# Hemostatic agents.



## Muppet (Aug 22, 2008)

Greetings all:
To the medical professionals or anybody for that matter:
What are you guys / girls using regarding hemostatic agents and what do you think about them? I have been to multiple sites ( product ) but I would like the "end user" thoughts. My commonwealth / state is in the progress of updating our pre-hospital standing orders to include hemostatics and the local powers to be ( medical directors / chiefs ) are stuck as to which product is the best. Hopefully I can offer imput to the higher since the decision is made @ the local level ( from a list of products from the state ). Any imput would be greatlly appreciated.

P.S.: If this thread is old, I will draw fire elsewhere.
F.M.


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## Muppet (Aug 22, 2008)

O.K. I just found the thread regarding hemostatics, so my head was in my 4th. point of contact. Still, any info, other that the prior thread would be appreciated.

F.M.


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## Sunny (Sep 2, 2008)

*hemostatics*

I like the z-med combat gauze and hemcon.  I carry both and use for differant types of bleeders. You have got to get training and pratice with both.


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## Muppet (Sep 2, 2008)

Sunny, thanks for the info. Also, thanks for what you do.

F.M.


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## medic101charlie (Sep 3, 2008)

We use Hem-Con on our air units and our critical care units. 

They haven't made it down to the street units yet.

I know several services in Tennessee using HemCon as well.


Jim


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## Muppet (Sep 4, 2008)

Charlie:
     I know that Hemcon is expensive. Do you know anything about the Quick clot sponge( besides what the site says )? Thanks for the reply.

F.M.


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## Sunny (Sep 4, 2008)

the quick clot sponges work well for cavity bleeders like aux. pockets gun shot wounds. the z-med combat gauze works just as well if not better. the combat gauze has many more application. i am not sure where you work as a paramedic but how many gun shot wounds have you seen in the last year. of the gsw how many are of a caliber of 7mm or above. dude i think quick clot would be a waste of money. money would be better spent on king ltd advanced airway.I know i have missed my fair share of in field intubations. some stats. say that up to 20% of advanced airway received in the er are misplace. let me get off my soapbox, if you have specific questions about heme control products please forward.


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## medic101charlie (Sep 4, 2008)

Sunny said:


> the quick clot sponges work well for cavity bleeders like aux. pockets gun shot wounds. the z-med combat gauze works just as well if not better. the combat gauze has many more application. i am not sure where you work as a paramedic but how many gun shot wounds have you seen in the last year. of the gsw how many are of a caliber of 7mm or above. dude i think quick clot would be a waste of money. money would be better spent on king ltd advanced airway.I know i have missed my fair share of in field intubations. some stats. say that up to 20% of advanced airway received in the er are misplace. let me get off my soapbox, if you have specific questions about heme control products please forward.



We carry King Airways as well.

These decisions are above my paygrade.

I use what is issued.


Jim


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## Muppet (Sep 4, 2008)

I work just outside of Philadelphia so we get our share of GSW's, mostly small arms but we have had a rash of gang shootings (assault type weapons) moving up from Phila. and Trenton. We also carry King LTD and perform M.E.I. (Etomidate). I don't know what the state will approve but I know that they are going to approve several types of hemos. It is up to the induvidual counties / squads to adopt what they think is "best". Leave it to a "commonwealth" to make things difficult.
Now on my "soapbox". How can medics miss tubes anymore with the advent of ETco2 adapters on the 12-leads? I do agree that "we, the profession" needs more practice in intubations. Ask the M.D's on here They will tell you. They need > 50 tubes in order to be called proficient. Off my soapbox. Thanks for the reply.

F.M.


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## Sunny (Sep 5, 2008)

Easy devil doc, I was trying to give fire medic my opinion not tell anyone how to do there job.

Moving on, research for yourself I have always been taught that most inexperienced shooter will tend wound victims in the hip. They will push the weapon and throw the round low and left “the gangsta blam...blam...phenomena" this is for the FBI typical seven yard gun fight. 
I myself have not had good luck with the packing the QC sponge in the irregular tracking cavities caused by the abnormal cavitations of rounds impacting the multi-angled bones of the hip.  

Now if you have victims taking rifle round to center mass from trained/street hard shooter QC sponges can be useful. QC sponges are much more user friendly than hemcon. This is what I train my non-medic operators to render buddy aid with. 

If this all sounds like BS or you have different opinion/information I would love to hear about it. I am always looking to improve.


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## Muppet (Sep 5, 2008)

Sunny, thanks for the info. I do not feel that you were trying to tell anybody what to do but I like the passion regarding health care.

F.M.


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## Doc P (Sep 5, 2008)

Combat gauze works GREAT...and it is very easy to use for many types of wounds. The problem with Hemcon (which works great as well) is that it needs to be placed on the source of the bleed (i.e. the vessel) and thus requires more training.


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## Muppet (Sep 7, 2008)

Doc P. Thanks. I don't think our powers to be would like us packing wounds on the way to the E.D. 

F.M.


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## Sunny (Sep 7, 2008)

I 100% agree with doc p. this man is obviously a gentleman and scholar.


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## medic101charlie (Sep 7, 2008)

Sunny said:


> Easy devil doc, I was trying to give fire medic my opinion not tell anyone how to do there job.
> 
> Moving on, research for yourself I have always been taught that most inexperienced shooter will tend wound victims in the hip. They will push the weapon and throw the round low and left “the gangsta blam...blam...phenomena" this is for the FBI typical seven yard gun fight.
> I myself have not had good luck with the packing the QC sponge in the irregular tracking cavities caused by the abnormal cavitations of rounds impacting the multi-angled bones of the hip.
> ...



Didn't mean to come across so terse.  Sorry about that.

Unfortunately, I left my urban 911 service before the widespread use of HemCon or other types of hemostatic agents. My current service is a rural/suburban 911 and Critical Care service. We do but 10-20 shootings a year, between the two counties I work for.

Our owner likes to have the flashy "cool guy stuff" so he bought HemCon as soon as it came out and put it on the choppers (which aren't even certified for AMS yet) and the critical care service. I think they used it once for an arterial bleed on a 45 minute critical care transport to a trauma center.

This ia good thread and full of good info.

Thanks for your service, Sunny.


Jim


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## Muppet (Sep 8, 2008)

I agree. Thanks for all of the info. I throught nobody was going to reply when I posted. While I am here. What tourniquets do you Medics pefer? That is also part of our updated S.O.P's. I guess the state finially realized that T.Q's do not cause harm when applied correctlly / 10-15 min. ride to a Level-1 Trauma. I have read that the CAT was cheap and that the SOF-T was o.k. How tru is that?

F.M.


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## surgicalcric (Sep 8, 2008)

CAT's: fairly inexpensive but they have had issues with some of the plastic parts on them breaking when used on larger/more muscular patients where more pressure is required.

SOFT-T's: good but a bit more expensive than the CAT.  They also dont work well on upper extremities on thin/less muscular patients.  They also dont have the issues of durability which the CAT does.

MAT, only used in training but I am very skeptical of the plastic ratchet.  The  release button and the buckle have been the cause of a couple loosening after application.  (I wont use them)

LBT Ratchet, great for legs.  They take up a bit more room in our kit so they are saved for the Aidbag.  I carry two.

There are several other TQ's but I dont carry them/use them.

Crip


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## medic101charlie (Sep 8, 2008)

surgicalcric said:


> CAT's: fairly inexpensive but they have had issues with some of the plastic parts on them breaking when used on larger/more muscular patients where more pressure is required.
> 
> SOFT-T's: good but a bit more expensive than the CAT.  They also dont work well on upper extremities on thin/less muscular patients.  They also dont have the issues of durability which the CAT does.
> 
> ...



Taking this conversation further IRT TQs, do you operators/medics carry different types of TQs? Or do you stay with one type? I have read where operators carry TQs on their persons for self care and buddy care. Is this personalized or unit dependent? 

I hope this is not OPSEC, but I was just curious.

On another note, I did some research on the combat gauze and have forwarded to our clinical director for further action. 


Jim


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## surgicalcric (Sep 8, 2008)

I carry a CAT centerline on my armor and a SOFT-T in my IFAK; the same is true for everyone on my ODA.

As for what I carry in my aidbags/on my person, I dont carry any CATs in my kit.  They are all SOFT-T's and LBT ratchet TQ's, this is depending on which bag I grab leaving the door (which is dependent on the mission.)

Remember, your job is very different than mine and there are TQ's on the market that may better suite your needs and those of your patients than me and my situation.  What we carry is often limited by size/weight.  Whereas you have a bus to carry your equipment around in.  FWIW, when I am home I enjoy greatly the room and carrying capacity of the ambulances in my FD.

HTH,

Crip


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## medic101charlie (Sep 8, 2008)

surgicalcric said:


> I carry a CAT centerline on my armor and a SOFT-T in my IFAK; the same is true for everyone on my ODA.
> 
> As for what I carry in my aidbags/on my person, I dont carry any CATs in my kit.  They are all SOFT-T's and LBT ratchet TQ's, this is depending on which bag I grab leaving the door (which is dependent on the mission.)
> 
> ...



Thanks for your input.

Jim


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## medic1 (Sep 8, 2008)

*Haemostatic Agents*

Hey Guys

I don't see any mention of CELOX here, I have used both Celox and Quikclot on arterial bleeds and find that the T-bag application of the Quikclot needs to be very near the bleed where as application of the CELOX is a 'cover-all' application and it stops major bleeds!

Medic 1


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## Muppet (Sep 9, 2008)

(1): Tea Bag! Am I missing something?
(2): Thanks for the reviews gentelman.
Cric: Where do you ride as a civilian Medic?

F.M.


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## Doc P (Sep 9, 2008)

Right now the two leading hemostatics are the combat gauze and woundstat...all the rest are being phased out.

As for TQ's that CAT is light weight and effective...when it doesn't break.  Personally I like the old Ranger Ratchet it's a bit cumbersome and yeah there is a bit of tissue damage, but it WORKS! Plus it holds a special place in my aid bag since we came up with and deployed with them back in '01


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## HoosierAnnie (Sep 9, 2008)

Guys, just wanted to let you know that I'm really enjoying reading this thread.  Since all of my experience is on the "in house" side of the ER doors, its nice to learn more about what goes on out in the field.  Besides, now I know who to ask when I have Q's about the typical sequence of events from evac chopper to surgery "in theater"


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## Muppet (Sep 9, 2008)

Doc. P.: Thanks. 
Hooiser: I am glad I got the replys that I did. It always helps to get the info. from the" horses mouth" / from the heros that are using the stuff. I did not have all this good stuff when I was in with the 82nd. / mid 90's. Thanks to all who gave the info and thanks for what you are doing.

Firemedic.


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## Sunny (Sep 9, 2008)

hey guys i made some calls and did a little more research hope this info help.

1. I called a friend who is a medic for the ATF Special Respond Team. He does not carry any hemostatic's. his take is that state-side he is so close to surgical intervention that  hemostatic agent will make the surgeons job more difficult and really do very little good.(A friend of mine had his SEAL career ended by an over zealous 91W that poured quickclot on a GSW that the hemorrhage was already controlled. He ended up loosing a great deal of muscle tissue from the debridment of the embedded quickclot. 
2. The official haemostatic for naval special warfare is combat gauze and wound stat.

TQ.
1.	I carry CAT midline under my mag pouches, SOF-T blow out (IFAK) kit. Two CAT and one SOF-T in my med bag. The two CATs I keep to help with moving TQs and converting in secondary care. I carry the extra SOF-T just in case my day really goes south.
2.	If I had my choice for a state-side TQ I would look at the cool inflatable brands on the market that can be titrated to the exact mmHG I need.

Firemedic- teabag refers tot the packaging of the quickclot. Before it came loose in a pour and hope version, now it is contained it a permeable cloth that look just like teabag. This teabag makes it more easily packed in to a wound.

Medic1- dude I liked celox also, but you have got to try the woundstat I think you will like it


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## Muppet (Sep 9, 2008)

Sunny: Thanks fot the info. Of course my mind went dirty regarding tea bag. Your ATF friend makes a good point and I will pass that along. In the big picture, just because "we" are issued the toys does not mean that it is right to use or good for our patients. Thanks for painting that picture. I did see the new packaging regarding quick clot and I don't know how effective that would be with the tea bag.

Firemedic.


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## car (Sep 9, 2008)

Firemedic said:


> (1): Tea Bag! Am I missing something?



You guys are the pros, but I worked for my dentist uncle as an assistant, while in college. After doing a particularly difficult extraction, my uncle would recommend that after an hour or so, if the socket was still bleeding, the patient get a tea bag, and bite down gently.

There is some sort of natural coagulant tea. (He also recommended a large shot of bourbon held in place over the socket for at least 30 seconds - if there was pain...)

I used it (tea bag) after they used a chisel to break one of my wisdom teeth for extraction. Stopped the bleeding pretty quickly.


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## Muppet (Sep 9, 2008)

Car: I have heard of that also. I was referring to the other tea bag. When I was in, I knew some knuckleheads that were talking about the tea bag when they got drunk on a saturday night @ the 2/325. That is why I did not dring alot when I was in. 

Firemedic.


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## car (Sep 9, 2008)

Firemedic said:


> Car: I have heard of that also. I was referring to the other tea bag. When I was in, I knew some knuckleheads that were talking about the tea bag when they got drunk on a saturday night @ the 2/325. That is why I did not dring alot when I was in.
> 
> Firemedic.




RGR!


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## Muppet (Sep 10, 2008)

Car: forgive my computer stupdity but what is RGR?

Firemedic.


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## medic1 (Sep 10, 2008)

*tea bag*

Sorry guys, should have made my self clear.........the tea-bag I meant was the Quick-Clot bag [looks like a tea bag], and yes the tissue disruption with the heating effect of the Q-C is not a nice effect. The CELOX, when presented in the OR/ Trauma Room just removes from the wound with no detrimental tissue effect, just like pulling out a sponge.

Medic 1


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## surgicalcric (Sep 10, 2008)

I concur with whats been said about WoundStat.  I still have a few QC packets laying around but same them for injecting into wound tracks (using a 60cc syringe).  Other than that its QC sponge and Woundstat for my guys (both are easy to use and Bravo proof for the most part).

Celox isnt bad but I found the WS to be more user friendly...

Firemedic,  I worked in upstate SC for 14 years as a firefighter/paramedic...  Now I am a NGSF bum.

RGR= Roger/got it/good-to-go/okay

Crip


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## Muppet (Sep 10, 2008)

I have it. Thank you. I am kind of stupid in computer lingo so I am still learning. This has been a good thread. Thanks for all who gave input.

Firemedic.


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## HeloMedic1171 (Dec 20, 2008)

Crip, I have yet to use the woundstat, but had several instructors at BCT3 say they couldn't get it to work on the goats.  what say you?  I think our unit will wind up going with combat gauze and celox or woundstat.  as for TQs, I like the CAT for it's weight and ease-of-use, I don't like that it's only good for 70-80% of people.  anyone tried the NATO Tourniquet?   it's basically a strap, 2 rings, and an aluminum securing device.  seems to work pretty well, haven't tried that one on a human yet, though, except in practice.  the MAT is shit.  don't bother.  the Ratchet TQ works, even if it is like using a sledgehammer to kill a fly.


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## surgicalcric (Dec 20, 2008)

HeloMedic1171 said:


> Crip, I have yet to use the woundstat, but had several instructors at BCT3 say they couldn't get it to work on the goats.  what say you?  I think our unit will wind up going with combat gauze and celox or woundstat.  as for TQs, I like the CAT for it's weight and ease-of-use, I don't like that it's only good for 70-80% of people.  anyone tried the NATO Tourniquet?   it's basically a strap, 2 rings, and an aluminum securing device.  seems to work pretty well, haven't tried that one on a human yet, though, except in practice.  the MAT is shit.  don't bother.  the Ratchet TQ works, even if it is like using a sledgehammer to kill a fly.



I have used WS on several patient role models and its worked well on each occasion, ORMV though.  I like the stuff personally.  I have a wide assortment of HCA's lying around and use different ones on different wounds every chance I get and since I get to do LTT nearly monthly I get alot of practice.

As for TQ's, every guy on my ODA carries two, one centerline and the other in his BOK.  One is a SOFT-T and the other a CAT.  Most of the guys have the CAT centerline save a couple of the larger guys who have two SOFT-T. Everyone practices with both, with both hands with their eyes closed...  Practice saves lives.  

The MAT is crap!  

I carry a couple ratchet TQ's for those pesky hard to control femoral bleeders.  Not sure I would call them overkill but they do take up some place in the aidbag...

I have seen the NATO TQ but havent felt the need to seek one to test.  I may very well do that this SFAUC class and will let you guys know what I think afterwards.

my .02


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## HeloMedic1171 (Dec 20, 2008)

Can't wait to hear your take.  I didn't get a chance to use woundstat or the NATO TQ in BCT3, but i did use everything else.  it's good to hear input from others who get better practice than I do. :)


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## Tendercare Doc (Apr 6, 2009)

I had a pt come in the ER with a severe arm lac proximal to the wrist and the ambulance crew used a BP cuff...whatever works right?


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## amlove21 (Apr 6, 2009)

well, im not saying anything new here at all, but i roll with 2 CATs on my LBE (below mag  pouch and IFAK, and 2 more in the ruck. If i have problems with the CAT (which i havent, which means i simply need to see more patients) I improvise from their clothing. 

As for the hemo's, i have used celox (eh) and quickclot AND quickclot AST (double eh) and the HEMCON dressing (not too shabby better than the other two) but have to give the ole FNG stamp of approval to the CG. Its the shit, you can pack the hell out of it, and it actually works pretty good superficially if you do it right. 

My 1:2c:


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## Tendercare Doc (Apr 6, 2009)

also, for bullet wound tracks, tampons work wonders


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## HeloMedic1171 (Apr 20, 2009)

tampons, Israeli's, Combat Gauze, and CATs.  that's what I got my grubby gorilla-sized hands on, so we'll see how it goes.  and let's not forget our trusty ace wraps and a shit-ton of kerlix....


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## surgicalcric (Apr 20, 2009)

Tendercare Doc said:


> also, for bullet wound tracks, tampons work wonders





HeloMedic1171 said:


> tampons, Israeli's, Combat Gauze, and CATs.... let's not forget our trusty ace wraps and a shit-ton of kerlix....



The theory behind using a tampon to plug a "hole" is good in theory (acedemic) but I feel that it misses the mark entirely when applied to bleeders in the field.

Wound packing is performed to occlude, by placing pressure on, the vessel hemorrhaging; it is not simply to fill a void thereby allowing the hemorrhage to continue until such time that the space is filled with O2 carrying hemoglobin.  Hence the term, "pack the bleeder, not the space."  

I carry, as does my team, very few Israeli dressings, which is more of a single use item (though it can be used for a couple things) and instead choose to carry copious amounts of kerlix and ace wraps with a few rolls of coban thrown in.

IMHO, kerlix and aces are a better alternative, but to each his own.

Crip


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## HeloMedic1171 (Apr 21, 2009)

I agree to a point, which is why even though I have a few of the "cool toys" I still have lots of what works.  I have never used tampons on a trauma patient....  only for nose bleeds, their intended use for my female soldiers, and as pranks for my males.  ("quit crying, here's a tampon"  ) in theory, it seems like the'yd work, so I have some tampax supers.  though, as I think about it, you'd have to work quickly, because as soon as they get wet, they expand, and you want them to apply pressure on the bleed, not just sponge up all the red stuff.

I was careful to pack them in pouches where I had space, but not enough to fit more kerlix.  in other words, the tampons are augmenting the kerlix...  I'm not leaving rolls of kerlix out to make room for them.  as for the CATs...  I'd like a couple of SOF-Ts, but I haven't been able to get those.... so since it's all I have, and I've had good experience with them, I packed as many as I could (9).  the israeli's are handy tools.  I like them.  the combat gauze, I'm a little sketchy on, though..... seems liike it works great in practice, sounds like it would make a big difference....... but I'm not ready to replace all my regular white fluffy stuff with it.  so again, I packed it where it fit, but not at the expense of Kerlix.  

I'm carrying 7 ace wraps, 15 rolls of kerlix, 9 kravats, 6 tampons, 9 CATs, 6 israeli's, and 4 rolls of combat gauze.....  and a few random items like an eye dressing, 2 abdominal dressings, and some original Quickclot.  that's all my bleeding items. I've got enough stuff where I feel comfortable I can handle what comes my way. if not, I'll improvise.  semper gumby.  

the only place I really disagree with you is the coban....  that stuff is wonderful, but it always seems to get squished inside my bag and then i can't get it to unroll and be useful, especially with gloves on.  Ace wraps and tapeworks every time, though.


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## FNULNU (Apr 21, 2009)

Is it a bad idea to use quick clot (or other shell fish based hemo products) on someone who is allergic to shell fish?  I have heard (from non med types) it's not a problem because it's made out of the shell part, not the fish, but never got a firm answer on it.


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## HeloMedic1171 (Apr 21, 2009)

that's the consensus amongst all the providers I've ever worked for.  I don't recall that all hemostatic agents are shellfish-based....  I thought that was only the Hemcon bandage.


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## surgicalcric (Apr 21, 2009)

HeloMedic1171 said:


> ...that stuff is wonderful, but it always seems to get squished inside my bag and then i can't get it to unroll and be useful, especially with gloves on.  Ace wraps and tapeworks every time, though.



Thats why I take it out of the package (cutting open one end), and dog ear the end.  Roll it back on itself a couple times and the tail becomes fairly easy to find even when wearing gloves.  ;)  After which you place the roll back in the package...

Crip


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## amlove21 (Apr 21, 2009)

Celox, and some of the other hemostatic dressings out there contain Chisotan, which is an ultra purified polysaccharide derivative of shrimp shells. There have been no reported cases of shellfish allergy secondary to administration of Celox. 

If there have been problems, i havent seen  them in print!


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## HeloMedic1171 (Apr 21, 2009)

> Thats why I take it out of the package (cutting open one end), and dog ear the end. Roll it back on itself a couple times and the tail becomes fairly easy to find even when wearing gloves.  After which you place the roll back in the package...



nice.  I'll try that.  thanks!


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## sierraleems (May 9, 2009)

*TQ's:*

I'd like to throw in a plug for the NATO TQ... I've used it on about 10 live tissue extremity bleeders (the same TQ!) and it's awesome. 
Plus: Indestructible, fits both large and very small extremities, and easy to ratchet down. 
Minus: Needs to be padded for patient comfort and operator needs to be trained since it's not obvious how to use at first. It's not 'tactical', though, due to it's moving metal parts so it was bagged in the socom recommendations. 

CAT: The new cat's are wider than the old ones, beefier,  and they have a nice tab on which you can record when the TQ was applied. Be warned though, if you're using the new cat around the upper thigh, I found it has to be ratcheted down to hell before it's effective at stopping arterial flow. It'll feel like the TQ's about to break and that's how tight it needs to be.
Minus: Technically one use only, it's not the best at stopping bleeding, but it works pretty well generally speaking. 

Hemostatic agents:

I would go with the 2008 TCCC reccomendations corrected for the recent woundstat findings... celox for those cavernous fast bleeders (real scientific haha!), and combat gauze or the less effective hemcon for converting tourniquets. If you have it and know how to use it well, quick clot works very well.


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