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An American soldier sustained this explosive injury when a grenade was tossed into his HUMVEE during a tour in Iraq. He saved his life and leg by forcing the explosive under the dash with his foot. The injury could have been accompanied by significant blood loss were it not for the quick attention of the Navy corpsman and his application of QuikClot, a hemostatic agent in granular form. (picture by Mark Plaster, MD)
 
 
Despite the horrors of  war, conflicts can also result in some positive contributions for delivery of medical care on and off the battlefield.  In fact many of today’s medical advances such as the concept of the “golden hour,” hemorrhage control products and the development of advanced aeromedical services can be attributed to combat trauma research.
 
Because mortality secondary to uncontrolled hemorrhage continues to be the leading preventable cause of mortality death in both the civilian and current military environments, accounting for up to 40% of civilian and 50% of combat related deaths, the military has focused much of its medical research on development of hemorrhage control. During this current conflict improved tourniquets, hemostatic agents and dressings have been developed, researched and fielded by the military with unprecedented speed. Furthermore, the “dogma” of applying the “ABC” principles to every patient in every circumstance has recently been called into question. In situations of massive external hemorrhage, many military educators are now teaching C (control bleeding) then A(airway) followed by B (breathing). These principles may have application to civilian practice, especially for an explosive injury or mass-casualty incident.
 
Tourniquets; not necessarily a “last resort”

Despite the civilian doctrine that tourniquet use is a “last resort,” tourniquets have been used safely and effectively on the battlefield since the 17th century. In spite of many strong opinions against tourniquet use by our civilian colleagues, this simple device is carried by every solider on today’s battlefield and is used frequently. While it is easy to see that the benefit of tourniquet use clearly outweighs the risk in a combat situation, there may also be civilian situations where tourniquet use is appropriate. Physicians and medics with combat experience have reported that many lives have been saved by a liberal use of proper, appropriately applied tourniquets.  
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CAT – Combat Application Tourniquet (CAT-Phil Durango, LCC)
MAT–Mechanical Advantage Tourniquet (MAT-Bio Cybernetics International)
SOFTT–Special Operations Forces Tactical Tourniquet
(SOFTT-Tactical Medical Solutions, LLC)
EMT–Emergency Military Tourniquet (EMT-Delfi Mecial Innovations Inc.)
Despite this, there remains resistance to the use of tourniquets in civilian settings.  However, several tourniquets (in graph above) have been studied in both animal and human settings and have demonstrated effectiveness with little to no harm. 
 
The tourniquets in the graph above have a mechanical advantage over improvised tourniquets by employing a windlass (CAT, SOFTT), a block-and-tackle (MAT), or pneumatic compression (EMT) system that allows for more effective vascular occlusion.

Also a wider strap allows for occlusion of blood flow at lower pressure, thus helping to minimize the potential for damage to underlying tissues.  In our tests, it seemed that the EMT device produced significantly less circumferential pain in both the leg and the arm than the other effective devices, but all of the above devices have shown effectiveness in both animal and observational human studies.

Hemostatic Agents

Hemostatic Agents were initially being developed in 1997 for combat trauma with the initial work on the dry Fibrin Dressing by Col John Holcomb and the American Red Cross. This work expanded exponentially after the start of the global war on terror and the immediate need for agents to aid in the control of external hemorrhage from penetrating trauma. This initial work has resulted in a myriad of hemostatic agents in 2007. This has been a good thing as the bottom line is that all hemostatic agents work better than plain gauze which was the “gold standard” since the time of the Spanish American war. It is also true that no agent is 100% effective, all these agents will or can fail in some circumstances. It is simply untrue that any agent will be 100% effective in every given wound.  The prices listed are based on several internet sources as of Jan 08.
 
click to view a high-res version of the chart below 
 
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Comments   

# Asst. Clinical Professor of EM, Univ of Pittsburgh SOMkip benko 2008-02-05 17:31
We added Hemcon to The Dental Box because we were so impressed with it's ability to stop bleeding. It's turning out to be very helpful in it's ability to help control bleeding extraction sites, especially in patients who take anticoagulants. ......
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# Hemcon works wellThomas Green 2008-02-07 00:08
We started using Hemcon in our ED and I have found that it works particularly well with AV fistula and graft bleeding in dialysis patients - so now instead of prolonged stays or possible overnight admissions, the patient gets to go home in an hour or two. A bit pricey but we have a protocol for it and its a nice plan B.
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# Captain MC USNR RErwin F Hirsch 2008-02-11 13:55
The use of quickclot in the case described IS not indicated. The magnitude of blood loss from a mangeld foot is NOT life threatning the application of the Hemostatic agent will make debridment more complicated and the potential consequences of the exothermic reaction could be a long term problem
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# Clinical coordinator SAM Medical productsCharles Combs 2008-02-13 02:45
I would just like to clarify a few issues about Celox.First is pricing and dosage Celox is available in both 15g and 35g not 30g as posted in the chart. Pricing is 16.00 US for a 15g and 25.00 US for the 35g.Also mentioned in the chart was the swine model test there were 12 per group not 6 as stated.
The quote in the words of a special operations medic “If it’s a powder it’s a nonstarter”. That could have fooled me by talking to a lot of guy's at an annual meeting held in Tampa ever y year. One person's opinion does not reflex how the rest of their peer's feel. And yes we are combat tested granted not to the extent that the other's have been. That being said Celox has only been out 18 months compared to 2-6 years depending on what product you want to compare it to.
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# CEORaymond Huey 2008-02-21 21:46
Excellent overview article of these new technologies. I would like to point out that Z-Medica has products specifically designed for the first responder and the ED and these products no longer have an exothermic reaction of any significance. QuikClot® 1st Response™ brand has been used multiple times in life saving situations from the Hudson valley region of New York State to Spokane, Washington. Z-Medica also offers QuikClot® Sport™ brand and QuikClot® Sport™ Silver brand for over the counter use. QuikClot® Sport™ Silver brand is effective against MRSA and other microbes effecting a five decibel reduction in one hour. Again, thanks for a good review article on these emerging technologies.
Ray Huey
CEO, Z-Medica Corporation
www.z-medica.com
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# Tourniquet specialist, Delfi Medical InnovationsAna Vargas 2008-02-22 03:13
Good article, great detail!!I would make a sharp distinction between the narrow windlass tourniquets and the wider pneumatic tourniquet (EMT).

The military issues the windlass tourniquets to every soldier while the pneumatic EMT is ssued to medics and evacuation vehicles only. This is because although the EMT offers more effective limb occlusion and substantially less pain than is narrow windlass counterparts, tourniquets such as the CAT are smaller and won’t puncture in a battlefield setting.

In contrast, in the pre-hospital and ED setting the EMT makes more sense because it is surgical tourniquet technology adapted for pre-hospital use. Currently, the EMT is gaining strong acceptance by EMS physicians.
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