Noncompressible Torso Hemorrhage Research Articles

Is it time to reframe resuscitation in trauma?

Trauma remains a significant cause of mortality and morbidity. Non-compressible torso haemorrhage is one of the key drives of these mortality data. Our contemporary management has focused on damage control...

Partial Occlusion, Less AKI: an AORTA Registry Analysis of pREBOA-PRO

Abstract Background Non-compressible torso hemorrhage remains a leading cause of potentially preventable deaths. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as an adjunct temporizing hemorrhage control. The complete occlusion strategy with the ER-REBOA catheter can cause distal ischemia when used for longer than 30 minutes. To specifically address this limitation, the pREBOA-PRO catheter was developed. The objective of the current study is to investigate the impact of longer, partial occlusion times provided by pREBOA-PRO on acute kidney injury and mortality. Methods This is a retrospective analysis of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry as of August 2023. Patients in the pREBOA-PRO group (n = 110) receiving partial occlusion in Zone 1 were contrasted to patients in the ER-REBOA group (n = 752) treated with complete occlusion in Zone 1. Between-group comparisons included demographics, clinical presentation, aortic occlusion (AO) strategy, clinical complications, and mortality. Results Demographics, clinical presentation, and mortality were indistinguishable between groups, except for age which was higher in the ER-REBOA group (44 vs. 38, p < 0.002). The partial AO strategy was employed more often in the pREBOA-PRO group (87% vs 33%, p < 0.05) and for longer periods (59 min vs. 50 min, p < 0.003). In contrast, AKI occurred less frequently in the pREBOA-PRO group (19% vs. 33%, p < 0.05). Conclusions The more frequently partial and longer occlusion times in Zone 1 with the use of pREBOA-PRO resulted in lower AKI incidence suggesting that this newer device is a safer extended bridge to hemorrhage control.

Using computed tomography to evaluate anatomic landmarks in taiwanese trauma patients for insertion of resuscitative endovascular balloon occlusion of the aorta: A retrospective cohort study.

Hemorrhage, particularly from non-compressible torso hemorrhage (NCTH) in the abdominopelvic region, is a leading cause of preventable trauma deaths. Resuscitative endovascular balloon occlusion of the aorta (REBOA), designed for aortic occlusion, has emerged as a tool for temporary hemorrhage control in recent years. However, attaining optimal REBOA placement in diverse demographic groups, such as Asian populations, may pose challenges owing to unique anatomical and physiological differences. This retrospective study analyzed trauma patients who underwent torso computed tomography (CT) at tertiary hospitals in Taiwan from January 2014 to January 2017. The OsiriX software was used to measure the endovascular lengths in the CT images. Among the 223 patients, the median vascular lengths and body measurements were higher in males. The optimal fixed insertion length was identified as 47.5cm for zone 1 with 99.43% accuracy and 25.5cm with 82.1% accuracy for zone 3. The landmark-guided method showed 100% accuracy for zone 1 when using the mid-sternum and 94.6% for zone 3 with the umbilicus as the guide with the distance between the umbilicus, xiphoid process, and pubic ramus. External validation confirmed the accuracy of the landmark-guided method. For zone 1 occlusions, a range of 44-48cm insertion length cross-referenced with the mid-sternal landmark is recommended. For zone 3 occlusions, using the umbilicus as a guide with the distance between the umbilicus, xiphoid process, and pubic ramus provided the highest accuracy.

A PROMPT Update on Partial REBOA: Initial Clinical Data and Overview of the DoD-Funded Partial REBOA Outcomes Multicenter ProspecTive (PROMPT) Study.

Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA) is an effective management for the transient responder, but the ischemic consequences of complete aortic occlusion currently limit its use. Multiple DoD-funded preclinical studies have clearly demonstrated that partial REBOA reduces distal ischemia to potentially extend safe occlusion times, while still providing effective temporization of noncompressible torso hemorrhage. Early versions of REBOA devices were designed to completely occlude the aorta and had little ability to provide partial occlusion. Recently, a new REBOA device (pREBOA-PRO) was designed specifically to allow for partial occlusion, with the hypothesis that this may reduce the complications of aortic occlusion and extend safe occlusion times while maintaining the benefits on cardiac and cerebrovascular circulation as well as reductions in resuscitation requirements. To ascertain the impact of a new purpose-built partial REBOA device on the extension of safe occlusion time, the Partial REBOA Outcomes Multicenter ProspecTive (PROMPT) trial compared available data from the pREBOA-PRO with existing data from 200 clinical uses of pREBOA-PRO and available data in the AAST AORTA Registry were reviewed to design primary endpoints and clinical evidence for a prospective multi-center trial, the PROMPT Study. Together with the endpoints identified in preclinical studies of partial REBOA, primary endpoints for the PROMPT study were identified and power analyses were conducted to determine the target patient enrollment goals. Results from the clinical implementation of partial REBOA at a single trauma center were used to conduct the initial power analysis for the primary endpoint of Acute Kidney Injury (AKI) after prolonged occlusion. The rate of AKI after complete REBOA was 55% (12/20) compared to 33% (4/12) after partial REBOA (Madurska etal., 2021). With an alpha of 0.05 and power (β) of 0.8, the projected sample size for comparison on a dichotomous outcome is 85 patients for the assessment of AKI. Initial power and endpoint analyses have been confirmed and extended with the ongoing analysis of partial and complete REBOA reported in the AORTA database. These analyses confirm preclinical findings which show that compared to complete REBOA, partial REBOA is associated with extended occlusion time in zone 1 (complete: 31 min vs. partial: 45 min, P = 0.003), lower rates of AKI after zone 1 occlusion (complete: 33% vs. partial: 19%, P = 0.05) and reduced resuscitation requirements (e.g., 25% reduction in pRBC administration: complete: 18 units vs. partial: 13 units, P = 0.02). The DoD-funded PROMPT study of partial REBOA will provide prospective observational clinical data on patients being treated with pREBOA-PRO. Outcomes will be stratified based on partial or complete occlusion to address whether partial REBOA has additional clinical benefits over complete REBOA, such as decreased distal ischemia, extension of safe occlusion time, improved hemodynamics during transition to and from occlusion, and reduced interoperative bleeding and blood product use. The results from this study are expected to confirm previous data demonstrating reduction of ischemic sequalae, improved transition to reperfusion, and reduced resuscitative requirements compared to complete REBOA.

REBOA to the Rescue: Successful Endovascular Resuscitation of Methemoglobinemia-Induced Cardiac Arrest

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is an endovascular occlusion device commonly used to temporize bleeding due to traumatic non-compressible torso hemorrhage. This case report presents the successful utilization of REBOA in the resuscitation of a critically ill trauma patient that presented to the emergency department status post motor vehicle collision, later found to have methemoglobinemia. The REBOA was placed as part of a catch-all trauma workup following cardiac arrest after intubation. The timely placement of the REBOA resulted in a return of spontaneous circulation within 30 seconds of balloon inflation. While it is not a definitive treatment of methemoglobinemia, REBOA allowed us to successfully resuscitate the patient until final diagnosis and treatment of the underlying methemoglobinemia could be made. The patient would go on to regain full neurologic function. We believe that this is the first reported resuscitation of a patient with methemoglobinemia utilizing the REBOA device.

Contemporary Utilization and Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta for Traumatic Noncompressible Torso Hemorrhage in Korea: A Retrospective Multi-Center Study

Purpose: This study aimed to evaluate the utilization and outcomes of resuscitative endovascular balloon occlusion of the aorta (REBOA) in managing noncompressible torso hemorrhage (NCTH) among trauma patients in Korea. The evolution of REBOA and its impact on patient survival was investigated as well as predictors of mortality.Methods: This retrospective study included 234 post-REBOA patients from 5 leading regional trauma centers across Korea between 2016 and 2021. Primary outcomes were in-hospital mortality, and secondary outcomes were various clinical parameters regarding REBOA, overall treatment flow, and complications. For comparative analyses, patients were dichotomized into in-hospital non-survivors or survivors. Then, generalized additive and linear regression models were used to evaluate the trend of in-hospital mortality.Results: The overall in-hospital mortality was 65.4%. The survivors had a higher proportion of responders following REBOA (87.7% vs 62.7%, <i>p</i> < 0.001). Key variables influencing outcomes included total occlusion time, red blood cell transfusion volume within the first 24 hours, revised trauma score, and systolic blood pressure gap. These factors significantly correlated with mortality rates in multivariate logistic regression.Conclusion: Over 6 years, survival rates for NCTH patients undergoing REBOA in Korea have shown improvement. Despite diverse REBOA protocols across institutions, the results underscore the need for continued research, standardized practices, and national quality control measures to further optimize patient outcome and establish more effective treatment protocols for NCTH.

Resuscitative Endovascular Balloon Occlusion of the Aorta in Non-Traumatic Out-of-Hospital Cardiac Arrest: A State-of-the-Art Review

Out-of-hospital cardiac arrest (OHCA) is one of the most important causes of death worldwide. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an interesting new device that has been developed as a bridge therapy to treat trauma patients with non-compressible torso hemorrhage. REBOA has also been tested in non-traumatic OHCA, but the results are inconclusive. The aim of this review is to describe the state of the art in the use of REBOA for the management of non-traumatic out-of-hospital cardiac arrest. We performed a state-of-the-art review of the literature, searching for the therapeutic role of REBOA in the management of non-traumatic OHCA. We interviewed PubMed, Central, and Embase, and searched for citations before May 2023 using these criteria: “non-traumatic out-of-hospital cardiac arrest” and “resuscitative endovascular balloon occlusion of the aorta”. We selected only observational studies because controlled trials have not been published yet. All studies demonstrated the feasibility of REBOA placement in the management of non-traumatic OHCA and the improvement of all perfusion markers. Although some important uncertainties still remain, REBOA has the potential to become a new cornerstone in the therapy of OHCA and change the management of cardiac arrest, especially in remote locations which require a long time for scene arrival and an even longer time for metropolitan hospital arrival, where an ECPR is available.

A Novel REBOA Training Curriculum for Emergency Medicine Residents: A Pilot Study

BackgroundResuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a potentially life-saving intervention to treat noncompressible torso hemorrhage. Traditionally, REBOA use has been limited to surgeons. However, emergency physicians are often the first point-of-contact and are well-versed in obtaining rapid vascular access and damage control resuscitation, making them ideal candidates for REBOA training. Study ObjectivesTo fill this gap, we designed and evaluated a REBOA training curriculum for emergency medicine (EM) residents. MethodsParticipants enrolled in an accredited 4-year EM residency program (N = 11) completed a 12-hour REBOA training course. Day 1 included lectures, case studies, and hands-on training using REBOA task trainers and perfused cadavers. Day 2 included additional practice and competency evaluations. Assessments included a 25-item written knowledge exam, decision-making on case studies, REBOA placement success, and time-to-placement. Participants returned at 4 months to assess long-term retention. Data were analyzed using t-tests and nonparametric statistics at p < 0.05. ResultsScores on a 25-item multiple choice test significantly increased from pre-training (65% ± 5%) to post-training (92% ± 1%), p < 0.001. On Day 2, participants scored 100% on correct recognition of REBOA indications and scored 100% on correct physical placement of REBOA. Exit surveys indicated increased preparedness, confidence, and support for incorporating this course into EM training. Most importantly, REBOA knowledge, correct recognition of REBOA indications, and correct REBOA placement skills were retained by the majority of participants at 4 months. ConclusionThis course effectively teaches EM residents the requisite skills for REBOA competence and proper placement. This study could be replicated at other facilities with larger, more diverse samples, aiming to expand the use of REBOA in emergency physicians and reducing preventable deaths in trauma.

Effective approaches to address noncompressible torso hemorrhage.

Noncompressible torso hemorrhage (NCTH) is now considered as the major cause of preventable death after both severe military and civilian trauma. Around 20% of all trauma patients still die from uncontrolled exsanguination along with rapidly evolving hemostatic failure. This review highlights the most recent advances in the field and provides an outline for future research directions. The updated definition of NCTH includes a combination of high-grade anatomical torso injury, hemodynamic instability, urgent need for hemorrhage control and aggressive hemostatic resuscitation. Therapeutic concepts consider the following three aspects: control the bleeding source (close the tap), resuscitate to maintain organ perfusion and restore hemostasis (fill the tank), and increase the body's resistance against ischemia (upgrade the armor). The concepts for the early management of NCTH have substantially evolved over the last decade. The development of new devices and techniques combined with early intervention of hemostatic failure have contributed to more successful resuscitations. Future research needs to refine and validate their potential clinical application.

Abdominal Aortic Junctional Tourniquets: Clinically Important Increases in Pressure in Aortic Zone 1 and Zone 3 in a Cadaveric Study Directly Relevant to Combat Medics Treating Non-Compressible Torso Hemorrhage.

"Non-compressible" torso hemorrhage (NCTH) is the leading cause of preventable battlefield death, requiring rapid surgical or radiological intervention, which is essentially precluded close to the point of injury. UK Joint Theatre Trauma Registry (JTTR) analysis 2002-2012 showed 85.5% NCTH mortality. JTTR vascular injury data 2003-2008 revealed 100% mortality in named truncal vessel injuries. Gas insufflation and hyper-pressure intraperitoneal fluid animal studies have demonstrated significant reductions in blood loss in splanchnic injuries. We hypothesized that the noninvasive Abdominal Aortic Junctional Tourniquet - Stabilized ( AAJT-S) would be a forward combat medic-delivered intervention to tamponade bleeding from vessels of the celiac trunk in descending aorta zone 1 by generating clinically significant proximal epigastric compartment pressure. Four cadaveric donors each had two manometric water-filled balloons placed intra-peritoneally (1 epigastric, 1 retropubic), con- nected to manometer tubing. Baseline pressures of 8cmH2O were set (equating mean intra-abdominal pressure (IAP). AAJT-S was applied and inflated to 250mmHg. Pressures were contemporaneously recorded. AAJT-S was removed, along with the epigastric manometer. We added 500mL of water to simulate blood through the epigastric aperture. The manometer was replaced and reset to 8cmH2O. AAJT-S was reapplied to 250mmHg, and IAP steady pressures were again recorded. Proximal compartment pressures reached a mean of 54.6cmH2O (40.2mmHg); distal compartment pressures achieved a mean of 46cmH2O (34mmHg.) With 500mL intra peritoneal fluid, proximal compartment achieved a mean of 52.25cmH2O (38.4mmHg); distal compartment achieved a mean of 35cmH2O (25.7mmHg.) BMI had a statistically significant inverse effect on epigastric pressure, in this study range (BMIs, 16.7-22.9kg/m2). This proved clinically insignificant, with sufficient pressure still achieved in all tests. The AAJT-S at 250mmHg achieves proximal epigastric compartment pressures of 40mmHg, with or without 500mL simulated free blood in the abdomen. This represents a highly significant and titratable reduction in blood flow within the celiac trunk branches. BMI does not have a clinically significant effect. AAJT-S application also produces zone 3 aortic and inferior vena cava occlusion. AAJT-S may be a point-of-injury intervention for forward medics that contributes to non-surgical hemorrhage control and likely clot stabilization for zone 1 vascular and solid organ injuries.

Efficacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control traumatic bleeding. However, its prolonged use potentially leads to ischemia-reperfusion injury (IRI). Partial REBOA (pREBOA) can alleviate ischemic burden; however, its security and effectiveness prior to operative hemorrhage control remains unknown. Hence, we aimed to estimate the efficacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun. Twenty Landrace pigs were randomized into control (no aortic occlusion) (n=5), intervention with complete REBOA (cREBOA) (n=5), continuous pREBOA (C-pREBOA) (n=5), and sequential pREBOA (S-pREBOA) (n=5) groups. In the cREBOA and C-pREBOA groups, the balloon was inflated for 60 min. The hemodynamic and laboratory values were compared at various observation time points. Tissue samples immediately after animal euthanasia from the myocardium, liver, kidneys, and duodenum were collected for histological assessment using hematoxylin and eosin staining. Compared with the control group, the survival rate of the REBOA groups was prominently improved (all P<0.05). The total volume of blood loss was markedly lower in the cREBOA group (493.14±127.31 mL) compared with other groups (P<0.01). The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups (P<0.05). At 120 min, the S-pREBOA group showed higher alanine aminotransferase (P<0.05) but lower blood urea nitrogen compared with the cREBOA group (P<0.05). In this trauma model with liver injury, a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure, despite persistent hemorrhage. Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures, and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.

Quaternized chitosan/oxidized bacterial cellulose cryogels with shape recovery for noncompressible hemorrhage and wound healing

Management of noncompressible torso hemorrhage is an urgent clinical requirement, desiring biomaterials with rapid hemostasis, anti-infection and excellent resilient properties. In this research, we have prepared a highly resilient cryogel with both hemostatic and antibacterial effects by chemical crosslinking and electrostatic interaction. The network structure crosslinked by quaternized chitosan and genipin was interspersed with oxidized bacterial cellulose after lyophilization. The as-prepared cryogel can quickly return to the original volume when soaking in water or blood. The appropriately sized pores in the cryogel help to absorb blood cells and further activate coagulation, while the quaternary ammonium salt groups on quaternized chitosan inhibit bacterial infections. Both cell and animal experiments showed that the cryogel was hypotoxic and could promote the regeneration of wound tissue. This research provides a new pathway for the preparation of double crosslinking cryogels and offers effective and safe biomaterials for the emergent bleeding management of incompressible wounds.

Transition ofResuscitative Endovascular Balloon Occlusion ofthe Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage.

Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.

Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics.

Short designer self-assembling peptide (dSAP) biomaterials are a new addition to hemostat group. It may provide diverse and robust toolboxes for surgeon to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), etal., with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell delivery carrier, transparent matrix barrier, etal. Herein, in multiple surgical specialties, dSAP biomaterials-based nano hemostats achieve safe, effective and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, postoperative bleeding or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. This article provides the state of art and all-round advancements of nano hemostatic approaches in surgery. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics. This article is protected by copyright. All rights reserved.

Abdominal aortic junctional tourniquet (AAJT-S): a systematic review of utility in military practice

IntroductionHaemorrhage is the leading cause of potentially survivable death on the battlefield. Despite overall improvement in battlefield mortality, there has been no improvement in survival following non-compressible torso haemorrhage (NCTH)....

Comparison of Outcomes Relating to REBOA Inflation Zones: Report from the ABO Trauma Registry

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporary management modality for non-compressible torso haemorrhage that can be deployed in the pre- and intrahospital setting. This study aimed to compare outcomes following balloon placement in the three aortic zones.&#x0D; Methods: This is a retrospective study using data from the ABO Trauma Registry. Relevant entries from January 2014 to December 2019 were used and stratified into three groups: those who received Zone 1, 2, or 3 balloon placements.&#x0D; Results: The study sample consisted of 237 patients: 63 (27%) women and 174 (73%) men, median age 35 years. The primary location of the REBOA balloon was in Zone 1 for 180 patients, while it was nine in Zone 2 and 48 in Zone 3. Complication rates and total durations did not differ significantly between inflation zones. Emergency department mortality rates for Zones 1 and 2 patients were significantly higher than for Zone 3 (P = 0.04), but there was no difference between groups in 24-hour and 30-day mortality rates.&#x0D; Conclusions: REBOA is currently used in the emergency setting for temporary stabilisation of the bleeding patient. In this cohort, balloon placement occurred in all zones of the aorta for similar durations, with no difference in complication rates between zones. Inadvertent Zone 2 placement was not found to be associated with increased complication rates.

Advanced Non-compressible Torso Hemorrhage Management is Combat Casualty Care's Moon Shot.

Non-compressible torso hemorrhage continues to cause considerable preventable mortality on the battlefield. In this editorial, we highlight the burden of deaths, the most at-risk torso structures, current interventions, and their limitations and recommendations for future research and device development.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) After Traumatic Brain Injury

Background: The effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) on progression of traumatic brain injury (TBI) are unclear. Two hypotheses prevail: increased mean arterial pressure may improve cerebral perfusion, or cause cerebral edema due to elevated intracranial pressure. This study compares outcomes in hypotensive, blunt trauma patients with TBI treated with and without REBOA.&#x0D; Methods: A retrospective analysis compared hypotensive (systolic blood pressure [SBP] &gt;90) blunt trauma patients with TBI treated with REBOA to those treated without. Patients with spontaneous circulation at admission and at initiation of aortic occlusion were included. Patients requiring cardiopulmonary resuscitation in the emergency department (ED) were excluded. Radius matching used age, injury severity score (ISS), abbreviated injury score (AIS)head, and Glasgow coma score (GCS) and SBP at ED arrival.&#x0D; Results: Of 232 patients, 135 were treated with REBOA and 97 without. REBOA patients were older and had higher ISS, AIS-head, AIS-chest and AIS- extremity. There was no difference in TBI severity, and mortality. In the matched analysis (n = 76 REBOA, n = 54 non-REBOA), there was no difference in ISS, AIS-head, pre-hospital, ED, or discharge GCS, ED SBP, or mortality. Despite longer hospital stays for REBOA patients, there was no difference in intensive care unit length of stay, rate of discharge home, or discharge GCS.&#x0D; Conclusions: REBOA was used in more severely injured patients, but was not associated with higher mortality rate. REBOA should be considered for use in patients with non-compressible torso hemorrhage and concomitant TBI, as it did not increase mortality, and outcomes were similar to non-REBOA patients.

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times.

Extending the time to definitive hemorrhage control in non-compressible torso hemorrhage (NCTH) is of particular importance in the battlefield where transfer times are prolonged and NCTH remains the leading cause of death. While REBOA is widely practiced as an initial adjunct for the management of NCTH, concerns for ischemic complications after 30 minutes of compete aortic occlusion deters many from Zone 1 deployment. We hypothesize that extended zone 1 occlusion times will be enabled by novel purpose built devices that allow for titratable partial aortic occlusion. This is a cross sectional analysis describing pREBOA-PRO zone 1 deployment characteristics at 7 level-1 trauma centers in the US and Canada (March 30, 2021 and June 30, 2022). In order to compare patterns of zone 1 aortic occlusion, the AORTA registry was utilized. Data was limited to adult patients who underwent successful occlusion in zone 1 (2013-2022). One hundred twenty-two patients pREBOA-PRO patients were included. Most catheters were deployed in zone 1 (73% n = 89) with a median zone 1 total occlusion time of 40 minutes (IQR 25-74). A sequence of complete followed by partial occlusion was used in 42% (n = 37) of zone 1 occlusion patients; a median of 76% (IQR 60-87%) of total occlusion time was partial occlusion in this group. As was seen in the prospectively collected data, longer median total occlusion times were observed in the titratable occlusion group in AORTA compared to the complete occlusion group. Longer zone 1 aortic occlusion times seen with titratable aortic occlusion catheters appear to be driven by the feasibility of controlled partial occlusion. The ability to extend safe aortic occlusion times may have significant impact to combat casualty care where exsanguination from non-compressible torso hemorrhage is the leading source of potentially preventable deaths. Level IV evidence.

Super-Elastic Carbonized Mushroom Aerogel for Management of Uncontrolled Hemorrhage.

Uncontrolled hemorrhage is still the most common cause of potentially preventable death after trauma in prehospital settings. However, there rarely are hemostatic materials that can achieve safely and efficiently rapid hemostasis simultaneously. Here, new carbonized cellulose-based aerogel hemostatic material is developed for the management of noncompressible torso hemorrhage, the most intractable issue of uncontrolled hemorrhage. The carbonized cellulose aerogel is derived from the Agaricus bisporus after a series of processing, including cutting, carbonization, purification, and freeze-drying. In vitro, the carbonized cellulose aerogels with porous structure show improved hydrophilicity, good blood absorption, and coagulation ability, rapid shape recoverable ability under wet conditions. And in vivo, the carbonized aerogels show effective hemostatic ability in both small and big animal serious hemorrhage models. The amount of blood loss and the hemostatic time of carbonized aerogels are all better than the positive control group. Moreover, the mechanism studies reveal that the good hemostatic ability of the carbonized cellulose aerogel is associated with high hemoglobin binding efficiency, red blood cell absorption, and platelets absorption and activation. Together, the carbonized aerogel developed in this study could be promising for the management of uncontrolled hemorrhage.