Page 48 - Journal of Special Operations Medicine - Fall 2014

Management of External Hemorrhage
in Tactical Combat Casualty Care:

Chitosan-Based Hemostatic Gauze Dressings
TCCC Guidelines – Change 13-05

Brad L. Bennett, PhD, NREMT-P; Lanny F. Littlejohn, MD; Bijan S. Kheirabadi, PhD;
Frank K. Butler, MD; Russ S. Kotwal, MD; Michael A. Dubick, PhD; Jeffrey A. Bailey, MD

ABSTRACT
Hemorrhage remains the leading cause of combat death Keywords: hemorrhage, hemostasis, hemostatic agents,
and a major cause of death from potentially survivable topical, dressing, bandage
injuries. Great strides have been made in controlling
extremity hemorrhage with tourniquets, but not all in-
juries are amenable to tourniquet application. Topical
hemostatic agents and dressings have also contributed Proximate Cause for the Proposed Change
to success in controlling extremity and compressible
junctional hemorrhage, and their efficacy continues 1. Since April 2008, no formal change proposal has
to increase as enhanced products are developed. Since been made to include additional hemostatic dress-
the addition of Combat Gauze (Z-Medica Corpora- ings to the guidelines, even though some of these
™
tion, Wallingford, CT, USA; http://www.z-medica.com/) have experimental evidence showing equal or greater
in April 2008 to the Tactical Combat Casualty Care efficacy than Combat Gauze and without reported
(TCCC) Guidelines, there are consistent data from ani- complications.
mal studies of severe hemorrhage that chitosan-based 2. There are consistent data now from animal models
hemostatic gauze dressings developed for battlefield of severe hemorrhage that chitosan-based hemostatic
application are, at least, equally efficacious as Com- gauze dressings developed for battlefield application
bat Gauze. Successful outcomes are also reported using are, at least, equally efficacious as Combat Gauze.
newer chitosan-based dressings in civilian hospital- There are eight reports of the equivalence of chi-
1–8
based surgical case reports and prehospital (battlefield) tosan-based gauze dressings with Combat Gauze in
case reports and series. Additionally, there have been no extremity arterial hemorrhage models (Celox Gauze;
noted complications or safety concerns in these cases or ChitoGauze Celox RAPID; Celox Trauma Gauze;
across many years of chitosan-based hemostatic dress- TraumaStat [Salem, OR, USA; http://www.oremedix
™
ing use in both the military and civilian prehospital sec- .com/products/traumastat.asp]; mini-sponge dressing).
tors. Consequently, after a decade of clinical use, there 3. Combat Gauze was selected for addition to the TCCC
is added benefit and a good safety record for using chi- Guidelines since it was reported in two Department of
tosan-based gauze dressings. For these reasons, many Defense (DoD) laboratories to be efficacious in a non-
specific US military Special Operations Forces, NATO coagulopathic animal model. However, other animal
militaries, and emergency medical services (EMS) and studies and clinical case reports show inconsistencies
law enforcement agencies have already implemented the with Combat Gauze as well as poor efficacy in coag-
widespread use of these new recommended chitosan- ulopathy-induced animals. 9,10 In a case series (N = 19)
based hemostatic dressings. Based on the past battlefield of combat casualties, seven patients were treated with
success, this report proposes to keep Combat Gauze as Combat Gauze (two of seven were coagulopathic) in
the hemostatic dressing of choice along with the new the prehospital setting, which then had to be removed
addition of Celox Gauze (Medtrade Products Ltd., in the operating room and replaced with another he-
™
Crewe, UK; http://www.celoxmedical.com/usa/products mostatic bandage to gain hemorrhage control. How-
11
/celox-gauze/) and ChitoGauze (HemCon Medical Tech- ever, more recently, Combat Gauze has demonstrated
®
nologies, Portland, OR, USA; http://www.hemcon.com/) good efficacy in other coagulopathic animal studies
to the TCCC Guidelines. compared with standard gauze. 12,13

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