Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians

Bulger, Eileen M.; Perina, Debra G.; Qasim, Zaffer; Beldowicz, Brian C.; Brenner, Megan; Guyette, Frances; Rowe, Dennis W.; Kang, Christopher; Gurney, Jennifer M; DuBose, Joseph J.; Joseph, Bellal; Lyon, Regan F.; Kaups, Krista L.; Friedman, Vidor E; Eastridge, Brian J.; Stewart, Ronald M.

doi:10.1136/tsaco-2019-000376

Cited by 145 publications

(158 citation statements)

References 33 publications

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“…Rapid insertion of a REBOA device, rapid blood transfusion, and application of a new pressure dressing on the right axilla would have been the preferred management in some centers. 1 In this patient with no blood pressure during the latter stages of transport and no palpable pulse in the trauma room, a cardiopulmonary arrest appeared imminent. For this reason, a resuscitative thoracotomy with cross-clamping of the descending thoracic aorta was chosen.…”

Section: Discussionmentioning

confidence: 82%

Long-term intra-arterial shunt

Feliciano

2020

Trauma Surg Acute Care Open

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This is a case report of a patient who sustained a stab wound to the right axilla with injuries to the right axillary artery and vein. The patient had near-exsanguination in the field and no recordable blood pressure upon admission to the trauma center. Resuscitation was performed with endotracheal intubation, a left anterolateral resuscitative thoracotomy with cross-clamping of the descending thoracic aorta, and the rapid infusion of crystalloid solutions and packed red cells. In the operating room, the third portion of the right axillary artery and the adjacent right axillary vein were found to be transected. As part of a ‘damage control’ procedure, the ends of the right axillary vein were ligated. A 14 French intra-arterial shunt was inserted into the transected ends of the right axillary artery to restore the flow to the right upper extremity. The patient’s postoperative course was complicated by a coagulopathy, adult respiratory distress syndrome (ARDS), and anuria. The coagulopathy and anuria resolved within the first 48 hours, but the patient’s ARDS was slow to resolve. On the 10th postinjury day, the patient was returned to the operating room for a definitive repair of the right axillary artery. After the intra-arterial shunt was removed, a reversed greater saphenous vein graft was inserted between the ends of the right axillary artery in a medial intermuscular (extra-anatomic) tunnel. The patient made an uneventful recovery and was discharged home on the 16th postinjury day.The following principles of advanced trauma care were part of the management of this patient: (1) occasional need for resuscitative thoracotomy with cross-clamping of the descending thoracic aorta in a patient without a thoracic injury; (2) ‘damage control’ operation with ligation of the right axillary vein and placement of a temporary intra-arterial shunt to restore the flow to the right upper extremity; and (3) vascular reconstruction with an extra-anatomic bypass in a previously contaminated field.

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Section: Discussionmentioning

confidence: 82%

Long-term intra-arterial shunt

Feliciano

2020

Trauma Surg Acute Care Open

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“…Nevertheless, these differences can provide meaningful opportunities to examine and include the perspectives from trauma surgeons practicing in LMICs Table 3 General characteristics, hemodynamics parameters, surgical and resuscitation strategies, REBOA procedure-related information, and outcomes for the propensity-matched cohort (Continued) into the teams producing the guidelines for REBOA use. To date, some guidelines have been published in well-recognized international journals [19][20][21]. Of note, however, these guidelines often lack the representation of physicians from LMICs in their list of authors, and only a few studies performed in LMICs are included in the references supporting the guidelines.…”

Section: Discussionmentioning

confidence: 99%

Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries

Manzano-Núñez

McGreevy²,

Orlas

et al. 2020

World J Emerg Surg

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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.

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“…There followed a statement from the American College of Surgeons highlighting indications, guidelines and complications. This statement has been recently updated and offers an excellent synopsis of key issues when considering utilisation of REBOA . Another paper presented a Delphi consensus statement covering similar aspects of REBOA …”

Section: Competing Interestsmentioning

confidence: 99%

REBOA: Where are we now?

Ellis

2020

Emerg Medicine Australasia

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Cited by 145 publications

References 33 publications

Long-term intra-arterial shunt

Long-term intra-arterial shunt

Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries

REBOA: Where are we now?

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