Impact of Time to Emergency Department Resuscitative Aortic Occlusion After Noncompressible Torso Hemorrhage

Abstract

Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.

Veno-arterial extracorporeal membrane oxygenation uses in trauma: a retrospective analysis of the Japanese nationwide trauma registry

“…A trauma surgeon is uncommon in Japan, and a surgeon who can provide hemostatic surgery is not always available in many emergency hospitals [14,15]. In addition, because immediate hemostatic surgery is often di cult, the use of bridging measures, such as VA-ECMO or REBOA, is more common in Japan than in the USA [16][17][18][19]. This describes the current characteristics of trauma care in Japan and how they differ from the global standard.…”

A bibliometric analysis of publications on trauma-related hemorrhagic shock from 2012 to 2022: Research landscape and future trends

“…[ 30 ] More recent studies have shown that rapid in-hospital intervention is often insufficient to compensate for severe exsanguination and hypovolemia that occurs before emergency department presentation. [ 31 ] Therefore, prehospital REBOA could be a feasible intervention for a significant portion of severely ill patients in a civilian setting; however, the evidence is limited. [ 28 ] Partial REBOA is currently discussed in preclinical studies, [ 29 ] but has not yet been fully validated.…”

Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle

“…However, despite this approach and various efforts to reduce prehospital time intervals, response intervals and trauma mortality have largely remained unchanged across the United States over the past decade 5,7 . Given the existing uncertainty around the practicality and benefits of further reducing prehospital response intervals, 7,8 it is imperative to explore alternative strategies to improve patient outcomes. One emerging approach is the application of remote damage control and hemostatic volume replacement procedures closer to the point of injury with prehospital blood transfusion (PHBT) programs 9 .…”