Page 50 - Journal of Special Operations Medicine - Fall 2014

than one mechanism. For example, Combat Gauze description of first-, second-, and third-generation
dressing is both a factor concentrator (absorbs water chitosan-based agents/dressings. See Table 2 for ideal
with the gauze) and a procoagulant (activates the clot- characteristics of hemostatic dressings pertinent to this
ting cascade with kaolin component). presentation. Another ideal characteristic for hemostatic
dressings for consideration is the addition of a radiop-
Smith et al. present the latest hemostatic dressings ague marker strip, making it x-ray identifiable for easy
16
since the last CoTCCC approval for adding topical detection (W. Dorlac, MD, personal communication, 4
hemostatics. These newer agents are Celox Gauze and February 2014). Medics can pack these dressings, for
Celox RAPID, HemCon ChitoGauze, TraumaStat, example, deep into junctional areas to control severe
Omni-Stat (www.omni-stat.com/), salmon thrombin- bleeding. Also, surgeons occasionally use these dressings
™
fibrinogen, modified rapid deployment hemostat, and off-label for internal use, and the radiopaque marker
the mini sponge dressing. However, not all dressings are strip will assist in locating these dressings packed into
cost-effective for military personnel to carry in their first tissues. Recent communication with the manufacture
aid kit, or they are not currently US Food and Drug Ad- confirmed that Celox Gauze products will add a radi-
ministration (FDA)−approved and commercially avail- opaque strip starting in 2014.
able. A recent article on third-generation hemostatic
dressings (April 2008 to present) provides an evidence-
based review of animal studies and clinical case reports Chitosan-Based Agents and Dressings
(hospital-based and prehospital studies) supporting Chitosans have widespread applications, have been widely
the addition of specific chitosan-based dressings to the studied in the biomedical field, and are highly biocompat-
TCCC Guidelines. Henceforth, the following discus- ible. Their chemistry has been previously described. 51,52
49
50
sion will be based solely on the evidence for specific Chitosan refers to a series of polymers derived from
chitosan-based dressings. See Table 1 for demographic crustacean chitin and is a complex carbohydrate that is

Table 1 First-, Second-, and Third-Generation Chitosan-Based Hemostatic Product Demographics
Product/Manufacturer Generation Mechanism of Action Form Application
HemCon Bandage First Cross-links red blood 4" × 4" wafer; Placed firmly over wound,
HemCon Medical Technologies cells (RBCs) to form 2" × 2" single- 3-min direct pressure
Portland, OR mucoadhesive barrier sided wafer
QuickClot Granules First Rapidly adsorbs water Granular zeolite Pour deep into wound,
Z-Medica in an exothermic (volcanic rock) pack standard gauze on
Wallingford, CT reaction to concentrate top of granules, 3-min
clotting factors direct pressure
ChitoFlex Second Cross-links RBCs to 3" × 9" roll; Placed firmly over wound,
HemCon Medical Technologies form mucoadhesive double-sided 3-min direct pressure
Portland, OR barrier
Omni-Stat (Celox granules) Second Cross-links RBCs to Granular Poured into wound,
MedTrade Products Ltd. form mucoadhesive chitosan (3g); 3- to 5-min direct pressure
Crew, UK barrier 4" × 4" pad
Celox Granules Second Cross-links RBCs to Granular Poured into wound,
MedTrade Products Ltd. form mucoadhesive chitosan 3- to 5-min direct pressure
Crew, UK barrier 35g (1.6 oz)
Celox-A Second Cross-links RBCs to Granular Applied from syringe-
MedTrade Products Ltd. form mucoadhesive chitosan (6g) like applicator into
Crew, UK barrier penetration wound;
3- to 5-min direct pressure
Celox RAPID Third Cross-links RBCs to Rolled or Packed into wound, 1-min
MedTrade Products Ltd. form mucoadhesive Z-fold products, direct pressure
Crew, UK barrier 10' length
Celox Gauze Third Cross-links RBCs to Rolled or Packed into wound,
MedTrade Products Ltd. form mucoadhesive Z-fold products, 3-min direct pressure
Crew, UK barrier 3" × 10'
ChitoGauze Pro Third Cross-links RBCs to Z-fold, Packed into wound,
HemCon Medical Technologies form mucoadhesive 12' length 2- to 5-min direct pressure
Portland, OR barrier

42 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014