Page 67 - Journal of Special Operations Medicine - Spring 2015

The Effects of Movement on Hemorrhage
When QuikClot Combat Gauze Is Used in a
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Hypothermic Hemodiluted Porcine Model

Jose Garcia-Blanco, MD; Brian Gegel, DNAP; James Burgert, DNAP;
Sabine Johnson, MS; Don Johnson, PhD, RN

ABSTRACT

Background: The purpose of this study was to compare failure. 2,8–10 Therefore, early control of hemorrhage is
the effectiveness of QuikClot Combat Gauze (QCG) essential for initial survival and for optimal recovery.
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to a control wound dressing to withstand movement in a
porcine model with hemodilution and hypothermia. De­ Hemostatic agents may be one of the easiest and most
sign: This was a prospective study with a between­sub­ effective methods of treating hemorrhage. They were
jects experimental design. Twenty­six Yorkshire swine specifically developed to treat severe, noncompressible
were randomly assigned to two groups: QCG (n = 13) hemorrhage in military and prehospital settings. The
or a control dressing (n = 13). Methods: The subjects US military’s Committee of Tactical Combat Casualty
were exsanguinated to 30% of the blood volume; hy­ Care (CoTCCC) is the group responsible for developing
pothermia was induced for 10 minutes. The hemostatic guidelines for the management of wounded military per­
agent, QCG, was placed into the wound, followed by sonnel. CoTCCC recommends QCG as the first hemo­
standard wound packing. If hemostasis was achieved, static agent for use in treatment of severe hemorrhage
5L of crystalloid solution were rapidly administered that cannot be controlled by a tourniquet. QCG is a
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intravenously, and the wound was again observed for rayon/polyester gauze impregnated with kaolin, a white,
rebleeding. If no bleeding occurred, the extremity on aluminosilicate, inert mineral. Kaolin promotes clotting
the side of the injury was systematically moved through by activation of factor XII (FXII) and factor XI (FXI)
flexion, extension, abduction, and adduction sequen­ in the intrinsic coagulation pathway. In addition, kao­
tially 10 times or until rebleeding occurred. Results: An lin promotes the activation of platelet­associated FXI,
independent t test indicated there were significant dif­ which activates the intrinsic coagulation pathway in pa­
ferences in the number of movements before rebleeding tients without clotting­factor deficiencies and those with
between the QCG group (mean ± standard deviation FXII deficiency. 12
[SD], 32.92 ± 14.062) and the control group (mean ±
SD, 6.15 ± 15.021) (p < .0001). Conclusion: QCG pro­ QCG has been found effective in controlling massive
duces a robust clot that can withstand more movement hemorrhage in normothermic swine. 13–15 However, be­
than a control dressing. tween 30% and 50% of trauma patients present with
hypothermia. 16,17 Hypothermia decreases the enzymatic
Keywords: movement, hemorrhage, QuikClot , Combat activity of clotting factors and impairs platelet func­
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Gauze , hypothermic hemodiluted porcine model tion. The association of hypothermic coagulopathy in
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a trauma victim results in increased risk for morbidity
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and mortality. Furthermore, hemodilution may in­
fluence the effectiveness of hemostatic agents. Several
Introduction
researchers have found that hemostatic agents are ef­
Trauma is the leading cause of morbidity and mortality fective in hemorrhage control but often fail following
in civilian and military populations, with uncontrolled crystalloid resuscitation. 10,19–27
hemorrhage as the major cause of death. During the
1–5
recent conflicts in Iraq and Afghanistan, uncontrolled A healthcare provider will attempt to minimize the move­
hemorrhage accounted for about 50% of battlefield ment in case of injury. However, the patient may move
deaths prior to evacuation. The mortality rate among because of pain, the victim may have to be moved out
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trauma patients with isolated systolic hypotension of the line of fire, and movement during evaluation may
(<90mmHg) is as much as 54%. Furthermore, signifi­ be necessary. Few studies have investigated the effects
7
cant blood loss predisposes individuals to hypothermia, of movement when a hemostatic agent is used. John­
coagulopathy, infection, acidosis, and multiple organ son and colleagues found QCG effective for controlling

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