Contemporary Utilization of Zone III REBOA for Temporary Control of Pelvic and Lower Junctional Hemorrhage Reliably Achieves Hemodynamic Stability in Severely Injured Patients

2019 ◽  
Vol 3 (2) ◽  
Author(s):  
Jason Pasley
Keyword(s):  
Vital Signs ◽  
Balloon Occlusion ◽  
Aortic Occlusion ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Systemic Complications ◽  
Occlusion Balloon ◽  
Valuable Adjunct ◽  
Care Surgery ◽  
Temporary Control

Background: Aortic occlusion is a valuable adjunct for management of traumatic pelvic and lower extremity junctional hemorrhage. Methods: The American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry was reviewed for patients requiring Zone III resuscitative endovascular balloon occlusion of the aorta (REBOA) from eight verified trauma centers. After excluding patients in arrest, demographics, elements of treatment and outcomes were identified. Results: From Nov 2013 – Dec 2016, 30 patients had Zone III REBOA placed. Median age was 41.0 (IQR 38); median ISS 41.0 (IQR 12). Hypotension (SBP < 90mm Hg) was present on admission in 30.0% and tachycardia (HR > 100 bpm) in 66.7%. Before REBOA placement, vital signs changed in this cohort with hypotension in 83.3% and tachycardia noted in 90%. Median initial pH was 7.14 (IQR 0.22), and median admission lactate 9.9 mg/dL (IQR 5). Pelvic binders were utilized in 40%. Occlusion balloon devices included Coda™ (70%), ER-REBOA™ (13.3%), Reliant™ (10%).  After REBOA, hemodynamics improved in 96.7% and stability (BP consistently > 90 mm Hg) was achieved in 86.7%. Median duration of REBOA was 53.0 mins (IQR 112). Median PRBC and FFP requirements were 19.0 units (IQR (17) and 17.0 units (IQR 14), respectively. One amputation unrelated to REBOA utilization was required. Systemic complications included AKI (23.3%) and MODS (10%). REBOA specific complications included groin hematoma (3.3%) and distal thromboembolization (16.7%). Survival to discharge was 56.7%, with in-hospital deaths occurring in the ED 7.7%, OR 23.1%, ICU 69.2%. Conclusions: This review discusses the specifics of the contemporary use of Zone III REBOA placement as well as local and systemic complications for patients in extremis with pelvic/junctional hemorrhage. Further review is required determine optimal patient selection. Level of Evidence: Level IV Study Type: Therapeutic Key Words   Zone III REBOA, Pelvic Bleeding, Junctional Hemorrhage

Validation of a Novel Clinical Criteria to Predict Candidacy for Aortic Occlusion: An Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Study

2020 ◽  
Vol 86 (10) ◽  
pp. 1418-1423
Author(s):  
Reynold Henry ◽  
Kazuhide Matsushima ◽  
Rachel N. Henry ◽  
Gregory A. Magee ◽  
Christoper P. Foran ◽  
...  
Keyword(s):  
Acute Care ◽  
Vital Signs ◽  
Balloon Occlusion ◽  
Aortic Occlusion ◽  
Acute Care Surgery ◽  
Trauma Patients ◽  
Clinical Criteria ◽  
Resuscitative Thoracotomy ◽  
Control Procedures ◽  
Care Surgery

For trauma patients with noncompressible truncal hemorrhage (NCTH), aortic occlusion (AO) is attempted with either resuscitative thoracotomy (RT) or the resuscitative endovascular balloon occlusion of the aorta (REBOA). However, it is often challenging to identify the group of patients who would benefit from AO procedures. We hypothesized that patients who met simple clinical criteria would have better outcomes following AO procedures. This is a retrospective cohort study using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database (November 2013-August 2019) which included patients who arrived with signs of life and underwent AO procedures (RT or zone 1 REBOA). Outcomes were compared between patients who met the criteria (admission vital signs: Glasgow Coma Scale (GCS) ≥9 and systolic blood pressure <90 mm Hg) and those who did not. Subgroup analyses were then conducted on patients who had a REBOA placed and those who underwent RT. A total of 998 patients met our inclusion criteria. Of those, a REBOA was placed in 364 patients (37%), while 634 (64%) underwent RT. The overall mortality rate in the criteria (+) group was significantly lower than that in the criteria (−) group (62 vs. 79%, P < .001). In patients who survived beyond the emergency department following AO procedures, those who met the criteria underwent hemorrhage control procedures more frequently (83% vs. 57%, P < .001). Our data suggest that simple clinical criteria could guide the provider for proceeding with AO in patients with suspected NCTH.

scholarly journals Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits

2019 ◽  
Vol 4 (1) ◽  
pp. e000269 ◽  
Author(s):  
Kaori Ito ◽  
Kahoko Nakazawa ◽  
Tsuyoshi Nagao ◽  
Hiroto Chiba ◽  
Yasufumi Miyake ◽  
...  
Keyword(s):  
Emergency Department ◽  
Injury Severity ◽  
Balloon Occlusion ◽  
Red Blood Cell Transfusion ◽  
Acute Care Surgery ◽  
Perioperative Outcomes ◽  
Emergency Laparotomy ◽  
Level Of Evidence ◽  
Anesthetic Care ◽  
Care Surgery

BackgroundIt is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice.MethodsThe data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared.ResultsCompared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation.DiscussionEmergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping.Level of evidenceIV

scholarly journals Is the Whole Greater than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador

2021 ◽  
Author(s):  
Amber Nicole Himmler ◽  
Monica Eulalia Galarza Armijos ◽  
Jeovanni Reinoso Naranjo ◽  
Sandra Gioconda Peña Patiño ◽  
Doris Sarmiento Altamirano ◽  
...  
Keyword(s):  
Latin America ◽  
Hemorrhagic Shock ◽  
Whole Blood ◽  
Vital Signs ◽  
Human Albumin ◽  
Acute Care Surgery ◽  
Trauma Patients ◽  
Transfusion Reaction ◽  
Shock Index ◽  
Care Surgery

Abstract Background: Hemorrhagic shock is a major cause of mortality in low-and-middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood program in Latin America and to discuss the outcomes of the patients that received whole blood (WB).Methods: We conducted a retrospective review of patients resuscitated with WB from 2013-2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included: gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, Revised Trauma Score (RTS) in trauma patients, intraoperative crystalloid (lactated ringers or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length-of-stay and in-hospital mortality.Results: The sample includes a total of 101 patients, 57 of whom were trauma and acute care surgery (TACS) patients and 44 of whom were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. Average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of whole blood. Overall mortality was 14/101 (13.86%) in the first 24 hours and 6/101 (5.94%) after 24 hours.Conclusion: Implementing a WB protocol is achievable in LMICs. Whole blood allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a whole blood program implemented in a civilian hospital in Latin America.

scholarly journals Placement accuracy of resuscitative endovascular occlusion balloon into the target zone with external measurement

2020 ◽  
Vol 5 (1) ◽  
pp. e000443 ◽  
Author(s):  
Shokei Matsumoto ◽  
Tomohiro Funabiki ◽  
Taku Kazamaki ◽  
Tomohiko Orita ◽  
Kazuhiko Sekine ◽  
...  
Keyword(s):  
Trauma Center ◽  
External Validation ◽  
Patient Characteristics ◽  
Balloon Occlusion ◽  
Trauma Patients ◽  
Target Zone ◽  
Level Of Evidence ◽  
Occlusion Balloon ◽  
Abdominal Bleeding ◽  
Placement Accuracy

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) should be safely placed at zone 1 or 3, depending on the location of the hemorrhage. Ideally, REBOA placement should be confirmed via fluoroscopy, but it is not commonly available for trauma bays. This study aimed to evaluate the accuracy of REBOA placement using the external measurement method in a Japanese trauma center.MethodsA retrospective review identified all trauma patients who underwent REBOA and were admitted to our trauma center from 2008 to 2018. Patient characteristics, REBOA placement accuracy, and complications according to target zones 1 and 3 were reviewed.ResultsDuring the study period, 38 patients met our inclusion criteria. The in-hospital mortality rate was 57.9%. REBOA was mainly used for bleeding from the abdominal (44.7%) and pelvic (36.8%) regions. Of these, 30 patients (78.9%) underwent REBOA for target zone 1, and 8 patients (21.1%) underwent REBOA for target zone 3. The proportion of abdominal bleeding source in the target zone 1 group was greater than that in the target zone 3 group (56.7% vs. 0%). Overall, the proportion of REBOA placement was 76.3% in zone 1, 21.1% in zone 2, and 2.6% in zone 3. The total REBOA placement accuracy was 71.1%. At each target zone, the REBOA placement accuracy for target zone 3 was significantly lower than that for target zone 1 (12.5% vs. 86.7%, p<0.001). No significant associations between non-target zone placement and patient characteristics, complications, or mortality were found.ConclusionsThe REBOA placement accuracy for target zone 3 was low, and zone 2 placement accounted for 21.1% of the total, but no complications and mortalities related to non-target zone placement occurred. Further external validation study is warranted.Level of evidenceLevel IV.

scholarly journals Development of an acute care surgery service in Rwanda

2019 ◽  
Vol 4 (1) ◽  
pp. e000332 ◽  
Author(s):  
Egide Abahuje ◽  
Isaie Sibomana ◽  
Elisee Rwagahirima ◽  
Christian Urimubabo ◽  
Robert Munyaneza ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Acute Care ◽  
Epidemiologic Study ◽  
Length Of Hospital Stay ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Midline Laparotomy ◽  
Resource Setting ◽  
Care Surgery ◽  
The Impact

BackgroundAcute care surgery (ACS) encompasses trauma, critical care, and emergency general surgery. Due to high volumes of emergency surgery, an ACS service was developed at a referral hospital in Rwanda. The aim of this study was to evaluate the epidemiology of ACS and understand the impact of an ACS service on patient outcomes.MethodsThis is a retrospective observational study of ACS patients before and after introduction of an ACS service. χ2 test and Wilcoxon rank-sum test were used to describe the epidemiology and compare outcomes before (pre-ACS)) and after (post-ACS) implementation of the ACS service.ResultsData were available for 120 patients before ACS and 102 patients after ACS. Diagnoses included: intestinal obstruction (n=80, 36%), trauma (n=38, 17%), appendicitis (n=31, 14%), and soft tissue infection (n=17, 8%) with no difference between groups. The most common operation was midline laparotomy (n=138, 62%) with no difference between groups (p=0.910). High American Society of Anesthesiologists (ASA) score (ASA ≥3) (11% vs. 40%, p<0.001) was more common after ACS. There was no difference in intensive care unit admission (8% vs. 8%, p=0.894), unplanned reoperation (22% vs. 13%, p=0.082), or mortality (10% vs. 11%, p=0.848). The median length of hospital stay was longer (11 days vs. 7 days, p<0.001) before ACS.ConclusionsAn ACS service can be implemented in a low-resource setting. In Rwanda, ACS patients are young with few comorbidities, but high rates of mortality and morbidity. In spite of more patients who are critically ill in the post-ACS period, implementation of an ACS service resulted in decreased length of hospital stay with no difference in morbidity and mortality.Level of evidencePrognostic and epidemiologic study type, level III.

scholarly journals Gender distribution and leadership trends in trauma surgery societies

2020 ◽  
Vol 5 (1) ◽  
pp. e000433
Author(s):  
Shannon Marie Foster ◽  
Jennifer Knight ◽  
Catherine Garrison Velopulos ◽  
Stephanie Bonne ◽  
D'Andrea Joseph ◽  
...  
Keyword(s):  
Critical Care ◽  
Gender Diversity ◽  
Trauma Surgery ◽  
Executive Leadership ◽  
Senior Author ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Gender Distribution ◽  
Surgical Critical Care ◽  
Care Surgery

IntroductionWomen are under-represented in the surgical disciplines and gender bias is believed to play a factor. We aimed to understand the gender distribution of membership, leadership opportunities, and scientific contributions to annual trauma professional meetings as a case study of gender issues in trauma surgery.MethodsRetrospective collection of membership, leadership, presentation and publication data from 2016 to 2018 Trauma/Acute Care Surgery/Surgical Critical Care (TACSCC) Annual Meetings. Gender was assigned based on self-identification in demographic information, established relationships, or public sources.ResultsWomen remain under-represented with only 28.1% of those ascertaining American Board of Surgery certification in critical care self-identifying as female. The proportion of female members in Eastern Association for the Surgery of Trauma (EAST) was comparable (29.4%), slightly lower for Western Trauma Association (WTA) (19.0%), and lowest for American Association for the Surgery of Trauma (AAST) (12.8%, p<0.05). In contrast, AAST had the highest proportion of female participants in executive leadership (AAST 32.5%, WTA 19.0%, EAST 18.8%) and WTA the highest for committee chairs (WTA 33.3%, AAST 27.8%, EAST 20.5%). AAST had the most significant increase in executive leadership during the last 3 years (AAST 28.6% to 41.6%). Invited lectureships, masters, panelists and senior author scientific contributions demonstrated the largest gap of academic representation of female TACSCC surgeons.ConclusionFewer women than men pursue careers in the trauma field. Continuing to provide mentorship, leadership, and scientific recognition will increase gender diversity in TACSCC. We must continue to promote, sponsor, recognize, invite, and elect ‘her’.Level of evidenceIII, Epidemiology.

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