No abstract

Therapeutic/care management study, level IV.

Overall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients.

Systematic review, level IV.

DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.

In a porcine hemorrhagic shock model, P-REBOA resulted in more physiologically tolerable hemodynamic and ischemic changes compared with C-REBOA. Additional work is needed to determine whether the benefits associated with P-REBOA can both extend the duration of intervention and increase survival.

Supplemental digital content is available in the text.

White, Joseph M.; Cannon, Jeremy W.; Stannard, Adam; Markov, Nickolay P.; Spencer, Jerry R.; and Rasmussen, Todd E., "Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock" (2011 Background. Noncompressible torso hemorrhage is the leading cause of potentially preventable death on the modern battlefield. The objective of this study is to characterize resuscitative aortic balloon occlusion (BO) compared to thoracotomy with aortic clamping in a model of hemorrhagic shock. Methods. A total of 18 swine (3 groups; 6 animals/group) were used in this study. Swine in class IV shock underwent no aortic occlusion (NO), thoracotomy and clamp occlusion (CO), or endovascular BO. Animals in the NO group underwent direct placement of a temporary vascular shunt (TVS) at the injury site, whereas animals in the CO and BO groups underwent aortic occlusion before TVS placement. Hemodynamic and physiologic measures were collected. Results. The central aortic pressure, carotid blood flow and brain oxygenation as measured by oximetry increased in the CO and BO groups compared to the NO group (P < .05). During resuscitation, the BO group was less acidotic than the CO group (pH,7.35 vs 7.24; P < .05) with a lower serum lactate level (4.27 vs 6.55; P < .05) and pCO2 level (43.5 vs 49.9; P < .05). During resuscitation, the BO group required less fluid (667 mL vs 2,166 mL; P < .05) and norepinephrine (0 mcg vs 52.1 mcg; P < .05) than the CO group. Conclusion. Resuscitative aortic BO increases central perfusion pressures with less physiologic disturbance than thoracotomy with aortic clamping in a model of hemorrhagic shock. Endovascular BO of the aorta should be explored further as an option in the management of noncompressible torso hemorrhage. (Surgery 2011;150:400-9.)