Topical Hemostatic Agent

Aka: Topical Hemostatic Agent, Hemostatic Agents

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II. Mechanism

  1. Topical Hemostatic Agents

III. Indications

  1. Significant Bleeding
    1. Indicated for rapid non-extremity bleeding not controlled with direct manual pressure

IV. Precautions

  1. Newer agents (Chitosan, Zeolite and mineral dressings) are not widely available
    1. Primarily found in military and large Trauma Centers as of 2013
  2. Risk of wound contamination with hemostatic agent (may require later Debridement)

V. Preparations: Agent Types

  1. Factor Concentrators (drying agents)
    1. Effective for low pressure, venous bleeding
    2. Zeolite Mineral Dressing (QuickClot)
    3. Mineral Dressing with Impregnated Kaolin
  2. Mucoadherents (gluing agents)
    1. Chitosan Dressing (HemeCon, Celox Gauze, ChitoGauze)
    2. Gelatin Hemostatic Agent (Gelfoam, Surgifoam)
    3. Regenerated Oxidized Cellulose (Surgicel)
    4. Tissue Adhesive (Skin Glue, Dermabond, Cyanoacrylate Tissue Adhesive)
  3. Procoagulants
    1. Combat Gauze (Mineral Dressing with Impregnated Kaolin)
    2. Topical Thrombin in Gelatin (Floseal)

VI. Preparations: Approach

  1. Minor bleeding
    1. Aluminum Chloride (e.g. Drysol, Xerac)
    2. Ferric Subsulfate (e.g. Monsel's Solution, AstrinGen)
    3. Silver Nitrate
    4. Gelatin Hemostatic Agent (Gelfoam, Surgifoam)
    5. Regenerated Oxidized Cellulose (Surgicel)
    6. Thrombin
  2. Significant bleeding (newer heomstatic agents, typically for bleeding at sites where Tourniquets cannot be used)
    1. Chitosan Dressing
    2. Zeolite Mineral Dressing
    3. Mineral Dressing with Impregnated Kaolin

VII. Preparations: Aluminum Chloride (e.g. Drysol, Xerac)

  1. Indications
    1. Hemostasis of minor bleeding typically following skin procedures (e.g. Shave Biopsy)
  2. Mechanism
    1. Hydrolyzes to form hydrogen chloride which has hemostatic and Vasoconstrictive properties
  3. Adverse Effects
    1. Local Paresthesias at application site

VIII. Preparations: Ferric Subsulfate (e.g. Monsel's Solution, AstrinGen)

  1. Indications
    1. Control of bleeding from small wounds on skin or mucosa (e.g. Colposcopy biopsy)
  2. Background
    1. One of the oldest Hemostatic Agents (described by Monsel in the 1850s)
  3. Mechanism
    1. Denatures and coagulates Proteins to form a membrane over small blood vessels
  4. Technique
    1. Clean bleeding site and apply local pressure
    2. Insert cotton swab into Monsel's Solution and stir to mix
    3. Apply cotton swab to bleeding site
  5. Adverse Effects
    1. May cause discoloration of tissue to which it has been applied

IX. Preparations: Silver Nitrate

  1. Indications
    1. Hemostatic agent for small wounds
  2. Mechanism
    1. Silver Nitrate sticks applied to small bleeding sites release silver that binds tissue Proteins
    2. Bound Protein precipitates into a black eschar that obstructs small blood vessels
  3. Technique
    1. Clean bleeding site and apply local pressure
    2. Apply Silver Nitrate stick to bleeding site
  4. Adverse Effects
    1. Exercise care to avoid Tattooing (e.g. on face) and to avoid local spread and damage to adjacent tissue

X. Preparations: Gelatin (Gelfoam, Surgifoam)

  1. Indications
    1. Small vessel bleeding typically from bone
  2. Mechanism
    1. Gelatin based network traps Platelets and Clotting Factors, facilitating clotting
    2. Gelatin is absorbant, swelling and compressing small bleeding sites
  3. Technique
    1. Various forms may be applied to bleeding sites including plugging bleeding open wounds
  4. Adverse Effects
    1. Risk of local infection at application site

XI. Preparations: Regenerated Oxidized Cellulose (Surgicel)

  1. Indications
    1. Small vessel bleeding typically following surgical procedure
  2. Technique
    1. Absorbable Fabric cut to size and applied to bleeding site
    2. May not be used with Thrombin

XII. Preparations: Topical Thrombin

  1. Indications
    1. Control of minor bleeding (e.g. Tongue Laceration) in patients with prolonged INR (e.g. Warfarin)
    2. Used in combination with gelatins
  2. Mechanism
    1. Thrombin facilitates Fibrinogen conversion to Fibrin in the formation of clot
  3. Preparations
    1. Bovine-derived Thrombin (Thrombin-JMI)
      1. Contraindicated in cow allergies
    2. Human plasma-derived Thrombin (Evithrom)
    3. Recombinant human Thrombin (rhThrombin)

XIII. Preparations: Chitosan Dressing (HemeCon, Celox Gauze, ChitoGauze)

  1. Derived from Chitin is shellfish exoskeletons
  2. Mechanism
    1. Local Vasoconstriction
    2. Mobilizes Clotting Factors and Platelets
    3. Mechanical sealing
  3. Efficacy
    1. Stops bleeding in 97% of wounds not stopped with direct pressure
    2. However, bleeding restarts within 1 hour in up to 70% of cases (and nearly all arterial Hemorrhage)

XIV. Preparations: Zeolite Mineral Dressing (QuickClot)

  1. Mechanism
    1. Factor Concentrator
    2. Increases Clotting Factor and Platelet concentration at wound sites via water absorption
  2. Efficacy
    1. Stops bleeding in 92% of wounds not stopped with direct pressure
    2. Effective for low pressure, venous bleeding
  3. Adverse effects
    1. Prior formulation caused severe local burns (no longer an issue with newer bead formulations)

XV. Preparations: Mineral Dressing with Impregnated Kaolin

  1. Mechanism (similar to Zeolite Mineral Dressings)
    1. Factor Concentrator
    2. Increases Clotting Factor and Platelet concentration at wound sites via water absorption
  2. Efficacy
    1. Slower control of bleeding
    2. Significantly increased survival in animal models
  3. Advantages
    1. Available as gauze rolls (3 inch wide, 4 yard long) that are now primary hemostatic agent used on battlefield

XVI. References

  1. Berry in Schrage (2013) Topical Hemostatic Agents, Medscape Emedicine
  2. Kheirabadi (2011) US Army Med Dep J p. 25-37
  3. Mason, Spangler and Nichols (2016) EM:Rap 16(11): 10-11
  4. Peralta in Sanfrey (2013) Overview of Topical Hemostatic Agents and tissues adhesives used in the operating room, UpToDate, Wolters-Kluwer
  5. Swaminathan and van de Leuv (2013) Crit Dec in Emerg Med 27(8): 11-17
  6. Achneck (2010) Ann Surg 251(2):217-28 [PubMed]

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