Hemostatic Dressings Research Articles

Oxidized dextran crosslinked polysaccharide/protein/polydopamine composite cryogels with multiple hemostatic efficacies for noncompressible hemorrhage and wound healing

Noncompressible hemorrhage caused by gunshots and sharp objects leads to higher trauma mortality, and cryogels have great potential in controlling noncompressible hemorrhage applications owing to their shape-memory properties. However, the use of non-toxic crosslinkers to prepare cryogels for noncompressible hemorrhage remains a challenge. In this study, a series of cryogels were prepared using oxidized dextran (ODex) as a biocompatible crosslinker, combined with the good hemostatic properties of chitosan (CS) and human-like collagen (HLC), and polydopamine nanoparticles (PDA-NPs) were also introduced to strengthen the shape recovery speed of the cryogels and further enhance their hemostatic performance. The CS/HLC/ODex/PDA-NPs (CHOP) cryogels presented a highly interconnected macroporous structure, powerful water/blood absorption capacity, robust mechanical performance, and rapid water/blood-triggered shape recovery. In vitro coagulation and coagulation mechanism tests showed that CHOP exhibited strong procoagulant ability, high adhesion to blood cells and fibrinogen, and the capacity to activate platelets and intrinsic pathways. In vivo hemostatic tests indicated that CHOP could effectively shorten the bleeding time and reduce the bleeding volume of liver incision bleeding and liver noncompressible hemorrhage. Meanwhile, CHOP exhibited good biocompatibility and biodegradability, and could promote wound healing. These results suggest that CHOP cryogels will be a promising hemostatic dressing.

New injectable chitosan-hyaluronic acid based hydrogels for hemostasis and wound healing

It is a challenge to develop hemostatic and wound dressings that are used for irregular shape and deep wound. Herein, a series of novel N-succinyl chitosan-oxidized hyaluronic acid based (NSC-OHA-based) hydrogels were fabricated, while calcium ions (Ca2+) and/or four-armed amine-terminated poly(ethylene glycol) (4-arm-PEG-NH2, labeled as PEG1) were introduced to regulate the mechanical behavior and bioactivities. We found all NSC-OHA-based hydrogels displayed self-healing and injectable performances. Besides, the addition of Ca2+ or PEG1 exhibited a positive effect on the adjustable mechanical behavior of hydrogels, providing the possibility to meet different mechanical requirements. Furthermore, Ca2+ or PEG1 significantly improved the biocompatibility, hemostasis and wound healing abilities of NSC-OHA hydrogel. Notably, compared with the commercial hemostatic agent (Arista™), hydrogels containing Ca2+ showed comparable hemostatic effects and significantly accelerated wound healing. Overall, the calcium-containing NSC-OHA hydrogels are promising for hemostasis and accelerating wound healing.

A Review on Electrospun Poly(amino acid) Nanofibers and Their Applications of Hemostasis and Wound Healing.

The timely and effective control and repair of wound bleeding is a key research issue all over the world. From traditional compression hemostasis to a variety of new hemostatic methods, people have a more comprehensive understanding of the hemostatic mechanism and the structure and function of different types of wound dressings. Electrospun nanofibers stand out with nano size, high specific surface area, higher porosity, and a variety of complex structures. They are high-quality materials that can effectively promote wound hemostasis and wound healing because they can imitate the structural characteristics of the skin extracellular matrix (ECM) and support cell adhesion and angiogenesis. At the same time, combined with amino acid polymers with good biocompatibility not only has high compatibility with the human body but can also be combined with a variety of drugs to further improve the effect of wound hemostatic dressing. This paper summarizes the application of different amino acid electrospun wound dressings, analyzes the characteristics of different materials in preparation and application, and looks forward to the development of directions of poly(amino acid) electrospun dressings in hemostasis.

Cellulose nanocrystal/calcium alginate-based porous microspheres for rapid hemostasis and wound healing

Porous microsphere hemostatic materials, which possess rapid hemostatic, antibacterial, and wound healing-promotion properties, have key advantages over hemostatic dressings with a single hemostatic function. Using rod-shaped cellulose nanocrystals as the supporting framework, sodium alginate/cellulose nanocrystal porous microspheres (SA/CNC) were prepared using an inverse emulsion method. After SA/CNC self-assembly with the antibacterial polymer ε-polylysine, the hemostatic porous microspheres (PSLMs) showed high porosity, high liquid absorption capacity, and excellent coagulation properties. The in vitro and in vivo coagulation properties of PSLMs were evaluated and compared with those of the commercially available chitosan hemostatic powder. PSLMs had marked hemostatic effects in the following mouse hemorrhage models: caudal (81.20 s), liver (48.44 s), and femoral artery (71.66 s). After the introduction of ε-polylysine with excellent antibacterial properties to PSLMs, PSLMs effectively inhibited the activities of Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa.

Police prehospital trauma care and hemorrhage control training as an indicator for elevated performance: A systematic review of literature

The global escalation of terrorist and felonious assaults in the civilian environment along with the Emergency Medical Services lack of training in tactical emergency casualty care lead the police forces to look for new training strategies regarding penetrating trauma management from Law Enforcement Personnel. USA police agencies approached the military committee for guidelines due to similarities presented between civilian incidents and warfare. Therefore, modified Tactical Emergency Casualty Care programs were developed. These programs were also adapted by the Hellenic Police Force, along with German, Italian, French and British Police. The aim was to elevate Law Enforcement Officers medical knowledge and practical skills in bleeding control, tension pneumothorax and airway management using hemostatic dressings, tourniquets, decompression needles and nasopharyngeal tubes respectively, in an ongoing situation. It is evident that LEOs training nowadays is more demanding as far as it concerns severe and life-threatening injury management, resulting to increased self-confidence and medical skill development. On the other hand, such training should be accessible and cost-efficient to the majority of field-operating personnel.

The Design and Feasibility of the: Radial Artery Puncture Hemostasis Evaluation - RAPHE Study, a Prospective, Randomized, Multicenter Clinical Trial.

Introduction and AimRadial artery approach angiography is the current gold standard for coronary status diagnostics and eventual percutaneous revascularization (PCI). Currently, application of adequate, patent hemostasis based physical torniquets are used for puncture site control, to avoid bleeding, radial artery occlusion and damage (RAO and RAD). The Radial Artery Puncture Hemostasis Evaluation (RAPHE) is a prospective, randomized, multicenter clinical trial designed to investigate new, simplified techniques of radial artery hemostasis utilizing physical compression free methods.Methods and ResultsThe RAPHE study has been designed to evaluate the efficacy and safety of two non-compression based radial artery hemostasis methods: a 100% chitosan bioactive hemostatic dressing and a purpose-built radial potassium-ferrate based topical hemostasis disc. These devices will be investigated in a standalone configuration. Control group is a standard pneumatic airbladder-based compression device. A total of 600 patients will be enrolled in a three-way randomization (1:1:1) with two study and one control groups. Safety and efficacy endpoints are RAO, puncture site hematoma formation and RAD respectively, consisting of dissection, (pseudo)aneurism and/or fistula formation, measured post-procedure and at sixty days.ConclusionThe results from this trial will provide valuable information on new, simplified methods of radial artery hemostasis options and possibly simplify post-puncture management of patients.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT04857385].

A Bio-Inorganic Hybrid Hemostatic Gauze for Effective Control of Fatal Emergency Hemorrhage in "Platinum Ten Minutes".

Death from massive hemorrhage represents a global problem. It is a challenging task to design hemostatic materials with significant efficacy, good biocompatibility, reliable safety, and high stability. In this study, we demonstrate an effective bio-inorganic hybrid hemostat fabricated by stepwise procedures of on-site growth of zeolite gauze and immobilization of trypsin on the zeolite gauze. The as-synthesized hybrid hemostat catalyzes the transition of prothrombin-to-thrombin and exhibits excellent procoagulant performance in the both normal plasma and FX-deficient plasma. The hemostatic treatment of junctional femoral artery rupture in the porcine model confirms that this hybrid hemostat manifests itself with superior hemostatic performance over commercial hemostatic dressings, in terms of a reduced time to hemostasis and blood loss. The stability of the hybrid hemostat is validated through high temperature and violent shaking evaluation. This bio-inorganic hybrid hemostat displays high procoagulant activity, low cytotoxicity, and extended shelf life which may achieve the "Platinum Ten Minutes" rescue in battlefield and traffic accident medicine.

Polyhexamethylene guanidine hydrochloride modified sodium alginate nonwoven with potent antibacterial and hemostatic properties for infected full-thickness wound healing

The development of multifunctional wound dressings has always been considered as a promising strategy to promote blood coagulation, inhibit bacterial infection, and accelerate wound healing. Herein, an antibacterial and hemostatic dressing (SA-PHMG) was developed based on sodium alginate (SA) nonwoven and polyhexamethylene guanidine hydrochloride (PHMG) through a completely green industrial route, including dipping, padding, and drying. According to studies, SA-PHMG dressings exhibited excellent liquid absorption capacity and water vapor permeability. Moreover, bactericidal assays have demonstrated that SA-PHMG dressings have ideal antibacterial activity against Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa and mixed bacteria, maintaining potent antibacterial activity even after 10 cycles of antibacterial trials or 50 times of washing or soaping. The in vitro evaluation of the hemostatic effect indicated that the SA-PHMG could significantly promote blood clotting by activating platelets, and in vitro and in vivo hemolysis, cytotoxicity and skin irritation studies demonstrated the ideal biocompatibility of the dressings. In addition, better wound closure and tissue regeneration were recorded using SA-PHMG nonwoven as the dressing based on an infected full-thickness wound model. In conclusion, this antibacterial, hemostatic, biocompatible, and environmentally friendly SA-PHMG nonwoven exhibit the potential for infected wound healing.

Development of a Hemostatic Urinary Catheter for Transurethral Prostatic Surgical Applications

To investigate a novel transurethral hemostatic catheter device with an integrated chitosan endoluminal hemostatic dressing (CEHD). Development and implementation of this technology may help address bleeding following surgery such as transurethral resection of prostate (TURP). Bleeding remains the most common complication following TURP, leading to increased morbidity and hospitalization. Investigation of hemostasis, delivery, safety and efficacy of the CEHD device is conducted using Female Yorkshire swine (N = 23). Hemostatic efficacy of the CEHD (N = 12) is investigated against a control of gauze (N = 12) in a splenic injury model (3 swine). The delivery, safety, and efficacy of the CEHD device (N = 10) are investigated against Foley-catheter control (N = 10) for 7 days using a swine bladder-neck-injury model. In the splenic injury study, 9/12 CEHD dressings successfully achieved hemostasis within 150 seconds (mean 83 seconds) vs success of 6/12 (mean 150 seconds) for gauze (P = .04). In the 7-day study, the CEHD was successfully deployed in 10/10 animals and all dressings were tolerated without histologic or clinical adverse effect. Hemostasis of the CEHD device was found to be noninferior to control catheters. Noninferiority is attributed to low bleeding rates in the swine bladder neck injury model. This investigation successfully demonstrated the feasibility of transurethral deployment of the CEHD in vivo. Routine use of safe and slowly dissolvable CEHDs could reduce the rate of complications and hospitalizations associated with bleeding and blood loss in TURP procedures. Further investigation is warranted.

An injectable hemostatic PEG-based hydrogel with on-demand dissolution features for emergency care

Uncontrolled bleeding from internal noncompressible wounds is a major cause of prehospital death in military personnel and civilian populations. An ideal hemostatic sealant for emergency care should quickly control blood loss and be removed without debridement for the follow-up treatment in the operating room, yet the lack of suitable materials to meet both requirements is the bottleneck. Herein, we suggest an injectable and dissolvable hydrogel sealant for hemorrhage management of noncompressible wounds. To this end, a 4-arm poly(ethylene glycol) (PEG) crosslinker modified with thioester linkages and terminated with aldehyde groups is designed and synthesized, and to modulate the gel properties and make it suitable as a hemostatic sealant, a mixed amino component composed of poly(ethylene imine) and adipic dihydrazide is employed to react with the PEG crosslinker to form the adhesive and elastic sealant for the first time. The aldehyde groups provide the adhesion to the tissues, and the amino component affords the procoagulant ability. More importantly, the thioester moieties allow the on-demand dissolution of sealant via a thiol-thioester exchange reaction upon exposure to an exogenous thiolate solution. In the rat femoral artery puncture and liver injury models, the administration of the hydrogel sealant dramatically reduces blood loss, and its subsequent removal does not induce rebleeding. Consequently, this hydrogel sealant with the unique feature of on-demand dissolution can not only efficiently control bleeding in emergent scenarios, but also allow non-traumatic re-exposure of wounds during subsequent surgical care. Statement of significanceSealants, adhesives or hemostatic dressings currently used in emergency situations not only require manual pressure to control bleeding, but also face removal by cutting and mechanical debridement to enable eventual surgical treatment. In this study, we design and develop an injectable and adhesive hydrogel sealant with good procoagulant capacity and on-demand dissolution feature. The application of the hydrogel sealant substantially reduces bleeding from internal noncompressible wounds without the need for direct pressure, and demonstrates for the first time that its controlled removal without debridement does not cause rebleeding. Considering that there are currently no commercial wound sealant systems with the feature of on-demand dissolution, the hydrogel sealant developed by us is expected to address an unmet clinical need.

Haemostatic wound dressing and pharmacologic agents for management of bleeding in dentistry

Haemostasis is a mechanism that, through different interdependent biologic processes, has the purpose of ensuring the integrity and permeability of the circulatory system. Haemostasis term means prevention the loss of blood. Interventions or treatments in the oral cavity, in particular those with a possibility of bleeding, represent a risk for patients with disorders of haemostasis. Prevention is the key to avoid bleeding complications after oral surgical procedures and therefore it is essential a detailed medical history of the patient. This paper investigates the effects of wound dressing and local pharmacologic treatments on haemostasis.

From battlefield to civilian emergency pre‑hospital care practice: lessons of modern warfare. Part i: external hemorrage arrest

An experience of external hemorrhage arrest in combat casualties of XXI century military conflicts (Iraq, Afghanistan) and the results of application of this experience in сivilian emergency pre‑hospital care practice are presented in the review. Data from PubMed, Cochrane Library and other free Internet resources since 2001 to 2021 were analyzed. High effectiveness and safety of modern tourniquets and hemostatic dressings use for hemorrhage arrest both in military and civilian trauma patients were established. The first promising results of application of new perspective hemostatic devices for «non tourniquetable» hemorrhages are presented as well.

Fabrication of chitosan nanofibrous scaffolds based on tannic acid and metal-organic frameworks for hemostatic wound dressing applications

Here, we developed chitosan (CS)-based nanofibrous scaffold consisting of tannic acid (TA) and zinc-based metal-organic framework (MOF) as a novel antibacterial and hemostatic wound dressing. The effect of MOF content and its incorporation within and onto CS/PVA-TA nanofibrous scaffolds were studied. The morphological characterization of fabricated nanofibrous scaffolds revealed the formation of uniform and bead-free nanofibers with an average diameter between 120 and 150 nm. The uniform and continuous decoration of MOF crystals on nanofibrous scaffold surfaces were confirmed by FESEM. The developed nanofibrous scaffolds exhibit appropriate physicochemical characteristics such as chemical and crystalline structure, surface wettability and swelling, and mechanical properties. It is shown that the incorporation of TA and MOFs greatly enhanced the hemostatic performance of the CS/PVA nanofibrous scaffold by providing rapid liquid absorbability and accelerating the aggregation of coagulation factors and platelets. Furthermore, the results of the MTT assay suggested the good biocompatibility of nanofibrous scaffolds containing MOF nanoparticles. The nanofibrous scaffolds exhibited excellent antibacterial activity against Escherichia coli and Staphylococcus aureus. The disk diffusion antibacterial assay showed that the nanofibrous scaffolds containing TA and MOF could protect wound from bacterial infection. The findings provide new insights to develop a MOF-modified nanofibrous structure with great potential for hemostatic wound dressing application.

Shape memory polymer foams with tunable interconnectivity using off-the-shelf foaming components.

The ability to easily and safety tune pore structures of gas-blown polyurethane shape memory polymer (SMP) foams could improve their outcomes as hemostatic dressings or tissue engineering scaffolds and enable overall commercialization efforts. Incorporating physical blowing agents into the polymer mix can be used to tune pore size and interconnectivity without altering foam chemistry. Enovate (HFC-254fa) is a commonly used physical blowing agent in gas-blown foams, but the Environmental Protection Agency (EPA) considers its use unacceptable because it is a hydrofluorocarbon that contributes to global warming. Here, off-the-shelf solvents accepted for use by the EPA, acetone, dimethyoxymethane (methylal), and methyl formate, were used as physical blowing agents by adding small volumes during foam fabrication. Increasing the physical blowing agent volume resulted in greater pore interconnectivity while maintaining SMP foam chemical and thermal properties. Pore size and interconnectivity also impacted cell and blood interactions with the foams. This work provides a safe and easy method for tuning SMP foam interconnectivity to aid in future commercialization efforts in a range of potential biomedical applications.

Comparison of modified rapid deployment hemostat dressing with standard haemostat as part of standardized perihepatic packing for major liver trauma in a level 1 trauma center

Introduction Uncontrolled hemorrhage is a major cause of mortality in surgery and trauma. Damage control surgery (DCS) is essential in the management of these cases. The use of topical hemostatic agents has increased over the last two decades with the evolution of DCS and trauma-induced coagulopathy. The aim of this study was to compare the performance of standard perihepatic packing with the addition of either a MRDH (modified rapid deployment hemostat) or a non-MRDH hemostatic dressing. Methods This was a retrospective, comparative analysis of prospectively collected data held in the registry of a level I trauma center in Bologna, Italy, between 2005 and 2019. 33 patients with grade IV/V liver injuries who underwent a standardized perihepatic packing with hemostatic dressings were enrolled in the study. The study group included 21 patients treated with standard packing plus MRDH. The control group included 12 patients treated with standard packing plus a combination of fibrillar absorbable hemostat and human fibrin sealant. Results The two groups were homogeneous in terms of age and American Association for the Surgery of Trauma (AAST) grade although the MRDH one seemed to have more severe injury: hemodynamic instability was present in 95% of MRDH patients vs. 83% in the control group. Also, Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 41 vs 35.5 and 47 vs 39.1, respectively. The incidence of re-bleeding requiring repacking at the second-look laparotomy was 4.7% in MRDH patients vs. 16.7% in non-MRDH patients ( p = .5, OR = 4). The overall complication rate was of 23% after the introduction of MRDH vs. 81% in the control group. Conclusion Despite the potential effectiveness of MRDH, this study does not seem to confirm a significant superiority of this hemostat over the standard.

Advances in Hemostatic Wound Dressings: Clinical Implications and Insight.

Hemorrhagic shock is one of the leading causes of prehospital death in the armed forces. In this state, the body begins to shut down because of blood volume depletion. In both civilian and military trauma, a significant number of hemorrhage deaths occur in the first several hours after injury. Researchers all over the globe are working to develop relatively inexpensive and easy-to-transport products to prevent soldiers from going into hemorrhagic shock. For example, many advances have been made during the last several years toward the development of ideal hemostatic dressings. No current hemostatic agents meet all of the requirements, but the ideal dressing would fulfill many important measures: minimizes or stops blood flow within minutes, contains hemostatic agents to enhance blood clotting, is easy to apply, does not need preapplication preparation, has a reasonably long shelf life, is safe to use, prevents bacterial or viral transmission, is stable at extreme temperatures, and is inexpensive. For this literature review, the authors conducted an extensive search of academic scientific databases for relevant keywords and assessed and summarized the results. This review aimed to identify recent advances in hemostatic wound dressings; summarize the currently available dressings and their supporting literature; and discuss the compositions, mechanisms of action, and clinical relevance of each category of dressing. In addition, case studies and suggestions for future research into hemorrhage control with new hemostatic agents are provided.

A bio-inspired multifunctional soy protein-based material: From strong underwater adhesion to 3D printing

The use of natural plant proteins to prepare underwater bonding materials with both strong adhesion and bonding performance underwater is a great challenge. Inspired by mussels and oysters, a Soy protein isolate (SPI)-based underwater adhesive (USPI-CaO) was designed and synthesized. First, 1, 2-epoxy-9-decene (A) was grafted onto SPI to obtain ASPI with unsaturated bond by ring-opening reaction. As a natural source of catechol groups, biological urushiol (U) was then grafted onto ASPI by free-radical polymerization to obtain USPI with underwater adhesion performance. Then, calcium oxide (CaO) was mixed with USPI to obtain inorganic-organic hybrid material (USPI-CaO) with underwater curing ability. The resultant USPI-CaO showed strong underwater adhesion and bonding performance to different materials (glass, metal, PVA, acrylic, wood, hogskin, rubber, ceramic etc., respectively) in different aqueous environments (pH = 5 or 9 water, simulated seawater, organic solvent, iron solution, T = 3 ℃ to 90 ℃ water, etc., respectively). Interestingly, USPI-CaO showed good plasticity and machinability in water, demonstrating its application prospects for underwater 3D printing and underwater fine machining. USPI-CaO also exhibited good antibacterial, mildew-resistant, and fire-resistant properties. USPI-CaO can potential be applied in various fields, such as sealing and repairing underwater/wastewater, wound and hemostatic dressings, wearable electronic devices, and submerged structures.

Advances in hemorrhage control resuscitation.

Despite significant advances in trauma management over the last twenty years, uncontrolled hemorrhage remains the leading cause of preventable death in trauma. We review recent changes affecting hemorrhage control resuscitation. Early blood product usage has become well established as a standard of care in trauma hemorrhage control. To enable this, low titer group A liquid plasma and group O whole blood are increasingly utilized. Single donor apheresis platelets have now replaced pooled donor platelets in the USA and are often pathogen reduced, which has implications for trauma resuscitation. Further work is examining timing and dosing of tranexamic acid and the debate in factor concentrate usage in trauma induced coagulopathy continues to evolve. The 'Stop the bleed' campaign has highlighted how important the use of hemostatic dressings are in hemorrhage control, as too is the expanded use of endovascular aortic occlusion. We highlight the ongoing research into desmopressin use and the undetermined significance of ionized calcium levels in trauma. Finally, we discuss our own hospital experience with coagulation testing and the paucity of evidence of improved outcomes with viscoelastic testing. Improving trauma coagulopathy diagnostics and hemorrhage control are vital if we are to decrease the mortality associated with trauma.

ITClamp-Mediated Wound Closure Speeds Control of Arterial Hemorrhage With or Without Additional Hemostatic Agents.

Exsanguination is the leading cause of preventable posttraumatic death, especially in the prehospital arena. Traditional hemorrhage control methods involve packing the wound with hemostatic agents, providing manual pressure, and then applying a pressure dressing to stabilize the treatment. This is a lengthy process that frequently destabilizes upon patient transport. Conversely, the iTClamp, a compact wound closure device, is designed to rapidly seal wound edges mechanically, expediting clot formation at the site of injury. To determine the efficacy of the iTClamp with and without wound packing in the control of a lethal junction hemorrhage. Given the limited available information regarding the efficacy of the iTClamp in conjunction with traditional hemostatic agents, this study used a swine model of severe junctional hemorrhage. The goal was to compare a multiagent strategy using the iTClamp in conjunction with XSTAT to the traditional method of Combat Gauze packing with pressure dressing application. Readouts include application time, blood loss, and rebleed occurrence. Mean application times of the iTClamp treatment alone or in conjunction with other hemostatic agents were at least 75% faster than the application time of Combat Gauze with pressure dressing. Percent blood loss was not significantly different between groups but trended the highest for Combat Gauze treated swine, followed by iTClamp plus XSTAT, iTClamp alone and finally iTClamp plus Combat Gauze. The results from this study demonstrate that the iTClamp can be effectively utilized in conjunction with hemostatic packing to control junctional hemorrhages.

Hemorrhage control-Proper application of direct pressure, pressure dressings, and tourniquets for controlling acute life-threatening hemorrhage.

Timely application of hemorrhage control interventions is lifesaving. Any amount of blood loss may be detrimental and, therefore, trauma-induced hemorrhage must be addressed immediately and aggressively. Early and prompt hemorrhage control is one of the main priorities of treating hemorrhagic shock. Trauma-induced hemorrhage remains a leading cause of preventable death. A vast majority of bleeding wounds encountered are not initially life-threatening but become life-threatening with delay in appropriate hemorrhage control. Appropriate immediate hemorrhage control interventions for the exsanguinating small animal include direct pressure, wound packing, hemostatic dressings, pressure bandage, and, possibly, tourniquet application. Although tourniquet application is a lifesaving intervention in people experiencing extremity hemorrhage, it has not been shown to be a necessary intervention for small animals. The aim of this companion article is to briefly describe the basic methods for achieving immediate hemorrhage control in small animals in a prehospital or life-threatening situation. Common sources of trauma-induced massive hemorrhage include injury to a major artery or other large vessel (eg, external jugular), a highly vascular organ(s) (liver and spleen), or from a combination thereof. Blood loss from a major arterial source (ie, femoral or carotid artery) may rapidly lead to exsanguination and death in as little as 3-5 min. Placing a circumferential compressive bandage that is too tight or restrictive around the neck, thorax, or abdomen may occlude the patient's airway, restrict chest expansion, or prevent adequate respiration. Noncircumferential bandages often do not generate sufficient enough pressure to abate arterial hemorrhage, particularly when systolic arterial blood pressure is restored postfluid resuscitation. Definitive hemostasis for massive internal hemorrhage is best achieved through early surgical intervention. Direct pressure remains the most effective "medical" intervention for initial hemorrhage control. When feasible, elevate and splint (immobilize) any bleeding extremity or body part as an adjunctive aid for hemorrhage control when used in conjunction with other methods of control, especially direct pressure.