February 19, 2009

 

 

 

When bleeding occurs, its crimson flag prompts from us a uniformly rapid response. How we control bleeding, however, has a marked impact on the ability of a wound to heal. Blood not only carries oxygen, CO₂ and nutrients, but once clotted also contains all of the signals needed to initiate normal wound healing.

 

Too often, in our knee-jerk response to control acute bleeding, we resort to the use of methods and agents that both create and destroy clot, removing the basis for optimal wound healing and often committing us to cycles of bleeding and clotting. Naturally, when bleeding is life threatening, we must focus on the control of bleeding at all costs. The great majority of bleeding episodes are not life threatening, though. If we hope to both stop the bleeding and set the stage for healing of the wound, we need to carefully weigh the methods we use.

 

Historically, bleeding has been classified in one of two ways:

 

Classification A: Arterial, Venous, Capillary and Mixed.

 

Classification B: High Pressure (Arterial), Low Pressure (Venous/Capillary) and Diffuse Oozing (Generally Capillary).

 

Families of hemostatic products have been developed and marketed on the basis of these classifications. However, neither of the classifications takes into account the fact that bleeding is typically a short lived phenomenon while wound healing (the ultimate objective) is a subtle process that requires a good beginning – and that beginning is a stable clot without creating tissue trauma.

 

The H1, H2 System, described below, classifies bleeding in such a way that hemostatic methods can be chosen that optimize the potential for normal wound healing. When bleeding occurs, since there is generally no time available for a systematic analysis of the situation, the H1, H2 system also takes into consideration and supports the subjective evaluation of the responder.   It is that response, in fact, that drives the choice of hemostatic agents under most circumstances. The classification is straightforward.

 

 

H1 bleeding is bleeding that is either life threatening or likely to lead to clinically significant blood loss.   It occurs outside of the controlled circumstances of an operating room. Examples include battlefield injuries and highway and other severe domestic trauma.   In this situation, bleeding must be controlled at all costs, even to the potential detriment of subsequent wound healing. Hemostatic agents that are used under these circumstances include tourniquets, cautery and powder-activated hemostats.

 

 

H2 bleeding, conversely, is not life threatening.  It can occur under controlled (i.e., operating room) or uncontrolled circumstances. Examples of H2 bleeding include abrasions, lacerations, nosebleeds and some components of all surgical procedures. Although achieving hemostasis is critical, it is best done with an eye toward preserving the tissue for the wound healing process that follows. Under circumstances of H2 bleeding, the most critical objectives, then, are to not only stop the bleeding but to keep the clot in place so that it provides the template and signals needed to get the right start toward healing.

 

Nearly all H1 bleeding is at some point converted to H2 bleeding as the situation comes under control. When this occurs, consideration should be given to a conversion from an H1 hemostat to an H2 hemostat.   According to Dr. Chip Rich, Director of Trauma at the UNC School of Medicine, the ideal overall hemostat has the following features:

 

It is -

1.    Hemostatic
2.    Non-adherent
3.    Absorbent
4.    Nothing is left behind
5.    Hemostasis persists when it is removed
6.    No tissue injury occurs
7.    Causes no obscuring of surgical field. Allows continued access to affected tissues.
8.    Affordable enough to be ubiquitous
9.    Ready to use, no mixing or other delay
10.  Familiar, friendly format in especially useful gauze-type format

 

Ideally, when H2 bleeding is encountered, the hemostat can also serve as the initial bandage so that clot stabilization is fully achieved. Most materials used to achieve H2 hemostasis cannot be used in this fashion because they adhere to the clot and upon removal, cause pain and tear away some or all of the clot. Gauze is an excellent example. A hemostat is needed that not only stops bleeding but does so in a way that stabilizes clot by not adhering significantly to the clot.

 

Of all hemostats, only Stasilon® has the ability to stop H2 bleeding, not adhere and also serve as the initial and subsequent bandage for the wound. Stasilon®’s hemostatic ability derives from its combination of glass fibers (which are highly reactive toward blood) and bamboo fibers (which rapidly wick red blood cells into a dense aggregate before fibrin forms, creating a cleavage plane for anti-adherence). When H2 bleeding occurs, Stasilon® can be relied upon to preserve clot to support the initial, critical stages of wound healing, supporting the age-old maxim: “Well begun is half done.”

 

In a clinical trial that was recently completed at the UNC School of Medicine Jaycee Burn Center, gauze and Stasilon® were compared side by side on uniformly created skin graft donor sites.   The endpoints were the amount of bleeding and the degree of adhesion of the bandage to the wound. Stasilon® significantly reduced bleeding compared to gauze and in 20/20 patients, Stasilon® was less adherent to the wound.

 

Stasilon® has also been tested as an H2 hemostat by many additional physicians, EMTs, veterinarians and the general public. In a survey of approximately 60 users, they reported the effectiveness of Stasilon® as follows:

 

 

 

        None: 71%

        Mild: 29%

        Moderate: 0%

        Severe: 0%

 

In summary, when facing a bleeding episode, the severity of the bleeding dictates whether an H1 or an H2 hemostat should initially be used. When bleeding is of the H1 type, once bleeding is controlled, attention turns to wound healing optimization prompting conversion to an H2 anti-adherent hemostat/dressing.   If the initial bleeding is of the H2 type, an H2 anti-adherent hemostatic dressing should be used and can also serve as the initial and subsequent dressing material. If wound cleansing prompts rebleeding, an H2 anti-adherent hemostatic dressing such as Stasilon® will provide the dual functionality of hemostasis and clot stabilization with minimal adhesion during dressing changes.