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Preperitoneal balloon tamponade and resuscitative endovascular balloon occlusion of the aorta

Alternatives to open packing for pelvic fracture-associated hemorrhage

Do, Woo S. MD; Forte, Dominic M. MD; Sheldon, Rowan R. MD; Weiss, Jessica B. MD; Barron, Morgan R. MD; Sokol, Kyle K. MD; Black, George E. MD; Hegge, Sara R. DVM, MPH; Eckert, Matthew J. MD; Martin, Matthew J. MD

Journal of Trauma and Acute Care Surgery: July 2019 - Volume 87 - Issue 1 - p 18–26
doi: 10.1097/TA.0000000000002266
2019 EAST PODIUM PAPER
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BACKGROUND The objective of this study was to compare the efficacy of preperitoneal balloon tamponade (PPB), resuscitative endovascular balloon occlusion of the orta (REBOA), and open preperitoneal packing (OP) in a realistic animal model of pelvic fracture-associated hemorrhage.

METHODS Thirty-nine swine underwent creation of open-book pelvic fracture and iliac vascular injury. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), zone 1 REBOA (n = 7), and zone 3 REBOA (n = 6) at a mean arterial pressure less than 40 mm Hg from uncontrolled hemorrhage. Primary outcome was survival at 1 hour. Secondary outcomes included survival in the immediate 10 m following intervention reversal, peak preperitoneal pressure (PP), blood loss, bleed rate, and peak lactate.

RESULTS Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p = NS). The injury was uniformly lethal without intervention, with survival time (mean) of 5 m, peak PP of 14 mm Hg, blood loss of 960 g, bleed rate of 450 g/m, and peak lactate of 2.6 mmol/L. Survival time (m) was extended to 44 with OP, 60 with PPB, and 60 with REBOA (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, 10 with zone 1 REBOA, and 6 with zone 3 REBOA (p < 0.05). Blood loss (g) was 850 with OP, 930 with PPB, 610 with zone 1 REBOA, and 370 with zone 3 REBOA (p < 0.01). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, 13.4 with zone 1 REBOA, and 5.3 with zone 3 REBOA (p < 0.01). Only 33% of zone 1 REBOA animals survived the initial 10 m after balloon deflation, compared to 60% for OP, 67% for PPB, and 100% for zone 3 REBOA (p < 0.01).

CONCLUSION Preperitoneal balloon tamponade and zone 3 REBOA are effective alternatives to OP in this animal model of lethal pelvic fracture-associated hemorrhage. Zone 1 REBOA extends survival time but with high mortality upon reversal.

From the Departments of Surgery and Clinical Investigations (W.S.D., D.M.R., R.R.S., J.B.W., M.R.B., K.K.S., G.E.B., S.R.H., M.J.E., M.J.M.), Madigan Army Medical Center, Tacoma, Washington; and Trauma and Emergency Surgery Service (M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon

Address for reprints: Matthew J. Martin, MD, Medical Corps, US Army Trauma and Emergency Surgery Service Legacy Emanuel Medical Center, 2801 North Gantenbein Avenue Portland, OR 97227; email: traumadoc22@gmail.com.

Meeting Presentation: 32nd EAST Annual Scientific Assembly, January 16, 2019.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Online date: April 25, 2019

© 2019 Lippincott Williams & Wilkins, Inc.