounds accounts for over half of all preventable deaths on the battlefield.11 Junctional zones, such as the groin, axilla, neck, and perineum present a particular problem to the medic trying to gain control of a haemorrhaging wound.39 These areas contain large vascular structures and proximal surgical control cannot be achieved within the extremity; they are unsuitable wounds for tourniquet application and it is difficult to maintain effective compression.

In a military operational setting, for many reasons, evacuation of seriously injured casualties can be significantly delayed. In civilian mass casualty incidents, or in remote environments, evacuation may also be delayed. Casualty care doctrine cannot therefore rely on achieving rapid surgical control of bleeding and non-surgical strategies must be refined to prevent fatal exsanguinations in the field.

With these goals in mind, several enhanced haemostatic dressings have been designed and assessed for their ability to control life-threatening haemorrhage on the battlefield. In 2003, Pusateri cited seven criteria for the ideal prehospital topical haemostatic dressing.46 The ability to stop haemorrhage from actively bleeding large arteries and veins within 2 min, delivered through a pool of blood; ready to use requiring no on scene mixing or preparation; simple to apply by casualty, non-medical first responder or medical staff; lightweight and durable; minimum 2 year shelf-life and wide temperature storage capability (ideally −10–55 °C); risk free – no injury or viral disease transmission risk; and inexpensive. While the ideal dressing has yet to be discovered, advanced dressings have already been deployed on military operations and by civilian emergency services. This paper reviews the current literature regarding topical prehospital haemostatic dressings and compares their ability to achieve and maintain haemostasis after life-threatening haemorrhagic injury. There have been thorough reviews of topical surgical haemostatics, but none that focus on pre-hospital use; instead they examine intra-operative haemostatic solutions and give prehospital dressings a cursory mention.3

Section snippets

Methods

Electronic literature searches were undertaken using the Web of Knowledge® and Medline® (Ovid®) databases. A broad search for English Language articles relating to haemostatic; battlefield or combat dressings was performed and followed by cross-reference searching by hand. Manufacturers of several agents were contacted to elicit technical information regarding manufacture, cost, licensing and mechanisms of action. Before inclusion into this review, research article abstracts were screened for

Agent description and classification

Several agents have been developed and marketed as enhanced haemostatic dressings. They can be grouped into three classes by mechanism of action: factor concentrators; mucoadhesive agents and procoagulant supplementors. Haemostatic products do not tend to have ‘generic’ alternative names; one manufacturer's ‘Chitosan’ may behave differently from another's; they are marketed under trade names and care providers are familiar with these. For these reasons, we have used trade names in this review.

Preclinical evidence

Clinical data is scant. That which exists is retrospective and observational. The obstacles impeding robust clinical data acquisition force investigators to employ animal models, most using swine, to study haemostatic dressings. To help compare products’ relative efficacy, these models can be broadly classified into three main groups, based on the challenge they present to the dressing system on test: venous haemorrhage, arterial haemorrhage, or mixed arterial and venous haemorrhage.

Clinical evidence

Again it is important to note the paucity of clinical data that supports the clinical use of these haemostatic products. Coalition militaries have deployed these agents widely in the field, but only six published series exist. Observational, or retrospective methodology weakens the literature. Ideally, any newly implemented agent should be supported by a robust data collection strategy. However, the constraints on data collection in the far-forward pre-hospital environment have to date

Discussion

HemCon and QuikClot have been available for 5 years. Both products have been deployed by the US and UK Armed Forces. In the UK Armed Forces, these dressings are issued to military medical technicians, for use on external injuries when conventional gauze field dressings have failed. Retrospective questionnaire data forms the strongest clinical evidence. Both HemCon and QuikClot appear to have been effective in clinical use, but the influence of reporting bias must not be overlooked. HemCon has

Conclusions

In 2003, Pusateri cited seven criteria for the ideal prehospital topical haemostatic dressing.46 The ability to stop haemorrhage from actively bleeding large arteries and veins within 2 min, delivered through a pool of blood; ready to use requiring no on scene mixing or preparation; simple to apply by casualty, non-medical first responder or medical staff; lightweight and durable; minimum 2 years shelf-life and wide temperature storage capability (ideally −10 to 55 °C); no injury or viral disease

Conflict of interest statement

The authors have not, and will not receive any financial remuneration or personal incentives for the completion of this work.

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