Page 104 - JSOM Summer 2018

TABLE 5 Patients Who Died and Interventions That Could Have with substantial physiologic derangement, 8%. Of concern is
Been Potentially Helpful that applying the AAJT at the aortic bifurcation in patients
ResQFoam REBOA AAJT Total with bleeding above this location may increase hemorrhage
Patients, No. % (n = 52) (n = 56) (n = 2) (N = 62) by raising the proximal blood pressure. This is noteworthy as
Died with uncontrolled the vast majority of injuries found in this study were above the
hemorrhage 45 (87) 48 (86) 2 (100) 54 (87) aortic bifurcation and in blunt trauma in particular the surface
Died because of 22 (42) 22 (39) 1 (50) 27 (50) location of signs injury did not correlate well with the location
hemorrhage of internal injury (Table 3). In the nine (5%) cases of penetrat-
Died because of brain 16 (31) 19 (34) 0 20 (32) ing trauma where the AAJT could have been of potential ben-
injury efit, an external site of injury was noted in the lower quadrants
Died because of stroke 1 (2) 1 (2) 0 1 (2) in the majority (69%) of cases. This suggests that given the
Died because of MOF 8 (15) 10 (18) 0 10 (16) transportability, limited learning curve, and rapid application
Died because of of this device, it may have a niche role for hemorrhage control
respiratory failure 1 (2) 1 (2) 0 1 (2) in patients with lower abdominal, pelvic, and junctional pen-
Died because of cardiac 3 (6) 3 (6) 1 (50) 3 (6) etrating injuries.
failure
REBOA, resuscitative endovascular balloon occlusion of the aorta; The use of ResQFoam (not yet FDA cleared) was of po-
AAJT, Abdominal Aortic and Junctional Tourniquet; uncontrolled tential benefit to 87% of patients, including patients with ei-
hemorrhage defined by patient receiving ≥3 units of red blood cells;
MOF, multiorgan failure. ther blunt or penetrating trauma and patients with substantial
physiologic derangement. While foam appears to require less
TABLE 6 Statistical Analysis Between Different Treatment Methods expertise and training than REBOA, there are several import-
REBOA vs REBOA vs ResQFoam vs ant considerations that must be kept in mind before its use.

AAJT ResQFoam AAJT A thorough examination of the abdomen, looking for both
Underwent laparotomy surgical scars and large abdominal wall defects, is necessary,
p value <.001 .0218 <.001 as both are potential contraindications to foam use. Previous
truncal surgery can cause intra-abdominal adhesions that may
Underwent laparotomy and had significant physiologic derangement prevent proper foam expansion or lead to an inability to, or
p value <.001 .1164 <.001 complications from, accessing the peritoneal cavity. Foam is
REBOA, resuscitative endovascular balloon occlusion of the aorta; also likely contraindicated with large diaphragmatic defects
AAJT, Abdominal Aortic and Junctional Tourniquet; p value, Mc-
Nemar test with the Bonferonni correction, significant at p < .017; as these injuries may limit the ability of foam to increase the
significant physiologic derangement defined by receiving ≥3 units of intra-abdominal pressure and cause its desired tamponade
red blood cells. effect. Furthermore, foam injection in this setting may com-
promise ventilation as leakage of foam into chest cavity could
foam and AAJT (p < .001). The comparable benefits did not result in a “foamothorax.” Diaphragmatic injuries are rarely
20
change in significance when considering patients with a sub- detectable on physical exam and are often only first discovered
stantial physiologic derangement as a subgroup. with diagnostic imaging or at surgery. Without the use of por-
table imaging adjuncts, such as ultrasound, it is unlikely that
a diaphragmatic injury can be reliably ruled out in the field.
Discussion
Finally, foam injection in a patient who otherwise may not re-
The results of this work suggest that REBOA and self-expand- quire a laparotomy exposes the patient to unnecessary surgery
ing foam could potentially benefit a large percentage (>85%) in order to remove the foam from their abdomen. Again, field

of injured patients with uncontrolled abdominal and pelvic use of ultrasound may assist with this diagnostic dilemma as
hemorrhage while the AAJT device could potentially benefit unstable patients with a positive focused assessment with so-
9%. Of these three methods, REBOA was of potential ben- nography in trauma (FAST) exam are the most likely group of
efit to the highest percentage (96%) of patients, including patients to benefit from ResQFoam.
the greatest number injured by blunt or penetrating trauma,
with substantial physiologic derangement, or who died with Limitations
uncontrolled hemorrhage. However, the invasive nature, chal-
lenge of obtaining vascular access, potential for local vascular This study has several limitations. As a retrospective study it
complications, and limited balloon inflation times in Zone 1 relies on the thoroughness and accuracy of trauma registry
before irreversible ischemia occurs mean that this technique is, data, resuscitation bay records, morbidity and mortality re-
at present, relatively restricted to being performed in facilities cords, and operative notes. This likely had the most significant
with skilled practitioners and immediate operative capability. impact on the location of intra-abdominal injury determined
As a result, of these three methods, the prehospital application from the operative notes. Here we assumed that the hemor-
of REBOA is likely the most limited. Although REBOA has rhage control method used could halt the bleeding that led
been successfully used in the field, 15,16 substantial investment to these patients receiving a laparotomy if the injury was in a
in training and resources will be required for this to occur with location where the method had the potential to be effective.
future regularity. At the present, the use of REBOA is not This may not have necessarily been the case. Furthermore,
23
recommended in patients with evidence of significant injury patients with substantial physiologic derangement may have
above the diaphragm where its use could elevate proximal had this derangement from injury outside of the abdomen and
blood pressure and, thus, increase hemorrhage. pelvis. However, in this study we assumed that any substantial
derangement was from an intra-abdominal or pelvic source
Of the 402 patients undergoing laparotomy, the AAJT device that would have benefited from the application of one of these
could have been potentially beneficial in 9%, and in those hemorrhage control techniques. Additionally, only one trauma

102 | JSOM Volume 18, Edition 2/Summer 2018