Combined, Converted, and Prophylactic Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Severe Torso Trauma: A Retrospective Study

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra-aortic balloon occlusion method in Japan; however, the protocols for its effective use in different pathological conditions remain unclear. This study aimed to summarise the strategies of REBOA use in severe torso trauma.Methods: Twenty-nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into the shock (n=12), cardiopulmonary arrest (CPA) (n=13), and non-shock (n=4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention, survival rates at 24 hours, and intervention details in each group.Results: In the shock group, 9 and 3 patients survived and died within 24 hours, respectively; time to intervention (56.6 vs 130.7 min, p=0.346) and total occlusion time (40.2 vs 337.7 min, p=0.009) were both shorter in surviving patients than in the casualties. In the CPA group, 10 patients were converted from resuscitative thoracotomy with aortic cross-clamp (RTACC); a single patient survived. Four patients in the non-shock group survived, having received prophylactic REBOA.Conclusions: The efficacy of REBOA for severe torso trauma depends on patient condition. In the shock group, time to intervention and total occlusion time correlated with survival. The use of REBOA with definitive haemostasis and minimum delays to intervention may improve outcomes. Patients with CPA are at a high risk of mortality; however, conversion from RTACC may be effective in some cases. Prophylactic intervention in the non-shock group may help achieve immediate definitive haemostasis.

Reliability of Focused Assessment With Sonography for Trauma in the Diagnosis of Blunt Torso Trauma

Objective: Focused assessment with sonography for trauma (FAST) is a widely used imaging technique for the diagnosis of blunt abdominal trauma and has its limitations and advantages. A meta-analysis was completed to evaluate the reliability of FAST, in the diagnosis of blunt torso trauma. Materials and Methods: A search was completed with Google Scholar, PubMed, National Center for Biotechnology Information (NCBI), MEDLINE, and Medscape databases, from 1993 up to 2020. Eligible studies were included for information about FAST examination of abdominal trauma. The animal research was excluded from this review process. The eligible studies were first categorized and then data analysis was performed, according to specific pathologic conditions. This literature review retrieved studies’ sample size, application, sensitivity, and a specificity of diagnosis using FAST for abdominal trauma. Results: In total, 100 articles were identified through the database search. Besides, five articles were identified through other sources. Then, screening was performed, and as such, 46 published studies were included that had a qualitative synthesis. Conclusion: FAST has a high sensitivity and specificity in the diagnosis of blunt abdominal trauma. However, a large range of sensitivity and specificity of FAST in the evaluation of torso trauma reveal that sonography is operator, technique, and equipment dependent.

REBOA as a Bridge to Brain CT in a Patient With Concomitant Brain Herniation and Haemorrhagic Shock - a Case Report

Introduction The management of complex trauma patient with concomitant brain injury and extra-cranial lesions is challenging since the requirement of a low pressure to limit the bleeding clashes with the need to maintain an adequate cerebral perfusion and to obtain a brain CT-scan. Here we present the use of REBOA as a bridge to CT scan in complex head and torso trauma. Case presentation A 59-years male patient involved in a car accident was admitted to our hospital after a car accident. He had a GCS of 3 with a left fixed pupil anisocoria. Despite right-sided chest decompression for pneumothorax and massive transfusion protocol for hemoperitoneum, blood pressure remained low; to temporally stabilize the patient and perform a brain CT scan a zone 1 REBOA was inserted and systolic blood pressure rose up from 60 mmHg to 110 mmHg. A brain CT scan highlighted a right subdural hematoma with a 8-mm midline shift. The patient went to the operating room to perform damage control surgery and, subsequently, a decompressive craniotomy. After 96 days of hospital stay, the patient was discharged at home with a complete neurological recovery. Conclusions The achievement of a rapid brain CT scan in traumatic brain injury is often crucial and has a deep impact in changing surgical management; moreover, duration of cerebral herniation is associated with worse outcome and increased mortality. In the light of this, the use of REBOA in selected cases of complex head and torso trauma could allow to gain time to go to the CT room in safe conditions.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

Metabolomics in postmortem cerebrospinal fluid diagnostics: a state-of-the-art method to interpret central nervous system–related pathological processes

In the last few years, quantitative analysis of metabolites in body fluids using LC/MS has become an established method in laboratory medicine and toxicology. By preparing metabolite profiles in biological specimens, we are able to understand pathophysiological mechanisms at the biochemical and thus the functional level. An innovative investigative method, which has not yet been used widely in the forensic context, is to use the clinical application of metabolomics. In a metabolomic analysis of 41 samples of postmortem cerebrospinal fluid (CSF) samples divided into cohorts of four different causes of death, namely, cardiovascular fatalities, isoIated torso trauma, traumatic brain injury, and multi-organ failure, we were able to identify relevant differences in the metabolite profile between these individual groups. According to this preliminary assessment, we assume that information on biochemical processes is not gained by differences in the concentration of individual metabolites in CSF, but by a combination of differently distributed metabolites forming the perspective of a new generation of biomarkers for diagnosing (fatal) TBI and associated neuropathological changes in the CNS using CSF samples.

Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study

Background It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. Methods This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a ‘paediatric patient group’ and an ‘adult patient group’. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR). Results A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients’ median age was 11 years (interquartile ranges 7–14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084). Conclusions It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.

The Use of a Urinary Balloon Catheter to Control Hemorrhage From Penetrating Torso Trauma: A Single-Center Experience at a Major Inner-City Hospital Trauma Center

Introduction Use of a urinary catheter balloon tamponade (UCBT) in controlling traumatic hemorrhage is a frequently employed but infrequently described technique. We aim to discuss the experience of balloon tamponade as a bridge to definitive hemorrhage control in the operating room. Methods This is retrospective review at a single institution from January 2008 to December 2018. We identified patients with active bleeding from penetrating torso trauma in whom UCBT was used to tamponade bleeding. We used revised trauma score (RTS), injury severity score (ISS), and new trauma and injury severity score (TRISS) to quantify injury severity. All surviving patients required definitively hemorrhage control in the operating room. Primary endpoint was mortality at 24 hours and 30 days. Results Twenty-nine patients were managed with UCBT. Nine had hemorrhage controlled in the trauma bay, including 4 with neck trauma and 5 with cardiac trauma. Twenty patients had hemorrhage controlled in the operating room, including 15 with cardiac trauma and 5 with intra-abdominal hemorrhage. Mean RTS, ISS, and TRISS in this population were: 5.93, 19.31, and 83.78, respectively. Of the 9 patients treated in the trauma bay, 1 (11.1%) died in the first 24 hours and 2 died in the first 30 days (22.2%). Of the 20 patients treated in the operating room, 0 (0%) patients died in the first 24 hours and 3 died in the first 30 days (15.0%). Conclusion UCBT is an effective tool that can be used to stabilize and bridge an actively bleeding patient to definitive hemorrhage control in the operating room.

Transcatheter arterial embolsation is efficient and safe for paediatric blunt torso trauma: a case-control study

Background: It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. Methods: This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a ‘paediatric patient group’ and an ‘adult patient group’. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR).Results: A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N=114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P=.221). The paediatric patients’ median age was 11 years (IQR 7–14). The predicted mortality rate (PMR) and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P=.026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P=.566, or 67% vs 85%, P=.084).Conclusions: It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.