Lessons Learned from a Decade of Conflict - Boekje Pienter

Delphi®EMTEmergency& MedicalPneumaticTourniquetC-A-T® CombatApplication Tourniquet®(SOF-TT). The Delphi Emergency & MedicalTourniquet (EMT) is the primary pneumatictourniquet used with fixed surgical facilitiesand unit aid stations. 5,6,7Compression bandages are widely usedthroughout the military. Several new commercialproducts represent a significant improvementover older, non-compression style bandages.These newer devices all incorporate a non-adherentbandage in the form of an elastic wrap tail.Sequential wrapping of the elastic tail generatesa compressive force that, when combined withgauze packing, creates an extremely efficient andeffective pressure bandage. TheEmergency Bandage by First CareProducts was the first of thesemodern compression bandages togain widespread acceptance.The Emergency Trauma Dressingby North American Rescue(NAR) represents a significantdesign improvement over olderdevices. 8 This elastic compressionwrap is a tighter weave and generatesgreater compressive force.The wrap’s “Quick Grip” feature(Velcro® enclosures equally spacedalong the wrap) prevents the entirewrap from unrolling prematurelyif the wrap is accidentally droppedduring application.Certain wound locations—such as the proximalextremities,axilla, groin, torsoand neck—makeit difficult to controlhemorrhage with directpressure and compressiondressings; tourniquets are alsoineffective in many of these areas.Researchers have developed severalnew tools and clinical guidelines to address thiscritical issue. Over the past few years, a number ofhemostatic agents, in both bandage and powderform, have been developed that actually arrest lifethreateningarterial hemorrhage. 9,10,11The most recent research conducted by both the Army and Navyresearch centers compared more than 10 types of hemostatic agentsfor controlling arterial hemorrhage in animal models. One granularproduct (WoundStat, manufactured by Trauma Cure) was found to havea 100% survival rate for subjects with wounds that would otherwisebe fatal. Another product, an improved gauze impregnated with akaolin substance (Combat Gauze, manufactured by Z-Medica), demonstratedgreater than 80% efficacy in independent lab presentationsto the research committee. This product is actually a pro-coagulant thatpromotes blood clotting.These newer hemostatic agents are proving to be both more effectiveand less expensive than those previously approved by the TCCCcommittee. In clinical trials, WoundStat showed the highestclinical efficacy, yet it is a granular-based product,which is problematic to adequatelyapply during tactical operations.Combat Gauze showed the nexthighest efficacy. Both were superiorto the benchmark HemCon andQuikClot. Celox, a granular chitosan-basedagent, also outperformedboth HemCon and QuikClot inboth USAIR and Naval Research LabStudies. Note: This data was taken fromthe “Comparative Testing and Analysisof New Hemostatic Agents in LethalInjury Models” presentation, which providespre-published data from the NavyResearch Lab and the Army Instituteof Surgical Research to the TCCCcommittee.ETDCompressionBandageHowever, Celox didn’t performas well as WoundStat or CombatGauze. It’s a lighter weight powderthan WoundStat, which makes applicationto arterial hemorrhage injurydifficult.Based upon the results of thesestudies and input from combat medicsregarding device preferences, the TCCCcommittee revised its recommendations. Thenewest guideline change is to utilize CombatGauze as the primary hemostatic agent, withWoundStat as the backup or when thewound characteristics are moreamenable to a granular agent.Hemostatic Agents:Combat GauzeWoundStatElsevier Public Safety War on Trauma 17