Keep Hemostatic Agents On Hand, Expert Advises

ACEP News
October 2009

By Doug Brunk
Elsevier Global Medical News

PORTLAND, ORE. -- Bone wax, a combination of beeswax and isopropyl, is one of the nontraditional topical hemostatic agents Dr. Daniel Berg keeps on hand.

As chief of dermatologic surgery at the University of Washington, Seattle, Dr. Berg has used it twice to tamponade bleeding of a bone: once on the skull and once in the nasal region.

"You warm up the bone wax, pack it, and stuff it into [the bleeding site] like Silly Putty," Dr. Berg said at the annual meeting of the Pacific Dermatologic Association. "Consider having a box of it on standby if you do any surgery, particularly on the scalp."

Possible complications include a granulomatous reaction, infection, and impediment of osteogenesis.

A new alternative to bone wax is Ostene, a water-soluble alkylene oxide copolymer manufactured by Ceremed Inc. that dissolves in 24 hours (Dermatol. Surg. 2008;34:431-45).

Dr. Berg also discussed Gelfoam, an absorbable gelatin sponge manufactured by Pharmacia and Upjohn, which he uses for diffuse oozing. The product, which promotes clotting and granulation, is applied after being moistened with saline or with a local anesthetic. "I don't like to put it into wounds that I'm covering over, because although it liquefies and is degraded, it can serve as a nidus for infection. A great use is to line forehead flap pedicles with Gelfoam."

Topical bovine thrombin is another agent he uses. Supplied as a sterile powder that has been freeze dried in the final container, along with mannitol and sodium chloride, thrombin directs conversion of fibrinogen to fibrin. It is sprayed on the wound or saturated on Gelfoam. Rare complications include allergy to bovine products, disseminated intravascular coagulation if the product gets into large vessels, and immune-mediated coagulopathies.

Dr. Berg also discussed hemostatic agents that contain microfibrillar collagen, such as Avitene, manufactured by Davol Inc. These products attract blood platelets and tend to be more effective than Gelfoam, he said.

Dr. Berg reported having no conflicts to disclose.

 

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