Page 69 - Journal of Special Operations Medicine - Fall 2017

dressing performance without the censor of data from animal Disclaimer
death. Additionally, this 10-minute distinction has proven ef- The views expressed are those of the authors and do not reflect
fective previously in similar product evaluation trials. 10 the official views of the Department of Defense or its compo-
nents. The experiments reported herein were conducted accord-
There was not a direct relationship between achievement of ing to the principles set forth in the National Institute of Health
hemostasis and survival in the data presented here. For ex- Publication No. 80-23, Guide for the Care and Use of Labora-
ample, animals that had relatively early hemostasis paradoxi- tory Animals and the Animal Welfare Act of 1996, as amended.
cally did not survive the full observation period. Furthermore,
animals that had little bleeding after dressing application still Disclosures
died. In fact, the animal that bled the least died the earliest The authors have indicated they have no financial relation-
in the XSTAT group. These contradictory results imply that ships relevant to this article to disclose.
the coagulopathy combined with the aggressive resuscitation
paradigm was partly responsible for the high mortality rates References
and not solely due to dressing performance. 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
(2001–2011): implications for the future of combat casualty care.
No manual pressure or pressure dressings were used in this J Trauma Acute Care Surg. 2012;73:S431–437.
study. Interestingly, a study performed by Navy researchers 2. Holcomb J, Caruso J, McMullin N, et al. Causes of death in U.S.
Special Operations Forces in the global war on terrorism: 2001–
did not find any difference with or without manual pressure in 2004. U.S. Army Med Dep J. 2007;Jan-Mar:24–37.
a similar model of swine axillary injury. The instructions for 3. Kragh JF, Kotwal RS, Cap AP, et al. Performance of junctional
13
XSTAT use are to “Cover the wound with an occlusive or pres- tourniquets in normal human volunteers. Prehosp Emerg Care.
sure dressing. If available, use an elastic bandage. If bleeding 2015;19(3):391–398.
persists, apply manual pressure until bleeding is controlled.” 4. Schwartz R, Reynolds BZ, Gordon RD, et al. Testing of junc-
19
The instructions for CG application are to “. . . apply pressure tional tourniquets by military medics to control simulated groin
hemorrhage. J Spec Oper Med. 2015;15(2):94–95.
for 3 minutes or until bleeding stops. Wrap and tie bandage 5. Morrison JJ, Percival TJ, Markov NP, et al. Aortic balloon oc-
to maintain pressure.” Standard gauze backing was used in clusion is effective in controlling pelvic hemorrhage. J Surg Res.
20
these experiments to make the findings more generalizable to 2012;177(2):341–347.
various wounding patterns. 6. Morrison JJ, Galgon RE, Jansen JO, et al. A systematic review
of the use of resuscitative endovascular balloon occlusion of the
There are limitations to this study, including the lack of a de- aorta in the management of hemorrhagic shock. J Trauma Acute
Care Surg. 2016;80(2):324–334.
fined correlation between hemostasis and survival, as men- 7. Walker NM, Eardley W, Clasper JC. UK combat-related pelvic
tioned. The wound produced was surgical and likely does not junctional vascular injuries 2008–2011: implications for future
reflect real-world injury patterns. However, XSTAT is designed intervention. Injury. 2014;45:1585–1589.
such that the small sponges can expand into any cavity shape. 8. Joseph B, Ibraheem K, Haider AA, et al. Identifying potential util-
Additionally, these experiments were performed in a controlled ity of resuscitative endovascular balloon occlusion of the aorta: an
laboratory setting with relatively small sample sizes. Neverthe- autopsy study. J Trauma Acute Care Surg. 2016;81:S128–S132.
less, the results produced statistically different results between 9. Bennett BL, Littlejohn L. Review of new topical hemostatic dress-
ings for combat casualty care. Mil Med. 2014;179(5):497–514.
the two products using this junctional injury model. 10. Rall JM, Cox JM, Songer AG, et al. Comparison of novel hemo-
static dressings with QuikClot Combat Gauze in a standardized
Currently, XSTAT is recommended by the CoTCCC as “best swine model of uncontrolled hemorrhage. J Trauma Acute Care
for deep, narrow-tract junctional wounds.” Future studies Surg. 2013;75:S150–156.
12
may aim to expand the recommendation of the CoTCCC to 11. Sims K, Montgomery HR, Dituro P, et al. Management of exter-
allow XSTAT to be applied to regions and circumstances out- nal hemorrhage in tactical combat casualty care: the adjunctive
use of XSTAT compressed hemostatic sponges: TCCC Guide-
™
side junctional wounds, such as the neck, abdomen, or pelvis. lines Change 15-03. J Spec Oper Med. 2016;16(1):19–28.
The product could also be used in different situations outside 12. Committee on Tactical Combat Casualty Care. TCCC guidelines
the point of injury, as was seen in the first combat casualty 3 June 2016. http://www.naemt.org/education/TCCC/guidelines
use. After failure to control intraoperative bleeding from a _curriculum. Accessed 7 February 2017.
11
leg wound by using cautery and hemostatic gauze, XSTAT was 13. Cestero RF, Song BK. The effect of hemostatic dressings in a sub-
successfully used to stop the bleeding. 11 clavian artery and vein transection porcine model. Technical Re-
port 2013=012. San Antonio, TX: Naval Medical Research Unit
San Antonio; 2013.
Conclusion 14. Mueller GR, Pineda TJ, Xie HX, et al. A novel sponge-based
wound stasis dressing to treat lethal noncompressible hemor-
The CoTCCC recently added XSTAT to its list of approved he- rhage. J Trauma Acute Care Surg. 2012;73:S134–139.
mostatic dressings. This study confirms that recommendation 15. Kragh JF Jr, Aden JK, Steinbaugh J, et al. Gauze vs XSTAT in
and provides new evidence of XSTAT’s efficacy in restoring wound packing for hemorrhage control. Am J Emerg Med. 2015;
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hemostasis in a rapidly bleeding wound. XSTAT-treated ani- 16. National Research Council. The Guide for the Care and Use of
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not result in increased survival in this model of uncontrolled 17. Kheirabadi BS, Mace JE, Terrazas IB, et al. Clot-inducing miner-
hemorrhage in swine with coagulopathy. als versus plasma protein dressing for topical treatment of external
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18. Kheirabadi BS, Arnaud F, McCarron R, et al. Development of a
Funding standard swine hemorrhage model for efficacy assessment of topi-
This work was supported by a grant from the Air Force cal hemostatic agents. J Trauma. 2011;71:S139–146.
Medical Service Research Development Test and Evaluation 19. RevMedx. XSTAT instructions for use.
program. 20. Z-Medica. QuikClot Combat Gauze instructions for use.

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