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Thread: Tourniquets and quick clot 2019

  1. #11
    10.3" Master Race TGS's Avatar
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    Quote Originally Posted by Nephrology View Post
    All great info. Only thing I'd add is that the evidence for the utility of QuikClot/other hemostatic agents in the prehospital management of external hemorrhage isn't exactly resounding. It might be helpful, but debatable how much it adds vs. traditional gauze dressing. See here for more. It's unlikely to be harmful, though, so if you don't mind paying the premium over regular gauze then go for it.
    That article is confusing as fuck, because for many recommendations to the panel, the panel says it's a weak recommendation with no evidence but then goes on to recommend the same thing.

    In addition, that article doesn't specify how long the bleed is allowed to continue before the hemostatic agent is applied. When applied soonest, there's negligible difference in studies. After the 2 minute mark is where hemostatic agents really shine compared to standard gauze, as the platelet level is very low and the blood has very limited clotting ability.

    I'm trying to find that study. It was posted here a few years ago.

    ETA: I don't think this is it as the conditions on the subjects were even more severe, but nonetheless displays the difference in effectiveness with a coagulopathic patient: Causey MW. The efficacy of Combat Gauze in extreme physiologic conditions, J of Surg Res, 2012 July: doi: 10.1016/j.jss.2012.06.020

    Quote Originally Posted by EMSWorld.com Synopsis
    In the animal model study, researchers at the Department of Surgery at Madigan Health Systems used an established and validated ischemia-reperfusion swine model to produce clinically significant metabolic acidosis and dilutional coagulopathy, which are primary conditions associated with hemorrhagic shock. Subjects experienced a 35% blood volume loss and maintained significant metabolic acidosis and dilutional coagulopathy for six hours and 50 minutes. They then incurred a femoral artery injury and bled for two minutes before randomized treatment with either Combat Gauze® or standard gauze. A single application of Combat Gauze® was able to stop bleeding in 89% of subjects. Following a second round of treatment, Combat Gauze® was able to successfully stop bleeding in 100% of subjects. Treatment with standard gauze in the same model showed a 100% failure rate after the first application, and resulted in only one case of successful hemostasis after a second application.
    Last edited by TGS; 02-06-2019 at 02:47 PM.
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  2. #12
    TANSTAAFL awp_101's Avatar
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    Thanks for the information and suggestions so far!

    I plan on getting additional training. All my hands on training other than CPR is 20 years old so I guess it's time.

    SeriousStudent, I'm next door to you in the Mid-Cities. The oldest boy and his family are moving back to the area next month so once they get settled I'm sure he'll want to hit a class as well. I'll probably try and make it a family trip and take both boys.
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  3. #13
    Quote Originally Posted by TGS View Post
    That article is confusing as fuck, because for many recommendations to the panel, the panel says it's a weak recommendation with no evidence but then goes on to recommend the same thing.

    In addition, that article doesn't specify how long the bleed is allowed to continue before the hemostatic agent is applied. When applied soonest, there's negligible difference in studies. After the 2 minute mark is where hemostatic agents really shine compared to standard gauze, as the platelet level is very low and the blood has very limited clotting ability.

    I'm trying to find that study. It was posted here a few years ago.

    ETA: I don't think this is it as the conditions on the subjects were even more severe, but nonetheless displays the difference in effectiveness with a coagulopathic patient: Causey MW. The efficacy of Combat Gauze in extreme physiologic conditions, J of Surg Res, 2012 July: doi: 10.1016/j.jss.2012.06.020
    That format is actually common for clinical guidelines. Basically, the committee/governing body does a literature review to gather evidence and then make a recommendation based on what they find. However, they grade the strength/quality of the evidence for/against a recommendation (often on an A-C scale) to give contextual qualification. This is important for a clinician's medical decision making: recommendations for a risky intervention (like surgery) needs good evidence to back it up.

    Re: hemostatic agents, basically what they said is that while the clinical studies out there are are of relatively low quality and strength (vs something like the Framingham Heart Study), the low risks associated with using hemostatic agent make the committee comfortable in recommending its use despite the weak evidence for its efficacy. Here's what they say about the evidence they found:

    The risk of bias associated with these
    studies is high because they are all single-arm studies
    with no comparison group. Sufficient data were not
    available to provide an estimate of survival rates or
    amputation rates in patients treated with hemostatic
    dressings. The overall strength of evidence for Key
    Question 6 was graded as Low using the GRADE
    system.
    I do think you have a point that a patient who is anticoagulated might benefit from chemical hemostatics more than otherwise healthy individuals, but I'm not sure if that's a conclusion I'd draw from this article with confidence. Conclusions drawn from a pig model of traumatic coagulopathy are a little less obviously applicable to average pre-hospital patient with penetrating trauma in domestic America.

    Specific limitations: Small sample size study with a fairly artificial arterial injury model (no TQ used, for example) and their measure of hemostatic success is pretty subjective. Very unsure what to make of their TEG, too. They also use the Student's T-test to evaluate stastistical significance which is patently inappropriate (no correction for paired testing, multiple comparisons, parametricity, etc). Just my 0.02USD
    Last edited by Nephrology; 02-06-2019 at 04:04 PM.

  4. #14

  5. #15
    10.3" Master Race TGS's Avatar
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    Quote Originally Posted by Nephrology View Post
    Conclusions drawn from a pig model of traumatic coagulopathy are a little less obviously applicable to average pre-hospital patient with penetrating trauma in domestic America.
    Why?

    The average domestic, pre-hospital patient requiring wound packing is going to have been bleeding well over two minutes by time that particular intervention is given, even if there's help with you when the incident occurs. Much, much longer if care is first delivered by an EMS response. They're probably going to be suffering some amount of coagulopathy.

    That's perfectly applicable, in my mind.

    Quote Originally Posted by Nephrology View Post
    their measure of hemostatic success is pretty subjective.
    How objective does it really need to be for us to draw obvious, reasonable conclusions?

    Is it still bleeding or no? It's not that complicated.

    I'd love for it to be bombproof and all, but caveat emptor analysis paralysis. "At some point we have to kill the engineers for progress to occur," all that.

    Quote Originally Posted by Nephrology View Post
    a fairly artificial arterial injury model (no TQ used, for example)
    Isn't that the point?

    To test the hemostatic gauze on its own as its calling card is primarily for junctional wounds where a TQ doesn't work? Not to mention introducing a TQ into the test would add another variable, undermining the results of the hemostatic gauze.

    As for the article you shared, it's also very limited. They only included a few studies to draw their conclusion, excluding even the study I posted where there's a pretty dramatic difference. On purpose? IDK......but let's consider it's also a poorly researched study that thinks they know better than CoTCCC who wrote the book on this stuff and have spent decades, not just a hot minute, determining best practices.
    Last edited by TGS; 02-06-2019 at 04:20 PM.
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  6. #16
    Quote Originally Posted by TGS View Post
    Why?

    The average domestic, pre-hospital patient requiring wound packing is going to have been bleeding well over two minutes by time that particular intervention is given, even if there's help with you when the incident occurs. Much, much longer if care is first delivered by an EMS response. They're probably going to be suffering some amount of coagulopathy.

    That's perfectly applicable, in my mind.
    I base my opinion on their description of the model (emphasis mine):

    We used an established and validated ischemia-reperfusion swine model to produce a clinically significant metabolic (lactic) acidosis and dilutional coagulopathy [10] . The model achieves a profound and sustained lactic acidosis through the combination of a 35% blood volume (24.5 mL/kg) hemorrhage followed by a 50-min ischemic phase achieved with a supraceliac aortic cross-clamp. After reperfusion by release of the cross-clamp, the swine are then resuscitated (using epinephrine to maintain mean arterial pressure >40 mm Hg and intravenous normal saline to keep central venous pressure >4) for 6 h, providing an acidotic and coagulopathic swine model for testing. After our model setup, we ensured appropriate physiologic conditions through laboratory analysis (coagulation profile, arterial blood gas analysis, and serum lactic acid measurement) and proceeded with the hemostatic dressing testing.
    These pigs are very sick; not exactly a classic EMS patient. I am intimately aware and understanding of the limitations of animal models (I work with a mouse model of inhalation injury/ARDS - no models are perfect) but these pigs are in rough shape.

    Even in the setting of acute coagulopathy in the field, the benefit of hemostatic vs. regular gauze is relatively minor. Very sick patients have much bigger problems; IV access, time to ED/OR, IV fluid resuscitation, etc will be greater determinants of outcome. Sure, you can use it and it may be superior to standard gauze, but it won't save your ass.

    Anecdotally, the coagulated patient I had with a big forehead bump/lac didn't respond at all to hemostatic dressing, even after I threw a figure 8 on a small arterial bleeder and put in a couple of deeps to bring the subQ tissue together. Had to apply pressure on his head for 45 minutes, during which he vasovagal'd on me and I thought he died, lol. Got to hit the code button.

    Quote Originally Posted by TGS View Post
    How objective does it really need to be for us to draw obvious, reasonable conclusions?

    Is it still bleeding or no? It's not that complicated.

    I'd love for it to be bombproof and all, but caveat emptor analysis paralysis. "At some point we have to kill the engineers for progress to occur," all that.
    Uh, it's actually not quite as black and white as you think. Also part of my objection to the article.

    Here is how the authors defined their endpoint for hemostasis:

    After applying the topical hemostatic dressing for 2 min, we observed the injured femoral artery for 5 min to assess for rebleeding. If bleeding recurred during this observational period, we removed the hemostatic dressing, took out the failed agent, and repeated the hemostatic process once using the same technique. The study end point was either hemostasis or 2 failed attempts at hemostasis.
    So, they apply dressing and pressure for 2 minutes, remove for 5 minutes, observe for bleeding. If bleeding, do this again. If it bleeds again, failure.

    I don't know about you, but I cannot envision a pre-hospital scenario in which pressure is applied at such intervals, nor do I think a study designed in this fashion really tells me very much at all.


    Isn't that the point?

    To test the hemostatic gauze on its own as its calling card is primarily for junctional wounds where a TQ doesn't work? Not to mention introducing a TQ into the test would add another variable, undermining the results of the hemostatic gauze.
    See above; even if it was a junctional bleed, I don't think the article you linked really tells me anything about how useful hemostatic gauze is vs. standard gauze.

    re: confounders; they can easily expand into other groups: TQ + standard gauze (SG); TQ + hemostatic gauze (HG); SG only; HG only; negative control. Costs more, sure, but it's not at all a ridiculous suggestion.


    As for the article you shared, it's also very limited. They only included a few studies to draw their conclusion, excluding even the study I posted where there's a pretty dramatic difference. On purpose? IDK......but let's consider it's also a poorly researched study that thinks they know better than CoTCCC who wrote the book on this stuff and have spent decades, not just a hot minute, determining best practices.
    ...The PDF I linked are the most recent (I believe) recs from the American College of Surgeons Committee on Trauma (ASCOT). Frank Butler (Chair of the CoTCCC) is an author. Their positions are not inconsistent. In fact, that text of PDF is basically identical to guidelines by the NHTSA, who had similar complaints about the available data (but also endorse their use anyway):

    Key Points
    • No studies identified for this report provided a direct comparison of hemostatic dressings
    with or without external wound pressure to non-hemostatic gauze with or without
    external wound pressure for the prehospital treatment of trauma patients with extremity
    hemorrhage.
    • Only one study, Lairet et al.,
    44 reported on survival in patients treated with hemostatic
    dressings (Table 15). While the study reported that hemostatic dressings were life-saving,
    it did not specify what dressings were used.
    • The primary outcome reported in five studies was the ability of the hemostatic dressings
    to stop bleeding.
    • Most studies reported no complications or adverse events (Table 16). However, QuikClot
    granules were associated with pain and discomfort from the exothermic reaction.

    [...]

    Strength of Evidence
    The risk of bias associated with these studies is high because they are all single-arm studies
    with no comparison group. Sufficient data were not available to provide an estimate of survival
    rates or amputation rates in patients treated with hemostatic dressings. The overall strength of
    evidence for Key Question 6 was assessed using the GRADE system.40-42 The results are
    reported in Table 17. Because all studies lacked comparison groups, we downgraded by one
    point for study limitations61 and assessed the strength of the evidence as Very Low
    A total of 15 articles were reviewed to establish their position (p169) on hemostatic agents (participant n = ~2000); more than a few, on par with the # used by TCCC to establish their (similar) guidelines (pS42).

    TLDR: hemostatic gauze may be better then standard gauze but the evidence for this conclusion is weak, and the benefit likely to be incremental vs. standard gauze. I think there are other new-ish technologies that are a lot more impactful for professionals (like the EZ-IO, use of ketamine for prehospital sedation/chemical restraint); similarly, for the non-professional first responder, the incremental advantage of hemostatic gauze will be less significant than solid first aid/CPR fundamentals and getting them to a hospital ASAP.

  7. #17
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    I try to always carry a SWAT-T and a Quickclot combat gauze. It's not much bigger than a wallet. SWAT-T isn't nearly as good as a CAT or SOFF-T, especially for one handed use, but it gives a lot more options than a regular tourniquet.

    Edited: I try to carry the Combat Gauze, the SWAT-T is always with me.
    Last edited by txdpd; 02-06-2019 at 07:24 PM.
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  8. #18
    10.3" Master Race TGS's Avatar
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    Quote Originally Posted by Nephrology View Post
    I base my opinion on their description of the model (emphasis mine):



    These pigs are very sick; not exactly a classic EMS patient. I am intimately aware and understanding of the limitations of animal models (I work with a mouse model of inhalation injury/ARDS - no models are perfect) but these pigs are in rough shape.

    Even in the setting of acute coagulopathy in the field, the benefit of hemostatic vs. regular gauze is relatively minor. Very sick patients have much bigger problems; IV access, time to ED/OR, IV fluid resuscitation, etc will be greater determinants of outcome. Sure, you can use it and it may be superior to standard gauze, but it won't save your ass.

    Anecdotally, the coagulated patient I had with a big forehead bump/lac didn't respond at all to hemostatic dressing, even after I threw a figure 8 on a small arterial bleeder and put in a couple of deeps to bring the subQ tissue together. Had to apply pressure on his head for 45 minutes, during which he vasovagal'd on me and I thought he died, lol. Got to hit the code button.



    Uh, it's actually not quite as black and white as you think. Also part of my objection to the article.

    Here is how the authors defined their endpoint for hemostasis:



    So, they apply dressing and pressure for 2 minutes, remove for 5 minutes, observe for bleeding. If bleeding, do this again. If it bleeds again, failure.

    I don't know about you, but I cannot envision a pre-hospital scenario in which pressure is applied at such intervals, nor do I think a study designed in this fashion really tells me very much at all.



    See above; even if it was a junctional bleed, I don't think the article you linked really tells me anything about how useful hemostatic gauze is vs. standard gauze.

    re: confounders; they can easily expand into other groups: TQ + standard gauze (SG); TQ + hemostatic gauze (HG); SG only; HG only; negative control. Costs more, sure, but it's not at all a ridiculous suggestion.



    ...The PDF I linked are the most recent (I believe) recs from the American College of Surgeons Committee on Trauma (ASCOT). Frank Butler (Chair of the CoTCCC) is an author. Their positions are not inconsistent. In fact, that text of PDF is basically identical to guidelines by the NHTSA, who had similar complaints about the available data (but also endorse their use anyway):



    A total of 15 articles were reviewed to establish their position (p169) on hemostatic agents (participant n = ~2000); more than a few, on par with the # used by TCCC to establish their (similar) guidelines (pS42).

    TLDR: hemostatic gauze may be better then standard gauze but the evidence for this conclusion is weak, and the benefit likely to be incremental vs. standard gauze. I think there are other new-ish technologies that are a lot more impactful for professionals (like the EZ-IO, use of ketamine for prehospital sedation/chemical restraint); similarly, for the non-professional first responder, the incremental advantage of hemostatic gauze will be less significant than solid first aid/CPR fundamentals and getting them to a hospital ASAP.

    Wait, wait, wait...…

    Okay, I need to go to PM because this is going way OT.

    This is making me laugh.
    "Are you ready? Okay. Let's roll."- Last words of Todd Beamer

  9. #19
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    Last month I took an IFAK course with Independence Training because I knew my chest seals and Quikclots were expired for several years -- since 2012 -- and then I thought I probably should get some refresher because the last CLS/TCCC thing I did was just as old.

    I like the SOFTT-W because it flat packs better in my ankle kit, but for me nothing beats the CATs for self-application with one hand only. The SOFTT-W works best in that situation if you position your body so that the windlass/wide portion is pinned against the nearest surface while you pull/tighten the strap.

    I have a couple older CATs (gen 3) and SOFTTs I don't mind sending you if you don't mind PMing me a shipping address. The older SOFTTs are easier to get on one-handed than the W's since it uses a clamp instead of a buckle, but the tension screw might get in the way of tightening the strap depending on how it's staged.

  10. #20
    Site Supporter Olim9's Avatar
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    Quote Originally Posted by Yung View Post
    I like the SOFTT-W because it flat packs better in my ankle kit, but for me nothing beats the CATs for self-application with one hand only.
    I gave up carrying SOFTTW’s and got the CAT for this exact reason. I’m excited for the new SOFTTW since it looks like it will be easier to get on one handed. I emailed Tacmed for an ETA on the new design and it’s going to be a few weeks with no particular set date.

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