The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been a hot topic on the cutting edge of trauma resuscitation for several years now. But who should be doing this procedure, on whom, and when? Tissue ischemia results from REBOA followed by reperfusion injury, organ dysfunction and potential cardiovascular collapse. Although appropriate patient selection is paramount, the system of care that surrounds this procedure is vital to minimizing delays to definitive hemorrhage control as well as the ischemic insult of aortic occlusion.
In 2018, the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) published a joint statement on the clinical use of REBOA2. This statement was met with much criticism from the emergency medicine/critical care world. Due to this, a revised statement has been published with different recommendations1. So, what does this statement say and how is it different from the 2018 statement?...Read More
You are working at a Level 1 Trauma Center; a 35-year-old female arrives via EMS from the scene of a motor vehicle accident. She was an unrestrained passenger, ejected 50 feet. She was hypotensive and hypoxic on scene with concern for head injury with a GCS of 7.She is clearly in shock on arrival with weak pulses, clammy skin, and a BP of 80/50mmHg, HR 140, sats 85%. She is intubated, a chest tube is placed on the left (with improvement in O2 sats to 95%), and a pelvic binder is placed for suspected pelvic fracture. eFast demonstrates free fluid in the pelvis. Massive Transfusion Protocol (MTP) has been activated appropriately, and despite rapid delivery of 4 units Packed Red Blood Cells (PRBCs), 2 units of Fresh Frozen Plasma (FFP) and 1 pack of Platelets, she remains hypotensive, with presumed hemorrhagic shock.The patient is destined for the OR, but you ask yourself, in traumatic hemorrhagic shock, is there a role for vasoactive agents?...Read More
Background: Evidence from the CRASH-2 trial showed an absolute reduction in mortality of 1.5% (NNT = 67) in patients with extracranial bleeding treated with tranexamic acid (TXA) within 3 hours of injury. However, CRASH-2 did not answer the question of effect on mortality in patients with intracranial hemorrhage (ICH), as these patients were excluded from the trial. It makes biologic sense that administration of TXA in patients with traumatic brain injury (TBI) might prevent or reduce ICH expansion and thus avert brain herniation and death. There were two smaller RCTs  that showed a reduction in death with TXA in patients with ICH. However, both of these trials were small and considered to be hypothesis generating only. TICH-2  was an international, randomized, double-blind, placebo-controlled phase 3 trial in adults with ICH from acute stroke with ≈2300 patients and showed no difference between groups in functional status at day 90. TICH-2 did show a small improvement in hematoma expansion at day 2 and death by day 7. Due to the fact that these findings were secondary outcomes they were also hypothesis generating. All of the above positive findings therefore required confirmation in a larger randomized trial, which has finally arrived…CRASH-3....Read More
Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
Resuscitate with blood products -> Activate massive transfusion protocol
Background: Trauma patients can be a rather difficult patient population to treat with multiple ongoing issues. There is always a balance of hemorrhage control vs prophylaxis for venous thromboembolism (VTE), as both can cause increased morbidity and mortality. One method to balance this challenging issue is retrievable inferior vena cava (IVC) filters, which at face value sound like a nice solution (Prevent VTE while avoiding worsening hemorrhage). The main issue with IVC filters is there is limited high quality data to support the use of these devices and IVC filters are not without their own long-term complications as well. Finally, there are also conflicting recommendations depending on which guidelines you choose to read ....Read More