To Bleed Or Not To Bleed…
October 17, 2012
10 Comments
Many of us in the preparedness community are concerned with collapse scenarios that involve civil unrest. Suspension of the Rule of Law, such as in the aftermath of a major disaster (e.g., Hurricane Katrina), we have to be prepared for traumatic injuries from a society gone rogue. One of the most important medical supplies to have on hand in this circumstance would be those that stop bleeding. In studies of casualties in the recent wars, 50% of those killed in action died of blood loss. 25% died within the first “golden” hour after being wounded.
Therefore, the question we must pose is, to paraphrase Hamlet, “To bleed or NOT to bleed”. Ever since there have been traumatic injuries, we have been concerned with the death from hemorrhage. The Egyptians mixed wax, barley, and grease to apply to a bleeding wound. The Chinese and Greeks used herbs like bayberry, stinging nettle, yarrow, and others for the same purpose. Native Americans would apply scrapings from the inside of fresh animal hides mixed with hot sand and downy feathers. These treatments would sometimes save a life, sometimes not.
The control of major hemorrhage rightly belongs to the emergency physician, paramedic, and trauma surgeon, but what if you find yourself without access to modern medical care? You may find yourself to be the end of the line with regards to a loved one’s survival. Although the thought of dealing with trauma yourself may be unpleasant, the issue cannot be ignored. You will have to learn to function as a survival medic if you want to keep it together, when things fall apart.
In the last decade or so, there have been advancements in clotting agents (also known as “hemostatic agents”) that give us an additional tool for the medical woodshed. Knowledge of their appropriate use in an emergency will increase the injured patient’s chance of survival.
Although there are various types of hemostatic agents on the market for medical storage, the two most popular are Quikclot and Celox. They are two different substances that are both available in a powder or powder-impregnated gauze.
Quikclot originally contained a volcanic mineral known as zeolite, which effectively clotted bleeding wounds but also caused a reaction that burned the patient and, sometimes, the medic. As a result, the main ingredient was replaced with another substance that does not burn when it comes in contact with blood..
The current generation of Quikclot is made from Kaolin, the same stuff you find in Kaopectate and is so common that it is said to be what makes Georgia clay red. It does not contain animal, human, or botanical components.
Contact between kaolin and blood immediately initiates the clotting process by activating Factor XII, a major player in hemostasis. The powder or impregnated gauze is applied and pressure placed on the wound for several minutes. Quikclot is FDA-approved and widely available; the gauze dressing is easier to deal with than the powder, but can be relatively expensive. Quikclot has a shelf life of 3 years or so, less if the packages are left out in the sun.
One negative with Quikclot is that it does not absorb into the body and, some believe, can be difficult to remove from the wound. This was certainly true of previous generations but it is claimed to no longer be as big an issue, especially if you use the gauze dressing. Use an irrigation syringe to flush the wound after the gauze is removed. If more than one gauze is required, don’t remove the first one: Place the second gauze on top.
In the The Journal of TRAUMA® Injury, Infection, and Critical Care , (Volume 68, Number 2, February 2010), the kaolin gauze was found to be as safe as standard surgical gauze.
Celox is the other popular hemostatic agent, and it is composed of chitosan, an organic material taken from purified shrimp shells. As such, those allergic to seafood could possibly have a reaction to Celox. This “powder” product is actually made up of high surface area flakes. When these tiny flakes come in contact with blood, they bond with it and form a clot that appears as a gel. Like Quikclot, it also comes in impregnated gauze dressings, which are, again, relatively expensive.
Celox will cause effective clotting even in those on anti-coagulants like Heparin, Warfarin or Coumadin without further depleting clotting factors. Chitosan, being an organic material, is gradually broken down by the body’s natural enzymes into other substances normally found there. Like Quikclot, Celox is FDA-approved. This study by the U.S. government compares Celox favorably to some other hemostatic agents: http://www.ncbi.nlm.nih.gov/pubmed/18211317
Both Quikclot and Celox gauze dressings have been tested by the U.S. and U.K. military and have been put to good use in Iraq and Afghanistan. To see both of these items in action, go to YouTube: “Celox demonstration” and “Quikclot demonstration”.
Although effective, you shouldn’t use these items as a first line of treatment in a bleeding patient. Pressure, elevation of a bleeding extremity above the heart, gauze packing and tourniquets should be your strategy here. If these measures fail, however, you have an effective extra step towards stopping that hemorrhage. Be sure to include one or both in your medical supplies.
For more info on treating hemorrhagic wounds, see our article: “Treating The Hemorrhagic Wound”
Dr. Bones
Celox FAQ:
http://www.celoxmedical.com/tech_faq.htm
Quikclot FAQ:
http://www.z-medica.com/healthcare/How-QuikClot-Works/FAQs.aspx
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Thank you. Great information.
I always know where to go to get more information on first aid and more ideas on what I can add to my first aid kit. You and your wife are awesome!
For smaller uncontrolled bleeding what abou 4×8 surgicel?
I have frequently used surgicel intra-operatively and have no doubt it will have some effect. In my experience, however, it doesn’t stop the major hemorrhages, more the constant oozing you see from raw, damaged tissue.
I disagree with your statement, “The control of major hemorrhage rightly belongs to the emergency physician, paramedic, and trauma surgeon…” The control of major hemorrhage has to happen immediately, if you wait the 8-10 minutes for the ambulance to arrive it’ll likely be too late, not to mention the 20-30 minutes before you arrive in an emergency room.
Everyone must learn the basics of controlling bleeding, especially a major hemorrhage. And this is not only for after a collapse–when there is no medical assistance available–but now, because if you wait for medical assistance it may be too late.
Good write up on comparing the two hemostatic agents. I have QuikClot in our kits. I’ve never used it, but have heard good reports from friends in the military.
You’re certainly right, Trace. I meant to say that once medical professionals are on the scene, they should be in charge. Everyone should know how to deal with bleeding emergencies. Check out “Treating the Hemorrhagic Wound” by using the seqarch engine on the uppoer right of this page. Also, check out Trace’s website “tracemypreps.com!
I am a paramedic and dislike hemostatic agents in the field in none combat operations. When Quickclot first became widely available, every volunteer first responder out there felt they needed to stock their go bag with the stuff. Even though Quickclots free training material and instruction state that is is a tool of last resort when a tourniquet cannot be used. (IIRC a few deaths were caused when the clotting agents caused PE). None the less, I saw it used time and time again on would that bleeding could have been controlled easily with a less invasive method, like simple direct pressure. Thankfully, that fad is over.
I have not taken the time to look into the newer version of quickclot, and it may indeed be a better product, but with the expense and limited shelf life and limited real world usefulness. Perhaps the single most damning thing I can say is that in my years as a paramedic, I have party to a large amount and wide variety of trauma, and never once have I had a situation that a hemostatic agent would have been helpful and we have never had a serious consideration of adding any to the stock of out ambulances. I have no doubt that Quickclot has saved lived, especially in combat. Wounds you can expect on a regular basis, especially blast wounds, are just not common in the non military emergency setting.
Furthermore, in an scenario where you cannot get to medical care and you are then the de facto definitive care, what do we do next. My upstanding is that is is a surgical procedure to remove the agent (at least the older versions).
Simple direct pressure is much more effective than people realize.The next step on an extremity is a tourniquet. Pressure points and elevation are not effective and are no longer taught in the pre hospital setting
That of course is just my$0.02. YMMV
Thank yall for what yall do.
Although the 3rd generation Quikclot (in which the main ingredient was replaced with Kaolin) does not cause exothermic reactions, it is still messy to remove. Celox is less so, as the gel-like clot is absorbed over time.
Everything you state regarding dealing with the hemorrhagic wound is correct, as I mention in the last paragraph and in my article on treating the hemorrhagic wound (see link last sentence of article). Direct pressure, judicious use of tourniquets, and appropriate application of dressings are the mainstays. Despite this, it is worthwhile to keep Celox or Quikclot as part of your “grid-down” long term survival supplies. A WROL situation could put you, as medic, in the position of dealing with injuries quite similar to battlefield wounds. Let’s hope it never gets to that.
Thanks for your input…
Dr. Bones
Amazing…