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Loe M, Broome JM, Mueller L, Simpson JT, Tatum D, McGrew P, Taghavi S, Jackson-Weaver O, DuBose J, Duchesne J. Resuscitative endovascular balloon occlusion of the aorta in the patient with obesity. J Trauma Acute Care Surg 2024:01586154-990000000-00806. [PMID: 39330924 DOI: 10.1097/ta.0000000000004411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKGROUND Palpation of anatomic landmarks is difficult in patients with obesity, which could increase difficulty of achieving femoral access and resuscitative endovascular balloon occlusion of the aorta (REBOA) placement. The primary aim of this study was to examine the association between obesity and successful REBOA placement. We hypothesized that higher body mass index (BMI) would decrease first-attempt success and increase time to successful aortic occlusion (AO). METHODS A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was performed on patients who underwent REBOA placement with initiation systolic blood pressure >0 mm Hg from years 2013-2022. Patients were excluded if they received cardiopulmonary resuscitation on arrival, underwent open AO, or missing data entries for variables of interest. Body mass index categorization was as follows: non-obese (<30), class I (30-34.9), class II (35-39.9), and class III (40+) obesity. Patients were also stratified by access technique, including use of palpation or ultrasound guidance. RESULTS Inclusion criteria were met by 410 patients. On binary analysis, no primary outcomes of interest, including rate of success, time to placement, or mortality, were significantly impacted by BMI. Among BMI subgroups, there was no statistical difference in injury severity, admission systolic blood pressure (SBP), or augmented SBP. At initiation of aortic occlusion, patients with class II and class III obesity had higher median SBP compared with non- and class I obese patients (p = 0.03). Body mass index subgroup did not impact likelihood of first-attempt success or conversion to open procedure. When stratified by access technique, there was no difference in success rates, time to success or mortality between groups. CONCLUSION Body habitus did not impact success of REBOA placement, time to successful AO, or mortality. Further, ultrasound guidance was not superior to landmark palpation for arterial access. Following traumatic injury without hemodynamic collapse, obesity should not deter providers from considering REBOA placement. LEVEL OF EVIDENCE Therapeutic/Care management, Observational, Cross-sectional; Level IV.
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Affiliation(s)
- Mallory Loe
- From the Division of Trauma and Critical Care, Department of Surgery (M.L., J.M.B., L.M., J.T.S., D.T., P.M., S.T., O.J., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; and R Adams Cowley Shock Trauma Center (J.D.), University of Maryland Medical Center, Baltimore, Maryland
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Liao CA, Huang SY, Hsu CP, Lin YC, Cheng CT, Huang JF, Li HH, Tung WY, Chen YJ, Chen KH, Wang ST. Resuscitative endovascular balloon occlusion of the aorta provides better survival outcomes for noncompressible blunt torso bleeding below the diaphragm compared to resuscitative thoracotomy. Injury 2024:111916. [PMID: 39384500 DOI: 10.1016/j.injury.2024.111916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 08/22/2024] [Accepted: 09/17/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) serves as a bridging intervention for subsequent definitive haemorrhagic control. This study compared the clinical outcomes of REBOA and resuscitative thoracotomy (RT) in patients with bleeding below the diaphragm. MATERIALS AND METHODS This retrospective cohort study included adult trauma patients who presented to the Trauma Quality Improvement Program between 2020 and 2021 and who underwent either REBOA or RT in the emergency department (ED). Patients with severe head and chest injuries, characterised by an Abbreviated Injury Scale (AIS) score greater than 3, were excluded. The clinical data of patients treated with REBOA and those treated with RT were compared, and multivariable logistic regression (MLR) was employed to identify prognostic factors associated with mortality. RESULTS A total of 346 patients were enrolled: 138 (39.9 %) received REBOA, and 208 (60.1 %) received RT at the ED. Patients in the RT group underwent ED cardiopulmonary resuscitation (CPR) more frequently (58.2 % vs. 23.2 %; p < 0.001) and had a higher mortality rate (87.0 % vs. 45.7 %; p < 0.001). Patients who died had lower Glasgow Coma Scale scores (6 [4.5] vs. 11 [4.9]; p < 0.001), underwent more ED CPR (58.6 % vs. 9.8 %; p < 0.001), and received RT more frequently (74.2 % vs. 26.5 %, p < 0.001). The MLR revealed that the major prognostic factors for mortality were systolic blood pressure (odds ratio [OR] 0.988, 95 % confidence interval [CI] 0.978-0.998; p = 0.014), ED CPR (OR 11.111, 95 % CI 4.667-26.452; p < 0.001), abdominal injuries with an AIS score ≥ 4 (OR 4.694, 95 % CI 1.921-11.467; p = 0.001) and RT (OR 5.693, 95 % CI 2.690-12.050; p < 0.001). CONCLUSIONS In cases of blunt trauma, prompt identification of the bleeding source is crucial. For patients with bleeding below the diaphragm, REBOA led to higher survival rates than did RT. However, it is important to consider the limitations of the database and the necessary exclusions from our analysis.
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Affiliation(s)
- Chien-An Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Centre, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan; Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Shu-Yi Huang
- Department of General Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Centre, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chiao Lin
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Centre, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Centre, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan.
| | - Hsi-Hsin Li
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
| | - Wen-Ya Tung
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
| | - Yi-Jung Chen
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
| | - Ken-Hsiung Chen
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
| | - Shih-Tien Wang
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan; National Quemoy University, Kinmen, Taiwan
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Hanif H, Fisher AD, April MD, Rizzo JA, Miskimins R, Dubose JD, Cripps MW, Schauer SG. An assessment of nationwide trends in emergency department (ED) resuscitative endovascular balloon occlusion of the aorta (REBOA) use - A trauma quality improvement program registry analysis. Am J Surg 2024; 238:115898. [PMID: 39173564 DOI: 10.1016/j.amjsurg.2024.115898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/17/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs). METHODS A retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs. RESULTS The analysis included 3398 REBOA procedures. Majority patients were male (76 %) with a median age of 40 years (27-58) and injury severity score of 20 (20-41). The most common mechanism was collision (64 %), with emergency surgeries most frequently performed for pelvic trauma (14 %). Level 1 trauma centers performed 82 % of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 % at 1-h post-placement, decreasing significantly to 42 % by discharge. CONCLUSIONS REBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge.
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Affiliation(s)
- Hamza Hanif
- University of New Mexico Hospital, Albuquerque, NM, USA.
| | - Andrew D Fisher
- University of New Mexico Hospital, Albuquerque, NM, USA; Texas National Guard, Austin, TX, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Trauma, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
| | | | - Joseph D Dubose
- Department of Surgery, University of Texas Dell School of Medicine, Austin, TX, USA
| | - Michael W Cripps
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield Research (COMBAT), University of Colorado School of Medicine, Aurora, CO, USA
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Omoto R, Umemura Y, Kato M, Nakahori Y, Fujimi S. A case of multiple organ injury resuscitated by collaboration of damage control surgery and interventional radiology in hybrid emergency room. Acute Med Surg 2024; 11:e925. [PMID: 38230353 PMCID: PMC10789916 DOI: 10.1002/ams2.925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024] Open
Abstract
Background Hybrid emergency room systems, namely hybrid ER (HER), enable us to perform computed tomography (CT), surgery, and interventional radiology (IVR) without patient transfer. HER significantly shortened the time to CT after arrival and allowed us to achieve early intervention, resulting in reduced mortality from exsanguination in patients with severe blunt trauma. Case Presentation We encountered a patient diagnosed with left common iliac artery occlusion and dissection caused by blunt traumatic compressive abdominal injury with transection of the small intestine, kidney, and adrenal and pelvic ring fractures. Although the patient experienced cardiopulmonary arrest (CPA) immediately after CT, we performed damage control surgery (DCS) and IVR after temporary aortic occlusion in the HER and resuscitated the patient. Conclusion The present case, in which rapid diagnosis and intervention were performed and the patient was successfully resuscitated, supports the efficacy of the HER system for managing severe blunt trauma.
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Affiliation(s)
- Ryosuke Omoto
- Department of Emergency MedicineOsaka General Medical CenterOsakaJapan
| | - Yutaka Umemura
- Department of Emergency MedicineOsaka General Medical CenterOsakaJapan
| | - Masanari Kato
- Department of Emergency MedicineOsaka General Medical CenterOsakaJapan
| | - Yasutaka Nakahori
- Department of Emergency MedicineOsaka General Medical CenterOsakaJapan
| | - Satoshi Fujimi
- Department of Emergency MedicineOsaka General Medical CenterOsakaJapan
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Moeng MS, Viljoen F, Makhadi S. The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit. World J Surg 2023; 47:2651-2658. [PMID: 37716931 PMCID: PMC10545629 DOI: 10.1007/s00268-023-07173-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. METHODS Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. RESULTS There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). CONCLUSIONS Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.
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Affiliation(s)
- Maeyane Stephens Moeng
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Francois Viljoen
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Shumani Makhadi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Trauma Emerg Surg 2023; 49:2031-2046. [PMID: 37430174 PMCID: PMC10520188 DOI: 10.1007/s00068-023-02271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany.
| | - Janusz Andres
- Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Luca Brazzi
- The Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Edoardo De Robertis
- The Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Sharon Einav
- The Intensive Care Unit, Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Carl Gwinnutt
- The Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bahar Kuvaki
- The Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey
| | - Pawel Krawczyk
- The Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew D McEvoy
- The Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pieter Mertens
- The Department of Anaesthesiology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Vivek K Moitra
- Division of Critical Care Anesthesiology, The Department of Anesthesiology, Columbia University, Columbia, NY, USA
| | - Jose Navarro-Martinez
- The Anesthesiology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), Biomedical Research (ISABIAL), Alicante, Spain
| | - Mark E Nunnally
- The Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael O Connor
- The Department of Anesthesiology & Critical Care, University of Chicago, Chicago, IL, USA
| | - Marcus Rall
- The Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany
| | - Kurt Ruetzler
- The Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jan Schmitz
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Karl Thies
- The Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Bethel, Germany
| | - Jonathan Tilsed
- The Department of Surgery, Hull University Teaching Hospitals, Hull, UK
| | - Mauro Zago
- General & Emergency Surgery Division, The Department of Surgery, A. Manzoni Hospital, Milan, Italy
| | - Arash Afshari
- The Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O'Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Anaesthesiol 2023; 40:724-736. [PMID: 37218626 DOI: 10.1097/eja.0000000000001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- From the University Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, University Hospital Ruhr-University Bochum, Minden, Germany (JH), Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital of Cologne, Cologne, Germany (BWB, JS), Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland (JA), Department of Surgical Sciences, University of Turin, Turin (LB), Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Italy (EdR), Intensive Care Unit, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE), Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK (CG), Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey (BK), Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland (PK), Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium (PM), Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee (MDM), Division of Critical Care Anesthesiology, Department of Anesthesiology, Columbia University, New York, USA (VKM), Anesthesiology Department, Dr Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), and Biomedical Research (ISABIAL), Alicante, Spain (JN-M), Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York (MEN), Department of Anesthesiology & Critical Care, University of Chicago, Illinois, USA (MO'C), Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany (MR), Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (KR), Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Germany (KT), Department of Surgery, Hull University Teaching Hospitals, Hull, UK (JT), General & Emergency Surgery Division, Department of Surgery, A. Manzoni Hospital, Milan, Italy (MZ) and Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet, Denmark and Department of Clinical Medicine, University of Copenhagen, Denmark (AA)
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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9
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Kim MS, Song SW. Commentary: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Live More? J Chest Surg 2023; 56:117-119. [PMID: 36864675 PMCID: PMC10008363 DOI: 10.5090/jcs.23.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 03/04/2023] Open
Affiliation(s)
- Myeong Su Kim
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Wu YT, Lewis MR, Arase M, Demetriades D. Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated with Increased Risk of Extremity Compartment Syndrome. World J Surg 2023; 47:796-802. [PMID: 36371514 DOI: 10.1007/s00268-022-06832-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. METHODS Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4 h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. RESULTS There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). CONCLUSION REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.
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Affiliation(s)
- Yu-Tung Wu
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Meghan R Lewis
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
| | - Miharu Arase
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA.
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11
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Singer KE, Wallen TE, Youngs J, Blakeman TC, Schuster RM, Stuever MF, Goodman MD. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Limits Ischemia-Reperfusion Injury After Simulated Aeromedical Evacuation. J Surg Res 2023; 283:118-126. [PMID: 36403405 DOI: 10.1016/j.jss.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/04/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION One of the advantages of partial Resuscitative Endovascular Balloon Occlusion of the Aorta (pREBOA) compared to the original model is the mitigation of reperfusion injury. The safety and efficacy of pREBOA have not been demonstrated in the setting of aeromedical evacuation. We hypothesized that the pREBOA would result in less ischemia-reperfusion injury after altitude exposure. METHODS Twenty-four swine underwent femur fracture with hemorrhage for 20 min, followed by resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment to Zone 1 and were randomized to pREBOA-PRO (Prytime Medical Devices Inc) full inflation, partial inflation, or sham inflation and then an altitude exposure of ground level or 8000 ft for 15 min. The primary endpoint was to examine if the balloon functioned at altitude. Our secondary endpoint was investigating evidence of ischemia-reperfusion by hemodynamic instability, electrolyte derangements, and acidosis. Comparisons were made by ANOVA. RESULTS After deflation, the partially inflated group maintained a higher mean arterial pressure (MAP) compared to fully inflated group (P = 0.026). Full REBOA pigs were more tachycardic compared to sham pREBOA at ground (P < 0.001) and this was exacerbated at altitude (P < 0.001). Full REBOA pigs were more acidotic than sham and pREBOA at ground pigs (P = 0.0006 and P = 0.0002, respectively). Altitude increased the acidosis in full REBOA pigs, resulting in a greater base deficit (P < 0.0001), lactate (P < 0.0001), and IL-6 (P = 0.006). CONCLUSIONS PREBOA resulted in less severe ischemia-reperfusion injury at both altitude and ground, while full balloon inflation at altitude exacerbated acidosis and ischemia-reperfusion injury. Efforts should therefore be made to utilize partial balloon occlusion when employing the REBOA catheter.
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Affiliation(s)
- Kathleen E Singer
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jackie Youngs
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - T Christopher Blakeman
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca M Schuster
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Mary F Stuever
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio; Center for the Sustainment of Trauma And Readiness Skills, United States Air Force, Cincinnati, Ohio
| | - Michael D Goodman
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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12
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Qasim Z. Resuscitative Endovascular Balloon Occlusion of the Aorta. Emerg Med Clin North Am 2023; 41:71-88. [DOI: 10.1016/j.emc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Cralley AL, Vigneshwar N, Moore EE, Dubose J, Brenner ML, Sauaia A. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg 2023; 158:140-150. [PMID: 36542395 PMCID: PMC9856952 DOI: 10.1001/jamasurg.2022.6393] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022]
Abstract
Importance Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1. Objective To compare outcomes of AO via RT vs REBOA zone 1. Design, Setting, and Participants This was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older. Exposures AO via REBOA zone 1 vs RT. Main Outcomes and Measures The primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)-free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS). Results A total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival. Conclusions and Relevance Results of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.
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Affiliation(s)
- Alexis L. Cralley
- Department of Surgery, School of Medicine, University of Colorado, Denver
| | - Navin Vigneshwar
- Department of Surgery, School of Medicine, University of Colorado, Denver
| | - Ernest E. Moore
- Department of Surgery, School of Medicine, University of Colorado, Denver
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Joseph Dubose
- Department of Surgery, School of Medicine, University of Texas, Austin
| | - Megan L. Brenner
- Department of Surgery, University of California, Riverside School of Medicine, Moreno Valley
| | - Angela Sauaia
- Department of Surgery, School of Medicine, University of Colorado, Denver
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora
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14
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Haruta K, Endo A, Shiraishi A, Otomo Y. Usefulness of resuscitative endovascular balloon occlusion of the aorta compared to aortic cross-clamping in severely injured trauma patients: Analysis from the Japan Trauma Data Bank. Acute Med Surg 2023; 10:e830. [PMID: 36936741 PMCID: PMC10014424 DOI: 10.1002/ams2.830] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023] Open
Abstract
Aim To compare in-hospital mortality of severely injured trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) or aortic cross-clamping (ACC). Methods In this multicenter, retrospective cohort study using data from a nationwide trauma registry of tertiary emergency medical centers in Japan (n = 280), trauma patients who underwent aortic occlusion at the emergency department from 2004 to 2019 were divided into two groups according to the treatment they received: patients treated with ACC and patients who underwent placement of a REBOA catheter. Multiple imputations were used to handle the missing data. In-hospital mortality of the patients who underwent REBOA or ACC was compared using a mixed-effect logistic regression analysis and a propensity score-matching analysis, in which the confounders, including baseline patient demographics and severity, were adjusted. Results Of 1,670 patients (1,137 with REBOA and 533 with ACC), 66% were male. The median age was 56 years, and the mortality rate was 55.2% in the REBOA group and 81.6% in the ACC group. The mixed-effect model regression analysis showed a significantly lower odds ratio for in-hospital mortality rate in the REBOA group (odds ratio 0.17; 95% confidence interval, 0.12-0.26). A similar odds ratio was observed in the propensity score matching analysis (odds ratio 0.27; 95% confidence interval, 0.18-0.40). Conclusion Compared with ACC, REBOA use was associated with decreased mortality in severely injured trauma patients.
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Affiliation(s)
- Koichi Haruta
- Graduate School of MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Department of Emergency Medicine, Shizuoka Prefectural Hospital OrganizationShizuoka General HospitalShizuokaJapan
| | - Akira Endo
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Department of Acute Critical Care MedicineTsuchiura Kyodo General HospitalIbarakiJapan
| | - Atsushi Shiraishi
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
- Emergency and Trauma CenterKameda Medical CenterChibaJapan
| | - Yasuhiro Otomo
- Department of Acute Critical Care and Disaster MedicineTokyo Medical and Dental University HospitalTokyoJapan
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15
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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16
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Broome JM, Ali A, Simpson JT, Tran S, Tatum D, Taghavi S, DuBose J, Duchesne J. IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE. Shock 2022; 58:275-279. [PMID: 36256624 DOI: 10.1097/shk.0000000000001988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.
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Affiliation(s)
- Jacob M Broome
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ayman Ali
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John T Simpson
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sherman Tran
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Danielle Tatum
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Juan Duchesne
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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17
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Aoki M, Abe T. Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta. Front Med (Lausanne) 2022; 9:888225. [PMID: 35783650 PMCID: PMC9243328 DOI: 10.3389/fmed.2022.888225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
- *Correspondence: Makoto Aoki
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
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18
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Reich CF, Levy NA, Beal MW. Evaluation of resuscitative endovascular balloon occlusion of the aorta catheter placement and comparison to resuscitative thoracotomy with aortic clamping in cadaver dogs. J Vet Emerg Crit Care (San Antonio) 2022; 32:623-628. [PMID: 35687424 DOI: 10.1111/vec.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/03/2021] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe placement of an aortic occlusion catheter in aortic zone 1 (Z1) and aortic zone 3 (Z3) in dogs and to compare time to placement in these zones with and without external chest compressions (ECC). Additional evaluations of time to placement in Z1 with time for resuscitative thoracotomy with aortic clamping (RT-AC) were performed. DESIGN Prospective ex vivo study. SETTING University teaching hospital. ANIMALS Ten canine cadavers. INTERVENTIONS Ten cadaver dogs were obtained from client donation after euthanasia. Cadavers were randomized to have balloon catheter placement into the right or left femoral artery via cutdown, with or without ECC. The xiphoid was used as an external anatomical landmark for Z1, and the spinous process of the 5th lumbar vertebra was used for Z3. Balloon placement was confirmed with radiography. Time to balloon placement in Z1 and Z3 and time to RT-AC were recorded. MEASUREMENTS AND MAIN RESULTS Median body weight was 23.5 kg (9-40 kg). Median time to Z1 placement was 6.6 minutes (4.6-12.4 minutes) with ECC and 6.9 minutes (3.3-13.1 minutes) without ECC and was not statistically different (P = 0.5). Median time to RT-AC was 1 minute (0.6-1.4 minutes), which was significantly faster than time to balloon placement in Z1 with or without ECC (P = 0.004 and P = 0.002, respectively). CONCLUSIONS Endovascular balloon occlusion of the aorta can be achieved by cutdown with and without ECC, but RT-AC is faster. Successful balloon position in Z1 could be achieved with knowledge of external anatomical landmarks, but landmarks for Z3 need further study.
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Affiliation(s)
- Colin F Reich
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Nyssa A Levy
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Matthew W Beal
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
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19
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Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: A nationwide observational study in Japan. J Trauma Acute Care Surg 2022; 93:418-423. [PMID: 35444149 DOI: 10.1097/ta.0000000000003650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used for postpartum hemorrhage (PPH) which is one of the leading causes of maternal mortality worldwide; however, its utility in the obstetrics setting remains unclear. Thus, this study aimed to describe the characteristics, demographics and mortality of patients with PPH who underwent REBOA. METHODS We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients with PPH who underwent REBOA from April 2012 to March 2020. We examined the patients' characteristics, interventions administered and in-hospital mortality. RESULTS We identified 143 patients with PPH who underwent REBOA. The most common cause of PPH was atonic postpartum hemorrhage (52.4%), followed by disseminated intravascular coagulation (29.4%) and amniotic fluid embolism documented (11.2%). Among patients who delivered at hospitals in which REBOA was performed (n = 55), 38.2% of patients experienced preterm births and 70.9% delivered via cesarean section. The proportion of patients who underwent transcatheter arterial embolization and hysterectomy was 53.8% and 16.1%, respectively. In-hospital mortality was 7.0%. CONCLUSION The results of the present study could be helpful in clinical decision-making and providing patients and families with additional treatment options for PPH. LEVEL OF EVIDENCE Therapeutic, level IV.
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20
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Khalid S, Khatri M, Siddiqui MS, Ahmed J. Resuscitative Endovascular Balloon Occlusion of Aorta Versus Aortic Cross-Clamping by Thoracotomy for Noncompressible Torso Hemorrhage: A Meta-Analysis. J Surg Res 2021; 270:252-260. [PMID: 34715536 DOI: 10.1016/j.jss.2021.09.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/31/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The effect of resuscitative endovascular balloon occlusion of aorta (REBOA) in lowering mortality rate compared to resuscitative thoracotomy (RT) is inconclusive. In this updated systematic review and meta-analysis, we determined the effectiveness of the two techniques in patients with noncompressible torso hemorrhage (NCTH). MATERIALS AND METHODS Online databases (PubMed, Embase, and MEDLINE) were searched until April 23, 2021, for original articles investigating the effect of REBOA on relevant outcomes (e.g., mortality in ED, mortality before discharge, in-hospital mortality, length of hospital stay and length of ICU stay) among NCTH patients in contrast to open aortic occlusion by RT. Data on baseline characteristics and endpoints were extracted. Review Manager version 5.4.1 and OpenMetaAnalyst were used for analyses. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% confidence intervals were calculated. RESULTS Eight studies were included having 3241 patients in total (REBOA: 1179 and RT: 2062). The pooled analysis demonstrated that compared to RT, mortality was significantly lower in the REBOA group in all settings: In emergency department (ED) (RR 0.63 [0.45, 0.87], P = 0.006, I2 = 81%), before discharge (RR= 0.86 [0.75, 0.98], P = 0.03, I2 = 93%), and in-hospital mortality (RR 0.80 [0.68, 0.95], P = 0.009, I2 = 85%). Similarly, the length of ICU stay was significantly lower in REBOA group (WMD = 0.50 [-0.48, 1.48], P = 0.32, I2 =97%). However, no significant differences were observed in the length of hospital stay (WMD = 0.0 [-0.26, 0.26] P = 1). CONCLUSIONS Our pooled analysis shows REBOA to be effective in reducing mortality among NCTH patients. However, due to limited studies, the positive findings should be viewed discreetly and call for further investigation.
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Affiliation(s)
- Saad Khalid
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
| | - Mahima Khatri
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Jawad Ahmed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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21
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Castellini G, Gianola S, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Coniglio C, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg 2021; 16:41. [PMID: 34384452 PMCID: PMC8358549 DOI: 10.1186/s13017-021-00386-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock. Methods We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible. We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique. Results We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (p = 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate. Conclusions Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00386-9.
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Affiliation(s)
- Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Carlo Coniglio
- Department of Anesthesiology, Intensive Care and Pre-Hospital Emergency Services, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Antonello Napoletano
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela Coclite
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela D'Angelo
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Alice Josephine Fauci
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Laura Iacorossi
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Roberto Latina
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Katia Salomone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Shailvi Gupta
- University of Maryland, Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Primiano Iannone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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Otsuka H, Takeda M, Sai K, Sakoda N, Uehata A, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study. J Trauma Acute Care Surg 2021; 91:287-294. [PMID: 34397952 DOI: 10.1097/ta.0000000000003193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. METHODS This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. RESULTS All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. CONCLUSION In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. LEVEL OF EVIDENCE Therapeutic/care management study, level V.
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Affiliation(s)
- Hiroyuki Otsuka
- From the Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
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23
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[Emergency thoracotomy in a severely injured patient after hemorrhagic shock in traumatic pelvic bleeding : Case report]. Unfallchirurg 2021; 125:568-573. [PMID: 34255104 DOI: 10.1007/s00113-021-01055-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
A case of in-hospital thoracotomy with subsequent open chest cardiopulmonary resuscitation of a polytraumatized patient is reported. Emergency thoracotomies are rare interventions in challenging situations. Up to now there are only few standards or uniform education and training concepts. The indications are often a borderline decision. The aim of thoracotomy and open resuscitation in combination with a reduction in circulation, for example by cross-clamping the aorta, is to save time to address reversible causes of the hemorrhage, redirect the blood volume into the vital cerebral and coronary circulation and minimize bleeding from subdiaphragmatic bleeding sources. Ultimately, in case of doubt, the thoracotomy can be performed for the patient's benefit with the appropriate indications.
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24
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Shi C, Li S, Wang Z, Shen H. Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage. Injury 2021; 52:1657-1663. [PMID: 33750584 DOI: 10.1016/j.injury.2021.02.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.
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Affiliation(s)
- Changgui Shi
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Song Li
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhinong Wang
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Hongliang Shen
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China.
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25
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Elkbuli A, Kinslow K, Sen-Crowe B, Liu H, McKenney M, Ang D. Outcomes of resuscitative endovascular balloon occlusion of the aorta (REBOA) utilization in trauma patients with and without traumatic brain injuries: A national analysis of the American College of Surgeons Trauma Quality Improvement Program data set. Surgery 2021; 170:284-290. [DOI: 10.1016/j.surg.2021.01.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 10/22/2022]
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26
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Manzano-Nuñez R, Chica-Yanten J, Naranjo MP, Caicedo-Holguin I, Ordoñez JM, McGreevy D, Puyana JC, Hörer TM, Moore EE, García AF. Use of REBOA in the universe of magical realism: a real-world review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.
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American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries. J Trauma Acute Care Surg 2021; 89:1197-1211. [PMID: 33230049 DOI: 10.1097/ta.0000000000002968] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
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28
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Abstract
ABSTRACT The emerging concept of endovascular resuscitation applies catheter-based techniques in the management of patients in shock to manipulate physiology, optimize hemodynamics, and bridge to definitive care. These interventions hope to address an unmet need in the care of severely injured patients, or those with refractory non-traumatic cardiac arrest, who were previously deemed non-survivable. These evolving techniques include Resuscitative Endovascular Balloon Occlusion of Aorta, Selective Aortic Arch Perfusion, and Extracorporeal Membrane Oxygenation and there is a growing literature base behind them. This review presents the up-to-date techniques and interventions, along with their application, evidence base, and controversy within the new era of endovascular resuscitation.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - James D Ross
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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29
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Kinslow K, Shepherd A, McKenney M, Elkbuli A. Resuscitative Endovascular Balloon Occlusion of Aorta: A Systematic Review. Am Surg 2021; 88:289-296. [PMID: 33605780 DOI: 10.1177/0003134820972985] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The data on resuscitative endovascular balloon occlusion of the aorta (REBOA) use continue to grow with its increasing use in trauma centers. The data in her last 5 years have not been systematically reviewed. We aim to assess current literature related to REBOA use and outcomes among civilian trauma populations. METHODS A literature search using PubMed, EMBASE, and JAMA Network for studies regarding REBOA usage in civilian trauma from 2016 to 2020 is carried out. This review followed preferred reporting items for systematic reviews and meta-analysis guidelines. RESULTS Our search yielded 35 studies for inclusion in our systematic review, involving 4073 patients. The most common indication for REBOA was patient presentation in hemorrhagic shock secondary to traumatic injury. REBOA was associated with significant systolic blood pressure improvement. Of 4 studies comparing REBOA to non-REBOA controls, 2 found significant mortality benefit with REBOA. Significant mortality improvement with REBOA compared to open aortic occlusion was seen in 4 studies. In the few studies investigating zone placement, highest survival rate was seen in patients undergoing zone 3. Overall, reports of complications directly related to overall REBOA use were relatively low. CONCLUSION REBOA has been shown to be effective in promoting hemodynamic stability in civilian trauma. Mortality data on REBOA use are conflicting, but most studies investigating REBOA vs. open occlusion methods suggest a significant survival advantage. Recent data on the REBOA technique (zone placement and partial REBOA) are sparse and currently insufficient to determine advantage with any particular variation. Overall, larger prospective civilian trauma studies are needed to better understand the benefits of REBOA in high-mortality civilian trauma populations. STUDY TYPE Systematic Review. LEVEL OF EVIDENCE III- Therapeutic.
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Affiliation(s)
- Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Aaron Shepherd
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
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30
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Bonanno AM, Graham TL, Wilson LN, Ross JD. Novel use of XSTAT 30 for mitigation of lethal non-compressible torso hemorrhage in swine. PLoS One 2020; 15:e0241906. [PMID: 33206692 PMCID: PMC7673511 DOI: 10.1371/journal.pone.0241906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/22/2020] [Indexed: 11/19/2022] Open
Abstract
Background Management of Non-Compressible Torso Hemorrhage (NCTH) consists primarily of aortic occlusion which has significant adverse outcomes, including ischemia-reperfusion injury, in prolonged field care paradigms. One promising avenue for treatment is through use of RevMedx XSTAT 30™ (an FDA approved sponge-based dressing utilized for extremity wounds). We hypothesized that XSTAT 30™ would effectively mitigate NCTH during a prolonged pre-hospital period with correctable metabolic and physiologic derangements. Methods and findings Twenty-four male swine (53±2kg) were anesthetized, underwent line placement, and splenectomy. Animals then underwent laparoscopic transection of 70% of the left lobe of the liver with hemorrhage for a period of 10min. They were randomized into three groups: No intevention (CON), XSTAT 30™-Free Pellets (FP), and XSTAT 30™-Bagged Pellets (BP). Animals were observed for a pre-hospital period of 180min. At 180min, animals underwent damage control surgery (DCS), balanced blood product resuscitation and removal of pellets followed by an ICU period of 5 hours. Postoperative fluoroscopy was performed to identify remaining pellets or bags. Baseline physiologic and injury characteristics were similar. Survival rates were significantly higher in FP and BP (p<0.01) vs CON. DCS was significantly longer in FP in comparison to BP (p = 0.001). Two animals in the FP group had pellets discovered on fluoroscopy following DCS. There was no significant difference in blood product or pressor requirements between groups. End-ICU lactates trended to baseline in both FP and BP groups. Conclusions While these results are promising, further study will be required to better understand the role for XSTAT in the management of NCTH.
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Affiliation(s)
- Alicia M. Bonanno
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Todd L. Graham
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Lauren N. Wilson
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - James D. Ross
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, United States of America
- * E-mail:
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31
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Manzano-Nunez R, McGreevy D, Orlas CP, García AF, Hörer TM, DuBose J, Ordoñez CA. Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries. World J Emerg Surg 2020; 15:57. [PMID: 33046096 PMCID: PMC7549081 DOI: 10.1186/s13017-020-00337-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/27/2020] [Indexed: 11/28/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries’ income based on the World Bank Country and Lending Groups. Methods We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. Results A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3). Conclusion There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia. .,Universidad del Rosario, Escuela de Medicina y Ciencias de la Salud, Bogotá, Colombia. .,Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia. .,R. Adams Cowley Shock Trauma, Baltimore, MD, USA.
| | - David McGreevy
- Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Claudia P Orlas
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia
| | | | - Tal M Hörer
- Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Joseph DuBose
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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32
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Campagna GA, Cunningham ME, Hernandez JA, Chau A, Vogel AM, Naik-Mathuria BJ. The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pediatric population: An evidence-based review. J Pediatr Surg 2020; 55:2128-2133. [PMID: 32061369 DOI: 10.1016/j.jpedsurg.2020.01.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/17/2019] [Accepted: 01/24/2020] [Indexed: 11/18/2022]
Abstract
Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Giovanni A Campagna
- Baylor College of Medicine, School of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Megan E Cunningham
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA
| | - Jose A Hernandez
- Texas Children's Hospital, Department of Radiology, Division of Pediatric Interventional Radiology, 6701 Fannin St, Houston, TX, 77030, USA
| | - Alex Chau
- Texas Children's Hospital, Department of Radiology, Division of Pediatric Interventional Radiology, 6701 Fannin St, Houston, TX, 77030, USA
| | - Adam M Vogel
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA
| | - Bindi J Naik-Mathuria
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA.
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Aoki M, Abe T, Hagiwara S, Saitoh D, Oshima K. Resuscitative endovascular balloon occlusion of the aorta may contribute to improved survival. Scand J Trauma Resusc Emerg Med 2020; 28:62. [PMID: 32605626 PMCID: PMC7325257 DOI: 10.1186/s13049-020-00757-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an increasingly used trauma resuscitation procedure, however, there are no reports of whether or not the survival of patients treated with REBOA increases over time. METHODS This retrospective cohort study from a nationwide trauma registry in Japan was conducted between 2004 and 2015. Patients treated with REBOA were divided into three calendar year periods: early-period (2004-2007), mid-period (2008-2011), and late-period (2012-2015). The primary outcome of in-hospital survival was compared between the periods (early-period: reference) using mixed effects logistic regression analysis after adjustment for characteristics, trauma severity, and therapeutic choices. RESULTS Of 236,698 trauma patients, 633 patients treated with REBOA were analyzed. Distribution of the patients across periods was as follows: early-period (91), mid-period (276), and late-period (266). In-hospital survival was 39, 49, and 60% in the early-period, mid-period, and late-period, respectively. In regression modeling, the late-period (OR = 2.976, 95% CI = 1.615-5.482) was associated with improved in-hospital survival compared to the early-period, however, the mid-period (OR = 1.614, 95% CI = 0.898-2.904) was not associated with improved survival. CONCLUSIONS Survival of patients treated with REBOA during the late-period improved compared with survival during the early-period, after adjustment for characteristics, trauma severity, and therapeutic choices. REBOA may be one of the important factors related to progression of modern trauma treatment.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Shuichi Hagiwara
- Department of Emergency Medicine, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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Singer KE, Morris MC, Blakeman C, Stevens-Topie SM, Veile R, Fortuna G, DuBose JJ, Stuever MF, Makley AT, Goodman MD. Can Resuscitative Endovascular Balloon Occlusion of the Aorta Fly? Assessing Aortic Balloon Performance for Aeromedical Evacuation. J Surg Res 2020; 254:390-397. [PMID: 32540506 DOI: 10.1016/j.jss.2020.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage remains a leading cause of death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) placement may occur before transport; however, its efficacy has not been demonstrated at altitude. We hypothesized that changes in altitude would not result in blood pressure changes proximal to a deployed REBOA. METHODS A simulation model for 7Fr guidewireless REBOA was used at altitudes up to 22,000 feet. Female pigs then underwent hemorrhagic shock to a mean arterial pressure (MAP) of 40 mm Hg. After hemorrhage, a REBOA catheter was deployed in the REBOA group and positioned but not inflated in the no-REBOA group. Animals underwent simulated aeromedical evacuation at 8000 ft or were left at ground level. After altitude exposure, the balloon was deflated, and the animals were observed. RESULTS Taking the REBOA catheter to 22,000 ft in the simulation model resulted in a lower systolic blood pressure but a preserved MAP. In the porcine model, REBOA increased both systolic blood pressure and MAP compared with no-REBOA (P < 0.05) and was unaffected by altitude. No differences in postflight blood pressure, acidosis, or systemic inflammatory response were observed between ground and altitude REBOA groups. CONCLUSIONS REBOA maintained MAP up to 22,000 feet in an inanimate model. In the porcine model, REBOA deployment improved MAP, and the balloon remained effective at altitude.
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Affiliation(s)
| | | | | | | | - Rosalie Veile
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Gerald Fortuna
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Joseph J DuBose
- Department of Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Mary F Stuever
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients. Eur J Trauma Emerg Surg 2020; 47:1779-1785. [PMID: 32300850 DOI: 10.1007/s00068-020-01370-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to examine the association of REBOA and mortality in a group of patients with penetrating trauma to the torso, treated in a level-I trauma center from Colombia. METHODS In a retrospective cohort study, patients with penetrating trauma, requiring emergency surgery, and treated between 2014 and 2018, were included. The decision to use or not use REBOA during emergent surgery was based on individual surgeon's opinion. A propensity score (PS) was calculated after adjusting for age, clinical signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage. Subsequently, logistic regression for mortality was adjusted for the number of red blood cells (RBC) transfused within the first six hours after admission, injury severity score (ISS), and quintiles of PS. RESULTS We included 345 patients; 28 of them (8.1%) were treated with REBOA. Crude mortality rates were 17.9% (5 patients) in REBOA group and 15.3% (48 patients) in control group (p = 0.7). After controlling for RBC transfused, ISS, and the PS, the odds of death in REBOA group was 78% lower than that in the control group (odds ratio [OR] 0.20, 95% confidence interval [95%CI] 0.05-0.77, p = 0.01). CONCLUSION We found that, when compared to no REBOA use, patients treated with REBOA had lower risk-adjusted odds of mortality. These findings should be interpreted with caution and confirmed in future comparative studies, if possible.
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Efficacy of venous access placement at a pre-hospital scene in severe paediatric trauma patients: a retrospective cohort study. Sci Rep 2020; 10:6433. [PMID: 32286495 PMCID: PMC7156689 DOI: 10.1038/s41598-020-63564-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/23/2020] [Indexed: 11/08/2022] Open
Abstract
Purpose: Aside from severe traumatic brain injury, uncontrolled bleeding and corresponding haemorrhage shock are the leading causes of traumatic deaths. No established recommendations exist about venous access placement for severely injured, bleeding children at a pre-hospital scene. This study sought to evaluate the association between pre-hospital venous access placement and mortality in a paediatric trauma population by analysing the Japan Trauma Data Bank (JTDB). Methods: This epidemiologic study compared the outcomes of severe traumatic paediatric patients with or without venous access placement at a pre-hospital scene. Data were obtained from JTDB from 2004 to 2015. Results: Of 4,109 patients who met our inclusion criteria, 144 patients received venous access placement and 3,965 patients did not. The probability of survival was lower in the venous access group than in the no access group (0.90 [0.67–0.97] vs. 0.97 [0.90–0.99], p < 0.01). After multivariable logistic analysis, venous access placement did not improve survival to hospital discharge (odds ratio = 1.40, confidence interval = 0.32–6.15, p = 0.653). Conclusions: The probability of survival was lower in the venous access group than in the no access group. Survival outcome at discharge was not affected by venous access placement at a pre-hospital scene.
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37
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Chung JS, Kim OH, Kim S, Jang JY, An GJ, Jung PY. Resuscitative Endovascular Balloon occlusion of the aorta in Impending Traumatic arrest: Is It Effective? JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Sepehri A, Sciadini MF, Nascone JW, Manson TT, O'Toole RV, Slobogean GP. Initial experience with the T-Clamp for temporary fixation of mechanically and hemodynamically unstable pelvic ring injuries. Injury 2020; 51:699-704. [PMID: 32037004 DOI: 10.1016/j.injury.2020.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/22/2020] [Indexed: 02/02/2023]
Abstract
In polytrauma patients with unstable pelvic ring injuries, pelvic binders interfere with femoral arterial access and are frequently removed for emergent endovascular and abdominal procedures. The 'trochanteric C-clamp' (T-clamp) is a novel technique described for rapid stabilization of the pelvis without fluoroscopic imaging, while ensuring adequate access to the groin. This case series reports the feasibility and safety following T-clamp application for unstable pelvic ring injuries in patients requiring simultaneous endovascular intervention. Between May 2018 - May 2019, seventeen patients with unstable pelvic ring injuries were treated with a T-clamp in conjunction with other emergent endovascular or intra-abdominal procedures. Nine presented with unstable APC injuries, seven with unstable LC injuries and one with a vertical shear pattern. Complications related to the T-clamp were prospectively collected. Following T-clamp application, there were two cases of intraoperative over-reduction, one of which required exchange for an anterior external fixator. This was the result of a concomitant acetabulum fracture leading to iatrogenic acetabular protrusion secondary to the T-clamp. Twelve cases maintained the T-clamp fixation postoperatively ranging from 1-3 days. One postoperative loss of reduction was noted and required exchange for anterior external fixator. In hemodynamically unstable patients who require emergent endovascular procedures, such as pelvic angiography and REBOA, T-clamp application offers a reasonably safe and effective method for expeditious stabilization of the pelvis while allowing unimpeded access to the abdomen, groin and pelvis. Caution should also be applied in patients with concomitant acetabulum fracture for risk of malreduction. Additionally, its prolonged postoperative use should be limited to patients who are not immediately suitable for fixation of the pelvis.
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Affiliation(s)
- Aresh Sepehri
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States
| | - Marcus F Sciadini
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States
| | - Jason W Nascone
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States
| | - Gerard P Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland, School of Medicine, 6th Floor, Suite 300, 110 S. Paca St, Baltimore, MD 21201, United States.
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King DR, Crowley JC, Frenk NE, Kaafarani HMA. Case 39-2019: A 57-Year-Old Woman with Hypotension and Trauma after a Motorcycle Accident. N Engl J Med 2019; 381:2462-2469. [PMID: 31851804 DOI: 10.1056/nejmcpc1909619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David R King
- From the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Massachusetts General Hospital, and the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Harvard Medical School - both in Boston
| | - Jerome C Crowley
- From the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Massachusetts General Hospital, and the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Harvard Medical School - both in Boston
| | - Nathan E Frenk
- From the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Massachusetts General Hospital, and the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Harvard Medical School - both in Boston
| | - Haytham M A Kaafarani
- From the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Massachusetts General Hospital, and the Departments of Surgery (D.R.K., H.M.A.K.), Anesthesia (J.C.C.), and Radiology (N.E.F.), Harvard Medical School - both in Boston
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40
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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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41
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Abstract
Traumatic injuries of the hip and pelvis are commonly encountered in the emergency department. This article equips all emergency medicine practitioners with the knowledge to expertly diagnose, treat, and disposition these patients. Pelvic fractures occurring in young patients tend to be associated with high-energy mechanisms and polytrauma. Pelvic and hip fractures in the elderly are often a result of benign trauma but are associated with significant morbidity and mortality.
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Affiliation(s)
- Jason V Brown
- Emergency Medical Services, United States Air Force, 96TW/SGOE, 307 Boatner Road, Eglin AFB, FL 32542, USA.
| | - Sharleen Yuan
- Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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42
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Matsumoto S, Hayashida K, Akashi T, Jung K, Sekine K, Funabiki T, Moriya T. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Torso Trauma in Japan: A Descriptive Study. World J Surg 2019; 43:1700-1707. [PMID: 30824958 DOI: 10.1007/s00268-019-04968-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to be an alternative to open aortic cross-clamping (ACC). However, its practical indication remains unknown. We examined the usage trend of REBOA and ACC in Japan for severe torso trauma and investigated whether these procedures were associated with the time of death distribution based on a large database from the Japan Trauma Data Bank (JTDB). METHODS The JTDB from 2004 to 2014 was reviewed. Eligible patients were restricted to those with severe torso trauma, which was defined as an abbreviated injury scale score of ≥4. Patients were classified into groups according to the aortic occlusion procedures. The primary outcomes were the rates of REBOA and ACC use according to the clinical situation. We also evaluated whether the time of death distribution for the first 8 h differed based on these procedures. RESULTS During the study period, a total of 21,533 patients met our inclusion criteria. Overall, REBOA was more commonly used than ACC for patients with severe torso trauma (2.8% vs 1.5%). However, ACC was more frequently used in cases of thoracic injury and cardiac arrest. Regarding the time of death distribution, the cumulative curve for death in REBOA cases was elevated much more slowly and mostly flat for the first 100 min. CONCLUSIONS REBOA is more commonly used compared to ACC for patients with severe torso trauma in Japan. Moreover, it appears that REBOA influences the time of death distribution in the hyperacute phase.
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Affiliation(s)
- Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-Shi, Kanagawa, 230-0012, Japan.
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Japan.
| | - Kei Hayashida
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, USA
| | - Taku Akashi
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Kazuhiko Sekine
- Department of Emergency Medicine, Saiseikai Central Hospital, Tokyo, Japan
| | - Tomohiro Funabiki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Japan
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43
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Knapp J, Bernhard M, Haltmeier T, Bieler D, Hossfeld B, Kulla M. [Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?]. Anaesthesist 2019; 67:280-292. [PMID: 29508015 DOI: 10.1007/s00101-018-0418-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.
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Affiliation(s)
- J Knapp
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Freiburgstrasse 8, Bern, Schweiz.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - T Haltmeier
- Universitätsklinik für Viszerale Chirurgie und Medizin, Universitätsspital Bern, Bern, Schweiz
| | - D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie und Intensivmedizin/Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - M Kulla
- Klinik für Anästhesiologie und Intensivmedizin/Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
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Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage? Curr Opin Anaesthesiol 2019; 32:213-226. [PMID: 30817398 DOI: 10.1097/aco.0000000000000699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. RECENT FINDINGS The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30-60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. SUMMARY REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts.
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45
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Petrone P, PÉRez-JimÉNez A, Rodríguez-Perdomo M, Brathwaite CEM, Joseph DK. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Trauma Patients: A Systematic Literature Review. Am Surg 2019. [DOI: 10.1177/000313481908500631] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an innovative method by which noncompressible bleeding in the torso can be mitigated until definitive treatment can be obtained. To perform a systematic review of the literature on the use of the REBOA in trauma patients. An English and Spanish literature search was performed using MEDLINE, PubMed, and Scopus, from 1948 to 2018. Keywords used were aortic balloon occlusion, resuscitative endovascular balloon, REBOA, hemorrhage, and resuscitative endovascular balloon occlusion of the aorta. The eligilibility criteria included only original and human subject articles. Nontrauma patients, nonbleeding pathology, letters, single case reports, reviews, and pediatric patients were excluded. Two hundred forty-six articles were identified, of which 17 articles were included in this review. The total number of patients was 1340; 69 per cent were men and 31 per cent women. In 465 patients, the aortic zone location was described: 83 per cent the balloon was placed in aortic zone I and 16 per cent in zone III. Systolic blood pressure increased at an average of 52 mmHg before and after aortic occlusion. Although 32 patients (2.4%) presented clinical complications derived from the procedure, no mortality was reported. The trauma-related mortality rate was 58 per cent (776/1340). REBOA is a useful resource for the management of non-compressive torso hemorrhage with promising results in systolic blood pressure and morbidity. Indications for its use include injuries in zones 1 and 3, whereas it is not clear for zone 2 injuries. Additional studies are needed to define the benefits of this procedure.
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Affiliation(s)
- Patrizio Petrone
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, New York
| | - Aida PÉRez-JimÉNez
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, New York
| | - Martín Rodríguez-Perdomo
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, New York
| | - Collin E. M. Brathwaite
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, New York
| | - D'andrea K. Joseph
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, New York
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Affiliation(s)
- Elizabeth Dauer
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA.
| | - Amy Goldberg
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
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47
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Long B, Hafen L, Koyfman A, Gottlieb M. Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians. J Emerg Med 2019; 56:687-697. [PMID: 31010604 DOI: 10.1016/j.jemermed.2019.03.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/25/2019] [Accepted: 03/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians. DISCUSSION Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA. CONCLUSIONS REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Lee Hafen
- Department of General Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Takashima N, Lee J, Minamidate N, Fujita T, Yamaji M, Sakaguchi T, Takeda T, Mabuchi H. Successful Surgery of Right Common Iliac Artery Injury during Lumbar Discectomy with Endovascular Balloon Occlusion of the Aorta Performed by Cardiologists. Ann Vasc Dis 2019; 12:60-62. [PMID: 30931059 PMCID: PMC6434366 DOI: 10.3400/avd.cr.18-00056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 19-year-old woman developed hypotension and abdominal distension during lumbar discectomy. Computed tomography revealed a right common artery injury and a large retroperitoneal hematoma. She was transferred to our hospital and brought to an angiography room directly. Endovascular balloon occlusion of the aorta was performed by cardiologists while surgeons were preparing for surgery. With the hemodynamics stabilized, the injured artery was repaired. In such a case, closing the artery as soon as possible, whether by clamping or by balloon occlusion, is vital. The ability to respond with a “Heart Team” is essential for a small-manpower hospital to rescue a patient with a serious condition.
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Affiliation(s)
- Noriyuki Takashima
- Department of Cardiovascular Surgery, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Junghun Lee
- Department of Cardiovascular Surgery, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Naoshi Minamidate
- Department of Cardiovascular Surgery, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Takanari Fujita
- Department of Cardiology, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Masayuki Yamaji
- Department of Cardiology, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Tomoko Sakaguchi
- Department of Cardiology, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Teruki Takeda
- Department of Cardiology, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Kotoh Memorial Hospital, Higashi-oumi, Shiga, Japan
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Resuscitative endovascular balloon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage: A 20-year experience in a Level I trauma center. J Trauma Acute Care Surg 2019; 84:449-453. [PMID: 29298239 DOI: 10.1097/ta.0000000000001794] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used as a noninvasive clamp of the aorta after diverse posttraumatic injuries. Balloon inflation in zone 3 (from the lower renal artery to the aortic bifurcation) can be performed to stop ongoing bleeding after severe pelvic trauma with life-threatening hemorrhage. The aim of our study was to describe our 20-year experience with REBOA in terms of efficacy and safety in patients with a suspicion of severe pelvic trauma and extreme hemorrhagic shock. METHODS We performed a retrospective study from 1996 to 2017 in a French Level I trauma center. All consecutive patients who underwent a REBOA procedure were included. REBOA indication relied on (1) extreme hemodynamic instability (systolic arterial blood pressure [SBP] < 60 mm Hg on admission, SBP < 90 mm Hg despite initial resuscitation in the trauma bay or posttraumatic cardiac arrest) and (2) positive pelvic X-ray. Efficacy endpoints were vital signs and coagulation parameters before and after balloon inflation. Safety endpoints were REBOA-related complications: vascular events, acute renal failure, and rhabdomyolysis. RESULTS Within the study period, 32 patients underwent a REBOA procedure. Only two patients had technical failure and balloon was not inflated in one patient. Nineteen patients did not survive at day 28. The REBOA significantly improved SBP from 60 (35-73) mm Hg to 115 (91-128) mm Hg (p < 0.001). We also reported a high rate of vascular complications (19%, n = 5 patients) but no amputation. Renal replacement therapy was initiated in 11 patients, and 15 patients had severe rhabdomyolysis. CONCLUSION The REBOA is safe and effective in improving hemodynamics after severe pelvic trauma and life-threatening hemorrhage. Our study supports the use of REBOA as a bridge to definitive hemostatic treatment after severe pelvic trauma. LEVEL OF EVIDENCE Therapeutic, level IV.
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REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta). Notf Rett Med 2019. [DOI: 10.1007/s10049-017-0396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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