Arts and Crafts: Gauze and Hemostatic Agents

It’s another Saturday afternoon with nothing to do but enjoy the beautiful California weather and contemplate the meaning of life. The day is young, the warmth just right, and I’m just counting down the minutes until I’ll be scootering back down into Berkeley for my friend Sumaiya’s 21st birthday! However, it’s still early in the afternoon and the boredom is settling in.

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Figure 1: The view from home

I just got off a video call with my friend who’s working towards a firefighter position in Southern California and he brought up an interesting topic in emergency medicine: the rise of hemostatic agents. Like a well trained salesman, he quickly gave me a run- down of the advantages of these new fancy bandages that I’ll highlight for you all as well.

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Figure 2: This is QuikClot, a new hemostatic agent for stopping wounds [1]
QuickClot is a proprietary hemostatic agent comprised of a synthetic matrix as well as kaolin, a rock and aluminum silicate that was first found in China to make porcelain in fine China. Nowadays, kaolin is primarily used in making paper brighter and glossier. [2] However, in QuikClot, kaolin acts to decrease the clotting time to reduce blood loss (exsanguination). The rise of hemostatic agents like QuikClot have arisen due to the inability of tourniquets to stop bleeding.

Kaolin has been used for testing for lupus anticoagulants, and is very sensitive to heparin, a blood thinner. [3] It is an aluminum silicate that has an unknown mechanism of action, but acts through a contact-activation pathway for clotting (contrasting the extrinsic tissue factor pathway that we know, that cleaves prothrombin into thrombin in a clotting cascade). [4] Addition of kaolin has been shown to activate clotting, which is why it has been used in QuikClot.

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Figure 3: Tourniquets can be made and used very easily in any setting to reduce bleeding. However, hemostatic agents found their home when some injuries were unable to be stopped by a tourniquet and gauze alone. [5]
For the EMT-B, normal procedure is to apply pressure to wounds with gauze that aren’t over an aiway to reduce bleeding and to prevent patients from entering shock (the loss of too much blood). However, in the case that the bleeding continues, even with applied pressure, a tourniquet is indicated for use above the point of injury. The tourniquet somewhat restricts blood flow (which is why nurses apply a tourniquet to your arm when they draw blood- to distend your veins).

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Figure 4: This is normal gauze, currently used in many regions for EMS. Refer to Figure 2 for QuickClot comparison

Originally, use of the tourniquet derived from military practices, before eventually trickling into civilian use. Like the shift in paradigm that brought tourniquets into normal use, hemostatic agents have been adopted by EMS agencies due to its efficacy at stopping clotting on the battlefield. [6] Retroactive studies have been analyzed to determine whether the hemostatic agents were not only indicated, but proved more effective What the results showed proved hemostatic agents to be conclusively more effective gauze.

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Figure 5: The main points of interest are the CT (clotting time), reduced by use of the hemostatic agent, and the MCF (maximum clot firmness). The alpha angle is essentially the derivative of the graph (want it to be higher) that represents the rate of at which the clot forms. [7]
Unfortunately, non-compressible hemorrhages (essentially the chest, abdomen, pelvis, and back) have been shown to be the leading cause of potentially survivable deaths on the battlefield. [8] However, hemostatic agents, which have not been fully adopted into civilian use, have been shown to be able to begin to treat exsanguination. While not a replacement for volume loss of blood, (refer to my last article here: Vampires and Blood Drawing Guidelines) reducing bleeding is critical to saving lives.

Problematically, the prohibitive cost of QuikClot may be part of the reason why it has not been implemented into widespread use. However, given the effectiveness of hemostatic agents like it, there should be no reason that widespread adoption of hemostatic agents in the near future will not take off. In the future, I hope that mysteries like the mechanism of action for coagulation due to kaolin may be researched so we can save the lives of our soldiers in war.

Your friendly resident vampire,

Joseph Maa

p.s. If anybody knows html well enough that they can fix the line spacing after images, I would love to know how to keep the text consistent. Cheers!

 

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