Page 163 - Journal of Special Operations Medicine - Winter 2015

equipment and improvements all along the continuum
of care from point of wounding to discharge from the The TCCC has given these individuals
hospital. However, in a military with the highest survival a vastly improved set of tools and skills
rate in our nation’s history, the 75th Ranger Regiment to better accomplish their heroic and
demonstrated that further improvements were possible. lifesaving deeds on the battlefield, and
Kotwal and his colleagues reported an 87 percent reduc-
tion in potentially preventable deaths (3 percent com- tourniquets and hemostatic dressings
pared with 24 percent in the U.S. military as a whole) are now a permanent fixture in their
through the establishment of a command-directed ca- aid bags.
sualty-response program that included TCCC training
and expertise for every person in the regiment—not just
medics. 11 recommend Combat Gauze as the first-line option for
the treatment of life-threatening hemorrhage not ame-
At this time, the U.S. military has more experience with nable to tourniquet placement because the combat med-
combat tourniquets than any military force in history, ics involved in the decision expressed a strong preference
and U.S. servicemen and servicewomen no longer step for a gauze-type hemostatic agent rather than a pow-
onto the battlefield without an individual first aid kit der or granules. WoundStat was recommended for use
that contains one or more tourniquets. when Combat Gauze was not successful in controlling
the hemorrhage. Subsequent safety testing at the US-
Hemostatic Dressings AISR found that WoundStat produced thromboembolic
Hemostatic dressings were not part of the original complications in animal models. These findings caused
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TCCC guidelines. These agents were developed shortly the CoTCCC to remove WoundStat as a recommended
after the onset of hostilities in Afghanistan. Both the agent, and its use was subsequently discontinued in the
HemCon bandage and QuikClot granules were devel- U.S. military.
oped commercially, and other options soon followed.
The challenge to the U.S. military was to decide which Combat Gauze is now the hemostatic dressing most
of the available hemostatic options to field. Compara- widely used by U.S. forces on the battlefield. The first
tive studies were carried out both at the USAISR and report of Combat Gauze use in combat noted a 79 per-
the Naval Medical Research Center in Bethesda, MD. cent success rate in 14 uses among Israeli Defense Force
These studies showed that both agents improved sur- personnel. Large U.S. retrospective studies of Combat
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vival compared with control groups in animal models of Gauze effectiveness in U.S. casualties have not yet been
lethal bleeding. done.

The U.S. Marine Corps was the first service to field a Newer hemostatic dressings are the subject of ongoing
hemostatic agent and selected the granular agent Qui- research. A study from the Naval Medical Research
kClot, which was judged to be the best option available Unit–San Antonio, TX, found that both Celox gauze
at the time. When the U.S. Army made its decision on and ChitoGauze produced higher 150-minute survival
which hemostatic agent to field, the HemCon dressing rates in the standardized USAISR femoral bleeding
had also become available. The two agents were found model than Combat Gauze. Survival was nine of 10 ani-
to be approximately equal in efficacy, but QuikClot mals with Celox gauze, seven of 10 with ChitoGauze,
produced an exothermic reaction when it contacted a seven of 10 with Combat Gauze XL, and six of 10 with
liquid (such as blood), which caused pain for the injured Combat Gauze. These differences are noteworthy but
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individual and produced burns. The Army elected to were not statistically significant. As of this writing, nei-
field HemCon, as did the USSOCOM. The use of these ther Celox gauze nor ChitoGauze have been tested in
two agents expanded rapidly throughout the U.S. mili- the USAISR hemostatic safety model described by Khei-
tary after 2003. Two retrospective studies, one on each rabadi. The U.S. military also does not have as much
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agent, were published by Wedmore et al. and Rhee et al. successful experience with these two agents as it has
and reported good success with battlefield use of these with Combat Gauze.For these reasons, the two agents
agents. 12,13 are recommended by the CoTCCC as backup choices to
Combat Gauze.
Newer hemostatic dressings became available in 2008
and underwent testing at the USAISR and the Naval Conclusion
Medical Research Center. These studies found that both Never in its long and distinguished history has the U.S.
Combat Gauze and WoundStat were consistently more military been so successful at saving the lives of individ-
effective than HemCon and QuikClot granules. As a uals wounded in combat. Many dedicated professionals
result, the CoTCCC modified the TCCC guidelines to in the Military Health System have played key roles in

The Hartford Consensus 151