POTD: REBOA

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is a procedure that involves placement of an endovascular balloon in the aorta to control hemorrhage and to augment afterload in traumatic arrest and hemorrhagic shock states. Evidence has show that REBOA tends to cause less physiological disturbance and has higher rates of technical success than aortic cross clamping that is commonly done with a thoracotomy.

 Should be considered and performed in conjunction with the surgical tem

 Anatomy (Aorta is divided into three seperate zones):

·      Zone I: extends from the origin of the left subclavian artery to the coeliac artery (approx. 20cm long in young adult males)

o   Generally measured to the xiphoid

o   Used for severe intra-abdominal or retroperitoneal hemorrhage

·      Zone II: extends from the coeliac artery to the most caudal renal artery (approx. 3cm long)

·      Zone III: extends distally from the most caudal renal artery to the aortic bifurcation (approx. 10cm long)

o   Generally measured to just above the umbilicus

o   Used for isolated pelvic, junctional or proximal lower extremity hemorrhage not amenable to tourniquet use

Indications for REBOA;

·      PEA arrest < 10 mins of down time secondary to exsanguination from sub-diaphragmatic hemorrhage and femoral vessels are immediately identifiable on US

·      Severe hypovolemic shock with SBP <70mmHg

·      Patients in agonal state due to non-compressible exsanguinating hemorrhage who are non or partially responsive to rapid volume resuscitation

o   Suspected or diagnosed intra-abdominal hemorrhage due to blunt trauma or penetrating torso injuries

o   Blunt trauma with suspected pelvic fracture and isolated pelvic hemorrhage (zone III)

o   Penetrating injury to the pelvic or groin area with uncontrolled hemorrhage

Contraindications for REBOA:

·      Age > 70

·      PEA arrest > 10 minutes

·      Cardiac arrest due to causes other than exsanguination

·      High clinical or radiological suspicion of proximal traumatic aortic dissection

·      Pre-existing terminal illness or significant comorbidities

Steps:

1.     Identify the CFA

2.     Scrub, drape, prepare sheath

3.     Place a femoral a-line

4.     Insert short guidewire into femoral arterial line

5.     Sequential dilation

6.     Insert the 12F sheath

7.     Insert long guide wire to mark

a.     Zone 1: Xiphoid (approx. 50cm, T4-L1 mark)

b.     Zone III: Umbilicus (appox 40cm, L2 to L4 mark)

8.     Insert catheter to mark

9.     Inflate balloon until moderate resistance is felt

a.     Zone I: about 20 to 25mL

b.     Zone III about 15 to 20mL

10.  Confirm placement with x-ray

Target goal to release the tamponade from the REBOA would be 30mins but no greater than 50 mins.

Complications:

·      Tissue ischemia may result from REBOA

·      Reperfusion injury may occur

·      Mechanical complications can occur from femoral artery access as well as injuries to the aorta and iliac artery

o   Arterial disruption, Dissection, Pseudoaneurysms, hematoma

·      Overinflating the balloon can result in balloon rupture or aortic injury

Controversies:

·      High quality evidence for efficacy of REBOA is currently lacking

·      Talks of weather REBOA is better suited for the prehospital setting or remote areas lacking immediate access to definitive surgical therapy

o   This would be for example in community hospitals where EM physicians can place them and arrange for transfer to a facility that has surgical interventions available.

·      EM physicians with advanced critical care training and proper credinataling can place a REBOA

References:

·      https://litfl.com/reboa-in-resuscitation/

·      https://rebelem.com/reboa-time/

·      https://www.east.org/education-career-development/publications/landmark-papers-in-trauma-and-acute-care-surgery/trauma/reboa

·      https://memorialhermann.org/services/specialties/trauma/about-us/newsletter/winter-2017/reboa-technique-provides-critical-bridge-to-surgery

·      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

·      https://tsaco.bmj.com/content/3/1/e000154

POTD: Blunt Cerebrovascular Injury

Todays POTD will be a trauma topic we frequently talked about at Shock Trauma but less frequently at Maimo.

 Blunt Cerebrovascular injury (BCVI): refers to a spectrum of injuries to the cervical carotid and vertebral arteries secondary to blunt trauma.

 Why is this Important?

If left untreated, patients with BCVI are at increased risk for stroke. Mortality may reach as high as 43%. Rare diagnosis which makes it even more important to consider evaluating for in all of your trauma patients that meet criteria and have the associated risk factors .

 Pathology:

The injury is caused by longitudinal stretching and injury to the vessels. Acceleration and deceleration can cause rotation and hyperextension of the neck, stressing the craniocervical vessels. This will lead to disruption of the intima. The intima tear then becomes a source of platelet aggregation that has a potential to cause downstream effects such as an embolic stroke or vessel occlusion

 Risk Factors:

·      High energy transfer mechanisms

·      LeFort II or III fractures

·      Mandibular fractures

·      Complex skull fracture/basilar skull fracture/occipital condyle fracture (most common risk facture)

·      Closed head injury with GCS < 6

·      Cervical spine fracture, subluxation, or ligamentous injury at any level

·      Near hanging with anoxic brain injury

·      Clothesline type injury or seat belt abrasion with significant swelling, pain, or AMS

·      Traumatic brain injury with thoracic injuries

·      Scalp degloving

·      Blunt cardiac rupture

·      Upper rib fractures

 Signs/Symptoms:

·      Arterial hemorrhage from neck/nose/mouth

·      Cervical bruit in patient < 50 years old

·      Expanding cervical hematoma

·      Focal neurologic defect

·      Neurologic defect inconsistent with CT head findings

·      Stroke on CT or MRI

 Diagnostics:

• ·      Standard of care CTA (80% sensitive and 97% specific)

• Should be considered when patient has one or more of the risk factors or signs and symptoms

• ·      Can also do MRI or arteriography but this is time consuming and labor intensive

 Grading Scale:

1.     Grade 1: Intimal irregularity or dissection < 25 % of luminal narrowing noted

2.     Grade 2: Dissection or intraluminal hematoma with > 25% luminal narrowing, intraluminal clot or visible intimal flap

3.     Grade 3: Pseudoaneurysm

4.     Grade 4: Complete occlusion

5.     Grade 5: Transection with active extravasation

 Management:

·       Antithrombotics (heparin) or Antiplatelets (aspirin, Plavix) 

·       Operative repair

·       Endovascular stenting

·       Grade 1 and 2 injuries: single antiplatlet agent (aspirin 81 or 325mg)

·       Grade 3: dual antiplatelets or therapeutic anticoagulation (heparin drip with PTT at goal)

·       Grade 4 and above: Dual antiplatelets or therapeutic anticoagulation as well as operative or endovascular intervention

·       Many low grade injuries heal within 7-10 days therefore early repeat CTA is recommended. Otherwise treatment may need to be continued for 3-6 months.

 References:

·      https://www.emra.org/emresident/article/blunt-cerebrovascular-injury/

·      https://rebelem.com/blunt-cerebrovascular-injury-bcvi-universal-imaging-for-all/

·      https://jss.amegroups.com/article/view/3790/html

·      https://radiopaedia.org/articles/blunt-cerebrovascular-injury?lang=us

·      https://www.east.org/education-career-development/practice-management-guidelines/details/blunt-cerebrovascular-injury

·      https://www.aliem.com/guideline-review-east-blunt-cerebrovascular-injury/

POTD: Testicular Dislocation

Today’s Trauma Tuesday POTD is about a rare but dangerous type of straddle injury in males: testicular dislocation.

Most commonly found in young males involved in a decelerating motorcycle accident, testicular dislocation presents with severe unilateral or bilateral scrotal and/or inguinal pain. Because there may be multiple other distracting injuries incurred as a result of the accident, a genitourinary exam will be vital in identifying this injury.

On exam, you will find that the testicle has been dislocated from its normal home in the scrotum to another location due to blunt force tearing the fascia of the spermatic cord. Half of the time, that location is the inguinal pouch, and you may find a palpable mass representing the testis at the inguinal crease. The corresponding hemiscrotum will be empty. Interestingly, unilateral and bilateral testicular dislocation appears to occur at the same rate, so don’t forget to check the other side as well. Other locations the dislocated testis may end up are the penis, the perineum, and the abdomen.

Manual reduction may be attempted but is often limited by intractable pain and therefore infrequently successful. There also may be concomitant torsion. Emergent urology consult for operative intervention is usually indicated.

Prolonged dislocation may affect fertility and increases the risk of testicular malignancy in the future

Sources:

Zavras N, Siatelis A, Misiakos E, Bagias G, Papachristos V, Machairas A. Testicular Dislocation After Scrotal Trauma: A Case Report and Brief Literature Review. (2014) Urology case reports. 2 (3): 101-4.

S. L. Schwartz, G. Faerber. Dislocation of the testis as a delayed presentation of scrotal trauma. (1994) Urology.