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Background: The purpose of this study was to characterize demographics, injury patterns, and initial management trends of facial fracture patients who were subject to interfacility transfer., Methods: Using the National Trauma Data Bank from 2007 to 2015, facial fracture patients arriving by interfacility transfer were included in the study., Results: Over 9 years, 171,618 patients were included, with 37.5 percent having an isolated facial injury. Isolated facial injury patients tended to be younger, less frequently white, more frequently assaulted, and more frequently underwent facial fracture operative repair during the index admission (all, p < 0.001). From 2007 to 2015, insurance coverage increased from 54.6 to 79.0 percent (R2 = 0.90, p < 0.001). In addition, there was a 45 percent proportional increase in patients 50 to 89 years of age compared to a 20 percent decrease in patients 0 to 39 years of age (both, R2 = 0.99, p < 0.001). The proportion of transfer patients with isolated facial injury increased over the study period (32.0 to 39.4 percent, R2 = 0.90, p < 0.001); however, there was a decline in operative intervention (29.5 to 22.1 percent, R2 = 0.94, p < 0.001) and a 151 percent increase in the proportion discharged from the emergency department upon transfer arrival (R2 = 0.99, p < 0.001)., Conclusions: Facial fracture patients subject to interfacility transfer comprise a wide array of demographics and injury patterns, with most having concomitant injuries and only a minority undergoing immediate operative intervention. Over time, this demographic has become older, sustained more isolated facial injury, and undergone fewer immediate operative interventions and is more frequently insured and more frequently discharged from the emergency department upon transfer arrival, reflecting increasing rates of secondary overtriage., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Introduction: Self-inflicted gunshot wounds to the face frequently result in devastating injuries; however, there is a paucity of large experiences describing determinants of mortality and outcomes., Methods: Using the National Trauma Databank from 2007 to 2015, patients suffering self-inflicted firearm facial injuries were included., Results: Over 9 years 7869 patients were included: 87.7% were male, 46.4% suffered traumatic brain injury (TBI) and overall in-hospital mortality was 44.7%. The majority (67.8%) of in-hospital mortality occurred within the first 24 hours. Using multiple regression, advanced age (>65 years), presence of TBI, admission hypotension, and decreased Glasgow coma score were each independently associated with increased odds of mortality (all P < 0.001). Mandible or combined mandible/midface fracture injury patterns were most likely to survive (P < 0.001). Of those surviving to hospital discharge, the median [interquartile range] length of stay was 13 [6, 23] days, 86.6% required an intensive care unit stay with 67% requiring intubation and 42.5% tracheostomy. Among survivors, the combined mandible and midface fracture pattern resulted in the highest rates of tracheostomy (70.5%), gastrostomy tube placement (50.5%), and facial operations (87.0%) with a median [interquartile range] of 5 [3, 7] operative trips (all P < 0.001)., Conclusions: Self-inflicted facial firearm injuries are highly morbid injuries with the majority of in-hospital deaths occurring the first hospital day. Differences including concomitant TBI, facial injury pattern, neurologic status, and presence of hypotension on admission were independently associated with survival/death. More extensive facial injuries (combined mandible and midface fracture patterns) were more likely to survive and required more intensive interventions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Introduction: We analyzed the perceptions of participants and faculty members in simulation-based comprehensive cleft care workshops regarding comprehensive cleft care delivery in developing countries., Methods: Data were collected from participants and faculty members in 2 simulation-based comprehensive cleft care workshops organized by Global Smile Foundation. We collected demographic data and surveyed what they believed was the most significant barrier to comprehensive cleft care delivery and the most important intervention to deliver comprehensive cleft care in developing countries. We also compared participant and faculty responses., Results: The total number of participants and faculty members was 313 from 44 countries. The response rate was 57.8%. The majority reported that the most significant barrier facing the delivery of comprehensive cleft care in developing countries was financial (35.0%), followed by the absence of multidisciplinary cleft teams (30.8%). The majority reported that the most important intervention to deliver comprehensive cleft care was creating multidisciplinary cleft teams (32.2%), followed by providing cleft training (22.6%). We found no significant differences in what participants and faculty perceived as the greatest barrier to comprehensive cleft care delivery (P = 0.46), or most important intervention to deliver comprehensive cleft care in developing countries (P = 0.38)., Conclusions: Our study provides an appraisal of barriers facing comprehensive cleft care delivery and interventions required to overcome these barriers in developing countries. Future studies will be critical to validate or refute our findings, as well as determine country-specific roadmaps for delivering comprehensive cleft care to those who need it the most., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The arterial pressure waveform is a composite of multiple interactions, and there may be more sensitive and specific features associated with hemorrhagic shock and intravascular volume depletion than systolic and/or diastolic blood pressure (BP) alone. The aim of this study was to characterize the arterial pressure waveform in differing grades of hemorrhage., Methods: Ten anesthetized swine (70-90 kg) underwent a 40% controlled exponential hemorrhage. High-fidelity arterial waveform data were collected (500 Hz) and signal-processing techniques were used to extract key features. Regression modeling was used to assess the trend over time. Short-time Fourier transform (STFT) was utilized to assess waveform frequency and power spectrum density variance., Results: All animals tolerated instrumentation and hemorrhage. The primary antegrade wave (P1) was relatively preserved while the renal (P2) and iliac (P3) reflection waves became noticeably attenuated during progressive hemorrhage. Several features mirrored changes in systolic and diastolic BP and plateaued at approximately 20% hemorrhage, and were best fit with non-linear sigmoidal regression modeling. The P1:P3 ratio continued to change during progressive hemorrhage (R 2  = 0.51). Analysis of the first three harmonics during progressive hemorrhage via STFT demonstrated increasing variance with high coefficients of determination using linear regression in frequency (R 2  = 0.70, 0.93, and 0.76, respectively) and power spectrum density (R 2  = 0.90, 0.90, and 0.59, respectively)., Conclusions: In this swine model of volume-controlled hemorrhage, hypotension was a predominating early feature. While most waveform features mirrored those of BP, specific features such as the variance may be able to distinguish differing magnitudes of hemorrhage despite little change in conventional measures.

Background: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis., Methods: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses., Results: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases., Conclusions: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population., Clinical Question/level of Evidence: Risk, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Body contouring in the postbariatric surgery patient improves quality of life and daily function., Objectives: To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery., Setting: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers., Methods: We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls., Results: One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046)., Conclusion: In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes., (Copyright © 2020. Published by Elsevier Inc.)

Background: Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population., Methods: The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population., Results: In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis., Conclusion: Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).

Background: The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (age ≤ 5 years)., Methods: Using the National Trauma Databank from 2007 to 2015, patients (age ≤ 5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT)., Results: Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], P < 0.001), and more frequently were insured by Medicaid (76.7% versus 41.9%, P < 0.001). NAT patients were more likely to sustain mandible fractures (38.9% versus 21.1%, P < 0.001), but less likely to sustain maxilla (9.8% versus 18.3%, P = 0.003), or orbital fractures (31.1% versus 53.4%, P < 0.001). Nonaccidental trauma patients had fewer instances of multiple facial fracture sites (8.9% versus 22.6%, P < 0.001). Among those sustaining mandible fractures, NAT patients were more likely to sustain condylar fractures (75.8% versus 48.4%, P < 0.001), but less likely to sustain subcondylar fractures (0% versus 13.2%, P = 0.002), or angle fractures (1.6 versus 8.7%, P = 0.048)., Conclusions: Differences exist in facial fracture patterns in accidental versus nonaccidental trauma within the pediatric population at highest risk for abusive head trauma. Specifically, NAT is associated with fractures of the mandibular condyle and involve fewer facial fracture sites. In the appropriate context, presence of these fractures/patterns should increase suspicion for NAT.

Purpose: Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes., Methods: Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016., Results: Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months)., Conclusions: Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.

Introduction: After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population., Methods: We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage., Results: Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty., Conclusions: We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

Purpose: Aortic occlusion (AO) increases proximal perfusion and may improve rates of return of spontaneous circulation (ROSC). The objective of this study was to investigate the hemodynamic effects of cardiopulmonary resuscitation (CPR) and AO by REBOA on patients in traumatic cardiac arrest., Methods: Patients admitted between February 2013 and May 2017 at a tertiary center who suffered traumatic arrest, had an arterial line placed during resuscitation, and received CPR and REBOA which were included. In-hospital CPR data were obtained from videography. Arterial waveforms were recorded at 240 Hz., Results: 11 consecutive patients were included, 82% male; mean (± SD) age 37 ± 19 years. 55% suffered blunt trauma and the remaining penetrating injuries. 64% arrested out of hospital. During compressions with AO, the mean systolic blood pressure (SBP) was 70 ± 22 mmHg, mean arterial pressure (MAP) 43 ± 19 mmHg, and diastolic blood pressure (DBP) 26 ± 17 mmHg. Nine (82%) had ROSC, with eight having multiple periods of ROSC and arrest in the initial period. In-hospital mortality was 82%. Cardiac ultrasonography was used during arrest in 73%. In two patients with arterial line data before and after AO, SBP (mmHg) improved from 51 to 73 and 55 to 96 during arrest after AO., Conclusions: High-quality chest compressions coupled with aortic occlusion may generate adequate perfusion pressures to increase the rate of ROSC. New technology capable of transducing central arterial pressure may help us to understand the effectiveness of CPR with and without aortic occlusion. REBOA may be a useful adjunct to high-quality chest compressions during arrest.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver for noncompressible torso hemorrhage. To our knowledge, this single-center brief report provides the most extensive anesthetic data published to date on patients who received REBOA. As anticipated, patients were critically ill, exhibiting lactic acidosis, hypotension, hyperglycemia, hypothermia, and coagulopathy. All patients received blood products during their index operations and received less inhaled anesthetic gas than normally required for healthy patients of the same age. This study serves as an important starting point for clinician education and research into anesthetic management of patients undergoing REBOA.

Background: Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures., Methods: Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed., Results: Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94-0.98]), age >65 versus <18 years (0.62 [0.59-0.64]), non-white race (0.95 [0.94-0.97]), uninsured versus Medicaid (0.88 [0.86-0.90]), hospital bed size (>600 vs ≤200 beds, 1.67 [1.61-1.73]), TBI (0.70 [0.69-0.71]), and C-spine injury (0.93 [0.90-0.96])., Conclusions: Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care.

Background: Presentation of pediatric facial fractures varies widely and many injuries are encountered infrequently by most practitioners. This study summarizes injury patterns in a large cohort of facial fractures and their subsequent surgical management., Methods: Demographic and clinical characteristics of patients 18 years of age or younger admitted between 2009 and 2015 to trauma centers participating in the National Trauma Data Bank were examined. Craniofacial fractures and reconstructive procedures performed at index admission were selected based on ICD-9 and AIS codes. A multivariable analysis was used to determine independent determinants of surgical repair., Results: Out of 60,094 pediatric patients evaluated in the US emergency departments, 48,821 patients were admitted and underwent open treatment (n = 8364; 17.1%) or closed treatment (n = 4244; 8.7%) of facial fractures. Falls were the most common mechanism of injury in infants and toddlers (<2-year-old, 44.4%, P <0.001), while motor vehicle collisions (32.9%, P <0.001) and assault (22.1%, P <0.001) were most commonly seen in adolescents (12-18-year-old). The frequency and odds of repair of facial fractures increased with advancing age, more so with open than closed treatment in adolescents (73.0%) as compared to infants and toddlers (50.3%). Children who sustained mandible fractures are the most likely to require surgical treatment at index-admission (odds ratio = 13.9, 95% confidence interval 13.1-14.8, P <0.001)., Conclusions: Population-based data shows that pediatric fracture patterns and associated early repair vary significantly with age. Patient demographics and hospital characteristics are significant determinants of surgical treatment that should be related to clinical outcomes in future studies.

Background: Self-inflicted gunshot wounds involving the face are highly morbid. However, there is a paucity of objective estimates of mortality. This study aims to provide prognostic guidance to clinicians that encounter this uncommon injury., Methods: A retrospective review of patients presenting to R Adams Cowley Shock Trauma Center (a Level I trauma center) with self-inflicted gunshot wounds to the face from 2007 to 2016. Isolated gunshot wounds to the calvaria or neck were excluded. The data were analyzed to determine predictors of survival., Results: Of the 69 patients that met inclusion criteria, 90 percent were male and 80 percent were Caucasian, with an age range of 21 to 85 years. The most frequently seen injury patterns showed submental (57 percent), intraoral (22 percent), and temporal (12 percent) entry sites. Fewer than half (41 percent) of the cohort sustained penetrative brain injury. Overall, there were 18 deaths (overall mortality, 26 percent), 17 of which were secondary to brain injury. Independent predictors of death included penetrative brain injury (OR, 17; p < 0.0001) and age. Mortality was 17 percent among patients younger than 65 years, compared with 73 percent for those aged 65 years or older (p = 0.0001). Gastrostomy placement was independently associated with 25 percent reduction in length of hospitalization (p = 0.0003)., Conclusions: Despite tremendous morbidity, the overwhelming majority of patients who present with facial self-inflicted gunshot wounds will survive, especially if they are young and have no penetrative brain injury. These findings should help guide clinical decisions for this devastating injury., Clinical Question/level of Evidence: Risk, III.

The objective of this study was to assess the results of a structured remediation program for surgical residents scoring poorly on the American Board of Surgery In-Training Examination®. Residents scoring below the threshold (<20th percentile) were placed in a remediation program consisting of textbook-based review and mandatory weekly quizzes overseen by the program director. The effects of the program were assessed over a five-year period (2014-2018). Of 168 tests taken, 23 (13.7%) instances of scoring below the threshold occurred (average percentile 11, range 1-19). Postremediation scores in the subsequent year improved with a median (IQR) percentile increase of 29 [23.5, 46] ( P < 0.001). Two residents scored below the threshold twice; all others continued to score above the threshold. Participation in a structured remediation program results in dramatic improvement in American Board of Surgery In-Training Examination® performance, and a single occurrence of poor performance does not necessarily lead to a permanent handicap in academic performance.

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.)

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) increases cardiac-afterload and is used for patients in hemorrhagic shock. The cardiac tolerance of prolonged afterload augmentation in this context is unknown. The aim of this study is to quantify cardiac injury, if any, following 2, 3 and 4 hours of REBOA., Methods: Anesthetized swine (70-90 kg) underwent a 40% controlled hemorrhage, followed by supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA) for 2 (n=5), 3 (n=5), and 4 hours (n=5). High-fidelity arterial wave form data were collected, and signal processing techniques were used to extract key inflection points. The adjusted augmentation index (AIx@75; augmentation pressure/pulse pressure, normalized for heart rate) was derived for use as a measure of aortic compliance (higher ratio = less compliance). Endpoints consisted of electrocardiographic, biochemical, and histologic markers of myocardial injury/ischemia. Regression modeling was used to assess the trend against time., Results: All animals tolerated instrumentation, hemorrhage, and REBOA. The mean (±SD) systolic blood pressure (mm Hg) increased from 65±11 to 212±39 (p<0.001) during REBOA. The AIx@75 was significantly higher during REBOA than baseline, hemorrhage, and resuscitation phases (p<0.05). A time-dependent rise in troponin (R 2 =0.95; p<0.001) and T-wave deflection (R 2 =0.64; p<0.001) was observed. The maximum mean troponin (ng/mL) occurred at 4 hours (14.6±15.4) and maximum T-wave deflection (mm) at 65 minutes (3.0±1.8). All animals demonstrated histologic evidence of acute injury with increasing degrees of cellular myocardial injury., Discussion: Prolonged REBOA may result in type 2 myocardial ischemia, which is time-dependent. This has important implications for patients where prolonged REBOA may be considered beneficial, and strategies to mitigate this effect require further investigation., Level of Evidence: II., Competing Interests: Competing interests: JM is a clinical advisory board member for Prytime Medical.

Background: There are numerous studies in the cardiovascular literature that have employed transesophageal echocardiography (TEE) in swine models, but data regarding the use of basic TEE in swine models is limited. The primary aim of this study is to describe an echocardiographic method that can be used with relative ease to qualitatively assess cardiovascular function in a porcine hemorrhagic shock model using resuscitative endovascular balloon occlusion of the aorta (REBOA)., Methods: Multiplane basic TEE exams were performed in 15 during an experimental hemorrhage model using REBOA. Cardiac anatomical structure and functional measurements were obtained. In a convenience sample (two animals from each group), advanced functional cardiovascular measurements were obtained before and after REBOA inflation for comparison with qualitative assessments., Results: Basic TEE exams were performed in 15 swine. Appropriate REBOA placement was confirmed using TEE in all animals and verified with fluoroscopy. Left ventricular volume was decreased in all animals, and left ventricular systolic function increased following REBOA inflation. Right ventricular systolic function and volume remained normal prior to and after hemorrhage and REBOA use. Mean ejection fraction (EF) decreased from 64% (S.D. 9.6) to 62.1 (S.D. 16.8) after hemorrhage and REBOA inflation (p = 0.76); fractional area of change (FAC) decreased from 49.8 (S.D. 9.0) to 48.5 (S.D. 13.6) after hemorrhage and REBOA inflation (p = 0.82)., Conclusion: Basic TEE, which requires less training than advanced TEE, may be employed by laboratory investigators and practitioners across a wide spectrum of experimental and clinical settings.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver used to decrease hemorrhage, and thus perfusion, below the level of aortic occlusion (AO). We sought to investigate lower extremity ischemia in patients who received REBOA. Between February 2013 and September 2016 patients at a tertiary center that received REBOA and survived more than six hours were enrolled. Thirty-one patients were identified, the mean ISS was 40 ± 14 and inhospital mortality was 39 per cent. Twenty received REBOA in zone 1 (distal thoracic aorta). Three (15%) developed lower extremity compartment syndrome (LECS) after zone 1 REBOA. Injury of iliofemoral arteries and veins was each associated with calf fasciotomies (both P = 0.005). A longer duration of AO at zone 1 was associated with calf and thigh fasciotomy (P = 0.046 and P = 0.048, respectively). Iliofemoral arterial injury was associated with thigh fasciotomy (P = 0.04). Eleven patients received REBOA in zone 3 (distal abdominal aorta). Five (45%) patients underwent fasciotomy; four (36%) due to LECS. Femoral arterial injury was associated with calf fasciotomies (P = 0.02). There was no association with sheath size or laterality and need for fasciotomy. Neither groin access for REBOA or AO solely caused limb loss or LECS. The contribution to distal ischemia by REBOA remains unclear in patients with lower extremity injury.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to decrease hemorrhage below the level of aortic occlusion (AO); however, the amount of collateral blood flow below the level of occlusion is unknown. Our aim was to investigate blood flow patterns during complete AO in patients who underwent CT scan after REBOA., Study Design: Between February 2013 and January 2017, patients who received REBOA and underwent CT scan with intravenous contrast during full AO were included. Patients were excluded if they had a CT scan performed with the balloon partially or fully deflated., Results: Nine patients (8 men) were included; all had blunt trauma. Mean Injury Severity Score (±SD) was 48 ± 8 and mean age was 45 ± 19 years. Four had supra-celiac AO, and 5 had infra-renal AO. Arterial contrast enhancement was noted below the level of AO in all patients, and distal to REBOA sheath placement in 5. Collateralization from arteries above and below the AO was identified in all patients. Contrast extravasation distal to AO was identified in 4 patients, and hematomas in 8. Distal vascular enhancement patterns varied by level of AO and contrast administration site., Conclusions: Aortic occlusion appears to dramatically decrease, but does not completely impede, distal perfusion during REBOA due to multiple pathways of collateralization. Active extravasation and hematomas can still be detected in the setting of full AO, with purposefully timed contrast and image acquisition. Blood flow persists below the level of both the AO and in-dwelling sheath. Dynamic flow studies are needed to determine the contribution of AO and sheath placement to distal tissue ischemia., (Copyright © 2017 American College of Surgeons. All rights reserved.)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a torso hemorrhage control technique. To expedite deployment, inflation is frequently performed as a blind technique with minimal imaging, which carries a theoretical risk of aortic injury. The objective of this study was to examine the relationship between balloon inflation, deformation and the risk of aortic rupture., Methods: Compliant balloon catheters were incrementally inflated in segments of cadaveric swine aorta. Serial longitudinal and circumferential measurements were recorded, along with the incidence of aortic rupture., Results: Fourteen cadaveric swine aorta segments were tested with mean (±SD) baseline aortic diameter (mm) of 14.2±3.4. Rupture occurred in three aortas. The mean baseline diameters (mm) of the aortic segments that were ruptured were significantly smaller than those that did not rupture (8.9±1.2 vs 15.6±1.9; P<0.001). The maximal circumferential stretch ratios were significantly higher in the aorta segments that ruptured compared with those that did not (1.9±0.1 vs 1.5±0.1; P<0.001). The maximal amount of balloon longitudinal deformation was 80 mm (116% longer than the intended working length)., Conclusions: Inflation of aortic balloon catheters carries an inherent risk of aortic injury, which may be minimized through an understanding of the intrinsic characteristics of the aorta and compliant balloons. Smaller diameter aortic segments undergoing overinflation, particularly beyond a circumferential stretch ratio of 1.8, are at risk of aortic rupture., Level of Evidence: Level II., Competing Interests: Competing interests: JJM and MLB are clinical advisory board members for Prytime Medical Inc.