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Resuscitative endovascular balloon occlusion of the aorta (REBOA): A bridge to definitive haemorrhage control for trauma patients in Scotland?
t h e s u r g e o n 1 2 ( 2 0 1 4 ) 1 1 9 e1 2 0
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Editorial
Resuscitative endovascular balloon occlusion of the aorta (REBOA): A bridge to definitive haemorrhage control for trauma patients in Scotland?
Haemorrhage is the leading cause of potentially preventable death from traumatic injury, worldwide.1,2 The majority of these deaths occur prior to hospital admission.3,4 and sources of haemorrhage in “non-compressible” regions e such as the chest, abdomen, or pelvis e are associated with particularly high mortality.5,6 The key to successful management is haemorrhage control and resuscitation.7 Data from the 2011 Scottish trauma audit shows that the relative risk of death in patients presenting with hypotension (defined as a systolic blood pressure of less than 90 mmHg) is 7.27 (95% CI: 5.03e10.50).8 There is also a mismatch between patients exhibiting signs of haemodynamic compromise at the scene of the accident, or during transfer to hospital, and the capabilities of the centre to which they are admitted. An analysis of Scottish Ambulance Service data has demonstrated that 76.4% of adult trauma patients with haemodynamic parameters suggestive of blood loss were taken to a hospital without full surgical capability.9 As the site of haemorrhage may not always be obvious, particularly following blunt trauma, this is concerning. A recent report by the Royal College of Surgeons of Edinburgh has highlighted deficiencies in Scottish trauma care,10 and has prompted the National Planning Forum to examine the issue of whether major trauma services in Scotland should be enhanced, in line with developments in England. Inclusive trauma systems e comprising emergency medical services, designated centres with stratified capability, and a comprehensive governance framework e have been shown to improve survival and functional outcomes from injury.11e13 Transfer to definitive care is associated with better outcomes than admission to the nearest hospital, and subsequent secondary transfer.14,15 However, this strategy is contingent upon accessibility, and by convention, most trauma systems rely on an acceptability threshold of 45 min. As Scotland’s population is both dispersed and eccentrically distributed, there is concern that transfer to a major trauma centre would result in unacceptable pre-hospital times. The adoption of a regionalised trauma network must not be at the expense of time dependent injuries, specifically haemorrhage, but facilitate access to definitive care.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of circulatory support, designed to help sustain critical physiology, until definitive haemorrhage control.16 It is a technique whereby a balloon is placed in either the thoracic or infra-renal aorta (depending on predicted pathology), providing inflow control and afterload augmentation.5 It is specifically designed as a haemorrhage control adjunct where the focus of exsanguination stems from a “noncompressible” region such as the abdomen, pelvis or groin. REBOA was originally described in the 1950s, during the Korean war,17 with further experience gained in the 1980s.18,19 Despite some successes, the technique did not enter mainstream clinical practice, mainly because of difficulties relating to balloon design and vascular access techniques. However, over the past decade, endovascular technology has matured, and there are now several off-the-shelf devices which can be placed by non-radiologists, without the need for image intensification, possibly even in the pre-hospital setting. A recent series of six patients from two US trauma centres has demonstrated no haemorrhage related mortality, despite significant physiological abnormalities and anatomical disruption.20 Nevertheless, aortic occlusion is associated with metabolic penalties, and balloon inflation time correlates inversely with survival.21 Definitive haemorrhage control must therefore be attained without delay, and in conjunction with assiduous resuscitation, particularly during balloon deflation. The resources, facilities and institutional experience required are thus considerable, and effectively limit the use of this technique to specialist centres. Pre-hospital REBOA would appear to be well suited to the geography of Scotland, which includes a spectrum of topography ranging from major urban lowland regions to rural Northern and island territories. The use of this technique in patients with haemorrhagic shock, who are injured in remote areas, would facilitate an extension of the window for salvage, and in turn permit transfer to definitive care. Scotland’s physician-led, pre-hospital services, particularly ones combined under the umbrella of ScotSTAR (Scottish Specialist Transport and Retrieval), would be ideal platforms from which to deliver such an adjunct. However, REBOA is more than a
120
t h e s u r g e o n 1 2 ( 2 0 1 4 ) 1 1 9 e1 2 0
pre-hospital intervention, and to be successful, must form part of a coherent strategy, delivered by an inclusive and integrated trauma system, providing expert and specialist care, both in- and out-of-hospital.
references
1. Tien H, Spencer F, Tremblay L. Preventable deaths from hemorrhage at a level I Canadian trauma center. J Trauma 2007;62:142e6. 2. Sanddal T, Esposito T, Whitney J. Analysis of preventable trauma deaths and opportunities for trauma care improvement in Utah. J Trauma 2011;70:970e7. 3. Chiara O, Scott JD, Cimbanassi S, Marini A, Zoia R, Rodriguez A, et al. Trauma deaths in an Italian urban area: an audit of prehospital and in-hospital trauma care. Injury 2002;33:553e62. 4. Gedeborg R, Chen L-H, Thiblin I, Byberg L, Melhus H, Michaelsson K, et al. Prehospital injury deaths e strengthening the case for prevention: nationwide cohort study. J Trauma 2012;72:765e72. 5. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am 2012;92:843e58. 6. Kisat M, Morrison J, Hashmi Z, Efron D, Rasmussen T, Haider A. Epidemiology and outcomes of non-compressible torso hemorrhage (NCTH) in Civilian trauma. J Surg Res 2013;184:414e21. 7. Gruen RL, Brohi K, Schreiber M, Balogh ZJ, Pitt V, Narayan M, et al. Haemorrhage control in severely injured patients. Lancet 2012;380:1099e108. 8. Scottish Trauma Audit Group. Audit of trauma management in Scotland 2012; 2012. 9. Peach C, Morrison J, Apodaca AN, Egan G, Watson H, Jansen JO. Destination healthcare facility of shocked trauma patients in Scotland: analysis of transfusion and surgical capability of receiving hospitals. The Surgeon 2013;11:272e7. 10. http://www.rcsed.ac.uk/media/167859/web_trauma%20care% 20report%202012.pdf [accessed June 2013]. 11. Gabbe BJ, Biostat GD, Lecky FE, Bouamra O, Woodford M, Jenks T, et al. The effect of an organized trauma system on mortality in major trauma involving serious head injury: a comparison of the United Kingdom and Victoria, Australia. Ann Surg 2011;253:138e43. 12. Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC, Judson R, et al. Improved functional outcomes for major trauma patients in a regionalized, inclusive trauma system. Ann Surg 2012;255:1009e15. 13. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366e78. 14. http://www.excellence.eastmidlands.nhs.uk/EasysiteWeb/ getresource.axd?AssetID¼36224 [accessed June 2013].
15. http://www.nao.org.uk/wp-content/uploads/2010/02/ 0910213.pdf [accessed June 2013]. 16. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 2011;71:1869e72. 17. Hughes C. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36:65e8. 18. Gupta B, Khaneja S, Flores L, Eastlick L, Longmore W, Shaftan G. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma 1989;29:861e5. 19. Low RB, Longmore W, Rubinstein R, Flores L, Wolvek S. Preliminary report on the use of the percluder occluding aortic balloon in human beings. Ann Emerg Med 1986;15:1466e9. 20. Brenner M, Moore L, Dubose J, Tyson G, McNutt M, Albarado R, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma 2013;75:506e11. 21. Martinelli T, Thony F, Decle´ty P, Sengel C, Broux C, Tonetti J, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010;68:942e8.
Jonathan J. Morrison* The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, UK Robbie A. Lendrum Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, UK Jan O. Jansen Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK Department of Intensive Care Medicine, Aberdeen Royal Infirmary, Aberdeen, UK NRS Research Fellow, Health Services Research Unit, University of Aberdeen, UK *Corresponding author. University of Glasgow, 4th Floor, Walton Building, Glasgow Royal Infirmary, Glasgow G4 0SF, UK. E-mail address: [email protected] 7 June 2013 Available online 8 January 2014 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.10.004
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Editorial
Resuscitative endovascular balloon occlusion of the aorta (REBOA): A bridge to definitive haemorrhage control for trauma patients in Scotland?
Haemorrhage is the leading cause of potentially preventable death from traumatic injury, worldwide.1,2 The majority of these deaths occur prior to hospital admission.3,4 and sources of haemorrhage in “non-compressible” regions e such as the chest, abdomen, or pelvis e are associated with particularly high mortality.5,6 The key to successful management is haemorrhage control and resuscitation.7 Data from the 2011 Scottish trauma audit shows that the relative risk of death in patients presenting with hypotension (defined as a systolic blood pressure of less than 90 mmHg) is 7.27 (95% CI: 5.03e10.50).8 There is also a mismatch between patients exhibiting signs of haemodynamic compromise at the scene of the accident, or during transfer to hospital, and the capabilities of the centre to which they are admitted. An analysis of Scottish Ambulance Service data has demonstrated that 76.4% of adult trauma patients with haemodynamic parameters suggestive of blood loss were taken to a hospital without full surgical capability.9 As the site of haemorrhage may not always be obvious, particularly following blunt trauma, this is concerning. A recent report by the Royal College of Surgeons of Edinburgh has highlighted deficiencies in Scottish trauma care,10 and has prompted the National Planning Forum to examine the issue of whether major trauma services in Scotland should be enhanced, in line with developments in England. Inclusive trauma systems e comprising emergency medical services, designated centres with stratified capability, and a comprehensive governance framework e have been shown to improve survival and functional outcomes from injury.11e13 Transfer to definitive care is associated with better outcomes than admission to the nearest hospital, and subsequent secondary transfer.14,15 However, this strategy is contingent upon accessibility, and by convention, most trauma systems rely on an acceptability threshold of 45 min. As Scotland’s population is both dispersed and eccentrically distributed, there is concern that transfer to a major trauma centre would result in unacceptable pre-hospital times. The adoption of a regionalised trauma network must not be at the expense of time dependent injuries, specifically haemorrhage, but facilitate access to definitive care.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of circulatory support, designed to help sustain critical physiology, until definitive haemorrhage control.16 It is a technique whereby a balloon is placed in either the thoracic or infra-renal aorta (depending on predicted pathology), providing inflow control and afterload augmentation.5 It is specifically designed as a haemorrhage control adjunct where the focus of exsanguination stems from a “noncompressible” region such as the abdomen, pelvis or groin. REBOA was originally described in the 1950s, during the Korean war,17 with further experience gained in the 1980s.18,19 Despite some successes, the technique did not enter mainstream clinical practice, mainly because of difficulties relating to balloon design and vascular access techniques. However, over the past decade, endovascular technology has matured, and there are now several off-the-shelf devices which can be placed by non-radiologists, without the need for image intensification, possibly even in the pre-hospital setting. A recent series of six patients from two US trauma centres has demonstrated no haemorrhage related mortality, despite significant physiological abnormalities and anatomical disruption.20 Nevertheless, aortic occlusion is associated with metabolic penalties, and balloon inflation time correlates inversely with survival.21 Definitive haemorrhage control must therefore be attained without delay, and in conjunction with assiduous resuscitation, particularly during balloon deflation. The resources, facilities and institutional experience required are thus considerable, and effectively limit the use of this technique to specialist centres. Pre-hospital REBOA would appear to be well suited to the geography of Scotland, which includes a spectrum of topography ranging from major urban lowland regions to rural Northern and island territories. The use of this technique in patients with haemorrhagic shock, who are injured in remote areas, would facilitate an extension of the window for salvage, and in turn permit transfer to definitive care. Scotland’s physician-led, pre-hospital services, particularly ones combined under the umbrella of ScotSTAR (Scottish Specialist Transport and Retrieval), would be ideal platforms from which to deliver such an adjunct. However, REBOA is more than a
120
t h e s u r g e o n 1 2 ( 2 0 1 4 ) 1 1 9 e1 2 0
pre-hospital intervention, and to be successful, must form part of a coherent strategy, delivered by an inclusive and integrated trauma system, providing expert and specialist care, both in- and out-of-hospital.
references
1. Tien H, Spencer F, Tremblay L. Preventable deaths from hemorrhage at a level I Canadian trauma center. J Trauma 2007;62:142e6. 2. Sanddal T, Esposito T, Whitney J. Analysis of preventable trauma deaths and opportunities for trauma care improvement in Utah. J Trauma 2011;70:970e7. 3. Chiara O, Scott JD, Cimbanassi S, Marini A, Zoia R, Rodriguez A, et al. Trauma deaths in an Italian urban area: an audit of prehospital and in-hospital trauma care. Injury 2002;33:553e62. 4. Gedeborg R, Chen L-H, Thiblin I, Byberg L, Melhus H, Michaelsson K, et al. Prehospital injury deaths e strengthening the case for prevention: nationwide cohort study. J Trauma 2012;72:765e72. 5. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am 2012;92:843e58. 6. Kisat M, Morrison J, Hashmi Z, Efron D, Rasmussen T, Haider A. Epidemiology and outcomes of non-compressible torso hemorrhage (NCTH) in Civilian trauma. J Surg Res 2013;184:414e21. 7. Gruen RL, Brohi K, Schreiber M, Balogh ZJ, Pitt V, Narayan M, et al. Haemorrhage control in severely injured patients. Lancet 2012;380:1099e108. 8. Scottish Trauma Audit Group. Audit of trauma management in Scotland 2012; 2012. 9. Peach C, Morrison J, Apodaca AN, Egan G, Watson H, Jansen JO. Destination healthcare facility of shocked trauma patients in Scotland: analysis of transfusion and surgical capability of receiving hospitals. The Surgeon 2013;11:272e7. 10. http://www.rcsed.ac.uk/media/167859/web_trauma%20care% 20report%202012.pdf [accessed June 2013]. 11. Gabbe BJ, Biostat GD, Lecky FE, Bouamra O, Woodford M, Jenks T, et al. The effect of an organized trauma system on mortality in major trauma involving serious head injury: a comparison of the United Kingdom and Victoria, Australia. Ann Surg 2011;253:138e43. 12. Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC, Judson R, et al. Improved functional outcomes for major trauma patients in a regionalized, inclusive trauma system. Ann Surg 2012;255:1009e15. 13. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366e78. 14. http://www.excellence.eastmidlands.nhs.uk/EasysiteWeb/ getresource.axd?AssetID¼36224 [accessed June 2013].
15. http://www.nao.org.uk/wp-content/uploads/2010/02/ 0910213.pdf [accessed June 2013]. 16. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 2011;71:1869e72. 17. Hughes C. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36:65e8. 18. Gupta B, Khaneja S, Flores L, Eastlick L, Longmore W, Shaftan G. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma 1989;29:861e5. 19. Low RB, Longmore W, Rubinstein R, Flores L, Wolvek S. Preliminary report on the use of the percluder occluding aortic balloon in human beings. Ann Emerg Med 1986;15:1466e9. 20. Brenner M, Moore L, Dubose J, Tyson G, McNutt M, Albarado R, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma 2013;75:506e11. 21. Martinelli T, Thony F, Decle´ty P, Sengel C, Broux C, Tonetti J, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010;68:942e8.
Jonathan J. Morrison* The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, UK Robbie A. Lendrum Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, UK Jan O. Jansen Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK Department of Intensive Care Medicine, Aberdeen Royal Infirmary, Aberdeen, UK NRS Research Fellow, Health Services Research Unit, University of Aberdeen, UK *Corresponding author. University of Glasgow, 4th Floor, Walton Building, Glasgow Royal Infirmary, Glasgow G4 0SF, UK. E-mail address: [email protected] 7 June 2013 Available online 8 January 2014 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.10.004