# Hemostatic Agents/Bleeding Control



## EMSDoc (Feb 27, 2008)

Hey everyone,

82ndTrooper asked in my introduction thread if I could start a discussion on the various hemostatic agents, and their effectiveness in controlling bleeding.  So, here are my thoughts, open to the general discussion...

Hemostatic agents such as chitosan dressings (i.e Celox, HemeCon), zeolite-based (i.e. QuikClot) dressings, cellulose based dressings (i.e. Surgicel or ActCel), and potato starch based (i.e. TraumaDEX) dressings use a dehydrative mechanism in which the plasma is absorbed by the dressing, inducing rapid clotting of the blood by bringing platelets into direct contact with each other.  The various dressings also can provide a matrix for the platelets to adhere to, which also helps to induce clotting.  All of these materials are inert -- and therefore will not affect the blood elsewhere, and are non-toxic.  Pure cellulose based dressings can be left in place, as they will be absorbed by the body over time.  The other dressings must be washed out of the wound at the hospital, as they are not absorbable by the body and would lead to infection if left in place indefinately.  There are also dressings available infused with either thrombin (clotting factor) or calcium (which induces the clotting cascade), but these are not widely available yet for general use and are still mostly in the testing phase.

To be honest, each company will provide for you a wealth of information where they claim that their product is much better than a competitor's.  The only major difference between the various products is that the older versions of the zeolite-based (lava rock) dressings would cause a rapid exothermic reaction when contacting water/plasma.  This could lead to burns.  Since then these dressings have been redesigned to cause less of a reaction.  All of the dressings currently marketed to the special operations and tactical arenas will control bleeding as advertised.  It is best to choose one based on ease of use and carry, and cost to you or your department, and ensure each provider knows where it is and how to use it.

A few caveats on these products:

1.  The MOST IMPORTANT steps to remember in bleeding control are DIRECT PRESSURE and a TOURNIQUET.  All hemostatic agents should be considered secondary bleeding control.

2.  Given that these agents must be washed out of the wound, and some can cause burns to the tissue, they should be used in life-threatening bleeding only.

3.  If you have a life threatening bleed not amenable to direct pressure and/or a tourniquet (i.e. femoral artery close to torso) then hemostatic agents can absolutely be life saving.

4.  Remember to place the agent AS LOW DOWN IN THE WOUND as you can -- ideally directly over the actively bleeding arterial vessel.  If the hemostatic agent is only on top of the bleeding wound, it can seal off the top, but continue to bleed underneith.

So in summary...

1.  Not a panacea
2.  Works well in secondary bleeding control after direct pressure and tourniquet fail or are not practical
3.  For life threatening wounds only
4.  Place as low down into wound as possible, ideally directly over bleeding vessel
5.  Depending on dressing used, burns to tissue and infection could be possible side effects
6.  All commercially available dressings will control bleeding if used as directed
7.  Base your decision on which dressing to use on cost, ease of carry/use, and its side effect profile

Hope that helps everyone.

EMSDoc :cool:


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## medic1 (Feb 29, 2008)

well done Doc

nice summery! I prefer Celox!!

Medic 1


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## charley7897 (Feb 29, 2008)

EMSDOC,

 Being that I am the clinical coordinator for one of the company's. You are completely right we do throw a lot of data at you. But that helps the medical provider make an educated decision on the products. And you are 100 percent right these are adjuncts to hemorrhage control nothing replaces the basics.


"*Given that these agents must be washed out of the wound, and some can cause burns to the tissue, they should be used in life-threatening bleeding only".*

 I would like to address this this point though. I know my grandmother who is 82 of sound mind and on blood thinners gets skin tears. She also was a nurse for many years when she gets a tear applies the product and then irrigates it out in the shower. This again goes back to product knowledge and knowing what it can be used for and what it is not suppose to be used for.

EMSDOC has it right though it's all about the basics first.


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## EMSDoc (Mar 1, 2008)

Charley --

You have a good point that there are uses for these products other than ones I have mentioned, and actually there are OTC versions (i.e. for nosebleeds) that are offered as well.  I agree with you that you should stick to the basics, use these products as secondary bleeding control or for unique situations, and be sure to read the data or talk to the company reps so you understand how the product works and who should use it and when.

I was very careful in my post not to promote or discourage anyone from using a specific brand, which is why I did not mention the brand I carry in my kit.  However, I do appreciate the data provided by each company -- and read all the data/studies available on these products -- which is why I feel comfortable with my statement that all the products work as designed, and you can use any brand with confidence.

Keep up the good work spreading the word about the importance of these products!

EMSDoc :cool:


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## pardus (Mar 1, 2008)

What happened to band aids?
\





;)


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## Chopstick (Mar 1, 2008)

pardus762 said:


> What happened to band aids?


Candyass! I thought you just rubbed sheep shit on it!


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## 8'Duece (Mar 1, 2008)

That was a quick response to my request and I thank you for your time and effort on this matter.  Good write up Doc !!!

One question. If there is ethrothremic reaction is it critical enough to cause blockage that would lead to other medical emergency procedures...............such as brain anuerism and cardiac failure ????

Just a thought ???


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## JustAnotherJ (Mar 1, 2008)

EMSDoc said:


> 4.  Remember to place the agent AS LOW DOWN IN THE WOUND as you can -- ideally directly over the actively bleeding arterial vessel.  If the hemostatic agent is only on top of the bleeding wound, it can seal off the top, but continue to bleed underneith.



Doc, thank you for you input.  Well said and informed.  I appreciate your emphasis on getting the agent as close as possible to the origin of the bleed.  I've seen misuse of hemostatic agents that caused more damage than necessary.  I, personally, found that when i compared celox and quickclot side my side (and used in the same manner), quickclot's heavier granules were more helpful in staying in the wound.  Celox (great product), however, did not do as well.  It was more of a powdery agent and liked to "float" up with the blood.  I'm not saying celox is out of the question, but it's niche is definately not in the "high volume, high pressure" catagory, IMO.

As a side note, the method i used to compare the two was immediate pressure, followed by packing the wound with 4x4s (enough to fill the cavity).  Then, direct pressure on the packed cavity and prep of the hemo agent.  After the prep, i did a rapid removal of the packing material, poured the agent in, and repacked the cavity (within seconds).  Both wounds were high pressure high volume femoral bleeds.  Quickclot stopped the bleeder, while celox needed to be reapplied.

Just my experiences.  input is welcome.

again, thanks for being on here Doc.


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## JustAnotherJ (Mar 1, 2008)

pardus762 said:


> What happened to band aids?



I've replaced all my CAT TQ's with The Hulk Band-Aids


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## charley7897 (Mar 1, 2008)

EMSDoc said:


> *I was very careful in my post not to promote or discourage anyone from using a specific brand, which is why I did not mention the brand I carry in my kit.  However, I do appreciate the data provided by each company -- and read all the data/studies available on these products -- which is why I feel comfortable with my statement that all the products work as designed, and you can use any brand with confidence.
> 
> Keep up the good work spreading the word about the importance of these products!
> 
> EMSDoc :cool:*




EMSDOC
Exactly I do not want this thread to turn in to a debate.There are several studies coming out with in the next 6-12 months that are not funded by any of the companies the more data the better.And in the next Brady Paramedic text hemostatics are going to be addressed for the first time. So civilian medics will start getting exposed to them while in school.I think they are going to be covered in the B and I text also.I will find out at EMS Today.


Medic1 

I didn't know you all were using it down there.But thanks for the thumbs up


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## charley7897 (Mar 1, 2008)

JustAnotherJ  


Question for you what size bag of Celox 15G or 35G ? Also when you say reapply are you talking adding a second bag?Also how long was pressure held for ?


Celox has an effect which I call the m&m effect when it gets into the cavity the majority of outside gets exposed to blood forms like a hard slimy shell however there is still yellow unexposed Celox in the center.If you manipulate the material with your palm like a massaging motion you tend to break that up and have more Celox to use.All of the Celox will still work to some extent after exposure it's not like others once its exposed it's done.This is do to it's mechanism on how it works which is Ionic bonds

We have Celox D coming out that will solve the a lot of these concerns on the high flow bleeds.


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## EMSDoc (Mar 1, 2008)

82ndtrooper --

The exothermic reaction is localized only to where the product touches the wound.  It does not have any systemic effects.  Also, the reaction only lasts about 10-20 seconds or so.  But if you have never seen it, you should take a zeolite-based dressing and place it in a cup of water... it is most impressive!

As I noted earlier the newer formulations of this product have been changed so this is less of an issue.  But to be honest, a localized burn vs. bleeding to death isn't really a contest in my book.

EMSDoc :cool:


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## x SF med (Mar 1, 2008)

JustAnotherJ said:


> I've replaced all my CAT TQ's with The Hulk Band-Aids




Not Scooby-Doo?

I think since you're AF maybe Hello Kitty would be nice too.:doh:

Thanks for the write up EMS Doc.  People forget how effective properly performed direct pressure can be - don't worry baout the pressure, the guy/gal is already leaking bodily fluids all over everything - how much more pain do you think good pressure is going to cause the patient.


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## 8'Duece (Mar 1, 2008)

EMSDoc said:


> 82ndtrooper --
> 
> The exothermic reaction is localized only to where the product touches the wound.  It does not have any systemic effects.  Also, the reaction only lasts about 10-20 seconds or so.  But if you have never seen it, you should take a zeolite-based dressing and place it in a cup of water... it is most impressive!
> 
> ...



Exactly the answer I was looking for.  Thanks again Doc !


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## Brooklynben (Mar 2, 2008)

I've always wondered how difficult some of these agents are later to debride from a wound?  For instance; are some of less exothermic compounds easier to wash out?


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## pardus (Mar 2, 2008)

JustAnotherJ said:


> I've replaced all my CAT TQ's with The Hulk Band-Aids



Holy shit!!!!

I almost pissed myself laughing at this one!


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## charley7897 (Mar 2, 2008)

Brooklynben said:


> I've always wondered how difficult some of these agents are later to debride from a wound?  For instance; are some of less exothermic compounds easier to wash out?




Some are very easy as simple irrigation with N/S .Other's require surgical debridement.Remember though everyone of the hemostics currently carried are considered *Temporary *Wound treatment.They still need to go in for surgical repair/exploration.


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## JustAnotherJ (Mar 4, 2008)

charley7897 said:


> JustAnotherJ
> 
> 
> Question for you what size bag of Celox 15G or 35G ? Also when you say reapply are you talking adding a second bag?Also how long was pressure held for ?
> ...



Hi Charley,
I was using the 35g bags.  I used a second bag on the reapplication and held each attempt for 5 minutes with flat direct pressure down onto the packed wound.

But allow me to elaborate a little better on what happened with the celox i used.  After I had packed the wound (femoral bleeder) with about 20-30 or so gauze pads to soak up all the blood, I quickly removed them and poured in the celox.  

Now here's where, either the inexperience in myself or the powdery nature of celox took over (either way, i'm open to criticism).  When the celox was initially poured in, the force of the blood flow and volume of blood that immediately pumped from the artery caused the celox was displace (on top of all this, since it is more "powdery" celox takes a fraction of a second longer to pour).  Now since the celox was essentially floating away from the open artery, it was difficult to create an effective clot.  

I repacked the wound because i knew this was going nowhere and needed to reattack.  

I hope that clears up my experience.

Now I have been informed of the "M&M" effect.  I did not witness it however.

Now all that being said...celox is great, no doubt about it.  But the issues that will keep me from using it are as follows:

Using it when it's windy.  Not because of vision ( I know there are no exothermic properties with Celox), but because I do not feel that I will be able to effectively deliver it into the wound.

The substance itself needs more weight (IMO) to stay in a deeper "high vol/high pressure" bleeder


I would bet that when those two issues are met, Celox will beat out Quickclot because it will then offer the best of both worlds.  No exothermic reactions, with ease of delivery and effectiveness.

p.s.  Thanks for the work you guys are doing at SAM Medical.


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## JustAnotherJ (Mar 4, 2008)

pardus762 said:


> Holy shit!!!!
> 
> I almost pissed myself laughing at this one!



I think we have an incontinence problem.  Someone's gettin a FOLEY!


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## charley7897 (Mar 4, 2008)

JustAnotherJ


  The only thing I would have done different would be pull out the gauze pads after first application. Then dump the second bag on top of the first.Then repack and reapply pressure.

  I understand your concern about windy conditions.Celox- D will solve a lot of your concerns. Basically its a blood soluble bag that you pack the wound with the bag. The bag dissolves and releases celox.

 But PM me or email me on my corporate email if you don't mind. Maybe I can arrange to come up and do an in service.

Thanks for the compliment.Its cools to come from being an end user to  be working for the company now.And we are very receptive to ideas or suggestions.


Thanks

Charley


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