Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.

BACKGROUND: Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients. METHODS: We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours. RESULTS: A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001). DISCUSSION: In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Sudden Esophageal Necrosis and Mediastinitis Associated with Invasive Candidiasis: A Case Report.

BACKGROUND Esophageal necrosis is a rare entity characterized by the presence of extensive circumferential necrosis of the esophagus. It generally affects older adults who have associated chronic pathologies and has a reported mortality rate of approximately 32%. Most patients with esophageal necrosis have a complex clinical course. CASE REPORT We present the case of a 37-year-old man with idiopathic chronic renal failure who presented to the Emergency Department with sudden esophageal necrosis and mediastinitis, associated with invasive candidiasis. Diagnosis was challenging owing to the rarity of the condition. The patient required intensive care management and multiple surgical procedures. CONCLUSIONS Esophageal necrosis is an uncommon pathology that can be fatal because of associated complications. Its pathophysiology is unclear, and its treatment is based on the control of local injury and signs and symptoms. Acute esophageal necrosis associated with invasive Candida sp. infection is even more infrequent, with only a few cases reported in the literature.

The critical threshold value of systolic blood pressure for aortic occlusion in trauma patients in profound hemorrhagic shock.

BACKGROUND: This study aimed to determine the critical threshold of systolic blood pressure (SBP) for aortic occlusion (AO) in severely injured patients with profound hemorrhagic shock. METHODS: All adult patients (>15 years) undergoing AO via resuscitative endovascular balloon occlusion of the aorta (REBOA) or thoracotomy with aortic cross clamping (TACC) between 2014 and 2018 at level I trauma center were included. Patients who required cardiopulmonary resuscitation in the prehospital setting were excluded. A logistic regression analysis based on mechanism of injury, age, Injury Severity Score, REBOA/TACC, and SBP on admission was done. RESULTS: A total of 107 patients underwent AO. In 57, TACC was performed, and in 50, REBOA was performed. Sixty patients who underwent AO developed traumatic cardiac arrest (TCA), and 47 did not (no TCA). Penetrating trauma was more prevalent in the TCA group (TCA, 90% vs. no TCA, 74%; p < 0.05) but did not modify 24-hour mortality (odds ratio, 0.51; 95% confidence interval, 0.13-2.00; p = 0.337). Overall, 24-hour mortality was 47% (50) and 52% (56) for 28-day mortality. When the SBP reached 60 mm Hg, the predicted mortality at 24 hours was more than 50% and a SBP lower than 70 mm Hg was also associated with an increased of probability of cardiac arrest. CONCLUSION: Systolic blood pressure of 60 mm Hg appears to be the optimal value upon which AO must be performed immediately to prevent the probability of death (>50%). However, values of SBP less than 70 mm Hg also increase the probability of cardiac arrest. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients.

BACKGROUND: There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. METHODS: Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test. RESULTS: A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. CONCLUSION: We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Chest Trauma Outcomes: Public Versus Private Level I Trauma Centers.

BACKGROUND: The goal of our study was to evaluate the differences in care and clinical outcomes of patients with chest trauma between two hospitals, including one public trauma center (Pu-TC) and one private trauma center (Pri-TC). METHODS: Patients with thoracic trauma admitted from January 2012 to December 2018 at two level I trauma centers (Pu-TC: Hospital Universitario del Valle, Pri-TC: Fundación Valle del Lili) in Cali, Colombia, were included. Multivariable logistic regression was used to assess for differences in in-hospital mortality, adjusting for relevant demographic and clinical characteristics. RESULTS: A total of 482 patients were identified; 300 (62.2%) at the Pri-TC and 182 (37.8%) at the Pu-TC. Median age was 27 years (IQR 21-36) and median Injury Severity Score was 25 (IQR 16-26). 456 patients (94.6%) were male, and the majority had penetrating trauma [total 465 (96.5%); Pri-TC 287 (95.7%), Pu-TC 179 (98.4%), p 0.08]. All patients arrived at the emergency room with unstable hemodynamics. There were no statistically significant differences in post-operative complications, including retained hemothorax [Pri-TC 19 vs. Pu-TC 18], pneumonia [Pri-TC 14 vs. Pu-TC 14], empyema [Pri-TC 13 vs. Pu-TC 13] and mediastinitis [Pri-TC 6 vs. Pu-TC 2]. Logistic regression did, however, show a higher odds of mortality when patients were treated at the Pu-TC [OR 2.27 (95% CI 1.34-3.87, p < 0.001]. CONCLUSIONS: Our study found significant statistical differences in clinical outcomes between patients treated at a Pu-TC and Pri-TC. The results are intended to stimulate discussions to better understand reasons for outcome variability and ways to reduce it.

The Challenge of Implementing the "Stop the Bleed" Campaign in Latin America.

BACKGROUND: Currently, several initiatives have emerged to empower the public to act as immediate responders in front of hemorrhaging victims. We aimed to evaluate the effectiveness of implementing the Stop the Bleed campaign and the association between the instructors' background and the theoretical and practical competences achieved by the participants in Latin America. METHODS: Medical students and general surgeons taught both allied health students and nonallied health students at a local university; the training had a master class followed by a practical component and a written test, as well as tourniquet placement was tested. RESULTS: 265 individuals received the training, and data were available for 243. Of these, 126 (52.07%) were women and the median age was 21 (IQR: 20-22) years. 121 (49.79%) were trained by general surgeons (group A) and 122 (50.21%) by medical students (group B). After the training, more than 98% of all participants perceived that they would most likely be capable of aiding correctly a bleeding victim by applying direct pressure and more than 90% of them felt confident in being able to apply a tourniquet. There were no statistically significant differences among both groups when comparing their post-training competence evaluations [Theoretical test score: group A = 5 (IQR: 4-5); group B = 5 (IQR: 4-5); P = 0.41] and [Practical competency of tourniquet deployment: group A = 119 (66.39%) versus group B = 120 (65.83%); P = 0.93]. CONCLUSIONS: The Stop the Bleed campaign can be effectively implemented in Latin America, and it can be taught by prequalified medical students without altering the learning objectives of the course.

A meta-analysis of the incidence of complications associated with groin access after the use of resuscitative endovascular balloon occlusion of the aorta in trauma patients.

BACKGROUND: Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients. METHODS: We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients who underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed. RESULTS: We identified 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients, respectively. Overall, complications related to groin access occurred in 5.6% of patients (n = 24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis that used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ = 0.73, p = 0.2, Tau-square = 0.2). In a second meta-analysis, we used the Freeman-Tukey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I = 16.3%). CONCLUSION: We found that the incidence of complications related to groin access was of 4-5% based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible?

BACKGROUND: Recent evidence suggests that resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective life-saving intervention in patients with severe torso trauma. However, the deployment of REBOA in patients with isolated penetrating intrathoracic injuries remains controversial. We propose that a median sternotomy be performed in conjunction with REBOA as a feasible and effective means of hemorrhage control in patients suffering from penetrating chest trauma who present hemodynamically unstable. The objective of our study was to present our initial experience with this approach. METHODS: A prospectively collected case series of the use of REBOA (10 Fr) in conjunction with a median sternotomy from January 2015 to December 2016 at a Level I Trauma Center. We included hemodynamically unstable non-compressible torso hemorrhage patients with penetrating chest trauma who underwent intraoperative REBOA deployment plus median sternotomy. RESULTS: A total of 68 trauma-related emergent thoracic surgeries were performed at our institution during the study period. Of these, seven suffered from penetrating chest trauma and non-compressible torso hemorrhage and underwent REBOA plus median sternotomy. Six out of the seven patients suffered intrathoracic vascular injuries: two subclavian arteries, two internal mammary arteries, two aortic arch, and five major central venous injuries. Four patients had an associated lung injury with AIS >3, of which two suffered a pulmonary hilar vessel disruption. REBOA-related complications included one case of upper gastrointestinal bleeding. Six out of the seven patients survived the 30-day follow-up. No adverse neurologic outcomes or deficits were observed in survivors. CONCLUSION: The combined use of REBOA and median sternotomy could be a feasible and effective alternative to hemorrhage control in patients with non-compressible torso hemorrhage secondary to penetrating chest trauma. These findings challenge the recommendation against the use of REBOA in penetrating intrathoracic injuries. Future studies with stronger designs and larger sample sizes are required to confirm our results. LEVEL OF EVIDENCE: Therapeutic, level V.