Pre-hospital CPR and early REBOA in trauma patients - Results from the ABOTrauma Registry.

10.21203/rs.2.19571/v1 ◽

2020 ◽

Author(s):

Peter Hilbert-Carius ◽

David T McGreevy ◽

Fikri M. Abu-Zidan ◽

Tal M. Hörer

Keyword(s):

Cardiac Arrest ◽

Survival Rate ◽

Hospital Admission ◽

Injury Severity ◽

Balloon Occlusion ◽

Trauma Patients ◽

Probability Of Survival ◽

Traumatic Cardiac Arrest ◽

Using Data

Abstract Background: Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods: Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results: Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to hospital with ongoing CPR. Nine patients (35%) died within the first 24 hours, while seventeen patients (65%) survived post 24 hours. The survival rate to hospital discharge was 27% (n=7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p=0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. Survival rate in the 16 patients responding to REBOA was 37.5% (n=6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from median (range) 56.5 (0-147) to 90 (0-200) mmHg. Conclusions: Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated. Keywords: REBOA, Cardiac Arrest, Trauma, CPR, Endovascular Resuscitation.

Assessment of trauma and injury severity score model for survival of trauma patients: a single centre experience

International Surgery Journal ◽

10.18203/2349-2902.isj20182771 ◽

2018 ◽

Vol 5 (7) ◽

pp. 2550

Author(s):

Umesh Gaikwad Gaikwad ◽

Nitin Wasnik ◽

Divish Saxena ◽

Murtaza Akhtar

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Trauma Patients ◽

Probability Of Survival ◽

Predicted Probability ◽

Revised Trauma Score ◽

Score Model ◽

Set Up ◽

Trauma And Injury

Background: Trauma and Injury Severity Score (TRISS) designed by Major Trauma Outcome Study (MTOS) in United States, is commonly used for outcome prediction in polytrauma patients. It determines the probability of survival (PS) of a patient from the Injury Severity Score (ISS) and Revised Trauma Score (RTS) using TRISS methodology.Methods: A total number of 136 patients presenting within 24 hours of trauma that were admitted were included in the study. The probability of survival was calculated using TRISS index (RTS, ISS, and age combination index). The predicted probability of survival and that of death among the study subjects were calculated using TRISS. A cut off 0.5 or lesser of TRISS score was taken as death and above 0.5 as survival status.Results: The mean TRISS among males and females were 86.12±21.76 and 79.49±27.70 and based on TRISS score the expected deaths were predicted to be 11.03%. But, in actual, the deaths were 23.52% showing a negative correlation with TRISS score in our set up thereby indicating a need to improve emergency facilities for trauma patients.Conclusions: TRISS methodology when applied to our setup predicted fewer deaths as compared to the actual deaths and also did not accurately predict the survival in the trauma patients.

Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-020-00827-5 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Francois-Xavier Ageron ◽

Timothy J. Coats ◽

Vincent Darioli ◽

Ian Roberts

Keyword(s):

Tranexamic Acid ◽

Acid Treatment ◽

Injury Severity ◽

External Validation ◽

Research Network ◽

Brier Score ◽

Trauma Patients ◽

Using Data ◽

The Uk ◽

The Impact

Abstract Background Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding. Methods We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients. Results We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9915 (9%) patients. Of these 5185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score = 6%) and good discrimination (C-statistic 0.90; 95% CI 0.89–0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%, P = 0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9915 as currently. Conclusion The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2017.01.010 ◽

2017 ◽

Vol 35 (5) ◽

pp. 731-736 ◽

Cited By ~ 31

Author(s):

James Daley ◽

Jonathan James Morrison ◽

John Sather ◽

Lisa Hile

Keyword(s):

Cardiac Arrest ◽

Balloon Occlusion ◽

Traumatic Cardiac Arrest ◽

Endovascular Balloon Occlusion

Assessing the need for resuscitative endovascular balloon occlusion of the aorta (REBOA) for management of non-compressible hemorrhage at a Canadian urban trauma centre

10.21203/rs.3.rs-198760/v1 ◽

2021 ◽

Author(s):

Elizabeth Purssell ◽

Sean Patrick ◽

Joseph Haegert ◽

Vesna Ivkov ◽

John Taylor

Keyword(s):

Injury Severity ◽

Retrospective Chart Review ◽

Balloon Occlusion ◽

Trauma Centre ◽

Trauma Patients ◽

Potential Candidate ◽

Study Objective ◽

Resuscitative Thoracotomy ◽

Less Invasive ◽

Endovascular Balloon Occlusion

Abstract Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive alternative to resuscitative thoracotomy (RT) for life threatening, infra-diaphragmatic, non-compressible hemorrhage from trauma. Existing evidence surrounding the efficacy of REBOA is conflicting; nevertheless, expert consensus suggests that REBOA should be considered in select trauma patients. There has been a paucity of studies that evaluate the potential utility of REBOA in the Canadian setting. The study objective was to evaluate the percentage of trauma patients presenting to a Level 1 Canadian trauma centre that would have met criteria for REBOA. Methods We conducted a retrospective chart review of patients recorded in the British Columbia Trauma Registry who warranted a trauma team activation (TTA) at our institution. We identified REBOA candidates using pre-defined criteria based on published guidelines. Each TTA case was screened by a reviewer, and then each Potential Candidate was reviewed by a panel of trauma physicians for determination of final candidacy. Results Fourteen patients were classified as Likely REBOA Candidates (2.2% of TTAs, median age 46.1 years, 64.3% female). These patients had a median Injury Severity Score of 31.5 (IQR 26.8). The main sources of hemorrhage in these patients were from abdominal injuries (71.4%) and pelvic fractures (42.9%). Conclusion The percentage of patients who met criteria for REBOA is similar to that of RTs performed at our Canadian institution. While REBOA would be performed infrequently, it is a less-invasive alternative to RT, which could be a potentially life-saving procedure in a small group of the most severely injured trauma patients.

Successfully REBOA performance: does medical specialty matter? International data from the ABOTrauma Registry

World Journal of Emergency Surgery ◽

10.1186/s13017-020-00342-z ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Peter Hilbert-Carius ◽

◽

David McGreevy ◽

Fikri M. Abu-Zidan ◽

Tal M. Hörer

Keyword(s):

Injury Severity ◽

Invasive Procedure ◽

Balloon Occlusion ◽

High Rate ◽

Future Research ◽

Trauma Patients ◽

Anatomic Landmarks ◽

Access Methods ◽

Angiography Suite ◽

Aortic Balloon Occlusion

Abstract Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure being increasingly utilized to prevent patients with non-compressible torso hemorrhage from exsanguination. The increased use of REBOA is giving rise to discussion about “Who is and who should be performing it?” Methods Data from the international ABO (aortic balloon occlusion) Trauma Registry from between November 2014 and April 2020 were analyzed concerning the question: By who, how, and where is REBOA being performed? The registry collects retrospective and prospective data concerning use of REBOA in trauma patients. Results During the study period, 259 patients had been recorded in the registry, 72.5% (n = 188) were males with a median (range) age of 46 (10-96) years. REBOA was performed in the ER in 50.5%, in the OR in 41.5%, and in the angiography suite in 8% of patients. In 54% of the patients REBOA was performed by surgeons (trauma surgeons 28%, vascular surgeons 22%, general surgeons 4%) and in 46% of the patients by non-surgeons (emergency physicians 31%, radiologists 9.5%, anesthetists 5.5%). Common femoral artery (CFA) access was achieved by use of external anatomic landmarks and palpation alone in 119 patients (51%), by cutdown in 57 patients (24%), using ultrasound in 49 patients (21%), and by fluoroscopy in 9 patients (4%). Significant differences between surgeons and non-surgeons were found regarding patient’s age, injury severity, access methods, place where REBOA was performed, location patients were taken to from the emergency room, and mortality. Conclusion A substantial number of both surgical and non-surgical medical disciplines are successfully performing REBOA to an almost equal extent. Surgical cutdown is used less frequently as access to the CFA compared with reports in older literature and puncture by use of external anatomic landmarks and palpation alone is used with a high rate of success. Instead of discussing “Who should be performing REBOA?” future research should focus on “Which patient benefits most from REBOA?”

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000723 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000723

Author(s):

James W Davis ◽

Rachel C Dirks ◽

David R Jeffcoach ◽

Krista L Kaups ◽

Lawrence P Sue ◽

...

Keyword(s):

Mortality Rate ◽

Patient Group ◽

Injury Severity ◽

Balloon Occlusion ◽

Physiological Data ◽

Trauma Patients ◽

Level Of Evidence ◽

Management Level ◽

Level I ◽

Emergent Laparotomy

BackgroundMortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA.MethodsThe trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg).ResultsDuring the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg.DiscussionMortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group.Level of evidenceTherapeutic/care management, level III.

Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: Usefulness for tranexamic acid treatment criteria.

10.21203/rs.3.rs-64755/v3 ◽

2020 ◽

Author(s):

Francois-Xavier Ageron ◽

Timothy J Coats ◽

Vincent Darioli ◽

Ian Roberts

Keyword(s):

Tranexamic Acid ◽

Acid Treatment ◽

Injury Severity ◽

External Validation ◽

Research Network ◽

Brier Score ◽

Trauma Patients ◽

Using Data ◽

The Uk ◽

The Impact

Abstract Background: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding.Methods: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients.ResultsWe included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9,915 (9%) patients. Of these 5,185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score=6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%; P=0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9,915 as currently. ConclusionThe BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

Distribution of the Probability of Survival Is a Strategic Issue for Randomized Trials in Critically Ill Patients

Anesthesiology ◽

10.1097/00000542-200107000-00014 ◽

2001 ◽

Vol 95 (1) ◽

pp. 56-63 ◽

Cited By ~ 62

Author(s):

Bruno Riou ◽

Paul Landais ◽

Benoît Vivien ◽

Philippe Stell ◽

Iheb Labbene ◽

...

Keyword(s):

Survival Rate ◽

Critically Ill ◽

Critically Ill Patients ◽

Randomized Clinical Trials ◽

Bimodal Distribution ◽

Trauma Patients ◽

Probability Of Survival ◽

Individual Probability ◽

Number Of Patients ◽

The Individual

Background Many randomized clinical trials in trauma have failed to demonstrate a significant improvement in survival rate. Using a trauma patient database, we simulated what could happen in a trial designed to improve survival rate in this setting. Methods The predicted probability of survival was assessed using the TRISS methodology in 350 severely injured trauma patients. Using this probability of survival, the authors simulated the effects of a drug that may increase the probability of survival by 10-50% and calculated the number of patients to be included in a triad, assuming alpha = 0.05 and beta = 0.10 by using the percentage of survivors or the individual probability of survival. Other distributions (Gaussian, J shape, uniform) of the probability of survival were also simulated and tested. Results The distribution of the probability of survival was bimodal with two peaks (< 0.10 and > 0.90). There were major discrepancies between the number of patients to be included when considering the percentage of survivors or the individual value of the probability of survival: 63,202 versus 2,848 if the drug increases the probability of survival by 20%. This discrepancy also occurred in other types of distribution (uniform, J shape) but to a lesser degree, whereas it was very limited in a Gaussian distribution. Conclusions The bimodal distribution of the probability of survival in trauma patients has major consequences on hypothesis testing, leading to overestimation of the power. This statistical pitfall may also occur in other critically ill patients.

35. Emergency Medical Services Use of Trauma Triage Criteria to Stratify Patients by Injury Severity and Need for Emergent Intervention

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00045702 ◽

1996 ◽

Vol 11 (S2) ◽

pp. S32-S32

Author(s):

Robert E. O'Connor ◽

Glen H. Tinkoff ◽

Susan Mascioli ◽

Ross E. Megargel

Keyword(s):

Injury Severity ◽

Vital Signs ◽

Penetrating Trauma ◽

Trauma Patients ◽

Chi Square ◽

Probability Of Survival ◽

Trauma Service ◽

Severity Scores ◽

Serious Injury ◽

Level I

Purpose: Prehospital triage criteria (PTC) have been used to classify patients according to risk of serious injury. This study was conducted determine whether PTC could be used to identify serious injury, the need for intensive care (ICU), or immediate operative intervention (IOI).Methods: Data for this observational study were gathered prospectively, at a level-I trauma center, from a patient cohort admitted to the trauma service from 01 February to 31 July 1995. Specific triage criteria, based on information given by EMS prior to arrival were used to categorize patients by severity. Patients classified as most serious (codes) had the following: shock, major anatomic injury or proximal penetrating trauma. Patients classified as more serious (alerts) had one of the following: abnormal vital signs, Glasgow Coma Scale <13, moderate anatomic injury, high-risk mechanism of injury, or co-morbid factors. Patients not meeting either set of criteria, but were admitted, served as controls (consults). Injury severity scores (ISS) and probability of survival (Probsurvival) were calculated for each patient. The percentage admitted to the ICU, operating room (OR), or requiring IOI, were tabulated. Statistical analysis was performed using ANOVA, Mest and chi-square.