Posted: 3/24/2019 12:11:21 PM EDT
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I couldn't find the medical forum, so this is a repost, which probably goes against a rule. Hemostatic dressings and junctional tourniquets are still new to a lot of folks. I provide the following three studies on the use of hemostatic dressings and JTQs. For hemostatics, I offer this: Hemostatic dressings have been through several improvements over the years. The first HemCon dressing and QuickClot granules has many issues. Currently, there are three main hemostatic dressings. QuikClot® Combat Gauze® which is kaolin based, Celox™? Gauze and HemCon™? ChitoGauze ® are chitosan based. There have been many animal studies and now a good number of studies in humans. From Iraq and Afghanistan, there are two retrospective studies from the prehospital setting. There was no survival benefit, but the cax who has a hemostatic dressing applied, tended to be more severely injured. They also had more TQs, analgesia, hypothermia prevention, and abx. They had lower mean hematocrits, platelet counts in the ED. The mean INR in the ED was significantly higher in the hemostatic recipients along with a worse mean base deficit. Overall, PRBCs, FFP, PLTs, and Cryo use were higher in those requiring hemostatic dressings. Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JRD, Antonacci MA. QuikClot™ Combat Gauze Use by Ground Forces in Afghanistan. J Spec Oper Med. 2017;17(2):100-5 Schauer SG, April MD, Naylor JF, Maddry JK, Arana AA, Dubick MA, Fisher AD, Cunningham CW, Pusateri AE. Prehospital Application of Hemostatic Agents in Iraq and Afghanistan. Prehospital Emergency Care. 2018:1-10. For junctional tourniquets, there is this: Junctional TQs came on the scene about 10 years ago. It wasn’t a new concept, the first to be picked up by the DoD was the Combat Ready Clamp (CRoC). It was based off of models from the 1800s. The models evaluated were the CRoC, SAM Junctional Tourniquet (SJT), Junctional Emergency Treatment Tool (JETT), and the Abdominal Aortic Junction Tourniquet (AAJT). There’re only a few human studies on Junctional TQs. When we published our data from the PHTR, there were 13 uses. The average effectiveness was 52% for the abdominal application and 100% for the AAJT. The average time to application of 92 and 171 seconds. JETT was 83% with average time to application of 130 seconds. SJT was 87% with average time to application of 101 seconds. CRoC was 95% with average time to application of 101 seconds. It was only effective 52% in healthy volunteers for aortic compression. A couple things, I’m a little surprised the CRoC could be applied faster than the JETT. The JETT isn’t the easiest to use, but anyone who’s messed with the CRoC, knows it take a bit. Two, while it is extremely effective, the CRoC hurts even when applied properly. Which makes be wonder if this could be applied properly as quickly in combat. Finally, the AAJT applied over the abdomen has a 50% mortality in animal studies at two hours. The authors state: “We would suggest that the moment a junctional tourniquet is applied, the patient should be urgently evacuated to an operating room, and that the junctional tourniquet should be removed only when a surgeon is able to obtain proximal control.” Seems like, a great idea, but combat doesn’t always allow for the urgent evacuation. Also, I believe there may be times when it is appropriate to take down a junctional TQ. They failed to discuss the case series from AFG, but it’s possible they had already submitted by the time it was published. Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney J. Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience. J Spec Oper Med. 2018;18(2):71-4. Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2019;86(3):532-9. Attached File Attached File Attached File Attached File |