Noncompressible Bleeding Research Articles

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Trauma Patients: A Systematic Literature Review

Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an innovative method by which noncompressible bleeding in the torso can be mitigated until definitive treatment can be obtained. To perform a systematic review of the literature on the use of the REBOA in trauma patients. An English and Spanish literature search was performed using MEDLINE, PubMed, and Scopus, from 1948 to 2018. Keywords used were aortic balloon occlusion, resuscitative endovascular balloon, REBOA, hemorrhage, and resuscitative endovascular balloon occlusion of the aorta. The eligilibility criteria included only original and human subject articles. Nontrauma patients, nonbleeding pathology, letters, single case reports, reviews, and pediatric patients were excluded. Two hundred forty-six articles were identified, of which 17 articles were included in this review. The total number of patients was 1340; 69 per cent were men and 31 per cent women. In 465 patients, the aortic zone location was described: 83 per cent the balloon was placed in aortic zone I and 16 per cent in zone III. Systolic blood pressure increased at an average of 52 mmHg before and after aortic occlusion. Although 32 patients (2.4%) presented clinical complications derived from the procedure, no mortality was reported. The trauma-related mortality rate was 58 per cent (776/1340). REBOA is a useful resource for the management of noncompressive torso hemorrhage with promising results in systolic blood pressure and morbidity. Indications for its use include injuries in zones 1 and 3, whereas it is not clear for zone 2 injuries. Additional studies are needed to define the benefits of this procedure.

Resuscitative endovascular balloon occlusion of the aorta during non-ST elevation myocardial infarction: A case report

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control technique that is increasingly being adopted for the management of noncompressible bleeding. In addition to limiting hemorrhage, REBOA increases blood flow to the heart, lungs, and brain. A small number of case reports and animal studies describe the use of REBOA to increase coronary perfusion during cardiopulmonary resuscitation. We report a case in which REBOA may have reversed ST-segment abnormalities during a Type II non-ST elevation myocardial infarction (NSTEMI) in a patient with previous trauma. We describe the presentation, course, and decision making that contributed to the use of REBOA in this case. Additionally, we will present a review of the literature on the effects of REBOA on coronary perfusion.

Hemostatic agents for hemorrhage control on the battlefied

Event Abstract Back to Event Hemostatic agents for hemorrhage control on the battlefied Henry Peng1 1 Defence Research and Development Canada, Canada Hemorrhage is the leading cause of death in both military and civilian trauma. A recent study indicated that the leading cause of death in Canadian Forces members in Afghanistan is hemorrhage at 38% of total death, followed by neurologic injury at 33% and blast injuries at 16%.[1] Significant advances in hemostatic biomaterials in the past decade have led to reduced mortality on the battlefield.[2] In this presentation, I will first describe the requirements for an ideal hemostatic agent on the battlefield and then review the current biomaterials and hemostats for topical and intravenous applications for combat hemorrhage. I will then talk about some of my work on development of injectable hemostatic gels, and PEGylation of fibrinogen and peptides for non-compressible bleeding which constitutes the leading cause of potentially preventable death on the battlefield. The hemostatic gels were composed of ploy(allylamine hydrochloride) (PAA) and multifunctional poly(ethylene glycol) (PEG) N-hydroxysuccinimide ester or oxidized dextran (Odex).[3][4] Gelation time depends on the solution concentration of each polymer (Figure 1). The PEGylation was conducted with 4-arm poly(ethylene glycol) (PEG) with N-hydroxysuccinimide ester end groups under different conditions and characterized using FTIR, MALDI-MS, a bicinchoninic acid assay and a PEG assay. The hemostatic efficacies of these biomaterials were evaluated in vitro using thrombelastography (Figures 2 and 3) and in vivo using animal bleeding models. Future research for hemorrhage control on the battlefield will be discussed as well. This work was supported by Defence Research and Development Canada under project 16ci; I would like to thank Dr. Blostein for the evaluation of hemostatic agents using animal models under a Defence Research and Development Canada contract.

Intravenous hemostats: challenges in translation to patients.

Excessive bleeding and the resulting complications are a leading killer of young people globally. There are many successful methods to halt bleeding in the extremities, including compression, tourniquets, and dressings. However, current treatments for internal hemorrhage (including from head or truncal injuries), termed non-compressible bleeding, are inadequate. For these non-compressible injuries, blood transfusions are the current treatment standard. However, they must be refrigerated, may potentially transfer disease, and are of limited supply. In addition, time is of the essence for halting hemorrhage, since more than a third of civilian deaths due to hemorrhage from trauma occur before the patient even reaches the hospital. As a result, particles that can cross-link activated platelets through the glycoprotein IIb/IIIa receptor expressed on activated platelets are being investigated as an alternative treatment for non-compressible bleeding. Ideally, these particles would interact specifically with platelets to stabilize the platelet plug. Initial designs used biologically derived microparticles with red blood cell fragment or albumin cores decorated with RGD or fibrinogen, which bind to GPIIb/IIIa. More recently there has been research into the use of fully synthetic nanoparticles with liposomal or polymer cores that crosslink platelets through a targeting peptide bound to the surface. Some of the challenges for the development of these particles include appropriate sizing to prevent blocking the capillaries of the lungs, immune system evasion to prevent strong reactions and increase circulation time, and storage and resuspension so that first responders can easily use the particles. In addition, the effectiveness of the variety of animal bleeding models in predicting outcomes must be examined before test results can be fully understood. Progress has been made in the development of particles to combat hemorrhage, but issues of immune sensitivity and storage must be resolved before these types of particles can be translated for human use.

Anticoagulant therapy for patients with ischaemic stroke

Anticoagulant therapy for ischaemic stroke aims to prevent recurrent ischaemic stroke and venous thromboembolism. Several large clinical trials have provided insight into the safety and efficacy of anticoagulant therapies. Anticoagulant treatment provides no net benefit over placebo or antiplatelet therapy in patients with acute ischaemic stroke of arterial or cardiac origin, because reductions in early recurrent ischaemic events and venous thromboembolism are offset by increases in bleeding events. For patients with ischaemic stroke of cardiac origin due to atrial fibrillation, long-term warfarin treatment reduces the risk of recurrent stroke by two-thirds compared with control, and by half compared with antiplatelet therapy. New anticoagulants, such as dabigatran, rivaroxaban and apixaban, are as efficacious and safe as warfarin, and have a rapid onset of action, few drug interactions, and predictable anticoagulant effects that do not require routine monitoring. However, the anticoagulant effects of the new drugs cannot be reliably measured or rapidly reversed in the event of major non-compressible bleeding or urgent surgery. In addition, the new agents cannot be used in patients with severe renal impairment or active liver disease. Ongoing research aims to resolve these limitations, examine whether the promising results of clinical trials can be translated into clinical practice, and monitor the long-term safety of anticoagulant therapies.

Pre-hospital fluids - when and how much?

When to give intravenous fluids, how much to give and whether intravenous fluids improve patient outcome remain controversial areas. Hypovolaemic shut down patients are difficult to connulate. The on scene is protracted and invariably relatively small volumes of fluid are infused. Those patients who are hypotensive invariably require definitive surgical intervention, therefore, any delay in reaching hospital can worsen outcome. Intravenous fluids given in states of uncontrolled and noncompressible bleeding will enhance blood loss. There is therefore a need to define those patient groups requiring pre-hospital intervention and optimal recusitation objectives in terms of blood pressure in the pre-hospital scene. This paper examines the current evidence base in both animal and human trials and makes recommendations for optimal fluid management in the trauma patient.

Comparison of ketoprofen and carprofen administered prior to orthopedic surgery for control of postoperative pain in dogs

Objective To compare analgesic and adverse effects of ketoprofen and carprofen when used to control pain associated with elective orthopedic surgeries in dogs. Design Prospective randomized clinical trial. Animals 93 client-owned dogs: 46 undergoing reconstruction of the cranial cruciate ligament, 47 undergoing femoral head and neck excision, and 15 control dogs anesthetized for radiographic procedures. Procedure Dogs undergoing surgery were randomly given ketoprofen, carprofen, or saline (0.9% NaCl) solution, SC, prior to surgery. Pain score and serum cortisol concentration were recorded for 12 hours after surgery for all dogs. When pain score was ≥ 7, oxymorphone was administered IM. Bleeding time was measured prior to and during surgery. Results The proportion of dogs that required oxymorphone was significantly higher for the carprofen and placebo groups than for the ketoprofen group. Pain score for the placebo group was significantly higher than for the ketoprofen and carprofen groups, 2,8, and 9 hours after surgery. Cortisol concentration was significantly higher for the placebo group than for the carprofen group at 4 and 6 hours after surgery. Significant differences were not detected between ketoprofen and carprofen groups with respect to pain score and cortisol concentration. Bleeding time was significantly longer for the ketoprofen group than for the other groups during surgery. One dog treated with ketoprofen developed a hematoma at the surgical site. Conclusions and Clinical Relevance Ketoprofen and carprofen given prior to surgery were effective for postoperative pain relief in dogs. However, ketoprofen should not be used when noncompressible bleeding may be a problem. (J Am Vet Med Assoc 1999;215:1105–1110)