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Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a potentially lifesaving but polarizing therapy due to the associated morbidity and uncertainty of who might benefit. Techniques such as partial (p)REBOA that provide hemodynamic support while reducing distal ischemia are now captured in the Aortic Resuscitation in Trauma and Acute Care (AORTA) registry. We hypothesized that pREBOA would be associated with improved mortality and fewer adverse outcomes. Methods: The AORTA registry was queried for adult patients who received complete (c)REBOA or pREBOA between 2020 and 2022. Patients were excluded if they had a head Abbreviated Injury Scale (AIS) ≥three or an AIS of six in any body region. Outcome measures were complications and mortality. Poisson regression analyses identified the independent effect of the type of approach on outcomes. Results: 164 patients met the inclusion criteria, with pREBOA used in 36% of cases and no significant difference in patient demographics, injury characteristics, or injury severity between pREBOA and cREBOA. There was no difference in mortality rate (44.1% vs 45.7%). After adjusting for potential confounders, no statistically significant difference in complications was detected between the two approaches [adjusted IRR (95% CI): 1.11 (0.54–2.27), p = 0.777]. This association persisted after subgroup analysis of aortic Zone one vs Zone three deployment. Conclusions: In this registry analysis, pREBOA did not reduce morbidity or mortality compared to cREBOA. Improving the granularity of clinical metrics in the AORTA registry is essential to understanding whether patients will benefit from pREBOA, and how to best implement this controversial resuscitation adjunct.

Abstract Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries’ income based on the World Bank Country and Lending Groups. Methods We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. Results A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3). Conclusion There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Purpose: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. Methods: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardized adjunct in the management of non-compressible hemorrhage. Ultrasound (US)-guided femoral access has been taught as the best practice for femoral artery cannulation. However, there is a lack of evidence to support its use in patients in extremis with severe hemorrhage. We hypothesize that no differences in outcome will exist between US-guided and to blind percutaneous or cutdown access methods. Methods: This was an international, multicenter retrospective review of all patients managed with REBOA from the ABOTrauma Registry and the AORTA database. REBOA characteristics and outcomes were compared among puncture access methods. Significance was set at P < 0.05. Results: The cohort included 523 patients, primarily male (74%), blunt injured (77%), with median age 40 (27–58), and an Injury Severity Score of 34 (25–45). Percutaneous using external landmarks/palpation was the most common femoral puncture method (53%) used followed by US-guided (27.9%). There was no significant difference in overall complication rates (37.4% vs 34.9%; P = 0.615) or mortality (47.8% vs 50.3%; P = 0.599) between percutaneous and US-guided methods; however, access by cutdown was significantly associated with emergency department (ED) mortality (P = 0.004), 24 hour mortality (P = 0.002), and in-hospital mortality (P = 0.007). Conclusions: In patients with severe hemorrhage in need of REBOA placement, the percutaneous approach using anatomic landmarks and palpation, when compared with US-guided femoral access, was used more frequently without an increase in complications, access attempts, or mortality.

Abstract Background The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration IRB approval number: HM20006627. Retrospective trial not registered.

Objectives To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.Setting The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011.Participants US and UK military personnel, local police, local military and civilians.Primary and secondary outcome measures An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables.Results Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066).Conclusions The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.Methods The American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.Results Location and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, p

Background: Aortic occlusion is a valuable adjunct for the management of traumatic pelvic and lower extremity junctional hemorrhage. Methods: The American Association for the Surgery of Trauma Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry was reviewed for patients requiring Zone III resuscitative endovascular balloon occlusion of the aorta (REBOA) from eight verified trauma centers. After excluding patients in arrest, demographics, elements of treatment, and outcomes were identified. Results: From November 2013 to December 2016, 30 patients had Zone III REBOA placed. Median age was 41.0 (interquartile range, IQR, 38); median injury severity score was 41.0 (IQR 12). Hypotension (SBP < 90 mm Hg) was present on admission in 30.0% and tachycardia (HR > 100 bpm) in 66.7%. Before REBOA placement, vital signs changed in this cohort with hypotension in 83.3% and tachycardia noted in 90%. Median initial pH was 7.14 (IQR 0.22), and median admission lactate 9.9 mg/dL (IQR 5). Pelvic binders were utilized in 40%. Occlusion balloon devices included Coda™ (70%), ER REBOA™ (13.3%), Reliant™ (10%). After REBOA, hemodynamics improved in 96.7% and stability (BP consistently > 90 mm Hg) was achieved in 86.7%. Median duration of REBOA was 53.0 mins (IQR 112). Median PRBC and FFP requirements were 19.0 units (IQR (17) and 17.0 units (IQR 14), respectively. One amputation unrelated to REBOA utilization was required. Systemic complications included AKI (23.3%) and MODS (10%). REBOA specific complications included groin hematoma (3.3%) and distal thromboembolization (16.7%). Survival to dis-charge was 56.7%, with in-hospital deaths occurring in the ED 7.7%, OR 23.1%, ICU 69.2%. Conclusions: This review discusses the specifics of the contemporary use of Zone III REBOA placement as well as local and systemic complications for patients in extremis with pelvic/junctional hemorrhage. Further review is required to determine optimal patient selection.