Search

BackgroundTrauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients.MethodsThe American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients

• Training is required for all doctors new to REBOA regardless of existing vascular access skills and simpler catheter systems. • Doctors skilled in vascular access benefit from an initial inter-procedural transfer of skills effect when first learning REBOA. • However, novice doctors perform equally well after a focussed simulation-based training, indicating that either group can learn the technical aspects of inserting REBOA. • A time-fixed simulation-based training program does not ensure technical proficiency of doctors learning REBOA, despite vast experience. • Individual skills assessment should be used to ensure proficiency following training for all doctors regardless of previous experience. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging and potentially life-saving procedure, necessitating qualified operators in an increasing number of centres. The procedure shares technical elements with other vascular access procedures using the Seldinger technique, which is mastered by doctors not only in endovascular specialties but also in trauma surgery, emergency medicine, and anaesthesiology. We hypothesised that doctors mastering the Seldinger technique (experienced anaesthesiologist) would learn the technical aspects of REBOA with limited training and remain technically superior to doctors unfamiliar with the Seldinger technique (novice residents) given similar training. This was a prospective trial of an educational intervention. Three groups of doctors were enroled: novice residents, experienced anaesthesiologists, and endovascular experts. The novices and the anaesthesiologists completed 2.5 h of simulation-based REBOA training. Their skills were tested before and 8–12 weeks after training using a standardised simulated scenario. The endovascular experts, constituting a reference group, were equivalently tested. All performances were video recorded and rated by three blinded experts using a validated assessment tool for REBOA (REBOA-RATE). Performances were compared between groups and with a previously published pass/fail cutoff. Sixteen novices, 13 board-certified specialists in anaesthesiology, and 13 endovascular experts participated. Before training, the anaesthesiologists outperformed the novices by 30 percentage points of the maximum REBOA-RATE score (56% (SD 14.0) vs 26% (SD 17%), p <0.01). After training, there was no difference in skills between the two groups (78% (SD 11%) vs 78 (SD 14%), p = 0.93). Neither group reached the endovascular experts' skill level (89% (SD 7%), p <0.05). For doctors mastering the Seldinger technique, there was an initial inter-procedural transfer of skills advantage when performing REBOA. However, after identical simulation-based training, novices performed equally well to anaesthesiologists, indicating that vascular access experience is not a prerequisite to learning the technical aspects of REBOA. Both groups would need more training to reach technical proficiency. [ABSTRACT FROM AUTHOR]

• Open pelvic fractures are a rare occurrence but present a high rate of mortality and morbidity. • Treatment interventions include preperitoneal pelvic packing (PPP), therapeutic angio-embolization, laparotomy, and faecal diversion. • Initial systolic blood pressure was identified as an independent risk factor for mortality. • PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures. : Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. : We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27–57 years) and median ISS was 34 (24–43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p <0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907–0.980; p = 0.003). A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings. [ABSTRACT FROM AUTHOR]

Introduction: Abdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries.Method: A pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality.Results: Ninety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026).Conclusions: THOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group. [ABSTRACT FROM AUTHOR]

• It is feasible to create a fully perfused human specimen model with circulating arterial and venous flow via a single arterial inflow cannula. • This perfused human flow model can be used in trauma scenario training for realistic training of advanced bleeding control techniques. • The use of AnubiFiX embalmed human specimen has the advantage of reusability while preserving color, flexibility, and suppleness of the tissues. • Regional arteriovenous flow can be used to reduce the development of tissue edema and increase the durability of the flow model. Prompt and effective hemorrhage control is paramount to improve survival in patients with catastrophic bleeding. In the ever-expanding field of bleeding control techniques, there is a need for a realistic training model to practice these life-saving skills. This study aimed to create a realistic perfused post-mortem human specimen (PMHS) flow model that is suitable for training various bleeding control techniques. This laboratory study was conducted in the SkillsLab & Simulation Center of Erasmus MC, University Medical Center Rotterdam, the Netherlands. One fresh frozen and five AnubiFiX® embalmed PMHS were used for the development of the model. Subsequent improvements in the exact preparation and design of the flow model were made based on model performance and challenges that occurred during this study and are described. Circulating arteriovenous flow with hypertonic saline was established throughout the entire body via inflow and outflow cannulas in the carotid artery and jugular vein of embalmed PMHS. We observed full circulation and major hemorrhage could be mimicked. Effective bleeding control was achieved by placing a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter in the model. Regional perfusion significantly reduced the development of tissue edema. Our perfused PMHS model with circulating arterial and venous flow appears to be a feasible method for the training of multiple bleeding control techniques. Regional arteriovenous flow successfully reduces tissue edema and increases the durability of the model. Further research should focus on reducing edema and enhancing the durability of the model. [ABSTRACT FROM AUTHOR]

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage.Methods: Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-).Results: During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts.Conclusion: PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to evaluate the current management and clinical outcomes in patients with hemodynamic instability due to pelvic fracture in three regional trauma centres in Korea.Patients and Methods: Three regional trauma centres participated in this study, and 157 patients who were admitted between January 2015 and December 2018 were enroled. Clinical data were collected prospectively as part of the Korean trauma data bank and were analysed retrospectively.Results: The mean age was 59.3 years, and 107 of 157 (68.2%) were male patients. The most common cause of injury was auto-pedestrian accidents, followed by falls and motor vehicle crashes. The mean admission systolic blood pressure and serum lactate level were 86.7 mmHg and 6.68 mmol/L, respectively. Twenty-four patients (15.3%) had a cardiac arrest in the emergency department (ED). The mean injury severity score was 39.1, and the mean probability of survival (Trauma and Injury Severity Score) was 48.7%. Sixty-six patients (42%) underwent pelvic angiography; 89 (56.7%), preperitoneal pelvic packing (PPP); 27 (17.2%), resuscitative endovascular balloon occlusion of the aorta (REBOA); 20 (12.7%), pelvic external fixation (PEF); and 13 patients (8.3%), internal iliac artery ligation (IIAL). Seventy-three patients (46.5%) died, including 40 (25.5%) who died from acute haemorrhage. With each year, the rates of REBOA and pelvic binder use continued to increase (p<0.001 and p = 0.005, respectively), but the number of PEF cases significantly decreased (p = 0.006). Age, initial lactate, low revised trauma score (RTS), combined abdominal injury, REBOA, and 4-hour requirement of packed red blood cells were independent risk factors associated with mortality, whereas during the period of 2017 and 2018, there were protective factors. The risk factors of mortality due to haemorrhage were cardiac arrest in the ED, RTS, combined chest and abdominal injuries, and IIAL.Conclusions: Since the establishment of regional trauma centres, the clinical outcomes of patients with hemodynamic instability due to pelvic fracture have significantly improved. As a haemostatic procedure for these patients, PEF has been used less frequently, while pelvic binder and REBOA showed significant increase in their use. [ABSTRACT FROM AUTHOR]

Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. III [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to evaluate the feasibility of en-route resuscitative endovascular balloon occlusion of the aorta (REBOA) on board of a helicopter.Methods: Six sedated male sheep (weighing 42-54 kg) underwent a controlled hemorrhage until the systolic blood pressure (BP) dropped to <90 mmHg, and were placed into a low capacity Eurocopter AS-350 (France). During the 30-minutes normal flight, every animal underwent blind (left side) and ultrasound-guided (US) (right side) vascular access (VA) to the femoral artery followed by REBOA: the first catheter (Rescue balloon, Japan) - into Zone I, the second one (MIT, Russia) - Zone III. In case of blind VA failure, an alternate US-puncture was attempted. Six experienced flight anesthetists were enrolled into the study. Vascular access and REBOA catheter placement (confirmed by X-Ray later) success rate and timing were recorded.Results: Among six blind punctures one was successful, 2/6 - were into the vein, 3/6 - completely failed and switched to US-punctures (making total number of US-punctures nine). Eight out of nine US-punctures were successful. However, correct wire insertion and sheath placement was performed in 1/6 animal in the 'blind' group and only in 6/9 animals in the 'US' group. It took a median of 65 seconds (range 5-260) for US-puncture and a median of 4 minutes to get the sheath in. Among the 9 VAs, there were 2 REBOA failures (1 ruptured balloon [MIT] and 1 mistaken vena cava placement primarily recognized by a sudden drop of BP and later confirmed by X-Ray). Five out of seven balloons were placed in a desired intra-aortic position: 4/5 in Zone I and 1/2 - in Zone III. A median time for a successful REBOA procedure was 5.0 (range 2.5-10.0) minutes (1 min after sheath placement).Conclusion: Our study demonstrates the potential feasibility of the en-route REBOA which can be performed within 5 minutes. Ultrasound-guidance is critically important to achieve en-route VA. [ABSTRACT FROM AUTHOR]

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving but high-risk emergency procedure in patients with haemorrhagic shock. Lack of physicians with competence in the procedure is a barrier to implementation of REBOA. It is currently unclear how training and assessment of competence should be done.Objectives: To report and evaluate research in training and assessment of competence in REBOA and femoral arterial access with the aim to investigate the effect of simulation-based training in the procedure and to provide suggestions for the future design of training programs and assessment tools.Methods: Following PRISMA guidelines, PubMed, Embase, and Cochrane Library databases were searched for studies on training or assessment of competence in REBOA and femoral arterial access. Bias assessment was done using the Medical Education Research Study Quality Instrument. Evidence level was assessed using GRADE.Results: Sixteen studies were included, six of them published as abstracts. Full-text studies included 189 trainees ranging in experience level from military medics to surgical specialists. Outcome measures were heterogenous; the most used were rater checklists, knowledge testing, and procedure time. All studies confirmed an effect of training of REBOA on procedural competence in a simulation setting but had a high degree of bias. No study developed or used an assessment tool supported by validity evidence and no study investigated mid and long-term outcomes.Conclusion: Simulation-based training of REBOA improves skills, however, the evidence level is very low and data cannot answer important questions on effect size, skill transfer and retention, and optimal course design. To advance research and training programmes, an assessment tool supported by validity evidence with broad applicability is needed. [ABSTRACT FROM AUTHOR]

• To reduce mortality from non-compressible truncal and junctional hemorrhage (NCTJH), the application of advanced bleeding control techniques should be optimized. • These techniques include REBOA, junctional tourniquets, Foley catheters, wound clamps, hemostatic gauzes, and injectable hemostatic agents. • More than half of Dutch trauma patients with NCTJH may benefit from advanced bleeding control techniques during initial trauma care. • On average, each level-1 trauma center treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. • Implementation of these techniques may contribute to reduction of mortality and morbidity from NCTJH. Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques. Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment. In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage. [ABSTRACT FROM AUTHOR]

Background: To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.Study Design: A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.Results: Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.Conclusions: Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times. [ABSTRACT FROM AUTHOR]

Background and Importance: Complex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries., Objective: To investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality., Design, Settings, and Participants: We used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3-5) from 2004 to 2018., Outcome Measures and Analysis: The primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation., Main Results: We analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37-0.96; p = 0.03)., Conclusion: Urgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interests., (Copyright © 2022. Published by Elsevier Ltd.)

Patients presenting with hemodynamic instability associated with pelvic fractures continue to have very high mortality and surgeons continue to seek damage control strategies that may improve survival. Strategies usually require massive transfusion, immediate pelvic stabilization and another adjunctive maneuver's such as angioembolization or preperitoneal pelvic packing to prevent hemorrhagic death. One current intervention that has regained some popularity in lieu of resuscitative thoracotomy is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This requires some manner of femoral arterial access to insert a balloon into the aorta and increase central blood pressure (cardiac and cerebral perfusion) and control active pelvic bleeding. Based on several animal models and an increasing number of publications, many US level I trauma centers have now opted to use REBOA in carefully selected patients showing signs of near cardiac arrest from non-compressible torso hemorrhage. Description of the current advances in aortic occlusion using catheter-based technology in the setting of severe shock for non-compressible torso hemorrhage from pelvic ring fracture is the purpose of this report., Competing Interests: Declaration of Competing Interest The first and third author have no conflicts of interest to disclose. The corresponding author is on the clinical advisory board of Prytime Medical, Inc., (Copyright © 2020. Published by Elsevier Ltd.)

Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy., Competing Interests: Declarations of Competing Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes myocardial injury from increased aortic afterload and supraphysiologic cardiac output. However, pharmacologic methods to attenuate high cardiac output and reduce myocardial injury have not been explored. We hypothesized that the use of esmolol during REBOA would reduce myocardial injury., Methods: Ten pigs were anesthetized and instrumented. Following 25% total blood volume hemorrhage, animals underwent 45 min of supraceliac (zone 1) REBOA with or without titration of esmolol to maintain heart rate between 80 and 100 beats per minute. Following the REBOA interventions, animals underwent 275 min of standardized critical care., Results: During REBOA, heart rate was significantly lower in the esmolol group compared to control animals (100 [88 - 112] vs 193 [172 - 203] beats/minute, respectively, p < 0.001) and the average mean arterial pressure (MAP) was lower in the esmolol group (88.0 [80.3-94.9] vs 135.1 [131.7-140.4] mmHg, respectively, p = 0.01). During the critical care phase, there were no differences in heart rate or MAP between groups. Animals in the intervention group received 237.9 [218.7-266.5] µg/kg of esmolol. There was a significant increase from baseline in serum troponins for the control group (p = 0.006) and significantly more subendocardial hemorrhage compared to animals treated with esmolol (3 [3 - 3] and 0 [0 - 0], p = 0.009, respectively)., Conclusion: In our porcine model of hemorrhagic shock, zone 1 REBOA was associated with myocardial injury. Pharmacologic heart rate titration with esmolol during occlusion may mitigate the deleterious effects of REBOA on the heart., Competing Interests: Declaration of Competing Interest Drs. Johnson, Neff, and Williams are founders of Certus Critical Care, Inc., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Early hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients., Methods: A 3-year (2015-2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups., Results: Of 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA., Conclusion: PPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings., Level of Evidence: Prognostic study, level III., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest. No specific funding was received for this study., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The objective of this study was to investigate the hemodynamic effects of aortic occlusion (AO) during Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) using a sophisticated continuous vital sign (CVS) monitoring tool., Methods: Patients admitted between February 2013 and May 2017 at a tertiary center that received REBOA were included. Patients in cardiac arrest before or at the time of REBOA were excluded. Time of AO was documented by time-stamped videography and correlated with CVS data., Results: 28 patients were included, mean (standard deviation) ISS was 38 (11). 18 received Zone 1 (distal thoracic aorta) and 10 received Zone 3 (distal abdominal aorta) AO. Among Zone 1 patients the pre-AO systolic blood pressure (SBP) nadir was 64 (19) mmHg, which increased to a mean of 124 (29) mmHg within 5 min after AO (p < 0.01). Among Zone 3 patients the pre-AO SBP nadir was 75 (19) mmHg, which increased to a mean of 98 (14) mmHg within 5 min after AO (p < 0.01). 72% of Zone 1 patients had episodes during AO where SBP was less than 90 mmHg as compared to 80% of Zone 3 patients (p = 0.51). 100% of Zone 1 patients had periods during AO where SBP was greater than 140 mmHg as compared to 70% Zone 3 patients (p = 0.04). The overall mean decrease in SBP after balloon deflation was 13 (20) mmHg (p < 0.01), with similar decreases among groups (14 (21) mmHg vs 12 (18) mmHg for Zone 1 and 3 patients, respectively (p = 0.85)). Patients undergoing Zone 1 AO were more likely to have an acute change (increase or decrease) in their heart rate immediately after AO as compared to Zone 3 AO (p = 0.048)., Conclusions: Significant hemodynamic alterations occur before, during, and after AO. The effects of Zone 1 AO on blood pressure and heart rate appear different than Zone 3 AO. This may have important implications for cardiac or cerebral function and perfusion goals, particularly with concomitant injuries such as cardiac contusion or traumatic brain injury., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: This study reviews and validates the practice of selective non-operative management (SNOM) of penetrating neck injury (PNI) in a South African trauma service and reviews the impact new imaging modalities have had on the management of this injury., Methodology: This study was performed within the Pietermaritzburg Metropolitan Trauma Service, in the city of Pietermaritzburg, Kwazulu-Natal, South Africa. A prospectively maintained trauma registry was retrospectively interrogated. All patients with PNI treated over a 46-month period were included within the study., Results: A total of 510 patients were included in the study. There were 452 stab wounds (SW) and 58 gunshot wounds (GSW). A total of 202 (40%) patients sustained isolated PNI, the remaining 308 (60%) patients sustained trauma to at least one additional anatomical region. An airway injury was identified in 29 (6%) patients; a pharyngo-oesophageal injury in 41 (8%) patients and a vascular injury in 86 (17%) patients. Associated injuries included three penetrating cardiac injuries (PCI) and 146 patients with haemo-pneumothoraces. Of the total cohort, 387 patients (76%) underwent CT Angiography (CTA), of which 70 (18%) demonstrated a vascular injury. Formal catheter directed angiogram (CDA) was performed on 16 patients with positive CTA but confirmed injury in only half of these patients. Of 212 patients (42%) who underwent water-soluble contrast swallow (WS-swallow), an injury was demonstrated in 29 (14%) cases. A total of 401 (79%) patients were successfully managed conservatively for PNI and 109 (21%) surgically or by endovascular intervention. Only five (1.2%) patients failed a trial of SNOM and required surgery. The in-hospital mortality rate was 2%. No deaths could be attributed to a failure of SNOM., Conclusion: SNOM of PNI is a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity, is associated with a low yield. CTA has a significant false positive rate and good clinical assessment remains the cornerstone of management., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

AAST-OIS grade V complex hepatic injuries are often fatal as a result of exsanguination. We report a patient presenting in extremis with a penetrating injury to the right kidney, liver, middle hepatic vein, diaphragm, and lung. A combination of intrahepatic balloon tamponade and hepatic venous stenting was used to control exsanguinating haemorrhage, the first time this combination has been reported. Rapid assessment and treatment and a team approach, together with the innovative application of haemostatic techniques, allowed a multidisciplinary team to salvage this patient., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We report the use of a Foley catheter, placed through the wound, to provide balloon tamponade of major bleeding from the neck and supraclavicular fossae. In 10 consecutive explorations for exsanguinating injury in these regions balloon tamponade was used eight times, and was judged to be fully effective in four patients, partly effective in one, and ineffective in three patients.