A Special Report on the Chitosan-based Hemostatic
Dressing: Experience in Current Combat Operations
Ian Wedmore, MD, John G. McManus, MD, MCR, Anthony E. Pusateri, PhD, and John B. Holcomb, MD
Background: Hemorrhage remains
a leading cause of death in both civilian
and military trauma patients. The Hem-
Con chitosan-based hemostatic dressing
is approved by the US Food and Drug
Administration (FDA) for hemorrhage
control. Animal data have shown the
HemCon dressing to reduce hemorrhage
and improve survival. The purpose of
this article is to report preliminary re-
sults of the hemostatic efficacy of the
HemCon dressing used in the prehospi-
tal setting on combat casualties.
Methods: A request for case infor-
mation on use of HemCon dressings in
Operation Iraqi Freedom and Operation
Enduring Freedom was sent to deployed
combat fatalities and up to 80% of civilian trauma fatalities
within the United States,1,2making new methods and prod-
ucts for hemorrhage control a research priority of the US
Army Department of Defense Combat Casualty Care Re-
search Program. New dressings for compressible areas, im-
proved tourniquets, and improved tourniquet guidelines and
systemic agents (i.e., recombinant activated factor VII) have
all been part of our research focus.3,4QuikClot (Z-Medica,
Newington, CT) and the HemCon chitosan-based dressing
(HemCon Inc., Tigard, OR) are two new hemostatic agents
among several products that have already been deployed.
This report outlines the initial experience using the HemCon
dressing as described by far forward military medical person-
Special Forces combat medics, physicians,
and physician assistants.
Results: Sixty-eight uses of the Hem-
Con dressing were reported and reviewed by
two US Army physicians. Four of the 68 cases
were determined duplicative resulting in a to-
tal of 64 combat uses. Dressings were utilized
externally on the chest, groin, buttock, and
abdomen in 25 cases; on extremities in 35 cas-
(97%) of the cases, the use of the HemCon
dressing resulted in cessation of bleeding or
improvement in hemostasis. There were two
reported dressing failures that occurred with
blind application of bandages up into large
cavitational injuries. Dressings were reported
to be most useful on areas where tourniquets
could not be applied to control bleeding. The
dressings were reported to be most difficult to
use in extremity injuries where they could not
be placed easily onto or into the wounds. No
complications or adverse events were re-
Conclusion: This report on the field
use of the HemCon dressing by medics
suggests that it is a useful hemostatic
dressing for prehospital combat casualties
and supports further study to confirm ef-
Hemorrhage control, Hemostatic dress-
J Trauma. 2006;60:655–658.
tandard gauze field dressings and direct pressure are
often inadequate in the control of hemorrhage. In fact,
uncontrollable hemorrhage accounts for almost 50% of
nel in the prehospital combat zone during the early stages of
current combat operations.
PATIENTS AND METHODS
In 2003, just before the start of Operation Iraqi Freedom,
the HemCon dressing was approved by the US Food and
Drug Administration and 2,500 were distributed to US Spe-
cial Operations Military medical personnel. Initial distribu-
tion was to forward deployed medics, followed by a more
general distribution to physicians and physician assistants
located in both Iraq and Afghanistan as more bandages be-
came available. Over 103,000 dressings have now been dis-
tributed into combat operations in Iraq and Afghanistan.
Providers were instructed to utilize the dressings in cases
where other standard techniques had failed or if they thought
there was a high likelihood of failure with standard tech-
niques. The use of this dressing is a standard component of
the Prehospital Trauma Life Support (PHTLS) military sec-
tion, and is taught to all Special Operations Forces (SOF) and
conventional Army medics in their respective training
In November 2003, in an effort to discern any issues
related to usage of HemCon dressings, the authors contacted
the forward deployed medical personnel who initially re-
ceived HemCon dressings and requested a response to a short
survey (Table 1). Communication with these widely dis-
persed and remote SOF teams was necessarily extremely
limited, so in-depth reviews were not possible. The authors
received approval to conduct a retrospective review of these
Submitted for publication December 2, 2004.
Accepted for publication November 22, 2005.
Copyright © 2006 by Lippincott Williams & Wilkins, Inc.
From the Madigan Army Medical Center (I.W.), Fort Lewis, Wash-
ington; and the US Army Institute of Surgical Research (J.G.M., A.E.P.,
J.B.H.), Fort Sam Houston, Texas.
The opinions or assertions expressed herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the US Department of the Army or the US Department of Defense.
Address for reprints: LTC John McManus, M.D., US Army Institute of
Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston,
TX 78234-6315; email: firstname.lastname@example.org.
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cases from the institutional review board at Brooke Army
Medical Center, Fort Sam Houston, TX. Initially, respondents
reported six successful cases. A second larger-scale request
was put out in early 2004 requesting information on hemor-
rhage control success and failure for the HemCon dressing.
This request resulted in another 62 cases reported. Due to
security reasons and combat situations, most reported cases
were based on verbal reports of HemCon dressing use from
the involved medics. The information on the clinical utility of
the HemCon dressing was obtained several days to weeks
after the casualty was treated.
Two US Army emergency physicians collected and re-
viewed a total of 68 cases of HemCon dressing use over a
1-year period. Four cases were determined to be duplicate
reports; thus, a total of 64 unique cases are described. No
adverse effects or complications were noted. The majority of
dressings (35 of 64 [55%]) were applied to wounds located on
patient extremities, whereas 25 of 64 (39%) were applied to
wounds located on the chest (trunk), groin (including one
penile wound), buttocks, and abdomen. The remaining four
uses of the HemCon dressing consisted of face and a neck
wounds. Bleeding was predominantly from a venous source
in 33 cases, arterial source in 7 cases, and unknown in 24
cases. Medics applied dressings in the prehospital setting.
The dressings were not placed into any abdominal or chest
In 42 (66%) of the cases, the HemCon dressings were
used after failure of traditional dressings such as gauze Ker-
lex and pressure dressings such as an ace wrap. In the re-
maining 22 cases, it was unclear if any methods had been
tried before HemCon application. In 62 (97%) of the cases
reported, the HemCon dressing completely stopped or greatly
improved bleeding. There were two cases where the bandage
failed to slow or stop bleeding. In both cases, the bandage
was placed blindly up into large cavitational wounds. In one
case, it stopped the bleeding but when the medic removed his
hand the dressing came out with his hand as a large clot
covered mass. In the second, it was placed up into a large
cavitational wound and bleeding continued. However, where
medics were able to visually see the application of the dress-
ing, hemostasis was achieved in all cases. Finally, in one
other case, the HemCon dressing initially failed on a foot
laceration from broken glass. The dressing was ineffective
because the bandage could not be applied into the small
wound. However, when the dressing was torn into small
pieces and placed into the laceration, hemostasis was at-
tained. Other than the foot laceration all other wounds were
due to improvised explosive devices, gunshot wounds, and
indirect fire (fragments).
The HemCon dressing is an FDA-approved hemostatic
agent currently used in the combat environment for the ex-
ternal temporary control of severely bleeding wounds, and
also has demonstrated efficacy based on animal work.6–8
Chitosan is a biodegradable, nontoxic, complex carbohydrate
derived from chitin (poly ? (1 to 4)-N-acetyl D-glu-
cosamine), a naturally occurring substance. Chitosan is the
deacetylated form of chitin. The generic term “chitosan”
generally is applied when the extent of deacetylation is above
70% and the generic term “chitin” is used when the extent of
deacetylation is insignificant, or below 20%. In the form of an
acid salt, chitosan demonstrates mucoadhesive activity.9This
makes it an ideal candidate for a hemostatic agent. Different
forms of chitosans have been used to enhance hemostasis in
animal studies involving bleeding from esophageal varices,
arterial catheter puncture sites, peritoneal abrasions, or sim-
ilar experimental insults.10–14
The HemCon dressing is a freeze-dried chitosan-based
dressing designed to optimize the mucoadhesive surface den-
sity and structural integrity of chitosan at the site of injury.
The current version of this dressing is sold commercially as
a 10 cm ? 10 cm ? ?2-mm thick square dressing with
nonabsorbable backing, and is packaged in a vacuum-sealed
aluminum pouch (Fig. 1). The prototype version of this dress-
ing significantly reduced blood loss and resuscitation fluid
use, and improved hemostasis and survival in an experimen-
tal model of severe hepatic injury and hemorrhage in swine.8
In a subsequent study that employed the commercial version
of the dressing, the HemCon dressing controlled bleeding in
Table 1 HemCon Dressing Data Collection Sheet
1. Anatomical area of injury
2. Type of bleeding
3. Other hemostatic measures attempted first?
4. Was the HemCon dressing applied before other measures?
5. Was the HemCon dressing effective in hemorrhage control?
The Journal of TRAUMA?Injury, Infection, and Critical Care
five of seven attempts in an experimental model that included
transection of the femoral artery and vein in pigs.6The
authors of the latter study noted that the dressing resulted in
“superb hemorrhage control” in five instances but failed com-
pletely in two others, raising issues with dressing-to-dressing
variability. It now appears that the company has solved the
issue of dressing variability.15There is evidence suggesting
that the HemCon dressing may act by enhancing platelet
function16and by incorporating red blood cells into the clot13
that forms at the site of the wound. However, it currently
appears that the principal cause behind the hemostatic effects
of HemCon dressing are its mucoadhesive properties.8
In this report, the medical providers felt the bandages
were most beneficial in 29 (45%) of the cases where a
tourniquet could not be utilized due to the proximity of the
injuries (i.e. groin, axilla) or inability to otherwise apply a
tourniquet such as a neck or face wound. In one case, the
bandage was placed on a leg wound in lieu of a tourniquet to
allow an injured soldier to return briefly to an ongoing com-
bat operation. The bandage was felt to be of less utility in
small extremity injuries where standard treatment alone
would have been effective. In 12 extremity cases, the super-
vising physicians who eventually received these casualties
felt the HemCon dressing may have been utilized “overzeal-
ously” and that standard dressings alone may have been as
effective as the $90 bandage. Due to the stiffness of the
bandage, it was also found to be more difficult to apply into
small wounds without cutting or tearing it to fit.
The need for hemorrhage control is not limited to combat
medicine. Uncontrolled hemorrhage accounts for up to 80%
of early civilian trauma deaths, although there are few deaths
from isolated extremity trauma in the civilian community.17
The ideal hemostatic dressing will require little training; be
nonperishable, durable, flexible and inexpensive; adhere to
the wound only; pose no direct risk of disease; not induce a
tissue reaction; and effectively control hemorrhage from ar-
terial, venous and soft tissue bleeding. As described in this
small case series and in animal studies,6–8the HemCon
dressing seems to meet many—but not all—of these require-
ments, with the main issue relating to flexibility of the current
dressing. Although we did not evaluate efficacy beyond ini-
tial use of the dressing, there were no reports of adverse
effects. This is the first report to document “real-world” use
and efficacy of the HemCon chitosan-based hemostatic dress-
ing for external hemorrhage on human patients.
This study is retrospective and observational by design
and thus has several limitations. Data were collected and
based on verbal and written accounts of HemCon dressing
use, rather than complete patient records due to security
reasons and the combat situation. Thus, selection and recall
bias may affect the results reported. Also, because this study
focused only on acute hemorrhage control in a combat envi-
ronment, the long-term follow-up was absent. Although no
adverse outcomes reports have arisen, it is possible that
hemostatic failure occurred after the initial application as well
as other possible complications from bandage use such as
infection, delayed wound healing and increased scarring.
Data collection in the prehospital military environment is
notoriously difficult, and in this series the ongoing combat
operations posed severe limitations on data collection and
follow-up. Although obviously not ideal, the data collected
do represent the largest case series of reports describing a
new hemostatic modality introduced during a war.
Previously, gauze was the only bandage used to control
hemorrhage in the prehospital combat environment. How-
ever, based on the above data the US Army has recently
decided to supply one HemCon dressing to every deployed
soldier, three for every Combat Life Saver, and five to every
medic in the combat theater. These dressings now join the
new tourniquets carried by all soldiers as the individual and
medic carried hemostatic devices of choice for severe combat
injuries. Finally, the HemCon bandage is now being utilized
in civilian emergency medical services for moderate to severe
Fig. 1. HemCon chitosan-based hemostatic dressing courtesy of
HemCon, Inc. HemCon bandage instructions for use:
dressing with pressure for 1–2 minutes or until dressing adheres and
bleeding is stopped. 2. Apply outer bandage to secure dressing on
wound site.3. Remove dressing within 48 hours.
external use only. Do not implant. Not for consumption. Do not eat.
Single use only. Do not apply over eyes.
Chitosan-based Hemostatic Dressing in Combat
Volume 60 • Number 3
In conclusion, the HemCon chitosan-based hemostatic Download full-text
dressing as used by medics appears to be a safe and useful
adjunct for the control of external hemorrhage in this case
series of prehospital combat patients. Further human prospec-
tive controlled studies are warranted.
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The Journal of TRAUMA?Injury, Infection, and Critical Care