Adjuncts to uncontrolled bleeding have been fielded for years. Research and development has expanded the options available for hemostatic agents that can allow for earlier control of hemorrhage and improve survival in the prehospital setting. Researchers focus on developing dressings which meet the following characteristics:

Based on preclinical data, many experts believe that QuikClot Combat Gauze (Z-Medica, Wallingford, CT) stands as the current standard of care for hemostatic dressings (Fig. 45.2). This flexible gauze made of rayon and polyester is impregnated with kaolin, an activator of the intrinsic clotting pathway. Hemostasis takes time to occur following the application of the dressing. As a result, wounds dressed with Combat Gauze should be manually compressed until active bleeding stops or at least 3 min.

New-generation dressings (e.g., Celox Gauze, MedTrade Products, Crewe, UK; Celox Trauma Gauze, MedTrade Products, Crewe UK; and ChitoGauze, HemCon, Portland, OR) have been developed and evaluated relative to Combat Gauze. Based on these studies, experts have concluded that these chitosan-based hemostatic agents are at least as effective as Combat Gauze in controlling severe bleeding. New TCCC recommendations support the use of Celox Gauze or ChitoGauze as acceptable substitutes for Combat Gauze in the management of external hemorrhage (see Fig. 45.2).

When dealing with penetrating injuries, visualization and identification of bleeding vessels may be challenging. Large cavities may be present but difficult to appreciate secondary to small entrance wounds—making packing of gauze into these wounds unpredictable. Given these obstacles, compressed hemostatic sponges have been developed. XStat (RevMedx, Wilsonville, OR; Fig. 45.3) is now recommended by the TCCC guidelines to control external hemorrhage from junctional bleeding sites that are poorly controlled with tourniquet application. XStat is devised to be used in gunshot or fragment injuries in which the entrance tract may be narrow, making it challenging to appropriately visualize bleeding vessels. Compressed, nonabsorbable mini-sponges coated with chitosan are housed within a lightweight syringe. Upon injection into the wound cavity, the mini-sponges contact blood and expand to greater than 15 times their original size, effectively increasing intracavitary pressure and eliminating the need to provide manual pressure on the site.

Preclinical data regarding the use of XStat versus traditional gauze has shown that the product is lighter to carry, is faster to apply, and provides a better ratio of pressure around wound cavities. Researchers have looked at the use of XStat-coated sponges in models of subclavian arterial and venous bleeding. These injuries are especially challenging to control as the clavicle overlies the vessels. In these models, all animals treated with the device survived, whereas survival for groups treated with standard gauze dressings only had survival rates of 38%.

While junctional and abdominal aortic tourniquets may provide control of iliac and femoral sources of bleeding, other options should be considered when bleeding sources are suspected to arise from higher in the torso. Resuscitative endovascular balloon occlusion of the aorta (REBOA ) for the management of central aortic and pelvic hemorrhage was first described in the mid-twentieth century. However, its clinical implementation has recently increased as endovascular techniques have improved. Balloon occlusion suppresses distal flow and hemorrhage and simultaneously increases cardiac afterload and aortic pressure, thereby increasing perfusion to the heart and brain. Moreover, when compared to traditional approaches such as resuscitative thoracotomy, REBOA has demonstrated a higher probability of survival and is obviously a less morbid and physiologically stressful intervention than an ED thoracotomy.

Arterial access is typically gained via femoral arterial cannulation (via either femoral cutdown, ultrasound guidance, or percutaneously without imaging). Following placement and balloon deployment, a variety of imaging studies (i.e., fluoroscopy, ultrasonography, and plain radiography) may be used to confirm appropriate placement of the balloon. If imaging is unavailable, then blind placement using measurements based on external landmarks has been shown to reliably place the balloon in the desired zone of the aorta in the majority of cases. When imaging studies are unavailable, deployment of the balloon should result in an immediate increase in systolic blood pressure that can serve as confirmation of proper placement. In a recent multicenter study, significantly more patients achieved hemodynamic stability when compared to open aortic occlusion techniques . Given these findings, REBOA stands as a viable option in the setting of noncompressible torso hemorrhage. That said, further studies will be necessary to determine the optimal indications for its use, the complication and adverse event profile, and improved device design to make placement easier and to potentially allow for controlled balloon deflation to allow partial restoration of flow prior to full balloon deflation.