aortic control for trauma - dignity health
TRANSCRIPT
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Aortic Control for TraumaJ A M E S N B O G E R T
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DisclosuresPrytime Medical
Acute Innovations
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ObjectivesImportance of Hemorrhage Control
History◦ Proximal control
◦ Aortic control
REBOA◦ Technique
◦ Current Data
◦ Future Directions
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TraumaLeading cause of death in patients < 44 years old
◦ Years of productive life lost
◦ Cost = $671 billion annually
$ 639 billion
GDP = $570 billion
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Trauma DeathsTrauma Deaths
◦ Disease of the young
◦ Hemorrhage
◦ Brain injury
Hemorrhage◦ 40-60% of trauma deaths
◦ Damage Control Resuscitation
◦ Hemostasis
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Trimodal distribution
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Hemorrhage controlDirect pressure
Hemostatic dressings
Proximal control◦ Tourniquet
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Tourniquets 1517: Hans von Gersdorff
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TourniquetsAll shapes and sizes
Proximal Control
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Stop the bleedingWhat about truncal hemorrhage?
Conventional Management◦ Replace volume
◦ Drive Fast
◦ Operative control
Proximal Control◦ Tourniquet?
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Tourniquet for the Trunk?
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40 Hypotensive non-responders at Detroit Receiving Hospital
Massive abdominal hemorrhage◦ 29 Thoracotomy with aortic occlusion (AO) first
◦ 11 Laparotomy first
***No statistical analysis done***
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Laparotomy First – 11 patients7 patients: immediate CV collapse
◦ Thoracotomy with AO
◦ 3/7 died
4 patients: persistent hypotension◦ AO with T-bar
◦ 2/4 died
Mortality 5/11
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Thoracotomy first – 29 patients22 patients: VS normal after AO
◦ 11/22 exsanguinated
◦ 27 min AO time in survivors
7 patients remained hypotensive after AO◦ 100% mortality
Mortality: 18/29
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ConclusionsRestore normal perfusion to heart and brain
Prevent CV collapse when abdomen open◦ “Internal Hemostat”
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1953
Intraluminal aortic occlusion in dogs
Feasible
Safe for up to 30 minutes
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1954
Intra-aortic occlusion of the aorta for refractory shock◦ Moribund after 10 U RBCs
Three patients met criteria◦ One died before balloon could be placed
◦ Two died after balloon was placed
Conclusion: Should be used earlier◦ Rescue therapy
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An Idea ahead of its timeCumbersome equipment
Poor results
Intra-aortic occlusion fell out of favor among trauma surgeons
Then …
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Uncontrolled hemorrhage vs Aortic occlusion
Intra-aortic occlusion leads to◦ Increased blood pressure
◦ Increased oxygen delivery to the brain
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REBOA
R resuscitative
E endovascular
B balloon
O occlusion
A aorta
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REBOA AnatomyZone I
◦ L Subclavian to Celiac
Zone II◦ Celiac to Renal aa.
Zone III◦ Renal aa.
◦ Aortic bifurcation
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Surface AnatomyXyphoid process – T10
◦ Above celiac trunk
◦ Lower border Zone 1
Umbilicus – L4◦ Aortic bifurcation
◦ Lower border of Zone 3
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Femoral AccessMust avoid cannulating SFA
◦ Open cut down
◦ Ultrasound guided percutaneous access
◦ Blind percutaneous access (enter CFA within 2 cm of inguinal ligament)
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Non-compressible torso hemorrhageResuscitative Thoracotomy REBOA
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Pelvic fractures non-responsive to resuscitation
SBP < 60 after
◦ 3L crystalloid,
◦ At least 1 U RBC,
◦ NE or Epi infusion
All patients made it to angio
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UT Houston and Shock Trauma
RT (72) vs REBOA (24)
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Improved survival in REBOA group
Among Survivors: 77% of REBOA group went home. 71% RT group went to SNF
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REBOA = 46
RT = 68
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AORTA Registry
No difference in survival
REBOA more likely to restore stability
Second attempt at occlusion more likely needed in the RT group
Similar rate of complications
RT more likely to have uncontrolled bleeding ABOVE level of occlusion (26% vs 10%)
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Japan Trauma Registry
191 REBOA vs 68 RT
Propensity matched
No difference in◦ ICU stay
◦ Mortality
◦ Blood transfusion
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625 REBOA patients propensity matched to 625 non-REBOA patients
Worse outcomes with REBOA compared to without REBOA
Median time to surgical intervention: 97 minutes for REBOA group
Median time to surgical intervention: 110 minutes for non-REBOA group
No difference in mortality between REBOA and non-REBOA groups if definitive control achieved
in less than 60 minutes.
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Pigs subjected to hemorrhage + TBI
30 min no intervention
Randomized to three groups◦ No intervention x 60 min
◦ REBOA x 60 min
◦ pREBOA x 60 min
Whole blood resuscitation at 90 min
Critical Care support x 360 min
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REBOALiterature: REBOA or RT
Practice: REBOA before RT needed
Hypotensive Trauma Patient
IVF resuscitation OR or IR control
RT
REBOA
Hypotensive Trauma Patient
IVF resuscitation OR or IR control RTREBOA
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REBOA – QuestionsOcclude aorta BEFORE cardiac arrest
◦ Patient selection
Decrease need for blood transfusion
Decrease need for surgery
Prolonged transport time
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ConclusionsMy current practice
◦ Pelvic fractures
◦ Prevent cardiac arrest
Wide open area for investigation◦ Patient selection
◦ TBI
◦ Titratable aortic control (pREBOA)
◦ Pre-hospital use
“An instrument of the devil that sometimes saves a life.”
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Thank You