Profound Shock Research Articles

Research Progress on Acute Kidney Injury in Patients with Cardiogenic Shock Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Cardiogenic shock (CS) is a life-threatening syndrome characterized by peripheral hypoperfusion and organ dysfunction caused by primary heart disease. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support device for CS, used in cases of profound shock, biventricular failure, respiratory failure, and cardiac arrest that require urgent maximal support. While VA-ECMO provides effective tissue perfusion and ensures oxygen supply to organs, it is also associated with severe complications, among which acute kidney injury (AKI) is one of the most common and serious. To date, no comprehensive review has been conducted on the pathophysiology, influencing factors, and treatment of AKI associated with VA-ECMO. This paper aims to elaborate on the pathophysiological mechanisms, influencing factors, and treatment options for AKI in patients with CS undergoing VA-ECMO, providing clinical and nursing references.

When to choose intraosseous access in prehospital trauma care: A registry-based study from the Israel Defense Forces

PurposePrompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements. MethodsA registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 – 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05. ResultsOf 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 – 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 – 23.3). ConclusionProfound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.

Immunologic Crosstalk and Host-Specific Immune Signature Associated with Dengue.

In tropical and subtropical regions, dengue fever is a common febrile illness that is mostly spread by Aedes mosquitoes. Urban population migration, inadequate water storage facilities, and high mosquito density are features associated with this disease. The severity of the illness ranges from mild to deadly dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS), often with severe cases causing profound shock from extensive plasma leakage, and may result in demise. The symptoms of the illness include headache, myalgia, retro-orbital pain, and hemorrhagic signs. There may also be an intermittent shift in blood vessel integrity and coagulation, but recovery is typically complete and rapid. In this review, we emphasize the immunological aspects of this illness. The intricate interactions among the virus, host genes, and host immune systems impact the pathophysiology of dengue. Postinfection antibody-dependent enhancement is prominent, which significantly influences the etiology and virulence of the disease. Whereas the severe form only manifests when the host immune system is actively working to eradicate the infection by secreting several inflammatory cytokines, chemokines, and lipid mediators, for example, early dengue virus infection (DVI) resulted in the production of Interleukin 2 (IL-2), IL-6, and later infection, IL-4, IL-5, and IL-10. Higher concentrations of interferons gamma (IFN-gamma), granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage migration inhibitory factor (MIF), IL-1, IL-2, IL-4, IL-6, IL-7, IL-10, IL-12, and IL-13 were found in DHF patients. These are significantly more prevalent in severe infections than in mild ones. Numerous immunopathogenic processes involving both virus and host variables influence the severity of dengue. There is growing evidence that a compromised immune system limits viral clearance and causes severe inflammation, which in turn causes dengue hemorrhagic fever and dengue shock syndrome. Furthermore, the capacity of DENV to infect a broad range of immune cells, such as macrophages, dendritic cells, mast cells, T and B cells, and monocytes, further dysregulates these cells' antiviral activities, leading to the spread of the virus. Even though a number of risk factors linked to the advancement of the disease have been suggested, further research and evaluation of novel technologies are necessary to understand the complicated etiology and develop reliable and effective vaccines to fight against this febrile illness.

Prolonged Impella 5.0/5.5 support within different pathways of care for cardiogenic shock: the experience of a referral center.

Impella 5.0 and 5.5 are promising low-invasive left ventricle (LV) temporary mechanical circulatory supports (tMCS) for cardiogenic shock due to LV mechanical unloading and are paired with powerful hemodynamic support. This study aimed to analyze data and destinies of patients supported with Impella 5.0/5.5 at a national referral center for cardiogenic shock and to assess the parameters associated with myocardial recovery and successful weaning. A single-center observational study was conducted on all patients treated with Impella 5.0 or 5.5 from March 2018 to July 2023. A total of 59 patients underwent Impella 5.0/5.5 implantation due to profound cardiogenic shock, with acute myocardial infarction being the most frequent cause of shock (42 patients, 71%). The median duration of Impella support was 13 days (maximum duration of 52 days). Axillary cannulation was feasible in almost all patients, and 36% were mobilized during support. A total of 44 patients (75%) survived to the next therapy/recovery: 21 patients experienced recovery and 15 and 8 were bridged to long-term LVAD and heart transplantation, respectively. The global survival rate was 66%. The predictors of native heart recovery at multivariate analysis were the number of days on tMCS before upgrade to Impella 5.0/5.5 [hazard ratio (HR) 0.68 (0.51-9) p = 0.0068] and improvement of LVEF within the first 7-10 days of support [HR 4.72 (1.34-16.7), p = 0.016]. Transcatheter systems such as Impella 5.0/5.5 revolutionized the field of tMCS. Myocardial recovery is the primary clinical target. Its prognostication and promotion are key to ensure the most proficuous course for each patient from cardiogenic shock to long-term event-free survival.

The Dual Faces of growth: Linear and non-linear effects of industrialization, financial development and natural resource rents on China's economy

The literature on driving indicators of economic growth shows diverse findings and commonly derives symmetric relationships. The current research aims to observe the linear and non-linear influence of primary indicators of interest. The results reveal that industrial value-added positively, while urbanization negatively influences China's short and long-term economic growth. Conversely, natural resource rents exhibit no immediate positive effect but contribute to long-term economic growth. A positive change in industrial value and financial development enhances economic growth with a more profound positive shock in the short and long run. Simultaneously, their negative change reduces the economic growth in China. Whether positive or negative, fluctuations in natural resource rents contribute to economic growth, waving the asymmetric dynamic in the short and long run. Further, urbanization boosts economic expansion during negative shocks but lacks significance during positive shocks in both short and long runs. Moreover, the frequency domain causation approves the structural transformation. In the same scenario, notable discrepancies in wavelet decomposition show significant fluctuations across all series, contributing to economic growth. To boost both immediate and sustained economic growth, investing in industries focused on value addition and refining urban planning to balance growth between megacities and smaller emerging urban areas is essential.

Examining Monetary Policy Measures and Their Impacts during and after the COVID Era: OECD Perspectives

Governments worldwide implemented various fiscal and monetary measures to address the adverse impacts of COVID-19 on their economies. The paper aims to examine the changes in the monetary policy measures due to COVID-19 and their impact on macroeconomic variables. To explore this relationship, this study utilizes fortnightly data from 2020 to 2023 on the OECD (Organisation for Economic Co-operation and Development) countries. The study employs a Panel Autoregressive Distributed Lag (ARDL) model to analyze the effects of the monetary policy responses of the OECD governments, and the obtained results reveal that within OECD countries, the prevailing trend of lower interest rate policies emerged during the pandemic. This policy approach yielded a dual effect: lowering both output growth and inflation rates, while concurrently exacerbating unemployment rates throughout the COVID-19 period. Consequently, it is clear that monetary policies have played a pivotal role in facilitating the recovery from a profound economic shock such as the COVID-19 pandemic. Given the significant economic repercussions of a pandemic and the crucial role that monetary policy plays in sustaining economic stability, the apparent lack of attention underscores the urgent necessity for additional discourse on this vital subject.

Unravelling the credit market shocks and investment dynamics: A theoretical and empirical perspective

This paper investigates the underlying credit market shocks that historically affected business investment in the Slovenian economy. In contrast to the existing literature, we explore more profound structural shocks beneath the credit demand and supply shocks. For the purpose of structural identification, we propose a theoretical model of the credit market that reveals the credit market imperfections on the side of credit supply as well as liquidity demand. The theoretical structure justifies our set of identifying restrictions, further evaluated with the structural Bayesian VAR model. Our results confirm the relevance of loan supply shocks for the business investment activity, suggesting the existence of credit market imperfections. Furthermore, business investment is strongly conditioned by liquidity demand shocks, which explain a significant part of the variation in investment activity. Even though loan supply shocks constrained the investment activity in Slovenia during the financial crisis, the results of our analysis suggest that banks predominantly reacted to the increasing financial risk as opposed to the changes in their profit functions. Based on the results, we may conclude that in the common monetary area, fiscal policy should implement country-specific measures to effectively address the business sector's expectations regarding the economy's medium- and long-term development.

Resuscitative endovascular balloon occlusion of the aorta in trauma management: a comprehensive study of clinical indications and challenges

BackgroundThe application of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma resuscitation, including for profound shock and cardiac arrest, has gained prominence. This study aimed to determine the...

Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study

Background Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures. Methods Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min. Results Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures. Conclusion In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

Deploying whole blood to the battlefield-The Israel Defense Forces Medical Corps initial experience during the 2023 war.

Military and prehospital medical organizations invest significant resources to advance the treatment of trauma patients aiming to reduce preventable deaths. Focus is on hemorrhage control and volume resuscitation with blood products, with adoption of Remote Damage Control Resuscitation (RDCR) guidelines. The Israel Defense Forces Medical Corps (IDF-MC) has been using tranexamic acid and freeze-dried plasma (FDP) as part of its RDCR protocol for more than a decade. In recent years, low-titer group O whole blood (LTOWB) has been integrated, on IDF evacuation helicopters and expanded to mobile ambulances, complementing FDP use in treating trauma patients in state of profound shock. During the war that erupted in October 2023, the IDF-MC made a decision to bring LTOWB forward, and to equip every combat brigade level mobile intensive care units with LTOWB, onboard armored vehicles. The goal was to make whole blood available as close as possible to the point of injury and within minutes from time of injury. We describe the IDF-MCs' efforts to bring LTOWB to the front lines and present four cases in which LTOWB was administered. All patients were young male, with significant blood loss following penetrating injuries. One patient died in the operating room, following hospital arrival and emergency thoracotomy. The others survived. Our initial experience with bringing LTOWB as close as possible to the point of injury during high intensity fighting is encouraging, showing patient benefit along with logistic feasibility. After action reports and data collection will continue.

Looking Back, Going Forward: Understanding Cardiac Pathophysiology from Pressure-Volume Loops.

Knowing cardiac physiology is essential for health care professionals working in the cardiovascular field. Pressure-volume loops (PVLs) offer a unique understanding of the myocardial working and have become pivotal in complex pathophysiological scenarios, such as profound cardiogenic shock or when mechanical circulatory supports are implemented. This review provides a comprehensive summary of the left and right ventricle physiology, based on the PVL interpretation.

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis.

The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: -0.076, 95%-CI: -0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.

Pediatric Profound Dengue Shock Syndrome and Use of Point-of-Care Ultrasound During Mechanical Ventilation to Guide Treatment: Single-Center Retrospective Study, 2013-2021.

Profound dengue shock syndrome (DSS) complicated by severe respiratory failure necessitating mechanical ventilation (MV) accounts for high case fatality rates among PICU-admitted patients. A major challenge to management is the assessment of intravascular volume, which can be hampered by severe plasma leakage and the use of MV. Retrospective cohort, from 2013 to 2021. Sixty-seven children with profound DSS supported by MV, some of whom underwent bedside point-of-care ultrasound (POCUS) for assessment and monitoring of hemodynamics and fluid administration. PICU of the tertiary Children's Hospital No. 2 in Vietnam. None. We analyzed data clinical and laboratory data during PICU stay. In particular, during use of MV (i.e., at times 0-, 6-, and 24-hr after commencement) and fluid resuscitation. The primary study outcome was 28-day in-hospital mortality, and the secondary outcomes were associations with changes in hemodynamics, blood lactate, and vasoactive-inotrope score (VIS). Patients had a median age of 7 years (interquartile range, 4-9). Use of POCUS during fluid management (39/67), as opposed to not using (28/67), was associated with lower mortality (6/39 [15%] vs. 18/28 [64%]; difference 49 % [95% CI, 28-70%], p < 0.001). Use of POCUS was associated with lower odds of death (adjusted odds ratio 0.17 [95% CI, 0.04-0.76], p = 0.02). The utilization of POCUS, versus not, was associated with greater use of resuscitation fluid, and reductions in VIS and pediatric logistic organ dysfunction (PELOD-2) score at 24 hours after MV and PICU discharge. In our experience of pediatric patients with profound DSS and undergoing MV (2013-2021), POCUS use was associated with lower odds of death, a higher volume of resuscitation fluid, and improvements in the blood lactate levels, VIS, and PELOD-2 score.

Using crises to leverage change and build resilience: Legacies and learnings from shocks

Abstract Background The economic crisis of 2008 and the Covid-19 pandemic acted as profound shocks on health systems around the world. During the financial crisis, Ireland was one of five European countries to receive a bailout from the Troika. The loss of sovereignty in governance and six austerity budgets created a huge challenge for the Irish health system and its ability to be resilient in the face of long-lasting shock. These constraints on resources and a shift in governance meant that Ireland's health infrastructure was weak going into the Covid-19 pandemic. Furthermore, the depletion of workforce numbers and low morale also presented challenges. Methods Semi-structured interviews were conducted with seven senior stakeholders as part of the wider RESTORE research project, following ethical approval from the research Institution. Nvivo software was used to conduct thematic analysis independently by three researchers. Results The financial crisis deeply impacted the Irish health system throughout the years of austerity. Due to these legacy issues, the system was in a relatively weak position when faced with the Covid-19 pandemic. Furthermore, a lack of long-term planning was evident during the recovery period and the system was unable to reverse many of the negative impacts brought on during austerity. However, the system proved adaptive and innovative in response to Covid-19, and the pandemic proved to be a catalyst for positive change, providing opportunities for long-term reform, alongside an immediate response to the crisis. This was facilitated by increased funding and a devolution in decision-making structures. Conclusions The findings raise the question of whether health systems are entering a state of permacrisis and if so what can be done to promote resilience and prepare for future shocks. Furthermore, it asks whether health systems should put resources into acute shocks or everyday crises and explores the relationship between these two foci and resilience.

S2426 Profound Hypovolemic Shock from Cemiplimab Induced Colitis: A Case Report

S2426 Profound Hypovolemic Shock from Cemiplimab Induced Colitis: A Case Report

Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience.

Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges. In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB. Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge. The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.

Extracorporeal Blood Purification with CytoSorb in 359 Critically Ill Patients

Introduction: Critically ill patients with inflammatory dysregulation and organ disfunction may benefit from blood purification, although the use of this technique has not been described in large case series. We evaluated clinical outcomes and survival in high-risk intensive care unit (ICU) patients who underwent extracorporeal blood purification. Methods: 359 consecutive ICU patients treated with CytoSorb were included. Results: Main admission diagnoses were 120 (34%) refractory cardiac arrest under mechanical chest compression; 101 (28%) profound cardiogenic shock; 81 (23%) post-cardiotomy cardiogenic shock; and 37 (10%) respiratory failure. Fifteen patients (4%) were positive for SARS-CoV-2 infection. We observed 49% 30-day mortality, 57% ICU mortality, and 62% hospital mortality, all lower than the 71% mortality predicted by SAPS II and 68% predicted by SOFA score. Parameters of shock and organ failure, above all vasoactive inotropic score, reduced during CytoSorb treatment. Multivariable analysis identified SAPS II, lactate dehydrogenase, ICU stay duration, vasoactive inotropic score, lactates, intra-aortic counterpulsation on top of VA-ECMO, and total bilirubin as predictors of mortality. No CytoSorb-related complications occurred. Conclusion: CytoSorb treatment was effective in reducing laboratory parameters of shock and vasoactive inotropic score with possible survival implications in a large population of critically ill patients.

Circulatory shock in adults in emergency department.

Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.

Cardiopulmonary Resuscitation

Cardiopulmonary Resuscitation

Evaluation of novel hemostatic agents in a coagulopathic swine model of junctional hemorrhage.

Hemostatic dressings are used extensively in both military and civilian trauma to control lethal noncompressible hemorrhage. The ideal topical hemostatic agent would provide reliable hemostasis in patients with profound acidosis, coagulopathy, and shock. This study aimed to compare next-generation hemostatic agents against the current military standard in a translational swine model of vascular injury and coagulopathy. Female Yorkshire swine were randomized to eight groups (total n = 63; control n = 14, per group n = 7) of hemostatic agents and included: QuikClot Combat Gauze (Teleflex, Morrisville, NC), which served as the control; BloodSTOP IX (LifeScience Plus, Mountain View, CA); Celox Rapid (Medtrade Product, Crewe, United Kingdom); ChitoSAM 100 (Sam Medical, Tualatin, OR); EVARREST Fibrin Sealant Patch (Ethicon, Raritan, NJ); TAC Wrapping Gauze (H&H Medical, Williamsburg, VA); ChitoGauze XR Pro (Tricol Biomedical, Portland, OR); and X-Stat 30 (RevMedX, Wilsonville, OR). Hemodilution via exchange transfusion of 6% hetastarch was performed to induce acidosis and coagulopathy. An arteriotomy was created, allowing 30 seconds of free bleeding followed by application of the hemostatic agent and compression via an external compression device. A total of three applications were allowed for continued/recurrent bleeding. All blood loss was collected, and hemostatic agents were weighed to calculate blood volume loss. Following a 180-minute observation period, angiography was completed to evaluate for technical complication and distal perfusion of the limb. Finally, the limb was ranged five times to assess for rebleeding and clot stability. All swine were confirmed coagulopathic with rotational thromboelastography and acidotic (pH 7.2 ± 0.02). BloodSTOP IX allowed a significant increase in blood loss and number of applications required to obtain hemostasis compared with all other groups. BloodSTOP IX demonstrated a decreased survival rate (29%, p = 0.02). All mortalities were directly attributed to exsanguination as a result of device failure. In surviving animals, there was no difference in extravasation. BloodSTOP IX had an increased rebleeding rate after ranging compared with QuikClot Combat Gauze ( p = 0.007). Most novel hemostatic agents demonstrated comparable efficacy compared with the currently military standard hemostatic dressing, CG.