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Taheri BD, Fisher AD, Eisenhauer IF, April MD, Rizzo JA, Guliani SS, Flarity KM, Cripps M, Bebarta VS, Wohlauer MV, Schauer SG. The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings. Transfusion 2024; 64 Suppl 2:S19-S26. [PMID: 38581267 DOI: 10.1111/trf.17823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/17/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.
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Affiliation(s)
- Branson D Taheri
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Air Education and Training Command, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio, USA
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Ian F Eisenhauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, Denver Health, Denver, Colorado, USA
- Navy Medicine Leader and Professional Development Command, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 14th Field Hospital, Fort Stewart, Georgia, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA, Fort Sam Houston, Texas, USA
| | - Sundeep S Guliani
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Kathleen M Flarity
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Cripps
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vikhyat S Bebarta
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Max V Wohlauer
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven G Schauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Schauer SG, April MD, Fisher AD, Wright FL, Winkle JM, Wright AR, Rizzo JA, Getz TM, Nicholson SE, Yazer MH, Braverman MA. A survey of low titer O whole blood use within the trauma quality improvement program registry. Transfusion 2024; 64 Suppl 2:S85-S92. [PMID: 38351716 DOI: 10.1111/trf.17746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. METHODS We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. RESULTS A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. CONCLUSIONS There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.
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Affiliation(s)
- Steven G Schauer
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 14th Field Hospital, Fort Stewart, Georgia, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Franklin L Wright
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie M Winkle
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Angela R Wright
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
| | - Todd M Getz
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maxwell A Braverman
- University of Texas Health at San Antonio, San Antonio, Texas, USA
- St. Lukes University Health Network, Bethlehem, PA, USA
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Avital G, Hernandez Torres SI, Knowlton ZJ, Bedolla C, Salinas J, Snider EJ. Toward Smart, Automated Junctional Tourniquets-AI Models to Interpret Vessel Occlusion at Physiological Pressure Points. Bioengineering (Basel) 2024; 11:109. [PMID: 38391595 PMCID: PMC10885917 DOI: 10.3390/bioengineering11020109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
Hemorrhage is the leading cause of preventable death in both civilian and military medicine. Junctional hemorrhages are especially difficult to manage since traditional tourniquet placement is often not possible. Ultrasound can be used to visualize and guide the caretaker to apply pressure at physiological pressure points to stop hemorrhage. However, this process is technically challenging, requiring the vessel to be properly positioned over rigid boney surfaces and applying sufficient pressure to maintain proper occlusion. As a first step toward automating this life-saving intervention, we demonstrate an artificial intelligence algorithm that classifies a vessel as patent or occluded, which can guide a user to apply the appropriate pressure required to stop flow. Neural network models were trained using images captured from a custom tissue-mimicking phantom and an ex vivo swine model of the inguinal region, as pressure was applied using an ultrasound probe with and without color Doppler overlays. Using these images, we developed an image classification algorithm suitable for the determination of patency or occlusion in an ultrasound image containing color Doppler overlay. Separate AI models for both test platforms were able to accurately detect occlusion status in test-image sets to more than 93% accuracy. In conclusion, this methodology can be utilized for guiding and monitoring proper vessel occlusion, which, when combined with automated actuation and other AI models, can allow for automated junctional tourniquet application.
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Affiliation(s)
- Guy Avital
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
- Israel Defense Forces Medical Corps, Ramat Gan 52620, Israel
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Affiliated with the Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel
| | | | - Zechariah J Knowlton
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Carlos Bedolla
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Eric J Snider
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
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Wolf JM, Mathieu L, Tintle S, Wilson K, Luria S, Vandentorren S, Boussaud M, Strelzow J. A global perspective on gun violence injuries. Injury 2023:S0020-1383(23)00392-3. [PMID: 37183087 DOI: 10.1016/j.injury.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION AND DEFINITIONS Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients. PRE-HOSPITAL CARE There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents. ACUTE TREATMENT Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions. DEFINITIVE CARE The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation. RESOURCES AND ETHICS There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.
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Affiliation(s)
- Jennifer Moriatis Wolf
- Department of Orthopaedic Surgery, Hand Surgery Fellowship, University of Chicago Medicine, 5841 S. Maryland Avenue, Room P211, Chicago, IL 60637, USA.
| | - Laurent Mathieu
- Department of Hand and Upper Extremity Surgery, Edouard Herriot Hospital, 5 place d'Arsonval, Lyon 69003, France; Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Scott Tintle
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, MD, USA
| | - Kenneth Wilson
- Division of Trauma Surgery, Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Shai Luria
- Hand and Microvascular Surgery, Hadassah University Hospital, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Stephanie Vandentorren
- Direction Scientifique et International, Santé Publique France, INSERM UMR 1219, Bordeaux Population Health Research Center, PHARes Team, University of Bordeaux, Bordeaux, France; Centre National de Ressources et de Résilience Lille-Paris (CN2R), Lille, France
| | - Marie Boussaud
- Department of Psychiatry, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart 92140, France
| | - Jason Strelzow
- Department of Orthopaedic Surgery, Hand Surgery Fellowship, University of Chicago Medicine, 5841 S. Maryland Avenue, Room P211, Chicago, IL 60637, USA
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Joarder M, Noureddine El Moussaoui H, Das A, Williamson F, Wullschleger M. Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review. Injury 2023; 54:1236-1245. [PMID: 36697284 DOI: 10.1016/j.injury.2023.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/01/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings. METHODS A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h). RESULTS The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported. CONCLUSION This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.
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Affiliation(s)
- Maisah Joarder
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - Hussein Noureddine El Moussaoui
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Arpita Das
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Frances Williamson
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Martin Wullschleger
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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Ronconi RWF, Moreira LH, de Lima CJ, Neto OP, Osorio RAL. Tourniquets, types and techniques in emergency prehospital care: A narrative review. Med Eng Phys 2023; 111:103923. [PMID: 36792231 DOI: 10.1016/j.medengphy.2022.103923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Massive uncontrolled hemorrhage is an important cause of preventable death in trauma. Therefore, applying an arterial tourniquet (TQ) is recommended as a pre-hospital measure to control bleeding after severe traumatic bleeding. Limb TQ applies circumferential compression proximally to the injury site to compress the arteries, resulting in blood flow and consequently hemorrhage interruption. The use of commercial tourniquets (C-TQ), which are designed, tested, and registered to control hemorrhages in pre-hospital care, is a consensus. However, they are still uncommon in many prehospital emergency services and the overall level of evidence in most studies is low. This narrative review aimed to characterize the importance of tourniquets use in prehospital emergency care and its application techniques. Furthermore, it proposes to stimulate the development of new devices, more accessible and easier to use, to suggest new directions of studies and medical education demands, with manikin and simulation development.
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Affiliation(s)
- Roger William Freire Ronconi
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil; Tacmed Brasil, Taubaté, São Paulo, Brazil.
| | - Livia Helena Moreira
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
| | - Carlos José de Lima
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
| | - Osmar Pinto Neto
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil; Arena235 Research Lab, São José dos Campos, São Paulo, Brazil
| | - Rodrigo Alexis Lazo Osorio
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
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