Clot-inducing minerals versus plasma protein dressing for topical treatment of external bleeding in the presence of coagulopathy.
BACKGROUND
Previous studies identified WoundStat (WS, smectite) and Combat Gauze (CG, kaolin-coated gauze) as the most effective available agents for controlling arterial bleeding with potential utility in casualty care. Tissue sealant properties of WS suggested its potential advantage over clot-promoting CG for treating coagulopathic bleeding. This study compared the efficacy of CG and WS with a fibrinogen-based (FAST) dressing to control bleeding in coagulopathic animals.


METHODS
Coagulopathy was induced in pigs (n = 55, 35 kg) by ∼50% isovolemic hemodilution and hypothermia (core temperature, 33°C ± 0.5°C). A 6-mm arteriotomy was made in the femoral artery and free bleeding allowed for 30 seconds. A test agent (n = 13-15 per group) or control product (gauze, GZ, n = 12) was applied to the wounds and compressed with a Kerlix gauze for 2 minutes. Fluid resuscitation was given, titrated to a mean arterial pressure of 65 mm Hg. Animals were observed for 180 minutes or until death. Angiography using the computed tomography method was performed on survivors, and local tissues were collected for histology.


RESULTS
No differences were seen in baseline measures. Coagulopathy, confirmed by a 31% increase in prothrombin time and a 28% reduction in clotting strength (maximum amplitude, thrombelastography assay), was similar in all groups before injury. The average pretreatment blood loss was 11.9 mL/kg ± 0.4 mL/kg with no difference among groups. Posttreatment blood loss, however, was significantly different (p = 0.015) ranging from 18.2 mL/kg ± 8.8 mL/kg (FAST) to 63.3 mL/kg ± 10.2 mL/kg (GZ controls). Stable hemostasis was achieved in 10 of 13 (FAST), 5 of 15 (CG), 2 of 15 (WS), and 1 of 12 (GZ) animals in each group, resulting in significantly different survival rates (8-77%; p = 0.001). The average survival times were 145 (FAST), 119 (CG), 75 (WS), and 74 (GZ) minutes for different groups (p < 0.002). The outcomes with the FAST dressing were significantly better than with WS or GZ in this coagulopathic bleeding model. Essentially, no difference was found between WS and GZ control. Computed tomography images showed limited blood flow only through the vessels treated with FAST dressings. Histologic observations of the vessels indicated minimal damage with FAST and CG and greater injury with WS with some residues present on the tissues.


CONCLUSIONS
The tissue sealant property of WS is apparently mediated by clot formation in the wound; therefore, it was ineffective under coagulopathic conditions. CG was partially effective in maintaining blood pressure up to 1 hour after application. FAST dressing showed the highest efficacy because of the exogenous delivery of concentrated fibrinogen and thrombin to the wound, which bypasses coagulopathy and secures hemostasis.
Hemostasis Division, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA. bijan.kheirabadi@us.army.mil
Bijan Shams
BS
Kheirabadi
James E
JE
Mace
Irasema B
IB
Terrazas
Chriselda G
CG
Fedyk
Krystal K
KK
Valdez
Martin J
MJ
MacPhee
Dawson
D
Beall
J Scot
JS
Estep
Michael A
MA
Dubick
Lorne H
LH
Blackbourne
D000818:Animals; D001458:Bandages; D001778:Blood Coagulation Disorders / Q000097:blood / Q000150:complications*; D004195:Disease Models, Animal; D006470:Hemorrhage / Q000097:blood / Q000209:etiology / Q000628:therapy*; D008297:Male; D008903:Minerals / Q000008:administration & dosage*; D010952:Plasma Substitutes; D011517:Prothrombin Time; D012709:Serum Albumin / Q000008:administration & dosage*; D000075462:Serum Albumin, Human; D012712:Serum Globulins / Q000008:administration & dosage*; D013552:Swine; D013916:Thrombelastography; D014947:Wounds and Injuries / Q000097:blood / Q000150:complications* / Q000628:therapy
D008903:Minerals; D010952:Plasma Substitutes; D012709:Serum Albumin; D012712:Serum Globulins; C008930:plasma protein fraction; D000075462:Serum Albumin, Human