What is the most effective hemostatic gauze or powder for traumatic bleeding, and which option is preferred in patients with anticoagulant therapy, coagulopathy, platelet dysfunction, or shellfish allergy?

Best Hemostatic Gauze or Powder for Traumatic Bleeding

QuikClot Combat Gauze (kaolin-impregnated gauze) is the hemostatic dressing of choice for traumatic bleeding and should be carried as the first-line treatment for life-threatening hemorrhage. 1, 2

Primary Recommendation

Use topical hemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries. 1 The European guideline on management of major bleeding following trauma (2023) provides the most recent high-quality guidance, recommending hemostatic agents as adjuncts when access to bleeding sites is challenging. 1

Specific Agent Selection

First-Line: QuikClot Combat Gauze (Kaolin-Based)

• QuikClot Combat Gauze is recommended by the Committee on Tactical Combat Casualty Care as the hemostatic dressing of choice, replacing all previous agents including HemCon. 3, 2
• In head-to-head comparison, Combat Gauze achieved stable hemostasis in 80% of animals versus 20% with standard gauze in severe arterial hemorrhage models. 2
• Combat Gauze secured hemostasis for 134.6 minutes compared to 35.7 minutes with other agents, with significantly longer survival times (167.3 vs 90.0 minutes). 2
• The hemostatic property is attributed to its kaolin coating, large surface area (3 inch x 4 yard), and absorbent nonwoven Rayon/polyester blend material. 2
• No exothermic reaction, burns, or serious adverse events have been reported with Combat Gauze, unlike earlier QuikClot granular formulations. 4, 5
• Systematic review of 809 patients (469 military, 340 civilian) showed bleeding cessation rates of 67-100% with Combat Gauze, median 90.5%. 5

Alternative Agents (Second-Line)

Celox Gauze (chitosan-based):

• Achieved 90% survival rate in comparative studies, the highest among tested agents, though not statistically superior to Combat Gauze. 6
• Demonstrated immediate hemostasis in 70% of applications with average posttreatment blood loss of 29 mL/kg. 6

HemCon ChitoGauze (chitosan-based):

• Achieved 70% survival rate with immediate hemostasis in 60% of applications. 6
• Poly-N-acetyl-glucosamine (derived from chitin/shellfish) demonstrated hemorrhage control in 10 patients with severe hepatic injuries, acidosis, and clinical coagulopathy. 1

Agents to Avoid or Use with Caution

HemCon RTS and Celox-D:

• Testing was discontinued after six consecutive unsuccessful attempts at achieving hemostasis in standardized arterial hemorrhage models. 2

TraumaStat:

• Achieved only 20% survival rate with hemostasis lasting only 35.7 minutes, significantly inferior to Combat Gauze. 2

Special Population Considerations

Patients on Anticoagulants or with Coagulopathy

• All hemostatic dressings work through physical mechanisms (concentration of clotting factors, platelet activation) rather than requiring intact coagulation cascades. 1
• Kaolin-based agents (Combat Gauze) activate Factor XII and accelerate the intrinsic coagulation pathway, making them effective even in coagulopathic patients. 2
• Chitosan-based agents (Celox, HemCon) work by direct platelet activation and mucoadhesion, independent of coagulation factor levels. 1, 6

Patients with Platelet Dysfunction

• Collagen-based agents directly trigger platelet aggregation and may be combined with thrombin for enhanced effect. 1, 7
• Gelatin-based products work primarily through mechanical tamponade (swelling reduces blood flow) rather than platelet function, making them suitable for platelet dysfunction. 1

Patients with Shellfish Allergy

CRITICAL CONTRAINDICATION: Avoid all chitosan-based products (Celox, HemCon ChitoGauze) in patients with shellfish allergy, as chitosan is derived from crustacean shells. 1

Safe alternatives for shellfish allergy:

• Kaolin-based: QuikClot Combat Gauze (mineral-based, no shellfish components) 2
• Collagen-based agents (derived from bovine or porcine sources) 1
• Gelatin-based products (derived from animal collagen) 1
• Oxidized cellulose products (plant-derived) 1

Application Technique

Apply hemostatic gauze directly into the wound with firm, continuous pressure for 3 minutes minimum. 2, 6

Pack the gauze tightly into the wound cavity to achieve direct contact with the bleeding vessel. 1, 5

Do not remove the initial dressing if bleeding continues; apply additional layers on top. 5

Maintain pressure throughout transport until definitive surgical control can be achieved. 1, 8

Clinical Context and Limitations

• Hemostatic dressings are most effective for compressible hemorrhage in anatomically accessible locations (extremities, scalp, neck). 1, 5
• They serve as adjuncts to, not replacements for, direct pressure, tourniquets, and definitive surgical control. 1, 8
• For junctional hemorrhages (groin, axilla) where tourniquets cannot be applied, hemostatic gauze combined with targeted pressure is the primary prehospital intervention. 5
• Inorganic hemostatics (zeolite, smectite) are primarily studied for external bleeding and prehospital use, not for internal surgical applications. 1

Evidence Quality Assessment

The recommendation for Combat Gauze is based on multiple animal studies showing superiority in standardized hemorrhage models, extensive military field experience (420+ documented applications), and systematic review of 809 patients. 2, 5, 6 However, high-quality randomized controlled trials in humans are lacking, and all clinical evidence is rated "very low" to "moderate" quality. 5 Despite this limitation, the consistency of findings across multiple studies and real-world military experience supports Combat Gauze as the evidence-based first choice. 3, 2, 5