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Hemostatic Dressings

Question Type:
Intervention
Full Question:
In patients with severe external bleeding (P), does the application of topical hemostatic dressings plus standard first aid (I), compared with standard first aid alone (C), change overall mortality , vital signs, hemostasis, complications, blood loss, major bleeding, incidence of cardiac arrest (O)?
Consensus on Science:
For the critical outcome of overall mortality, we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 human case series(Cox 2009, 248S) enrolling 26 patients, demonstrating that 7.7% of patients with hemostatic dressings (2/26) died (no comparison group). We also identified very-low-quality evidence (downgraded for indirectness) from 7 animal RCT studies(Alam 2003, 1077; Acheson 2005, 865; Kozen 2008, 74; Arnaud 2009, 848; Arnaud 2009, 632; Kheirabadi 2009, 450; Devlin 2011, 237) showing benefit, where 29.1% (25/86) of subjects who were treated with hemostatic dressings died, compared with 65.8% (54/82) who were not treated with hemostatic dressings (RR, 0.44; 95% CI, 0.31–0.64). For the critical outcome of hemostasis, very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 4 human case series(Wedmore 2006, 655; Brown 2009, 1; Cox 2009, 248S; Ran 2010, 584) enrolling 130 participants demonstrated that hemostasis occurred in 90.8% of participants (118/130) (no comparison group). We also identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 3 animal studies(Kozen 2008, 74; Kheirabadi 2009, 450; Causey 2012, 301) showing benefit where hemostasis occurred in 74.2% (23/31) who were treated with hemostatic dressings, compared with 50% (13/26) who were not treated with hemostatic dressings (RR, 1.48; 95% CI, 0.96–2.30). For the critical outcome of complications, very-low-quality evidence (downgraded for indirectness and imprecision) from 4 human case series studies(Wedmore 2006, 655; Brown 2009, 1; Cox 2009, 248S; Ran 2010, 584) enrolling 96 participants demonstrated that complications from hemostatic dressings occurred in 3% of participants (3/96) (no comparison group). For the important outcome of time to bleeding cessation, very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 human case series(Brown 2009, 1-7) demonstrated that 73% of participants (25/34) achieved hemostasis in under 3 minutes after a hemostatic dressing was applied (no comparison group).
Treatment Recommendation:
We suggest hemostatic dressings be used by first aid providers when standard first aid hemorrhage control (including direct pressure with or without a dressing) cannot control severe external bleeding (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place increased value on the benefits of hemostasis, which outweigh the risks (including infection and/or burns). The cost of the intervention is moderate. This PICO question specifically addressed hemostatic dressings and does not apply to other agents (such as granules) that may be applied alone or followed by a gauze dressing. A rerun of the literature search performed in January 2015 found no new studies that would change the treatment recommendation or strength of recommendation. The 2010 consensus on science treatment recommendation stated that application of topical hemostatic agents to control life-threatening bleeding not controlled by standard techniques was “reasonable,” although the best agents and the conditions under which it should be applied were not known. For 2015, it remains unclear when hemostatic dressings compared with other interventions, such as direct pressure with or without gauze dressing and/or tourniquets, should be used for the control of severe bleeding. However, the task force thinks that hemostatic dressings may be of greatest use in severe external bleeding in locations where a tourniquet cannot be applied, or when a tourniquet is not available and standard hemorrhage control (direct pressure with or without gauze dressing) is not effective. Effective use of hemostatic dressings requires that first aid providers be trained in proper application techniques.
CoSTR Attachments:
2015 02 15 CoSTR Hemostatic dressings.docx    
2015 02 15 GRADE table Hemostatic dressings.docx    

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