Category Archives: Procedures

REBOA At An Academic Trauma Center

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is the big thing these days. I’ve written about this topic in the past, and a number of centers continue to refine our understanding of this new(er) tool.  A recent paper from the University of Florida – Gainesville outlines their experience in implementing this procedure at an academic Level I trauma center.

This trauma program is staffed by a group of surgeons who have considerable experience in guidewire-based skills, fellowship or military exposure, and/or completion of a vascular fellowship. One surgeon attended a trauma endovascular skills course (6 hrs).  An internal education program with a 1.5 hour slide presentation and some hands-on simulation training was developed. All surgeons and residents completed this program.

A retrospective review of their experience from June 2015 to March 2017 was carried out on unstable trauma patients due to hemorrhage. All cases were performed in a hybrid OR with imaging capabilities. A 12Fr REBOA catheter was initially used, but was changed to 7Fr once that catheter became commercially available.

Here are the factoids:

  • 16 patients underwent REBOA in this 22 month period; mean SBP was 97 torr and mean ISS was 39
  • Hemodynamic status improved in 10 of 16 patients to a mean SBP 132
  • 14 survived the initial operative procedure, but only 6 survived to hospital day 30. It appears that all of these patients were neurologically normal (GCS 15+0).
  • 1 survivor developed a common femoral artery pseudoaneurysm
  • The authors made the interesting comment that they also performed 8 ED thoracotomies (EDT) during this period and that there were no survivors
  • The authors concluded that the procedure was beneficial, that extensive training was not needed, and that it should be available trauma centers

Bottom line: But not so fast! This was a very select academic Level I center. The surgeons had extensive wire skills and vascular experience. All procedures were performed in a hybrid room, which is a very controlled OR setting. And they only performed REBOA every 6 weeks or so. 

REBOA is still an advanced procedure, and the average trauma surgeon would probably benefit from some more intensive training to ensure adequate initial skills. But if the surgeon can’t then maintain their skills via somewhat regular practice, errors may creep in. In a group of 6-8 surgeons, each may only get to perform the procedure once a year! Add in some interested emergency physicians, and no one can keep in practice.

The bit about ED thoracotomy is a bit of a red herring. Typically, this procedure is performed once the patient has lost their vital signs. Comparing mortality from REBOA with EDT here is not valid, because it appears that most of the REBOA patients in this study still had vital signs when it was inserted. It would be interesting if the authors shared the outcomes in the REBOA patients who had the device inserted after arrest to level the playing field with EDT.

So what to do? Be cautious and thorough if you are planning to try out REBOA at your center. Do the math. On how many patients per year can I expect to perform this? How many physicians want credentialing to do it? How many procedures can the typical physician expect per year? What is the baseline level of physician training and what additional training is needed? Will I report my experience to a national registry or write it up for sharing?

These are important questions! Everyone wants to play with the newest shiny toy in the toybox. But make sure that when you do play with it, you are able to provide the maximum benefit to your patients with the least amount of harm!

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ED Thoracotomy Survey: Read The Answers! (Rest of the World)

Last time, I posted summary info for ED thoracotomy on US trauma centers. Here’s a rundown of the answers provided by international respondents. A few duplicates from the same hospitals have been merged into single answers for them. The total number of international centers for the tables below is now 43.

Level of trauma center (or equivalent)

Level I 22
Level II 8
Level III 6
No level 7

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 30
About every month (6-15) 6
A couple of times a month (16-30)4 4
About every week (31-52) 2
Not specified 1

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 22
Penetrating 17
Blunt 4

 

Do you use a practice guideline for ED thoracotomy?

Yes 17
No 16
I’m not sure 10

 

Do you use REBOA in your ED?

No 32
Yes 9
I’m not sure 2

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 39
Emergency physician 25
Surgical resident / fellow 15
Emergency medicine resident 7
Intensivist 1
ED intern / medical officer 1
No one 1

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 32
Emergency physician 15
Surgical resident / fellow 9
Emergency medicine resident 1
Thoracic surgeon on call 1
Trauma team leader 1
Never done one 1

 

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ED Thoracotomy Survey: Read The Answers! (US)

Again, thanks for all who submitted their survey answers. Here’s a rundown of the answers provided by US respondents. A few duplicates from the same hospitals have been merged into single answers for them. Total number of US centers for the tables below is 149.

Level of trauma center

Level I 83
Level II 37
Level III 15
Level IV 1
Level V 2
Seeking verification/designation 1
No level 10

 

How many ED thoracotomies are performed per year at your hospital?

A few per year (<6) 83
About every month (6-15) 35
A couple of times a month (16-30) 23
About every week (31-52) 8

 

What type of trauma do you perform ED thoracotomy for?

Both blunt and penetrating 79
Penetrating 64
Blunt 5

 

Do you use a practice guideline for ED thoracotomy?

Yes 86
No 47
I’m not sure 15

 

Do you use REBOA in your ED?

No 88
Yes 58
I’m not sure 3

 

And now for the questions you’ve been waiting for!

Who could perform ED thoracotomy at your hospital? (n=149)

Surgeon 145
Emergency physician 109
Surgical resident / fellow 93
Emergency medicine resident 66
APP (PA, NP) 2 at one Level I and one Level V
Family physician 1 at one Level V
Family medicine resident 1 at one Level V

 

Who usually performs ED thoracotomy at your hospital? (n=149)

Surgeon 115
Emergency physician 25
Surgical resident / fellow 69
Emergency medicine resident 17
Never done one 3
Family physician or family nurse practitioner 1 at one Level V

 

Who usually performs ED thoracotomy at your hospital? (By trauma center level)

Level I (n=83) II (n=37) III (n=15)
Surgeon 64 35 11
Emergency physician 8 3 6
Surgical resident 63 4 1
Emergency medicine resident 12 1 2
No one 0 0 1

 

Join me tomorrow when I review the international data!

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Coming Tomorrow: ED Thoracotomy Survey Results

The data is in!

Thanks to everybody (all 200+ of you) who participated in the ED thoracotomy survey over the past month. I’m currently compiling the results and will post them here over the next two days.

Here is a summary of who responded:

  • 50% were emergency medicine physicians or residents
  • 22% were surgeons or surgical residents
  • 15% were nurses
  • 6% were advanced practice providers such as NPs or PAs

And where were they located?

As you can see, the vast majority (167) were from the United States. Australia, Canada, and Denmark added another 18, and a variety of other countries contributed the remaining 27 surveys.

Over the next two days, I’ll focus on the US data, then look at the results from the rest of the world.

Again, thanks for contributing!

 

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Long-Term Experience With Endovascular Aortic Repair For Trauma

For decades, the treatment of blunt injury to the thoracic aorta was open repair. The big debate at the time was use of cardiac bypass vs fast clamp and sew. But starting in 1997 with the introduction of thoracic endovascular aortic repair (TEVAR) of this injury, we have rapidly moved to the point where most traumatic aortic injuries are repaired using this technique.

A report that was written nearly a decade ago indicated a relatively high complication rate for the procedure. Graft complications were reported in 18% of patients, with 14% showing endoleaks. Stroke and left arm ischemia were also reported.

The diagram above shows insertion for management of an aneurysm, but the technique is similar for trauma. Blunt aortic injury occurs closer to the left subclavian artery and care must be taken to place the endograft closer to but not covering its orifice.

As the insertion systems and stents improved, short term events have been on the decline. Unfortunately, long term followup data has been hard to come by.

Until now. An article that is not yet in print reports 11 years of experience and followup with patient undergoing TEVAR at the ShockTrauma center in Baltimore.

Here are the factoids:

  • 88 patients underwent TEVAR during the study period, all from blunt trauma
  • Average ISS was 38, showing these patients were severely injured
  • Overall mortality was 7%, but none was due to the TEVAR procedure
  • TEVAR-related complication rate was 9% Endoleaks at the ends of the graft occurred in 4 patients, and all required repair. There were 4 other minor leaks that resolved on their own.
  • 26 had all or part of the left subclavian orifice covered at initial operation. None developed ischemia, although 2 had a prophylactic carotid-subclavian bypass before TEVAR.
  • The longest followup imaging occurred 8 years after the procedure. No long-term complications were noted.

Bottom line: TEVAR has essentially replaced open repair of the aorta, except in special cases. We continue to learn from our experience, and the complication rate is still falling. Other than endoleaks recognized in the postop period, most other complications rarely occur. Long term followup is poor, but in the patients who do return, there were no complications. But remember, this is an expected sampling bias. If the patient had major problems and/or died, they would just be lost to followup. We would never know.

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