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Goel R, Tiwari G, Varghese M, Bhalla K, Agrawal G, Saini G, Jha A, John D, Saran A, White H, Mohan D. Effectiveness of road safety interventions: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1367. [PMID: 38188231 PMCID: PMC10765170 DOI: 10.1002/cl2.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Background Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge. Objectives The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels. Search Methods The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019. Selection Criteria The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes. Data Collection and Analysis The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2. Main Results The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality. Authors' Conclusions The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.
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Affiliation(s)
- Rahul Goel
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Geetam Tiwari
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Kavi Bhalla
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Girish Agrawal
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Abhaya Jha
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Denny John
- Faculty of Life and Allied Health SciencesM S Ramaiah University of Applied Sciences, BangaloreKarnatakaIndia
| | | | | | - Dinesh Mohan
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
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Berard D, Vega SJ, Torres SIH, Polykratis IA, Salinas J, Ross E, Avital G, Boice EN, Snider EJ. Development of the PhysioVessel: a customizable platform for simulating physiological fluid resuscitation. Biomed Phys Eng Express 2022; 8. [PMID: 35344943 DOI: 10.1088/2057-1976/ac6196] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/12/2022]
Abstract
Uncontrolled hemorrhage is a leading cause of death in trauma situations. Developing solutions to automate hemorrhagic shock resuscitation may improve the outcomes for trauma patients. However, testing and development of automated solutions to address critical care interventions, oftentimes require extensive large animal studies for even initial troubleshooting. The use of accurate laboratory or in-silico models may provide a way to reduce the need for large animal datasets. Here, a tabletop model, for use in the development of fluid resuscitation with physiologically relevant pressure-volume responsiveness for high throughput testing, is presented. The design approach shown can be applied to any pressure-volume dataset through a process of curve-fitting, 3D modeling, and fabrication of a fluid reservoir shaped to the precise curve fit. Two case studies are presented here based on different resuscitation fluids: whole blood and crystalloid resuscitation. Both scenarios were derived from data acquired during porcine hemorrhage studies, used a pressure-volume curve to design and fabricate a 3D model, and evaluated to show that the test platform mimics the physiological data. The vessels produced based on data collected from pigs infused with whole blood and crystalloid were able to reproduce normalized pressure-volume curves within one standard deviation of the porcine data with mean residual differences of 0.018 and 0.016, respectively. This design process is useful for developing closed-loop algorithms for resuscitation and can simplify initial testing of technologies for this life-saving medical intervention.
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Affiliation(s)
- David Berard
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | - Saul J Vega
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | | | - I Amy Polykratis
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | - Evan Ross
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | - Guy Avital
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America.,Trauma & Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat-Gan, Israel.,Division of Anesthesia, Intensive Care & Pain Management, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Emily N Boice
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
| | - Eric J Snider
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, TX, United States of America
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Use of Haemostatic Devices for the Control of Junctional and Abdominal Traumatic Haemorrhage: A Systematic Review. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Catastrophic haemorrhage accounts for up to 40% of global trauma related mortality and is the leading cause of preventable deaths on the battlefield. Controlling abdominal and junctional haemorrhage is challenging, especially in the pre-hospital setting or ‘under fire’, yet there is no haemostatic agent which satisfies the seven characteristics of an ‘ideal haemostat’. We conducted a systematic search of Embase, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to evaluate the feasibility and efficacy of three types of haemostatic devices. Participants included any trauma patient in a pre-hospital setting, perfused human cadavers, or healthy human volunteer simulations. The haemostatic devices reviewed were REBOA, iTClampTM, and four junctional tourniquets: AAJT, CRoC, JETT, and SJT. The SJT had the best user survey performance of the junctional tourniquets, and the four junctional tourniquets had an overall efficacy of 26.6–100% and an application time of 10–203 s. The iTClampTM had an efficacy of 60–100% and an application time of 10–60 s. REBOA had an efficacy of 71–100% and an application time ranging from 5 min to >80 min. In civilian and military trauma patients the use of junctional tourniquets, iTClamp, or REBOA, mortality varied from 0–100%. All of these studies were deemed low to very low in quality, hence the reliability of data presented in each of the studies is called into question. We conclude that despite limited data for these devices, their use in the pre-hospital environment or ‘under fire’ is feasible with the correct training, portable imaging, and patient selection algorithms. However, higher quality studies are required to confirm the true efficacy of these devices.
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Jamal L, Saini A, Quencer K, Altun I, Albadawi H, Khurana A, Naidu S, Patel I, Alzubaidi S, Oklu R. Emerging approaches to pre-hospital hemorrhage control: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1192. [PMID: 34430633 PMCID: PMC8350651 DOI: 10.21037/atm-20-5452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
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Affiliation(s)
- Leila Jamal
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aman Saini
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keith Quencer
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aditya Khurana
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
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Use of bilobed partial resuscitative endovascular balloon occlusion of the aorta is logistically superior in prolonged management of a highly lethal aortic injury. J Trauma Acute Care Surg 2021; 89:464-473. [PMID: 32467463 DOI: 10.1097/ta.0000000000002797] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable technique for management of noncompressible torso hemorrhage. The major limitation of the current unilobed fully occlusive REBOA catheters is below-the-balloon ischemia-reperfusion complications. We hypothesized that partial aortic occlusion with a novel bilobed partial (p)REBOA-PRO would result in the need for less intraaortic balloon adjustments to maintain a distal goal perfusion pressure as compared with currently available unilobed ER-REBOA. METHODS Anesthetized (40-50 kg) swine randomized to control (no intervention), ER-REBOA, or pREBOA-PRO underwent supraceliac aortic injury. The REBOA groups underwent catheter placement into zone 1 with initial balloon inflation to full occlusion for 10 minutes followed by gradual deflation to achieve and subsequently maintain half of the baseline below-the-balloon mean arterial pressure (MAP). Physiologic data and blood samples were collected at baseline and then hourly. At 4 hours, the animals were euthanized, total blood loss and urine output were recorded, and tissue samples were collected. RESULTS Baseline physiologic data and basic laboratories were similar between groups. Compared with control, interventions similarly prolonged survival from a median of 18 minutes to over 240 minutes with comparable mortality trends. Blood loss was similar between partial ER-REBOA (41%) and pREBOA-PRO (51%). Partial pREBOA-PRO required a significantly lower number of intraaortic balloon adjustments (10 ER-REBOA vs. 3 pREBOA-PRO, p < 0.05) to maintain the target below-the-balloon MAP. The partial ER-REBOA group developed significantly increased hypercapnia, fibrin clot formation on TEG, liver inflammation, and IL-10 expression compared with pREBOA-PRO. CONCLUSION In this highly lethal aortic injury model, use of bilobed pREBOA-PRO for a 4-hour partial aortic occlusion was logistically superior to unilobed ER-REBOA. It required less intraaortic balloon adjustments to maintain target MAP and resulted in less inflammation.
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Heindl SE, Wiltshire DA, Vahora IS, Tsouklidis N, Khan S. Partial Versus Complete Resuscitative Endovascular Balloon Occlusion of the Aorta in Exsanguinating Trauma Patients With Non-Compressible Torso Hemorrhage. Cureus 2020; 12:e8999. [PMID: 32775079 PMCID: PMC7402546 DOI: 10.7759/cureus.8999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemorrhage is a major cause of death globally, yet our options to control the condition have remained limited. The standard intervention for patients suffering from a non-compressible torso hemorrhage (NCTH) typically involves resuscitative thoracotomy (RT) with aortic cross-clamping. Apart from being extraordinarily invasive, the survival rates for this procedure remain low. Over the years, research has surfaced that offers much promise regarding the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in exsanguinating patients. Although this type of procedure is not yet universally recognized as a gold standard, it holds some hope for the development of additional research regarding how we can make use of this advancement to improve survival in trauma patients. Complete REBOA (c-REBOA) has not gained wide acceptance due to the undeniable effects it has on normal physiology, metabolic effects, long-term complications, and mortality. Partial REBOA (p-REBOA) is not yet fully validated by research but could potentially be the answer to our problem. The critical question that we should address at this juncture is as follows: how can we improve the survival of patients with an NCTH in the least invasive way possible, while also reducing the feared complications associated with c-REBOA?
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Affiliation(s)
- Stacey E Heindl
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Dwayne A Wiltshire
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ilmaben S Vahora
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.,Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Transition from abdominal aortic and junctional tourniquet to zone 3 resuscitative endovascular balloon occlusion of the aorta is feasible with hemodynamic support after porcine class IV hemorrhage. J Trauma Acute Care Surg 2020; 87:849-855. [PMID: 31589194 DOI: 10.1097/ta.0000000000002426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Traumatic hemorrhage remains a major cause of death in rural civilian and combat environments. Potential interventions to control hemorrhage from the pelvis and lower junctional regions include the abdominal aortic and junctional tourniquet (AAJT) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT requires low technical skills and may thus be used by nonmedical professionals, but is associated with time-dependent ischemic complications. In combination with delayed patient evacuation, it may therefore be deleterious. Transition to zone 3 REBOA in higher levels of care may be a possibility to maintain hemostasis, mitigate adverse effects and enable surgery in patients resuscitated with the AAJT. It is possible that a transition between the interventions could lead to hemodynamic penalties. Therefore, we investigated the feasibility of replacing the AAJT with zone 3 REBOA in a porcine model of uncontrolled femoral hemorrhage. METHODS Domestic pigs (n = 12) averaging 57 kg were exposed to a class IV uncontrolled hemorrhage from the common femoral artery. The animals were randomized to 60-minute AAJT (n = 6) or 30-minute AAJT with transition to 30-minute zone 3 REBOA. Hemodynamic and metabolic parameters and ultrasonographic measurements of the common femoral artery were collected. RESULTS Transition from AAJT to zone 3 REBOA caused a significant decrease in mean arterial pressure (25 mm Hg). Hemostasis was maintained. The common femoral artery diameter decreased by 1.8 mm (38%) after hemorrhage and further 0.7 mm (23%) after aortic occlusion. CONCLUSION Transition from AAJT to zone 3 REBOA after a class IV bleeding is feasible with hemodynamic support. Vascular access to the femoral artery for REBOA insertion poses a technical challenge after hemorrhage and AAJT application. LEVEL OF EVIDENCE Laboratory animal study, level IV.
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Sadeghi M, Dogan EM, Karlsson C, Jansson K, Seilitz J, Skoog P, Hörer TM, Nilsson KF. Total resuscitative endovascular balloon occlusion of the aorta causes inflammatory activation and organ damage within 30 minutes of occlusion in normovolemic pigs. BMC Surg 2020; 20:43. [PMID: 32122358 PMCID: PMC7053141 DOI: 10.1186/s12893-020-00700-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes physiological, metabolic, end-organ and inflammatory changes that need to be addressed for better management of severely injured patients. The aim of this study was to investigate occlusion time-dependent metabolic, end-organ and inflammatory effects of total REBOA in Zone I in a normovolemic animal model. Methods Twenty-four pigs (25-35 kg) were randomized to total occlusion REBOA in Zone I for either 15, 30, 60 min (REBOA15, REBOA30, and REBOA60, respectively) or to a control group, followed by 3-h reperfusion. Hemodynamic variables, metabolic and inflammatory response, intraperitoneal and intrahepatic microdialysis, and plasma markers of end-organ injuries were measured during intervention and reperfusion. Intestinal histopathology was performed. Results Mean arterial pressure and cardiac output increased significantly in all REBOA groups during occlusion and blood flow in the superior mesenteric artery and urinary production subsided during intervention. Metabolic acidosis with increased intraperitoneal and intrahepatic concentrations of lactate and glycerol was most pronounced in REBOA30 and REBOA60 during reperfusion and did not normalize at the end of reperfusion in REBOA60. Inflammatory response showed a significant and persistent increase of pro- and anti-inflammatory cytokines during reperfusion in REBOA30 and was most pronounced in REBOA60. Plasma concentrations of liver, kidney, pancreatic and skeletal muscle enzymes were significantly increased at the end of reperfusion in REBOA30 and REBOA60. Significant intestinal mucosal damage was present in REBOA30 and REBOA60. Conclusion Total REBOA caused severe systemic and intra-abdominal metabolic disturbances, organ damage and inflammatory activation already at 30 min of occlusion.
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Affiliation(s)
- Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, SE-70185, Örebro, Sweden.
| | - Emanuel M Dogan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jenny Seilitz
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, SE-70185, Örebro, Sweden
| | - Per Skoog
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, SE-70185, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, SE-70185, Örebro, Sweden
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Bailey ZS, Cardiff K, Yang X, Gilsdorf J, Shear D, Rasmussen TE, Leung LY. The Effects of Balloon Occlusion of the Aorta on Cerebral Blood Flow, Intracranial Pressure, and Brain Tissue Oxygen Tension in a Rodent Model of Penetrating Ballistic-Like Brain Injury. Front Neurol 2019; 10:1309. [PMID: 31920932 PMCID: PMC6930175 DOI: 10.3389/fneur.2019.01309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022] Open
Abstract
Trauma is among the leading causes of death in the United States. Technological advancements have led to the development of resuscitative endovascular balloon occlusion of the aorta (REBOA) which offers a pre-hospital option to non-compressible hemorrhage control. Due to the prevalence of concomitant traumatic brain injury (TBI), an understanding of the effects of REBOA on cerebral physiology is critical. To further this understanding, we employed a rat model of penetrating ballistic-like brain injury (PBBI). PBBI produced an injury pattern within the right frontal cortex and striatum that replicates the pathology from a penetrating ballistic round. Aortic occlusion was initiated 30 min post-PBBI and maintained continuously (cAO) or intermittently (iAO) for 30 min. Continuous measurements of mean arterial pressure (MAP), intracranial pressure (ICP), cerebral blood flow (CBF), and brain tissue oxygen tension (PbtO2) were recorded during, and for 60 min following occlusion. PBBI increased ICP and decreased CBF and PbtO2. The arterial balloon catheter effectively occluded the descending aorta which augmented MAP in the carotid artery. Despite this, CBF levels were not changed by aortic occlusion. iAO caused sustained adverse effects to ICP and PbtO2 while cAO demonstrated no adverse effects on either. Temporary increases in PbtO2 were observed during occlusion, along with restoration of sham levels of ICP for the remainder of the recordings. These results suggest that iAO may lead to prolonged cerebral hypertension following PBBI. Following cAO, ICP, and PbtO2 levels were temporarily improved. This information warrants further investigation using TBI-polytrauma model and provides foundational knowledge surrounding the non-hemorrhage applications of REBOA including neurogenic shock and stroke.
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Affiliation(s)
- Zachary S Bailey
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Katherine Cardiff
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Xiaofang Yang
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Janice Gilsdorf
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Deborah Shear
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Lai Yee Leung
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage. J Trauma Acute Care Surg 2019; 85:717-724. [PMID: 29985233 DOI: 10.1097/ta.0000000000002013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Uncontrolled hemorrhage is a leading cause of tactical trauma-related deaths. Hemorrhage from the pelvis and junctional regions are particularly difficult to control due to the inability of focal compression. The Abdominal Aortic and Junctional Tourniquet (AAJT) occludes aortic blood flow by compression of the abdomen. The survivability of tourniquet release beyond 120 minutes is unknown and fluid requirements to maintain sufficient blood pressure during prolonged application are undetermined. We therefore compared 60-minute and 240-minute applications and release of the AAJT for 30 minutes, with crystalloid fluid therapy, after a Class II hemorrhage. METHODS Sixty-kilogram anesthetized pigs were subjected to 900-mL hemorrhage and AAJT application for 60 minutes (n = 5), 240 minutes (n = 5), and fluid therapy only for 240 minutes (n = 5) and reperfusion for 30 minutes. RESULTS The AAJT application was hemodynamically and respiratory tolerable for 60 minutes and 240 minutes. Cumulative fluid requirements decreased by 64%, comparable to 3000 mL of crystalloids. Mechanical ventilation was impaired. AAJT increased the core temperature by 0.9°C compared with fluid therapy. Reperfusion consequences were reversible after 60 minutes but not after 240 minutes. A 240-minute application resulted in small intestine and liver ischemia, persisting hyperkalemia, metabolic acidosis, and myoglobinemia, suggesting rhabdomyolysis. CONCLUSION The AAJT application for 240 minutes with reperfusion was survivable in an intensive care setting and associated with abdominal organ damage. Long time consequences and spinal cord effects was not assessed. We propose an application time limit within 60 minutes to 240 minutes, though further studies are needed to increase the temporal resolution. The AAJT application may be considered as a rescue option to maintain central blood pressure and core temperature in cases of hemorrhagic shock from extremity bleedings, if fluid therapy is unavailable or if the supply is limited. LEVEL OF EVIDENCE Therapeutic study, level II.
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Gruionu G, Gruionu LG, Duggan M, Surlin V, Patrascu S, Velmahos G. Feasibility of a Portable Abdominal Insufflation Device for Controlling Intraperitoneal Bleeding After Abdominal Blunt Trauma. Surg Innov 2019; 26:662-667. [DOI: 10.1177/1553350619869057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Uncontrolled bleeding contributes to 30% to 40% of trauma-related deaths and is the leading cause of potentially preventable deaths. Currently, there is no effective method available to first responders for temporary control of noncompressible intraabdominal bleeding while patients are transported to the hospital. Our previous studies demonstrated that abdominal insufflation provides effective temporary bleeding control. The study aims to prove the feasibility (insufflation to a target pressure) and safety (cardiovascular and respiratory effects) of a novel portable abdominal insufflation device (PAID) designed to control the intraperitoneal bleeding caused by abdominal trauma. The PAID prototype is based on a patented design and manufactured via additive manufacturing. PAID contains a 16-g CO2cartridge and an electronic pressure transducer. PAID was tested on a bench top and a swine animal model. For the animal model study, the intraperitoneal pressure as well as cardiorespiratory parameters (hearth rate, SpO2[peripheral capillary oxygen saturation], and blood pressure) were continuously monitored during the insufflation procedure. The prototype functioned according to specifications on both bench top and animal models. CO2insufflation of the peritoneal cavity was delivered up the target 20 mm Hg and maintained for 30 minutes from 1 or 2 cartridges in the swine model. No intraoperative incidents were registered, and all the recorded physiological parameters were within normal limits. The PAID prototype is a feasible, easy to use device that provides quick, controlled, and safe insufflation of the peritoneal cavity. Future studies will focus on testing the next-generation, semiautomatic PAID prototype in a severe intraabdominal injury model.
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Affiliation(s)
- Gabriel Gruionu
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Michael Duggan
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Valeriu Surlin
- University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Stefan Patrascu
- University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - George Velmahos
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Ketelaars R, Reijnders G, van Geffen GJ, Scheffer GJ, Hoogerwerf N. ABCDE of prehospital ultrasonography: a narrative review. Crit Ultrasound J 2018; 10:17. [PMID: 30088160 PMCID: PMC6081492 DOI: 10.1186/s13089-018-0099-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023] Open
Abstract
Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.
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Affiliation(s)
- Rein Ketelaars
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Gabby Reijnders
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Geert-Jan van Geffen
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nico Hoogerwerf
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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13
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Anderson KL, Fiala KC, Castaneda MG, Boudreau SM, Araña AA, Bebarta VS. Left ventricular compressions improve return of spontaneous circulation and hemodynamics in a swine model of traumatic cardiopulmonary arrest. J Trauma Acute Care Surg 2018; 85:303-310. [PMID: 29613954 DOI: 10.1097/ta.0000000000001901] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prehospital cardiopulmonary resuscitation, including closed chest compressions, has commonly been considered ineffective in traumatic cardiopulmonary arrest (TCPA) because traditional chest compressions do not produce substantial cardiac output. However, recent evidence suggests that chest compressions located over the left ventricle (LV) produce greater hemodynamics when compared to traditional compressions. We hypothesized that chest compressions located directly over the LV would improve return of spontaneous circulation (ROSC) and hemodynamics when compared with traditional chest compressions, in a swine model of TCPA. METHODS Transthoracic echocardiography was used to mark the location of the aortic root (traditional compressions), and the center of the LV on animals (n = 26) which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced. After 10 minutes of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 minutes followed by advanced life support (ALS) for an additional 10 minutes. During BLS, the area of maximal compression was verified using transesophageal echocardiography. Hemodynamic variables were averaged over the final 2 minutes of the BLS and ALS periods. RESULTS Five (38%) of the LV group achieved ROSC compared with zero of the aortic root group (p = 0.04). Additionally, there was an increase in aortic systolic blood pressure (SBP), aortic diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) at the end of both the BLS (95% confidence interval, SBP, -49 to -21; DBP, -14 to -5.6; and CPP, -15 to -7.4) and ALS (95% confidence interval: SBP, -66 to -21; DBP, -49 to -6.8; and CPP, -51 to -7.5) resuscitation periods among the LV group. CONCLUSION In our swine model of TCPA, chest compressions performed directly over the LV improved ROSC and hemodynamics when compared with traditional chest compressions.
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Affiliation(s)
- Kenton L Anderson
- From the Department of Emergency Medicine (K.L.A.), Stanford University School of Medicine, Palo Alto, California; Department of Emergency Medicine (K.C.F.), Madigan Army Medical Center, Tacoma, Washington; CREST Research Program (M.G.C., S.M.B.), Wilford Hall Ambulatory Surgical Center, Lackland AFB, Texas; US Air Force En Route Care Research Center, United States Army Institute of Surgical Research (A.A.A.), Fort Sam Houston, Texas; and Department of Emergency Medicine (V.S.B.), University of Colorado School of Medicine, Aurora, Colorado
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Barron MR, Kuckelman JP, McClellan JM, Derickson MJ, Phillips CJ, Marko ST, Sokol K, Eckert MJ, Martin MJ. Mobile forward-looking infrared technology allows rapid assessment of resuscitative endovascular balloon occlusion of the aorta in hemorrhage and blackout conditions. J Trauma Acute Care Surg 2018; 85:25-32. [PMID: 29965939 DOI: 10.1097/ta.0000000000001932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Objective assessment of final resuscitative endovascular balloon occlusion of the aorta (REBOA) position and adequate distal aortic occlusion is critical in patients with hemorrhagic shock, especially as feasibility is being increasingly investigated in the prehospital setting. We propose that mobile forward-looking infrared (FLIR) thermal imaging is a fast, reliable, and noninvasive method to assess REBOA position and efficacy in scenarios applicable to battlefield and prehospital care. METHODS Ten swine were randomized to a 40% hemorrhage group (H, n = 5) or nonhemorrhage group (NH, n = 5). Three experiments were completed after Zone I placement of a REBOA catheter. Resuscitative endovascular balloon occlusion of the aorta was deployed for 30 minutes in all animals followed by randomized continued deployment versus sham in both light and blackout conditions. Forward-looking infrared images and hemodynamic data were obtained. Images were presented to 62 blinded observers for assessment of REBOA inflation status. RESULTS There was no difference in hemodynamic or laboratory values at baseline. The H group was significantly more hypotensive (mean arterial pressure 44 vs. 60 mm Hg, p < 0.01), vasodilated (systemic vascular resistance 634 vs. 938dyn·s/cm, p = 0.02), and anemic (hematocrit 12 vs. 23.2%, p < 0.01). Hemorrhage group animals remained more hypotensive, anemic, and acidotic throughout all three experiments. There was a significant difference in the temperature change (ΔTemp) measured by FLIR between animals with REBOA inflated versus not inflated (5.7°C vs. 0.7°C, p < 0.01). The H and NH animals exhibited equal magnitudes of ΔTemp in both inflated and deflated states. Blinded observer analysis of FLIR images correctly identified adequate REBOA inflation and aortic occlusion 95.4% at 5 minutes and 98.8% at 10 minutes (positive predictive value at 5 minutes = 99% and positive predictive value at 10 minutes = 100%). CONCLUSIONS Mobile thermal imaging is an easy, rapid, and reliable method for assessing distal perfusion after occlusion by REBOA. Smartphone-based FLIR technology allows for confirmation of adequate REBOA placement at the point of care, and performance was not degraded in the setting of major hemorrhage or blackout conditions.
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Affiliation(s)
- Morgan R Barron
- From the Department of Surgery (M.R.B., J.P.K., J.M.M., M.J.D., C.J.P., S.T.M., K.S., M.J.E., M.J.M.), Madigan Army Medical Center, Tacoma, Washington; and Trauma and Emergency Surgery Service (M.J.E., M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon
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Schneider N, Küßner T, Weilbacher F, Göring M, Mohr S, Rudolph M, Popp E. Invasive Notfalltechniken – INTECH Advanced. Notf Rett Med 2018. [DOI: 10.1007/s10049-018-0475-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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16
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Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress? Curr Opin Crit Care 2018; 22:563-571. [PMID: 27805960 DOI: 10.1097/mcc.0000000000000367] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive damage control procedure for life-threatening abdominal or pelvic haemorrhage. The purpose of this review is to summarize the current understanding and experience with REBOA, outline potential future applications of this technology, and highlight priority areas for further research. RECENT FINDINGS REBOA is a feasible method of achieving temporary aortic occlusion and can be performed rapidly, with a high degree of success, in the emergency setting (including at the scene of injury) by appropriately trained clinicians. The procedure supports central perfusion, controls noncompressible haemorrhage, and may improve survival in certain profoundly shocked patient groups; but is also associated with significant risks, including ischaemic tissue damage and procedural complications. Evolutions of this strategy are being explored, with promising proof-of-concept studies in the fields of partial aortic occlusion and the combination of REBOA with extracorporeal support. SUMMARY Noncompressible torso haemorrhage is the leading cause of preventable trauma deaths. The majority of these deaths occur soon after injury, often before any opportunity for definitive haemorrhage control. For a meaningful reduction in trauma mortality, novel methods of rapid haemorrhage control are required.
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Damage control surgery in weightlessness: A comparative study of simulated torso hemorrhage control comparing terrestrial and weightless conditions. J Trauma Acute Care Surg 2017; 82:392-399. [PMID: 27787439 DOI: 10.1097/ta.0000000000001310] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR. METHODS A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy. RESULTS All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5). CONCLUSION Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.
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18
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Pezy P, Flaris AN, Prat NJ, Cotton F, Lundberg PW, Caillot JL, David JS, Voiglio EJ. Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population. JAMA Surg 2017; 152:351-358. [PMID: 27973670 DOI: 10.1001/jamasurg.2016.4757] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater. Objective To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry. Design, Setting, and Participants A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015. Main Outcomes and Measures Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits. Results Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population. Conclusions and Relevance Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.
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Affiliation(s)
- Pierre Pezy
- Ministère de la Défense, Service de Santé des Armées, Ecole de Santé des Armées, Lyon-Bron, France2Unité Mixte de Recherche T9405, Laboratoire d'Anatomie, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
| | - Alexandros N Flaris
- Unité Mixte de Recherche T9405, Laboratoire d'Anatomie, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France3Unit of Emergency Surgery, Department of Surgery, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France4Protypon Neurological-Neuromuscular Center, Thessaloniki, Greece5Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Nicolas J Prat
- Institut de Recherche Biomédicale des Armées, Soutien médico-chirurgical des forces, Brétigny sur Orge, France
| | - François Cotton
- Unité Mixte de Recherche T9405, Laboratoire d'Anatomie, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France7Department of Radiology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Peter W Lundberg
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jean-Louis Caillot
- Unit of Emergency Surgery, Department of Surgery, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Jean-Stéphane David
- Department of Anaesthesia and Critical Care Medicine, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Eric J Voiglio
- Unité Mixte de Recherche T9405, Laboratoire d'Anatomie, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France3Unit of Emergency Surgery, Department of Surgery, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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Abstract
Noncompressible torso hemorrhage (NCTH) constitutes a leading cause of potentially preventable trauma mortality. NCTH is defined by high-grade injury present in one or more of the following anatomic domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus hemodynamic instability or the need for immediate hemorrhage control. Rapid operative management, as part of a damage control resuscitation strategy, remains the mainstay of treatment. However, endovascular techniques are evolving and may become more mainstream with the advent of hybrid rooms that can deliver concurrent open and radiologic/endovascular management of traumatic hemorrhage.
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Affiliation(s)
- Jonathan J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, UK.
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20
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Andres J, Scott J, Giannoudis PV. Resuscitative endovascular balloon occlusion of the aorta (REBOA): What have we learned? Injury 2016; 47:2603-2605. [PMID: 27817883 DOI: 10.1016/j.injury.2016.10.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jose Andres
- Orthopedic Surgery Department, Hotpital Universitari Vall d'Hebron, Barcelona, Spain
| | - Julian Scott
- Academic Department of Vascular Surgery, LGI, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK.
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21
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van Oostendorp SE, Tan ECTH, Geeraedts LMG. Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting. Scand J Trauma Resusc Emerg Med 2016; 24:110. [PMID: 27623805 PMCID: PMC5022193 DOI: 10.1186/s13049-016-0301-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/01/2016] [Indexed: 01/15/2023] Open
Abstract
Introduction Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed. Methods Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research. Results Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available. Conclusion Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.
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Affiliation(s)
- S E van Oostendorp
- Department of Trauma Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - E C T H Tan
- Department of Trauma Surgery and Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands.,Royal Netherlands Army, Utrecht, The Netherlands
| | - L M G Geeraedts
- Department of Trauma Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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Abstract
Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK; St Mary's Major Trauma Centre, Imperial College, London, UK.
| | - Karel Habig
- Greater Sydney HEMS Service, Sydney, Australia
| | | | - Amy Hughes
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
| | - Gareth Davies
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
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Kirkpatrick AW, Tien H, LaPorta AT, Lavell K, Keillor J, Wright Beatty HE, McKee JL, Brien S, Roberts DJ, Wong J, Ball CG, Beckett A. The marriage of surgical simulation and telementoring for damage-control surgical training of operational first responders: A pilot study. J Trauma Acute Care Surg 2015; 79:741-7. [PMID: 26422331 PMCID: PMC4623848 DOI: 10.1097/ta.0000000000000829] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable posttraumatic death. Many such deaths may be potentially salvageable with remote damage-control surgical interventions. As recent innovations in information technology enable remote specialist support to point-of-care providers, advanced interventions, such as remote damage-control surgery, may be possible in remote settings. METHODS An anatomically realistic perfused surgical training mannequin with intrinsic fluid loss measurements (the "Cut Suit") was used to study perihepatic packing with massive liver hemorrhage. The primary outcome was loss of simulated blood (water) during six stages, namely, incision, retraction, direction, identification, packing, and postpacking. Six fully credentialed surgeons performed the same task as 12 military medical technicians who were randomized to remotely telementored (RTM) (n = 7) or unmentored (UTM) (n=5) real-time guidance by a trauma surgeon. RESULTS There were no significant differences in fluid loss between the surgeons and the UTM group or between the UTM and RTM groups. However, when comparing the RTM group with the surgeons, there was significantly more total fluid loss (p = 0.001) and greater loss during the identification (p = 0.002), retraction (p = 0.035), direction (p = 0.014), and packing(p = 0.022) stages. There were no significant differences in fluid loss after packing between the groups despite differences in the number of sponges used; RTM group used more sponges than the surgeons and significantly more than the UTM group (p = 0.048). However, mentoring significantly increased self-assessed nonsurgeon procedural confidence (p = 0.004). CONCLUSION Perihepatic packing of an exsanguinating liver hemorrhage model was readily performed by military medical technicians after a focused briefing. While real-time telementoring did not improve fluid loss, it significantly increased nonsurgeon procedural confidence, which may augment the feasibility of the concept by allowing them to undertake psychologically daunting procedures.
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Affiliation(s)
- Andrew W Kirkpatrick
- From the Canadian Forces Health Services (A.W.K., H.T., J.W., A.B.); Departments of Surgery (A.W.K., D.J.R., C.G.B.), Critical Care Medicine (A.W.K.), and Community Health Sciences (D.J.R.), and Regional Trauma Services (A.W.K., C.G.B.), Foothills Medical Centre; and Innovative Trauma Care (J.L.M.), Edmonton, Calgary, Alberta; Sunnybrook Health Sciences Centre (H.T.), Toronto; and Royal College of Physicians and Surgeons (S.B.); and Flight Research Laboratory (J.K., H.E.W.B.), National Research Council of Canada, Ottawa, Ontario, Canada; Rocky Vista University, Parker, Colorado (A.T.L.); and Strategic Operations (K.L.), San Diego, California
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Alted López E. Are the paradigms in trauma disease changing? Med Intensiva 2015; 39:382-9. [PMID: 26068224 DOI: 10.1016/j.medin.2015.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/23/2015] [Accepted: 03/29/2015] [Indexed: 11/26/2022]
Abstract
Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit.
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Affiliation(s)
- E Alted López
- Unidad de Cuidados Intensivos de Trauma, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
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