Do We Need Combat Gauze?

wound packing

There has been an ongoing discussion in the local tactical medicine community regarding the results of some of the research on hemostatic gauze, with the takeaway point being the position that wound packing with standard gauze is as effective as packing with combat gauze and other hemostatic agents for hemorrhage control.

This position seems to be based on this study from 2011 that compares Celox gauze (which specific product is unclear), Combat Gauze, and standard gauze in a “no hold” model of porcine blood loss (i.e., with no pressure applied following initial wound packing).  The study was designed this way in an attempt to more realistically model care under fire scenarios in which it may not be possible to apply a pressure dressing or hold direct pressure while the patient is moved to a more hospitable environment. It must be noted that this is contrary to the manufacturer’s instructions (and standard TEMS instruction via PHTLS, TCCC, etc) which stress the importance of direct pressure applied after the wound has been packed. While this study draws the conclusion that “advanced hemostatic dressings do not perform better than conventional gauze in an injury and application model similar to a care under fire scenario,” the results actually show that Celox gauze had a shorter time to clot than both Combat Gauze and standard gauze.

I have a problem with this study design. I think it extremely unlikely as a civilian paramedic, even in the tactical/special operations setting, that I will find myself in a scenario where I am able to pack a wound but subsequently unable to apply pressure  in the form of manual pressure, a pressure dressing, or both. The “no hold” model is largely irrelevant in my operational environment.

More likely is a scenario where I am able to apply the product per the instructions and the standard of care, to include the application of direct pressure, and subsequently need to move the patient, administer fluids, or both. A 2012 study closely approximates this scenario:

Swine were randomly assigned to either the QCG () or the control group (). Investigators transected the femoral artery and vein in each swine. After one minute of uncontrolled hemorrhage, the hemostatic agent, QCG, was placed into the wound followed by standard wound packing. The control group underwent the same procedures but without a hemostatic agent. After five minutes of direct pressure, a standard pressure dressing was applied. After 30 minutes, dressings were removed, and the wound was observed for rebleeding for 5 minutes. If hemostasis occurred, 5 liters of crystalloid was given over 5 minutes, and the wound was observed for rebleeding for 5 additional minutes. If no bleeding occurred, the extremity on the side of the injury was moved.

The results of this study:

The amount of bleeding in the QCG group ranged from 0 to 514 mL; control group ranged from 0 to 1002 mL. The amount of resuscitation fluid in the QCG group ranged from 3000 to 5000 mL; the control group ranged from 0 to 3000 mL. The number of movements for the QCG group ranged from 3 to 40, and for control group it ranged from 0 to 9.

If we do insist on the “no hold” model, a more recent study from May of this year found Celox Rapid Gauze superior to both standard gauze and combat gauze in application time and blood loss.

Based on the most recent research, it is clear that modern hemostatic dressings are vastly superior to standard gauze for hemorrhage control, and the suggestion that standard gauze is equivalent is grossly misinformed. While Celox Rapid Gauze was not included in the study which replicates what I consider to be realistic conditions, the 2013 “no hold” study indicates that it may be a superior choice to Combat Gauze.

It is worth mention that in the absence of hemostatic agents, wound packing with standard gauze is a viable alternative and is superior to pressure alone. To my knowledge, this technique is still not being taught in conventional EMS education.

For those seeking a more in depth discussion and comparison of other hemostatic dressings, see this study conducted by the Navy in 2012.

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