[Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]

Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus.

CONCLUSION

The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation.

Implementation and Adaptation of Pathway of Resuscitative Endovascular Balloon Occlusion of the Aorta after Traumatic Injury

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an invented method to facilitate a minimally invasive occlusion of the aorta to stop a life-threatening hemorrhage. This review described an established pathway for noncompressible exsanguination (REBOA procedures) in trauma patients at a Level 1 trauma center. A detailed description starting from the structural changes of the hospital and facilities itself, the initial thoughts, implementation of the process, and continuous revision and improvement of guidelines were discussed. A multidisciplinary core team consisting of trauma surgeons, anesthesiologists, interventional radiologists, and operating room (OR) staff developed step-by-step clinical practice guidelines for using REBOA at our trauma center. A comprehensive training program for specialized procedural training was implemented to ensure the competency of all relevant medical personnel in managing trauma patients. The REBOA guidelines underwent plan-do-check-act quality cycle improvement until the latest guidelines were reached with each use of REBOA in a trauma patient, leading to further auditing of the guidelines to identify areas for improvement. The current review discusses the critical role of adopting innovative technologies and adapting protocols in trauma care, particularly for vulnerable patients with a high risk of morbidity and mortality. Continuous process improvement, procedural refinement, and evolving guidelines are essential prerequisites for optimizing patient outcomes. We described a valuable framework for other trauma programs to implement and adapt similar endovascular bleeding control approaches, thereby potentially enhancing patient care.

Available equipment for traumatic haemorrhage management in Austrian prehospital physician response units: a nationwide survey and analysis of guideline adherence

BACKGROUND

Traumatic injuries, particularly those involving massive bleeding, remain a leading cause of preventable deaths in prehospital settings. The availability of appropriate emergency equipment is crucial for effectively managing these injuries, but the variability in equipment across different response units can impact the quality of trauma care. This prospective survey study evaluated the availability of prehospital equipment for managing bleeding trauma patients in Austria.

METHODS

A nationwide survey was conducted across 139 Austrian Prehospital Physician Response Units (PRUs) to evaluate the presence and adherence to guidelines of bleeding control equipment. The digitally distributed survey included questions on equipment types, such as pelvic binders, tourniquets, haemostatic gauze, and advanced intervention sets. Data were analysed against the most recent recommendations and guidelines to assess conformity and identify gaps.

RESULTS

The survey achieved a 96% response rate, revealing that essential equipment like pelvic binders and tranexamic acid was available in all units, with tourniquets present in 99% of them. However, few services carried advanced equipment for procedures like REBOA or thoracotomy. While satisfaction with the current equipment was high, with 80% of respondents affirming adequacy, the disparities in the availability of specific advanced tools highlight potential areas for improvement, offering a promising opportunity to enhance trauma care capabilities.

CONCLUSIONS

While essential emergency equipment for haemorrhage control is uniformly available across Austrian PRUs, the variation in advanced tools underscores the need for standardised equipment protocols. The urgency for regular kit updates following prehospital guidelines and training is essential to enhance trauma care capabilities and ensure that all emergency response units are equipped to manage severe injuries effectively. This standardisation could lead to improved patient outcomes nationwide.

Guidelines in trauma-related bleeding and coagulopathy: an update

PURPOSE OF REVIEW

The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated.

RECENT FINDINGS

A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma).

SUMMARY

Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.

Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy

Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.

[Intra-abdominal vascular injuries after blunt abdominal trauma]

Vascular injuries and hemorrhaging are serious potential complications in the management of patients with blunt abdominal trauma. The treatment depends on the extent and localization and can range from surveillance to endovascular treatment up to open surgery. The keys to success include the focused assessment with sonography for trauma (FAST) management and timely decision making. Abdominal vascular trauma continues to be a difficult problem and open and endovascular techniques continue to evolve in order to address this complex disease process.

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course

Background

The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas.

Methods

The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail.

Results

In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries.

Conclusion

The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Case report: Resuscitative endovascular balloon occlusion after iatrogenic injury of the common iliac artery during neurosurgical dorsal lumbar microdiscectomy

Introduction and importance

This case report describes resuscitative endovascular balloon occlusion (REBOA) of the aorta in a patient with life-threatening iatrogenic bleeding of the right common iliac artery during elective dorsal lumbar spine surgery. REBOA is an emergency procedure for temporary intra-aortic balloon occlusion being increasingly reported and published since its inauguration in 1954. The interdisciplinary management of hemorrhage and technical notes for a successful REBOA procedure will be presented.

Case presentation

A 53-year-old female patient was admitted to the neurosurgery clinic suffering from left-sided L5 radiculopathy. During surgery, the anterior longitudinal ligament was perforated and an arterial vessel was lacerated. The patient became hemodynamically unstable demanding prompt supine repositioning and cardiopulmonary resuscitation (CPR). REBOA enabled cardiovascular stabilization after 90 min of CPR and laparotomy with vascular reconstruction and contributed to the survival of the patient without major clinical deficits. The patient was discharged from the ICU after 7 days.

Clinical discussion

Resuscitative endovascular balloon occlusion of the aorta is an emergency procedure to control life-threatening hemorrhage. REBOA should be available on-scene and applied by well-trained vascular surgery personnel to control vascular complications or extend to emergency laparotomy and thoracotomy with aortic cross-clamping in case of in-hospital non-controllable hemorrhages. In case of ongoing CPR, we recommend surgical groin incision, open puncture of the pulseless common femoral artery, and aortic balloon inflation in REBOA zone I. Hereby, fast access and CPR optimization for heart and brain perfusion are maintained.

Conclusion

Training for REBOA is the decisive factor to control selected cases of in-house and outpatient massive arterial abdominal bleeding complications.

[Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]

Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.