blood clot what do we think

[DeploymentMedicineIntl.]

Hello Gents, I hope this finds you all well.
Just thought I'd throw our two pence in the ring, hopefully it may be of use.
A bit of background - DMI is by far the leading global figure in the development of haemostatic agent training (amongst other things). Almost all new products come through us for our input and we currently train thousands of US, UK and European personnel in their use. If it's on the market, you can be sure that it's been through our grubby little fingers and used exhaustively, then returned to the manufacturer with recommendations for future development. These products include all Quikclot generations (Granules, ACS, ACS+,Combat Gauze), Hemcon, Chitoflex, Instaclot, Ballisticlot, Woundstat, Celox and many more that never made it past the first hurdle! I hasten to add, we do not SELL any of these products, we are keen to reserve the right to be completely impartial in all cases.

With regards to the original question - one thing we know for sure is that Quikclot works! As with anything though, it only works if the user is properly trained. Watching a DVD and reading the back of the packet doesn't quite cut it. One of the problems we face is that current operational theatres are flooded with the stuff, but adequate training remains a rarity, therefore there is a lot of ineffective and inappropriate use of Quikclot.

Granular agents require some skill, so that they can be applied to where they need to go, it can be difficult to get them deep into a bleeding wound. Good training will overcome this.

Good things about Quikclot - It saves lives when used properly
Bad things about Quikclot - Slightly harder to use, granular Quikclot gets hot, once again, not a problem if you train properly.

Quikclot myths - If you get it in your eyes it will burn them out!!!
Err... no it won't. we have done extensive research into this. The exothermic effects of Quikclot are cumulative, meaning that if there's loads of it (and loads of fluid), it will get hot. If there's only a bit of it, it can't get hot. You cannot put enough Quikclot into your eye for it to get hot (and we've tried!), there is also not enough fluid in your eye for it to activate any exothermic reaction. If you do get it in your eye, just rinse it out as if it were sand. We have done this on lots of occasions!

Z-Medica have concentrated on the delivery method and heat production of new generations of Quikclot. in a nutshell:

Quikclot ACS (Advanced Clotting Sponge) - granules contained in a teabag, easily directed towards the point of bleeding, still got really hot though, just took a bit longer. Now discontinued.

Quikclot ACS + - same teabag, now no heat production, great product.

Quikclot Combat Gauze - recently on the market, FDA approved in the States, license pending here in the UK. This stuff is roll gauze impregnated with quikclot. It is completely indistinguishable from normal gauze, just pack it in, apply pressure, let it do it's magic! This stuff, in our opinion will be hard to beat.

We are at a really exciting stage of haemostatic agent development, in a few short years we have seen huge leaps in technology in this area.
New Tactical Combat Casualty Care guidelines in the US now recommend the use of Quikclot Gauze and also Woundstat. The following is an extract from a report delivered by the US Army Institute for Surgical Research:
“A number of… new agents have undergone testing both at the U.S. Army Institute for Surgical Research (USAISR) and the Naval Medical Research Center (NMRC). The findings from these studies were presented to the Committee on TCCC (CoTCCC) on 1 April 2008. Three different swine bleeding models were used: a 6mm femoral artery punch model at USAISR and both a 4mm femoral artery punch model and a femoral artery/vein transaction model at NMRC. Both the NMRC and the USAISR studies found Combat Gauze and Woundstat to be consistently more effective than the hemostatic agents HemCon and QuikClot previously recommended in the 2006 TCCC guidelines. No significant exothermic reaction was noted with either agent…

In light of these findings, the CoTCCC voted to recommend Combat Gauze as the first line treatment for life-threatening hemorrhage that is not amenable to tourniquet placement. Woundstat is recommended as the backup agent in the event that Combat Gauze does not effectively control the hemorrhage. The primary reason for this order of priority is that combat medical personnel on the committee expressed a strong preference for a gauze-type hemostatic agent rather than a powder or granule. This preference is based on field experience that powder or granular agents do not work well in wounds where the bleeding vessel is at the bottom of a narrow wound tract. A gauze-type hemostatic agent is more effective in this setting. Combat Gauze was also noted to be more easily removable from the wound site at the time of surgical repair…

The changes noted above and any additional changes approved will be incorporated into the upcoming Seventh Edition of the Prehospital Trauma Life Support Manual.”


Woundstat is a new granular product which is poured in and basically massaged into the base of the wound. Fresh bleeding and granules turn into a sticky clay like substance within seconds. It's amazing stuff.

To address another point - Haemostatic Agents vs Tourniquets.
Not really much to say about this as Haemostatic agents are designed to arrest massive haemorrhage in places not amenable to tourniquet use, primarily, inguinal and axilla (groin and armpit) areas, where body armour doesn't protect you so well.

And finally, application and removal of tourniquets.
If a tourniquet has been applied either in the Care Under Fire or Tactical Field Care phases of care, it is the responsibilty of the attending Medic to determine whether that tourniquet is still required, or if it can be downgraded.

For a non-medic, or a medic with little experience in this field, it is perfectly acceptable to apply the tourniquet and leave it in place without interference. As stated in earlier posts, it's doing a pretty important job.
However, providing that good packing and an effective compression dressing have also been applied with that tourniquet, and have been in situ for some time, it is very likely that a clot has been formed which will be robust enough to see the casualty through his medevac. How do we know if the tourniquet, packing and dressing have been successful? - release the tourniquet slowly and take a look. If it re-bleeds, tighten it up and leave it alone, no big deal. However, if you loosen the tourniquet and find that the packing and pressure are now able to do the job, congratulations, you've just done your casualty and your team a huge favour. You are applying intelligent thought to the medicine you are providing.
Firstly, you now have another tourniquet back in the game. The next guy who needs it might just be you!
Secondly, tourniquets are extremely painful, it doesn't matter which one you use, they all hurt if applied nice and tightly. You will notice that casualties with tourniquets applied will hoover up your entire supply of pain meds within a very short period of time. After downgrading his tourniquets, your pain meds will go a lot further. Most of us here work in an environment where we do not have endless supplies of equipment and drugs, therefore, we must be clever about how we use them.
Now, don't get me wrong, if that tourniquet is the only thing keeping that guy from going home in a box, then there is no question that it stays on. But regular reassessment of the wound is simply good medicine.

Sorry for the long post, but I hope it helps. Like I said, it's just our two pence worth - it's nice to see important issues being debated.

CP Medic, thanks for the recommendation, come down to ours and I'll get the brews on.

Have a good day Gents,

John
DMI (UK)

[morrigan]

Very interesting thread.... thanks guys

[cpmedic]

Top post John, I am aiming to pop over if Daffyd ever answers his phone

Ill bring some cake!

[alex666]

Rush of blood to the head - deleted

[K9medic]

Just a quick thank you gentlemen. This post, in the 20 minutes that it has taken me to read it, delivered more relevant information on the control of “catastrophic bleeding, than some courses I have attended have.

[M4MED]

Great post John, great minds......I agree completely, apart from the woundstat part as I have no experience of this agent. Have you got anymore info on this please? With granules, the biggest problem I have found is lack of knowledge and training. Guys just filling a hole with this stuff. If the site of the bleed is deep, the agent just forms a clot / plug at the surface and the bleed continues internally. First responders with minimal training see no external bleeding and believe they have done their job effectively.
No criticism of the agents, just adequate training packages.
Given the info you posted above ref the Combat gauze;

1. When do you expect the license and sale of this in the UK?
2. Has Hemcon been removed from US Army service?
3. How does the combat gauze compare to Chitoflex? I have used it and it worked well. They appear very similar, although, if it truely is gauze impregnated with the haemostatic agent, it could be more flexible and pliable than the former and therefore feed into the narrow tracts better.

If in doubt, tourniquet or 15 stone on top of a handful of gauze pads!!!

Thanks again

M4MED