Page 42 - Journal of Special Operations Medicine - Spring 2016

– Level C: Expert opinion, case studies, or standards 7. Preliminary studies have shown that a chitosan-free
of care. version of XStat produces the same hemostatic efficacy
with decreased cost. Follow-on research should in-
Using this taxonomy, the level of evidence for this change clude comparative studies using a chitosan-free XStat
is Level C. application.

8. A smaller-diameter applicator to facilitate XStat de-
Recommendations for livery to a narrower wound tract should also be evalu-
Further Research and Development
ated. This also would potentially reduce the treatment
1. Evaluate XStat as a potential adjunct to allow for cost and provide added capability to treat smaller en-
extremity and junctional tourniquet conversion. This trance/wound tracts.
would entail observation times of at least 6 hours and
potentially as long as 72 hours if this product is intended 9. The Mueller and Cestero studies used only a 60- minute
to help medics meet the proposed prolonged field care observation time. Further studies should include longer
goal of 72 hours of prehospital care. observation periods (4 hours and beyond) so that the
utility of XStat for prolonged field-care scenarios may
2. Additional research should be conducted comparing be evaluated.
XStat with both hemostatic dressings and junctional
tourniquets in various large-animal bleeding models, in-
cluding neck injury. This additional research should also Acknowledgments
include narrow-tract junctional wounds that approxi- The authors gratefully acknowledge the research as-
mate the width of the entrance tract from wounds from sistance provided by Mrs Danielle Davis of the Joint
military assault rifles (both 5.56mm and 7.62mm) with Trauma System. The authors also thank the Department
severe bleeding in the depths of the wound tract. of Defense Trauma Registry for providing much of the
casualty data discussed in this paper and CAPT Zsolt
3. If supported by the research findings, consideration Stockinger for his review of earlier drafts of this paper
should be given to approving XStat for use in neck and CAPT (retired) Steve Giebner for his editorial as-
wounds. sistance on the manuscript.

4. Some narrow-tract wounds may communicate with
the thoracic or peritoneal spaces. What will happen if the Disclaimer
XStat minisponges are inadvertently injected into these The opinions or assertions contained herein are the pri-
spaces? Research is needed to address this question. vate views of the authors and are not to be construed as
official or as reflecting the views of the Department of
5. A research project should be undertaken as a com- the Army or the Department of Defense. This recom-
bined effort of the Joint Trauma System and the AFMES mendation is intended to be a guideline only and is not
to identify all casualties, including those killed in action a substitute for clinical judgment.
who are not entered in the DoD Trauma Registry, who
sustained life-threatening hemorrhage from narrow-
tract penetrating trauma. This effort should also note Release
whether the wounds were amenable to treatment with This document was reviewed by the Director of the Joint
limb tourniquets, hemostatic dressings, or junctional Trauma System and by the Public Affairs Office and the
tourniquets, and whether these devices were used. Operational Security Office at the US Army Institute of
Surgical Research. It is approved for unlimited public
6. The Joint Trauma System Performance Improve- release.
ment process should be used to identify all future ca-
sualties on whom XStat is used and how it performed.
Additionally, the records of casualties who would have Disclosures
been good candidates for hemorrhage control with The authors have no disclosures.
XStat (life-threatening hemorrhage from narrow-tract
penetrating trauma not amenable to treatment with
limb tourniquets, hemostatic dressings, or junctional References
tourniquets, or not responding to these treatment mo- 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battle-
dalities), but for whom XStat was not used, should field (2001–2011): implications for the future of combat ca-
also be identified and reviewed for opportunities to sualty care. J Trauma Acute Care Surg. 2012;73(6 suppl 5):
improve. S431–437.

26 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016