Hemostatic agents have been designed to provide temporary control of life-threatening hemorrhage due to penetrating trauma. The military saw a need for a more efficacious hemostatic dressing when injuries sustained from penetrating trauma were unable to be controlled with their standard Army Field Bandage. Hemostatic agents were initially designed for immediate “infield” control of severe hemorrhage. A limiting factor in their early use was the exothermic reaction of the first generation products. They are not a substitute for standard first-line hemorrhage control techniques. These agents are routinely used on patients not responding to initial management. As mortality from uncontrollable hemorrhage remains the number one cause of death in both civilian and military traumatic injuries, the role of these agents continues to grow.10
Hemostatic dressings are indicated for penetrating injury resulting in uncontrollable arterial or venous hemorrhage. They are not indicated in minor injuries or those responding to standard management. These agents have repeatedly demonstrated their ability to effectively control life-threatening hemorrhage and frequently prevent the need for tourniquet use or vessel ligation.10,11 Early hemostatic agents produced a tissue damaging exothermic reaction. They have since been improved by limiting the temporary wound temperature to a maximum of 40°C.12
The majority of commercially available hemostatic agents are produced in bandage form. However, there are several agents (Celox and TraumaDEX [Bleed-X], for example) that are available in a powder form. In this form, the agent is poured or applied with a commercial applicator directly into the wound. While showing favorable hemostatic outcomes, agents in powder form may require additional time to ensure complete removal from the wound,13 therefore making these forms less desirable for some applications.
Advanced planning must take place when deciding on which hemostatic agent to select since it is likely to be cost prohibitive to carry multiple agents. We will explain the different mechanisms of action relied on by each agent to achieve hemorrhage control. The agents discussed in this section represent the most common of those currently being used in the prehospital environment. All of these agents have been tested and shown to achieve adequate hemorrhage control following the failure of traditional methods, or in cases of large bore arterial or venous injury (ie, liver lacerations, aortic injury, etc).14-17
Zeolite, a volcanic mineral, adsorbs water from the hemorrhage site in an exothermic reaction, allowing coagulation factors and platelets to collect and initiate clot formation.11 QuikClot (Z-Medica, Wallingford, CT) uses zeolite technology and is FDA approved. It was originally developed in powder form, and is now available for civilian use in dressing form. QuikClot is the primary hemostatic agent used by the US Armed Forces.15 In a recent study, swine sustaining lethal groin injuries, QuikClot achieved a 0% mortality rate.10
Chitosan, the active agent in several hemostatic agents, is derived from chitin, the structural component of the exoskeleton of crustaceans. Both HemCon (HemCon Medical Technologies, Inc, Portland, OR) and a new agent, Celox (MedTrade Products Ltd, Crewe, England) rely on chitosan as their active ingredient. Chitosan is effective by causing blood to gel when it comes in contact with it. The newly formed gel allows the dressing to adhere to the wound edges, forming a seal and stopping the hemorrhage.18 Since no exothermic reaction is taking place when using chitosan products, heat injury is not a complication of these agents. Both HemCon and Celox are FDA approved and available for civilian use (Figure 57-3). A recent study proved the newer agent Celox to be as efficacious as the more established HemCon and QuikClot.16
Conveniently carried items for addressing wounds and hemorrhage. Pictured here is an EMS physician's tactical vest with pockets containing items for immediate intervention of life-threatening wounds and hemorrhage: two Celox trauma gauze packets, 6-in hemorrhage control bandage, two chest seals, two tourniquets, two thoracostomy needles, #10-blade scalpel, trauma shears, and gloves.
TraumaDEX (Bleed-X) (Medafor Inc, Minneapolis, MN) is an example of a hemostatic agent containing the active ingredient, poly-N-acetyl glucosamine. This agent relies on a complex, biodegradable polysaccharide incorporated into microporous hemospheres to absorb water out of blood, leaving an increased concentration of coagulation factors and platelets to form a clot.14 TraumaDEX (Bleed-X) is FDA approved and available in powder form by means of “injection” into a wound.