Torso hemorrhage remains a leading cause of potentially preventable death within trauma, acute care, vascular, and obstetric practice. A proportion of patients exsanguinate before hemorrhage control. ...Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive hemostasis. A systematic review was conducted to characterize the current clinical use of REBOA and its effect on hemodynamic profile and mortality.
A systematic review (1946-2015) was conducted using EMBASE and MEDLINE. Original studies on human subjects, published in English language journals, were considered. Articles were included if they reported data on hemodynamic profile and mortality.
A total of 83 studies were identified; 41 met criteria for inclusion. Clinical settings included postpartum hemorrhage (5), upper gastrointestinal bleeding (3), pelvic surgery (8), trauma (15), and ruptured aortic aneurysm (10). Of the 857 patients, overall mortality was 423 (49.4%); shock was evident in 643 (75.0%). Pooled analysis demonstrated an increase in mean systolic pressure by 53 mm Hg (95% confidence interval, 44-61 mm Hg) following REBOA use. Data exhibited moderate heterogeneity with an I of 35.5.
REBOA has been used in a variety of clinical settings to successfully elevate central blood pressure in the setting of shock. Overall, the evidence base is weak with no clear reduction in hemorrhage-related mortality demonstrated. Formal, prospective study is warranted to clarify the role of this adjunct in torso hemorrhage.
Systematic review, level IV.
Noncompressible torso hemorrhage (NCTH) constitutes a leading cause of potentially preventable trauma mortality. NCTH is defined by high-grade injury present in one or more of the following anatomic ...domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus hemodynamic instability or the need for immediate hemorrhage control. Rapid operative management, as part of a damage control resuscitation strategy, remains the mainstay of treatment. However, endovascular techniques are evolving and may become more mainstream with the advent of hybrid rooms that can deliver concurrent open and radiologic/endovascular management of traumatic hemorrhage.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of ...trauma patients in shock undergoing REBOA versus no-REBOA.
This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000-2019). REBOA (R; 2015-2019) patients were propensity matched 2:1 to historic (H; 2000-2012) and contemporary (C; 2013-2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively.
A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups.
In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
Variations in admission patterns have been previously identified in non-elective surgical services, but minimal data on the subject exists with respect to burn admissions. Improved understanding of ...the temporal pattern of burn admissions could inform resource utilization and clinical staffing. We hypothesize that burn admissions have a predictable temporal distribution with regard to the time of day, day of week, and season of year in which they present.
A retrospective, cohort observational study of a single burn center from 7/1/2016 to 3/31/2021 was performed on all admissions to the burn surgery service. Demographics, burn characteristics, and temporal data of burn admissions were collected. Bivariate absolute and relative frequency data was captured and plotted for all patients who met inclusion criteria. Heat-maps were created to visually represent the relative admission frequency by time of day and day of week. Frequency analysis grouped by total body surface area against time of day and relative encounters against day of year was performed.
2213 burn patient encounters were analyzed, averaging 1.28 burns per day. The nadir of burn admissions was from 07:00 and 08:00, with progressive increase in the rate of admissions over the day. Admissions peaked in the 15:00 hour and then plateaued until midnight (p<0.001). There was no association between day of week in the burn admission distribution (p>0.05), though weekend admissions skewed slightly later (p = 0.025). No annual, cyclical trend in burn admissions was identified, suggesting that there is no predictable seasonality to burn admissions, though individual holidays were not assessed.
Temporal variations in burn admissions exist, including a peak admission window late in the day. Furthermore, we did not find a predictable annual pattern to use in guiding staffing and resource allocation. This differs from findings in trauma, which identified admission peaks on the weekends and an annual cycle that peaks in spring and summer.
The experimental control of turbulent boundary layers using streamwise travelling waves of spanwise wall velocity, produced using a novel active surface, is outlined in this paper. The innovative ...surface comprises a pneumatically actuated compliant structure based on the kagome lattice geometry, supporting a pre-tensioned membrane skin. Careful design of the structure enables waves of variable length and speed to be produced in the flat surface in a robust and repeatable way, at frequencies and amplitudes known to have a favourable influence on the boundary layer. Two surfaces were developed, a preliminary module extending 152 mm in the streamwise direction, and a longer one with a fetch of 2.9 m so that the boundary layer can adjust to the new surface condition imposed by the forcing. With a shorter, 1.5 m portion of the surface actuated, generating an upstream-travelling wave, a drag reduction of 21.5
%
was recorded in the boundary layer with
R
e
τ
= 1125. At the same flow conditions, a downstream-travelling produced a much smaller drag reduction of 2.6
%
, agreeing with the observed trends in current simulations. The drag reduction was determined with constant temperature hot-wire measurements of the mean velocity gradient in the viscous sublayer, while simultaneous laser Doppler vibrometer measurements of the surface recorded the wall motion. Despite the mechanics of the dynamic surface resulting in some out-of-plane motion (which is small in comparison to the in-plane streamwise movement), the positive drag reduction results are encouraging for future investigations at higher Reynolds numbers.
Trauma resulting in hemorrhage from vascular disruption within the torso is a challenging scenario, with a propensity to be lethal in the first hour following trauma. The term noncompressible torso ...hemorrhage (NCTH) was only recently coined as part of contemporary studies describing the epidemiology of wounding during the wars in Afghanistan and Iraq. This article provides a contemporary review of NCTH, including a unifying definition to promote future study as well as a description of resuscitative and operative management strategies to be used in this setting, and sets a course for research to improve mortality following this vexing injury pattern.
Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal ...use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications.
RSNA, 2022.
Abstract Background Non-compressible torso hemorrhage (NCTH) is the leading cause of potentially preventable death in military trauma, but the civilian epidemiology is unknown. The aim of this study ...is to apply a military definition of NCTH, which incorporates anatomic and physiological criteria, to a civilian population treated at trauma centers in the US. Methods Patients (age >16 y) from 197 Level 1 trauma centers (approximately 95% of all US Level 1 centers) in the National Trauma Data Bank 2007–2009 that sustained a named torso vessel injury, pulmonary injury, grade IV solid organ injury, or pelvic fracture with ring disruption were included. Of these, patients with a systolic blood pressure <90 mmHg were considered to have NCTH. Multivariable logistic regression was used to identify patient and injury factors associated with NCTH and mortality after adjusting for the following covariates: patient (age, gender, ethnicity, and insurance status), injury (Glasgow Coma Scale, injury type, Injury Severity Score, anatomic region), and clinical (major surgical procedure, need for transfusion, and intensive care unit admission) characteristics. Results Of the 1.8 million patients in the 2007–2009 National Trauma Data Bank, 249,505 met the anatomic criteria for non-compressible torso injury (NCTI). Of these, 20,414 (8.2%) patients had associated hemorrhage. The rate of pulmonary and torso vessel injury was similar (53.4% and 50.6%, respectively), with solid organ injury identified in 27.0% of patients and pelvic injury in 8.9%. The overall mortality rate of patients with NCTI and NCTH was 6.8% and 44.6%, respectively. The most lethal injury was major torso vessel injury (OR 1.54, 95% CI 1.33–1.78), followed by pulmonary injury (OR 1.32, 95% CI 1.18–1.48). Lower mortality was found in patients with pelvic injury (OR 0.80, 95% CI 0.65–0.98). Conclusions The military definition of NCTH can be usefully applied to civilians to identify patients with lethal injuries and high resource needs. Investigating the implications of NCTH on patient triage is recommended.
Abstract Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control and resuscitative adjunct that has been demonstrated to improve central perfusion during ...hemorrhagic shock. The aim of this study was to characterize the systemic inflammatory response associated and cardiopulmonary sequelae with 30, 60, and 90 min of balloon occlusion and shock on the release of interleukin 6 (IL-6) and tumor necrosis factor alpha. Materials and methods Anesthetized female Yorkshire swine ( Sus scrofa, weight 70–90 kg) underwent a 35% blood volume–controlled hemorrhage followed by thoracic aortic balloon occlusion of 30 (30-REBOA, n = 6), 60 (60-REBOA, n = 8), and 90 min (90-REBOA, n = 6). This was followed by resuscitation with whole blood and crystalloid over 6 h. Animals then underwent 48 h of critical care with sedation, fluid, and vasopressor support. Results All animals were successfully induced into hemorrhagic shock without mortality. All groups responded to aortic occlusion with a rise in blood pressure above baseline values. IL-6, as measured (picogram per milliliter) at 8 h, was significantly elevated from baseline values in the 60-REBOA and 90-REBOA groups: 289 ± 258 versus 10 ± 5; P = 0.018 and 630 ± 348; P = 0.007, respectively. There was a trend toward greater vasopressor use ( P = 0.183) and increased incidence of acute respiratory distress syndrome ( P = 0.052) across the groups. Conclusions REBOA is a useful adjunct in supporting central perfusion during hemorrhagic shock; however, increasing occlusion time and shock results in a greater IL-6 release. Clinicians must anticipate inflammation-mediated organ failure in post-REBOA use patients.
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique in trauma; however, the physiologic sequelae have not been well quantified. The objectives of ...this study were to characterize the burden of reperfusion and organ dysfunction of REBOA incurred during 30 or 90 min of class IV shock in a survivable porcine model of hemorrhage. Methods After induction of shock, animals were randomized into 4 groups ( n = 6): 30 min of shock alone (30-Shock) or with REBOA (30-REBOA) and 90 min of shock alone (90-Shock) or with REBOA (90-REBOA). Cardiovascular homeostasis was then restored with blood, fluid, and vasopressors for 48 h. Outcomes included mean central aortic pressure (MCAP), lactate concentration, organ dysfunction, histologic evaluation, and resuscitation requirements. Results Both REBOA groups had greater MCAPs throughout their shock phase compared to controls ( P < .05) but accumulated a significantly greater serum lactate burden, which returned to control levels by 150 min in the 30-REBOA groups and 320 min in the 90-REBOA group. There was a greater level of renal dysfunction and evidence of liver necrosis seen in the 90-REBOA group compared to the 90-Shock group. There was no evidence of cerebral or spinal cord necrosis in any group. The 90-REBOA group required more fluid resuscitation than the 90-Shock group ( P = .05). Conclusion REBOA in shock improves MCAP and is associated with a greater lactate burden; however, this lactate burden returned to control levels within the study period. Ultimately, prolonged REBOA is a survivable and potentially life-saving intervention in the setting of hemorrhagic shock and cardiovascular collapse in the pig.
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