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What's the difference in all the hemostasis agents?

The number of published articles on the use of hemostasis agents keeps increasing. Why is that??? The answer is simple – there is a need to stop bleeding. Many of these articles do clarify the differences in the active ingredients that control bleeding; however I have seen too many recent articles that have some of this information wrong, very wrong. For those of us who depend on the experience, knowledge and expertise of these authors, and also the editorial boards of these journals to make certain article content is correct, this just confuses us and even perhaps can make us a little angry. We all need objective, correct information and not subjective, incorrect information.

The purpose of this blog is to provide some clarification with the most objective and accurate information I can offer.

What makes a hemostasis agent work?

        • Zeolith – is a derivative of volcanic rock that is chemically inert and has a physical, not chemical action; Zeolite contains no human, animal or botanical proteins
          • The 1st Zeolite product, in the form of loose granules, was developed by the U.S. manufacturer Z-Medica and was FDA approved in May 2002 under the brand name QuikClot®
          • When applied to a bleeding wound, the smaller water molecules in the blood are absorbed by the Zeolite, resulting in rapid coagulation and the formation of blood clots -> stops the bleeding
          • The bleeding stops because the platelets and clotting factor molecules in the blood are left alone to do their work in forming blood clots
          • The physical action of Zeolite produces heat, but the heat is not the mechanism of action, the absorption of water is why it works
          • Z-Medica introduced the 2nd generation of their Zeolite product in 2005; the granules were now in a bag / pouch, to be used on bleeding wounds, and under the brand name QuikClot ACS™
          • The 3rd generation of a Zeolite product was introduced in 2007 by Z-Medica and named ACS+™
            • A cooler formula, with less heat generated, but with the same physical reaction to absorb the water molecules -> stop the bleeding
            • Also packaged in a bag / pouch and available in both 25g and 100g sizes
          • Zeolite hemostasis products are no longer manufactured and any reference to Zeolite in a current published journal article should only be in an historical perspective

       

            • Kaolin – is a derivative of the earth’s clay and contains the mineral kaolinite; Kaolin has no human, animal or botanical proteins
              • Kaolin was introduced as a hemostasis agent in medical gauze in 2008, by the U.S. manufacturer Z-Medica
                • This effectively made this the 4th generation of product offered by this manufacturer
                  • In the U.S. and many parts of the world, this 4th generation was introduced with the brand name QuikClot Combat Gauze®
                  • In Europe this same product was introduced with the name QuikClot® Z-Folded Gauze™
                    • Since late 2016 the brand name QuikClot Combat Gauze® is now accepted by EU regulatory and is it’s legal product name
                • Kaolin is impregnated into non-woven medical gauze for the use on bleeding wounds
                • Kaolin activates the injured person’s intrinsic blood coagulation sequence (clotting cascade)…
                • …activates Factor XII, Factor XI and pre-kallikrein -> stops the bleeding
                • The bleeding stops because blood clots are formed due to the change in the injured person’s clotting cascade
                • In comparison to Zeolite, Kaolin produces no heat
                  • This is where many published authors get it wrong and incorrectly associate QuikClot® kaolin products with heat generation
                  • Some users have come to the conclusion that if the clotting cascade is disrupted with the use of anticoagulant agents (i.e. vitamin K antagonist, unfractionated heparin, anti-platelet agents, or thrombin inhibitors) that Kaolin products will not work
                    • Based on independent, but also peer reviewed publications, this is not true.
                    • References:
                      1. Cripps ME, et al.; In Vitro Effects of a Kaolin Coated Hemostatic Dressing on Anticoagulated Blood; J Trauma Acute Care Surg. September 2018; 85: 485-490
                      2. Travers S, et al.; Hemostatic dressings in civil prehospital practice: 30 uses of QuikClot Combat Gauze; European Journal of Emergency Medicine. September 2015
                      3. Bar J, et al.; Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents; Prehospital and Disaster Medicine. October 2017
                      4. Vilardo N, et al.; The use of QuikClot combat gauze in cervical and vaginal hemorrhage; Gynecologic Oncology Reports. 21 (2017)
                      5. Garcia-Blanco J, et al.; The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model. J Spec Oper Med. 2015 Spring; 15(1):57-60
                      6. Johnson D, et al.; The effects of QuikClot Combat Gauze® on hemorrhage control in the presence of hemodilution and hypothermia. Ann Med Surg. 2014 June; 3(2):21-25
                      7. Sena MJ, et al.; Pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model. J Surg Res. 2013 Aug; 183(2):704-9
                      8. Allison HA.; Hemorrhage Control: Lessons Learned From the Battlefield Use of Hemostatic Agents That Can Be Applied in a Hospital Setting. Crit Care Nurs Q. 2019 Apr/Jun; 42(2):165-172. doi: 10.1097/CNQ.0000000000000249. PubMed PMID: 30807340
                      9. Boulton AJ, Lewis CT, Naumann DN, Midwinter MJ. Prehospital haemostatic dressings for trauma: a systematic review. Emerg Med J. 2018 Jul; 35(7):449-457. doi: 10.1136/emermed-2018-207523. Epub 2018 May 4. Review. PubMed PMID: 29728411
                      10. George T, et al. Impact of Marine Exposure on Hemostatic Gauzes Using Thromboelastography. J Spec Oper Med. Spring 2019;19(1):89-94. PubMed PMID: 30859534.

                 

                      • Chitosan – – is a derivative of the hard outer skeleton of marine shell fish that is prepared using an alkaline substance
                        • Chitosan products were 1st introduced in 2002 by the U.S. manufacturer HemCon Medical Technologies with the brand name HemCon® Bandage.
                          • Today there are many generations and numerous manufacturers of Chitosan based hemostasis products
                          • Some of the brand names you may be familiar with are:
                            • ChitoGauze® PRO
                            • Celox™ Gauze
                            • ChitoSAM™ 100
                          • As of the writing of this blog, and to the best knowledge of this writer, Chitosan products are available as sponges and gauze
                          • Applied to a bleeding wound, Chitosan products activate platelets thus making red blood cells more “sticky” -> stops the bleeding
                          • The bleeding stops when the red blood cells form a gel-like clot that some users refer to as tamponading the wound and others call a pseudo-clot
                          • Some users have come to the conclusion that because Chitosan products clot by platelet activation, and do not follow the patient’s intrinsic / extrinsic clotting cascade, they are more effective for patients on anticoagulant agents
                              • Please see the reference list above.
                              •  
                                Recommendations from the Committee on Tactical Combat Casualty Care (CoTCCC) – in effect since 2008:
                                TCCC Guidelines for Medical Personnel, 1, August, 2018 https://www.deployedmedicine.com/market/11
                                Massive Hemorrhage – Point 3:
                                a. “Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.”
                                b. “For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.”
                                – Alternative hemostatic adjuncts:
                                – Celox Gauze or
                                – ChitoGauze or
                                – XStat (best for deep, narrow-tract junctional wounds)
                                – “Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat). Each dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a different type applied. (Note: XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.)”
                                – “If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.”

                                My final comments:

                                        • Every user of a hemostasis agent must understand their specific need and be well-informed about the products that are available
                                        • Every user of a hemostasis agent must be aware that forming a clot at the wound site can save a life
                                        • Every user of a hemostasis agent must be very careful to not dislodge that clot because then your patient is once again in a life-threatening situation

                                We are available to assist if there are any questions regarding the information above. If we do not know the answer we will do our best to get it and work to respond to all queries within 72 hours. info@medicalsci.com