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Purpose: As resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed in an extremely emergent situation, achieving competent clinical practice is mandatory. Although there are several educational courses that teach the REBOA procedure, there have been no reports evaluating the impact of training on clinical practice. Therefore, this study is aimed to evaluate the effects of the course on procedural performance during resuscitation and on clinical outcomes. Methods: Patients who were managed at a regional trauma center in Dankook University Hospital from August 2016 to February 2018 were included and were grouped as precourse (August 2016–August 2017, n=9) and postcourse (September 2017–February 2018, n=9). Variables regarding injury, parameters regarding REBOA procedure, morbidity, and mortality were prospectively collected and reviewed for comparison between the groups. Results: Demographics and REBOA variables did not differ between groups. The time required from arterial puncture to balloon inflation was significantly shortened from 9.0 to 5.0 minutes (P=0.003). There were no complications associated with REBOA after the course. Mortality did not show any statistical difference before and after the course. Conclusions: The endovascular training for REBOA pilot course, which uses a modified form of flipped learning, realistic simulation of ultrasound-guided catheter insertion and balloon manipulation, and competence assessment, significantly improved procedural performance during resuscitation of trauma patients.

A 59-year-old male patient presented to the emergency department after a tractor rollover accident. His Injury Severity Score was 41 points. He had multiple pelvic bone fractures and a left common femoral artery injury with soft tissue loss. The injured arteries with skin defect were initially managed with endarterectomy and primary repair. However, the sepsis secondary to the infection from a skin defect became uncontrolled. The infected wound developed massive hemorrhage from the repaired arteries. Supportive measures were initiated to achieve hemostasis but unsuccessful. We performed an anastomosis with a prosthetic graft from the common iliac artery to the femoral artery above the knee, avoiding the wound through the lateral side of the anterior superior iliac spine. After revascularization, the patient recovered uneventfully. An extraanatomic graft reconstruction should be considered early when the autologous vein is unsuitable.

A central venous catheter (CVC) is usually placed to replace the spilled blood volume or inject a vasopressor. Among central catheterizations, the anatomy of the femoral vessel is lesser complex than that of others, and femoral venous catheterization is most easily cannulated percutaneously. However, endovascular training should be considered to complete the deployment of the central catheter and prevent complications systematically. Therefore, this study aimed to share the precise CVC procedure in the femoral vein and to impart endovascular techniques through simulation video clips and pictures.

Isolated iliac artery aneurysm (IAA) is rare, but can be fatal. Emergency surgery is performed in cases of hemorrhagic shock due to a suddenly ruptured IAA, which may have a high mortality rate because of massive non-compressible torso hemorrhage (NCTH). Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as an alternative to aortic cross-clamping via open thoracotomy to achieve hemostasis in trauma patients with profound shock due to NCTH and is considered an emerging bridging therapy for damage control. However, there is limited information on the use of REBOA in non-trauma patients with shock. Herein, we describe a patient with impending cardiac arrest due to isolated ruptured IAA, in whom perioperative bleeding was successfully controlled by REBOA.

Cardiac tamponade is an acute life-threatening condition that predominantly involves the intra-pericardial space; however, an expanding mediastinal hematoma can also sometimes cause cardiac tamponade. Here we describe the case of a 45-year-old male driver in whom a traffic accident resulted in rupture of the left internal thoracic artery (ITA), extra-pericardial hematoma, and sternal fracture. After resuscitation, he was scheduled to undergo angio-embolization to repair the ruptured left ITA, but he suddenly developed cardiac tamponade that required a decompressive sternotomy. Nevertheless, the patient had an uncomplicated recovery, and this case suggests that extra-pericardial cardiac tamponade should be considered as a possible consequence of retro-sternal hematoma due to traumatic ITA rupture.

Background: Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines. Objectives: The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities. Methods: We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed. Results: We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records. Conclusion: We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.

The following recommendations are presented herein: All trauma patients admitted to the resuscitation room should be constantly (or periodically) monitored for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation, body temperature, electrocardiography, Glasgow Coma Scale, and pupil ref lex (1C). Chest AP and pelvic AP should be performed as the standard initial trauma series for severe trauma patients (1B). In patients with severe hemodynamically unstable trauma, it is recommended to perform extended focused assessment with sonography for trauma (eFAST) as an initial examination (1B). In hemodynamically stable trauma patients, eFAST can be considered as the initial examination (2B). For the diagnosis of suspected head trauma patients, brain computed tomography (CT) should be performed as an initial examination (1B). Cervical spine CT should be performed as an initial imaging test for patients with suspected cervical spine injury (1C). It is not necessary to perform chest CT as an initial examination in all patients with suspected chest injury, but in cases of suspected vascular injury in patients with thoracic or high-energy damage due to the mechanism of injury, chest CT can be considered for patients in a hemodynamically stable condition (2B). CT of the abdomen is recommended for patients suspected of abdominal trauma with stable vital signs (1B). CT of the abdomen should be considered for suspected pelvic trauma patients with stable vital signs (2B). Whole-body CT can be considered in patients with suspicion of severe trauma with stable vital signs (2B). Magnetic resonance imaging can be considered in hemodynamically stable trauma patients with suspected spinal cord injuries (2B).

Objectives: As a protective measure to slow down the transmission of coronavirus disease 2019 in Korea, social distancing was implemented from February 29th, 2020 This study aimed to evaluate the prevalence of domestic incidents and intentional injury during March 2020 when social distancing was in effect Methods: There were 12,638 patients who visited the Level 1 trauma center of Chungnam province with injuries from domestic incidents, familial discord, and intentional injury The prevalence of injuries during March 2020 was compared with the average of the previous 5 years, and the average for every March between 2015 and 2019 Results: The prevalence of domestic incidents in March 2020 was significantly higher than the 5-year average, and the average for every March from 2015 to 2019 (p < 0 001) Familial discord (p = 0 002) and intentional injury (p = 0 031) were more frequently observed in March 2020 Adolescents showed a markedly higher level of intentional injury in March 2020 than in both the 5-year average (p = 0 031), and average for every March over the previous 5 years (p = 0 037) Conclusion: The prevalence of domestic incidents and intentional injury were significantly higher during the period of social distancing in Korea There is a need for social consensus, better policies, and psychological support services, especially if faced with a second or third wave of coronavirus disease

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: This retrospective multicenter study analyzed trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the Republic of Korea. Methods: This study was conducted from February 2017 to May 2018 at three regional trauma centers in the Republic of Korea. The patients were divided into two groups (cardiopulmonary resuscitation [CPR] and No-CPR) for comparative analysis based on two criteria (complication and mortality) for logistic regression analysis (LRA). Results: There were significant differences between the CPR and No-CPR groups in mortality (p=0.003) and treatment administered (p=0.016). By LRA for complications, total occlusion has significantly lesser risk than intermittent or partial occlusion in both univariate (odds ratio [OR] 0.06, 95% confidence interval [CI] 0.00-0.36, p=0.01) and multivariate (OR 0.05, 95% CI 0.00-0.38, p=0.01) analyses. The Rescue had a higher risk than the Coda or Reliant in univariate analysis (OR 4.91, 95% CI 1.14-34.25, p=0.05); however, it was not statistically significant in multivariate a nalysis (OR 6.98, 95% CI 1.03-74.52, p=0.07). By LRA for mortality, the CPR group was the only variable that had a significantly higher risk of mortality than the No-CPR group in both univariate (OR 17.59, 95% CI 3.05-335.25, p=0.01), and multivariate (OR 24.92, 95% CI 3.77-520.51, p=0.01) analyses. Conclusions: This study was conducted in the early stages of REBOA implementation in the Republic of Korea and showed conflicting results from studies conducted by multiple institutions. Therefore, additional research with more accumulated data is needed.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as an adjunct procedure for non-compressible torso hemorrhage in patients with hemorrhagic shock. With appropriate indications, REBOA should be performed for resuscitation regardless of the physician’s specialty. Despite its effectiveness in traumatized patients with hemorrhagic shock, performing REBOA has been challenging due to physicians’ lack of experience. Even though training in endovascular skills is mandatory, many physicians cannot undergo sufficient training because of the limited number of endovascular simulation programs. Herein, we share simulation video clips, including those of a vascular circuit model for simulation; sheath preparation; long guidewire and balloon catheter preparation; ultrasound-guided arterial access; sheath insertion or upsizing; and balloon positioning, inflation, and migration. The aim of this study was to provide educational video clips to improve physicians’ endovascular skills for REBOA.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered an emerging adjunct therapy for profound hemorrhagic shock, as it can maintain temporary stability until definitive repair of the injury. However, there is limited information about the use of this procedure in children. Herein, we report a case of REBOA in a pediatric patient with blunt trauma, wherein the preoperative deployment of REBOA played a pivotal role in damage control resuscitation. A 7-year-old male patient experienced cardiac arrest after a motor vehicle accident. After 30 minutes of cardiopulmonary resuscitation, spontaneous circulation was achieved. The patient was diagnosed with massive hemoperitoneum. REBOA was then performed under ongoing resuscitative measures. An intra-aortic balloon catheter was deployed above the supraceliac aorta, which helped achieved permissive hypotension while the patient was undergoing surgery. After successful bleeding control with small bowel resection for mesenteric avulsion, thorough radiologic evaluations revealed hypoxic brain injury. The patient died from deterioration of disseminated intravascular coagulation. Although the patient did not survive, a postoperative computed tomography scan revealed neither remaining intraperitoneal injury nor peripheral ischemia correlated with the insertion of a 7-Fr sheath. Hence, REBOA can be a successful bridge therapy, and this result may facilitate the further usage of REBOA to save pediatric patients with non-compressible torso hemorrhage.

Purpose: Despite recent developments in the management of trauma patients in South Korea, a standardized system and guideline for trauma treatment are absent. Methods: Five guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Results: Restrictive volume replacement must be used for patients experiencing shock from trauma until hemostasis is achieved (1B). The target systolic pressure for fluid resuscitation should be 80-90 mmHg in hypovolemic shock patients (1C). For patients with head trauma, the target pressure for fluid resuscitation should be 100-110 mmHg (2C). Isotonic crystalloid fluid is recommended for initially treating traumatic hypovolemic shock patients (1A). Hypothermia should be prevented in patients with severe trauma, and if hypothermia occurs, the body temperature should be increased without delay (1B). Acidemia must be corrected with an appropriate means of treatment for hypovolemic trauma patients (1B). When a large amount of transfusion is required for trauma patients in hypovolemic shock, a massive transfusion protocol (MTP) should be used (1B). The decision to implement MTP should be made based on hemodynamic status and initial responses to fluid resuscitation, not only the patient’s initial condition (1B). The ratio of plasma to red blood cell concentration should be at least 1:2 for trauma patients requiring massive transfusion (1B). When a trauma patient is in life-threatening hypovolemic shock, vasopressors can be administered in addition to fluids and blood products (1B). Early administration of tranexamic acid is recommended in trauma patients who are actively bleeding or at high risk of hemorrhage (1B). For hypovolemic patients with coagulopathy non-responsive to primary therapy, the use of fibrinogen concentrate, cryoprecipitate, or recombinant factor VIIa can be considered (2C). Conclusions: This research presents Korea''s first clinical practice guideline for patients with traumatic shock. This guideline will be revised with updated research every 5 years.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

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.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.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 (p0.001 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.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.

Traumatic chylothorax is a rare condition following blunt trauma. Although a chyle leak resulting from direct damage to the duct may occur at any level because of an anatomical variation, an airway obstruction due to thoracic duct injury after blunt trauma has never been described. Here, we report a very unusual case with airway obstruction due to thoracic duct injury after whiplash injury. A 60-year-old man presented to the emergency department with allodynia after blunt trauma. Initial chest computed tomography (CT) showed a prevertebral hematoma and pneumomediastinum from C2 to T3 spinal level without vertebral fracture. Seven days later, repeat CT showed an increased amount of mediastinal and prevertebral fluid collection extending to the upper neck level with airway compression. He underwent an operation to drain the fluid via a neck incision and a thoracic duct ligation via right thoracotomy and was discharged without complaint. The findings suggest that if hematoma and pneumomediastinum are found in the prevertebral space at the level of the cervical and upper thoracic spine, the patient should be closely observed to exclude the complication of airway obstruction caused by thoracic duct injury.

Noncompressible torso hemorrhage (NCTH), if not controlled promptly, leads to death. In the acute setting, aortic occlusion can be performed as damage control surgery (DCS) for hemorrhage originating from the abdomen and pelvis. With the development of endovascular technology, an intra-aortic balloon can be used to achieve aortic occlusion and decrease hemorrhage. Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as a salvage technique for the temporary stabilization of patients with NCTH. However, balloon occlusion is not easily performed in trauma patients. In this article, we described preparation, technical description, and conceptual understanding of REBOA.

Pulmonary contusion complicated with endobronchial hemorrhage is potentially life-threatening, particularly in patients with tracheobronchial tree disruption and severe airway bleeding after blunt trauma, and pose a high mortality risk. In such cases, extracorporeal membrane oxygenation (ECMO) can be used as a salvage treatment modality. However, the use of ECMO for moribund trauma patients with respiratory failure may be limited for several reasons, such as intractable bleeding. In this case report, we describe a patient with severe bilateral pulmonary contusions with tracheobronchial tree disruption that was successfully treated using heparin-free venovenous ECMO.

Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemothorax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed massive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superficial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges.

Purpose: Despite the numerous protocols and evidence-based guidelines that have been published, application of the therapeutics to eligible patients is limited in clinical settings. Therefore, a rounding checklist was developed to reduce errors of omission and the implementation results were evaluated. Methods: A checklist consisting of 12 components (feeding, analgesia, sedation, throm boembolic prophylaxis, head elevation, stress ulcer prevention, glucose control, pressure sore prevention, removal of catheter, endotracheal tube and respiration, delirium mon itoring, and infection control) was recorded by assigned nurses and then scored by the staff for traumatized, critically ill patients who were admitted in the trauma intensive care unit (ICU) of Dankook University Hospital for more than 2 days. A total of 170 patients (950 sheets) between April and October 2016 were divided into 3 periods (period 1, April to June; period 2, July to August; and period 3, September to October) for the analysis. Questionnaires regarding the satisfaction of the nurses were conducted twice during this implementation period. Results: Record omission rates decreased across periods 1, 2, and 3 (19.9%, 12.7%, and 4.2%, respectively). The overall clinical application rate of the checklist increased from 90.1% in period 1 to 93.8% in period 3. Among 776 (81.7%) scored sheets, the rates of full compliance were 30.2%, 46.2%, and 45.1% for periods 1, 2, and 3, respectively. The overall mean score of the questionnaire regarding satisfaction also increased from 61.7 to 67.6 points out of 100 points from period 1 to 3. Conclusions: An ICU rounding checklist could be an effective tool for minimizing the omission of preventative measures and evidence-based therapy for traumatized, critically-ill patients without overburdening nurses. The clinical outcomes of the ICU checklist will be evaluated and reported at an early date.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a salvage technique changing the paradigm in the management of non-compressible torso hemorrhage. However, training for the REBOA procedure is rarely performed. The endovascular training for REBOA (ET-REBOA) course was conducted to develop the endovascular skills of participants. Methods: Sixteen residents and 12 specialists participated in this educational course. All participants were provided with pre-course learning materials that consisted of a lecture on the introduction of REBOA and a demonstration video clip a week before the course. The ET-REBOA course consisted of two sections: an ultrasound-guided sheath insertion on the puncture model, and a balloon manipulation on the vascular circuit model. A 13-item procedure checklist and the time required to perform the procedure were examined. Pre/post self-reported confidence score and course satisfaction questionnaire was obtained. Results: Twenty-eight participants performed the 56 REBOA procedures. Seven of 16 residents failed their first attempt. On the first attempt, the median total time for REBOA from ultrasound-guided vascular access to balloon inflation was 1139 ± 250 s in the resident group and 828 ± 280 s in the specialist group. The median shortened time for completion was 273 s in the resident group and 290 s in the specialist group. A significant decrease in procedure task time was observed between first and second attempt in the resident group (p = 0.016), specialist group (p = 0.004), and in total amongst all participants (p < 0.001). Conclusion: The ET-REBOA course significantly decreased the time taken to perform the REBOA procedure with high satisfaction of the participants. The course could be an effective curriculum for the development of endovascular skills for performing REBOA.

Background: The assessment of hemodynamic variables is a mainstay in the management of critically ill patients. Hemodynamic variables may help physicians to choose among use of a vasopressor, an inotropic agent, or discontinuation of drugs. In this study, we aimed to investigate the usefulness of advanced hemodynamic variables in clinical decision-making. Methods: Surveys regarding the case were administered to 25 surgeons working in nationally designated trauma centers or on trauma teams, using a voting system at a medical conference. The patient was a 67-year-old male with a crush injury of the left leg after a pedestrian traffic accident, who had aggravated pulmonary edema after leg amputation. Three clinical situations were given and the decision choices were: immediately after amputation, in 8 hours, and on the second day after amputation. Three kinds of variables from hemodynamic monitoring systems were provided for each clinical situation: conventional hemodynamic variables, including central venous pressure; variables from pulse contour analysis (PCA) [cardiac output (CO), stroke volume index, stroke volume variation (SVV), and systemic vascular resistance index); and variables from transpulmonary thermodilution (TPTD) technique (global ejection fraction and extravascular lung water index). The changes in decisions according to each provided hemodynamic variable were investigated and analyzed. Results: The advanced hemodynamic parameters were considered to have a decisive effect on choosing vasopressors and inotropic agents. The decision was changed in 88% (22/25) of physicians using variables from the advanced monitoring systems. Among them, 82% (18/22) of physicians chose hemodynamic variables from the TPTD technique as their reason for change regarding management of a patient with severe pulmonary edema. Conclusions: Advanced monitoring systems might be helpful in decision-making for critically ill patients. Multiple parameters and trends in change could be more important than a single value. Clinicians should select the system most appropriate according to its advantages and limitations, and interpret the variables obtained correctly.

Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry. Methods Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome. Results There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived. Conclusions Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

The shortage of available organ donors is a significant problem and various efforts have been made to avoid the loss of organ donors. Among these, extracorporeal membrane oxygenation (ECMO) has been introduced to help support and manage potential donors. Many traumatic brain injury patients have healthy organs that might be eligible for donation for transplantation. However, the condition of a donor with a fatal brain injury may rapidly deteriorate prior to brain death determination; this frequently results in the loss of eligible donors. Here, we report the use of venoarterial ECMO to support a potential donor with a fatal brain injury before brain death determination, and thereby preserve donor organs. The patient successfully donated his liver and kidneys after brain death determination.

Percutaneous intervention is widely used to treat peripheral vascular disease. Ipsilateral antegrade femoral arterial access for femoropopliteal disease provides a mechanical advantage with regard to wire and stent control; however, it is associated with vascular complications and significant morbidity and mortality secondary to retroperitoneal hemorrhage from a high puncture site or vascular closure device (VCD) failure. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed as damage control surgery in patients with non-compressible torso hemorrhage. We describe a patient with hemorrhagic shock secondary to VCD failure, who was successfully treated by REBOA as damage control surgery. To our knowledge, this is the first reported case in the English literature of successful REBOA in a patient with hemorrhagic shock secondary to VCD failure.

Background: Maintenance of adequate vascular access for hemodialysis is important in patients with end-stage renal disease. Once arteriovenous fistula (AVF) occlusion occurs, the patient should be treated with rescue therapy. This study was performed to evaluate the results of a rescue therapy for AVF occlusion. Methods: From January 2008 to December 2012, 47 patients who underwent surgical rescue therapy for AVF occlusion after graft AVF formation, were enrolled in this study. The patients were divided into two groups, namely the graft repair group (group A, n=19) and the thrombectomy group (group B, n=28). Postoperative results of both groups were analyzed retrospectively. Results: There were no statistically significant differences in the clinical characteristics between the two groups. In terms of the duration of AVF patency after the first rescue therapy, group A showed a longer AVF patency duration than group B (24.5±21.9 months versus 17.7±13.6 months), but there was no statistically significant difference (p=0.310). In terms of the annual frequency of AVF occlusion after the rescue therapy of group A was lower than that of group B (0.59 versus 0.71), but there was no statistically significant difference (p=0.540). The AVF patency rates at 1, 2, 3, and 5 years after the first rescue therapy in group A were 52.6%, 31.5%, 21.0%, and 15.7%, respectively, and those in group B, they were 32.1%, 25.0%, 17.8%, and 7.14%, respectively. There was no statistically significant difference (p=0.402). Conclusion: Graft repair revealed comparable results. Although there was no statistically significant difference, the patent duration and annual frequency of AVF occlusion of group A were better than those of group B. Therefore, graft repair is considered as a safe and useful procedure for maintaining graft AVF.

A 42-year-old woman with irregular uterine contractions and a history of two prior cesarean sections was admitted. At 35 weeks of gestation, preterm labor with vaginal bleeding led to a cesarean section. During placenta removal it was revealed to be a percreta and uncontrollable massive bleeding ensued. Intraoperative resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed, which has been used as a resuscitative adjunct for trauma patients with noncompressible torso hemorrhage and a hysterectomy was successfully completed. Gauze packing for temporary abdominal closure and angio-embolization were performed to further control bleeding. The packed gauze was removed 2 days later and the patient recovered uneventfully. To the best of our knowledge, this is the first reported case in South Korean literature of the successful application of a REBOA as a salvage treatment for hemorrhage control, and REBOA could be a life-saving procedure for patients with peripartum hemorrhaging.

Background: Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to evaluate the feasibility of VATS lobectomy for pathologic stage I NSCLC. Material and Methods: Between December 2003 and December 2007, 529 patients with pathologic stage I NSCLC underwent lobectomies (373 thoracotomy, 156 VATS). Patients in both groups were selected after being matched by age, gender and pathologic stage using propensity score method, to create two comparable groups: thoracotomy and VATS groups, and the overall survival, recurrence-free survival, complication and length of hospitalization were compared between these two groups. Results: After the patients were matched by age, gender and pathologic stage, 272 patients remained eligible for analysis, 136 in each group (mean age of 59.5 years; 70 men, 66 women; 80 stage IA, 56 stage IB). There was no statistical difference in other preoperative clinical characteristics between the two groups. No hospital mortality was observed in both groups. Overall 3-year survival rate was 97.4% in thoracotomy group and 96.6% in VATS groups (p=0.76). During the follow-up, 20 patients (14.7%) developed recurrence in thoracotomy group, including loco-regional recurrence in 7, distant metastasis in 13. In VATS group, 13 patients (9.6%) developed recurrence, including loco-regional recurrence in 4, distant metastasis in 9. Three-year recurrence-free survival rate was 81.8% in thoracotomy group and 85.3% in VATS groups (p=0.43). There was no significant difference in postoperative complications between thoracotomy and VATS groups (30 cases in 22 patients vs. 19 cases in 17 patients, p=0.65, odds ratio=1.19). The mean hospital stay of VATS group was 2 days shorter than that of thoracotomy group (8.8±6.5 days vs. 6.3±3.3 days, p＜0.05). Conclusion: VATS lobectomy for pathologic stage I lung cancer is a feasible operation with shorter hospitalization, while surgical outcome is comparable to thoracotomy lobectomy.

Background During the past decade, video-assisted thoracic surgery (VATS) lobectomy has been performed with increasing frequency in patients with early-stage non–small cell lung cancer (NSCLC). However, questions remain as to whether VATS lobectomy reduces local recurrence and improves long-term survival in patients with NSCLC. Methods We retrospectively reviewed short-term and midterm outcomes, including postoperative morbidity, mortality, recurrence rate, and survival, in patients undergoing VATS lobectomy. Results Between 2003 and 2008, 704 patients underwent VATS lobectomy for the following indications: NSCLC (n = 548), carcinoid tumors (n = 7), pulmonary metastases (n = 22), and benign diseases (n = 127). One hundred eleven of 548 clinical stage I NSCLC patients (20.3%) experienced pathologic upstaging postoperatively. There were 9 in-hospital deaths (1.3%); all of these patients died of acute respiratory distress syndrome. Sixty-four patients experienced postoperative complications (9.1%). The median follow-up was 20 months for patients with NSCLC. During follow-up, 54 patients had a recurrence, and 13 patients died. Disease-free survival for patients with pathologic stage I disease was 92.7% at 1 year and 87.6% at 3 years. For patients with pathologic N1 (n = 55) and N2 diseases (n = 41), disease-free survival at 3 years was 79.3% and 57.1%, respectively. Conclusions Video-assisted thoracoscopic surgery lobectomy is a technically feasible and safe operation with excellent survival for early-stage lung cancer. For patients with pathologic N1 or N2 diseases after VATS lobectomy, survival was not compromised by this minimally invasive approach.

Background: Preoperative chemotherapy has been adopted in our hospital as a standard treatment for non-small cell lung cancer patients with N2 disease. However, there have been cases of pathologic N2 disease that have been detected after curative-intent surgical resection. We retrospectively studied the outcomes of initial surgical treatment without neoadjuvant therapy in patients with unexpected N2 non-small cell lung cancer. Material and Method: Between January 1995 and June 2007, 225 patients were diagnosed with pathologic N2 disease after they underwent initial pulmonary resection without neoadjuvant therapy. Among them, 170 patients were preoperatively diagnosed with lymph node stage N0 or N1. We retrospectively reviewed their medical record and analyzed the outcomes. Result: The overall 5-year survival rate was 35.4%. The prognostic factors that were significantly associated with survival were no adjuvant therapy, histologic cell types other than adenocarcinoma or squamous cell carcinoma, a pathologic T stage more than T1, old age (≥70 years) and no mediastinoscopic biopsy. During the follow-up, 79 patients (46.5%) experienced tumor recurrence, including loco-regional recurrence in 20 patients (25.3%) and distant metastasis in 56 (70.9%). The 5-year recurrence-free survival rate was 33.7%. Conclusion: Based on our findings, the survival was good for patients with unexpected N2 non-small cell lung cancer and who underwent initial pulmonary resection without neoadjuvant therapy. A prospective comparative analysis is needed to obtain more conclusive and persuasive results.

We report temperature sensors with amorphous indium-gallium-zinc oxide (a-IGZO) thin-film transistors (TFTs). The threshold voltage of a-IGZO TFTs shows linear dependency with temperature, which enables them to be used for temperature sensing. The single TFT sensor is simple, but its sensitivity is not high. However, significantly better sensitivity can be achieved by connecting several TFTs in a parallel series to create a multi-TFT sensor. The performances of the TFT sensors fabricated both for single and multi-TFTs are well matched with simulation results.

The complete nucleotide sequence of mumps virus isolated in Korea, Dg1062/Korea/98 (Dg1062), was determined. As other mumps viruses, its genome was to be 15,384 nucleotides (nts) in length and encoded seven proteins. The both 5' and 3' ends were confirmed to be 55 and 24 nts by RACE method, respectively. The full-length nucleotide sequence of Dg1062 isolate differed from other strains by 2.9-6.8% in the nucleotide sequence level, resulting in 206 nucleotide and 54 amino acid substitutions which were observed in only Dg1062 isolate relative to the consensus sequences of other strains. Despite the variations of amino acids over the full genome including HN gene, it might be considered that this isolate have no significant variations in the antigenic sites. This result is the first report of full-length genome of genotype I strain and provides an overview on the diversity of genetic characteristics of circulating mumps virus.