Page 128 - JSOM Winter 2018

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FIGURE 2 A type of trauma bandage (OLAES; Tactical Medical Granular-type hemostatic agents (e.g., WoundStat ; Trau-
Solutions). maCure,) are generally avoided owing to their questionable
efficacy for controlling major arterial hemorrhage and their
ability to complicate wound repair and cause an embolism
to the brain and lungs. Under high arterial flow, granular
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agents tend to wash away before allowing a clot to form. They
also tend to require extensive and meticulous debridement to
remove completely from the body, thus making wound and
vascular repair more challenging. Zeolite-based granular-type
agents are highly exothermic (reaching up to 65°C [149°F]),
causing burns and significant tissue damage; avoid using these
products. Because of their potential adverse health effects,
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granular products such as WoundStat are not currently recom-
mended by the US Army Institute of Surgical Research for use
in combat casualty care. 24
Hemostatic devices
X-Stat :
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X-Stat (RevMedx, http://www.revmedx.com/) is a hemostatic
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manufacturer may recommend removing the initial gauze, device recently introduced to the market and designed for
sweeping out any pooled blood (without disrupting any controlling hemorrhage from gunshot and shrapnel wounds
thrombus formation), and repacking the wound with new that are not amenable to direct manual pressure or tourni-
gauze impregnated with fresh hemostatic agent. quet application. X-Stat incorporates several small, nonab-
sorbable, rapidly expandable, hemostatic sponges into either
Wound packing a syringe-like applicator to be injected into the wound or a
For canines, wound packing is most applicable for controlling z-folded dressing embedded with expanding sponges. Upon
deep, compressible junctional hemorrhages and/or deep contact with blood or exudate, the hemostatic sponges rapidly
wounds in large muscle bellies in the neck, upper extremity expand, causing a tamponade effect in the wound. A pressure
above the elbow (triceps) and stifle (caudal thigh area), or in bandage is applied to secure the expanding sponges within the
the perineal area. Massive bleeding in these locations is not wound. Similar to wound packing techniques using impreg-
easily controlled by direct digital pressure application alone nated hemostatic dressing or Kerlix gauze, the X-Stat devices
and is not amenable to tourniquet application. Because of the are not indicated for open wounds to the thoracic or abdom-
lack of significant musculature in the canine’s distal limbs be- inal cavities.
low the elbows and knees, wound packing is not necessary or
feasible for distal extremity wounds; direct pressure and pres- iT Clamp :
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sure bandages are highly effective for arresting hemorrhage in The iTClamp (Innovative Trauma Care, https://www.innovative
these locations. traumacare.com) is a mechanical clamp with several small
needles used to seal wounds located primarily on the extremi-
Dressing material and hemostatic agents for wound packing: ties, the neck, and junctional regions (i.e., axilla, inguinal). By
Dressing materials used for wound packing in humans are firmly sealing the wound edges of the overlying skin, the de-
similarly effective and applicable for use in canines. Available vice creates a closed wound with an underlying compartment.
options primarily include impregnated hemostatic gauze or As a stable clot forms within the closed compartment space,
dressing (preferred) and standard Kerlix gauze or dressing. it eventually tamponades the bleeding vessel. As compared
The current Prehospital Trauma Life Support guideline recom- with wound packing or applying a junctional tourniquet, the
mends the use of topical hemostatic agents to control hemor- iTClamp is more user friendly, allowing for quicker applica-
rhage at sites not amenable to tourniquet placement and that tion. It is useful, particularly, when a junctional tourniquet is
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are not controlled by direct pressure alone. In the absence of not available or when time does not permit applying a junc-
8
hemostatic dressing, standard Kerlix roll gauze is an effective tional tourniquet or wound packing. Experimentally and clin-
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alternative for wound packing. However, due to the lack of ical evidence supports the iTClamp as a safe, fast, and effective
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hemostatic agent in Kerlix gauze, holding continuous pressure device for controlling external blood loss. 28–30
is warranted for at least 10 minutes as compared with the rec-
ommended 3–5 minutes with hemostatic dressing. Available Tourniquet Application
hemostatic dressings consists of z-folded dressing and gauze Limb tourniquets
pads impregnated with either kaolin (e.g., QuikClot Combat In human combat casualties, early tourniquet (TQ) applica-
Gauze [Z-Medica, http://www.z-medica.com/]) or chitosan tion is a life-saving intervention for massive, trauma-induced
(e.g., CELOX [Medtrade Products, http://www.celoxmedical extremity hemorrhage. Lessons learned over the past 16 years
.com/na/] and ChitoGauze [HemCon Medical Technologies, from the conflicts in Iraq, Afghanistan, and other world events
https://www.tricolbiomedical.com]). To date, evidence does (e.g., Boston Marathon bombing in 2013) provides evidence
not describe any serious adverse effects, exothermic reaction, that early and appropriate TQ application: reliably stops ex-
or thromboembolic formation associated with the use of im- tremity hemorrhage, is safe when applied for brief periods of
pregnated hemostatic agents made with kaolin or chitosan. 24,25 time (< 2 hours), and reduces overall case fatality rates. 31–33
A review of all available hemostatic products is beyond the
scope of this article, and the reader is referred to the article by Immediate TQ application to abate extremity hemorrhage is
Devlin et al. 26 not as necessary of a life-saving intervention in canines as it is

126 | JSOM Volume 18, Edition 4 / Winter 2018