The end of balloons? Our take on the UK-REBOA trial

Resuscitative endovascular balloon occlusion of the aorta for trauma patients with uncontrolled hemorrhage: a retrospective target trial emulation (the AT-REBOA target trial)

BACKGROUND

Noncompressible truncal hemorrhage is a major contributor to preventable deaths in trauma patients and, despite advances in emergency care, still poses a big challenge.

OBJECTIVES

This study aimed to assess the clinical efficacy of trauma resuscitation care incorporating Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) compared to standard care for managing uncontrolled torso or lower body hemorrhage.

METHODS

This study utilized a target trial design with a matched case-control methodology, emulating randomized 1 : 1 allocation for patients receiving trauma resuscitation care with or without the use of REBOA. The study was conducted at a high-volume trauma center in Southern Austria, including trauma patients treated between January 2019 and October 2023, aged 16 and above, with suspected severe non-compressible torso hemorrhage. The primary outcome was 30-day in-hospital mortality. Secondary outcomes were in-hospital mortality rates at 3, 6, 24 h, and 90 days, need for damage control procedures, time to these procedures, computed tomography (CT) scan rates during resuscitation, complications, length of intensive care and in-hospital stay, and causes of death.

RESULTS

Median age was 55 [interquartile range (IQR) 42-64] years. Median total injury severity, assessed by Injury Severity Score, was 46.5 (IQR: 43-57). There was no significant difference in 30-day in-hospital mortality between groups [9/22 (41%) vs. 9/22 (41%), odds ratio: 1.00, 95% confidence interval (CI): 0.3-3.36, P  > 0.999]. Lower mortality rates within 3, 6, and 24 h were observed in the REBOA group; in a Cox proportional hazards model, hazard ratio (95% CI) for mortality in the REBOA group was 0.87 (0.35-2.15). Timing to damage control procedures did not significantly differ between groups, although patients in the REBOA group underwent significantly more CT scans. Bleeding was cited as the main cause of death less frequently in the REBOA group.

CONCLUSION

In severely injured patients presenting with possible major non-compressible torso hemorrhage, a systematically implemented resuscitation strategy including REBOA during the initial hospital phase, is not associated with significant changes in mortality.

[Thoracoabdominal Trauma Caused by Blast and Gunshot Injuries]

In Germany, blast and gunshot injuries are uncommon but complex injury entities. Due to the global political situation, terrorist attacks, accidents, or acts of violence, these injuries are potentially part of the reality of care for every anaesthetist, surgeon, and emergency physician. In principle, this type of injury should be treated in a trauma centre with appropriate expertise, but the knowledge of basic treatment principles is necessary for all practitioners. First, emergency training and surgical simulation courses should be carried out regularly to remain confident in emergency surgery techniques and treatment strategies. In addition, minimally invasive methods are predominantly used in elective surgery, meaning that the routine of primarily open surgery is missing. Therefore, it is important that surgeons learn surgical steps to be better prepared for emergency open surgery.The critical principle of damage control surgery is stopping the bleeding and the contamination and preventing a delay in intensive care therapy. For penetrating thoracic trauma, a chest tube must be inserted. If the patient is hemodynamically unstable, an anterolateral thoracotomy should be performed to achieve bleeding control, e.g., by cross-clamping the aorta or pulmonary hilum. For stable patients, a video-assisted thoracoscopy might be an option.The standard abdominal approach is the median laparotomy. Bleeding control can be achieved by hiatal aortic cross-clamping and packing of the abdomen, followed by a systematic exploration. If necessary, a laparostomy must be established. Moreover, if chest injuries are ruled out, the resuscitative endovascular balloon occlusion of the aorta (REBOA) can be considered as a bridge to surgery.Whether projectiles, fragments, or shrapnels require removal depends on the location and the potential complications of tissue dissection. Penetrating injuries due to blasts and gunshots are always contaminated.

Analysis of the current usage of resuscitative endovascular balloon occlusion of the aorta (REBOA) in pediatric trauma patients: a retrospective observational study from the American College of Surgeons-Trauma Quality Improvement Program databases

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been an established life-saving procedure for adult trauma patients, but the evidence for its use in pediatric patients is still under question. The purpose of this study was to examine the outcome of REBOA in pediatric patients.

Methods

We retrospectively analyzed observational cohort data from the American College of Surgeons-Trauma Quality Improvement Program from 2017 to 2019. We analyzed 183 506 trauma patients aged 7-18, and 111 patients were matched by propensity score analysis. Basic demographics, injury severity, trauma type, and clinical outcomes of the patients receiving REBOA and those not receiving REBOA were compared. In the REBOA patients, a subgroup analysis was performed to evaluate the potential influence of age and body weight on the outcomes of REBOA.

Results

After the pretreatment factors were balanced for the REBOA and no-REBOA groups, the patients in the REBOA group had more transfused packed red blood cells within the first 4 hours (3250 mL vs. 600 mL, p<0.001), and the mortality rate was higher in the REBOA group, but it did not reach statistical significance (56.8% vs. 36.5%, p=0.067). No significant difference was detected regarding in-hospital complications. In the subgroup analysis of the patients who received REBOA, we discovered no significant difference in mortality and complications between the subgroups when compared by age (>15 years old/≤15 years old) or weight (>58 kg or ≤58 kg).

Conclusions

Pediatric trauma patients who received REBOA were not significantly associated with an increased risk of mortality when compared with no-REBOA patients with matched basic demographics and pretreatment factors. Younger age and lighter body weight did not seem to influence the outcomes of REBOA regarding survival and complications.

Level of evidence

Level III.

Advanced Critical Care Techniques in the Field

Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.

Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) could prevent lethal exsanguination and support cardiopulmonary resuscitation. In prehospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. The aim of this study was to establish consensus on the use and implementation of REBOA in civilian prehospital settings for noncompressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings.

METHODS

A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA experts with different medical specialties, backgrounds, and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject.

RESULTS

Panel members reached consensus on potential (contra)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and prehospital REBOA.

CONCLUSION

The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of noncompressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For prehospital REBOA and early femoral artery access, consensus was reached on (contra)indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of prehospital REBOA for noncompressible truncal hemorrhage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Nomogram for predicting in-hospital mortality in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta: a retrospective multicenter study

Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) had been introduced as an innovative procedure for severe hemorrhage in the abdomen or pelvis. We aimed to investigate risk factors associated with mortality after REBOA and construct a model for predicting mortality. This multicenter retrospective study collected data from 251 patients admitted at five regional trauma centers across South Korea from 2015 to 2022. The indications for REBOA included patients experiencing hypovolemic shock due to hemorrhage in the abdomen, pelvis, or lower extremities, and those who were non-responders (systolic blood pressure (SBP) < 90 mmHg) to initial fluid treatment. The primary and secondary outcomes were mortality due to exsanguination and overall mortality, respectively. After feature selection using the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting, a multivariate logistic regression (MLR) model and nomogram were constructed. In the MLR model using risk factors selected in the LASSO, five risk factors, including initial heart rate (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.98-1.00; p = 0.030), initial Glasgow coma scale (aOR, 0.86; 95% CI 0.80-0.93; p < 0.001), RBC transfusion within 4 h (unit, aOR, 1.12; 95% CI 1.07-1.17; p < 0.001), balloon occlusion type (reference: partial occlusion; total occlusion, aOR, 2.53; 95% CI 1.27-5.02; p = 0.008; partial + total occlusion, aOR, 2.04; 95% CI 0.71-5.86; p = 0.187), and post-REBOA systolic blood pressure (SBP) (aOR, 0.98; 95% CI 0.97-0.99; p < 0.001) were significantly associated with mortality due to exsanguination. The prediction model showed an area under curve, sensitivity, and specificity of 0.855, 73.2%, and 83.6%, respectively. Decision curve analysis showed that the predictive model had increased net benefits across a wide range of threshold probabilities. This study developed a novel intuitive nomogram for predicting mortality in patients undergoing REBOA. Our proposed model exhibited excellent performance and revealed that total occlusion was associated with poor outcomes, with post-REBOA SBP potentially being an effective surrogate measure.

Trauma systems in high socioeconomic index countries in 2050

Considerable political, structural, environmental and epidemiological change will affect high socioeconomic index (SDI) countries over the next 25 years. These changes will impact healthcare provision and consequently trauma systems. This review attempts to anticipate the potential impact on trauma systems and how they could adapt to meet the changing priorities. The first section describes possible epidemiological trajectories. A second section exposes existing governance and funding challenges, how these can be met, and the need to incorporate data and information science into a learning and adaptive trauma system. The last section suggests an international harmonization of trauma education to improve care standards, optimize immediate and long-term patient needs and enhance disaster preparedness and crisis resilience. By demonstrating their capacity for adaptation, trauma systems can play a leading role in the transformation of care systems to tackle future health challenges.