Page 49 - Journal of Special Operations Medicine - Fall 2014

4. To date, there is no single hemostatic agent or dress- US Special Operations Command have led to the more
ing that has all the ideal characteristics for battlefield ubiquitous distribution and use of hemorrhage control
trauma. 14–16 Because 38% of all combat casualties re- interventions by prehospital first responders. Great
quiring blood transfusion are coagulopathic, there strides have been made in controlling extremity hem-
17
is a need for an enhanced hemostatic dressing, such orrhage with tourniquets. 34–36 Topical hemostatic agents
as chitosan-based dressings or fibrin dressing, that (i.e., granules, powders) and dressings (i.e., an agent in-
can stop bleeding independently of host coagulation corporated into gauze or bandage) have also contributed
status. Fibrin dressings are efficacious, but they are to success in controlling extremity and compressible
14
not cost-effective for the individual first responder junctional hemorrhage, and their efficacy continues to
to carry, and they are better suited for surgical increase as enhanced products are developed. 14–16,37–40
application. 11,18 Even with these recent advances, there remain require-
5. In contrast, chitosan-based dressings work indepen- ments for ongoing research and development of hem-
dently of host clotting pathways and consistently are orrhage control dressings and devices in an effort to
reported to be efficacious in coagulopathic conditions continue to decrease the potentially survivable mortality
(hypothermia or heparin) using animal models. 19–24 rate (~24%) in Operational Forces to the 0% to 3%
33
6. Successful outcomes are also reported using newer level successfully demonstrated by the US Army 75th
chitosan-based dressings (Celox Gauze) in civilian Ranger Regiment. 41
hospital-based (surgical) case reports 25–27 and prehos-
pital (battlefield) case reports and series. 28,29 Addition- The collective studies on the first-generation of hemo-
ally, there have been no noted complications or safety static agents were essential for the Committee on Tacti-
concerns in these cases or across many years of chi- cal Combat Casualty Care (CoTCCC) to examine the
tosan-based hemostatic dressing use (HemCon Ban- evidence-based research and make decisions for select-
®
dage [HemCon Medical Technologies; http://www ing HemCon Bandage as the first hemostatic agent in
.hemcon.com/products/] and Celox granules) in both 2003 and QuickClot granules (Z-Medica Corpora-
®
the military 30,31 and civilian prehospital sectors. tion; http://www.z-medica.com/) as a backup agent in
32
7. Because of the long-term history of chitosan use and the 2006 TCCC Guidelines. Subsequently, a number
42
safety in animal, prehospital, and surgical settings with- of second-generation hemostatic agents and dressings
out complications, chitosan-based dressings have been were tested at both the US Army Institute of Surgical
adopted for use (either carried with Combat Gauze Research and the Naval Medical Research Center. Both
or carried as the only dressing) in specific US Special DoD laboratories reported that Combat Gauze, Wound-
Operations Forces, the U.K. Ministry of Defense, and Stat (Traumacure, Inc., Bethesda, MD, USA; http://www
at least eight other NATO militaries (Celox Gauze .TraumaCure.com.), and Celox were consistently more
and Celox RAPID); the Medical College of Georgia effective than the previously selected first-generation he-
hospital emergency department (ChitoGauze); the mostatic agents. 43–46 Consequently, the CoTCCC voted
California Emergency Medical Service Authority (Ce- (April 2008) to recommend Combat Gauze dressing as
lox Gauze, Celox RAPID, HemCon ChitoFlex along the first-line treatment for life-threatening hemorrhage
with Combat Gauze); and numerous US elite tactical from wounds not amenable to tourniquet placement.
federal, state, city, and county law enforcement teams WoundStat was recommended as the backup agent
(Celox Gauze, Celox RAPID, ChitoGauze). because combat medical personnel expressed a strong
8. For the same benefit, medics have multiple options preference for a gauze-type hemostatic dressing rather
to manage battlefield trauma (e.g., airway devices than a granule for application. However, based on
47
and pain medications, etc.); specific chitosan-based subsequent animal safety studies, WoundStat was later
dressings should be made available to medics and removed from the TCCC Guidelines.
48
first responders as another option to control severe
bleeding in the domain of risk versus benefit. Topical hemostats are classified most commonly by
mechanism of action into three types: factor concentra-
tors, procoagulants, and mucoadhesives. Factor con-
15
Background
centrators adsorb water from blood and concentrate the
Although aggressive control of external hemorrhage in clotting factors present (QuikClot granules). Procoagu-

the prehospital environment has had a considerable im- lants either activate the clotting cascade (Combat Gauze)
pact on morbidity and mortality during recent conflicts or provide clotting factors such as fibrinogen and/or
in Afghanistan and Iraq, hemorrhage remains the lead- thrombin (dry fibrin sealant dressing). Mucoadhesives
ing cause of combat death and a major cause of death are primarily chitosan based and work by cross-linking
from potentially survivable injuries. Joint efforts from cellular blood components to form a mucoadhesive bar-
33
the Naval Medical Research Center, the US Army Insti- rier (HemCon Bandage, ChitoGauze, Celox Gauze).
tute of Surgical Research, US Central Command, and Some hemostatic agents and dressings function as more

Chitosan-Based Hemostatic Gauze Dressings 41