William Teeter1, Anna Romagnoli2, Philip Wasicek2, Peter Hu3, Shiming Yang3, Deborah Stein2, Thomas Scalea2, Megan Brenner2. 1. Department of Trauma and Surgical Critical Care, University of Maryland Medical System/R Adams Cowley Shock Trauma, Baltimore, MD. Electronic address: williamteeter@umm.edu. 2. Department of Trauma and Surgical Critical Care, University of Maryland Medical System/R Adams Cowley Shock Trauma, Baltimore, MD. 3. Department of Trauma and Surgical Critical Care, University of Maryland Medical System/R Adams Cowley Shock Trauma, Baltimore, MD; Shock Trauma and Anesthesiology Research Center, University of Maryland, School of Medicine, Baltimore, MD.
Abstract
STUDY OBJECTIVE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an alternative to resuscitative thoracotomy for proximal aortic control in select patients with exsanguinating hemorrhage below the diaphragm. The purpose of this study is to compare interruptions in closed chest compression or open chest cardiac massage during REBOA versus resuscitative thoracotomy. METHODS: From May 2014 to December 2016, patients in arrest who received aortic occlusion with REBOA or resuscitative thoracotomy were included. Total cardiac compression time was defined as the total time that closed chest compression was performed for REBOA patients and the total time that closed chest compression (before resuscitative thoracotomy) and open chest cardiac massage (after thoracotomy) were performed for resuscitative thoracotomy patients. Cardiac compression fraction was defined as the time compressions occurred during the entire resuscitation phase. All resuscitations were captured by multiview, time-stamped videography. RESULTS: Fifty patients with aortic occlusion after arrest were enrolled: 22 REBOA and 28 resuscitative thoracotomy. Most were men (86%) (median age 30.2 years, interquartile range [IQR] 24.9 to 42.3; median Injury Severity Score 27, IQR 16 to 42; neither differed between groups). The median duration of total cardiac compression time was 945 seconds (IQR 697 to 1,357) for REBOA versus 496 seconds (IQR 375 to 933) for resuscitative thoracotomy. During initial resuscitation, compressions occurred 86.5% of the time (SD 9.7%) during resuscitation with REBOA versus 35.7% of the time (SD 16.4%) in patients receiving resuscitative thoracotomy. Cardiac compression fraction improved after open cross clamp in resuscitative thoracotomy patients to 73.2% of the time (SD 18.0%) but remained significantly less than the same period for REBOA (86.7%; SD 9.4%). Mean cardiac compression fraction for REBOA was significantly improved over that for resuscitative thoracotomy (86.2% [SD 9.1%] versus 55.3 [SD 17.1%]; mean difference 31.0%; 95% confidence interval for difference 22.7% to 39.23%; P<.001). Median pause in resuscitation related to procedural tasks was 0 seconds (IQR 0 to 13) for REBOA and 148 seconds (IQR 118 to 223) in resuscitative thoracotomy. CONCLUSION: Total duration of interruptions of cardiac compressions is shorter for patients receiving REBOA versus resuscitative thoracotomy before and during resuscitation with aortic occlusion. Markers for perfusion during resuscitation must be examined to understand the effects of cardiac compressions and aortic occlusion on patients in arrest because of hemorrhagic shock.
STUDY OBJECTIVE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an alternative to resuscitative thoracotomy for proximal aortic control in select patients with exsanguinating hemorrhage below the diaphragm. The purpose of this study is to compare interruptions in closed chest compression or open chest cardiac massage during REBOA versus resuscitative thoracotomy. METHODS: From May 2014 to December 2016, patients in arrest who received aortic occlusion with REBOA or resuscitative thoracotomy were included. Total cardiac compression time was defined as the total time that closed chest compression was performed for REBOA patients and the total time that closed chest compression (before resuscitative thoracotomy) and open chest cardiac massage (after thoracotomy) were performed for resuscitative thoracotomy patients. Cardiac compression fraction was defined as the time compressions occurred during the entire resuscitation phase. All resuscitations were captured by multiview, time-stamped videography. RESULTS: Fifty patients with aortic occlusion after arrest were enrolled: 22 REBOA and 28 resuscitative thoracotomy. Most were men (86%) (median age 30.2 years, interquartile range [IQR] 24.9 to 42.3; median Injury Severity Score 27, IQR 16 to 42; neither differed between groups). The median duration of total cardiac compression time was 945 seconds (IQR 697 to 1,357) for REBOA versus 496 seconds (IQR 375 to 933) for resuscitative thoracotomy. During initial resuscitation, compressions occurred 86.5% of the time (SD 9.7%) during resuscitation with REBOA versus 35.7% of the time (SD 16.4%) in patients receiving resuscitative thoracotomy. Cardiac compression fraction improved after open cross clamp in resuscitative thoracotomy patients to 73.2% of the time (SD 18.0%) but remained significantly less than the same period for REBOA (86.7%; SD 9.4%). Mean cardiac compression fraction for REBOA was significantly improved over that for resuscitative thoracotomy (86.2% [SD 9.1%] versus 55.3 [SD 17.1%]; mean difference 31.0%; 95% confidence interval for difference 22.7% to 39.23%; P<.001). Median pause in resuscitation related to procedural tasks was 0 seconds (IQR 0 to 13) for REBOA and 148 seconds (IQR 118 to 223) in resuscitative thoracotomy. CONCLUSION: Total duration of interruptions of cardiac compressions is shorter for patients receiving REBOA versus resuscitative thoracotomy before and during resuscitation with aortic occlusion. Markers for perfusion during resuscitation must be examined to understand the effects of cardiac compressions and aortic occlusion on patients in arrest because of hemorrhagic shock.