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Volume 17, Issue 4 (2025)
3 2025, 17(4): 355-360 |
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Received: 2025/10/6 | Accepted: 2025/11/13 | Published: 2025/11/19
Received: 2025/10/6 | Accepted: 2025/11/13 | Published: 2025/11/19
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Mohammadebrahimi H, Rasooli S, Dorri S, Shahraki S. Development of the “AJA” Haemostatic Pack for Prehospital and Battlefield Haemorrhage Control. 3 2025; 17 (4) :355-360
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1- Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2- PhD Candidate, Department of Health Care Management, Faculty of Health, Tehran Medical Science, Islamic Azad University, Tehran, Iran
2- PhD Candidate, Department of Health Care Management, Faculty of Health, Tehran Medical Science, Islamic Azad University, Tehran, Iran
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Introduction
In today’s modern world, despite numerous advancements in medical science, hemorrhagic shock remains the leading cause of mortality on the battlefield and the second leading cause of death in civilian trauma [1]. Hemorrhage is recognized as the foremost preventable cause of death following trauma [2]. On the battlefield, not only is the time available for controlling bleeding limited, but the severity of wounds and the high likelihood of multiple concomitant injuries further complicate wound management [3]. Coagulopathy, hypothermia, infection, and multi-organ damage are among the potential complications associated with severe hemorrhage, of which coagulopathy represents the primary consequence of bleeding in trauma patients [4, 5].
More than 25% of patients suffering from hemorrhage develop coagulopathy by the time they arrive at the emergency department, a condition that is one of the leading causes of both early and late mortality [4]. Therefore, effective hemorrhage management in prehospital settings and empowering injured individuals to control bleeding are top priorities for emergency response teams and healthcare management authorities, as these measures significantly reduce mortality rates and secondary complications.
Throughout history, humanity has continually sought effective methods for hemorrhage control—efforts that have been most prominently reflected in battlefield medicine. Blackbourne et al. identified combat wound management as one of the hallmarks of the military medical revolution, referring to this evolution as a “medical earthquake” [6]. Between the 16th and 18th centuries, various rudimentary methods, such as pouring hot oil or gunpowder onto bleeding wounds, were employed to achieve hemostasis. In the 19th century, during the American Civil War and the Crimean War, significant advancements emerged in hospital systems, anesthesia, antisepsis, and nursing care. During World War I and World War II, the widespread use of antibiotics, blood transfusions, positive-pressure ventilation for penetrating lung injuries, traction for femoral fractures, and surgical interventions for hemorrhage control became established practices. In the Korean and Vietnam wars, further progress was made with the introduction of renal dialysis, the use of medical evacuation helicopters, vascular repair techniques, and the identification of acute respiratory distress syndrome (ARDS) in non-penetrating lung injuries to improve hemorrhage management. In the Iraq and Afghanistan wars, the application of tourniquets, topical hemostatic agents and dressings, the prevention of hypothermia, and the treatment of hypotension gained significant attention and were extensively utilized [7].
This ongoing pursuit of improved strategies for hemorrhage management in both military and civilian settings remains one of the key priorities for modern governments. Today, researchers continue to seek the most effective and rapid-acting hemostatic agents capable of achieving relatively stable hemostasis. Hemostatic agents, defined as substances that promote blood clot formation [8], can play a crucial role in achieving hemostasis in prehospital environments and preventing hemorrhage-related mortality [1]. Pusateri et al. state that an ideal, high-quality hemostatic agent suitable for use in battlefield or prehospital conditions should possess several essential characteristics, including the ability to stop arterial and major venous bleeding within two minutes of application, with effective absorption at the bleeding site, readiness for immediate use without the need for on-site mixing or pre-application preparation, ease of application by the injured person, a fellow soldier, or a medic with minimal training, a lightweight and easily portable design, a minimum shelf life of two years under environmental conditions ranging from –10°C to +55°C, and safe usage, with no risk of additional tissue injury or infection transmission; 7. cost-effectiveness and affordability [2, 9].
Although the introduction of hemostatic dressings and agents represents one of the most significant medical advancements in recent decades, no truly ideal hemostatic agent has yet been identified [1]. Therefore, based on these considerations, the primary objective of this research project was to design and develop the most effective hemostatic pack possible for hemorrhage control in both military and civilian contexts—one that maximally fulfills the criteria defined by Pusateri et al. [2].
In minor wounds, gentle pressure or basic first-aid measures is often sufficient to stop bleeding. However, in cases of major trauma, extensive surgery, or battlefield injuries, such basic interventions are inadequate, and more advanced and comprehensive measures are required [8]. Today, various hemostatic agents are employed worldwide to control bleeding. During the Iraq War, the U.S. Army implemented the use of tourniquets, and follow-up assessments demonstrated that their application led to a notable decrease in morbidity, a reduced risk of limb amputation, a significant reduction in the incidence of shock, and a marked improvement in survival rates [10]. Another widely adopted method in advanced military systems involves the use of modern medicated dressings. Some of the hemostatic agents incorporated in these dressings—reported in the literature to accelerate hemostasis—include kaolin, a clay-derived mineral that effectively promotes clotting but does not undergo proper metabolic processing in the human body and can remain indefinitely within tissues [8, 11]; zeolite, a mineral composed of silicon, aluminum, sodium, magnesium oxides, and quartz, known as a rapid coagulant that, while highly effective, produces heat during water absorption, posing a risk of tissue injury and burns [12]; chitosan, a biopolymer with a favorable metabolic profile and relatively low production cost; and dry fibrin sealant, which is more effective than chitosan but considerably more expensive to produce [13, 14].
This study aimed to develop a hemostatic pack for hemorrhage control in both military and civilian environments, incorporating key attributes of an ideal product.
Materials and Methods
This design-and-development study, conducted in 2023, aimed at producing a hemostatic pack and was carried out in three distinct phases, including production of chitosan-impregnated gauze, design and fabrication of a self-aid tourniquet, and product design and packaging.
In phase I, shrimp shells were obtained from local shrimp farms. The shells were thoroughly washed with clean water and then spread under direct sunlight for a full day to ensure complete drying. The dried shells were subsequently crushed into small particles ranging from 2 to 6mm in size. Due to the lack of industrial equipment at this stage, the research team used a Moulinex household grinder, processing the shells in several rounds until the desired consistency was achieved. The resulting powder was sieved to obtain a uniform particle size, and its suitability for further processing was verified by a consulting pharmacist and chemist.
To maintain consistency in subsequent steps, the resulting powder was divided into 100-gram portions. A few drops of salicylic acid were added to each 100-gram sample, which was then left at room temperature for four hours. The powder was subsequently immersed in one liter of 7% hydrochloric acid (HCl) at room temperature for 24 hours to remove mineral components, such as calcium carbonate and calcium phosphate. The mixture was filtered, and the remaining solid residue was washed thoroughly with distilled water and re-filtered to ensure complete removal of residual acid.
The remaining shell material was then immersed in one liter of 10% sodium hydroxide (NaOH) solution for another 24 hours to eliminate organic substances such as proteins, lipids, and pigments. After filtration and repeated washing with distilled water, the final powder was oven-dried at 50°C for six hours.
In the next step, chitosan was produced through the deacetylation of chitin using a 50% sodium hydroxide solution. Specifically, the dried chitin powder was added to the alkaline solution and exposed to microwave heating for 20 minutes. The material was then washed again with distilled water, filtered, and dried, yielding the final chitosan product.
In most industrialized countries, an autoclave is typically used for the deacetylation process, operating at approximately 120°C for 4 to 6 hours in the presence of sodium hydroxide. In contrast, the research team utilized a microwave-based method, which represents a more modern and efficient approach—reducing the reaction time from six hours to twenty minutes—while eliminating the need for costly industrial equipment and specialized pressure chambers.
Throughout the production phase, the research team repeated the chitosan extraction process several times using 100-gram batches of shrimp shells to refine and optimize the procedure. Ultimately, from each 100-gram batch of shrimp shells, approximately 5 to 15g of high-quality chitosan were obtained.
In phase II, to design the tourniquet, the research team modeled it after the U.S. military’s Combat Application Tourniquet (CAT). There is no equivalent domestic product, and the team specifically based their design on the seventh-generation CAT. Due to the proprietary nature of the original product and its high cost, the team recreated the tourniquet using reference images and the closest available materials in the local market.
The primary materials included a 6-cm-wide polypropylene strap, plastic buckles and clips, and a rotating rod sourced from a suitcase handle. The initial strap length was set at 120cm but was later revised to 105 cm and ultimately finalized at 95cm. Industrial sewing machines were employed to stitch the straps securely. The final prototype weighed approximately 300g, making it heavier than the U.S. model, which weighs around 120g.
In phase III, for the packaging of the chitosan-impregnated gauze, V-Pack paper was used due to its superior sterility and extended shelf life of up to nine months. The packs were sterilized in a hospital autoclave. In addition, Surgifix was procured as another component of the pack. The rationale for using Surgifix lies in its ease of application, minimal time requirements, low training demands, portability, lightweight design, and avoidance of the complexities associated with other tools such as adhesive dressings or bandages. For example, adhesive dressings require careful removal of the protective layer using a fingernail. If the adhesive sticks to the medicated portion, separating it becomes difficult, potentially rendering it ineffective during an emergency. Similarly, the proper application of a bandage necessitates correct handling of the roll, precise wrapping, and secure fixation with a clip or knot—a process that can be particularly challenging in self-aid situations, especially if the injured limb is the hand and the individual has limited use of the other hand.
Finally, all components of the pack—including the sterile gauze, tourniquet, and Surgifix—were placed in a durable, thick zip-lock polyethylene pouch. This packaging method was chosen for its strength, minimal weight, and low cost, making it suitable for the product. The complete pack was then further sealed using heat-shrink packaging to enhance durability and shelf life.
Findings
The research team successfully produced sterile gauze impregnated with chitosan powder. For each gauze piece, 15g of chitosan powder derived from shrimp shells was applied in dry form. The team prepared 10-cm-wide V-Pack paper (considered the most suitable dimension for single-roll packaging of gauze) and used a Class A autoclave test as a sterility indicator to produce 10 prototype packs. The packs were then delivered to the hospital’s CSR officer—one of the investigators—so that, following the hospital’s sterilization protocol, the research team’s packs could be sterilized in the autoclave and returned for further evaluation.
A prototype of the self-aid tourniquet was designed and manufactured, inspired by modern military models. The strap of the tourniquet was finalized at a length of 95cm. The final product weighed approximately 300g, making it heavier than the U.S. model, which weighs 125g. With the procurement of Surgifix, the components of the hemostatic pack were effectively completed.
For final packaging, Surgifix was procured as the final component of the AJA hemostatic pack. In practice, after the injured individual applies the tourniquet to the affected limb and exerts pressure, the hemostatic gauze is opened and placed directly on the wound. Surgifix, which is compatible with all limbs, is then applied over the gauze to secure it in place.
After the production and procurement of all components, they were assembled into a complete package. This package included a chitosan-impregnated gauze, a self-aid tourniquet, and a Surgifix, all enclosed within a thick, durable zip-lock polyethylene pouch. To enhance durability and shelf life, the entire package was further secured using heat-shrink polyethylene. The packaging was designed to be lightweight and compact while allowing rapid and easy access in emergency situations.
The rationale for this packaging choice was to ensure both ease of use and portability, allowing the entire pack to fit conveniently into a soldier’s or emergency responder’s bag or backpack. Cardboard packaging was deemed unsuitable due to its weight, susceptibility to water penetration, and tendency to degrade over time. Packaging as a small plastic bag or suitcase produced via 3D printing or CNC machines, although advantageous in some respects, was not practical due to the significantly higher production costs.
Therefore, the team opted for robust polyethylene pouches similar to those used by the Iranian postal service for parcel delivery. These pouches provide the necessary strength, fit easily into responders’ backpacks, are lightweight, inexpensive, and offer adequate protection against air, dust, and moisture. The research team unanimously agreed that this packaging was suitable for enclosing the AJA hemostatic pack. To further enhance durability and longevity during transport and field use, the entire pack was subsequently sealed using heat-shrink wrapping.
Discussion
This study aimed to develop a hemostatic pack for hemorrhage control in both military and civilian environments, incorporating key attributes of an ideal product. The AJA hemostatic pack, comprising chitosan-impregnated gauze, a self-aid tourniquet, and Surgifix enclosed in a durable polyethylene pouch with heat-shrink wrapping, offered a comprehensive, portable solution for prehospital and battlefield hemorrhage control. This aligns with the need for rapid and effective interventions in trauma settings, where uncontrolled bleeding remains a leading cause of preventable death [15]. The successful production of sterile chitosan-impregnated gauze using 15g of shrimp-derived chitosan powder per piece demonstrated a practical approach to enhancing hemostatic efficacy. Chitosan-based agents promote clot formation through electrostatic interactions with erythrocytes, independent of host coagulation pathways, making them particularly suitable for coagulopathic conditions common in severe trauma [15].
This is consistent with narrative reviews emphasizing the advantages of chitosan dressings, like Celox Gauze and ChitoGauze, which achieve hemostasis in 70-90% of prehospital cases and are recommended for junctional and extremity bleeding in military protocols [15]. Recent studies have confirmed the efficacy of chitosan in controlling severe hemorrhage, even under conditions where the body’s coagulation system is impaired, such as hypothermia or anticoagulant therapy [16-18]. Published research from 2015 to 2025, including studies by Javanmardi et al. [19], the Department of Science and Technology, India [20], and others [14], has demonstrated that chitosan, due to its high biocompatibility, antimicrobial properties, and biodegradability, outperforms hemostatic agents based on zeolite or kaolin, which may cause tissue burns or leave residual particles in the body [12, 21].
Furthermore, the use of V-Pack paper for single-roll packaging and autoclave sterilization ensures sterility and ease of deployment, addressing logistical challenges in field environments. This is similar to lessons from battlefield applications, where quick application and biocompatibility are critical for reducing mortality [22].
The design of the self-aid tourniquet, finalized at 95cm in length and weighing approximately 300g, draws inspiration from modern military models but is heavier than the U.S. standard (125g), potentially impacting portability. However, its emphasis on self-application aligns with evidence-based guidelines advocating for tourniquets as the first line of defense for extremity hemorrhage when direct pressure fails, with military studies showing survival rates of up to 92% [10].
Research has shown that the use of validated commercial tourniquets achieves a high success rate in controlling limb hemorrhages [14]. However, in the context of handmade or “DIY” tourniquets, multiple reports indicate a failure rate exceeding 85%, often due to insufficient pressure or inappropriate materials [23]. Despite these challenges, the design implemented in this project focuses on pressure mechanisms and lockable buckles to improve the effectiveness of a handmade tourniquet. This weight difference may reflect material choices optimized for durability in resource-limited settings, although future iterations could incorporate lighter composites to enhance user mobility, as suggested by reviews of tourniquet efficacy in prehospital trauma, where rapid occlusion of arterial flow significantly reduces blood loss [23].
Integrating the tourniquet with hemostatic gauze and Surgifix facilitates a sequential approach—tourniquet application followed by gauze placement and fixation—which mirrors joint position statements recommending the combined use of tourniquets, wound packing, and hemostatic dressings for comprehensive control, particularly in self-aid scenarios where training demands are low [24].
The procurement of Surgifix as a compatible, lightweight fixation tool overcomes the limitations of traditional bandages or adhesive dressings, such as difficulties in emergency removal or secure wrapping with one hand, thereby minimizing time and complexity in application [25]. This rationale is supported by lessons learned from the use of hemostatic dressings, where ease of application and portability are key to effective bleeding control in austere environments, reducing the risk of rebleeding and enabling intervention by laypersons or injured individuals [25].
The final packaging, contained in a thick zip-lock polyethylene pouch and further secured with heat shrink, prioritizes compactness, water resistance, and rapid access, contrasting with unsuitable options like cardboard due to degradation risks. This choice aligns with systematic reviews advocating for robust, inexpensive packaging to protect agents against environmental factors in prehospital systems [11]. Compared to high-cost alternatives like 3D-printed cases, this option enhances affordability and scalability, echoing availability surveys in civilian EMS, where low-cost adoption barriers influence the utilization of hemostatic agents [26].
Overall, the AJA pack’s components address gaps in current prehospital tools by combining mucoadhesive chitosan for direct wound hemostasis [3], mechanical tourniquet occlusion [10], and elastic fixation for sustained pressure [27]. Evidence from combat casualty care reviews indicates that these components have comparable efficacy to established products like QuikClot Combat Gauze and Celox in reducing blood loss and improving survival [7]. The pack’s design supports tactical combat casualty care (TCCC) principles, in which integrated kits enable massive hemorrhage control in tactical field care, potentially translating military lessons to civilian hospitals for scenarios such as postpartum or surgical bleeding [22].
The AJA hemostatic pack can serve as a critical tool for the initial management of trauma in civilian settings, such as road traffic accidents, which are the second leading cause of death in Iran and the primary contributor to years of life lost [28, 29]. Given that a significant proportion of these deaths result from uncontrolled hemorrhage during the first minutes following an incident, this product has the potential to substantially reduce fatalities by enabling non-specialists to provide immediate first-aid care [21, 28].
Limitations include the tourniquet’s increased weight, which may necessitate optimization, as well as the need for clinical trials to validate field efficacy beyond prototypes, since preclinical animal models often overestimate human outcomes [11]. Future research should evaluate the AJA pack’s performance in randomized controlled trials, focusing on time to hemostasis, user training, and cost-effectiveness in diverse trauma populations [28]. This development contributes to evolving hemostatic strategies, emphasizing accessible, multi-component packs to mitigate hemorrhage-related mortality in resource-constrained settings [7].
This research successfully designed and developed a hemostatic pack comprising chitosan-impregnated gauze and a self-aid tourniquet. Although the preliminary results are promising, further studies are required to fully validate the product’s efficacy and confirm its safety, including animal models and clinical trials conducted under appropriate ethical approvals. Additionally, optimizing the weight and dimensions of the tourniquet to enhance portability represents the next step toward preparing the product for commercialization.
Conclusion
The AJA hemostatic pack represents a low-cost, indigenous solution for prehospital hemorrhage control, promoting self-sufficiency in emergency medical systems.
Acknowledgments: We would like to extend our heartfelt thanks to the National Center for Strategic Research in Medical Education (NSR).
Ethical Permissions: This research project, registered as a national initiative under the number 972074 was awarded the Bronze Medal in the Entrepreneurship category of the 10th National Olympiad of Medical Sciences Students in Iran. All phases of the study were carried out in accordance with the principles of ethics in biomedical research.
Conflicts of Interests: Nothing to declare.
Authors' Contribution: Mohammadebrahimi H (First Author), Methodologist/Main Researcher (40%); Rasooli SA (Second Author), Introduction Writer/Statistical Analyst (30%); Dorri S (Third Author), Discussion Writer (20%); Shahraki S (Fourth Author), Discussion Writer (10%)
Funding/Support: This research project was conducted with financial support and stepwise supervision from the National Center for Strategic Research in Medical Education (NSR).
In today’s modern world, despite numerous advancements in medical science, hemorrhagic shock remains the leading cause of mortality on the battlefield and the second leading cause of death in civilian trauma [1]. Hemorrhage is recognized as the foremost preventable cause of death following trauma [2]. On the battlefield, not only is the time available for controlling bleeding limited, but the severity of wounds and the high likelihood of multiple concomitant injuries further complicate wound management [3]. Coagulopathy, hypothermia, infection, and multi-organ damage are among the potential complications associated with severe hemorrhage, of which coagulopathy represents the primary consequence of bleeding in trauma patients [4, 5].
More than 25% of patients suffering from hemorrhage develop coagulopathy by the time they arrive at the emergency department, a condition that is one of the leading causes of both early and late mortality [4]. Therefore, effective hemorrhage management in prehospital settings and empowering injured individuals to control bleeding are top priorities for emergency response teams and healthcare management authorities, as these measures significantly reduce mortality rates and secondary complications.
Throughout history, humanity has continually sought effective methods for hemorrhage control—efforts that have been most prominently reflected in battlefield medicine. Blackbourne et al. identified combat wound management as one of the hallmarks of the military medical revolution, referring to this evolution as a “medical earthquake” [6]. Between the 16th and 18th centuries, various rudimentary methods, such as pouring hot oil or gunpowder onto bleeding wounds, were employed to achieve hemostasis. In the 19th century, during the American Civil War and the Crimean War, significant advancements emerged in hospital systems, anesthesia, antisepsis, and nursing care. During World War I and World War II, the widespread use of antibiotics, blood transfusions, positive-pressure ventilation for penetrating lung injuries, traction for femoral fractures, and surgical interventions for hemorrhage control became established practices. In the Korean and Vietnam wars, further progress was made with the introduction of renal dialysis, the use of medical evacuation helicopters, vascular repair techniques, and the identification of acute respiratory distress syndrome (ARDS) in non-penetrating lung injuries to improve hemorrhage management. In the Iraq and Afghanistan wars, the application of tourniquets, topical hemostatic agents and dressings, the prevention of hypothermia, and the treatment of hypotension gained significant attention and were extensively utilized [7].
This ongoing pursuit of improved strategies for hemorrhage management in both military and civilian settings remains one of the key priorities for modern governments. Today, researchers continue to seek the most effective and rapid-acting hemostatic agents capable of achieving relatively stable hemostasis. Hemostatic agents, defined as substances that promote blood clot formation [8], can play a crucial role in achieving hemostasis in prehospital environments and preventing hemorrhage-related mortality [1]. Pusateri et al. state that an ideal, high-quality hemostatic agent suitable for use in battlefield or prehospital conditions should possess several essential characteristics, including the ability to stop arterial and major venous bleeding within two minutes of application, with effective absorption at the bleeding site, readiness for immediate use without the need for on-site mixing or pre-application preparation, ease of application by the injured person, a fellow soldier, or a medic with minimal training, a lightweight and easily portable design, a minimum shelf life of two years under environmental conditions ranging from –10°C to +55°C, and safe usage, with no risk of additional tissue injury or infection transmission; 7. cost-effectiveness and affordability [2, 9].
Although the introduction of hemostatic dressings and agents represents one of the most significant medical advancements in recent decades, no truly ideal hemostatic agent has yet been identified [1]. Therefore, based on these considerations, the primary objective of this research project was to design and develop the most effective hemostatic pack possible for hemorrhage control in both military and civilian contexts—one that maximally fulfills the criteria defined by Pusateri et al. [2].
In minor wounds, gentle pressure or basic first-aid measures is often sufficient to stop bleeding. However, in cases of major trauma, extensive surgery, or battlefield injuries, such basic interventions are inadequate, and more advanced and comprehensive measures are required [8]. Today, various hemostatic agents are employed worldwide to control bleeding. During the Iraq War, the U.S. Army implemented the use of tourniquets, and follow-up assessments demonstrated that their application led to a notable decrease in morbidity, a reduced risk of limb amputation, a significant reduction in the incidence of shock, and a marked improvement in survival rates [10]. Another widely adopted method in advanced military systems involves the use of modern medicated dressings. Some of the hemostatic agents incorporated in these dressings—reported in the literature to accelerate hemostasis—include kaolin, a clay-derived mineral that effectively promotes clotting but does not undergo proper metabolic processing in the human body and can remain indefinitely within tissues [8, 11]; zeolite, a mineral composed of silicon, aluminum, sodium, magnesium oxides, and quartz, known as a rapid coagulant that, while highly effective, produces heat during water absorption, posing a risk of tissue injury and burns [12]; chitosan, a biopolymer with a favorable metabolic profile and relatively low production cost; and dry fibrin sealant, which is more effective than chitosan but considerably more expensive to produce [13, 14].
This study aimed to develop a hemostatic pack for hemorrhage control in both military and civilian environments, incorporating key attributes of an ideal product.
Materials and Methods
This design-and-development study, conducted in 2023, aimed at producing a hemostatic pack and was carried out in three distinct phases, including production of chitosan-impregnated gauze, design and fabrication of a self-aid tourniquet, and product design and packaging.
In phase I, shrimp shells were obtained from local shrimp farms. The shells were thoroughly washed with clean water and then spread under direct sunlight for a full day to ensure complete drying. The dried shells were subsequently crushed into small particles ranging from 2 to 6mm in size. Due to the lack of industrial equipment at this stage, the research team used a Moulinex household grinder, processing the shells in several rounds until the desired consistency was achieved. The resulting powder was sieved to obtain a uniform particle size, and its suitability for further processing was verified by a consulting pharmacist and chemist.
To maintain consistency in subsequent steps, the resulting powder was divided into 100-gram portions. A few drops of salicylic acid were added to each 100-gram sample, which was then left at room temperature for four hours. The powder was subsequently immersed in one liter of 7% hydrochloric acid (HCl) at room temperature for 24 hours to remove mineral components, such as calcium carbonate and calcium phosphate. The mixture was filtered, and the remaining solid residue was washed thoroughly with distilled water and re-filtered to ensure complete removal of residual acid.
The remaining shell material was then immersed in one liter of 10% sodium hydroxide (NaOH) solution for another 24 hours to eliminate organic substances such as proteins, lipids, and pigments. After filtration and repeated washing with distilled water, the final powder was oven-dried at 50°C for six hours.
In the next step, chitosan was produced through the deacetylation of chitin using a 50% sodium hydroxide solution. Specifically, the dried chitin powder was added to the alkaline solution and exposed to microwave heating for 20 minutes. The material was then washed again with distilled water, filtered, and dried, yielding the final chitosan product.
In most industrialized countries, an autoclave is typically used for the deacetylation process, operating at approximately 120°C for 4 to 6 hours in the presence of sodium hydroxide. In contrast, the research team utilized a microwave-based method, which represents a more modern and efficient approach—reducing the reaction time from six hours to twenty minutes—while eliminating the need for costly industrial equipment and specialized pressure chambers.
Throughout the production phase, the research team repeated the chitosan extraction process several times using 100-gram batches of shrimp shells to refine and optimize the procedure. Ultimately, from each 100-gram batch of shrimp shells, approximately 5 to 15g of high-quality chitosan were obtained.
In phase II, to design the tourniquet, the research team modeled it after the U.S. military’s Combat Application Tourniquet (CAT). There is no equivalent domestic product, and the team specifically based their design on the seventh-generation CAT. Due to the proprietary nature of the original product and its high cost, the team recreated the tourniquet using reference images and the closest available materials in the local market.
The primary materials included a 6-cm-wide polypropylene strap, plastic buckles and clips, and a rotating rod sourced from a suitcase handle. The initial strap length was set at 120cm but was later revised to 105 cm and ultimately finalized at 95cm. Industrial sewing machines were employed to stitch the straps securely. The final prototype weighed approximately 300g, making it heavier than the U.S. model, which weighs around 120g.
In phase III, for the packaging of the chitosan-impregnated gauze, V-Pack paper was used due to its superior sterility and extended shelf life of up to nine months. The packs were sterilized in a hospital autoclave. In addition, Surgifix was procured as another component of the pack. The rationale for using Surgifix lies in its ease of application, minimal time requirements, low training demands, portability, lightweight design, and avoidance of the complexities associated with other tools such as adhesive dressings or bandages. For example, adhesive dressings require careful removal of the protective layer using a fingernail. If the adhesive sticks to the medicated portion, separating it becomes difficult, potentially rendering it ineffective during an emergency. Similarly, the proper application of a bandage necessitates correct handling of the roll, precise wrapping, and secure fixation with a clip or knot—a process that can be particularly challenging in self-aid situations, especially if the injured limb is the hand and the individual has limited use of the other hand.
Finally, all components of the pack—including the sterile gauze, tourniquet, and Surgifix—were placed in a durable, thick zip-lock polyethylene pouch. This packaging method was chosen for its strength, minimal weight, and low cost, making it suitable for the product. The complete pack was then further sealed using heat-shrink packaging to enhance durability and shelf life.
Findings
The research team successfully produced sterile gauze impregnated with chitosan powder. For each gauze piece, 15g of chitosan powder derived from shrimp shells was applied in dry form. The team prepared 10-cm-wide V-Pack paper (considered the most suitable dimension for single-roll packaging of gauze) and used a Class A autoclave test as a sterility indicator to produce 10 prototype packs. The packs were then delivered to the hospital’s CSR officer—one of the investigators—so that, following the hospital’s sterilization protocol, the research team’s packs could be sterilized in the autoclave and returned for further evaluation.
A prototype of the self-aid tourniquet was designed and manufactured, inspired by modern military models. The strap of the tourniquet was finalized at a length of 95cm. The final product weighed approximately 300g, making it heavier than the U.S. model, which weighs 125g. With the procurement of Surgifix, the components of the hemostatic pack were effectively completed.
For final packaging, Surgifix was procured as the final component of the AJA hemostatic pack. In practice, after the injured individual applies the tourniquet to the affected limb and exerts pressure, the hemostatic gauze is opened and placed directly on the wound. Surgifix, which is compatible with all limbs, is then applied over the gauze to secure it in place.
After the production and procurement of all components, they were assembled into a complete package. This package included a chitosan-impregnated gauze, a self-aid tourniquet, and a Surgifix, all enclosed within a thick, durable zip-lock polyethylene pouch. To enhance durability and shelf life, the entire package was further secured using heat-shrink polyethylene. The packaging was designed to be lightweight and compact while allowing rapid and easy access in emergency situations.
The rationale for this packaging choice was to ensure both ease of use and portability, allowing the entire pack to fit conveniently into a soldier’s or emergency responder’s bag or backpack. Cardboard packaging was deemed unsuitable due to its weight, susceptibility to water penetration, and tendency to degrade over time. Packaging as a small plastic bag or suitcase produced via 3D printing or CNC machines, although advantageous in some respects, was not practical due to the significantly higher production costs.
Therefore, the team opted for robust polyethylene pouches similar to those used by the Iranian postal service for parcel delivery. These pouches provide the necessary strength, fit easily into responders’ backpacks, are lightweight, inexpensive, and offer adequate protection against air, dust, and moisture. The research team unanimously agreed that this packaging was suitable for enclosing the AJA hemostatic pack. To further enhance durability and longevity during transport and field use, the entire pack was subsequently sealed using heat-shrink wrapping.
Discussion
This study aimed to develop a hemostatic pack for hemorrhage control in both military and civilian environments, incorporating key attributes of an ideal product. The AJA hemostatic pack, comprising chitosan-impregnated gauze, a self-aid tourniquet, and Surgifix enclosed in a durable polyethylene pouch with heat-shrink wrapping, offered a comprehensive, portable solution for prehospital and battlefield hemorrhage control. This aligns with the need for rapid and effective interventions in trauma settings, where uncontrolled bleeding remains a leading cause of preventable death [15]. The successful production of sterile chitosan-impregnated gauze using 15g of shrimp-derived chitosan powder per piece demonstrated a practical approach to enhancing hemostatic efficacy. Chitosan-based agents promote clot formation through electrostatic interactions with erythrocytes, independent of host coagulation pathways, making them particularly suitable for coagulopathic conditions common in severe trauma [15].
This is consistent with narrative reviews emphasizing the advantages of chitosan dressings, like Celox Gauze and ChitoGauze, which achieve hemostasis in 70-90% of prehospital cases and are recommended for junctional and extremity bleeding in military protocols [15]. Recent studies have confirmed the efficacy of chitosan in controlling severe hemorrhage, even under conditions where the body’s coagulation system is impaired, such as hypothermia or anticoagulant therapy [16-18]. Published research from 2015 to 2025, including studies by Javanmardi et al. [19], the Department of Science and Technology, India [20], and others [14], has demonstrated that chitosan, due to its high biocompatibility, antimicrobial properties, and biodegradability, outperforms hemostatic agents based on zeolite or kaolin, which may cause tissue burns or leave residual particles in the body [12, 21].
Furthermore, the use of V-Pack paper for single-roll packaging and autoclave sterilization ensures sterility and ease of deployment, addressing logistical challenges in field environments. This is similar to lessons from battlefield applications, where quick application and biocompatibility are critical for reducing mortality [22].
The design of the self-aid tourniquet, finalized at 95cm in length and weighing approximately 300g, draws inspiration from modern military models but is heavier than the U.S. standard (125g), potentially impacting portability. However, its emphasis on self-application aligns with evidence-based guidelines advocating for tourniquets as the first line of defense for extremity hemorrhage when direct pressure fails, with military studies showing survival rates of up to 92% [10].
Research has shown that the use of validated commercial tourniquets achieves a high success rate in controlling limb hemorrhages [14]. However, in the context of handmade or “DIY” tourniquets, multiple reports indicate a failure rate exceeding 85%, often due to insufficient pressure or inappropriate materials [23]. Despite these challenges, the design implemented in this project focuses on pressure mechanisms and lockable buckles to improve the effectiveness of a handmade tourniquet. This weight difference may reflect material choices optimized for durability in resource-limited settings, although future iterations could incorporate lighter composites to enhance user mobility, as suggested by reviews of tourniquet efficacy in prehospital trauma, where rapid occlusion of arterial flow significantly reduces blood loss [23].
Integrating the tourniquet with hemostatic gauze and Surgifix facilitates a sequential approach—tourniquet application followed by gauze placement and fixation—which mirrors joint position statements recommending the combined use of tourniquets, wound packing, and hemostatic dressings for comprehensive control, particularly in self-aid scenarios where training demands are low [24].
The procurement of Surgifix as a compatible, lightweight fixation tool overcomes the limitations of traditional bandages or adhesive dressings, such as difficulties in emergency removal or secure wrapping with one hand, thereby minimizing time and complexity in application [25]. This rationale is supported by lessons learned from the use of hemostatic dressings, where ease of application and portability are key to effective bleeding control in austere environments, reducing the risk of rebleeding and enabling intervention by laypersons or injured individuals [25].
The final packaging, contained in a thick zip-lock polyethylene pouch and further secured with heat shrink, prioritizes compactness, water resistance, and rapid access, contrasting with unsuitable options like cardboard due to degradation risks. This choice aligns with systematic reviews advocating for robust, inexpensive packaging to protect agents against environmental factors in prehospital systems [11]. Compared to high-cost alternatives like 3D-printed cases, this option enhances affordability and scalability, echoing availability surveys in civilian EMS, where low-cost adoption barriers influence the utilization of hemostatic agents [26].
Overall, the AJA pack’s components address gaps in current prehospital tools by combining mucoadhesive chitosan for direct wound hemostasis [3], mechanical tourniquet occlusion [10], and elastic fixation for sustained pressure [27]. Evidence from combat casualty care reviews indicates that these components have comparable efficacy to established products like QuikClot Combat Gauze and Celox in reducing blood loss and improving survival [7]. The pack’s design supports tactical combat casualty care (TCCC) principles, in which integrated kits enable massive hemorrhage control in tactical field care, potentially translating military lessons to civilian hospitals for scenarios such as postpartum or surgical bleeding [22].
The AJA hemostatic pack can serve as a critical tool for the initial management of trauma in civilian settings, such as road traffic accidents, which are the second leading cause of death in Iran and the primary contributor to years of life lost [28, 29]. Given that a significant proportion of these deaths result from uncontrolled hemorrhage during the first minutes following an incident, this product has the potential to substantially reduce fatalities by enabling non-specialists to provide immediate first-aid care [21, 28].
Limitations include the tourniquet’s increased weight, which may necessitate optimization, as well as the need for clinical trials to validate field efficacy beyond prototypes, since preclinical animal models often overestimate human outcomes [11]. Future research should evaluate the AJA pack’s performance in randomized controlled trials, focusing on time to hemostasis, user training, and cost-effectiveness in diverse trauma populations [28]. This development contributes to evolving hemostatic strategies, emphasizing accessible, multi-component packs to mitigate hemorrhage-related mortality in resource-constrained settings [7].
This research successfully designed and developed a hemostatic pack comprising chitosan-impregnated gauze and a self-aid tourniquet. Although the preliminary results are promising, further studies are required to fully validate the product’s efficacy and confirm its safety, including animal models and clinical trials conducted under appropriate ethical approvals. Additionally, optimizing the weight and dimensions of the tourniquet to enhance portability represents the next step toward preparing the product for commercialization.
Conclusion
The AJA hemostatic pack represents a low-cost, indigenous solution for prehospital hemorrhage control, promoting self-sufficiency in emergency medical systems.
Acknowledgments: We would like to extend our heartfelt thanks to the National Center for Strategic Research in Medical Education (NSR).
Ethical Permissions: This research project, registered as a national initiative under the number 972074 was awarded the Bronze Medal in the Entrepreneurship category of the 10th National Olympiad of Medical Sciences Students in Iran. All phases of the study were carried out in accordance with the principles of ethics in biomedical research.
Conflicts of Interests: Nothing to declare.
Authors' Contribution: Mohammadebrahimi H (First Author), Methodologist/Main Researcher (40%); Rasooli SA (Second Author), Introduction Writer/Statistical Analyst (30%); Dorri S (Third Author), Discussion Writer (20%); Shahraki S (Fourth Author), Discussion Writer (10%)
Funding/Support: This research project was conducted with financial support and stepwise supervision from the National Center for Strategic Research in Medical Education (NSR).
Keywords:
Hemostatics [MeSH], Tourniquets [MeSH], Chitosan [MeSH], Hemorrhage [MeSH], Emergency Medical Services [MeSH], Military Medicine [MeSH]
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