Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study

Balloon Rises Above: REBOA at Zone 1 May Be Superior to Resuscitative Thoracotomy

BACKGROUND

The use of Zone 1 REBOA for life-threatening trauma has increased dramatically.

STUDY DESIGN

The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2).

RESULTS

A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18).

CONCLUSIONS

In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.

Potential harms of emergency department thoracotomy in patients with persistent cardiac arrest following trauma: a nationwide observational study

Emergency department thoracotomy (EDT) was incorporated into traumatic out-of-hospital cardiac arrest (t-OHCA) resuscitation. Although current guidelines recommend EDT with survival predictors, futility following EDT has been demonstrated and the potential risks have not been thoroughly investigated. This study aimed to elucidate the benefits and harms of EDT for persistent cardiac arrest following injury until hospital arrival. This retrospective cohort study used a nationwide trauma registry (2019-2021) and included adult patients with t-OHCA both at the scene and on hospital arrival. Survival to discharge, hemostatic procedure frequency, and transfusion amount were compared between patients treated with and without EDT. Inverse probability weighting using a propensity score was conducted to adjust age, sex, comorbidities, mechanism of injury, prehospital resuscitative procedure, prehospital physician presence, presence of signs of life, degree of thoracic injury, transportation time, and institutional characteristics. Among 1289 patients, 374 underwent EDT. The longest transportation time for survivors was 8 and 23 min in patients with and without EDT, respectively. EDT was associated with lower survival to discharge (4/374 [1.1%] vs. 22/915 [2.4%]; adjusted odds ratio [OR], 0.43 [95% CI 0.22-0.84]; p = 0.011), although patients with EDT underwent more frequent hemostatic surgeries (46.0% vs. 5.0%; adjusted OR, 16.39 [95% CI 12.50-21.74]) and received a higher amount of transfusion. Subgroup analyses revealed no association between EDT and lower survival in patients with severe chest injuries (1.0% vs. 1.4%; adjusted OR, 0.72 [95% CI 0.28-1.84]). EDT was associated with lower survival till discharge in trauma patients with persistent cardiac arrests after adjusting for various patient backgrounds, including known indications for EDT. The idea that EDT is the last resort for t-OHCA should be reconsidered and EDT indications need to be deliberately determined.Trial registration This study is retrospectively registered at University Hospital Medical Information Network (UMIN ID: UMIN000050840).

Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results

Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.

Acute Kidney Injury in Hypotensive Trauma Patients Following Resuscitative Endovascular Balloon Occlusion of the Aorta Placement

BACKGROUND

ER-Resuscitative Endovascular Balloon Occlusion of the Aorta (ER-REBOA) is an adjunct tool to achieve hemostasis in trauma patients with non-compressible torso hemorrhage. The development of the partial REBOA (pREBOA) allows for distal perfusion of organs while maintaining occlusion of the aorta. The primary aim of this study was to compare rates of acute kidney injury (AKI) in trauma patients who had placement of either a pREBOA or ER-REBOA.

METHODS

A retrospective chart review of adult trauma patients who underwent REBOA placement between September 2017 and February 2022 was performed. Baseline demographics, information on REBOA placement, and post-procedure complications including AKI, amputations, and mortality were recorded. Chi-squared and T-test analyses were performed with P < .05 considered to be significant.

RESULTS

A total of 68 patients met study inclusion criteria with 53 patients (77.9%) having an ER-REBOA. 6.7% of patients treated with pREBOA had a resulting AKI, while 40% of patients treated with ER-REBOA had a resulting AKI, and this difference was significant (P < .05). The rates of rhabdomyolysis, amputations, and mortality were not significantly different between the two groups.

CONCLUSION

The results from this case series suggest that patients treated with pREBOA have a significantly lower incidence of developing an AKI compared to ER-REBOA. There were no significant differences in rates of mortality, and amputations. Future prospective studies are needed to further characterize the indications and optimal use for pREBOA.

Survival after traumatic cardiac arrest is possible—a comparison of German patient-registries

Background

Out-of-hospital cardiac arrest (OHCA) due to trauma is rare, and survival in this group is infrequent. Over the last decades, several new procedures have been implemented to increase survival, and a “Special circumstances chapter” was included in the European Resuscitation Council (ERC) guidelines in 2015. This article analysed outcomes after traumatic cardiac arrest in Germany using data from the German Resuscitation Registry (GRR) and the TraumaRegister DGU® (TR-DGU) of the German Trauma Society. 

Methods

In this study, data from patients with OHCA between 01.01.2014 and 31.12.2019 secondary to major trauma and where cardiopulmonary resuscitation (CPR) was started were eligible for inclusion. Endpoints were return of spontaneous circulation (ROSC), hospital admission with ROSC and survival to hospital discharge.

Results

1.049 patients were eligible for inclusion. ROSC was achieved in 28.7% of the patients, 240 patients (22.9%) were admitted to hospital with ROSC and 147 (14.0%) with ongoing CPR. 643 (67.8%) patients were declared dead on scene. Of all patients resuscitated after traumatic OHCA, 27.3% (259) died in hospital. The overall mortality was 95.0% and 5.0% survived to hospital discharge (47). In a multivariate logistic regression analysis; age, sex, injury severity score (ISS), head injury, found in cardiac arrest, shock on admission, blood transfusion, CPR in emergency room (ER), emergency surgery and initial electrocardiogram (ECG), were independent predictors of mortality.

Conclusion

Traumatic cardiac arrest was an infrequent event with low overall survival. The mortality has remained unchanged over the last decades in Germany. Additional efforts are necessary to identify reversible cardiac arrest causes and provide targeted trauma resuscitation on scene.

Trial registration

DRKS, DRKS-ID DRKS00027944. Retrospectively registered 03/02/2022.

Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta

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.

External validation and insights about the calibration of the return of spontaneous circulation after cardiac arrest (RACA) score

Background

The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.

We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy.

Methods

We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test.

Results

The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines.

Conclusions

Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.

Safety and Effectiveness of Aortic Occlusion for Those Undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): A Retrospective Single-Center Study

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporarily control bleeding and maintain the cerebral and coronary blood flow in cases in which it is difficult to control hemorrhagic shock. However, the safety and effectiveness of REBOA remains uncertain.

OBJECTIVES

This study aimed to estimate the safety and effectiveness of aortic occlusion in patients who undergo REBOA catheter placement.

METHODS

We conducted a retrospective study of patients who underwent REBOA catheter placement at Fukuyama City Hospital Emergency Medical Center from August 1, 2008 to March 31, 2020. A propensity score-matching analysis was used to compare 30-day survival between patients who undergo REBOA catheter placement with and without aortic occlusion.

RESULTS

Overall, 122 of the 147 who underwent REBOA catheter placement at Fukuyama City Hospital were eligible for inclusion. Thirty-five patients in the Occlusion group and 35 patients in the Nonocclusion group were selected by propensity score matching. According to the 30-day survival rate, the difference between the two groups was not statistically significant (p = 0.288 log-rank test). Moreover, the required treatment, the types and incidence of complications, and other outcomes did not differ according to the presence or absence of aortic occlusion in patients who underwent REBOA catheter placement.

CONCLUSION

According to the results of this study, in trauma patients who undergo REBOA catheter placement, the presence of aortic occlusion was not significantly associated with 30-day mortality. Furthermore, the performance of aortic occlusion was not associated with a significant increase in complications.

Increased mortality with resuscitative endovascular balloon occlusion of the aorta only mitigated by strong unmeasured confounding: An expanded analysis using the National Trauma Data Bank

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being increasingly adopted to manage noncompressible torso hemorrhage, but a recent analysis of the 2015 to 2016 Trauma Quality Improvement Project (TQIP) data set showed that placement of REBOA was associated with higher rates of death, lower extremity amputation, and acute kidney injury (AKI). We expand this analysis by including the 2017 data set, quantifying the potential role of residual confounding, and distinguishing between traumatic and ischemic lower extremity amputation.

METHODS

This retrospective study used the 2015 to 2017 TQIP database and included patients older than 18 years, with signs of life on arrival, who had no aortic injury and were not transferred. Resuscitative endovascular balloon occlusions of the aorta placed after 2 hours were excluded. We adjusted for baseline variables using propensity scores with inverse probability of treatment weighting. A sensitivity analysis was then conducted to determine the strength of an unmeasured confounder (e.g., unmeasured shock severity/response to resuscitation) that could explain the effect on mortality. Finally, lower extremity injury patterns of patients undergoing REBOA were inspected to distinguish amputation indicated for traumatic injury from complications of REBOA placement.

RESULTS

Of 1,392,482 patients meeting the inclusion criteria, 187 underwent REBOA. After inverse probability of treatment weighting, all covariates were balanced. The risk difference for mortality was 0.21 (0.14-0.29) and for AKI was 0.041 (-0.007 to 0.089). For the mortality effect to be explained by an unmeasured confounder, it would need to be stronger than any observed in terms of its relationship with mortality and with REBOA placement. Eleven REBOA patients underwent lower extremity amputation; however, they all suffered severe traumatic injury to the lower extremity.

CONCLUSION

There is no evidence in the TQIP data set to suggest that REBOA causes amputation, and the evidence for its effect on AKI is considerably weaker than previously reported. The increased mortality effect of REBOA is confirmed and could only be nullified by a potent confounder.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Resuscitative Endovascular Balloon Occlusion of Aorta Versus Aortic Cross-Clamping by Thoracotomy for Noncompressible Torso Hemorrhage: A Meta-Analysis

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, I^{2 =} 93%), and in-hospital mortality (RR 0.80 [0.68, 0.95], P = 0.009, I^{2 =} 85%). Similarly, the length of ICU stay was significantly lower in REBOA group (WMD = 0.50 [-0.48, 1.48], P = 0.32, I^{2 =}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.

Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study

Background

Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA.

Methods

A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age ≥ 16, at least one trauma with Abbreviated Injury Scale score (AIS) ≥ 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival.

Results

Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36–70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22–41), and median transport time was 11 min (IQR 6–17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%.

Conclusion

The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically.

Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series

AIMS

Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA.

METHODS

Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded.

RESULTS

Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min. An increase in etCO₂ over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died.

CONCLUSION

Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.