Independent Research

1. WHY IS CELOX RAPID HAEMOSTATIC GAUZE STILL ONLY AN ALTERNATIVE IN THE TCCC GUIDELINES DESPITE OFTEN OUTPERFORMING QUIKCLOT COMBAT GAUZE? Ersin Saraç

Translated English:

CELOX Rapid Haemostatic Gauze has been the primary haemostatic dressing for more than a decade in the armed forces of the United Kingdom and several other NATO countries. Despite consistently demonstrating superior haemorrhage control in a number of experimental studies compared with QUIKCLOT Combat Gauze, it continues to be listed by the Tactical Combat Casualty Care (TCCC) guidelines as an approved alternative rather than the primary recommendation.

1. Mechanisms of Haemostasis

QUIKCLOT Combat Gauze (Kaolin)

QUIKCLOT Combat Gauze works through a coating of kaolin, an aluminum silicate clay mineral. When kaolin comes into contact with blood, it activates Factor XII (Hageman factor), initiating the intrinsic coagulation pathway. This accelerates thrombin generation and fibrin clot formation, meaning its effectiveness depends on the body’s natural coagulation cascade.

CELOX Gauze (Chitosan)

CELOX Gauze contains chitosan, a naturally derived cationic polysaccharide. Unlike kaolin, chitosan acts independently of the classical coagulation cascade. It binds to red blood cells, promotes platelet activation, and forms a strong physical barrier over the wound. As a result, it remains effective even in patients with coagulopathy or those receiving anticoagulant therapy.

Standard Sterile Gauze

Standard sterile gauze contains no active haemostatic agent. It relies solely on pressure and absorption and depends entirely on the patient’s own clotting ability.

2. Haemostasis Times According to TCCC

Current TCCC guidance recommends maintaining at least 3 minutes of direct pressure when applying haemostatic gauze.

• QUIKCLOT Combat Gauze: ~3–5 minutes (Primary recommendation)
• CELOX Gauze: ~2–4 minutes (Approved alternative)
• Standard Sterile Gauze: ~8–12 minutes (Not recommended for severe haemorrhage)

In Kheirabadi’s standardized porcine femoral artery model, CELOX Rapid achieved 75% haemostasis without external compression, compared with 38% for Combat Gauze.

3. Performance in Different Types of Bleeding

Studies have shown that CELOX Gauze performs particularly well in severe arterial bleeding, with lower blood loss and higher survival rates in several animal models. Both CELOX and QUIKCLOT perform well in venous bleeding, while standard gauze is often inadequate for high-flow haemorrhage.

The greatest difference is seen in hypothermic and coagulopathic casualties. Because CELOX acts independently of the coagulation cascade, it maintains effectiveness during hypothermia, acidosis, haemodilution, and anticoagulant use. QUIKCLOT, which depends on activation of the coagulation cascade, may be less effective under these conditions.

4. Complications

Both modern QUIKCLOT Combat Gauze and CELOX Gauze are non-exothermic and do not generate clinically significant heat.

CELOX demonstrates stronger tissue adhesion, reducing the risk of rebleeding during casualty transport, although it may require more careful removal. QUIKCLOT has an extensive safety record, while purified medical-grade chitosan used in CELOX has shown excellent biocompatibility and antimicrobial properties.

5. Why Does TCCC Still Recommend Combat Gauze First?

According to the evidence reviewed, five principal reasons explain the current TCCC recommendation:

1. Historical timing – Combat Gauze was available in gauze form when TCCC made its original decision in 2008; CELOX was not.
2. Limited evidence at the time – The advantages of CELOX under coagulopathic conditions were demonstrated only in later studies.
3. Greater U.S. military experience – Combat Gauze had already accumulated extensive operational use and a well-established safety record.
4. Statistical thresholds – Although several studies favoured CELOX, the differences were not always statistically significant enough to justify changing military guidelines.
5. Institutional risk management – Large-scale changes require overwhelming evidence, extensive safety data, training, procurement, and logistical changes.

Conclusion

Combat Gauze remains the TCCC’s primary recommendation because of its extensive operational history, established safety profile, and logistical integration.

CELOX Gauze offers several potential advantages, including faster haemostasis, improved performance in hypothermic and coagulopathic patients, reduced blood loss, and stronger resistance to rebleeding during transport. These factors have led the United Kingdom and several other NATO nations to adopt CELOX as their primary battlefield haemostatic dressing.

Ultimately, this reflects the difference between scientific evidence and institutional decision-making. While CELOX may outperform Combat Gauze in several important scenarios, changing a military clinical guideline requires overwhelming evidence, long-term safety data, and consideration of operational, training, and supply-chain implications.

Original LinkedIn post by Ersin Saraç. English translation and republication with the author’s permission.

(21) ŞİDDETLİ KANAMA DURDURMADA ”QUICKCLOT COMBAT GAZLI BEZ Mİ? YOKSA ”CELOX RAPID” Mİ? | LinkedIn