Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS: We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS: Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION: This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Arterial Access Complications Following Percutaneous Femoral Access in 24-Hour Resuscitative Endovascular Balloon Occlusion of the Aorta Survivors.

INTRODUCTION: With the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) comes the potential for vascular access site complications (VASCs) and limb ischemic sequelae. We aimed to determine the prevalence of VASC and associated clinical and technical factors. METHODS: A retrospective cohort analysis of 24-h survivors undergoing percutaneous REBOA via the femoral artery in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between Oct 2013 and Sep 2021 was performed. The primary outcome was VASC, defined as at least one of the following: hematoma, pseudoaneurysm, arteriovenous fistula, arterial stenosis, or the use of patch angioplasty for arterial closure. Associated clinical and procedural variables were examined. Data were analyzed using Fisher exact test, Mann-Whitney-U tests, and linear regression. RESULTS: There were 34 (7%) cases with VASC among 485 meeting inclusion criteria. Hematoma (40%) was the most common, followed by pseudoaneurysm (26%) and patch angioplasty (21%). No differences in demographics or injury/shock severity were noted between cases with and without VASC. The use of ultrasound (US) was protective (VASC, 35% versus no VASC, 51%; P = 0.05). The VASC rate in US cases was 12/242 (5%) versus 22/240 (9.2%) without US. Arterial sheath size >7 Fr was not associated with VASC. US use increased over time (R2 = 0.94, P < 0.001) with a stable rate of VASC (R2 = 0.78, P = 0.61). VASC were associated with limb ischemia (VASC, 15% versus no VASC, 4%; P = 0.006) and arterial bypass procedures (VASC 3% versus no VASC 0%; P < 0.001) but amputation was uncommon (VASC, 3% versus no VASC, 0.4%; P = 0.07). CONCLUSIONS: Percutaneous femoral REBOA had a 7% VASC rate which was stable over time. VASC are associated with limb ischemia but need for surgical intervention and/or amputation is rare. The use of US-guided access appears to be protective against VASC and is recommended for use in all percutaneous femoral REBOA procedures.

Use of a disposable vascular pressure device to guide balloon inflation of resuscitative endovascular balloon occlusion of the aorta: a bench study.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for rapid hemorrhage control is increasingly being used in trauma management. Its beneficial hemodynamic effects on unstable patients beyond temporal hemostasis has led to growing interest in its use in other patient populations, such as during cardiac arrest from nontraumatic causes. The ability to insert the catheters without fluoroscopic guidance makes the technique available in the prehospital setting. However, in addition to correct positioning, challenges include reliably achieving aortic occlusion while minimizing the risk of balloon rupture. Without fluoroscopic control, inflation of the balloon relies on estimated aortic diameters and on the disappearing pulse in the contralateral femoral artery. In the case of cardiac arrest or absent palpable pulses, balloon inflation is associated with excess risk of overinflation and adverse events (vessel damage, balloon rupture). In this bench study, we examined how the pressure in the balloon is related to the surrounding blood pressure and the balloon's contact with the vessel wall in two sets of experiments, including a pulsatile circulation model. With this data, we developed a rule of thumb to guide balloon inflation of the ER-REBOA catheter with a simple disposable pressure-reading device (COMPASS). We recommend slowly filling the balloon with saline until the measured balloon pressure is 160 mmHg, or 16 mL of saline have been used. If after 16 mL the balloon pressure is still below 160 mmHg, saline should be added in 1-mL increments, which increases the pressure target about 10 mmHg at each step, until the maximum balloon pressure is reached at 240 mmHg (= 24 mL inflation volume). A balloon pressure greater than 250 mmHg indicates overinflation. With this rule and a disposable pressure-reading device (COMPASS), ER-REBOA balloons can be safely filled in austere environments where fluoroscopy is unavailable. Pressure monitoring of the balloon allows for recognition of unintended deflation or rupture of the balloon.

Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol.

BACKGROUND: Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources. OBJECTIVE: This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite. STUDY DESIGN: This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes. RESULTS: A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups. CONCLUSION: A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.

Penetrating injuries in Germany - epidemiology, management and outcome an analysis based on the TraumaRegister DGU®.

BACKGROUND: The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4-5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment. MATERIALS AND METHODS: Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany. RESULTS: From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit. CONCLUSIONS: In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database.

BACKGROUND: Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment. METHODS: A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI). RESULTS: Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036). CONCLUSION: Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Intra-abdominal Inferior Vena Cava Injuries: Operative Strategies and Outcomes.

Visceral vascular injuries are relatively uncommon even in busy urban trauma centers. The inferior vena cava (IVC) is the most frequently injured visceral vein and can be a complex operative challenge. Despite advances in early volume resuscitation, improved transport times, prompt operative intervention, and hemorrhage control, mortality rates have remained largely unchanged. This article conducts an in-depth review of the literature surrounding IVC injuries and a detailed discussion of operative strategies and management as survivability is ultimately dependent on the grade of injury, location, and the presence of hemorrhagic shock.

Hepatic Pseudoaneurysm Incidence After Liver Trauma.

BACKGROUND: Posttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury. METHODS: We conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review. RESULTS: Six hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications. CONCLUSIONS: The incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry.

BACKGROUND: Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS: Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS: Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION: Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Hypocalcaemia and traumatic coagulopathy: an observational analysis.

BACKGROUND AND OBJECTIVES: Haemorrhage-associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway-mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. MATERIALS AND METHODS: Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre-hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as <1·11 mmol/l, and acute traumatic coagulopathy was defined as initial INR >1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. RESULTS: There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9; 95% CI: 1·01-8·3, P = 0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24 h post-admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P < 0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P = 0·047)). CONCLUSION: Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials.

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion.

INTRODUCTION: In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs. METHODS: The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative. RESULTS: Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS. CONCLUSION: This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

Critical developments of 2018: A review of the literature from selected topics in transfusion. A committee report from the AABB's Clinical Transfusion Medicine Committee.

BACKGROUND: The AABB compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine. An abridged version of this work is being made available in TRANSFUSION, with the full-length report available as Appendix S1 (available as supporting information in the online version of this paper). STUDY DESIGN AND METHODS: Papers published in late 2017 and 2018 are included, as well as earlier papers cited for background. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed. RESULTS: The following topics are covered: "big data" and "omics" studies, emerging infections and testing, platelet transfusion and pathogen reduction, transfusion therapy and coagulation, transfusion approach to hemorrhagic shock and mass casualties, therapeutic apheresis, and chimeric antigen receptor T-cell therapy. CONCLUSION: This synopsis may be a useful educational tool.

[Epidemiology and risk factors of adverse outcome in nonvariceal upper gastrointestinal bleeding]. / Épidemiologiia i faktory riska neblagopriiatnogo iskhoda pri nevarikoznykh krovotecheniiakh iz verkhnikh otdelov zheludochno-kishechnogo trakta.

AIM: To identify risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding. MATERIAL AND METHODS: Epidemiological observational analytical longitudinal retrospective cohort study included 312 patients who were hospitalized in the Clinical Hospital #40 of Yekaterinburg in 2014-2016. The main inclusion criterion was nonvariceal upper gastrointestinal bleeding. RESULTS: In-hospital mortality was 31 (9.9%) of 312 patients. Multivariate analysis confirmed the following risk factors of mortality: severity of blood loss (OR 22.70, 95% CI 5.08-102.00); open surgery (OR 15.20, 95% CI 2.71-74.80); M. Charlson comorbidity index (OR 2.15, 95% CI 1.34-3.43); risk of recurrent bleeding according to T. Rockall scale (OR 1.76, 95% CI 1.18-2.64). CONCLUSION: Independent risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding are severe hemorrhagic shock, open surgery, high M. Charlson comorbidity index and risk of recurrent bleeding according to T. Rockall scale.

Computerized Axial Tomography in patients with severe abdominal trauma: is it a justifiable risk? / Tomografia no trauma abdominal grave: risco justificável?

OBJECTIVE: to evaluate the evolution of severe abdominal trauma patients, for whom the massive transfusion protocol was triggered, and who were submitted to Computed Axial Tomography (CAT) in the emergency room (ER), in order to verify the patient's prognosis and the diagnostic efficiency of CAT in this scenario. METHODS: retrospective, longitudinal and observational study performed at a referral center for trauma care in Curitiba, Parana, Brazil. We selected 60 severe abdominal trauma patients who had massive transfusion protocol activation and divided them into two groups: patients who underwent CAT at ER and patients who did not. We verified the diagnostic accuracy of CAT-scan examination and compared the number of deaths, hospitalization time, and transfused blood components in both groups. RESULTS: considering the 60 patients, 66.67% received red blood cells at ER; 33.3% underwent CAT on admission due to hemodynamic improvement, and 66.7% did not perform the examination at the entrance. The percentage of deaths was 35% in both groups. Considering the two groups, the difference between the mean lengths of hospital stay was not statistically significant, as well as the difference between the mean numbers of transfused red blood cells. In the group that underwent CAT, 45% did not require exploratory laparotomy. CONCLUSION: CAT could be rapidly performed in patients with hemodynamic instability on arrival at ER, sparing some patients from an unnecessary exploratory laparotomy and not significantly influencing mortality.

OBJETIVO: avaliar a evolução de pacientes vítimas de trauma abdominal grave, nos quais o protocolo de transfusão maciça foi acionado, e que foram submetidos à Tomografia Axial Computadorizada (TAC) no Pronto Socorro (PS), com o intuito de verificar o prognóstico do paciente e a eficiência diagnóstica da TAC nesse cenário. MÉTODOS: estudo retrospectivo, longitudinal e observacional, feito em centro de referência para trauma. Foram selecionados 60 pacientes vítimas de trauma abdominal grave que ativaram o protocolo de transfusão maciça, divididos em dois grupos: os submetidos à TAC no PS e os que não foram. Verificou-se a acurácia da TAC, comparou-se o número de óbitos nos dois grupos, o tempo de internamento e os hemocomponentes transfundidos. RESULTADOS: dos 60 pacientes, 66,67% receberam concentrados de hemácias ainda no PS; 33,3% foram submetidos à TAC na admissão, pela melhora hemodinâmica, e 66,7% não realizaram o exame na entrada. O percentual de óbitos foi de 35% em ambos os grupos. A diferença entre as médias do tempo de internamento entre os grupos não foi estatisticamente significativa, assim como a média da quantidade de concentrado de hemácias transfundido. No grupo que fez TAC, 45% não necessitaram de laparotomia exploratória. CONCLUSÃO: a TAC pôde ser realizada de maneira rápida em pacientes com instabilidade hemodinâmica na chegada ao PS, não influenciou significativamente a mortalidade e poupou alguns doentes de uma laparotomia exploratória desnecessária.

Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage.

BACKGROUND: Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH). METHODS: Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90). RESULTS: 274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS). CONCLUSION: FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.

BACKGROUND: Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS: A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS: Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION: Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

Tomografia no trauma abdominal grave: risco justificável? / Computerized Axial Tomography in patients with severe abdominal trauma: is it a justifiable risk?

RESUMO Objetivo: avaliar a evolução de pacientes vítimas de trauma abdominal grave, nos quais o protocolo de transfusão maciça foi acionado, e que foram submetidos à Tomografia Axial Computadorizada (TAC) no Pronto Socorro (PS), com o intuito de verificar o prognóstico do paciente e a eficiência diagnóstica da TAC nesse cenário. Métodos: estudo retrospectivo, longitudinal e observacional, feito em centro de referência para trauma. Foram selecionados 60 pacientes vítimas de trauma abdominal grave que ativaram o protocolo de transfusão maciça, divididos em dois grupos: os submetidos à TAC no PS e os que não foram. Verificou-se a acurácia da TAC, comparou-se o número de óbitos nos dois grupos, o tempo de internamento e os hemocomponentes transfundidos. Resultados: dos 60 pacientes, 66,67% receberam concentrados de hemácias ainda no PS; 33,3% foram submetidos à TAC na admissão, pela melhora hemodinâmica, e 66,7% não realizaram o exame na entrada. O percentual de óbitos foi de 35% em ambos os grupos. A diferença entre as médias do tempo de internamento entre os grupos não foi estatisticamente significativa, assim como a média da quantidade de concentrado de hemácias transfundido. No grupo que fez TAC, 45% não necessitaram de laparotomia exploratória. Conclusão: a TAC pôde ser realizada de maneira rápida em pacientes com instabilidade hemodinâmica na chegada ao PS, não influenciou significativamente a mortalidade e poupou alguns doentes de uma laparotomia exploratória desnecessária.

ABSTRACT Objective: to evaluate the evolution of severe abdominal trauma patients, for whom the massive transfusion protocol was triggered, and who were submitted to Computed Axial Tomography (CAT) in the emergency room (ER), in order to verify the patient's prognosis and the diagnostic efficiency of CAT in this scenario. Methods: retrospective, longitudinal and observational study performed at a referral center for trauma care in Curitiba, Parana, Brazil. We selected 60 severe abdominal trauma patients who had massive transfusion protocol activation and divided them into two groups: patients who underwent CAT at ER and patients who did not. We verified the diagnostic accuracy of CAT-scan examination and compared the number of deaths, hospitalization time, and transfused blood components in both groups. Results: considering the 60 patients, 66.67% received red blood cells at ER; 33.3% underwent CAT on admission due to hemodynamic improvement, and 66.7% did not perform the examination at the entrance. The percentage of deaths was 35% in both groups. Considering the two groups, the difference between the mean lengths of hospital stay was not statistically significant, as well as the difference between the mean numbers of transfused red blood cells. In the group that underwent CAT, 45% did not require exploratory laparotomy. Conclusion: CAT could be rapidly performed in patients with hemodynamic instability on arrival at ER, sparing some patients from an unnecessary exploratory laparotomy and not significantly influencing mortality.

Use of Vasopressor Increases the Risk of Mortality in Traumatic Hemorrhagic Shock: A Nationwide Cohort Study in Japan.

OBJECTIVES: To evaluate the possible association of vasopressor use with mortality in traumatic hemorrhagic shock patients. DESIGN: Retrospective cohort study. SETTING: Traumatic hemorrhagic shock patients at 260 emergency hospitals in Japan between 2004 and 2015. PATIENTS: Three-thousand five-hundred fifty-one traumatic hemorrhagic shock patients who had systolic hypotension (< 90 mm Hg) on arrival at the emergency department and a blood transfusion received within the first 24 hours. INTERVENTIONS: The use of vasopressor for traumatic hemorrhagic shock within the first 24 hours. MEASUREMENTS AND MAIN RESULTS: Among 236,698 trauma patients, 3,551 were included in the study. Overall, 198 of 459 patients (43%) in the vasopressor+ group expired compared with 481 of 3,092 patients (16%) in the vasopressor- group. Use of vasopressor had an odds ratio of 2.172 (95% CI, 1.666-2.833) for in-hospital mortality adjusted for age, gender, year of onset, cause of injury, mechanism of injury, vital signs at the emergency department, Injury Severity Score, use of prehospital IV fluid, and volume of blood transfusion within the first 24 hours. In the propensity score-matched cohort and two subgroup analyses (massive transfusion and survivable injury models), use of vasopressor was associated with higher mortality (odds ratio, 2.168; 95% C, 1.442-3.320), (odds ratio, 2.029; 95% CI, 1.414-2.911; massive transfusion model), and (odds ratio, 1.959; 95% CI, 1.364-2.814; survivable injury model). CONCLUSIONS: Use of vasopressor for traumatic hemorrhagic shock was associated with mortality after controlling for biases (trauma severity; volume of fluid resuscitation).

Early arterial access for resuscitative endovascular balloon occlusion of the aorta is related to survival outcome in trauma.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in refractory hemorrhagic shock patients. Since the optimal timing of arterial access remains unclear, we evaluated the preocclusion status of patients, and elapsed time from the arrival to the hospital is associated with the survival outcomes in the REBOA patients. METHODS: From August 2011 to December 2016, The Diagnostic and Interventional Radiology in Emergency, Critical care and Trauma-Intra-Aortic Balloon Occlusion (DIRECT-IABO) investigators registered refractory hemorrhagic shock patients undergoing REBOA from 23 hospitals in Japan. Patient characteristics, mechanism of injury, Injury Severity Score (ISS), preocclusion and postocclusion systolic blood pressure, duration of aortic occlusion, clinical time course, and survival outcome were recorded and analyzed. Binary logistic regression analysis was used with mortality and Kaplan-Meier survival analysis was conducted to demonstrate the difference between early and delayed access groups. RESULTS: Among the enrolled 207 cases, the following patients were excluded from the analysis: five since they were younger than 18 years, nine due to failed attempts at REBOA, 51 nontrauma patients, and 33 who received resuscitative thoracotomy plus REBOA. Thus, the remaining 109 cases were analyzed (30-day survivors, n = 60; nonsurvivors, n = 49). The preocclusion systolic blood pressure was higher, and both hospital arrival to initial arterial access and duration of occlusion were shorter in the survivors. Lower ISS (odds ratio, 0.944; 95% confidence interval, 0.907-0.982; p = 0.0039) and shorter arrival to access (odds ratio, 0.989; 95% confidence interval, 0.979-0.999; p = 0.034) were significantly associated with 30-day survival in the logistic regression analysis. The cutoff point of 21.5 minutes was used in the receiver operating characteristic analysis. The early access group showed a significantly shorter time of arrival to definitive hemostasis and also demonstrated a significantly higher survival in the Kaplan-Meier survival analysis (p = 0.014, Log-rank test). CONCLUSION: The arrival to access time and ISS were significantly associated with mortality in the REBOA patients in Japan. The early access group demonstrated better survival. The proactive early access in the resuscitation phase might be related to better patient outcomes. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

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.